"There's no pamphlet for the kind of sex I have": HIV-related risk factors and protective behaviors among transgender men who have sex with nontransgender men

Do transgender men have equal access to health care and engagement in preventive health behaviors compared to cisgender adults?

Using 2015 Behavioral Risk Factor Surveillance System data, this study investigates whether transgender men have equal access to health care and engagement in preventive health behaviors compared to cisgender adults in the U.S. and whether race/ethnicity, socioeconomic status, and rural residence moderate these relationships. Once controlling for sociodemographic factors, we do not find differences for transgender men. Rural transgender men were less likely to have a personal doctor or receive a blood cholesterol screening than their urban peers; transgender men with less education were more likely to have a cholesterol screening. We detail implications for social workers within health care.

HIV Prevalence, Sexual Partners, Sexual Behavior and HIV Acquisition Risk Among Trans Men, San Francisco, 2014

We surveyed 122 trans men using a hybrid sampling method that included randomly selected physical and online venues and peer referral to measure HIV prevalence and risk behaviors. HIV prevalence was 0% (one-sided 97.5% confidence interval 0-3.3%). Of 366 partnerships described, 44.8% were with cisgender women, 23.8% with cisgender men, 20.8% with trans men, and 10.7% with trans women. Condomless receptive anal and front hole/vaginal sex averaged one to three episodes per six months. HIV prevalence in trans men is likely closer to heterosexual cisgender men and women in San Francisco than trans women or MSM. Prevention prioritizing trans women and MSM, coupled with individualized and relevant sexual health education for trans men with partners from these populations, may best address the HIV prevention needs of trans men. Systematic collection of transgender status in Census and health data is needed to understand other health disparities among trans men.

Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S

In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.

Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S

In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.

Sexual HIV risk among gay, bisexual and queer transgender men: findings from interviews in Vancouver, Canada

Gay, bisexual, queer and other men who have sex with men are disproportionately affected by HIV in Canada. While up to 63% of transgender men identify as gay, bisexual or queer and report a variety of HIV sexual risk behaviours, transgender men are often overlooked within epidemiological HIV surveillance and research. While a growing body of research has begun to examine sexual risk for transgender gay, bisexual and queer men, most studies have been conducted in the USA. This study explored sexual HIV risk for this population in the Canadian context, specifically in British Columbia, in an environment of publically funded universal access to healthcare, including HIV testing and treatment. We conducted interviews with 11 gay, bisexual and queer transgender men. Participants' narratives suggest that HIV risk for these transgender men is shaped by a diversity of sexual behaviours, including inconsistent condom use, seeking partners online for greater safety and accessing HIV/STI testing and other healthcare services despite facing transition-related barriers. Public health prevention and health education must recognise the presence of transgender men and ensure health services and broader population health promotion meet the unique sexual health needs of this sub-population of gay, bisexual and queer men.

Transgender People and HIV Prevention: What We Know and What We Need to Know, a Call to Action

Transgender people have been disproportionally affected by HIV, particularly transgender women. Their increased vulnerability to HIV is due to multiple issues, including biological (eg, increased efficiency of HIV transmission through receptive anal sex), epidemiological (eg, increased likelihood of having HIV-infected partners), structural (eg, social stigma limiting employment options), and individual factors (eg, internalized stigma leading to depression and substance use and risk-taking behaviors). There have been limited culturally appropriate HIV prevention interventions for transgender people, with many key prevention studies (eg, the iPrEx PrEP study) enrolling transgender women in a study focusing on men who have sex with men. This has resulted in limited understanding of the optimal ways to decrease transgender people's risk for HIV acquisition. The current supplement of JAIDS is designed to review what is known about HIV prevention for transgender people and to highlight new insights and best practices. The study reviews recent epidemiologic data, the pharmacology of HIV prophylactic agents in individuals who may be using exogenous hormones, and several recent multi-component interventions designed to address the lived experience of transgender people. Additionally, the study reviews the work going on at the NIH to address transgender health in general and HIV prevention in specific, as well as two important papers related to clinical trial design issues and the ethical conduct of research in this frequently disenfranchised population. It is the hope of the HIV Prevention Trials Network (HPTN) that this supplement will promote new knowledge around transgender health and the requisite issues that need to be addressed in order to conduct optimal clinical trials. The ultimate hope is that the information distilled in this supplement will inform investigators, clinicians, and public health officials in order to design further research to develop optimal prevention interventions for transgender people and to implement these interventions in ways that are culturally congruent and health promoting.

Attitudes, Beliefs, and Barriers to PrEP Among Trans Men

The study examined the attitudes and knowledge of transgender men (trans men) regarding pre-exposure prophylaxis (PrEP) for HIV. Three focus groups of trans men were conducted with a trans male facilitator for a total of 21 participants. Six themes were identified; the range of information about PrEP and possible side effects, the economic realities for trans men, finding a trans-competent provider, trans male sexuality, the importance of contraception, and condom use. Despite identified risk and some information that has been disseminated, many trans men still lack adequate information regarding PrEP. There exist significant barriers to PrEP access for trans men. Participants commented that many providers avoid important discussions regarding sexuality and contraception. The education of health care professionals must include competency in working with transgender populations. More research is needed with regard to interactions between PrEP, testosterone, and hormonal contraception.

HIV-Related Sexual Risk Among Transgender Men Who Are Gay, Bisexual, or Have Sex With Men

BACKGROUND

This study is among the first to examine factors associated with HIV-related sexual risk among transgender men and other transmasculine persons who are gay, bisexual, or have sex with men (T-GBMSM).

METHODS

In 2009-2010, 433 transgender people in Ontario, Canada, participated in a multimode respondent-driven sampling survey, including 158 T-GBMSM. Analyses were weighted using respondent-driven sampling II methods to adjust for differential recruitment probabilities; confidence intervals (CI) were adjusted for clustering by shared recruiter. Prevalence ratios (PR) for associations with past-year high sexual risk (condomless intercourse outside a seroconcordant monogamous relationship) were estimated using average marginal predictions from logistic regression.

