Mindfulness, Mental Health, and Violence Exposure Among Transgender Female Sex Workers Living with HIV in the Dominican Republic

Abstract

Purpose:

Mental illness is a significant public health issue among transgender female sex workers (FSW). A variety of factors inform the prevalence of mental illness among transgender FSW, including violence exposure and stigma. Mindfulness, the process of paying attention to the immediate experience with awareness and attentiveness in a nonjudgmental way, has been shown to improve mental health among stigmatized populations, including cisgender FSW living with HIV. This analysis examines the relationship between mindfulness and mental health among transgender FSW living with HIV in the Dominican Republic (DR) and investigates if mindfulness impacts the relationship between violence exposure and mental health.

Methods:

One hundred transgender FSW living with HIV participated in a cross-sectional survey in Santo Domingo, DR, in 2019. We conducted multivariate linear regressions to assess the relationship between mindfulness and anxiety and depression, respectively, adjusting for covariates. We also conducted multivariate linear regression for the impact of violence exposure (a three-class latent variable) on each outcome, moderating for mindfulness and adjusting for covariates.

Results:

Mindfulness was associated with lower depression and anxiety scores and moderated the relationship between violence exposure and depression, but only for those in the mid-level violence exposure class.

Conclusion:

This formative work creates a strong foundation for future implementation and evaluation of mindfulness-based interventions with this population to address their mental health needs. Future research should examine the relationships between mindfulness, social support, social cohesion, and social change.

Introduction

Mental health is a significant public health issue among transgender women globally. Adult transgender women in the United States had 3 times higher lifetime prevalence of depression compared to the general population and 7–10 times higher prevalence of suicide plans and attempts. ¹ In low- and middle-income countries (LMICs), reported lifetime suicide attempts by transgender women ranged from 41.7% to 52.2%. ² Female sex workers (FSW) also experience a high burden of mental illness compared to the general population. In a prior systematic review in LMICs, FSW were found to have a prevalence of 41.8% for depression, 21.0% for anxiety, and 40.8% for psychological distress. ³

In the Dominican Republic (DR), one study found that 73.6% of transgender FSW reported feeling sometimes or always depressed in the past 6 months and 22.5% had attempted suicide. ⁴ Another study reported 34.0% of transgender FSW had borderline abnormal or abnormal anxiety. ⁵ A variety of factors inform the prevalence of mental illness among transgender FSW, including violence exposure, stigma, and substance use.^2–4,6–11

Research shows that mindfulness, the process of paying attention with awareness and attentiveness to the immediate experience in a nonjudgmental way,^12,13 improves mental health outcomes for a variety of populations, including those facing systemic stigma.^14–20 Through mindfulness-based interventions (MBIs), changes can occur regarding emotion regulation, attention control, acceptance, self-referential processing, positive reappraisal, and self-awareness, which may interrupt the pathway from stigma and stress to mental illness.^16,20–22 Among cisgender FSW living with HIV in the DR, for example, mindfulness significantly reduced the odds of having moderate-to-severe depression and anxiety. ²³

This article builds on the work of Kerrigan et al. with cisgender FSW living with HIV in the DR ²³ to examine the relationship between mindfulness and mental health among transgender FSW living with HIV in the DR and expands to further investigate how mindfulness impacts the relationship between violence exposure and mental health for this population. We hypothesize that (1) mindfulness will be associated with lower levels of depression and anxiety for transgender FSW living with HIV and (2) mindfulness will significantly decrease the negative impact of violence exposure on anxiety and depression for this population.

Methods

Ethical review

The Institutional Review Boards (IRB) of the Johns Hopkins University (JHU) and the Instituto Dermatológico y Cirugía de Piel (IDCP) approved this study. The George Washington University IRB deferred to the JHU IRB.

