Caught between different worlds: how transgendered women may be "forced" into risky sex.

Evidence suggests that HIV incidence among transgendered women (biological males who have adopted the gender-role identity of a woman) is exceptionally high (Clements-Noelle, Marx Guzman, & Katz, 2001; Elifson et al., 1993; Kellog, Clements-Noelle, Diley, Katz, & McFarland, 2001; Kenagy, 2002; Nemoto, Operario, Keatley, Han,& Soma, 2004). Incidence may be greatest among African American transgendered women (Clements-Noelle, Marx Guzman, & Katz, 200; Nemoto et al., 2004). For example, in a study of nearly 400 transgendered women, the overall prevalence of HIV was 35%, with the African Americans being nearly six times more likely than their White counterparts to be infected (Clements-Noelle et al., 2001).

Clearly, transgendered women are a marginalized population in the United States. The associated stigma and loss of economic opportunity may place many transgendered women in circumstances that lead to commercial sex work (Bockting, Robinson, & Rosser, 1998; Elifson et al., 1993; Nemoto, Operario, Keatley, Han,& Soma, 2004; Nemoto, Operario, Keatley, Villegas, 2004). Further, economic deprivation may preclude transgendered women from medical care thereby necessitating they obtain injections of silicone and hormones from street vendors (Wiessing, van Roosmalen, Koedijk, Bielman, & Houweling, 1999). Lack of condom use during sex work combined with potential exposure to HIV from contaminated needles/syringes magnify HIV risk for this population.

Prevalence of HIV risk behavior among transgendered women may be greater than that of gay men, bisexual men, and heterosexual women (Nemoto, Luke, Mamo, Ching, & Patria, 1999). From a psychosocial perspective, the search for effective HIV intervention strategies is dependent upon improved understanding of life circumstances experienced by transgendered women. The required depth of this understanding may best be achieved by qualitative research. Unfortunately, only a few such studies have been published. A recent study found that transgendered women had unprotected sex with primary partners to feel emotionally connected and to validate their gender identity. Transgendered women reported using drugs to cope with stress pertaining to sex work, transphobia, and economic deprivation (Nemoto et al., 2004). A less recent study found that transgendered women experienced a host of issues ranging from sexual identity conflict, shame, and isolation to compulsive sexual behavior, sex work, and shared needles for hormone injections (Bockting et al., 1998). Given the magnitude of HIV risk and the potential to develop effective intervention strategies for transgendered women, expanded qualitative research efforts are warranted.

Accordingly, the purpose of this study was to qualitatively explore potential reasons why transgendered women may engage in sexual risk behavior that could lead to their acquisition of HIV infection. Specifically, we conducted this investigation with a sample comprised predominately of transgendered women who identified as Black or African American and who resided in a large metropolitan area of the Southern United States.

Method

Study Sample

In late 2004 through early 2005, 17 transgendered women were enrolled in this qualitative study. The study co-investigator (Nicole L. Pitts) actively solicited the participation of transgendered women through gay, lesbian, bisexual, and transgender (GLBT) groups and through organizations that provided support group meetings specifically for transgendered women. Persons were also recruited from two venues known to attract transgendered women (a cafe and coffee house). Referrals were also used (i.e., transgendered woman who completed an interview may have referred another transgendered woman to the study). Potential volunteers were asked whether they would be willing to answer three questions: (1) Do you consider yourself to be a transgendered woman?, (2) Are you knowingly HIV positive?, and (3) Are you between the ages of 18 and 45 years? Women who identified as transgendered, who stated they were not knowingly HIV positive, and who indicated being 18 years of age or older, but not more than 35, were asked for their willingness to volunteer in a study designed to investigate HIV risk behavior of transgendered women. To preserve anonymity, a waiver of written informed consent was obtained. The Institutional Review Board at the University of Kentucky approved the study protocol. A $25 incentive was provided to all study participants.

