Anti-LGBTQ Laws are Propagating as Violence, Undermining Transgender Health

By: Ranier Simons, ADAP Blog Guest Contributor

As 2024 ends there is the painful reality that Donald J. Trump is returning to The White House, and with him promises of rolling back protections for LGBTQ people…and in some cases, even denying them care. The anxiety and fear are very authentic, and there is real world evidence of how discriminatory policies adversely impact already marginalized communities. One glowing example is how HIV prevention is undermined by LGBTQ-related attacks (legislation) and violence!

Photo Source: Le Monde

The concept of infrastructure does not always connote a physical embodiment of something. Infrastructure also encompasses societal structures, including culturally pervasive attitudes and legal policies. The problematic domestic and global infrastructure adversely affecting the lives of LGBTQ people is harmful to their well-being on many levels, including HIV prevention. The societal infrastructure set against LGBTQ contains aspects of physical violence as well as anti-LGBTQ legislation. The rate of violence perpetrated against LGBTQ in general, in addition to specific Transgender violence, is higher than the heterosexual general population.[1] Transgender violence and anti-LGTBQ laws and policies impede HIV prevention efforts, resulting in avoidable individual and public health adverse outcomes.

Over 500 anti-LGBTQ bills were introduced in the United States in 2023, almost tripling in number from 2022 to 2023.[2] This legislation is multi-focused, including attacks on health care, civil rights, public accommodations, and even education.[2] A recent study from the UNC Gillings School of Global Public Health found that there is a clear interconnection between discriminatory anti-LGBTQ legislation and HIV prevention.[3] Anti-LGBTQ legislation and policies adversely affect HIV prevention by increasing stigma and decreasing health care access.[3]

Photo Source: FiveThirtyEight

Many of the laws target transgender people and youth specifically, including efforts to deny gender-affirming care. This includes laws to prohibit the changing of gender or sex on identification or medical records. Some laws are purposed to ban the discussion of LGBTQ issues in schools. Regardless of the focus, the legislation contributes to LGBTQ stigma that even occurs in health settings.[4] This is due to a history of pathologizing LGBTQ identity, behavior, and desire in medicine.[4] Two-thirds of LGBTQ adults have experienced discrimination in the past year compared to four in ten non-LGBTQ adults.[4] The stigma fueled by anti-LGBTQ legislation is dehumanizing. It adversely affects the self-worth of individuals affected, which contributes to discouraging positive health-seeking behaviors and influences treatment when it is obtained.

Testing and PrEP use are significant tenets of HIV prevention. The UNC study showed that PrEP use was lower in states with more anti-LGBTQ legislation activity. Youth living in states with fewer anti-LGBTQ policies or counties with majorities of Democratic voters had higher levels of PrEP use. This positive increase in PrEP use was compounded for youth who lived in both a more progressive state and county.[4] Approximately 7.6% of U.S. adults identify as LGBTQ in 2024, and that number is increasing. Regular testing is a part of PrEP adherence. When stigma negatively affects access to testing, it simultaneously weakens the ability to maintain PrEP adherence even if PrEP is available.

Anti-LGBTQ laws are propagating concurrently as violence, specifically against transgender individuals, is an issue. One study out of San Diego, for example, showed that there were 229 documented cases of fatal violence against transgender women in the United States between 2013 and 2021.[5] The bulk of these cases, 78%, were Black victims, which included Afro-Latinas. Over half of these occurred in the South, followed in prevalence by the Midwest. This also reflects the number of recent anti-LGBTQ bills, with most being introduced in the South and the Midwest.[6] As of November 19, 2024, the Human Rights Campaign reports 372 transgender and gender-expansive victims of fatal violence from 2013 to the present.[7] These fatalities are only the reported ones. The actual numbers are estimated to be higher.

