Prevention Toolkit > CAPS Fact Sheet - What Are the HIV Prevention Needs of Male-to-Female Transgender Persons

What Are the HIV Prevention Needs of Male-to-Female Transgender Persons (MTFs)?

What does being transgender mean?

Transgender is an umbrella term used to describe persons who cannot or choose not to conform to societal gender norms associated with their physical sex. 1 Such individuals have gender identities, expressions or behaviors not traditionally associated with their birth sex. Transgender persons live their lives to varying degrees as their chosen gender and may self-identify as female, male, trans-women or -men, non-operative transsexuals, pre-operative transsexuals, transsexuals who have completed surgical sex reassignment, transvestites or cross-dressers, among others. These terms vary regionally and over time.

Because male-to-female transgender individuals (MTFs) have higher rates of HIV-related risks and HIV than female-to-male transgender persons, this fact sheet will focus on MTFs.

Are MTFs at risk?

Yes. MTFs have high rates of HIV infection, with overall rates of 35% in San Francisco in 1997 and 22% in Los Angeles in 1998. 2,3 A study of MTF sex workers in Atlanta found that 68% tested positive for HIV. 4 Infections among MTFs continue to rise, with an estimated rate of new infections of 3-8% per year. 3,5 African American MTFs have higher rates of HIV than other racial/ethnic groups. 2-5

Injection drug use is also common among MTFs, putting them at high risk for HIV. In a San Francisco study, 18% of the respondents reported non-hormonal injection drug use in the past six months and half of this group shared syringes. 2 MTFs may inject female hormones as well, in order to feminize their bodies. HIV risk through hormone injection varies regionally, with New York reporting more risk than in San Francisco, due to differences in availability of hormones and hormone syringes. 2,6 In San Francisco, the needle exchange programs offer hormone syringes and a number of public health clinics offer free or low-cost hormone therapy.

What places MTFs at risk?

Transphobia, or the pervasive social stigmatization of MTFs, greatly exacerbates their HIV risk. This intense stigmatization results in their social marginalization, which includes the denial of educational, employment and housing opportunities. 7,8 It also creates multiple barriers to accessing health care. Such marginalization lowers MTFs' self esteem, increases the likelihood of survival sex work and lessens the likelihood of safer sex practices. 9 All of this leads to high rates of HIV, STDs, drug use and attempted suicide.

MTFs primarily have sex with men and are likely to engage in receptive anal sex, which puts them at increased risk. 2,3,10 Some MTF sex workers are willing to not use condoms with their paying partners if they are offered more money. 8 However, some studies show that most unprotected sex occurs with primary partners, not paying partners. 3

What are barriers to HIV prevention?

Psychosocial factors such as poverty, low self-esteem, depression, feelings of isolation, rejection, and powerlessness are cited by MTFs as barriers to sexual and drug risk reduction. For example, many MTFs state that they engage in unprotected sex because it validates their female gender identity and boosts their self-esteem. 10,11 For many MTFs, securing employment and housing are more pressing issues than HIV and must be addressed before HIV prevention efforts can be effective. 11

Many transgender individuals do not access HIV prevention or health services due to the insensitivity of service providers and health care staff 11,12 or fear of being revealed as transgender. 13 Some HIV prevention programs for MTFs face challenges renting space due to transphobia.

What's being done?

The Transgender Resources and Neighborhood Space (TRANS) Project, at the Center for AIDS Prevention Studies (CAPS) in San Francisco, CA, provides workshops addressing substance abuse, HIV, commercial sex work, self care and general life skills. It also hosts an informal drop-in center where clients can relax, shower and socialize. MTF outreach workers facilitate all activities. The Project collaborates with Walden House Transgender Recovery Program, which provides expanded therapy, counseling, mentorship programs and life training skills that address the unique needs of MTFs. 14

The Program in Human Sexuality (PHS) at the University of Minnesota developed and evaluated a community-based program for MTFs based on the health belief model and eroticizing safer sex. Although the program was well received, feedback from participants stressed the need for a comprehensive health-based approach because clients' concerns around gender overrode their HIV concerns. PHS now offers All Gender Health seminars based on a sexual health model that address HIV risk in the context of participants' lives and cover topics such as stigmatization, dating, sexual functioning, substance abuse and violence. They combine education with entertainment, featuring MTF celebrities and MTF health professionals. 15

The Transgender Harm Reduction Program in West Hollywood, CA, conducts outreach to MTFs at risk--both those living on the streets and in the suburbs. The program consists of outreach, community skills building workshops, mentoring and job training. Workshop topics include grooming and hygiene, legalization and documentation, health care and hormone therapy, as well as explicit HIV risk reduction. Implicit in the program is the importance of increasing self esteem in order to adopt safer behavior. 16

Gender Identity Support Services for Transgenders (GISST) in Boston, MA, has been serving HIV- and HIV+ individuals since 1993. GISST provides AIDS education, HIV testing, alcohol and drug rehabilitation, counseling, job training, social skills, social acceptance and gender identity counseling. They host luncheons on topics such as surgery and hormones, featuring speakers, videos and clients sharing experiences. 17

What more should be done?