RESULTS

Of T-GBMSM (mean age = 29.8; 52% living full time in felt gender; 25% Aboriginal or persons of color; 0% self-reported HIV positive), 10% had high sexual risk activity in the past year. Among the 34% with a past-year cisgender (non-transgender) male sex partner, 29% had high sexual risk. In multivariable analyses, older age, childhood sexual abuse (adjusted PR, APR = 14.03, 95% CI: 2.32 to 84.70), living full time in one's felt gender (APR = 5.20, 95% CI: 1.11 to 24.33), and being primarily or exclusively attracted to men (APR = 5.54, 95% CI: 2.27 to 13.54) were each associated with sexual risk. Of psychosocial factors examined, past-year stimulant use (APR = 4.02, 95% CI: 1.31 to 12.30) and moderate depressive symptoms (APR = 5.77, 95% CI: 1.14 to 29.25) were associated with higher sexual risk.

CONCLUSIONS

T-GBMSM seem to share some HIV acquisition risk factors with their cisgender counterparts. HIV prevention interventions targeting T-GBMSM who are predominantly attracted to men and interventions addressing sequelae of childhood sexual abuse may be warranted.

The Sexual Health of Transgender Men: A Scoping Review

There is a general paucity of research concerning the sexual health of transgender individuals, and most existing research focuses on transgender women. A scoping review concerning the sexual health of transgender men was conducted to identify gaps in the literature and to highlight opportunities for future research and intervention. A comprehensive search of seven databases was conducted. The Joanna Briggs Institute Reviewers' Manual was used as a framework. Some 7,485 articles were initially identified using a search strategy applied to seven online databases: 54 articles were identified as relevant to the research questions and reviewed in detail; of those, 33 were included in the final analysis. Studies were conceptualized into four broad themes: sexual behaviors, sexual identity, sexual pleasure and sexual function, and transactional sex. Besides an overall lack of research, existing studies were often characterized by small convenience samples that do not allow for generalization to the larger population of transgender men. Significant gaps in the literature regarding sexual coercion, sexual and intimate partner violence, and relationship quality and functioning among transgender men exist. There is a need to improve the scope and depth of research examining the sexual health of this population, especially concerning sexual risk behaviors and structural barriers to sexual health care access.

Testosterone and sexual risk among transmen: a mixed methods exploratory study

Little research has explored the link between the behavioural effects of testosterone use among transmen and HIV risk. We conducted a mixed methods study to explore testosterone use among transmen and the behavioural effects on HIV risk. A sample of 122 transmen from San Francisco participated in a cross-sectional quantitative survey and 14 transmen participated in 2 focus group discussions. Most participants (81.9%) were currently taking hormones. Participants attributed testosterone use to new sexual behaviours among 69% of transmen, changes in sexual attraction (49%), and increased frequency of sexual activity (72%). Among current testosterone users, 3.3% had cisgender men as partners before starting testosterone, whereas after starting testosterone, 25.4% did. Similarly, 4.1% had a transgender woman as a sexual partner before starting testosterone and 13.9% after starting testosterone. Findings suggest that testosterone's side effects were associated with transmen's desires for sex with cisgender men who have sex with men. The reported increase in attraction to and sex with partners from populations with a high HIV prevalence may have important implications for HIV risk among transmen, especially as the availability of transgender health services may draw transmen to a context in which HIV prevalence is high.

Barriers and facilitators to HIV and sexually transmitted infections testing for gay, bisexual, and other transgender men who have sex with men

Transgender men who have sex with men (trans MSM) may be at elevated risk for HIV and other sexually transmitted infections (STI), and therefore require access to HIV and STI testing services. However, trans people often face stigma, discrimination, and gaps in provider competence when attempting to access health care and may therefore postpone, avoid, or be refused care. In this context, quantitative data have indicated low access to, and uptake of, HIV testing among trans MSM. The present manuscript aimed to identify trans MSM's perspectives on barriers and facilitators to HIV and STI testing. As part of a community-based research project investigating HIV risk and resilience among trans MSM, 40 trans MSM aged 18 and above and living in Ontario, Canada participated in one-on-one qualitative interviews in 2013. Participants described a number of barriers to HIV and other STI testing. These included both trans-specific and general difficulties in accessing sexual health services, lack of trans health knowledge among testing providers, limited clinical capacity to meet STI testing needs, and a perceived gap between trans-inclusive policies and their implementation in practice. Two major facilitators were identified: access to trusted and flexible testing providers, and integration of testing with ongoing monitoring for hormone therapy. Based on these findings, we provide recommendations for enhancing access to HIV and STI testing for this key population.

Comprehensive HIV Prevention for Transgender Persons

Transgender persons are at high risk for HIV infection, but prevention efforts specifically targeting these people have been minimal. Part of the challenge of HIV prevention for transgender populations is that numerous individual, interpersonal, social, and structural factors contribute to their risk. By combining HIV prevention services with complementary medical, legal, and psychosocial services, transgender persons' HIV risk behaviors, risk determinants, and overall health can be affected simultaneously. For maximum health impact, comprehensive HIV prevention for transgender persons warrants efforts targeted to various impact levels-socioeconomic factors, decision-making contexts, long-lasting protections, clinical interventions, and counseling and education. We present current HIV prevention efforts that reach transgender persons and present others for future consideration.

The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices

INTRODUCTION

Globally, transgender ("trans") women are one of the key populations most disproportionately impacted by HIV. Pre-exposure prophylaxis (PrEP) is the newest and most promising biomedical HIV prevention intervention to date. This paper reviews relevant literature to describe the current state of the science and describes the potential role of PrEP among trans women, including a discussion of unique considerations for maximizing the impact of PrEP for this vulnerable population.