Prevention of violence against transgender people is a public health issue. Anti-LGBTQ policies and laws amplify the insecurity of daily existence that transgender individuals face. Adversity in dealing with daily survival is compounded by discrimination and lack of access to health care. Globally, on average, approximately 2/3 of transgender individuals are aware of their HIV status.[8] Also globally, the percentage of transgender individuals who avoid HIV testing due to discrimination and stigma is estimated to range from 47% to 73%. Additionally, those who have experienced discrimination in a healthcare setting are three times more likely to avoid seeking out healthcare than transgender people who have not experienced it.[8]

Photo Source: CDC

Social attitudes, the reality of violence, and anti-LGBT laws, including criminalization based on gender identity, contribute to the isolation of transgender people. Regardless of whether the isolation is externally or internally propagated, it adversely affects their mental health. Transgender individuals’ continuous exposure to harassment, bias, and discrimination contributes to poor mental health.[6] Poor mental health leads to things such as substance abuse and other detrimental patterns of behavior, which are barriers to effective HIV prevention, which includes medication adherence for transgender individuals living with HIV. 

Approximately one million people identify as transgender in the U.S., with 9.2% of those living with HIV. In addition to intravenous drug use, unsafe injection practices while injecting hormones can contribute to the increased likelihood of HIV transmission.[7] Sexual violence against transgender individuals also contributes to HIV transmission, especially since it is mainly unreported, and the victims do not seek out medical attention. Additionally, transgender people face housing and employment discrimination, which exacerbates challenges with maintaining proactive health maintenance, including HIV prevention.[7]

The adverse impact of HIV prevention challenges among people who identify as LGBTQ because of anti-LGBTQ laws and policies is significant. It is imperative to repeal toxic legislation and create beneficial policies that strengthen infrastructure to support HIV prevention and care. Legal protections and proactive policies will help fight against stigma and systemic structural barriers.

[1] Truman, J. L., Morgan, R. E., & U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. (2022). Violent Victimization by sexual orientation and gender Identity, 2017–2020. In Statistical Brief. https://bjs.ojp.gov/content/pub/pdf/vvsogi1720.pdf

[2] Choi, A. (2024, January 22). Record number of anti-LGBTQ bills were introduced in 2023. Retrieved from https://www.cnn.com/politics/anti-lgbtq-plus-state-bill-rights-dg/index.html

[3] Kelly, N. K., Ranapurwala, S. I., Pence, B. W., Hightow-Weidman, L. B., Slaughter-Acey, J., French, A. L., Hosek, S., & Pettifor, A. E. (2024). The relationship between anti-LGBTQ legislation and HIV prevention among sexual and gender minoritized youth. AIDS (London, England), 38(10), 1543–1552. https://doi.org/10.1097/QAD.0000000000003926

[4] Dawson, L., Kates, J., Montero, A., and Kirzinger, A. (2024, September 30). LGBTQ Health Policy. Retrieved from https://www.kff.org/health-policy-101-lgbtq-health-policy/

[5] Halliwell, P., Blumenthal, J., Kennedy, R., Lahn, L., & Smith, L. R. (2024). Characterizing the prevalence and perpetrators of documented fatal violence against Black transgender women in the United States (2013–2021). Violence Against Women. https://doi.org/10.1177/10778012241289425 

[6] ACLU. (2024). Mapping Attacks on LGBTQ Rights in U.S. State Legislatures in 2024. Retrieved from https://www.aclu.org/legislative-attacks-on-lgbtq-rights-2024

[7] HRC. (2014, November 19). The Epidemic of Violence Against the Transgender & Gender-Expansive Community in the U.S. Retrieved from https://reports.hrc.org/an-epidemic-of-violence-2024#epidemic-numbers

[8] UNAIDS. (2021). HIV and Transgender and Other Gender-Diverse People: Human Rights Fact Sheet Series. Retrieved from https://www.unaids.org/sites/default/files/media_asset/04-hiv-human-rights-factsheet-transgender-gender-diverse_en.pdf

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates. 

Coronavirus-Related Blood Shortages Lead to Blood Donor Reforms, But Discrimination Remains

By: Sarah Hooper,  intern, ADAP Advocacy Association, and rising senior at East Carolina University

Since the outbreak of Coronavirus, decisions have been made within the government on many topics including financial relief for students, unemployment and others. One of these decisions involves blood donations. On April 2, the U.S. Food and Drug Administration ("FDA") revised their guidelines which previously banned gay men from donating blood for a year after sexual intercourse with another man.

