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Published in final edited form as: J Homosex. 2014;61(8):1117–1130. doi: 10.1080/00918369.2014.872502

A Comparison of Mental Health, Substance Use, and Sexual Risk Behaviors Between Rural and Non-Rural Transgender Persons

KEITH J HORVATH 1, ALEX IANTAFFI 2, REBECCA SWINBURNE-ROMINE 3, WALTER BOCKTING 4
PMCID: PMC4301267  NIHMSID: NIHMS649101  PMID: 24380580

Abstract

The aim of this study was to compare the mental health, substance use, and sexual risk behaviors of rural and non-rural transgender persons. Online banner advertisements were used to recruit 1,229 self-identified rural and non-rural transgender adults (18+ years) residing in the United States. Primary findings include significant differences in mental health between rural and non-rural transmen; relatively low levels of binge drinking across groups, although high levels of marijuana use; and high levels of unprotected sex among transwomen. The results confirm that mental and physical health services for transgender persons residing in rural areas are urgently needed.

Keywords: transgender, rural, urban, online survey

The transgender population is a diverse group of individuals who transcend culturally defined categories of gender, and includes transsexuals (who seek medical intervention to feminize or masculinize their body), crossdressers (who wear clothing typically associated with the other sex), drag queens and kings (female and male impersonators), and other gender variant individuals (Bockting, 1999). It has been argued that transgender persons form a unique community with distinct norms and practices that differ from persons identifying as either exclusively male or female (Valentine, 2007). Whether transgender persons live outside the gender binary or transition into female or male identities, their health needs are distinct from persons whose sex assigned at birth aligns with their gender identity (Mayer et al., 2008; Feldman & Bockting, 2003).

Transgender persons have been estimated to comprise about 0.2% of the U.S. population overall (Mathy, 2002), but they carry a disproportionate burden of heath disparities that include both physical and mental health problems (Bauer, Travers, Scanlon, & Coleman, 2012; Committee on Lesbian Gay Bisexual and Transgender Health Issues and Research Gaps and Opportunities, Board on the Health of Select Populations, & Institute of Medicine, 2011; Nuttbrock et al., 2012). A recent review of transgender persons in the United States found that approximately 28% were infected with HIV and 21% were infected with other sexually transmitted infections, with highest infection rates among transgender women of color (Herbst et al., 2008). Another study showed that nearly 52% of transgender persons (compared to 22% of non-transgender persons) living in Los Angeles reported HIV infection, with highest rates among Black participants (Edwards, Fisher, & Reynolds, 2007). In addition, studies of transgender samples show high rates of depression (44%), anxiety (33%; Bockting et al., 2013), alcohol use (Operario, Nemoto, Iwamoto, & Moore, 2011; Ramirez-Valles, Garcia, Campbell, Diaz, & Heckathorn, 2008), attempted suicide (Liu & Mustanski, 2012), and illicit drug (27%) and hormone (34%) use (Herbst et al., 2008). Despite the clear need to address the concerns facing transgender persons, many of the needed services are not available either because of lack of resources or stigma and discrimination (Grant, Mottet, Tanis, Herman, Harrison, & Keisling, 2011).

Environmental circumstances, including place of residency, are recognized as important determinants that affect the health of groups and individuals (Jackson, 2003). Of particular concern may be availability of services and qualified providers in rural communities. Studies show that rural communities may not be well equipped to meet the needs of under-served individuals, resulting in higher mental and physical health disparities for persons residing in less populated areas compared to those in urban communities (Chu & Selwyn, 2008; Leira, Hess, Torner, & Adams, 2008; Thorpe, Van Houtven, Sleath, & Thorpe, 2010). A study of HIV service utilization by people living with HIV in different-sized communities showed that rural residents were less likely to attend four or more health care appointments per year and less likely to receive antiretroviral medication for HIV infection if they were Black (Wilson et al., 2011). Similarly, the availability of providers to manage testosterone therapy among transgender patients may be particularly sparse in rural areas; this is problematic since at least one study showed that transgender persons receiving testosterone therapy reported significantly higher quality of life than those who were not receiving such services (Newfield, Hart, Dibble, & Kohler, 2006).