METHODS

Available information, including but not limited to existing scientific literature, about trans women and PrEP was reviewed and critiqued based on author expertise, including PrEP clinical trials and rollout.

RESULTS

To date, PrEP demonstration projects and clinical trials have largely excluded trans women, or have not included them in a meaningful way. Data collection strategies that fail to identify trans women in clinical trials and research further limit the ability to draw conclusions about trans women's unique needs and devise strategies to meet them. Gender-affirming providers and clinic environments are essential components of any sexual health programme that aims to serve trans women, as they will largely avoid settings that may result in stigmatizing encounters and threats to their identities. While there is currently no evidence to suggest drug-drug interactions between PrEP and commonly used feminizing hormone regimens, community concerns about potential interactions may limit interest in and uptake of PrEP among trans women.

CONCLUSIONS

In scaling up PrEP for trans women, it is essential to engage trans communities, utilize trans-inclusive research and marketing strategies and identify and/or train healthcare providers to provide gender-affirming healthcare to trans women, including transition-related care such as hormone provision. PrEP implementation guidelines must consider and address trans women's unique barriers and facilitators to uptake and adherence.

Sexual and Gender Diversity within the Black Men who have Sex with Men HIV Epidemiological Category

Epidemiological categories not only reflect existing frameworks for public health, but reify how subpopulations are defined, understood, and targeted for interventions. The sweeping categorization of Black men who have sex with men (BMSM) used in HIV research and intervention work is one such example. The current paper builds upon previous critiques of the "MSM" nomenclature by delineating the sexual and gender diversity embedded in the term as it pertains specifically to Black peoples. The emphasis is on developing greater specificity about the sociocultural and structural factors that may be shared among these subgroups, such as racism and poverty, and the factors that are likely to distinguish the groups, such as levels of sexual minority identification, access to lesbian, gay, bisexual, and transgender (LGBT) services and community, and experiences with anti-bisexual or anti-transgender bias. The aim then is to provide a framework for HIV health policy work for Black sexual minority cisgender men (SMCM) and gender minorities (GM).

Global health burden and needs of transgender populations: a review

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Inequities in access to HIV prevention services for transgender men: results of a global survey of men who have sex with men

INTRODUCTION

Free or low-cost HIV testing, condoms, and lubricants are foundational HIV prevention strategies, yet are often inaccessible for men who have sex with men (MSM). In the global context of stigma and poor healthcare access, transgender (trans) MSM may face additional barriers to HIV prevention services. Drawing on data from a global survey of MSM, we aimed to describe perceived access to prevention services among trans MSM, examine associations between stigma and access, and compare access between trans MSM and cisgender (non-transgender) MSM.

METHODS

The 2014 Global Men's Health and Rights online survey was open to MSM (inclusive of trans MSM) from any country and available in seven languages. Baseline data (n=3857) were collected from July to October 2014. Among trans MSM, correlations were calculated between perceived service accessibility and anti-transgender violence, healthcare provider stigma, and discrimination. Using a nested matched-pair study design, trans MSM were matched 4:1 to cisgender MSM on age group, region, and HIV status, and conditional logistic regression models compared perceived access to prevention services by transgender status.

RESULTS

About 3.4% of respondents were trans men, of whom 69 were included in the present analysis. The average trans MSM participant was 26 to 35 years old (56.5%); lived in western Europe, North America, or Oceania (75.4%); and reported being HIV-negative (98.6%). HIV testing, condoms, and lubricants were accessible for 43.5, 53.6, and 26.1% of trans MSM, respectively. Ever having been arrested or convicted due to being trans and higher exposure to healthcare provider stigma in the past six months were associated with less access to some prevention services. Compared to matched cisgender controls, trans MSM reported significantly lower odds of perceived access to HIV testing (OR=0.57, 95% CI=0.33, 0.98) and condom-compatible lubricants (OR=0.54, 95% CI=0.30, 0.98).

CONCLUSIONS

This first look at access to HIV prevention services for trans MSM globally found that most reported inadequate access to basic prevention services and that they were less likely than cisgender MSM to have access to HIV testing and lubricants. Results indicate the need to enhance access to basic HIV prevention services for trans MSM, including MSM-specific services.

Putting the t in tools: a roadmap for implementation of new global and regional transgender guidance

Transgender (trans) activists and global health partners have collaborated to develop new tools and guidance for assessing and addressing HIV and other health needs within trans populations. Trans women experience a heavy burden of HIV and other sexually transmitted infections (STIs), high incidence of violence and difficulties accessing gender-affirming services. At the same time, little has been published on trans men's health, HIV issues, needs and experiences. Young trans people are especially marginalized and vulnerable, with few programmes and services specifically tailored to their needs. Trans-specific data and guidance are needed to adapt the global response to HIV to meet the needs of the trans population. While the needs of this group have only recently received attention, global, regional and other technical guidance documents are being developed to address these gaps. Regional blueprints for comprehensive care for trans people in Latin America, the Caribbean, and Asia and the Pacific are now available. These tools - supported by the Pan American Health Organization, World Health Organization, US President's Emergency Plan for AIDS Relief and the United Nations Development Programme, in collaboration with regional trans groups - provide a contextual map, indicating opportunities for interventions in health, HIV, violence, stigma and discrimination, social protection and human rights. Global guidance includes the World Health Organization's Policy Brief: Transgender People and HIV, and the interagency publication, Implementing Comprehensive HIV and STI Programmes with Transgender People. Community empowerment and capacity building are the focus of the new tools for global and regional transgender guidance. The goal is to strengthen and ensure community-led responses to the HIV challenge in trans populations. This article describes the new tools and guidance and considers the steps needed to use them to appropriately support and engage transgender populations within national AIDS, STI, and sexual and reproductive health responses and programmes. The time to use these tools and guidance for advocacy, strategic planning, capacity building, programme design and training is now.

