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Measuring ethnicity, especially indigenousness, but not race is common in Latin America. At least one country, Ecuador, has also included both the interviewer’s observation and respondent’s self-identity in censuses (Hall and Patrinos, ed., 2006)Bolivia in 2001 characterized respondents as indigenous or not using a matrix of language and self-identity variables (Comisión Económica para América Latina y el Caribe, CEPAL, 2005)
84% of women and 88% of men in the 2008-09 survey identified themselves the same way the interviewer did, as either indigenous or ladino13% of women and 8% of men self-identified as indigenous, but were identified by the interviewer as ladinoCross-identification in the other direction was rare (around2%), and the remaining cases had ‘other’ or no response on one or both ethnicity variables
Lots of other countries, including the US, have grappled for decades with differences between these two measures, and with deciding which one is “right” or best for a certain research or policy context.
Why can’t we just choose the measure that’s easiest or cheapest to implement?Newer DHS data using self-identity aren’t directly comparable with results from previous years, the main reason official reports continue to present the interviewer’s observation alone.
Some political and implementation issues that have arisen elsewhere:In 2012 Bolivia’s census recorded respondents’ identification with any one of 40 indigenous groups or Afro-Bolivian, but did not include “mestizo.” Critics suggested that the decision was “calculated to protect Evo Morales' presidency” and fears of expropriation reportedly led people to underreport their assets.
Why do you think the US Census Bureau would risk offending people by keeping the term “Negro” in its questionnaire?Before 1960, census-takers filled out the form and chose the category for each person they counted. Self-identification was fully in place by 1970.
In preliminary work using a dichotomous ethnicity variable, we tested effect sizes both ways.Although our answer to the question “Is the indigenous group at higher risk?” didn’t change, ethnicity did show stronger effects on HIV risk factors using the interviewer’s observation (e.g. differences between the two groups were more pronounced)
We added a third category to the independent variable, comparing odds for ladinos and the cross-identified group separately to those for indigenous respondents.
On nearly every outcome, the ladino and cross-identified groups were comparably (and significantly) different from indigenous respondents.In these examples for the odds for ever having had an HIV test were 2.25 times higher for ladino women compared to indigenous women, and 2.46 times higher for cross-identified women compared to indigenous women. The odds of having comprehensive HIV knowledge were 1.58 times higher for ladino men compared to indigenous men and there was a marginal difference between cross identified men and indigenous men.
From “Conceptualizing and Categorizing Race and Ethnicity in Health Services Research,” 2005.Our results echo this conclusion. The indigenous population becomes ‘ladinoized’ if self-identification is used to determine group membership, lessening demographic and risk factor distinctions between the groups. Other studies have opted to measure acculturation directly using validated scales.
Another example: American Indianpopulationgrew 255% between 1960 and 1996, largely through changing patterns of racial self-identification. (Passel, 1996)
COSIDRA has disseminated the findings of the study nationally.High-level meetings with the National Statistics Institute, Ministries, donors and civil society to discuss the implications of our findings and of measuring ethnicity on the upcoming census.
-Delinking of behavior from lived experience, social context, to focus on individual behavior.-largely focused on sexual behavior, rather than overall health and well-beingDSM = “Diagnostic and Statistical Manual of Mental Disorders”After last bullet – while the inclusiveness of this term has increased diversity with this group, there may be a loss nuance. For example, transgender women, who are often included in this group, have different life experiences and vulnerabilities to HIV.
MSM is a population that has emerged from HIV research and practice-it’s a way to define a group based on a high-risk behavior vs. sexual orientation. You may have men who self-identify as heterosexual, be married to a woman and have sex with another man and you would be leaving them out of your study. May be harder to reach group b/c not necessarily at Gay venues, etc.-sexual orientation refers to who you are attracted to sexually, someone of the same or different biological sex
Transgender women have often been included as sub-group of MSM in much HIV research and surveillanceCoined in the 1970s, transgender referred to people who lived full-time in the gender opposite to their sex (generally) assigned at birth, but did not seek gender reassignment surgery.In the 1990s, transgender evolved to be an umbrella term to describe the identities and experiences of individuals who transgress traditional categories of sex and gender. As a personal identity, transgender is used by people who “feel a need to express a gender identity different from the one society associates with their genitals” It is an umbrella term encompassing many identities including transsexuals, cross-dressers, transvestites, intersexuals othersThe boundaries of identity for transgender people remains nebulous. Sex is generally thought of as biologically based, with the physical body, hormones and chormosomes indicating sex. Sex is usually designated soley on the physical appearance of genitalia. Categories of female and male are putatively seen as exhaustive, mutually exclusive and immutable. Some believe that sex, like gender, is also socially constructed. Gender is traditionally been viewed as a natural and essential counterpart to sex. It is an ascribed status which designates the psychological, social and cultural aspects of maleness and femaleness. Gender, gender roles and gender presentation are susceptible to cultural definitions and can change over time. Gender identity is the internal, private experience of one’s gender, it is a self-attribution of genderGender roles are social, public, with implied expectations, obligations and privileges associated with each gender.Femininity and masculinity are ideological constructions whose manifestations (women, men, girls and boys) are recreated in each generation according to the intermeshing requirements of social, cultural, econoic and biological necessities.