Data Collection

Interviews occurred in a private area agreeable to study participants. Because recruitment occurred in public places, private areas were most often nearby restrooms, stairwells, or in eating establishments. Interviews lasted, on average, about 30 min. The interviewer was trained by investigators at Emory University and the Centers for Disease Control and Prevention and she possessed ample experience interviewing people (mostly gay men) about their sexual behavior. She also openly identified as a transgendered woman. All interviews were recorded on audiotape.

Structured Questions

To facilitate women's responses we used a semistructured interview instrument. Women were first asked to state their racial identification, age, income, and education level and to state how they publicly identify, for example, transgender and straight (meaning a biological male who has adopted the gender-role identity of a woman and has sex with biological men); transgender and gay (meaning a biological male who has adopted the gender-role identity of a woman and has sex with biological women). To assess women's thought processes regarding HIV and other STDs, the interviewer asked questions regarding whether the participants had ever been tested for HIV and about any STDs they may have been diagnosed with at any point in their lives. Subsequently, women were asked to describe their risk for HIV/STD and to compare their risk behavior both to women who are not transgendered and to other women who are transgendered.

Data Analysis

The first author (Richard A. Crosby) listened to all audiotaped interviews and transcribed the data. Subsequently, he sorted the responses into themes by using grounded theory. Nicole L. Pitts also listened to the interviews and subsequently verified these themes.

Results

Characteristics of the Sample

All women identified as transgendered, with 14 of them stating they were currently taking hormones. None stated they had undergone sex reassignment surgery. Fourteen of the women identified as Black/African American. Four women stated they were currently in a relationship with a steady boyfriend, and one was in a steady relationship with a girlfriend. Only a few of the women indicated earning more than $20,000 per year, yet the majority (n = 11) indicated having an education of at least "some college" or vocational school beyond high school. Eight of the women were currently or recently involved in commercial sex work (street work). Six identified as "transgendered straight," 5 identified as "straight females," 2 as "bisexual females," 2 as "transgendered gay," 1 as "transgendered bisexual," and 1 as "other" (not specified).

Theme One: Looking for Love

Women commonly reported they had a strong need/desire to be loved by a man. Many of these women stated they had and would engage in unprotected sex to obtain and preserve such a relationship. For example, one woman stated, "I get a lot of negative feeling from society--all aspects--men who treat you nice are rare--you don't want to lose this over condoms." Another suggested that, "trans (referring to herself and others like her) have a need to accepted--will reach out to anyone who cares and will run out and have sex to get love where [they] can--guys know you are weak for love and affection." Another stated, "The masculine guys make me feel girlish--I give riskier behavior to that feeling." Yet another woman suggested that even abusive relationships are good because she gets money, support, and "acceptance as a girl." Other women made comments such as "I want to be treated like a girl--a lady--the whole experience" and "I'm looking for a man to love me for me--not because I'm transsexual." One woman succinctly said, "Its about caring and feelings--being with a man makes me feel more like a lady." This sentiment was expressed by another woman who said she had sex with a guy, who she later found was HIV-positive, without using a condom because he "treated me like a lady." Part of this theme included a sentiment that such acceptance by a man may be very hard to find: "Sometimes you play Russian roulette--caught between two worlds--when someone does accept you, you'll do anything." One woman described the difficulty as coming down to "trying be loved as a woman by man."

Theme Two: Hormones Are Vital

All except 3 women were currently using female hormones to establish and maintain a feminine appearance. Nine of these women obtained their hormones through nonmedical means, including the Internet, transgendered friends, and street vendors. For these women, obtaining hormone injections often involved sharing needles and syringes thereby adding to their risk of HIV infection. As one woman noted, "Sometimes you have to share [needles]--I need these [hormones] to pass and be a little accepted." Many of these women purchased injections from street vendors: "[You] go by the corner and let them hit you--give em' your $20." Another stated that she obtains hormones from a girlfriend and they inject together and she added, "we clean these [needles] with alcohol." Yet another woman intimated that only sharing the injection equipment with girlfriends was a protective strategy. Several women stated they were well aware of the HIV risk imposed by sharing needles and syringes but that clean injection equipment was hard to obtain. An African American woman perceived that White girls could probably convince a pharmacist to sell them clean needles/syringes, but Black girls would not have the same luxury: "Clean needles are hard to come across--to buy--a White girl could buy them."