Non-monosexual Partnerships: Information, Motivation and Self-Efficacy among Methamphetamine-Using Men Who Have Sex with Men Who Also Have Sex with Women or Transgender Persons

OBJECTIVES

Sex with more than one gender is associated with higher substance use, and sexual HIV risk.

METHODS

We examined knowledge, motivation, and self-efficacy to engage in safer substance use and sexual behavior among methamphetamine-using U.S. men who have sex with more than one gender (N=343).

RESULTS

Almost half(46.2%) of the men reported having sex with a man and a woman or transgender partner in the last 30 days. Compared to monosexual MSM, non-monosexual MSM reported greater condom use self-efficacy however, they reported more sexual partners who inject drugs.

CONCLUSION

We observed distinct differences between men who do or do not have sex with more than one gender.

HIV Risk Among Men Who Have Sex With Men, Women Who Have Sex With Women, Lesbian, Gay, Bisexual and Transgender Populations in South Africa: A Mini-Review

BACKGROUND

The HIV epidemic in South Africa is characterized mainly by heterosexual transmission. Recently, the importance of targeting key populations and marginalized groups, including men who have sex with men (MSM) and transgender people, has been added to the national agenda.

OBJECTIVES

This mini-review explores the current state of empirical research on HIV risk and MSM, women who have sex with women (WSW), lesbian, gay, bisexual and transgender (LGBT) populations in South Africa in order to assess the current state of research and identify gaps in the literature.

METHOD

Peer-reviewed empirical social and behavioral articles on HIV prevalence and risk focusing on MSM, WSW, and LGBT populations published since 2006 were included in this mini-review.

RESULTS

In total 35 articles were included: 30 on MSM, gay, and/or bisexual male-identified populations, three on WSW, lesbian, and/or bisexual female-identified populations, two on LGB youth, and none on transgender populations.

CONCLUSION

Despite South Africa being the country with the largest number of people living with HIV in the world, there is a limited amount of research in South Africa on HIV and non-normative gender identities and sexualities, especially WSW, lesbian, and/or bisexual female-identified populations, transgender populations, and LGB youth. Research with MSM, WSW, and LGBT populations should be prioritized in South Africa in order to appropriately inform HIV prevention strategies that meet the specific needs of these marginalized groups.

Adult development and quality of life of transgender and gender nonconforming people

PURPOSE OF REVIEW

Research on the health of transgender and gender nonconforming people has been limited with most of the work focusing on transition-related care and HIV. The present review summarizes research to date on the overall development and quality of life of transgender and gender nonconforming adults, and makes recommendations for future research.

RECENT FINDINGS

Pervasive stigma and discrimination attached to gender nonconformity affect the health of transgender people across the lifespan, particularly when it comes to mental health and well-being. Despite the related challenges, transgender and gender nonconforming people may develop resilience over time. Social support and affirmation of gender identity play herein a critical role. Although there is a growing awareness of diversity in gender identity and expression among this population, a comprehensive understanding of biopsychosocial development beyond the gender binary and beyond transition is lacking.

SUMMARY

Greater visibility of transgender people in society has revealed the need to understand and promote their health and quality of life broadly, including but not limited to gender dysphoria and HIV. This means addressing their needs in context of their families and communities, sexual and reproductive health, and successful aging. Research is needed to better understand what factors are associated with resilience and how it can be effectively promoted.

Use of the Internet to Meet Sexual Partners, Sexual Risk Behavior, and Mental Health in Transgender Adults

The purpose of this study was to examine the use of the internet to meet sexual partners among transgender individuals and examine correlates of this use, including sexual risk behavior, discrimination experiences, and mental health. A sample of 166 transgender adults (112 male-to-female transgender women and 54 female-to-male transgender men) were recruited in community venues and anonymously completed measures assessing these variables. Most participants (64.5 %) were HIV-negative, 25.2 % were HIV-positive, and 10.3 % did not know their HIV status. Overall, 33.7 % of participants reported having met a sexual partner over the internet, which did not differ significantly between transgender women and men. Among these individuals, transgender women reported significantly more lifetime internet sexual partners (median = 3) than transgender men (median = 1). Use of the internet to meet sexual partners was associated with lower self-esteem but not with depression, anxiety, somatic distress or discrimination experiences. Among transgender women, use of the internet to meet sexual partners was associated with each of the 11 sexual risk behaviors examined, including having multiple partners, sex under the influence of drugs, number of unprotected anal or vaginal sex acts, and history of commercial sex work. The use of the internet to meet partners was not associated with sexual risk behavior among transgender men (0/11 variables assessed). Although the internet is a common mode of meeting sexual partners among some transgender adults, it may also be a potential venue for prevention interventions targeting transgender individuals at particularly high risk for HIV acquisition.

LifeSkills for Men (LS4M): Pilot Evaluation of a Gender-Affirmative HIV and STI Prevention Intervention for Young Adult Transgender Men Who Have Sex with Men

Young adult transgender men who have sex with men (TMSM) engage in sexual behaviors that place them at risk of sexually transmitted infections (STIs) including HIV. To date, no HIV and STI prevention interventions have been developed specifically for young adult TMSM. To address this gap, the current study aimed to (1) adapt a small group-based behavioral HIV prevention intervention designed for young transgender women ("LifeSkills") to address the unique HIV and STI prevention needs of young TMSM ages 18-29 years and (2) conduct a pilot evaluation of the intervention ("LifeSkills for Men"; LS4M). LS4M was carried out in an iterative approach with community input along the way, which allowed for refinement of the intervention manual and enhanced participant acceptability. A LS4M Task Force was convened to guide intervention development/adaptation and study implementation. Initially, focus groups were conducted to examine the sexual health needs, concerns, and stressors facing young TMSM (n = 12; mean age = 23.8 years; 16.7% people of color). Next, LS4M was pilot tested (n = 17; mean age = 24.3 years; 23.5% people of color) to assess acceptability with the study population and feasibility of all study procedures. Overall attendance, participation rates, and positive feedback from participants demonstrate that LS4M is highly acceptable and feasible to carry out with young TMSM. Trends in outcome measures across 4 months of follow-up suggest that participation in the intervention may improve mental health, reduce internalized stigma, and reduce HIV- and STI-related risk behaviors. Further testing of the intervention enrolling young TMSM with recent sexual risk behavior at baseline and with a control group is warranted. Lessons learned for future work with young TMSM are discussed.