In these new guidelines, the FDA has instead recommended a three month wait period for these men. This will remain in place throughout the course of COVID-19 or within 60 days of the emergency being lifted, according to The Hill.

The national blood supply has been critically low, according to The Red Cross. Pleas for donations from healthy donors have been made within the past years, but with the recent outbreak of COVID-19, the need is much greater now.

According to their website, the American Red Cross provides roughly 40% of the nation’s blood and blood components, all volunteer based. Group O- blood is the most highly sought-after blood group, because it is universally accepted by other blood types.

The recent change in FDA guidelines to allow men who have sex with men to donate blood after 3 months may seem as better than the previous guidelines, which it is. However, this recent guideline change has revealed many issues with the blood donation program in America.

It was only in December of 2015 that the FDA moved their lifetime ban on gay and bisexual men donating blood to a one year wait period.

“Blood centers nationwide screen potential donors by asking a set of questions written to determine risk factors that could indicate possible infection with a transmissible disease, such as HIV or hepatitis. According to the FDA, this pre-screening eliminates up to 90% of donors who may be carrying a blood-borne disease,” the Human Rights Campaign said.

This raises the question: if screening donors is already a universal concept in blood donation, why should gay men have to wait a period of time to donate blood? Even if a gay man had sexual encounter with an HIV positive person, if they went through the pre-screening process for blood donation and reported either they had sex with another man who they were unsure of their sexual history and/or they had sex with a man who they are sure is HIV positive, wouldn’t that eliminate the risk there?

The American Red Cross tests all donated blood after donations for infectious diseases, but it may not be 100% effective in donors who may have been infected with a blood-borne pathogen recently.

However, if a gay man has taken the necessary precautions to protect against transmission of blood-borne diseases such as HIV or hepatitis, I see no reason as to why they cannot safely donate blood- especially in a time of crisis and a national shortage.

In an article written for USA Today, David Oliver spoke on issues he’s faced as a gay man attempting to donate blood amid Coronavirus.

“The first and only time I donated blood; I hadn't had sexual contact with another man. Heck, I hadn’t yet come out. I was 21 years old and passed out shortly after doing it. Over the six years since then, it has been too easy for me to throw my hands up and say: "Well, I can't even donate anyway." But during this time of crisis, I would give anything to help,” Oliver said.

This narrative is all too common among LGBTQ+ men. The need for blood is greater than ever, and if screening processes are taken and donors are open about their past possible exposure to pathogens, I see no reason as to why this blood shortage could not be addressed by all Americans.

Photo Source: Change.org

“The American Red Cross believes blood donation eligibility should not be determined by methods that are based upon sexual orientation. We are committed to working toward achieving this goal,” The American Red Cross said.

The goal of blood donation eligibility not being based upon sexual orientation is an achievable one. Americans must look past their ignorance and outdated ideas of LGBTQ+ men and blood donation to help the greater good.

References:

• Blood Needs & Blood Supply. (n.d.). Retrieved from https://www.redcrossblood.org/donate-blood/how-to-donate/how-blood-donations-help/blood-needs-blood-supply.html
• Human Rights Campaign. (n.d.). Blood Donations and the LGBTQ Community. Retrieved from https://www.hrc.org/resources/blood-donations
• LGBTQ Donors. (n.d.). Retrieved from https://www.redcrossblood.org/donate-blood/how-to-donate/eligibility-requirements/lgbtq-donors.html
• Oliver, D. (2020, March 30). Red Cross is asking for blood donations amid coronavirus. Because I'm gay, I'm excluded. Retrieved from https://www.usatoday.com/story/opinion/voices/2020/03/20/coronavirus-let-lgbtq-men-donate-blood-amid-shortage-column/2876677001/
• Weixel, N. (2020, April 2). FDA loosens restrictions on gay men donating blood amid pandemic. Retrieved from https://thehill.com/homenews/administration/490824-fda-loosens-restrictions-on-gay-men-donating-blood-amid-coronavirus#.XoYgEQB4AkA.twitter

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

When Shit Hits the Fan...Daraprim Style!