Societal fear and intolerance toward transgender persons severely limit the ability of many MTFs to lead healthy lives. Some cities and states have enacted transgender anti-discrimination laws in housing and employment, and areas without such laws should consider this. Transgender activism and advocacy have helped advance these changes.

Peer-based prevention efforts for MTFs should be developed and evaluated, including: 1) late night/early morning outreach for sex workers; 2) needle exchange programs that offer hormone syringes; and 3) individual and group interventions that focus on the psychosocial barriers to HIV risk reduction. Hiring and training MTFs for prevention programs would provide much-needed employment opportunities to this community as well as facilitate culturally appropriate HIV prevention efforts. 12 Making hormone therapy more accessible may be a good way to encourage MTFs to use health services where they could obtain HIV prevention information. Such interventions will be most effective if they are coupled with housing, education and employment efforts. Prevention efforts need to include partners and friends of MTFs.

MTFs have been invisible in the Centers for Disease Control and Prevention (CDC) HIV classification system, showing up as either men who have sex with men or heterosexual women. Transgender-specific categories need to be included on all federal and local data collection forms.

There is a great need for transgender sensitivity training for all public service providers, including doctors, nurses and clinic staff (receptionists), and law enforcement and emergency services workers (police, paramedics, firefighters). Advocacy for increased access to health care and cultural relevancy within research, policy work and education have been cited as ways to improve transgender health. 18

Says who?

1. Gender Education and Advocacy. Gender Variance: A Primer. 2001. www.gender.org/resources/dge/gea01004.pdf

2. Clements-Nolle K, Marx R, Guzman R, et al. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons in San Francisco: Implications for public health intervention. American Journal of Public Health. 2001;91:915-921.

3. Simon PA, Reback CJ, Bemis CC. HIV prevalence and incidence among male-to-female transsexuals receiving HIV prevention services in Los Angeles County (letter). AIDS. 2000;14: 2953-2955.

4. Elifson KW, Boles J, Posey E, et al. Male transvestite prostitutes and HIV risk. American Journal of Public Health. 1993;83:260-262.

5. Kellogg TA, Clements-Nolle K, McFarland W, et al. Incidence of Human Immunodeficiency Virus (HIV) among male-to-female transgendered persons in San Francisco. Journal of the Acquired Immune Deficiency Syndromes. in press.

6. McGowan CK. Transgender needs assessment. The HIV Prevention Planning Unit of the New York City Department of Health. December 1999.

7. Green J. Investigation into Discrimination against Transgendered People: A Report by the Human Rights Commission, City and County of San Francisco. 1994;1:8-10 & 43-52.

8. Nemoto T, Luke D, Mamo L, et al. HIV risk behaviors among male-to-female transgenders in comparison with homosexual or bisexual males and heterosexual females. AIDS Care.1999;11:297-312.

9. Bockting WO, Robinson BE, Rosser BR. Transgender HIV prevention: a qualitative needs assessment. AIDS Care. 1998;10:505-525.

10. Boles J, Elifson KW. The social organization of transvestite prostitution and AIDS. Social Science and Medicine. 1994;39:85-93.

11. Clements-Nolle K, Wilkinson W, Kitano K. HIV Prevention and Health Service Needs of the Transgender Community in San Francisco. in W. Bockting & S Kirk editors: Transgender and HIV: Risks, prevention and care. Binghampton, NY: The Haworth Press, Inc. 2001; in press

12. Feinberg L. Trans health crisis: for us it's life or death. American Journal of Public Health. 2001;91:897-900.

13. Xavier J. The Washington Transgender Needs Assessment Survey. Administration for HIV & AIDS, District of Columbia Government. 2000.

14. UCSF CAPS, Health Studies for People of Color. Contact Joanne Keatley 415/476-2364.

15. Bockting WO, Rosser S, Coleman E. Transgender HIV prevention: a model education workshop. Journal of the Gay and Lesbian Medical Association. 2000;4:175-183.

16. Reback K, Lombardi EL. HIV risk behaviors of male-to-female transgenders in a community-based harm reduction program. International Journal of Transgenderism. 1999;3:1+2.

17. Hope Mason T, Connors MM, Kammerer CA. Transgenders and HIV risks: needs assessment. Prepared by the Massachusetts Department of Public Health, HIV/AIDS Bureau. August 1995. GISST: 617/720-3413.

18. Lombardi E. Enhancing transgender health care. American Journal of Public Health. 2001;91:869-872.

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to CAPS.web@ucsf.edu. © September 2001, University of California