Transgender Women: Why HIV Rates Are So High

Woman having HIV test
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Around the world, transgender women have been reported to have disproportionately high rates of HIV.  Although often categorized with men who have sex with men for research purposes, transgender women have their own unique HIV risk factors and concerns. For example, transgender women experience many structural barriers to success throughout their lives. These include problems with access to employment, housing, and other basic life necessities. Such barriers have been associated with increased likelihood of trying out risky behaviors, such as unprotected anal sex. Barriers may be even higher for transgender women of color. 

How common is HIV among transgender women? A 2013 meta-analysis found that, in five high-income countries, an average of 22  percent  of transgender women were HIV positive. In fact, transgender women were almost 50 times more likely to be HIV-infected than the general adult population. Other estimates of HIV rates in U.S. transgender women range from 16-17 percent among white and Latina women to more than 56 percent of black women. These rates are substantially higher than the general population and similar to rates seen in men who have sex with men. 

Who Are These Women?

Transgender women live in many countries around the world. They go by a variety of different names, but they have one thing in common. Transgender women are individuals whose sex assigned at birth was male but whose gender identity is female. Aside from that, they live many different lives.They may be heterosexual, homosexual, or bisexual. They may be married or single, employed or unemployed. They may have dropped out of school or teach at a university. 

Some transgender women live as women part of the time. Others live as women full time. Some use cross-sex hormone treatment to help affirm their gender. (These hormones can cause changes in the skin and breast growth, among other effects.) Others also undergo various types of gender confirmation surgery. The choices transgender women make in how to affirm and express their identity can sometimes contribute to HIV risk. 

Trans Misogyny

Transgender women often experience a great deal of stigma and discrimination, particularly when their appearance does not conform to expected standards of femininity for the cultures where they live. Julia Serano has coined the term "trans-misogyny" in her book Whipping Girl. She uses the term to describe the ways in which bias against transgender women often reflects both their transgender identities and their identities as women.

In general, transgender women  report significantly more discrimination than transgender men. This may be, in part, because of problematic, gender-essentialist notions that position any person with a penis as a sexual threat to women. Examples of this can be seen in debates around public accommodation laws. People who are against bathroom laws talk about the threat of "men" in women's bathrooms because they don't see transgender women as women. However, few people express concerns about transgender men using the men's room. They also don't recognize the risk that transgender women take if they use men's facilities instead. 

Three Ways That Trans-Misogyny Contributes to HIV Risk

Trans-misogyny and general discrimination against transgender individuals contribute to HIV risk for transgender women in a number of ways:

  1. Transgender women may experience significant discrimination when seeking housing and employment. This can lead to risky situations such as ending up homeless or needing to engage in sex work to survive. Sex work is a major risk factor for acquiring HIV, and transgender sex workers live on every continent. Homeless individuals are also more likely to inject hormones illegally, including with shared needles. 
  2. Trans-misogyny is associated with an increased risk of depression, and transgender women are widely believed to have higher than background rates of trauma and addiction. Injection drug use is another major risk factor for HIV acquisition. 
  3. Transgender individuals often have reduced access to healthcare due, among other things, to medical providers discomfort in treating them. They may also be reluctant to seek out health care, including HIV testing if they've had poor experiences with doctors in the past. 

Biology and HIV Risk for Transgender Women

Unrelated to trans-misogyny, there are also several biological reasons why transgender women may be at increased HIV risk. These include the frequent practice of receptive anal intercourse, particularly unprotected anal intercourse. Anal intercourse is considered a high-risk activity for HIV. Vaginal intercourse after genital surgery may also be particularly risky for transgender women.  Finally, research suggests that the tissue used to create the neo-vagina may also increase HIV risk compared to the risk seen for vaginal intercourse in cisgender women


Behavioral factors play a role in the high HIV risk seen for transgender women. However, social and structural factors may actually be more important. Increasing access to healthcare and reducing gender-based stigma and trans-misogyny could be powerful tools in reducing HIV risk in this population. 

Note: There is a large population of transgender men who experience many of the same issues of stigma and discrimination discussed in this article. However, this article focuses on transgender women because of the high rates of HIV they experience.

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