A psychosocial study of male-to-female transgendered and male hustler sex workers in São Paulo, Brazil

Reducing intersectional stigma among transgender women in Brazil to promote uptake of HIV testing and PrEP: study protocol for a randomised controlled trial of Manas por Manas

INTRODUCTION

Globally, transgender ('trans') women experience extreme social and economic marginalisation due to intersectional stigma, defined as the confluence of stigma that results from the intersection of social identities and positions among those who are oppressed multiple times. Among trans women, gender-based stigma intersects with social positions such as engagement in sex work and substance use, as well as race-based stigma to generate a social context of vulnerability and increased risk of HIV acquisition. In Brazil, trans women are the 'most at-risk' group for HIV, with 55 times higher estimated odds of HIV infection than the general population; further, uptake of HIV testing and pre-exposure prophylaxis (PrEP) among trans women is significantly lower than other at-risk groups. Through extensive formative work, we developed Manas por Manas, a multilevel intervention using HIV prevention strategies with demonstrated feasibility and acceptability by trans women in Brazil, to address intersectional stigma and increase engagement in the HIV prevention continuum.

METHODS AND ANALYSIS

We are conducting a two-arm randomised wait-list controlled trial of the intervention's efficacy in São Paulo, Brazil, to improve uptake of HIV testing and PrEP among transgender women (N=400). The primary outcomes are changes in HIV testing (self-testing and clinic based), changes in PrEP uptake and changes in PrEP persistence at baseline and follow-up assessment for 12 months at 3-month intervals.

ETHICS AND DISSEMINATION

This study was approved by University of California, San Francisco Institutional Review Board (15-17910) and Comissão Nacional de Ética em Pesquisa (Research Ethics National Commission, CAAE: 25215219.8.0000.5479) in Brazil. Participants provided informed consent before enrolment. We are committed to collaboration with National Institutes of Health officials, other researchers, and health and social services communities for rapid dissemination of data and sharing of materials. The results will be published in peer-reviewed academic journals and scientific presentations.

TRIAL REGISTRATION NUMBER

NCT03081559.

Violence Exposure Among Adolescent Boys and Young Men in Colombia With a Lifetime History of Transactional Sex

PURPOSE

There is a paucity of research examining the contextual factors that shape the violence experienced by those engaged in transactional sex, particularly among adolescent boys and young men. Recognizing the acute vulnerability among youth engaged in transactional sex, this analysis examined the associations between lifetime transactional sex and experience of violence among 13- to 24-year-old males.

METHODS

Using data from two strata of the 2018 Violence Against Children and Youth Survey from Colombia, logistic regressions were used to estimate the association between engagement in transactional sex and violence exposure. Three groups of violence outcomes were examined: violence victimization, violence perpetration, and witnessing violence.

RESULTS

Violence victimization and witnessing violence were widespread. Adolescent boys and young men with a lifetime history of transactional sex were significantly more likely to experience violence victimization than those without a lifetime history of transactional sex, particularly intimate partner violence (adjusted odds ratio [aOR]: 5.23 and 5.41) and caregiver emotional violence (aOR: 7.23 and 8.74). In the national and priority samples respectively, those with a lifetime history of transactional sex were also significantly more likely to witness violence within the home (aOR: 4.42 and 4.99) and outside of the home (aOR: 7.24 and 28.32).

DISCUSSION

Although research is needed to determine causal pathways, our findings highlight the ubiquity of violence and the criticality of supporting this group of adolescent boys and young men. Interventions for those with a history of transactional sex should address factors that may contribute to drivers of violence and transactional sex.