Although not expressed commonly, a few other issues related to hormones warrant mention. One woman astutely noted that sex reassignment surgery was not an option based on her low income: "Without money it's [surgery] not much of an issue--hormones are the key." Another woman stated that sex is not an issue or concern for her and that, instead, the issue is transitioning to "being a girl." Indeed, women's strong perceived need for constant use of hormones was apparent in the remarks of many women who said they sometimes sell (or have sold in the past) sex to obtain hormones. The actual composition of hormones sold on the streets was also considered by a few women. One said she had purchased "hormone injections" that turned out to be mostly water. Again, the premise that friends can be trusted was apparent: "Get my hormones from truthful girls (they get theirs from a doctor)." Finally, one woman had a very interesting perspective on HIV and hormone use. When speaking about her fears of ever getting HIV, she stated, "You can't take hormones if you have HIV." The implication of her statement is that one fear of becoming HIV positive involves a risk of having to discontinue hormone use.

It is important to note that differences between the women in the sample existed relative to hormone use. As one woman noted, "I'm different than other T-girls. I don't need to change [use hormones] to feel accepted." In discussing her risk of HIV infection, another woman said, "Being trans does not place me at greater risk--no street sex, and I get professional injections of estrogen."

Theme Three: Street Sex Is Common

Even women who had not engaged in prostitution (street sex) suggested that this practice is a part of life for transgendered women. As one woman said, "I thank God that I have not had to turn a trick for a sandwich, but I might have to next week." Most women who had engaged in street sex did so on the basis of discrimination in the job market, leaving street sex as the only viable option: "T-girls are being forced into [risky sex] out in [the] streets with no one caring--no one takes them in." Another stated, "Society is the biggest risk ... it negatively pushes us [T-girls] into doing things.... Prostitution is a way of life because we are kicked out of the loop" (n = 9).

As is common in prostitution, women reported earning more money for street sex when condoms were not used: "You have to make money when you can--men won't date you if you want to use condoms." The need for money was also apparent in comments such as: "You don't have time to think to get a condom--you need the $100." Another woman said, "I insist on using condoms 75% of the time--the other 25% will pay more if we don't use one." Another said, "I go out four times a week and have 3 to 5 guys each time--[I] try to always use condoms, but ..." Discrimination on the employment market was frequently blamed on a mismatch between legal identifications records (indicating male sex) and outward identification (indicating female gender): As succinctly put by one woman, "I lose jobs because I won't give up women's clothes."

Several women specifically described an irony about their negative standing with society daring the day but their apparent value to men buying sex at night. "Men come to me because they think I'm a woman--they buy me things--I perform oral sex without cure, but with romance situations we may have anal sex." Another noted, "[They] make fun of you in the day but try to pick you up at night." Another woman currently selling sex on the streets said, "Men don't want me except for sex--it's all you are good for." In a related manner, some of the women described night hours as a time when they could "pass" and therefore gain validation of their feminine identity. This feeling included the practice of having street sex. As noted by one woman during her description of street sex, "You can be a girl." Another woman suggested that transgendered women go to the streets for acceptance, and some girls only get love from their pimps and their customers.

Women involved in street sex typically described drug use as part of the street sex environment. A common sentiment was, "Drugs make sex work tolerable." One woman who stated her occupation was a "show girl" (and did not report selling sex) said, "I take drugs, especially in this environment [clubs]; it is big in the trans community and most show girls do drugs."