A global research synthesis of HIV and STI biobehavioural risks in female-to-male transgender adults

There is a growing interest in HIV infection and sexually transmitted infection (STI) disease burden and risk among transgender people globally; however, the majority of work has been conducted with male-to-female transgender populations. This research synthesis comprehensively reviews HIV and STI research in female-to-male (FTM) transgender adults. A paucity of research exists about HIV and STIs in FTMs. Only 25 peer-reviewed papers (18 quantitative, 7 qualitative) and 11 'grey literature' reports were identified, most in the US or Canada, that include data identifying HIV and STI risks in FTMs (five with fully laboratory-confirmed HIV and/or STIs, and five with partial laboratory confirmation). Little is known about the sexual and drug use risk behaviours contributing to HIV and STIs in FTMs. Future directions are suggested, including the need for routine surveillance and monitoring of HIV and STIs globally by transgender identity, more standardised sexual risk assessment measures, targeted data collection in lower- and middle-income countries, and explicit consideration of the rationale for inclusion/exclusion of FTMs in category-based prevention approaches with MSM and transgender people. Implications for research, policy, programming, and interventions are discussed, including the need to address diverse sexual identities, attractions, and behaviours and engage local FTM communities.

Characteristics of Transgender Residents of Massachusetts Cities With High HIV Prevalence

Geographic context can influence individual risk in populations disproportionately susceptible to HIV infection, such as transgender people. We examined factors associated with residing in Massachusetts cities with the highest HIV prevalence (geographic "hotspots") in a 2013 sample of 433 transgender adults who were not infected with HIV. Residing in hotspots was associated with older age, non-White race/ethnicity, low income, incarceration history, polydrug use, smoking, binge drinking, and condomless receptive anal sex during one's most recent sexual encounter with a partner who was assigned male sex at birth. Future research to understand the interpersonal and socio-structural factors that drive localized epidemics among transgender people is warranted.

Syndemics and gender affirmation: HIV sexual risk in female-to-male trans masculine adults reporting sexual contact with cisgender males

Female-to-male trans masculine adults who have sex with cisgender (non-transgender) males (TMSM) represent an understudied population in relation to HIV/sexually transmitted infection (STI) risk. This study examined the role of syndemic conditions and social gender affirmation processes (living full-time in one's identified gender) in potentiating sexual risk among TMSM adults in Massachusetts, US. Cross-sectional data were restricted to TMSM who reported lifetime sexual behaviour with a cisgender male (n = 173; mean age = 29.4, SD = 9.6; 18.5% people of colour; 93.1% non-heterosexual identity; 56.1% hormones/surgery). Sexual risk outcomes were: lifetime STI diagnoses, three or more sexual partners in the previous six months, and condomless anal/vaginal sex at last encounter with a cisgender male. Age- and survey mode-adjusted logistic regression models regressed sexual risk outcomes on the main effect of syndemics (six indicators summed: binge drinking, substance use, depression, anxiety, childhood abuse, intimate partner violence), followed by the interaction of syndemics and social gender affirmation. Syndemics were associated with increased odds of all sexual risk indicators (adjusted odds ratios [aORs] = 1.32-1.55; p < 0.0001). Social gender affirmation moderated the association between syndemics and condomless anal/vaginal sex at last encounter with a cisgender male (p < 0.0001). Syndemics were associated with sexual risk in TMSM who had socially affirmed their gender (aOR = 1.79; 95% CI = 1.42-2.25; p < 0.001), but not among those TMSM who had not (aOR = 0.86; 95% CI = 0.63-1.19; p = 0.37). Findings suggest that syndemic pathways to sexual risk are similar for TMSM who have socially gender affirmed as for cisgender MSM. Integration of syndemics and gender affirmation frameworks is recommended in interventions to address TMSM sexual risk.

HIV Testing by Transgender Status at Centers for Disease Control and Prevention-Funded Sites in the United States, Puerto Rico, and US Virgin Islands, 2009-2011

OBJECTIVES

We examined HIV testing services, seropositivity, and the characteristics associated with newly identified, confirmed HIV-positive tests among transgender individuals.

METHODS

We analyzed data (2009-2011) using bivariate and multivariable logistic regression to examine the relationships between HIV positivity and sociodemographic and risk characteristics among male-to-female transgender individuals.

RESULTS

Most of the testing was conducted in females (51.1%), followed by males (48.7%) and transgender individuals (0.17%). Tests in male-to-female transgender individuals had the highest, newly identified confirmed HIV positivity (2.7%), followed by males (0.9%), female-to-male transgender individuals (0.5%), and females (0.2%). The associated characteristics with an HIV-positive test among male-to-female transgender individuals included ages 20 to 29 and 40 to 49 years (adjusted odds ratio [AOR] = 2.8; 95% confidence interval [CI] = 1.4, 5.6 and AOR = 2.8; 95% CI = 1.3, 5.9, respectively), African American (AOR = 4.6; 95% CI = 2.7, 7.9) or Hispanic/Latino (AOR = 2.6; 95% CI = 1.5, 4.5) race/ethnicity, and reporting sex without condom within the past year (AOR = 1.9; 95% CI = 1.3, 2.6), sex with an HIV-positive person (AOR = 1.5; 95% CI = 1.1, 2.0), or injection drug use (AOR = 2.0; 95% CI = 1.3, 3.0).