Peer Navigation to Support Transgender Women's Engagement in HIV Care: Findings from the Trans Amigas Pilot Trial in São Paulo, Brazil

Trans women living with HIV (TWH) have suboptimal HIV care engagement. We pilot tested Trans Amigas, a theory-based, trans-specific peer navigation (PN) intervention to address barriers to care in São Paulo, Brazil. TWH were randomized to the PN intervention (n = 75) or control (n = 38) condition. Control participants were referred to trans-friendly HIV care. Intervention participants were assigned a navigator who conducted nine in-person one-on-one sessions and bi-weekly phone or text check-ins to help participants overcome barriers to care and work towards gender affirmation and healthcare goals. We followed participants for 9 months to determine intervention feasibility, acceptability, and preliminary efficacy in improving retention in care. Analyses were intention to treat (ITT). Intervention acceptability was high: at end line, 85.2% of PN participants said they would continue receiving services and 94.4% would recommend peer navigation to a friend. A priori feasibility criteria were met: 92% of eligible participants enrolled and 70% were retained at 9 months; however, only 47% achieved moderate or better adherence to both in-person and phone/text program components. Though the pilot was not powered for efficacy, ITT findings trended toward significance, with intervention participants 40% more likely to be retained in care at the end of the study. Population-specific peer programming to support care engagement is acceptable, feasible, and can improve HIV outcomes for Trans women living with HIV.

Violence Against Male Sex Workers: A Systematic Scoping Review of Quantitative Data

Sex workers are recognized to be potentially vulnerable to violence and abuse. However, the extent and nature of violence committed against male sex workers remains under reported. The aim of this evidence scoping review was to identify the prevalence of violence against male sex workers globally. A systematic search was conducted of 8 databases from 1990 to the end of December 2016. In total, quantitative data from 27 studies conducted in 18 countries were included in the review. Evidence indicates that some male sex workers, especially those in non-Western countries, do experience high levels of violence. The largest proportion of studies reported data on sexual violence, whilst the most common type of violence experienced overall by male sex workers was that of 'verbal or emotional abuse or threats'. The views and experiences of male sex workers should be integrated fully into sex work debates, policy and service provision.

HEALTH VULNERABILITIES OF TRANSGENDER SEX WORKERS: AN INTEGRATIVE REVIEW

ABSTRACT Objective: to identify the health vulnerabilities of transgender sex workers. Method: an integrative review conducted in July 2020 in the PubMed, Web of Science, SCOPUS, CINAHL, IBECS and LILACS databases, with no language or time restrictions. The following descriptors indexed in DeCS and MESH and their respective synonyms were used: “Transgender persons”, “Sex workers” and “Health vulnerability”. The data were analyzed based on thematic analysis. Results: a total of 547 articles were retrieved and, after the selection and analysis process, 34 were included in this review. Four thematic classes emerged: “Knowledge, prevention and exposure to STIs in sex work”; “Use (and abuse) of illegal substances and alcohol”; “The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies”; and “Psychosocial diseases, discrimination and challenges of transgender sex workers”. Conclusion: the health vulnerabilities experienced by transgender sex workers are marked by discrimination, social exclusion, stigma, incarceration contexts, physical, psychological and sexual violence and use of illegal substances and alcohol, in addition to difficulties in accessing essential services such as health, education and leisure.

Optimising HIV programming for transgender women in Brazil

In Brazil, little data is available to inform HIV prevention programming for travestis and transgender ('trans') women, despite the existence of a social movement that has gained strength in recent years. We conducted formative research in Rio de Janeiro to gather trans women's perspectives on combination HIV prevention approaches. Framing the analysis within the model of gender affirmation, we found that several social and contextual factors inhibited participants' access to HIV prevention and treatment. Experienced and anticipated gender-related discrimination and HIV stigma were linked to the avoidance of HIV testing, health services and HIV status disclosure. Participants recommended HIV prevention interventions which combined socio-structural interventions, such as peer-based empowerment and social support, with biomedical interventions such as pre-exposure prophylaxis (PrEP). Participants expressed a preference for programmes and interventions that emphasised a gender-affirmative approach, promoted autonomy and aimed to reduce stigma and discrimination in public health services.