Women selling sex and not using condoms were very aware of their elevated risk of HIV infection. Several noted they insisted on condom use for anal sex. For example, "Money affects my decision to use condoms--[I] will take a chance [sometimes] if I need money for clothes, hormones, etc...." but only for oral--"always use for anal"--its not worth the risk--I don't want to be killed." Another woman emphatically stated that she always used condoms for street work. Some women selling sex were also keenly aware that men choosing to have sex with transgendered women may be very likely to have HIV: "A lot of men go back and forth between straight and trans women--they keep it [the AIDS epidemic] going." Some women (including those not selling sex) suggested that HIV-positive men may intentionally try to infect transgendered women. For example, one woman (who had sex with 30 male partners in the past year) suggested that most guys who are HIV-positive won't disclose this and thus it's risky to have sex with them and that some "purposely want to infect t-women." This perception included STDs. As stated by another woman, "Guys may not care about t-girls so they may not care about preventing transmission of STDs to them."

Theme Four: Discrimination and HIV Risk

Another common theme extracted from women's narrative is that their HIV risk is tied to societal discrimination and transphobia. For example, one woman stated, "Society, even gay people, discriminate against you--society puts me at risk [for HIV]." Perceptions of discrimination were diverse. This sentiment, expressed by 1 woman, may be typical: "You love who you are but the world doesn't." Discrimination problems included very specific issues such as not being accepted in homeless shelters ("Can't go to a homeless shelter looking like me--they make you feel like a trouble maker.") as well as a more generalized sense of discrimination ("Society can make trans women feel low (low self-esteem) creating a stigma--a fatalism--regarding HIV risk."). Moreover, discrimination problems pertaining to HIV prevention were described. For example, 1 woman stated, "Prevention (HIV) material is not geared to us." Another woman was talking about HIV prevention posters and remarked, "Nobody looks like me." Yet another stated, "Being trans is a greater risk [than not being trans]; we are not being reached--the public doesn't understand us." Although not typical of the women interviewed, 1 woman's statement was quite profound: "Trans is a jail--dealing with self- and public issues--I don't know where I fit in." In the last few minutes of her interview, 1 women urgently expressed that t-girls need to have more information about condoms--"something so simple can keep you from dying--you're not going to get AIDS just because your transsexual." The discrimination women experienced included discrimination from gay men. At a minimum, women felt that their HIV prevention needs greatly different from those of gay men, and therefore they were not being well served by current services and programs. This included broader issues such as support groups ("Gay support groups are no good--they don't deal with my issues."

Discussion

The four themes identified in these interview with 17 transgendered women are all linked to a larger picture of HIV risk. Several observations stemming from the combined themes are therefore warranted. First, these women exist in a reality that involves multiple and formidable barriers to the practice of safer sex. Their desire to find love with a man may be entwined with their need for acceptance and economic support. One could argue that these dynamics mimic those experienced by biological women. However, a key difference may be that transgendered women have been placed (by society) in the extremely difficult position of working in minimum-level occupations while being faced with the task of obtaining a constant supply of hormones and having to cope with the discrimination imposed upon society (including the gay community) against transgendered women.

A second key difference between transgendered women and biological women may also be useful to consider with respect to the dynamics of engaging in risky sex. Narratives from many of the women in this study included the terms "girl" and "lady." Although speculative, it is conceivable that many transgendered women may perceive a need to be ultra-feminine (as suggested by the use of these terms). To the extent that an ultra-feminine identity is adopted, transgendered women may consequently feel that submission to male sexual desire is part of their gender-role identity. Thus, in the context of an ongoing struggle to achieve their feminine gender identity, transgendered women may be far more likely than biological women to forego sexual safety to meet their psychological (identity-based) needs.