It is in this context that USAID’s Central American Regional HIV Program requested that MEASURE conduct a health service utilization study among MSM in San Salvador, El SalvadorThe HIV epidemic in El Salvador is concentrated among MSM, TW and Sex WorkersWe know from a 2008 HIV Prevalence and Behavior Study that HIV prevalence was 10.8% among MSM, a figure that included TW.
We faced a serious challenge when initiating the study. After El Salvador’s 2008 HIV prevalence study, TW groups were strong advocates that demanded TW specific data. They did not want to be considered a sub-group of MSM that could not be disaggregated in the results. They wanted to be able to say something about their community/population for advocacy, programming, funding, etc. We didn’t have enough money to do two separate surveys… We spent a lot of time deciding whether to include TW in the sample or exclude. As you can tell from the image of the report cover, we included them.We made this decision based on several factors: We wanted did not want to exclude such a highly vulnerable group from the studyFrom previous studies we knew that TW were highly socially connected to MSM in San Salvador and would be collected in an RDS sampleWhile we didn’t know if we would have enough TW in the study to be able to disaggregate, we coordinated with USAID’s AIDSTAR ONE Project, which was going to implement a mixed methods health services study among TW at the same time we were in the field.
What did we do? We designed a study that aimed to:Describe past-year health service utilization, including general health and HIV/STI services.Identify factors that may influence health service utilization.Determine the extent of experienced discrimination from healthcare providers We made efforts to ensure that we were explicitly acknowledging TW in our study population, byReaching out and gathering input from TW organzations and our own field teamDeveloping eligibility criteria and survey questions that were inclusive of TWIncluding a TW as part of the interviewer teamIncluding a TW as a seed in implementation of respondent driving samplingWe also made efforts to measure the related constructs accurately. Again we reached out to TW organizations, sharing our tools and gating inputImportantly, we measured gender identity and sexual orientation separately, and we will take about this in a few slides.-We anticipated getting about 10% of our sample as TW, which consistent with the 2008 BBSS and other studies in El Salvador and the region.-If we excluded TW, we would have no data on that population.-Concern about getting a small percentage, from which populations would be eager to First issue we had to confront was about representing each population in the study The second issue, was about measuring constructs appropriately in the study, so as not to generalize experiences of one group with the other (wrongly attributing findings to both groups), or to miss findings important within each group.
For bothstudies:18 years of age or olderA man or transgender woman who had anal sex (receptive or penetrative) with another man or transgender woman in the last 12 monthsLived, worked, or studied in San Salvador for at least 3 months prior to the interviewIn possession of an RDS coupon given to them by someone they know who participated in the study (exception for seeds)
Examples of how we framed quesitons to be inclusive:READ QUESTIONS
We also asked separate questions to measure gender identity and sexual orientationIn many HIV studies in concentrated epidemics, transgender women have been included as a sub-group of the MSM population. In Central America and other regions, the constructs of gender identity and sexual orientation has been conflated and generally asked a single question. As a reminder, Gender identity is defined as one’s personal sense of gender, of being a man or a woman or something different Sexual orientation is one’s erotic and emotional attraction to another. Our classification of sexual orientation is generally assumed to be based on biological sex.
Here we have an example of how the question was asked in the 2008 El Salvador Biological and Behavioral Surveillance Study. READ QUESTIONThis form of the question makes the selection of one’s gender identity and sexual orientation mutually exclusive. If you identify as a transgender, you cannot choose a sexual orientation.