The role of sexual risk behaviors on PrEP awareness and interest among men who have sex with men in Latin America

In Latin America, men who have sex with men (MSM) remain disproportionately impacted by HIV. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool and has been FDA approved in the United States since 2012, but no Latin American state, with the recent exception of Brazil, has implemented PrEP guidelines. We carried out a multinational online survey of MSM in Latin America (n = 22698) in 2012 to assess whether MSM at highest risk of HIV acquisition (i.e., those engaging in condomless anal sex [CAS; n = 2606] and transactional sex [n = 1488]) had higher levels of awareness of PrEP, PrEP use and interest in participating in a PrEP trial. After adjusting for demographic and psychosocial characteristics including depressive symptoms, hazardous alcohol use, childhood sexual abuse, and sexual compulsivity, transactional sex and CAS were associated with increased PrEP awareness (aOR = 1.29, 95% CI: 1.05-1.59, p < .001 and aOR = 1.22, 95% CI: 1.11-1.34, p < .001, respectively) and PrEP trial interest (aOR = 1.45, 95% CI: 1.25-1.71, p < .001 and aOR = 1.74, 95% CI: 1.57-1.95, p < .001, respectively). Findings demonstrate substantial awareness of and interest in PrEP among MSM with behavioral risk factors for HIV in Latin America, suggesting that this region is primed for PrEP implementation, which has been slow.

Male Sex Workers in Spain: What has Changed in the Last Lustrum? A Comparison of Sociodemographic Data and HIV Sexual Risk Behaviors (2010-2015)

The purpose of this study is to compare the evolution of risky factors related to HIV infection among Male Sex Workers (MSW) in Spain between 2010 and 2015. Participants were 180 MSW: 100 in 2010 and 80 in 2015. Socio-demographic characteristics, condom use with clients and personal partners, and other aspects about HIV infection were explored (serostatus, HIV information, perceived risk and fear, and drug use). The proportion of Spanish MSW (nonimmigrants) (5.5 vs. 62.5 %), educational level (19.8 vs. 40.5 % reported university degree), and the percentage of self-identified as bisexual (20.2 vs. 55.8 %) increased in 2015, whereas the percentage of MSW who self-identified as sex workers (62 vs. 25.8 %) decreased. The percentage of condom use has decreased during oral sex (76.8 vs. 35.5 %), vaginal sex (97.6 vs. 50.7 %) and insertive (99.6 vs. 92.2 %) and receptive (99.7 vs. 93 %) anal sex. The proportion of MSW living with HIV climbed from 1.1 to 13.6 %. The possible influence of economic crisis over MSW's profile changes in the 5-year period, and the necessity of more efficient health strategies based on culture and sexual orientation are discussed. The evolution observed indicates that this population is still at high risk for HIV and STI, therefore governmental resources have to be increased due the consequences among MSW and general society.

A cross-sectional study of associations between casual partner, friend discrimination, social support and anxiety symptoms among Chinese transgender women

Anxiety symptoms are the prevalent mental disorders for transgender women. However, only a few studies are available pertaining to this problem among Chinese Transgender women. Chinese Transgender women are a vulnerable population which is exposed to discrimination and loss of social support due to their gender identity and transition. This study was conducted to estimate the prevalence and factors associated with anxiety symptoms among Chinese transgender women. A cross-sectional study was performed by convenience sampling. This comprised of 209 Chinese transgender women in Shenyang, China. The Zung Self-Rating Anxiety Scale (SAS) was used to assess anxiety symptoms for these transgender women. Hierarchical multiple regression analysis was performed to explore the associated factors of SAS. The prevalence of anxiety symptoms in Chinese transgender women was found to be 34.5%. Regression analyses indicated that SAS was associated with casual partnership, friend discrimination and social support in the final model. Sexual partnership and discrimination contributed the most to the model, R-square, accounting for 19.2% and 15.5% of the total variance respectively. Chinese transgender women showed considerably high level of anxiety symptoms. It was also found that they were exposed to significant transition challenges, such as high risk sexual partnership, excessive discrimination and a reduction in social support. Furthermore, anxiety symptoms was best predicted by the absence or presence of a casual partner, friend discrimination and social support rather than the disclosure of their gender identity, knowledge of HIV prevention and health service. Improvement of social support, reduction of friend discrimination and determination of the characteristics of risky sexual partnerships especially for the casual partner can help to attenuate anxiety symptoms and increase mental well-being for transgender women.