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

Earlier this month, relatively few people within the healthcare community, patient advocacy movement and frankly the general public probably knew much about the drug Daraprim (pyrimethamine). Not anymore! The drug, along with the pharmaceutical company that recently purchased the rights to sell it, Turing Pharmaceuticals, was transformed into a household name overnight. A 5000% price increase can have that sort of effect.

Turing Pharmaceutical's young CEO, Martin Shkreli, didn't help his new company's PR nightmare with some of his initial comments. But it is Mr. Shkreli who will most likely be responsible for the increased scrutiny over pharmaceutical drug pricing, and the process behind it. Stakeholders -- including physicians, pharmacists, healthcare professionals, pharmaceutical companies, patients -- can have honest disagreements over the issue of drug pricing, and each side has very valid merits behind their respective arguments. What happened with the Daraprim price hike is something entirely different, and even more troubling.

Source: Business Insider

The reaction to the 5000% price hike speaks volumes, too.

The National Alliance of State & Territorial AIDS Directors (NASTAD) immediately pounced on the decision, writing a letter to the Health Resources and Services Administration's Office of Pharmacy Affairs. The NASTAD letter sounded the alarm on behalf of patients living with HIV/AIDS across the country, since the drug is commonly prescribed under the AIDS Drug Assistance Programs (ADAPs). Several ADAPs have reportedly experienced difficulty in acquiring Daraprim at the discounted 340B price.

"It is apparent that Turing has violated HRSA’s non-discrimination requirements for the 340B program, and NASTAD believes that this discriminatory restriction on purchasing at the 340B price is ongoing. NASTAD requests that HRSA investigates Turing’s violations of the non-discrimination requirement and imposes appropriate penalties," argued NASTAD's Executive Director, Murray Penner. [1]

A full version of the letter can be read here.

The Human Rights Campaign's CEO,  condemned Mr. Shkreli and Turing Pharmaceuticals. The HRC statement read, "Your greed in raising the single-pill price from less than $15 to more than $750 is unconscionable. It immediately puts at risk scores of medically vulnerable people, including those living with HIV, and women who are pregnant. Medical organizations have estimated that this predatory move could increase the average cost per year for an adult patient reliant on the drug to more than $630,000." [2]

A full version of the letter can be read here.

The news media smelled blood, and they too focused their attention on the issue. "PRICE GOUGING CEO NOW TARGETING AIDS DRUG ASSISTANCE PROGRAMS," read the headline by the popular online news magazine, HIVEqual. Even business-oriented news outlets couldn't resist raising the red flag, evidenced by "Drug companies are reeling after the Martin Shkreli incident — and it could shake up the entire industry," published by Business Insider.

And of course, Twitter lit up like a Christmas tree. The following are just a few of the hundreds of thousands of the Tweets screaming about the 5000% price increase:

Ironically, there are only approximately 8,000 Daraprim prescriptions filled annually. [3] But that shouldn't matter, and it most certainly doesn't matter to the patients who rely on those prescriptions.

Turing Pharmaceuticals has already back-tracked from its absurd price hike, but the damage is done and lawmakers from both political parties will surely seek to tame the 800-pound gorilla in the room. The egregious example set by Mr. Shkreli must lead to an open, honest dialogue about the cost of health care in this country -- including drug pricing, insurance companies gouging patients, and even the shortcomings of the publicaly-financed health programs in this country. It should be a conversation that the advocacy community can come together with one, unified voice!

[1] National Alliance of State & Territorial AIDS Directors, "NASTAD ASKS FOR FEDERAL INVESTIGATION IN RESPONSE TO DARAPRIM PRICING AND ACCESS," September 22, 2015.
[2] Human Rights Campaign, "HRC President Chad Griffin Calls on Drug Manufacturer to Roll Back Unconscionable 5000 percent Price Hike On Life-Saving Treatment," September 22, 2015.
[3] The New York Times, "Drug Goes From $13.50 a Tablet to $750, Overnight," September 20, 2015.