In the 2011 MEASURE study, we asked two separate questions. First we asked the respondents to identify their sexual orientation.In a separate question we asked them to indicate their gender identity.
The 2011 MEASURE study had nearly twice as many TW in the study compared to the 2008 biological and behavioral surveillance study. Our study found 18.5% of the sample to be TW compared to 9.1 of the 2008 study.It is possible that there are more transgender women in our study because of the explicit inclusion of TW in the eligibility criteria.It is also possible that there appears to be more TW in our study because we measured gender identity separate from sexual orientation, while in the other study TW had to choose between sexual orientation and gender identity.2008 BBSS, only data from San Salvador is represented in this slide – pie chart?-In SM an additional 26 TW and 166 MSM participated; weighted percent in SM of TW was 12.1%; 93 TW total
There is a possibility that if a transgender woman had to choose between identifying as being heterosexual or as transgender we would have inflated the percentage of MSM considered to be heterosexual.Why important? Heterosexual MSM are considered to be hardest to reach and bridge population.
Wewerealsoabletoseedifferences in characteristics of thestudypopulationbygenderidentity.For example more MSM had medical insurance and a regular healthcareprovidercomparedtotransgenderwomen.Menos de un cuarto (menos de 25%) reportaron tener un seguro medico o proveedor regular de salud.Mas HSH tienen seguro medico y un proveedor regular que MTNota: Definición de proveedor regular – Usted tiene un médico u otro profesional de salud a quien acude normalmente cuando está enfermo o necesita cuidado médico
As anotherexampletransgenderwomenwere more likelytoreportexperiencingdiscrimanationfrom a healthcareprovidercomparedto MSM.For example 74% of TW reportedbeingrefusedhealthservicesbecause of genderidentityor sexual orientationcomparedto 55% of MSM Lamayoria de los HSH y mujeres trans experimentaron discriminación de parte de un proveedor de salud. Por ejemplo 55% fueron tratado con menos respeto por un proveedor alguna vez.59% recibio peor calidad de servicios por ser HSH/mujer transLe negaron servicios a 58% Y 58% sintio que era necesario decirle al proveedor que era heterosexual.54.4% reporto altos niveles de discriminación por parte del proveedorMT reportan MAS discriminacion por parte de un proveedor de salud HSH
We also see differences in social vulnerability between the two groups. MSM were more likely to report having been homeless in the 6 months prior to the study compared to TWWhereas, TW were more likely to report having been incarcerated or to have engaged in sex work than MSM
Surprisingly there was no difference between MSM and TW in the percentage who reported experiencing abuse or maltreatment in the past 12 months.We hypothesized that more TW women would have reported experiencing maltreatment or abuse because their stigma is generally more visible. These results may indicate that stigma takes many forms and can be equally detrimental to both groups.Nota – no hay unadiferencia entre experincias de abuso y maltrato en los ultimos 12 meses entre HSH y mujeres trans)
Increased risk due to transmission probability and contact rate.-generalized epidemic – national prevalence is above 1%-concentrated, national prevalence is below 1% but above 5% in higher risk populations-low level, mixed above 1%, but not too high, and above 5% in higher risk groups (Caribbean)
-Developed as a mechanism to obtain population-based generalizable estimates of surveillance for HIV/STI
Median network size – 10 (1-350)
La mayoria se identifico como hombre, pero casi 20% se auto-identifico como mujer transgenero.En cuanto a orientacion sexual, 38% son hombres gay u homosexual. 44% son Hombres bisexuales o heterosexuales. 14% son mujeres trans que se identifican como heterosexual y 4% son mujeres trans que se identifican como gay o bisexual.Casi 69% tienen una pareja hombre o una pareja trans
Measuring Ethnic and Sexual Identities: Lessons from Two Studies in Central America
Measuring Ethnic and Sexual IdentitiesLessons from two studies in Central America
Session ObjectivesAfter the presentations, participants will be able to: Give examples of ethnic and sexual identity-related questions from two recent studies Relate how these constructs were central to the research questions Highlight implications for the studies‟ findings Apply lessons learned to other research efforts
Ethnicity and HIV Risk Factors in Guatemala:Measuring indigenous identity and its effects
Study Overview Indigenous Guatemalans are highly disadvantaged on many measures of health and well-being – are they also at higher risk for HIV? Secondary analysis of the ENSMI (DHS) women‟s and men‟s datasets from 2008-09 Multivariate logistic regression for different ethnic groups on 5 factors (early sexual debut, lifetime sexual partners, HIV knowledge, HIV testing, sex worker patronage)http://www.cpc.unc.edu/measure/publications/tr-12-86
Ethnicity in Guatemala The government of Guatemala recognizes four pueblos: Ladino, Maya, Xinca and Garífuna Around 60% of the population is ladino; the other three groups are officially designated as indigenous Mayans constitute 99% of the indigenous population Twenty-three linguistically distinct Mayan subgroups are centered in the country‟s rural western highlands
Who is indigenous, who is ladino? Ethnicity is mutable and multidimensional, but most surveys use a single categorical variable to measure it ENSMI and the national census have long histories of obtaining data on ethnicity via „interviewer‟s observation‟ In 2008-09, an ethnic self-identity question was added:“Do you consider yourself to be indigenous, ladino, or some other ethnicity?”
