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RESEARCH AND PRACTICE |
The authors are with the Center for AIDS Prevention Studies, University of California, San Francisco.
Correspondence: Requests for reprints should be sent to Tooru Nemoto, PhD, Center for AIDS Prevention Studies, University of California, San Francisco, 74 New Montgomery St, Suite 600, San Francisco, CA 94105 (e-mail: tnemoto{at}psg.ucsf.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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Objectives. The authors examined HIV risk behaviors among African American, Asian/Pacific Islander (API), and Latina male-to-female (MTF) transgender persons in order to improve HIV prevention programs.
Methods. Individual survey interviews with MTF transgender persons of color (n = 332; 112 African Americans, 110 Latinas, and 110 APIs) were conducted.
Results. Prevalence and correlates of receptive anal sex and unprotected receptive anal sex (URAS) varied by type of partner (primary, casual, or commercial sex partners). URAS with primary partners was associated with drug use before sex; URAS with casual partners was associated with HIV-positive status and drug use before sex; and URAS with commercial sex partners was associated with African American ethnicity and low income.
Conclusions. Findings on current risk behaviors among MTF transgender persons provided meaningful implications for HIV prevention interventions.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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San Francisco, a city known for acceptance of sexual diversity, has a large, multicultural MTF transgender population. Data from anonymous HIV testing sites in San Francisco indicated an incidence rate of 7.8 per 100 person-years—the highest for any risk group in the city.12 Ethnic differences in HIV seroprevalence among MTF transgender persons have been reported in studies conducted in San Francisco and Los Angeles.2,8,12 African Americans showed the highest HIV seroprevalence (44%–63%), followed by Latinas (26%–29%), Whites (16%–22%), and Asian/Pacific Islanders (APIs) (4%–27%). Correlates of HIV-positive status include ethnicity (i.e., being African American), socioeconomic status (i.e., having less than a high school degree), lifetime sexual partners (i.e., > 200 partners), and lifetime history of injection drug use.2 Furthermore, HIVpositive participants were more likely than HIV-negative participants to report unprotected receptive anal sex (URAS) with primary partners and injection drug use in the past 6 months.2
Qualitative research has explored the social and ecological context for HIV vulnerability among MTF transgender persons, revealing that socioeconomic and psychological adversity contribute to the high prevalence of HIV-related risk behaviors.13 Because of discrimination and stigma, many MTF transgender persons lack employment, live below the poverty threshold, and engage in high-risk sex work.14 Psychosocial consequences of stigma described by MTF transgender persons, including depression and poor self-esteem, contribute to low negotiation power in relationships with primary partners and low self-efficacy to negotiate safe sex.15 Focus group findings suggested that some MTF transgender persons engage in casual sex with multiple partners to affirm their female gender identities and engage in substance use to cope with stress associated with sex work and depression.15
In this article we investigate correlates of recent HIV-related risk behaviors in a sample of African American, Latina, and API male-to-female transgender persons in San Francisco. We focus on understanding current HIVrelated risk behaviors to identify factors that can be addressed in behavioral interventions aiming to reduce future infections and transmissions. Many previous studies with MTF transgender persons using HIV status as an outcome have implied causal linkages between participants’ risk behaviors and current HIV status; however, it is likely that for many HIV-positive subjects, HIV infection preceded (and may lead to an increase in) recent risk behaviors. One study showed that 65% of MTF transgender persons who tested positive for HIV already knew their HIV status and that 58% of HIV-positive transgender persons were currently receiving HIV antiretroviral therapy.2 Therefore, treating current HIV status as an outcome may not be appropriate and does not provide meaningful implications for future risk reduction interventions. The authors investigated the association of recent HIV risk behaviors among MTF transgender persons of color with demographic characteristics (including race, age, income, preoperative/postoperative status), sexual behaviors (with primary partners, casual sex partners, or commercial sex partners), sex under the influence of alcohol and drugs, and HIV/sexually transmitted disease (STD) status.
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METHODS |
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Between November 2000 and July 2001, a team of MTF transgender interviewers recruited participants from a range of community venues identified through mapping. Four San Francisco AIDS service organizations with transgender-specific programs referred 46% of the sample. To be considered eligible for the study, each participant had to (1) identify as an MTF transgender person (including pre- and postoperative status); (2) identify as African American, API, or Latina; (3) have a history of exchanging sex for money or drugs; and (4) be 18 years of age or older. Those who fulfilled eligibility criteria voluntarily met with a MTF transgender interviewer (matched by ethnicity) in a private interview space either in the project office or at collaborating agencies. Using a protocol approved by the University of California, San Francisco committee on human research, interviewers obtained informed consent orally and administered the survey. Latinas completed the survey in Spanish or English with the bilingual Latina interviewer. Upon completing surveys, participants received financial reimbursement, a safe-sex kit, and a list of agencies with services for transgenders.
Measures
Sexual behaviors.
Participants reported sexual behaviors with 3 types of male partners: primary, casual, and commercial. Primary partners were defined as persons with whom participants had a relationship, such as boyfriends or spouses. Casual partners were defined as nonpaying private partners with whom participants engaged in casual sex, such as 1-night stands. Commercial sex partners were defined as customers who paid for sex.