Study design and recruitment

One hundred transgender FSW participated in a cross-sectional survey in Santo Domingo, DR, in 2019. They provided verbal consent and completed an interviewer-administered survey in Spanish at the IDCP. Additional details on recruitment and data collection are published elsewhere.^7,24

Measures

Mindfulness

Mindfulness was measured using the Cognitive and Affective Mindfulness Scale–Revised (CAMS-R), a 10-item measure with a range of 10–40. ²⁵ An example of an item from the CAMS-R is “I can accept things I cannot change: Rarely/Not at all; Sometimes; Often; or Almost Always.” The variable was included as a summative score with a higher score representing a greater level of mindfulness. The measure had a Cronbach’s α of 0.84.

Mental health

Depression was measured using the Patient Health Questionnaire-9 (PHQ-9), a nine-item scale related to the previous 2 weeks with a range of 0–27. ²⁶ An example of an item from the PHQ-9 is “Over the last 2 weeks, how often have you been bothered by any of the following problems? Feeling down, depressed, or hopeless.” The variable was included as a summative score with a higher score representing a greater level of depressive symptoms. The measure had a Cronbach’s α of 0.85. Anxiety was measured using the anxiety module of the Hospital Anxiety and Depression Scale (HADS-A), a seven-item scale related to the previous week with a range of 0–21. ²⁷ An example of an item from the HADS-A is “I feel restless as I have to be on the move.” The variable was included as a summative score with a higher score representing a greater level of anxiety symptoms. The measure had a Cronbach’s α of 0.85.

Violence exposure

Based on a latent class analysis of violence exposure among this sample of transgender FSW, ⁵ we included the identified violence exposure classes: low reported violence exposure, sex work-related police harassment, and sex work-related violence and harassment.

Sociodemographic and behavioral characteristics

We measured age in years. Educational attainment was based on whether the participant completed high school or higher versus primary school only. Relationship status was based on whether the participant was currently partnered (married or living together as if married) or not partnered (single, divorced, or widowed). Average monthly income included all revenue sources during the past 6 months (presented as DR pesos/1000). We assessed alcohol use disorder (AUD) ²⁸ based on three questions on the frequency of drinking alcohol per week, the number of drinks consumed per event, and the frequency of consuming six or more drinks at a time ²⁹ ; these comprise a 15-point scale where those with a score of 0–2 were coded as “Not at risk for AUD” and those with a score of 3 or higher were coded as “At risk for AUD.” We assessed illicit drug use based on whether the participant reported any marijuana, crack, cocaine, heroin, ecstasy, and/or other drugs use in the past 6 months versus not at all.

Stigmatization

We used an 11-item adapted version of the Transgender Identity Stigma Scale ³⁰ to make it culturally relevant and specific to the DR; an example of an item from the scale is “How often has your family not accepted you because of your transgender identity? Never; Once or twice; A few times; or Many times.” This summative score had a range of 11–44 and a Cronbach’s α of 0.81. We measured internalized HIV stigma using a 10-item scale with a range of 10–30 based on the Berger HIV Stigma Scale; an example item from the scale is “Having HIV makes me feel like a bad person: Agree, Disagree, or Strongly Disagree.” ³¹ The summative scale had a Cronbach’s α of 0.83.

Four domains of sex work-related stigma were included from the Experiences of Sex Work Stigma (ESWS) scale; context-specific domain scores were created using item response theory methods, which are detailed in the original paper by Kerrigan et al. ³² The domains are as follows: treatment (12 items; example item: “When thinking about the last 6 months, have people around you done the following things because of your sex work. Please tell me if it is something that has been done to you ALWAYS, SOMETIMES, or NEVER: Distanced themselves from you”; Cronbach’s α: 0.82), silence (eight items; example item: “Thinking about the last 6 months, I would like to know if it is something that you have done ALWAYS, SOMETIMES, or NEVER: You have done everything you can to keep sex work a secret”; Cronbach’s α: 0.91), shame (six items; example item: “Thinking about the last 6 months, I would like to know if you have ever felt like this ALWAYS, SOMETIMES or NEVER: Excluded”; Cronbach’s α: 0.77), and dignity (six items; example item: “Thinking about the last 6 months, I would like to know if you have ever felt like this ALWAYS, SOMETIMES or NEVER: Proud”; Cronbach’s α: 0.89).

