HIV Risk in Transgender Men and Women

Understanding Why Transgender People Are at Increased HIV Risk

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Transgender Equality Network at Dublin Gay Pride March 2010. Photo Credit: William Murphy

Data regarding HIV rates in transgender people is often difficult to find as female to male (FTM) and male to female (MTF) are not gender classifications typically noted on many surveillance reports. The state of California is a rare exception, having adding MTF and FTM as registered gender choices in 2002.

A 2008 study concluded that among the transgender population in California, 6.8% were HIV-positive. This was that highest prevalence rate of any group in the state, including men who have sex with men (MSM). What's more, African Americans within the transgender community had an infection rate of nearly 29%.

HIV among the transgender population remains an important, and understudied, social issue. Sociocultural perceptions about sex and gender work to marginalize the community as a whole, placing transgender men and women at increased vulnerability to infection and disease progression.

Defining Transgender

The term transgender is an inclusive term for a person whose gender identity and expression differ from what's expected as a result of their birth gender. Gender identities falling under the umbrella of transgender include:

  • Crossdresser - one who wears clothes usually assigned to the opposite sex
  • Bi-gender - those who feel their gender identity encompasses both male and female
  • Transsexual - those who find their gender identity is in conflict with their anatomical sex. These individuals feel their physiological body does not represent their true gender self.
  • Transvestite - another (outdated) term for a crossdresser
  • Cisgender - one who identifies with the gender they were assigned at birth
  • Genderqueer - used to describe a person who identifies as both male and female; neither male not female; or a gender outside the traditional two gender (male and female) system

It is not uncommon for people to confuse gender identity and sexual orientation, or to connect the two when no association is present. By definition, sexual orientation describes a pattern of emotional, romantic, or sexual attraction to another person. The scientific consensus is that sexual orientation is not a choice and is instead influenced by a combination of hormonal and genetic factors early in uterine development.

Gender identity, by contrast, refers to the gender or genders a person identifies as. Gender identity can change over time and does not always relate to sexual orientation. For instance, if someone born male identifies as female, she could be bisexual, heterosexual or homosexual.

HIV Incidence Among Transgender People

While transmission routes in the transgender community are much the same as any other population, there are some factors that place transgender people at a higher HIV risk.

  • The fears and risk of disclosure often makes it difficult to identify and reach members of the transgender community. Not only does this complicate efforts for prevention outreach, materials used to effect outreach are often non-specific to the population or, worse yet, gender biased.
  • By and large, those who identify as transgender perceive their anatomy differently than the medical community would. Without a common point of reference, health promotion and education becomes difficult. The medical community is frequently insensitive to this identification chasm, making health promotion and education all the more difficult.
  • Those identifying as transgender often experiment sexually and can sometime perceive risk differently—say, between to MTF transgenders identifying as lesbians. In addition, many are involved in sex work to support substance addictions; to make money for hormonal therapy; or because employment discrimination places them at economic vulnerability. Needle sharing is common among those who inject hormones increasing even further the risk of transmission.

What Can Be Done?

Gaps in treatment, care and outreach are evident in communities where transgender HIV rates run high. Increasing effort is being made to fill these gaps, integrating transgender-specific services that provides community members safe and confidential access to testing, medications and support. 

Key points of transgender-specific HIV services:

  • Providers must understand the needs of the transgender community and remain sensitive to issues of gender identification and personal identity.
  • Insurance companies must understand the importance of hormonal therapy and make better effort to provide affordable treatment with supportive care.
  • Prevention education needs to be targeted specific to the transgender community in a manner that is sensitive to their needs, concerns and fears.
  • Individual providers must make special care to ensure their patients feel safe disclosing their gender identities and to respect the terms of those identities once disclosed (i.e., the transgender-appropriate use of "he" or "she").
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