Studies of transgender persons residing in urban areas show high rates of health care utilization. In a recent study of male-to-female transgender persons, 77% of participants had health care insurance, and 81% had seen a primary care doctor in the past year, with these factors associated with reductions in several high-risk behaviors (Sanchez, Sanchez, & Danoff, 2009). In comparison, little research to date has been conducted to document the experiences of rural transgender persons; however, small qualitative studies show that lesbian, gay, bisexual, and transgender (LGBT) populations in rural settings have distinct health needs. In addition to lack of health care resources, poor transportation infrastructure is a structural barrier to the provision of services in rural areas, while lack of community and a hostile social climate emerge as social barriers among rural LGBT populations in the United States (Oswald & Culton, 2003; Willging, Salvador, & Kano, 2006; Drumheller & McQuay, 2010; King & Dabelko-Schoeny, 2009). Although not all of the studies included transgender participants, it is reasonable to anticipate that transgender persons in rural settings face similar challenges. Moreover, a study of 20 mental health providers in New Mexico showed that most believed that there is no difference in their work with LGBT and non-LGBT clients (Willging, Salvador, & Kano, 2006). The authors of this study suggest that this “therapeutic neutrality” may impede effective service delivery for LGBT individuals residing in rural areas.

Despite the potentially high burden of mental and physical problems facing transgender persons in rural settings, most studies of transgender individuals have been conducted in U.S. urban population centers with relatively large concentrations of transgender individuals. To date, no studies have compared the sexual, mental health, and substance use profiles of transgender persons residing in rural areas to those residing in non-rural areas. Given the considerable health disparities faced by transgender persons, there is an urgent need for a greater understanding of the needs of transgender persons living in the rural United States. The overall aim of this article is to address this gap in understanding to begin to identify what resources are most urgently needed for transgender persons residing in the rural United States.

METHODS

Recruitment and Participants

Data for the current study were collected as part of a larger investigation of the influence of gender on HIV risk among the U.S. transgender population. Participants were recruited using banner advertisements on transgender community Web sites and messages posted to online mailing lists, journals, and forums. To be eligible for the study, persons must have self-identified as transgender (defined as transsexual, crossdresser/transvestite, drag queen/king, or other transgender), be 18 years of age or older, and have lived in the United States at the time the survey was completed. To be inclusive and obtain diversity in transgender identities, sampling was stratified by setting an enrollment quota for each type of transgender identity. This resulted in a large convenience sample of 1,229 participants. The demographics of this sample compared to the U.S. census data indicated a wide geographic distribution across the country that largely approximated the relative general population size; as a group, participants were younger, more likely to identify as White (non-Hispanic) or multiracial (less likely as Black or Hispanic), more educated but reporting less household income, more likely to be single, and less likely to live in metropolitan areas (see Rosser, Oakes, Bockting, & Miner, 2007).

Measures

Measures used in this analysis included demographics, substance use, mental health variables, and sexual risk behaviors. The demographic variables were age, race (White vs. non-White), ethnicity (Hispanic vs. non-Hispanic), education (high school or less, some college, or college degree or more), relationship status (currently in marriage or civil union, previously married, and never married), and poverty defined as having an income of less than twice the 2003 poverty level based on family size.

Substance use variables included two dichotomous drug use variables (any use of marijuana during previous 3 months and any use of illegal drugs other than marijuana over past 3 months), as well two dichotomous alcohol use variables (regular heavy alcohol use over past 3 months and binge drinking during last 30 days). Consistent with National Institute on Alcohol Abuse and Alcoholism (NIAAA, National Institute on Alcohol Abuse and Alcoholism, 2012) guidelines, regular heavy drinking was defined as more than four drinks a day or more than 14 drinks a week for individuals born with male anatomy and as more than three drinks a day or more than seven drinks a week for individuals born with female anatomy. Binge drinking, as suggested by the NIAAA, was defined as more than five drinks per day for those born with male anatomy and more than four drinks per day for those born with female anatomy.

Mental health variables included a dichotomous item indicating whether the respondent had ever attempted suicide, as well as overall and scale scores from the Brief Symptom Inventory (BSI 18, Derogatis, 1993; α = .94). Scale scores included measures of anxiety (α = .89), depression (α = .92), and somatization (α = .82), with higher scores indicating a greater number of endorsed symptoms. The Rosenberg Self-Esteem Scale was also included as a mental health variable (Crandal, 1973; α = .93).

