A key population at risk for HIV within the worldwide epidemic response has been overlooked, according to a new study: transgender sex workers, along with their clients, have been missing from HIV national surveillance and program interventions. One reason could be that their gender is often misclassified.
The study “HIV risk and preventive interventions in transgender women sex workers,” published in July in The Lancet, took a look at the knowledge gaps regarding transgender women and prevention interventions.
According to the study, when a legally authorized gender or gender appropriate identification is absent, it can heighten the discrimination a transgender person may face, restricting their access to adequate healthcare, education, employment, and voting rights. The combination of discrimination and stigma restricts their economic opportunities. Some transgender women have turned to sex work as a result to fund a livelihood that includes fees for gender-affirming hormones, injections, and surgeries so they appear more feminine and can increase their earning power. Transgender sex workers also receive community support from their peers and gender validation from their male clients.
- These women face an increased exposure to violence, reduced rates of condom use and increased risk of sexual transmitted infection.
- Transgender women detained or imprisoned in connection with sex work are often placed in male facilities which places them at sexual risk and drug injection.
- They are reported to participate in high levels of drug use and the use is often associated with sex with their partners and clients.
- Many transgender women have faced stigma and discrimination in medical settings. Also, their costly surgical interventions are not always covered. As a result, some transgender women will needle-share or use contaminated needles for hormone or silicone injections.
- When achieving feminization, erectile dysfunction can occur and interfere with correct condom use.
- The new vaginal lining of transgender women can be subject to micro tears due to mechanical and physiological factors.
HIV is primarily transmitted in transgender women through condomless intercourse with male partners, the study says. It also shows that these women might be more likely to engage in condomless receptive anal intercourse with stable partners than with clients as a way of expressing intimacy. However, this sexual activity has been linked to higher rates of substance misuse, low self-esteem and self-efficacy. Few transgender women ask about the sexual status of their stable partners.