Quality of Life of Transgender Women From China and Associated Factors: A Cross-Sectional Study

INTRODUCTION

Transgender women are exposed to stressful situations such as gender transition and transition-related discrimination because of their limited acceptance by the general population and inadequate government-supplied resources, which can compromise their quality of life (QOL). However, there is a paucity of research on the QOL of transgender women from China.

AIMS

To assess the QOL of transgender women from China and explore its associated factors.

METHODS

A cross-sectional study was performed by convenience sampling in Shenyang, China from January 2014 to July 2014. This sample consisted of 209 transgender women. The women were interviewed face-to-face to assess their QOL and related factors using the 36-item Short-Form Health Survey, the Adult Dispositional (Trait) Hope Scale, and the EGO Resilience Scale.

MAIN OUTCOME MEASURES

Response scores were calculated based on a questionnaire design. Hierarchical multiple regression analysis was performed to explore factors associated with QOL.

RESULTS

Transgender women who used hormone therapy reported significantly lower levels of the physical component summary (PCS) and the mental component summary (MCS) compared with those who did not (P < .05). Hierarchical multiple regression analysis showed that of the 23 independent variables, 8 were significantly associated with the PCS and 9 were significantly associated with the MCS. The PCS was significantly and negatively associated with age and being chased or insulted by law enforcement officials. The PCS was positively associated with not using hormone therapy, having no casual partners, less discrimination from friends, knowledge of HIV prevention, hope, and resilience. Educational level and being chased or insulted by law enforcement officials were negatively associated with the MCS, whereas not using hormone therapy, having no regular partners or casual partners, less discrimination from friends, less social discrimination, knowledge of HIV prevention, and hope were positively associated with the MCS.

CONCLUSION

Chinese transgender women reported high levels of physical QOL but low levels of mental QOL. Their mental QOL was more pronounced than their physical QOL. Transition status and sexual partnership played the most important roles in physical and mental health. Furthermore, mental QOL was best predicted by assessing positive capabilities, such as levels of hope. Future interventions should focus on recognizing transition status and identifying risky sexual partnerships, especially for the casual partners involved in these partnerships. In addition, positive capabilities are needed to ameliorate the negative impact of transition on QOL in Chinese transgender women.

A new public health context to understand male sex work

Background

Researching male sex work offers insight into the sexual lives of men and women while developing a more realistic appreciation for the changing issues associated with male sex work. This type of research is important because it not only reflects a growing and diversifying consumer demand for male sex work, but also because it enables the construction of knowledge that is up-to-date with changing ideas around sex and sexualities.

Discussion

This paper discusses a range of issues emerging in the male sex industry. Notably, globalisation and technology have contributed to the normalisation of male sex work and reshaped the landscape in which the male sex industry operates. As part of this discussion, we review STI and HIV rates among male sex workers at a global level, which are widely disparate and geographically contextual, with rates of HIV among male sex workers ranging from 0% in some areas to 50% in others. The Internet has reshaped the way that male sex workers and clients connect and has been identified as a useful space for safer sex messages and research that seeks out hidden or commonly excluded populations.

Future directions

We argue for a public health context that recognises the emerging and changing nature of male sex work, which means programs and policies that are appropriate for this population group. Online communities relating to male sex work are important avenues for safer sexual messages and unique opportunities to reach often excluded sub-populations of both clients and male sex workers. The changing structure and organisation of male sex work alongside rapidly changing cultural, academic and medical discourses provide new insight but also new challenges to how we conceive the sexualities of men and male sex workers. Public health initiatives must reflect upon and incorporate this knowledge.