Sexual behaviors assessed for the purposes of this study include the presence or absence of unprotected intercourse with a primary partner or with a non-primary partner in the past three months. Intercourse was defined as penis-anus or penis-vagina penetration and must have included a penis or vagina with which the participant was born or a penis or vagina that was surgically constructed. In addition, the presence or absence of unprotected intercourse with any partner was calculated by summing unprotected intercourse with primary and non-primary partners.

Procedures

All study procedures were approved by the University of Minnesota Institutional Review Board. Upon clicking on the Web-based banner advertisement or link embedded in the posted message, the homepage with information about the study opened up. Using the computer interface, participants were screened and informed consent was obtained. Participants then proceeded to take an online survey that took about 50 minutes to complete, for which they were offered a $30 online gift certificate. Of 1,373 surveys received, 1,229 (90%) were deemed complete and from unique individuals (see Miner, Bockting, Swinburne-Romine, & Raman, 2012 for detail on de-duplication and validation protocol).

Participants were categorized as rural or non-rural based on the community description that they selected. Those who identified their community as either rural or small town were classified as “rural,” while those who reported being from city of any size, a large town, or from a suburban area were classified as “non-rural.” Fourteen individuals provided community descriptions that could not be categorized, and they were not included in the analyses.

Analyses

Differences between rural and non-rural transgender groups were calculated separately for transgender women (i.e., male-to-female transgender) and transgender men (i.e., female-to-male transgender). Proportions and means were used to characterize demographic, mental health, substance use, and sexual risk items. A separate set of t tests was run for each block of variables: demographics, mental health, substance use, and sexual risk behavior. Significance level was set at p = .01 to reduce the chance of Type 2 error. Trends are reported below p < .05.

RESULTS

Demographic Characteristics

Differences in demographic characteristics between rural and non-rural transgender groups are shown in Table 1. Among transwomen, the average age was similar for rural (38.7 years) and non-rural (37.3 years) participants, and a similar proportion was single (43% rural vs. 50% non-rural), poor (28% rural vs. 22% non-rural), and HIV-positive (2% rural vs. 4% non-rural). No differences in transgender identities were found among transwomen by rural residency. A significantly lower proportion of rural transwomen was Hispanic (2% rural vs. 6% non-rural) or had a college degree (33% rural vs. 46% non-rural) than non-rural transwomen (p < .01). There was a trend (p < .05) for a higher percentage of rural transwomen to self-report as White (85% rural vs. 78% non-rural) and single (50% rural vs. 43% non-rural).

TABLE 1.

Demographic Characteristics by Residency

Rural
 Non-rural
% N % N t Sig
Transwomen 214 478
Age (Mean, SDa) 38.72 12.78 37.28 12.09 –1.43 .15
White race 85 181 78 372 –2.16 .03
Hispanic/Latino ethnicity 2 4 6 29 2.93 .00
Povertyb 28 59 22 102 –1.66 .10
HIV-positive 2 2 4 12 1.21 .23
% N % N χ 2 Sig
Transgender identity 2.95 .40
Transsexual 37.7 80 41.5 197
Cross-dresser/transvestite 31.1 66 25.1 119
Drag queen 6.6 14 8.0 38
Other male-to-female 24.5 52 25.5 121
Education 11.91 .00
High school or less 18 38 11 54
Some college 50 106 43 206
College degree or higher 33 70 46 218
Relationship status 6.43 .04
Married/Civil Union 35 74 25 121
Widow/Divorce/Separated 23 49 25 118
Single, never married 43 91 50 239
% N % N t Sig
Transmen 130 393
Age (Mean, SDa) 26.22 8.690 26.22 7.143 –0.01 .99
White race 79 103 76 299 –0.74 .46
Hispanic/Latino ethnicity 6 8 6 24 –0.02 .99
Povertyb 46% 58 42 160 –0.86 .39
HIV-positive 0% 0 1 2 .72 .47
% N % N χ 2 Sig
Transgender identity 0.59 .90
Transsexual 50.0 65 49.5 192
Cross-dresser/transvestite 6.2 8 4.6 18
Drag king 9.2 12 10.3 40
Other female-to-male 34.6 45 35.6 138
Education 6.14 .05
High school or less 19 25 11 45
Some college 53 69 53 209
College degree or higher 28 36 35 139
Relationship status 2.64 .27
Married/Civil Union 12 15 7 29
Widow/Divorce/Separated 4 5 6 22
Single, never married 85 110 87 341
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a

Standard deviation

b

Income less than 2× the 2003 HHS guidelines for poverty.