CONCLUSIONS

High levels of HIV positivity among transgender individuals, particularly male-to-female transgender individuals, underscore the necessity for targeted HIV prevention services that are responsive to the needs of this population.

Sexually transmitted diseases treatment guidelines, 2015

These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.

Laboratory-confirmed HIV and sexually transmitted infection seropositivity and risk behavior among sexually active transgender patients at an adolescent and young adult urban community health center

The sexual health of transgender adolescents and young adults who present for health care in urban community health centers is understudied. A retrospective review of electronic health record (EHR) data was conducted from 180 transgender patients aged 12-29 years seen for one or more health-care visits between 2001 and 2010 at an urban community health center serving youth in Boston, MA. Analyses were restricted to 145 sexually active transgender youth (87.3% of the sample). Laboratory-confirmed HIV and sexually transmitted infections (STIs) seroprevalence, demographics, sexual risk behavior, and structural and psychosocial risk indicators were extracted from the EHR. Analyses were descriptively focused for HIV and STIs. Stratified multivariable logistic regression models were fit for male-to-female (MTF) and female-to-male (FTM) patients separately to examine factors associated with any unprotected anal and/or vaginal sex (UAVS). The mean age was 20.0 (SD=2.9); 21.7% people of color, 46.9% white (non-Hispanic), 21.4% race/ethnicity unknown; 43.4% MTF, and 56.6% FTM; and 68.3% were on cross-sex hormones. Prevalence of STIs: 4.8% HIV, 2.8% herpes simplex virus, 2.8% syphilis, 2.1% chlamydia, 2.1% gonorrhea, 2.8% hepatitis C, 1.4% human papilloma virus. Only gonorrhea prevalence significantly differed by gender identity (MTF 2.1% vs. 0.0% FTM; p=0.046). Nearly half (47.6%) of the sample engaged in UAVS (52.4% MTF, 43.9% FTM, p=0.311). FTM more frequently had a primary sex partner compared to MTF (48.8% vs. 25.4%; p=0.004); MTF more frequently had a casual sex partner than FTM (69.8% vs. 42.7% p=0.001). In multivariable models, MTF youth who were younger in age, white non-Hispanic, and reported a primary sex partner had increased odds of UAVS; whereas, FTM youth reporting a casual sex partner and current alcohol use had increased odds of UAVS (all p<0.05). Factors associated with sexual risk differ for MTF and FTM youth. Partner type appears pivotal to understanding sexual risk in transgender adolescents and young adults. HIV and STI prevention efforts, including early intervention efforts, are needed in community-based settings serving transgender youth that attend to sex-specific (biological) and gender-related (social) pathways.

Using a two-step method to measure transgender identity in Latin America/the Caribbean, Portugal, and Spain

Few comparative data are available internationally to examine health differences by transgender identity. A barrier to monitoring the health and well-being of transgender people is the lack of inclusion of measures to assess natal sex/gender identity status in surveys. Data were from a cross-sectional anonymous online survey of members (n > 36,000) of a sexual networking website targeting men who have sex with men in Spanish- and Portuguese-speaking countries/territories in Latin America/the Caribbean, Portugal, and Spain. Natal sex/gender identity status was assessed using a two-step method (Step 1: assigned birth sex, Step 2: current gender identity). Male-to-female (MTF) and female-to-male (FTM) participants were compared to non-transgender males in age-adjusted regression models on socioeconomic status (SES) (education, income, sex work), masculine gender conformity, psychological health and well-being (lifetime suicidality, past-week depressive distress, positive self-worth, general self-rated health, gender related stressors), and sexual health (HIV-infection, past-year STIs, past-3 month unprotected anal or vaginal sex). The two-step method identified 190 transgender participants (0.54%; 158 MTF, 32 FTM). Of the 12 health-related variables, six showed significant differences between the three groups: SES, masculine gender conformity, lifetime suicidality, depressive distress, positive self-worth, and past-year genital herpes. A two-step approach is recommended for health surveillance efforts to assess natal sex/gender identity status. Cognitive testing to formally validate assigned birth sex and current gender identity survey items in Spanish and Portuguese is encouraged.

The invisibility of gender diversity: understanding transgender and transsexuality in nursing literature

PURPOSE

Increasingly, people are living their lives without strict attachment to one gender. In this paper, we discuss key discourses identified in a literature review of transgender and transsexual issues in nursing. Our aim is to highlight the power of dominant discourse and lack of adequate understanding of gender diversity on the part of nurses. We use stories of trans people to illustrate these discourses. An increased awareness may support respectful care of those who do not fit comfortably within culturally defined parameters of male and female.

CONCLUSION

The invisibility of gender diversity in health care remains a threat to ethical nursing care. The effects of invisibility of transgender people in health care result in a cycle of repetition where those who have been denied recognition in turn avoid disclosure. Key discourses addressing trans people in nursing literature include invisibility, advocacy, cultural competence, and emancipation.

PRACTICE IMPLICATIONS

There is a need for further education about gender diversity in order to dispel and counter misunderstandings, stigma, and invisibility. This can be achieved through sustained efforts in nursing research and educational curricula to include gender diversity and trans people. Policies for the protection of those who change their sex or identify outside the dominant gender schema are urgently needed.

HIV risk behaviors in the U.S. transgender population: prevalence and predictors in a large internet sample

To study the influence of gender on HIV risk, a sample of the U.S. transgender population (N = 1,229) was recruited via the Internet. HIV risk and prevalence were lower than reported in prior studies of localized, urban samples but higher than the overall U.S. population. Findings suggest that gender nonconformity alone does not itself result in markedly higher HIV risk. Sex with nontransgender men emerged as the strongest independent predictor of unsafe sex for both male-to-female (MtF) and female-to-male (FtM) participants. These sexual relationships constitute a process that may either affirm or problematize gender identity and sexual orientation, with different emphases for MtFs and FtMs, respectively.