Ethnicity in the 2008-09 ENSMI Men Women 4% 3% 37% 44% 44% 47% 8% 13% Indigenous Cross-Identified* Ladino Other/No Response*Respondents who self-identified as indigenous but were identified by the interviewer as ladino
Long histories and broad ramifications In 1950, census enumerators classified 4% of locally- identified indigenous Guatemalans as ladino; in 1964, 16% were cross-classified (Early, 1974) A 1998 study in Brazil concluded that previous studies had underestimated the country‟s racial inequality, because they relied on self-classification (Telles & Lim) Cause of death affects coroners‟ classification of US decedents‟ race in 1993: “non-racial characteristics thus shape official statistics” (Noymer et. al, 2011)
Why does it matter how we measureethnicity in Guatemala? Different dimensions of ethnic identity might have different effects on HIV risk and other outcomes there The validity and reliability of ethnicity questions, including the two in current use, may vary Conclusions about the size and vulnerability of different groups can affect program and policy decisions The Government of Guatemala officially supports ethnic self-determination
“A dispute over ethnicity marked census-taking day in Bolivia as the landlocked Andean nations population submitted Wednesday to its first national head count in 11 years.”Text: Carlos Valdez for the Associated Press, 2012. Photos: Página Siete, La Razon
“After more than a century, the Census Bureau is dropping its use of the word „Negro‟ to describe black Americans in surveys”Source: Jason Howerton for the Associated Press, 2013
Ethnicity in our analysis Should cross-identified respondents in Guatemala be considered indigenous or ladino? What matters more: ethnic self-identity or the interviewer‟s observation? Regardless of how its members were identified, the indigenous group had lower adjusted odds of sexual risk, comprehensive knowledge and HIV testing But these results obscured the profile of cross-identified respondents, a group with unique potential to explain possible measurement effects
Three categories instead of two Self- InterviewerCategories identification ObservationIndigenous Indigenous IndigenousCross-identified Indigenous LadinoLadino Ladino Ladino
Illustrative Adjusted Odds Ratios of HIV risk by Ethnicity WOMEN MEN Adjusted OR Adjusted OR Ever tested for HIV Indigenous Reference Reference Cross-identified 2.46 (1.93-3.13)*** 1.18 (0.64-2.16) Ladino 2.25 (1.98-3.03)*** 1.57 (0.95-2.59)* Comprehensive HIV Knowledge Indigenous Reference Reference Cross-identified 1.17 (0.95-1.43) 1.46 (0.97-2.22)* Ladino 1.63 (1.40-1.89)*** 1.58 (1.27-1.97)*** *p<0.10; **p<0.05; ***p<0.001 ^Adjusted for age, education, marital status, household wealth quintile, urban/rural residence, geographic region of residence
“The strength of relationship betweenethnicity and health outcomesappears influenced by „acculturation,‟the extent to which members of anethnic group have adopted the beliefsand practices of another group.”(Ford and Kelly, 2005)
Conclusions Guatemalans construct ethnic self-identities that aren‟t reliably predicted by the “interviewer‟s observation,” but both may reflect useful concepts for health research Using an ethnic self-identity measure could increase the estimated size of the indigenous population in Guatemala by as much as 13% Ethnic self-identification has clear potential to increase estimates of HIV risk in the indigenous population, because of acculturation among the cross-identified
Conclusions (cont.) The choice of measure could also have profound implications for analyses gauging ethnic disparities on other health outcomes If the cross-identified population grows, these measurement effects would be even more substantial Researchers should consider investing in formative research for question design, and engage indigenous communities in these efforts
Next Steps Guatemala‟s Presidential Commission against Indigenous Racism and Discrimination is holding high-level meetings to discuss the findings of the study and implications for measuring ethnicity in national studies Both categorical ethnicity measures as well as ethnic markers (language, traditional dress), will likely be included in the 2013 ENSMI Analysis of these data could identify the questions or question sets with the highest construct validity, and that best distinguish population groups on health outcomes
Health Service Utilization among Men Who Have Sex with Men and Transgender Women in El Salvador: Using gender identity andsexual orientation as distinct constructs
Evolution of Public Health Approachto Sexual Minorities Homosexuality classified as a mental disorder in the DSM until 1973. Specific health needs of sexual minorities largely unexplored until the HIV epidemic in mid-1980s. Increased vulnerability to HIV led to a focus on gay men as a “risk group,” increasing stigma, both for these groups and people living with HIV. Movement to focus on behavior that increased transmission risk for HIV, i.e. “MSM - men who have sex with men.”