Among transmen, rural and non-rural participants were similar in mean age (both 26.2 years old), and with respect to White race (79% rural vs. 76% non-rural), Hispanic ethnicity (both 6%), the proportion living in poverty (46% rural vs. 42% non-rural), HIV-positive status (0% rural vs. 1% non-rural), transgender identity status, and single relationship status (85% rural vs. 87% non-rural). A trend (p < .05) was found for a smaller percentage of rural transmen holding a college degree than non-rural transmen (28% rural vs, 35% non-rural).

Mental Health

The proportion of participants reporting a prior suicide attempt and mean scores on the BSI Global Severity Index, BSI somatization scale, BSI depression scale, BSI anxiety scale, Rosenberg Self-esteem scales are shown in Table 2. A trend for a higher mean score on the BSI somatization scale was found among rural transwomen compared to non-rural transwomen (p < .05). Otherwise, no differences were found between rural and non-rural transwomen with respect to lifetime suicide attempts, BSI Global Severity Index, BSI depression scores, BSI anxiety scores, or self-esteem.

TABLE 2.

Mental health factors by residency

Rural
 Non-rural
Mental Health Mean SDb Mean SD t Sig
Transwomen
Suicide attempt (Lifetime) 25% n = 49 27% n = 116 –0.40 .69
BSI 18 Global Severity Indexa 18.21 13.47 16.07 14.39 –1.76 .08
BSI 18 Somatizationa 3.90 4.24 3.17 3.81 –2.05 .04
BSI 18 Depressiona 8.22 6.59 7.68 6.15 –0.98 .33
BSI 18 Anxietya 6.09 5.41 5.22 5.37 –1.88 .06
Rosenberg Self-Esteem Scale 5.01 1.45 5.11 1.38 0.81 .42
Transmen
Proportion attempted suicide 38% n = 40 41% n = 145 –0.59 .55
BSI 18 Global Severity Indexa 23.55 16.21 18.42 14.01 –2.94 .00
BSI 18 Somatizationa 5.77 5.08 4.41 4.45 –2.67 .01
BSI 18 Depressiona 9.43 7.14 7.32 5.94 –2.77 .01
BSI 18 Anxietya 8.34 6.58 6.70 5.48 –2.33 .02
Rosenberg Self-Esteem Scale 4.54 1.43 4.95 1.35 2.69 .01
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a

Raw score

b

Standard deviation.

More noticeable differences in mental health items were found between rural and non-rural transmen. Although a similar proportion of rural (38%) and non-rural (41%) transmen reported a prior lifetime suicide attempt, rural transmen reported significantly higher scores on the BSI Global Severity Index, BSI somatization scale, and BSI depression scale (p < .01). In addition, rural transmen reported significantly lower self-esteem than their non-rural counterparts. The difference in BSI anxiety scale was nearly significant as well (p = .02).

Substance Use

Differences in substance use items by residency and stratified by transgender identity are shown in Table 3. Overall, no differences in substance use factors were found between rural and non-rural transwomen or transmen. A relatively small—but concerning—percentage of transwomen reported heavy alcohol use on a regular basis (6% for rural vs. 7% for non-rural), binge drinking (10% for rural vs. 7% for non-rural), and illicit drug use excluding marijuana (8% for rural vs. 9% for non-rural) in the past 3 months. Rates of heavy alcohol use (7% for rural vs. 12% non-rural), binge drinking (10% for rural and non-rural), and non-marijuana drug use (7% for rural vs. 13% for non-rural) were slightly higher among transmen. Reports of marijuana use for both transwomen (15–21%) and transmen (29–32%) were high.

TABLE 3.