Analysis

We assessed the distribution of all variables through descriptive statistics. One variable had missing data (educational attainment, n = 1); in order to keep all participants in the analysis, missing data were combined with the reference group category (i.e., primary school or less). We examined multicollinearity among the independent variables; all had variance inflation factor values <10.

We conducted bivariate analyses to identify sociodemographic, behavioral, occupational, and stigmatization factors associated with the two outcomes (depression and anxiety). We considered variables significant at the p ≤ 0.20 level in the bivariate analyses for inclusion in the multivariate models. We then used backward stepwise selection to identify covariates significant at p < 0.05 and included them in the multivariate linear regression models. The final multivariate models assessed the relationship between mindfulness and each outcome, adjusting for the relevant covariates.

Finally, we assessed the role of mindfulness as a moderator of the relationship between violence exposure and depression and anxiety, respectively. We conducted the same multivariate linear regression models for each of the outcomes but included an interaction term for violence exposure class and mindfulness.

We conducted all analyses in StataMP 17. ³³ A p value of <0.05 was used to determine significance for the multivariate regression analyses.

Results

Demographics

Table 1 presents an overview of key demographic characteristics of participants. The mean mindfulness score was 31.19 (range = 18–40). When looking at distribution across the three latent classes for violence exposure, 45% were in the low reported violence exposure class, 37% were in the sex work-related police harassment class, and 18% were in the sex work-related violence and harassment class. The mean anxiety score was 6.00 (range = 0–18), and the mean depression score was 6.53 (range = 0–23).

Table 1.

Sociodemographic and Psychosocial Characteristics of Transgender Female Sex Workers Living with HIV (N = 100)

	Mean (SD) or n (%)
Mindfulness
CAMS-R score	31.19 (5.76)
Mental health
PHQ-9 score	6.53 (5.50)
HADS-A score	6.00 (4.67)
Violence exposure
Violence exposure class
Low reported violence exposure	45 (45%)
Sex work-related police harassment	37 (37%)
Sex work-related violence and harassment	18 (18%)
Sociodemographics
Age	34.08 (9.96)
Education attainment
High school or higher	74 (74%)
Primary school only/missing	26 (26%)
Marital status
Currently partnered	16 (16%)
Not partnered	84 (84%)
Average monthly income (DR pesos/1000)	18.73 (17.01)
Substance use
Alcohol use disorder risk
At risk	77 (77%)
Not at risk	23 (23%)
Illicit drug use in past 6 months
Any	55 (55%)
None	45 (45%)
Stigmatization
Transgender stigma	28.31 (7.54)
Internalized HIV stigma	22.75 (2.82)
Sex work-related stigma
Silence	44.02 (9.70)
Shame	57.82 (8.13)
Treatment	59.92 (4.94)
Dignity	50.23 (8.74)

CAMS-R, Cognitive and Affective Mindfulness Scale–Revised; DR, Dominican Republic; HADS-A, Hospital Anxiety and Depression Scale–Anxiety; PHQ-9, Patient Health Questionnaire; SD, standard deviation.

Bivariate analyses

Table 2 presents the results for all of the bivariate linear regression analyses of the relationship between depression and anxiety, respectively, with each variable. For every point increase in mindfulness score, anxiety (β = −0.48; 95% confidence interval [CI]: −0.61 to −0.35; p < 0.001) and depression (β = −0.54; 95% CI: −0.70 to −0.38; p < 0.001) scores decreased. Violence exposure was associated with higher anxiety (β = 4.58; 95% CI: 2.13–7.02; p < 0.001) and depression (β = 4.94; 95% CI: 2.06–7.83; p < 0.01), but only for those in the sex work-related violence and harassment class compared to those in the low reported violence exposure class.

Table 2.