Although some of the women talked about "always" using condoms, others suggested that this is a difficult and even impractical task. They suggested that condoms maybe antithetical to achieving and maintaining a meaningful relationship with men. Some women also indicated that condoms were problematic when selling sex to men. In either case, it should be recognized that transgendered women were very much seeking to validate their identities as women, and such efforts typically imply that their role in sexual encounters is receptive rather than insertive. Thus, condom use was a task of negotiation and, unfortunately, women may have had very little bargaining power because of the associated stigmas and discrimination connected to being transgendered. This lack of condom use may be more dangerous for transgendered women than biological women for two reasons: (1) Men who have sex with transgendered women may be more likely to have (and not disclose) HIV (a perception expressed by several women interviewed) and (2) anal receptive sex may impose greater risk of HIV infection (because of easier tearing and abrasion) than penile-vaginal sex.

Second, about one half of the women can be characterized as experiencing HIV risk on the basis of their exposure (current or past) to unclean needles and syringes used to inject street-based hormones. The potential importance of this risk factor should not be underestimated, given that hormones are quite likely one of the most vital needs (if not he most vital) of transgendered women. For women with the ability to obtain their hormones within a medical context the safety issues are resolved, but for so many others the drive to "feminize" may be pushing them into injection behaviors that result in HIV acquisition. Because hormones are not a drug, it is conceivable that transgendered women are unlikely to perceive themselves as injection drug users (IDUs), thereby making them potentially oblivious to prevention messages and programs promoting the use of clean needles/syringes among IDUs.

Third, the apparent disconnect between transgendered women and the gay community (not to mention the general community) is clearly a risk factor for HIV. The absence of social and emotional support networks may be pushing women into risky sexual relationships in their attempts to find love and acceptance. Further, the absence of identification with HIV prevention messages and programs may leave many transgendered women in a lurch with respect to basic information, motivation, and skills needed to adopt HIV protective behaviors (condom use and--if applicable--clean injection practices). The more insipid consequence of being marginalized as transgendered women is the all too common lack of a place for these women in the job market, thereby forcing the issue of street sex. For so many women in this study, all of the discrimination issues could potentially be compounded by also being African American. One woman captured this by saying that being African American, transsexual, a sex worker, and jobless was "everything possible to destroy you."

Implications

In 1999, the American Public Health Association (2000) passed a resolution to intensify efforts pertaining to transgender health issues. Clearly, the prevention of HIV acquisition and transmission is one of these issues, and other issues (e.g., stigma, depression, lack of medical insurance) may exacerbate HIV risk taking behaviors. From an anatomical point of view, it is important to bear in mind that transgendered women are quite likely to be receiving partners in unprotected anal sex--a risk behavior that is relatively likely to transmit HIV from an infected partner. However, from a sociocultural perspective it is critical to note that transgendered women may experience life in a world that is far different than that of gay men. Intervention strategies that fail to recognize this distinction may not be effective.

The findings intimate that tailored HIV prevention efforts designed to protect transgendered women may benefit from a focus on the concept of gender identity. Unlike biological sex, gender is a psychological construct and it exists in degrees across a continuum ranging from extremely feminine to extremely masculine. Recognition that transgendered women may be located toward the feminine extreme of this continuum may be important given that their concept of femininity may include stereotypical perceptions that suggest sexually submissive behavior, including the practice of yielding to men who do not want to use condoms. Indeed, one intervention challenge may be helping transgendered women to be more sexually assertive without compromising their perception of what it means to be feminine.