Substance use factors (past 3 months) by residency

Rural
 Non-rural
% N % N t Sig
Transwomen 195 434
Regular Heavy Alcohol Use 6 12 7 32 0.56 .58
Binge Alcohol Use 10 19 7 29 –1.25 .21
Marijuana use 15 29 21 89 1.74 .08
Non-Marijuana Drug use 8 16 9 40 0.41 .68
Transmen 110 357
Regular Heavy Alcohol Use 7 8 12 41 1.4 .16
Binge Alcohol Use 10 11 10 35 –0.04 .97
Marijuana use 29 32 32 114 0.56 .58
Non-Marijuana Drug use 7 8 13 46 1.86 .06
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Sexual Risk Behavior

Similar to substance use, no differences were found by residency in sexual risk behavior among transwomen and transmen (Table 4). However, the proportion of unprotected sex with any, primary, and other sexual partners in the past 3 months is noticeably high for rural (42% any; 40% primary; 39% other) and non-rural (45% any; 44% primary; 32% other) transwomen. In comparison, a lower proportion of rural transmen report unprotected sex with any (16%), primary (16%), or other (13%) sexual partners.

TABLE 4.

Sexual risk behaviors (past 3 months) by residency

Rural
 Non-rural
% N % N t Sig
Transwomen
Unprotected sex with Primary partner 40 51 44 108 0.57 .57
Unprotected sex with Other partner 39 27 32 58 –0.92 .36
Unprotected sex with Any partner 42 69 45 155 0.52 .60
Transmen
Unprotected sex with Primary partner 16 13 19 47 0.67 .50
Unprotected sex with Other partner 13 5 19 26 0.79 .43
Unprotected sex with Any partner 16 17 21 66 1.00 .32
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Note: Percentages are based on the number of individuals with partners of the given type.

DISCUSSION

This study is the first study, to the best of our knowledge, to directly compare the mental health, substance use, and sexual risk behaviors of rural and non-rural transwomen and transmen, made possible by the use of the Internet to recruit participants into the study. Primary findings include: (1) significant differences in mental health between rural and non-rural transmen, (2) relatively low levels of binge drinking across groups—however, high levels of marijuana use, and (3) high levels of unprotected sex across all types of sex partners among transwomen. Each of these findings is discussed in greater detail below.

Rural residents face a number of health disparities compared to their non-rural counterparts (Eberhardt & Pamuk, 2004). These disparities may be particularly magnified for LGBT persons, who report high levels of lifetime suicide attempts in this and other studies (for a review, see Horvath, Remafedi, Fisher, & Walrath, 2012). A recent report by the Institute of Medicine (Committee on Lesbian Gay Bisexual and Transgender Health Issues and Research Gaps and Opportunities et al., 2011) reported that LGBT people face barriers to equitable health care that profoundly affect their overall well-being. Understanding outcome disparities, provider attitudes and education, ways in which the care environment can be improved, and the experiences of LGBT individuals seeking care would provide a base from which to address these inequities. (p. S-7)

The results of this study suggest that transmen residing in rural areas may face the greatest barriers to care and are in need of mental health services. Achieving this is particularly difficult since transgender persons are considered a hidden population (Meyer, 2001), and they may be difficult to reach in stigmatizing settings. A possible approach to deliver mental health services to rural or hidden transmen is through the use of telemedicine (Madison et al., 2012). Despite continued concerns over its cost and the benefit of telemedicine approaches over face-to-face approaches, most reviews of telemedicine show that it can be an effective approach to health care delivery (Ekeland, Bowes, & Flottorp, 2010). Regardless of approach, the results of this study support the call for greater research to determine best practices for strengthening health care services for LGBT populations (Committee on Lesbian Gay Bisexual and Transgender Health Issues and Research Gaps and Opportunities et al., 2011) and suggest that this may be particularly urgent with respect to mental health services for rural transmen.

Binge drinking is common in the United States, with one in six adults reporting binge drinking in the previous 30 days and doing so on average 4 times per month (Kanny, Liu, Brewer, Garvin, & Balluz, 2012). In the same report, binge drinking was twice as common in men as women (Kanny et al., 2012). In comparison, binge drinking in the past 30 days was reported by less than 10% of participants, regardless of gender identity (transwomen or transmen) or residency (rural or non-rural). Although reported binge drinking was relatively low in this sample, recent marijuana use was notably high. Nearly one third of rural and non-rural transmen reported marijuana use in the past 30 days, compared to 6% of U.S. adults who reported marijuana use in the past month (SAMHSA, 2008). Differences in substance use rates between rural and urban transgender persons and those found among representative samples of the U.S. population may be due to differences in study design and sampling strategies. However, fully understanding the degree of sampling bias in studies of transgender persons is beyond current sampling techniques (i.e., it is not feasible to generate an accurate sampling frame of transgender persons). An alternative explanation to sampling bias is that transgender populations have substance use norms that are more similar to those of men who have sex with men (MSM) than the general population. A probability sample of MSM residing in four cities showed that 19% of men reported frequent drug use and 9% reported heavy-frequent alcohol use (Stall et al., 2001), which is similar to findings reported in this study of transgender persons. These results add to the mounting evidence that transgender persons have unique norms and risks, and services will need to be tailored to meet the needs of this population.