Diversity among Sexual Minorities MSM MSM is a population that has emerged from HIV research and practice (1992)1 Defines the population based on a high-risk sexual behavior vs. sexual orientation (homosexual, gay, bisexual, heterosexual) Allows for inclusion of men who do not identify as gay/homosexual and have sex with other men. Examples include: gay-identified men, heterosexual men who have sex with other men, bisexual men, male sex workers (regardless of their sexual orientation)
Diversity among Sexual Minorities Transgender A transgender (trans) person is someone whose gender identity differs from their biological sex (assigned to them at birth) Gender: What society believes about the appropriate roles, duties, rights, responsibilities, accepted behaviors, opportunities and status of men and women, in relation to one another Gender-identity is a personal sense of being a man, woman or something different, regardless of their sexual orientation Transgender women is a common term for people born biologically male with female identification or expression
Study Overview USAID‟s Central American Regional HIV Program requested that MEASURE conduct a study of health service utilization among MSM in San Salvador to inform HIV prevention programming
Challenge Do we include or exclude TW from our study? Local TW groups strongly advocated to not be considered as MSM, but they wanted data about their population Did not have sufficient funding for a TW-specific study
How to include MSM and TW as part ofthe study population? Representation in the Measuring constructs study population: accurately: Outreach to/input from TW Outreach to/input from TW organizations, field team organizations, field team Inclusive eligibility criteria Separate gender identity and questions and sexual orientation TW as part of interviewer measures team Inclusion of TW seed
Reframing study eligibility criteria 2008 Biological and behavioral surveillance study A man who had anal sex with another man in the last 12 months 2011 Health Service Utilization study A man or transgender woman who had anal sex (receptive or penetrative) with another man or transgender woman in the last 12 months
Questions inclusive of TWEXAMPLES: The last time you had an HIV test, did the provider have sufficient knowledge about the health needs of men who have sex with men or transgender women? Approximately how many people know that you form sexual relationships with men or transgender women?
Gender Identity: Sexual OrientationPersonal sense ofbeing a man or awoman orsomething different ≠ One‟s erotic and emotional attraction to another • Man • Gay/Homosexual • Woman • Bisexual • Trans Woman • Heterosexual • Trans Man • Others • Others
EL SALVADOR Biological and BehavioralSurveillance Study 2008Sexually, how do you identify yourself? 1 = Heterosexual 2 = Bisexual Sexual Orientation 3 = Gay/Homosexual 4 = Transvestite 5 = Transsexual Gender Identity 6 = Transgender 7 = Other
Separating Sexual Orientation andGender Identity Sexual Orientation Gender identity In terms of your sexual What is your gender orientation, how do you identify? (read responses) identify? Man Gay / homosexual Woman Bisexual Transgender woman Heterosexual Other ________________ Other _______________
Representation of TW in 2008 BBSScompared to 2011 HSU study 2008 BBSS 2011 HSU study 91.0% 81.5% 18.5% 9.1% Percent of sample population Percent of sample population TW, n=67 MSM, n=508 TW, n=164 MSM, n=506
Sexual orientation by gender identity MSM TWGay/homosexual Bisexual Heterosexual Gay/homosexual Bisexual Heterosexual 52.0% 81.1% 43.2% 4.7% 11.1% 7.8% Sexual orientation Sexual orientation
Medical insurance and regular healthcare provider, by gender identity MSM (n=506) 25% 27% Trans women (n=164) 14% 10% Medical insurance Regular health care provider
Experiences of discrimination by a healthcare provider for being MSM or a transwoman (n=669) 71% 76% 74% 69% 52% 56% 55% 55% Treated with less Received poorer Refused services ** Needed to act more respect** quality of services** masculine* MSM Trans women
Social vulnerability by gender identity 53.4% 28.6% 24.9% 29.0% 15.6% 12.5% Homelessness** Incarceration* Sex work** MSM TW
Abuse and maltreatment due to sexual orientation Maltreatment and abuse was defined as, hitting, punching, k icking, threats, scoldin g or humiliations 21% 21% MSM (n=506) TW (n=164)Victim of abuse of maltreatment due to sexual orientation
Conclusions Framing of eligibility criteria, composition of field team, and diversity in seeds for RDS, can achieve a larger proportion of TW as part of MSM studies Distinguishing between gender identity and sexual orientation as separate constructs is a more accurate measurement technique, and allowed for a more nuanced understanding of the needs of each subgroup.