Bivariate Linear Regression of Sociodemographic and Psychosocial Variables on Mental Health

	Anxiety (HADS-A)		Depression (PHQ-9)
	β; 95% CI	p value	β; 95% CI	p value
Mindfulness (CAMS-R)	−0.48; −0.61 to −0.35	<0.001	−0.54; −0.70 to −0.38	<0.001
Violence exposure class (reference low reported)
Sex work-related police harassment	1.44; −0.51 to 3.38	0.146	−0.07; −2.37 to 2.22	0.950
Sex work-related violence and harassment	4.58; 2.13 to 7.02	<0.001	4.94; 2.06 to 7.83	0.001
Age	−0.01; −0.11 to 0.08	0.787	0.02; −0.09 to 0.14	0.658
Marital status (not partnered as reference)	3.13; 0.66 to 5.59	0.013	3.24; 0.32 to 6.16	0.030
Educational attainment (primary school or less as reference)	−1.40; −3.51 to 0.70	0.189	−1.00; −3.49 to 1.49	0.429
Average monthly income	−0.00; −0.06 to 0.05	0.862	−0.06; −0.13 to 0.00	0.057
Alcohol use disorder (not at risk as reference)	1.19; −1.02 to 3.39	0.288	0.52; −2.09 to 3.12	0.694
Illicit drug use (none as reference)	2.26; 0.44 to 4.08	0.015	1.65; −0.53 to 3.83	0.136
Transgender stigma	0.17; 0.05 to 0.29	0.007	0.17; 0.03 to 0.31	0.019
Internalized HIV stigma	0.16; −0.18 to 0.49	0.354	0.29; −0.10 to 0.68	0.141
Sex work-related stigma
Silence	−0.03; −0.13 to 0.06	0.494	0.03; −0.09 to 0.14	0.624
Shame	0.25; 0.15 to 0.36	<0.001	0.30; 0.18 to 0.42	<0.001
Treatment	0.36; 0.18 to 0.53	<0.001	0.40; 0.19 to 0.61	<0.001
Dignity	−0.09; −0.19 to 0.02	0.104	−0.11; −0.23 to 0.01	0.082

Bolded values denote variables with a p value ≤0.20; these were considered for inclusion in the multivariate models. CI, confidence interval.

Multivariate linear regression of mindfulness on mental health

Increases in mindfulness score were associated with a decreased anxiety score (β = −0.38; 95% CI: −0.51 to −0.24; p < 0.001), adjusting for ESWS-Shame, illicit drug use in the past 6 months, and relationship status. Increases in mindfulness score were also associated with a decreased depression score (β = −0.40; 95% CI: −0.57 to −0.23; p < 0.001), adjusting for ESWS-Shame, relationship status, and violence exposure. See Table 3 for full results.

Table 3.

Multivariate Linear Regression of Mindfulness on Mental Health

	Anxiety (HADS-A)		Depression (PHQ-9)
	β; 95% CI	p value	β; 95% CI	p value
Mindfulness (CAMS-R)	−0.38; −0.51 to −0.24	<0.001	−0.40; −0.57 to −0.23	<0.001
Sex work-related stigma: Shame	0.12; 0.02 to 0.22	0.015	0.15; 0.02 to 0.27	0.025
Illicit drug use (none as reference)	2.12; 0.73 to 3.51	0.003	N/A
Marital status (not partnered as reference)	2.31; 0.40 to 4.22	0.018	2.21; −0.17 to 4.60	0.069
Violence exposure class (low reported as reference)
Sex work-related police harassment	N/A		−1.20; −3.15 to 0.75	0.226
Sex work-related violence and harassment	N/A		1.37; −1.31 to 4.05	0.311

Bolded values denote variables with a p value <0.05; these results were considered statistically significant. N/A, not applicable.

Multivariate regression of violence exposure on mental health with mindfulness as moderator

Mindfulness only reduced the impact of violence exposure on depression score for those in the sex work-related police harassment class, compared to those in the low reported violence exposure class (β = −0.55; 95% CI: −0.90 to −0.20; p < 0.01). See Table 4 for full results.

Table 4.