Similar to prior studies (Edwards et al., 2007; Grant et al., 2011), this sample of transwomen appear to be at substantial risk for HIV infection. It is noteworthy that rural transwomen had equivalent levels of sexual risk behavior as non-rural transwomen, who may have greater access to sex partners. These results suggest that transwomen, regardless of residency, are in urgent need of HIV risk reduction services. However, while such services may be available in large population centers, they are likely less available in rural areas. A possible solution to delivering HIV prevention services to rural transwomen is through the use of technology, including Internet and mobile devices. However, a recent analysis of transgender-related Web pages showed very few Web pages that contained intervention services for transgender persons (Horvath, Iantaffi, Grey, & Bockting, 2012). Technology-based approaches to reducing sexual risk behavior among LGBT populations are promising (Noar, Black, & Pierce, 2009); however, studies are needed to assess their efficacy among rural transgender populations.

This study is limited in several ways. First, participants were recruited using a convenience sampling strategy via the Internet. Therefore, the results are not generalizable to all transgender persons or transgender persons who do not use the Internet. Second, we did not conduct statistical tests to analyze differences between mental health, substance use, and sexual risk factors between transwomen and transmen. These differences were examined in a prior study (Bockting et al., 2013), and the focus of this article was to explore differences between transgender persons residing in rural and non-rural areas.

Despite these limitations, this study makes an important contribution to the literature by being the first to compare groups of rural and non-rural transgender persons across a number of mental and physical health factors. The results confirm that mental health services are needed in rural areas, particularly for transgender men, and there is an urgent need to target rural transwomen with sexual prevention interventions to reduce their risk for HIV and other sexual transmitted infections. Finally, greater research is needed to understand the interplay and cumulative effect of mental health, substance use, and sexual risk factors on health care utilization among, and overall wellbeing of, rural transgender populations.

Acknowledgments

FUNDING

The authors acknowledge the invaluable input and support from the national Transgender Community Advisory Board of the main study that provided the data on which this report is based. This study was funded by grants from the National Institute on Drug Abuse (Gender Identity and HIV Risk, 1R01DA015269; Walter Bockting, Principal Investigator) and the Eunice Kennedy Shriver National Institute on Child Health and Human Development (Gender Identity and HIV Risk II, 9R01HD057595; Walter Bockting, Principal Investigator).

Contributor Information

KEITH J. HORVATH, Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA.

ALEX IANTAFFI, Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA.

REBECCA SWINBURNE-ROMINE, Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA.

WALTER BOCKTING, School of Nursing & Physicians and Surgeons, Columbia University, New York, New York, USA.