Trans people's experience of sexuality in the Netherlands: a pilot study

This pilot study explores the specificity of 12 Dutch trans people's experience of sexuality in order to provide new hypotheses and perspectives for future research. Emerging themes include the interconnection of sexual development with coming out and transition processes, the way incongruence between gender identity, gendered embodiment, and social perception of gender affected participants' experience of sexuality, and changes in physical sexual functioning after hormone therapy and/or various types of surgery. Our research design allowed for subjective accounts of trans people's experience of sexuality and detailed descriptions of changes in sexuality that occurred over time and throughout the coming out and transitioning processes.

Sexual risk behaviors and psychosocial health concerns of female-to-male transgender men screening for STDs at an urban community health center

The sexual health of female-to-male (FTM) transgender men remains understudied. De-identified electronic medical records of 23 FTMs (mean age = 32, 48% racial/ethnic minority) who screened for sexually transmitted diseases (STDs) between July and December 2007 at a Boston, Massachusetts area health center were analyzed. Almost half (48%) were on testosterone and 39% had undergone chest surgery; none had undergone genital reconstruction. The majority (57%) were bisexual, and 30% reported sex with nontransgender males only in the prior three months. One individual was HIV-infected (4.3%) and two (8.7%) had a history of STDs (all laboratory-confirmed). Overall, 26% engaged in sexual risk behavior in the prior three months (i.e., unprotected sex with a nontransgender male, condom breakage, or anonymous sex). The majority (61%) had a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) diagnosis (52% depression, 52% anxiety, and 26% adjustment disorder), and regular alcohol use was common (65%). Alcohol use, psychosocial distress histories, and sex with males only (versus with males and females) were associated with sexual risk in the past three months. Transgender men have concomitant psychosocial health vulnerabilities which may contribute to sexual risk behaviors. Future research is needed to understand the myriad social, behavioral, and biological factors that contribute to HIV and STD vulnerability for FTMs.

Female-to-male transmasculine adult health: a mixed-methods community-based needs assessment

BACKGROUND

There is a dearth of health research about transgender people.

OBJECTIVES

This mixed-methods study sought to formatively investigate the health and perceived health needs of female-to-male transmasculine adults.

DESIGN

A cross-sectional quantitative needs assessment (n = 73) and qualitative open-ended input (n = 19) were conducted in June 2011. A latent class analysis modeled six binary health indicators (depression, alcohol use, current smoking, asthma, physical inactivity, overweight status) to identify clusters of presenting health issues.

RESULTS

Four clusters of health indicators emerged: (a) depression; (b) syndemic (all indicators); (c) alcohol use, overweight status; and (d) smoking, physical inactivity, overweight status. Transphobic discrimination in health care and avoiding care were each associated with membership in the syndemic class. Qualitative themes included personal health care needs, community needs, and resilience and protective factors.

CONCLUSIONS

Findings fill an important gap about the health of transmasculine communities, including the need for public health efforts that holistically address concomitant health concerns.

Gender Affirmation: A Framework for Conceptualizing Risk Behavior among Transgender Women of Color

Experiences of stigma, discrimination, and violence as well as extreme health disparities and high rates of sexual risk behavior and substance use have been well-documented among transgender women of color. Using an intersectional approach and integrating prominent theories from stigma, eating disorders, and HIV-related research, this article offers a new framework for conceptualizing risk behavior among transgender women of color, specifically sexual risk behavior and risky body modification practices. This framework is centered on the concept of 'gender affirmation,' the process by which individuals are affirmed in their gender identity through social interactions. Qualitative data from 22 interviews with transgender women of color from the San Francisco Bay Area in the United States are analyzed and discussed in the context of the gender affirmation framework.

Gender Affirmation: A Framework for Conceptualizing Risk Behavior among Transgender Women of Color

Experiences of stigma, discrimination, and violence as well as extreme health disparities and high rates of sexual risk behavior and substance use have been well-documented among transgender women of color. Using an intersectional approach and integrating prominent theories from stigma, eating disorders, and HIV-related research, this article offers a new framework for conceptualizing risk behavior among transgender women of color, specifically sexual risk behavior and risky body modification practices. This framework is centered on the concept of 'gender affirmation,' the process by which individuals are affirmed in their gender identity through social interactions. Qualitative data from 22 interviews with transgender women of color from the San Francisco Bay Area in the United States are analyzed and discussed in the context of the gender affirmation framework.

Coming out for a third time: transmen, sexual orientation, and identity

Female-to-male (FTM) transgender persons are often assumed to have been lesbian in sexual orientation prior to transition and to have maintained a primary attraction for women after transition. However, limited research and anecdotal information from clinicians who work with FTM have indicated that many identify as gay men post-transition. This article described the results of a qualitative study that employed interviews with 17 FTM in order to understand their experience of transition and sexual orientation. Of the 17 participants, seven identified as lesbian prior to transition, three as heterosexual, and seven as bisexual or queer. After transition, 10 identified as gay men and the remaining seven identified as bisexual or queer. Four patterns of sexual behavior emerged from the data and were described and discussed. These patterns were named steadfast, aligned, shifted, and fluid. These findings bring additional options to the belief that there are two distinct types of transgender: a homosexual subtype and a nonhomosexual subtype.

Sexual Health of Trans Men Who Are Gay, Bisexual, or Who Have Sex with Men: Results from Ontario, Canada

Recent reports have addressed the sexual health of female-to-male transgender or transsexual people who are gay, bisexual, and/or have sex with men (trans GB-MSM) using urban convenience samples. The Trans PULSE Project conducted a multimode, respondent-driven sampling survey in Ontario, Canada, in 2009-2010. Weighted estimates were calculated for trans GB-MSM (n = 173) for sexual orientation, behavior, partners, and HIV-related risk, as well as for psychosocial stressors and sexual satisfaction. An estimated 63.3% (95% CI [50.4, 73.5]) of trans men were GB-MSM (173/227). Results indicate great diversity in sexual behavior and experiences. Implications for sexual health promotion, counseling, and medical care are addressed.