Works cited1. Beyrer, C. Baral, S. van Griensve, F. et al. (2012). Global epidemiology of HIV infection in men who have sex with men. Lancet. Vol. 380: 367- 377.2. Baral SD, Poteat T, Stromdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013,13:214-222.3. Minesterio de Salud Pulica y Asistencia Social, Universidad de Valle, y Centros para la Prevencion y Control de Enfermedades. Encuesta Centroamericana de Vigilancia de Compartamiento Sexual y Prevalencia de VIH/ITS en Poblaciones Vulnerables, El Salvador. In; 2009.4. Joing United Nations Programme on HIV/AIDS; Country Fact Sheet, El Salvador, 2009.
Special thanks to USAID Guatemala and the USAID Central America Regional HIV/AIDS Program for providing the support that made this work possible!MEASURE Evaluation is a MEASURE project funded by the U.S. Agencyfor International Development and implemented by the Carolina PopulationCenter at the University of North Carolina at Chapel Hill in partnership withFutures Group International, ICF Macro, John Snow, Inc., ManagementSciences for Health, and Tulane University. Views expressed in thispresentation do not necessarily reflect the views of USAID or the U.S.Government. MEASURE Evaluation is the USAID Global Health Bureausprimary vehicle for supporting improvements in monitoring and evaluationin population, health and nutrition worldwide.Visit us online at http://www.cpc.unc.edu/measure.
Increased Risk for HIV among MSM & TW Disproportionate burden of HIV among men who have sex with men (MSM) and transgender women (TW) in both generalized and concentrated epidemic settings. Globally, the prevalence of HIV among MSM is estimated to be between 14-18%1 , and 19.1% among TW2. In San Salvador HIV prevalence among MSM is estimated at 10.8% among MSM and 9.7%% among TW3, but is only 0.8% for general population of El Salvador5.
NICARAGUA Biological and BehavioralSurveillance Study 2009-2010 Among men who have sex with men there are those who self- identify as gay, bisexual, heterosexual, transvestite, transsexual, transgender. How do you self-identify? 1 = Heterosexual 2 = Bisexual Sexual Orientation 3 = Gay 4 = Homosexual 5 = Transvestite 6 = Transsexual Gender Identity 7 = Transgender 8 = Other
Respondent-Driven Sampling10 A variant of chain referral sampling, wherein peers recruit peers. Designed to reach “hidden” populations that are socially networked. A coupon system is used to link recruits/recruiters, and secondary incentives. Initiated by purposively selected members of the target population, “seeds.” Reduces biases associated with chain-referral methods by limiting the number of coupons per participant, and achieving long recruitment chains that allows the sample to reach “equilibrium.”
Recruitment ChainsN=670 Seed, men Seed, TW Recruit, men Recruit, TWMid November 2011 toMid February 2012
Gender Identity & Sexual Orientation % (IC 95%) Gender Identity Male 81.5 (76.9-85.7) Trans female/Female 18.5 (14.3-23.1) Sexual Orientation Man - Gay / Homosexual 37.9 (32.1-43.4) Man - Bisexual / Heterosexual 43.7 (38.0-50.7) Trans woman - Heterosexual 14.3 (10.5-18.1) Trans woman - Gay / Bisexual 4.1 (2.0-6.0)