Transactional sex among men who have sex with men in Latin America: economic, sociodemographic, and psychosocial factors

OBJECTIVES

We assessed factors associated with engagement in transactional sex among men who have sex with men recruited from one of the largest Internet sites for men seeking social or sexual interactions with other men in Latin America.

METHODS

We constructed multilevel logistic regression models to analyze factors associated with engagement in transactional sex in 17 Latin American countries in 2012.

RESULTS

Of 24 051 respondents, 1732 (7.2%) reported being paid for sexual intercourse in the past 12 months. In a multivariable model, higher country-level unemployment was associated with increased odds of transactional sex (adjusted odds ratio [AOR] = 1.07 per 1% increase in unemployment; 95% confidence interval [CI] = 1.00, 1.13). Individual or interpersonal factors associated with increased odds of engagement in transactional sex included self-reported HIV (AOR = 1.33; 95% CI = 1.04, 1.69) or sexually transmitted infection (AOR = 1.33; 95% CI = 1.11, 1.59), childhood sexual abuse history (AOR = 1.75; 95% CI = 1.48, 2.06), intimate partner violence (past 5 years, AOR = 1.68; 95% CI = 1.45, 1.95), and sexual compulsivity (AOR = 1.77; 95% CI = 1.49, 2.11).

CONCLUSIONS

Structural-level economic interventions and those that address individual and interpersonal factors may improve HIV prevention efforts among men who have sex with men who engage in transactional sex.

A Preliminary Model of Motivation for Pornography Consumption Among Men Participating in Zoophilic Virtual Environments

Although zoophilic blogs and websites attract the attention of zoophiles and others who are curious about this sexual activity, the motivations for consuming this type of pornography are not clear. This study aimed to confirm the factorial validity of the Pornography Consumption Inventory in an online sample of men with sexual interest in animals, and to construct an association model between motivations for pornography consumption and the following psychological variables: depression, sexual impulsiveness, and strength of sexual interest in animals. In this cross-sectional study, we located a website that catered to a network of people with a sexual interest in animals. Subsequently, a questionnaire was made available online to members of this network. Results support the 4-factor model of the Pornography Consumption Inventory. Depression and strength of sexual interest in animals were negatively and positively correlated with the sexual curiosity factor, respectively. Sexual impulsiveness was positively associated with the emotional avoidance, excitement seeking, and sexual pleasure factors. Depression and sexual impulsiveness were positively correlated. Psychological factors can differently motivate the consumption of pornography among men who visit zoophilic blogs and websites. With these preliminary data, we can identify some characteristics of this population.

HIV prevention interventions for young male commercial sex workers

The sex industry, where men sell sexual services to other men or women, has grown in recent years. These men who offer sexual services are particularly vulnerable to HIV infection due to such factors as: frequency of risky sexual practices, number of sex partners, drug-taking, prevalence of sexually-transmitted infections (STI) and their specific situation of social exclusion which may hinder access to health services. These multi-faceted realities faced by sex workers explain the burgeoning interest in new avenues of scientific research. There are too few preventive programs however aimed at this population group and the studies that evaluate their effectiveness are fewer still. In this article we survey more recent studies on the difficulties of implementing programs for HIV prevention in male sex workers (MSW), as well as the studies that have gauged the impact of preventive programs in this group.

Global burden of HIV among men who engage in transactional sex: a systematic review and meta-analysis

BACKGROUND

Men who engage in transactional sex, the exchange of sex for money, goods, or other items of value, are thought to be at increased risk of HIV, but there have been no systematic attempts to characterize HIV burden in this population. We undertook a systematic review and meta-analysis to quantify the burden in this population compared with that of men in the general population to better inform future HIV prevention efforts.

METHODS

We searched seven electronic databases, national surveillance reports, and conference abstracts for studies of men who engage in transactional sex published between 2004-2013. Random effects meta-analysis was used to determine pooled HIV prevalence and prevalence ratios (PR) for the difference in HIV prevalence among men who engage in transactional sex as compared to general population men.