Multivariate Linear Regression of Violence Exposure on Mental Health with Mindfulness as a Moderator

	Anxiety (HADS-A)		Depression (PHQ-9)
	β; 95% CI	p value	β; 95% CI	p value
Mindfulness (CAMS-R)	−0.31; −0.51 to −0.10	0.003	−0.16; −0.40 to 0.07	0.175
Violence exposure class (low reported as reference)
Sex work-related police harassment	4.68; −4.83 to 14.19	0.331	16.19; 4.91 to 27.49	0.005
Sex work-related violence and harassment	3.54; −6.44 to 13.53	0.482	7.97; −3.87 to 19.81	0.185
Interaction term
Mindfulness × sex work-related police harassment	−0.13; −0.43 to 0.16	0.378	−0.55; −0.90 to −0.20	0.003
Mindfulness × sex work-related violence and harassment	−0.06; −0.40 to 0.27	0.698	−0.20; −0.59 to 0.19	0.312
Sex work-related stigma: Shame	0.10; −0.01 to 0.20	0.062	0.16; 0.04 to 0.28	0.012
Illicit drug use (none as reference)	2.09; 0.69 to 3.50	0.004	N/A
Marital status (not partnered as reference)	2.12; 0.17 to 4.07	0.121	1.89; −0.42 to 4.19	0.107

Bolded values denote variables with a p value <0.05; these results were considered statistically significant.

Discussion

We examined the relationship between mental health, mindfulness, and violence exposure among transgender FSW living with HIV in the DR. Our first hypothesis is supported, while the second hypothesis is only partially supported.

Higher mindfulness scores were associated with reduced levels of anxiety and depression among this sample of transgender FSW living with HIV. These findings mirror similar research conducted with cisgender FSW living with HIV, which found a nearly 20% decrease in the odds of both moderate-to-severe depression and anxiety for each unit increase in mindfulness. ²³ One explanation for this association is that mindfulness can disrupt the pathway from chronic stress, which transgender FSWs face due to intersecting forms of oppression and stigmatization related to gender identity, HIV status, and sex work,^{7,8,24,34–36} to depression and anxiety. Past research shows that mindfulness can reduce rumination and worry related to difficult experiences and emotions, which can increase vulnerability to depression and anxiety, and increase cognitive and emotional flexibility, improving emotional reactivity and behavioral regulation.^22,37–39

The positive association between mindfulness and depression and anxiety is particularly noteworthy given the role mental health plays in addressing other health issues, including the HIV continuum of care. People living with HIV (PLWH) who also experience depression and anxiety have significantly lower retention in care compared to those without depression and anxiety. ⁴⁰ Poor mental health can decrease the intention and capacity of PLWH to engage with HIV-related care, including attending appointments and taking their medication.^23,41–43 In the opposite direction, some transgender women also note that HIV care and mental health care are competing priorities, with the latter being ignored while trying to address the former, resulting in an overall negative impact on their quality of life because they are not treating the whole person. ⁴⁴

FSW face high rates of verbal, physical, and sexual abuse from a variety of perpetrators,^5,36,45–47 which can harm their mental health.^23,45 We hypothesized that mindfulness would moderate the negative impact of violence exposure on both depression and anxiety scores. This was only partially supported. Mindfulness was associated with a significant reduction in the negative impact of violence exposure on participants’ depression scores, but only for participants in the sex work-related police harassment class. The depression score decreased, on average, at a higher rate with the increase in mindfulness for those in the sex work-related police harassment class compared to the low reported violence exposure class.

One explanation of why our hypothesis was only partially supported is that more severe violence exposure may reduce the ability of survivors to engage in mindfulness. A study with survivors of intimate partner violence with post-traumatic stress disorder found that participants struggled to engage in mindfulness because it “heightened their awareness of intense emotions that they had difficulty tolerating.” ⁴⁸ Furthermore, mindfulness can improve emotional regulation, including lowered physiological reactivity to and emotional interference by unpleasant triggers, which is thought to be a key component explaining the positive benefits of mindfulness. ²¹ It may be harder for transgender FSW experiencing more forms of violence from more perpetrators to practice mindfulness due to challenges with emotional regulation.