REFERENCES

  1. Bauer G, Travers R, Scanlon K, Coleman TA. High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: A province-wide respondent-driven sampling survey. BMC Public Health. 2012;12:292. doi: 10.1186/1471-2458-12-292. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bockting WO. From construction to context: Gender through the eyes of the transgendered. SIECUS Report. 1999;28(1):3–7. [Google Scholar]
  3. Bockting WO, Miner MH, Swinburne-Romine R, Hamilton A, Coleman E. Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health. 2013;103:943–951. doi: 10.2105/AJPH.2013.301241. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Chu C, Selwyn PA. Current health disparities in HIV/AIDS. AIDS Read. 2008;18(3):144–146. 152–148, C143. [PubMed] [Google Scholar]
  5. Committee on Lesbian Gay Bisexual and Transgender Health Issues and Research Gaps and Opportunities, Board on the Health of Select Populations, & Institute of Medicine . The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. National Academies Press; Washington, DC: 2011. [PubMed] [Google Scholar]
  6. Crandal R. The measurement of self-esteem and related constructs. In: Robinson JP, Shaver PR, editors. Measures of social psychological attitudes. ISR; Ann Arbor, MI: 1973. pp. 80–82. [Google Scholar]
  7. Derogatis LR. Brief Symptom Inventory: Administration, scoring, and procedures manual. NCS Pearson; Minneapolis, MN: 1993. [Google Scholar]
  8. Drumheller K, McQuay B. Living in the buckle: Promoting LGBT outreach services in conservative urban/rural centers. Communication Studies. 2010;61(1):70–86. [Google Scholar]
  9. Eberhardt MS, Pamuk ER. The importance of place of residence: Examining health in rural and nonrural areas. American Journal of Public Health. 2004;94(10):1682–1686. doi: 10.2105/ajph.94.10.1682. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Edwards JW, Fisher DG, Reynolds GL. Male-to-female transgender and transsexual clients of HIV service programs in Los Angeles County, California. American Journal of Public Health. 2007;97(6):1030–1033. doi: 10.2105/AJPH.2006.097717. doi:10.2105/ajph.2006.097717. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Ekeland AG, Bowes A, Flottorp S. Effectiveness of telemedicine: a systematic review of reviews. International Journal of Medical Informatics. 2010;79(11):736–771. doi: 10.1016/j.ijmedinf.2010.08.006. [DOI] [PubMed] [Google Scholar]
  12. Feldman J, Bockting WO. Transgender health. Minnesota Medicine. 2003;86(7):25–32. [PubMed] [Google Scholar]
  13. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: A report of the national transgender discrimination survey. National Center for Transgender Equality and National Gay and Lesbian Task Force; Washington, DC: 2011. [Google Scholar]
  14. Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N, HIV/AIDS Prevention Research Synthesis Team Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior. 2008;12(1):1–17. doi: 10.1007/s10461-007-9299-3. [DOI] [PubMed] [Google Scholar]
  15. Horvath KJ, Iantaffi A, Grey J, Bockting W. A review of the content and format of online transgender-related webpages. Health Communication. 2012;27:457–466. doi: 10.1080/10410236.2011.610256. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Horvath KJ, Remafedi G, Fisher SK, Walrath CM. Addressing suicide and self-harm behaviors among LGBT youth in systems of care. In: Fisher S, Blau GM, Poirier J, editors. Addressing the needs of youth who are LGBT and their families: A system of care approach. Brookes Publishing Company; Baltimore, MD: 2012. [Google Scholar]
  17. Jackson RJ. The impact of the built environment on health: An emerging field. American Journal of Public Health. 2003;93(9):1382–1384. doi: 10.2105/ajph.93.9.1382. doi:10.2105/AJPH.93.9.1382. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Kanny D, Liu Y, Brewer RD, Garvin WS, Balluz L. Vital signs: Binge drinking prevalence, frequency, and intesity among adults—United States, 2010. Morbidity and Mortality Weekly Report. 2012;61(1):14–19. [PubMed] [Google Scholar]
  19. King S, Dabelko-Schoeny H. “Quite frankly, I have doubts about remaining”: Aging-in-place and health care access for rural midlife and older lesbian, gay, and bisexual individuals. Journal of LGBT Health Research. 2009;5(1–2):10–21. [Google Scholar]
  20. Leira EC, Hess DC, Torner JC, Adams HP., Jr. Rural-urban differences in acute stroke management practices: A modifiable disparity. Archives of Neurology. 2008;65(7):887–891. doi: 10.1001/archneur.65.7.887. [DOI] [PubMed] [Google Scholar]
  21. Liu RT, Mustanski B. Suicidal ideation and self-harm in lesbian, gay, bisexual, and transgender youth. American Journal of Preventive Medicine. 2012;42(3):221–228. doi: 10.1016/j.amepre.2011.10.023. [DOI] [PubMed] [Google Scholar]