FINDINGS

Of 66 studies included representing 31,924 men who had engaged in transactional sex in 28 countries, pooled biological assay-confirmed HIV prevalence was 10.5% (95% CI = 9.4 to 11.5%). The highest pooled HIV prevalence was in Sub-Saharan Africa (31.5%, 95% CI = 21.6 to 41.5%), followed by Latin America (19.3%, 95% CI = 15.5 to 23.1%), North America (16.6%, 95% CI = 3.7 to 29.5%), and Europe (12.2%, 95% CI = 6.0 to 17.2%). Men who engaged in transactional sex had an elevated burden of HIV compared to the general male population (PR = 20.7, 95% CI = 16.8 to 25.5).

CONCLUSIONS

The global burden of HIV is disproportionately high among men who engage in transactional sex compared with the general male population. There is an urgent need to include this population in systematic surveillance as well as to scale-up access to quality HIV prevention programs.

Client demands for unsafe sex: the socioeconomic risk environment for HIV among street and off-street sex workers

OBJECTIVE

Among sex workers (SWs) in Vancouver, Canada, this study identified social, drug use, sex work, environmental-structural, and client-related factors associated with being offered and accepting more money after clients' demand for sex without a condom.

DESIGN

Cross-sectional study using baseline (February 2010 to October 2011) data from a longitudinal cohort of 510 SWs.

METHODS

A 2-part multivariable regression model was used to identify factors associated with 2 separate outcomes: (1) being offered more money for sex without a condom in the last 6 months; and (2) accepting more money, among those who had been offered more money.

RESULTS

The sample included 490 SWs. In multivariable analysis, being offered more money for sex without a condom was more likely for SWs who used speedballs, had higher average numbers of clients per week, had difficulty accessing condoms, and had clients who visited other SWs. Accepting more money for sex without a condom was more likely for SWs self-reporting as a sexual minority and who had experienced client violence and used crystal methamphetamine less than daily (versus none) and less likely for SWs who solicited mainly indoors for clients (versus outdoor/public places).

CONCLUSIONS

These results highlight the high demand for sex without a condom by clients of SWs. HIV prevention efforts should shift responsibility toward clients to reduce offers of more money for unsafe sex. Programs that mitigate the social and economic risk environments of SWs alongside the removal of criminal sanctions on sex work to enable condom use within safer indoor workspaces are urgently required.

Perceived discrimination and depression among low-income Latina male-to-female transgender women

Background

This study examines exposure to perceived discrimination and its association with depression among low-income, Latina male-to-female transgender women as well as evaluates the impact of sexual partner violence and mistreatment on depression.

Methods

A total of 220 Latina male-to-female transgender women who resided in Los Angeles, California, were recruited through community based organizations and referrals. Participants completed individual interviews using a structured questionnaire. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9). Perceived discrimination was assessed using a fifteen-item measure that was designed to assess the experiences of maltreatment of transgender individuals. Multinomial logistic regression was used to examine the association between perceived discrimination and depression after controlling for the presence of other variables.

Results

Of the sample, 35% reported significant depressive symptoms (PHQ-9 ≥ 15). Additionally, one-third of the participants indicated that in the two weeks prior to the interviews they had thought either of hurting themselves or that they would be better off dead. The extent of perceived discrimination in this population was extensive. Many of the participants experienced discrimination on a daily basis (14%) or at least once or twice a week (25%) as demonstrated by a positive response to at least 7 of 15 items in the measure of perceived discrimination. Almost six out of ten participants admitted that they had been victims of sexual partner violence. Those who reported more frequent discrimination were more likely to be identified with severe depression. There was also a notable association between self-reported history of sexual partner violence and depression severity.

Conclusions

A significant association between depression severity and perceived discrimination was identified. How exposure to discrimination leads to increased risk of mental health problems needs additional investigation. Models investigating the association between perceived discrimination and depression among transgender women should include sexual partner violence as a potential confounding variable.