We also found that shame, a form of internalized sex work-related stigma, was significant in both of the moderated regression analyses; this might be another explanation for the limited impact of mindfulness on both depression and anxiety scores in these models. Internalized shame can involve viewing oneself as inadequate, flawed, or undeserving, which can have numerous negative health outcomes, including psychological health. ¹⁹ A post-hoc test found that shame increased marginally for those in the mid-level exposure class (β = 3.10; 95% CI: −0.18 to 6.38; p < 0.10) and significantly for those in the higher-level exposure class (β = 9.53; 95% CI: 5.41–13.65; p < 0.001), compared to the lower-level exposure class.

Experiencing physical and sexual violence and harassment, particularly from known perpetrators, may increase feelings of shame, which then further impedes the ability of survivors to engage in mindfulness. It is also important to note the bidirectional relationship that exists between shame and mindfulness, as it is also possible that the violence exposure reduces the ability to engage in mindfulness and therefore leads to higher levels of shame.^20,49 Given that this analysis is cross-sectional, we are unable to test the temporal relationship between these variables.

These results suggest that the impact of being in the sex work-related violence and harassment class requires a multifaceted intervention, which may include, but not be limited to, mindfulness training. Future research should also consider the role of social support and cohesion, which suppressed the impact of intimate partner violence on depression among transgender women,^50,51 in conjunction with mindfulness as a way to reduce the impact of violence on mental health. Furthermore, new evidence suggests that MBIs not only have benefits for the individual internally but also increase their ability and willingness to engage with others for prosocial shifts. ⁵² Mindfulness interventions might be able to both increase transgender FSWs’ ability to regulate their emotions in response to violence and harassment and their connection with other FSWs in order to decrease feelings of shame related to their work.

Limitations

This analysis is based on cross-sectional data from a relatively small, nonrepresentative sample. We could not assess when mental health outcomes occurred in relation to one’s use of mindfulness techniques; when violence occurred in relation to mental health outcomes; or when violence occurred in relation to one’s mindfulness practice. Rather than separating individual types of violence from individual perpetrators, this analysis included a more nuanced version of violence exposure that considers patterns of violence reported among this sample. However, participants were assigned to a violence exposure class based on a probability score, which means the participants may not have experienced the types of harassment and violence associated with their assigned class. Finally, this analysis is not an evaluation of an MBI but of the level of mindfulness each participant reported.

Conclusions

Mindfulness was associated with improved mental health outcomes among transgender FSW living with HIV and moderated the negative impact of violence exposure on depression for participants in the sex work-related police harassment class. This formative work creates a strong foundation for future implementation and evaluation of an MBI with this population. These findings support the potential for MBIs to strengthen transgender FSWs’ capacity to manage chronic stress and marginalization in the context of community-driven approaches that also address social–structural determinants. Future research is needed to examine the relationships between mindfulness, social support, social cohesion, and social change.

Authors’ Contributions

B.J.M.: Conceptualization, formal analysis, methodology, visualization, and writing—original draft. Y.D.: Investigation, writing—review and editing, and funding acquisition. M.P. and H.G.: Investigation and writing—review and editing. C.B.: Writing—review and editing and funding acquisition. D.K.: Conceptualization, writing—review and editing, supervision, and funding acquisition.

Abbreviations

AUD

alcohol use disorder

CAMS-R

cognitive and affective mindfulness scale–revised

DR

Dominican Republic

ESWS

experiences of sex work stigma

FSW

female sex worker

HADS-A

hospital anxiety and depression scale-anxiety

IDCP

Instituto Dermatológico y Cirugía de Piel

IRB

institutional review board

JHU

Johns Hopkins University

LMIC

low- and middle income country

MBI

mindfulness-based intervention

PHQ-9

patient health questionnaire

PLWH

people living with HIV

Disclaimer

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the article.

Cite this article as: Maclin BJ, Donastorg Y, Perez M, Gomez H, Barrington C, Kerrigan D (2026) Mindfulness, mental health, and violence exposure among transgender female sex workers living with HIV in the Dominican Republic, Transgender Health 11:3, 206–213, DOI: 10.1177/26884887251365815.