Background InformationTransgender study data is hard to find due in part to the fact that female to male (FTM) and male to female (MTF) are not gender choices on many surveillance reports. California is an exception; adding MTF and FTM as gender choices in 2002. In a 2008 report by J. Herbst et.al data showed that among the transgender population in California, 6.8% was HIV positive, the highest for any group in the state, including men who have sex with men. What's more, according to the study, African Americans within the transgender population of California had an infection rate of nearly 29%. Still, estimated infection rates can vary a great deal, depending on the persons surveyed and how HIV status was determined; either stated by the person or confirmed by HIV test. Regardless, HIV among the transgender population is an important issue. Yet, finding medical resources, emotional support, and HIV educational material for the transgender population is difficult. Despite elevated HIV risk, prevention policy, research, and surveillance do not give the transgender community the attention it deserves or requires. Cultural and social perceptions of sex and gender work to marginalize the transgender population as a whole. Let's explore further gender identity and the issue of HIV among the transgender population.
Transgender DefinedThe term transgender is an inclusive term for a person whose gender identity and expression differ from what's expected as a result of their birth gender. Gender identities under the umbrella of transgender include but aren't limited to:
One who wears clothes usually assigned to the opposite sex
Those who feel their gender identity encompasses both male and female.
Those who find their gender identity is in conflict with their anatomical sex. These individuals feel their physiological body does not represent their true gender self.
Another term for a crossdresser, it is a fairly outdated term; not preferred by many crossdressers.
A term used to describe a person who identifies as both male and female; neither male not female; or a gender outside the traditional two gender (male and female) system.
Are Gender Identity and Sexual Orientation the Same?It is not uncommon for people to confuse gender identity and sexual orientation or to connect the two when no connection is present. In fact I caught myself confusing the two when first writing this article. Let's see if I can clarify the difference.
Sexual orientation describes a pattern of emotional, romantic, or sexual attraction to another person. The scientific consensus is that sexual orientation is not a choice and is instead influenced by a combination of hormonal and genetic factors early in uterine development.
Gender identity refers to the gender or genders a person identifies as. Gender identity can change over time and does not always relate to sexual orientation. For instance, if someone born male identifies as female, she could be bisexual, heterosexual, or homosexual.
HIV Incidence Among Transgender PopulationWhile transmission routes in the transgender community are much the same as any other population, there are some factors that place those who identify as transgender at a higher HIV risk.
Because of disclosure fears and risks, identifying and finding the transgender community is difficult. This in turn makes it difficult to target prevention messages to the transgender community. In addition, prevention messages are often biased according to gender. If one doesn't identify as a particular gender, the prevention message may not be received at all.
- Physiologic Health
Often those who identify as transgender perceive their anatomy differently than the medical community would. Without a common point of reference, health promotion and education becomes difficult. For example, an anatomical male who identifies as female may refer to her anus as her vagina. The medical community is seldom sensitive to this identification, making health promotion, health care, and education difficult.
Those identifying as transgender often experiment sexually, and may not be aware of or comfortable with common safer sex options. In addition, many get involved in sex work in an effort to support substance addictions, to make money for the purchase of necessary hormonal therapy, or because employers discriminate against transgender people and make it difficult for them to find legal jobs. Some reuse or share needles to inject their hormones because of the insurance industry's unwillingness to cover hormonal therapy. As in any population, these sexual behaviors and sharing of needles increase HIV transmission risk.
Issues With HIV CareCaring for people living with HIV is very difficult, regardless of who you are. But those identifying as transgender face even more barriers to HIV care. These include:
Finding a medical provider who is sensitive and aware of transgender issues is difficult. Many transgender people avoid medical care because they have a hard time finding providers sensitive to their needs.
- Hormonal Therapy
Hormonal therapy is essential to the transgender population. Unfortunately, many insurance companies don't pay for hormonal therapy. Many AIDS Drug Assistance Programs (ADAP) refuse payment as well. Finding safe ways to obtain needed hormones and clean needles and syringes is a daunting task. Many resort to sex for money, sharing needles, and purchasing hormones on the streets to meet their hormonal needs.
What Can Be Done?Much can be accomplished through education. Examples of what is needed include:
- Providers must understand the needs of the transgender community.
- Insurance companies must understand the importance of hormonal therapy and the need for hormonal coverage.
- Prevention education needs to be targeted to the transgender community in a manner that is sensitive to their needs, concerns and fears.
- Providers must make sure their patients feel safe disclosing their gender identities.
Herbst, J. et al; "Estimating HIV Prevalence and Risk Behaviors of Transgender Persons in the United States: A Systematic Review"; AIDS Behavior; 2007.