Gender Affirmation: A Framework for Conceptualizing Risk Behavior among Transgender Women of Color

Experiences of stigma, discrimination, and violence as well as extreme health disparities and high rates of sexual risk behavior and substance use have been well-documented among transgender women of color. Using an intersectional approach and integrating prominent theories from stigma, eating disorders, and HIV-related research, this article offers a new framework for conceptualizing risk behavior among transgender women of color, specifically sexual risk behavior and risky body modification practices. This framework is centered on the concept of 'gender affirmation,' the process by which individuals are affirmed in their gender identity through social interactions. Qualitative data from 22 interviews with transgender women of color from the San Francisco Bay Area in the United States are analyzed and discussed in the context of the gender affirmation framework.

High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: a province-wide respondent-driven sampling survey

BACKGROUND

Studies of HIV-related risk in trans (transgender, transsexual, or transitioned) people have most often involved urban convenience samples of those on the male-to-female (MTF) spectrum. Studies have detected high prevalences of HIV-related risk behaviours, self-reported HIV, and HIV seropositivity.

METHODS

The Trans PULSE Project conducted a multi-mode survey using respondent-driven sampling to recruit 433 trans people in Ontario, Canada. Weighted estimates were calculated for HIV-related risk behaviours, HIV testing and self-reported HIV, including subgroup estimates for gender spectrum and ethno-racial groups.

RESULTS

Trans people in Ontario report a wide range of sexual behaviours with a full range of partner types. High proportions - 25% of female-to-male (FTM) and 51% of MTF individuals - had not had a sex partner within the past year. Of MTFs, 19% had a past-year high-risk sexual experience, versus 7% of FTMs. The largest behavioural contributors to HIV risk were sexual behaviours some may assume trans people do not engage in: unprotected receptive genital sex for FTMs and insertive genital sex for MTFs. Overall, 46% had never been tested for HIV; lifetime testing was highest in Aboriginal trans people and lowest among non-Aboriginal racialized people. Approximately 15% of both FTM and MTF participants had engaged in sex work or exchange sex and about 2% currently work in the sex trade. Self-report of HIV prevalence was 10 times the estimated baseline prevalence for Ontario. However, given wide confidence intervals and the high proportion of trans people who had never been tested for HIV, estimating the actual prevalence was not possible.

CONCLUSIONS

Results suggest potentially higher than baseline levels of HIV; however low testing rates were observed and self-reported prevalences likely underestimate seroprevalence. Explicit inclusion of trans people in epidemiological surveillance statistics would provide much-needed information on incidence and prevalence. Given the wide range of sexual behaviours and partner types reported, HIV prevention programs and materials should not make assumptions regarding types of behaviours trans people do or do not engage in.

Transmen: the HIV risk of gay identity

Many female-to-male transgender individuals, or transmen, are situated within the gay community, one of the highest risk communities for HIV, yet there has been little research regarding the experience of risk for these transmen. Seventeen transmen were interviewed regarding their sexuality and HIV risk behavior. Fourteen of the 17 reported having non-trans gay men as sexual partners. Risk behaviors included not using condoms with multiple partners who were HIV-positive, or of unknown HIV status. Aspects of risk included the unfamiliarity of the gay community and the lack of safe sex negotiating skills. The dynamics of acceptance and rejection between transmen and non-trans gay men impacted risk by compromising safety. Incorrect assumptions regarding transmen, non-trans gay men, and risk included beliefs that neither person could be at risk. Other aspects included the impact of testosterone on sexual behavior, the changed bodies of transmen, and sex work.

HIV in transgender communities: syndemic dynamics and a need for multicomponent interventions

Transgender communities are among the groups at highest risk for HIV infection in the United States. Using syndemic theory, we examine how HIV risk in transgender communities is embedded in multiple co-occurring public health problems, including poor mental health, substance use, violence and victimization, discrimination, and economic hardship. Although safer sex counseling and testing programs are essential platforms for HIV intervention, these modalities alone may be insufficient in reducing new infections. Multicomponent interventions are necessary to respond to the complex interacting syndemic factors that cumulatively determine HIV vulnerability in transgender individuals.

A mixed methods study of the sexual health needs of New England transmen who have sex with nontransgender men

The sexual health of transmen--individuals born or assigned female at birth and who identify as male--remains understudied. Given the increasing rates of HIV and sexually transmitted diseases (STDs) among gay and bisexual men in the United States, understanding the sexual practices of transmen who have sex with men (TMSM) may be particularly important to promote sexual health or develop focused HIV prevention interventions. Between May and September 2009, 16 transmen who reported sexual behavior with nontransgender men completed a qualitative interview and a brief interviewer-administered survey. Interviews were conducted until redundancy in responses was achieved. Participants (mean age, 32.5, standard deviation [SD] = 11.1; 87.5% white; 75.0% "queer") perceived themselves at moderately high risk for HIV and STDs, although 43.8% reported unprotected sex with an unknown HIV serostatus nontransgender male partner in the past 12 months. The majority (62.5%) had used the Internet to meet sexual partners and "hook-up" with an anonymous nontransgender male sex partner in the past year. A lifetime STD history was reported by 37.5%; 25.0% had not been tested for HIV in the prior 2 years; 31.1% had not received gynecological care (including STD screening) in the prior 12 months. Integrating sexual health information "by and for" transgender men into other healthcare services, involving peer support, addressing mood and psychological wellbeing such as depression and anxiety, Internet-delivered information for transmen and their sexual partners, and training for health care providers were seen as important aspects of HIV and STD prevention intervention design and delivery for this population. "Embodied scripting" is proposed as a theoretical framework to understand sexual health among transgender populations and examining transgender sexual health from a life course perspective is suggested.