  22. Madison M, Rudman WJ, Hart-Hester S, Caputo N, French M, Jones WA. Leveraging health information technology and health information management in rural America: A health summit commentary. Journal of Rural Health. 2012;28(1):4–7. doi: 10.1111/j.1748-0361.2011.00383.x. [DOI] [PubMed] [Google Scholar]
  23. Mathy RM. Transgender identity and suicidality in a nonclinical sample: Sexual orientation, psychiatric history, and compulsive behaviors. Journal of Psychology and Human Sexuality. 2002;14(4):47–65. [Google Scholar]
  24. Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, Landers S. Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health. 2008;98(6):989–995. doi: 10.2105/AJPH.2007.127811. doi:10.2105/AJPH.2007.127811. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Meyer IH. Why lesbian, gay, bisexual, and transgender public health? American Journal of Public Health. 2001;91:856–859. doi: 10.2105/ajph.91.6.856. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Miner MH, Bockting WO, Swinburne-Romine R, Raman S. Conducting Internet research with the transgender population: Reaching broad samples and collecting valid data. Social Science Computer Review. 2012;30(2):202–211. doi: 10.1177/0894439311404795. doi:10.1177/0894439311404795. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. National Institute on Alcohol Abuse and Alcoholism Moderate and binge drinking. 2012 Retrieved from http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking.
  28. Newfield E, Hart S, Dibble S, Kohler L. Female-to-maile transgender quality of life. Quality of Life Research. 2006;15:1447–1457. doi: 10.1007/s11136-006-0002-3. [DOI] [PubMed] [Google Scholar]
  29. Noar SM, Black HG, Pierce LB. Efficacy of computer technology-based HIV prevention interventions: A meta-analysis. AIDS. 2009;23(1):107–115. doi: 10.1097/QAD.0b013e32831c5500. [DOI] [PubMed] [Google Scholar]
  30. Nuttbrock L, Bockting W, Rosenblum A, Hwahng S, Mason M, Macri M, Becker J. Gender abuse, depressive symptoms, and HIV and other sexually transmitted infections among male-to-female transgender persons: A three-year prospective study. American Journal of Public Health. 2013;103:300–307. doi: 10.2105/AJPH.2011.300568. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Operario D, Nemoto T, Iwamoto M, Moore T. Risk for HIV and unprotected sexual behavior in male primary partners of transgender women. Archives of Sexual Behavior. 2011;40(6):1255–1261. doi: 10.1007/s10508-011-9781-x. [DOI] [PubMed] [Google Scholar]
  32. Oswald F, Culton LS. Under the rainbow: Rural gay life and its relevance for family providers. Family Relations. 2003;52:72–81. [Google Scholar]
  33. Ramirez-Valles J, Garcia D, Campbell RT, Diaz RM, Heckathorn DD. HIV infection, sexual risk behavior, and substance use among Latino gay and bisexual men and transgender persons. American Journal of Public Health. 2008;98(6):1036–1042. doi: 10.2105/AJPH.2006.102624. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Rosser BRS, Oakes JM, Bockting WO, Miner M. Capturing the social demographics of hidden sexual minorities: An Internet study of the transgender population in the United States. Sexuality Research and Social Policy. 2007;4(2):50–64. [Google Scholar]
  35. SAMHSA Substate estimates from the 2002–2004 National Surveys on Drug Use and Health. 2008 Retrieved from http://oas.samhsa.gov/subState2k6/toc.cfm.
  36. Sanchez NF, Sanchez JP, Danoff A. Health care utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. American Journal of Public Health. 2009;99(4):713–719. doi: 10.2105/AJPH.2007.132035. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Stall R, Paul JP, Greenwood G, Pollack LM, Bein E, Crosby GM, Catania JA. Alcohol use, drug use and alcohol related problems among men who have sex with men: The Urban Men’s Health Study. Addiction. 2001;96(11):1589–1601. doi: 10.1046/j.1360-0443.2001.961115896.x. [DOI] [PubMed] [Google Scholar]
  38. Thorpe JM, Van Houtven CH, Sleath BL, Thorpe CT. Rural-urban differences in preventable hospitalizations among community-dwelling veterans with dementia. Journal of Rural Health. 2010;26(2):146–155. doi: 10.1111/j.1748-0361.2010.00276.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Valentine D. Imagining transgender: An ethnography of a category. Duke University Press; Durham, NC: 2007. [Google Scholar]
  40. Willging CE, Salvador M, Kano M. Pragmatic help seeking: How sexual and gender minority groups access mental health care in a rural state. Psychiatric Services. 2006;57:871–874. doi: 10.1176/ps.2006.57.6.871. [DOI] [PubMed] [Google Scholar]
  41. Wilson LE, Korthuis T, Fleishman JA, Conviser R, Lawrence PB, Moore RD, Gebo KA. HIV-related medical service use by rural/urban residents: A multistate perspective. AIDS Care. 2011;23(8):971–979. doi: 10.1080/09540121.2010.543878. [DOI] [PMC free article] [PubMed] [Google Scholar]

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