Innovative and tailored intervention strategies are needed to help transgendered women adopt HIV-protective behaviors. Findings from this study support and extend those from two other qualitative investigations (Bockting et al., 1998; Nemoto et al., 2004). In essence, the psyhosocial dynamics that underpin HIV risk behavior of transgendered women are probably consequences of social stigma, high need for affection, acceptance/validation as a woman, the need to earn an income, isolation of mainstream society including gay and lesbian groups, and an intense need to obtain hormones. These observations suggest that interventions aimed only at the individual-level (i.e., those targeting knowledge, attitudes, and beliefs of transgendered women) are less likely to be effective than those including structural changes in communities and the alteration of policy to accommodate the unique needs of this population. Thus, although a less recent publication showed a null effect for intervention at the individual-level (Bockting, Rosser, & Scheltema, 1999), a more recently tested intervention that included socio-ecological components showed much greater promise (Nemoto, Operario, Keatley, Nguyen, & Sugano, 2005). Although far more qualitative and quantitative research is needed, it is quite likely that a socio-ecological focus may be very productive in designing future interventions for transgendered women at risk of HIV infection (DiClemente, Salazar, & Crosby, 2005). In the interim, practical guidance for interventions could include tailoring HIV prevention messages and media campaigns to transgendered women. For example, in New York City, HIV prevention education materials have included a poster of a phallic woman putting a condom on her penis. This type of image may help transgendered women identify with HIV prevention messages.

Conclusion

Although much more investigation is needed, findings from this qualitative study suggest that some transgendered women may experience substantial barriers to practicing safer sex and may magnify their risk of HIV via hormone injection through the use of contaminated needles/syringes. These barriers appear to be related to the marginalization of this population by society, including the gay community. Transgendered women may also engage in risky sex as a trade-off to fill a strong need for love and acceptance (as a female) from men. By being caught between worlds (straight, gay, male, and female), transgendered women may be placed into situations in which avoiding HIV risk is extremely difficult.

References

Bockting, W. O., Robinson, B. E., & Rosser, B. R. (1998). Transgender HIV prevention: A qualitative needs assessment. AIDS Care, 10, 505-525.

Bockting, W. O., Rosser, B. R., & Scheltema K. (1999). Transgender HIV prevention: Implementation and evaluation of a workshop. Health Education Research Theory and Practice, 14, 177-183.

Clements-Noelle, K., Marx R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status of transgendered persons: Implications for public health intervention. American Journal of Public Health, 91, 915-921.

DiClemente, R. J., Salazar, L. F., & Crosby, R. A. (2005). Prevention and control of sexually transmitted infections among adolescents: the importance of a socio-ecological perspective--A commentary. Public Health, 29, 124-139.

Elifson, K. W., Boles, J., Posey, E., Sweat, M., Darrow, W., & Elsea W. (1993). Male transvestite prostitutes and HIV risk. American Journal of Public Health, 83, 260-262.

Kellog, T. A., Clements-Noelle, K., Diley, J., Katz, M. H., & McFarland, W. (2001). Incidence of human immunodeficiency virus among male-to-female transgendered persons in San Francisco. Journal of Acquired Immune Deficiency Syndromes, 28, 380-384.

Kenagy, G. P. (2002). HIV among transgendered people. AIDS Care, 14, 127-134.

Nemoto, T., Luke, D., Mamo, L., Ching, A., & Patria, J. (1999). HIV risk behaviors among male-to-female transgenders in comparison with homosexual or bisexual males and heterosexual females. AIDS Care, 11, 297-312.

Nemoto, T., Operario, D., Keatley, J., Han, L., & Soma, T. (2004). HIV risk behaviors among male-to-female transgendered persons of color in San Francisco. American Journal of Public Health, 94, 1193-1199.

Nemoto, T., Operario, D., Keatley, J., Nguyen H, & Sugano E. (2005). Promoting health for transgender women: Transgender resources and neighborhood space (TRANS) program in San Francisco. American Journal of Public Health, 95, 382-384.

Wiessing, L. G., van Roosmalen, M. S., Koedijk, P., Bielman, B., & Houweling, H. (1999) Silicones, hormones, and HIV in transgender street prostitutes. AIDS, 13, 2315-2317.

Richard A. Crosby

University of Kentucky

Nicole L. Pitts

Emory University

Correspondence should be addressed to Richard A. Crosby, College of Public Health, University of Kentucky, 121 Washington Ave., Lexington, KY 40506. E-mail: [e-mail]