For each type of partner, participants reported whether in the past 30 days they had engaged in receptive anal sex (partner puts penis in participant’s anus) and whether they had ever engaged in unprotected receptive anal sex (URAS) with each type of partner during the past 30 days. Variables were dichotomized as follows: not engaging in the behavior versus engaging in the behavior.
Health outcomes. Participants indicated whether they had ever been tested for HIV and the result of their last test, as well as whether they had ever tested positive for any of 6 STDs (i.e., chlamydia, genital warts, gonorrhea, herpes, syphilis, and trichomoniasis) in the past 12 months. These were dichotomized into 2 variables: HIV status (negative = 0, positive = 1), and recent STD history (none in the past 12 months = 0, any in the past 12 months = 1).
Substance use. Measures of substance use were modified from the National Institute of Drug Abuse Risk Behavior Assessment.17 We focused here on only 3 variables; that is, whether they had sex with primary, casual, or commercial partners under the influence of any illicit drug in the past 30 days (no sex under the influence in the past 30 days = 0; any sex under the influence in the past 30 days = 1).
Statistical Analysis
A Pearson 
2 test was conducted to assess associations between ethnicity and categorized demographics, HIV status, and STD status. Multivariate logistic regression was performed to identify predictors on each of 6 binary outcome measures: receptive anal sex with primary partner, casual partners, and commercial partners; and URAS with primary partner, casual partners, and commercial partners. Our goal was to achieve a parsimonious model while satisfying good fit. Before modeling, we listed theoretically important and interesting predictors and cross-tabulated them with each of the 6 outcome measures. After the procedures described by Hosmer and Lemeshow,18 variables with statistically significant levels less than .25 by Pearson 2 test were selected as candidates to enter the multivariate logistic model. A backward stepwise procedure was then used to remove those predictors with an adjusted statistically significant level greater than .20. Finally, the Hosmer–Lemeshow goodness-of-fit test was used to assess model fit. All analyses were conducted using SPSS (SPSS Inc; Chicago, Ill).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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). More than half of the sample was foreign born. Among Latinas, most were born in Mexico (52%), followed by the Caribbean (16%), South and Central America (13%), and Spain (1%); 18% of Latinas were born in the United States. Among APIs, most were born in the Philippines (54%), followed by Southeast Asia (26%), South Korea (2%), and China or Hong Kong (2%); 14% of APIs were born in the United States. The average age was 34 years (range 18–60 years of age). Over one third of the sample did not complete high school; 54% earned less than $1000 in the past 30 days, and under half (49%) had permanent housing during the past 6 months. The 3 most common self-identified genders were female (36%), preoperative transgender (31%), and preoperative transsexual (21%). Few had undergone sexual reassignment surgery; among them, 73% identified as female and 24% as postoperative transsexual. A majority identified as heterosexual.
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). African Americans were older (mean = 36.5 years) than Latinas (mean = 32.9) or APIs (mean = 32.9) (P < .05). Latinas had relatively little education; 61% of Latinas had not completed high school, whereas 64% of APIs had completed at least some college. Latinas were most likely to currently engage in sex work. APIs were more likely to have a full-time job, higher income, and permanent housing than other ethnic groups. APIs were most likely to have had sex reassignment surgery and to identify as female.
Health Outcomes
Ninety-eight percent of the MTF transgender sample reported having ever tested for HIV. Of those who had been tested, 26% reported being HIV-positive. Another 68% reported being HIV-negative; 4% were unsure and 1% refused to report their status. Fourteen percent reported testing positive for any STD during the past 12 months, including herpes (5%), gonorrhea (4%), genital warts (3%), syphilis (3%), chlamydia (2%), and trichomoniasis (1%).
Self-reported HIV status varied significantly by ethnicity (Table 1). African Americans were more likely than Latinas and APIs to report having HIV, and African Americans and Latinas were both more likely than APIs to report having any STD in the past 12 months.
Sex Under the Influence of Drugs
Sex while under the influence of illicit drugs was common. Among participants who reported having a primary partner, 55% engaged in sex with them while under the influence of drugs during the past 30 days; the rate was highest among African Americans (63%) and Latinas (60%) compared with APIs (41%) (2 = 6.49, P < .05). Close to half (45%) of the participants who had casual partners reported having sex with them under the influence of drugs during the past 30 days; the rate was highest among African Americans (71%), followed by Latinas (53%) and APIs (43%) (2 = 5.98, P < .05). Roughly half (52%) of the participants who had sex with commercial partners reported having sex with them while under the influence of drugs in the past 30 days, with no significant ethnic group differences.
Sexual Behaviors
Receptive anal sex.
In the past 30 days, 52% of the sample reported having had a primary partner, 36% at least 1 casual partner, and 40% at least 1 commercial partner. Among those who reported having each respective partner, 77% had receptive anal sex with a primary partner, 71% had receptive anal sex with a casual partner, and 74% had receptive anal sex with a commercial partner. Table 2 shows bivariate associations between these 3 sexual behaviors and demographics, STD history, HIV status, and sexual risk factors in the past 30 days.
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). Models for primary and commercial sex partners showed adequate goodness of fit. Significant predictors of receptive anal sex with a primary partner were being African American or Latina relative to API, being 18 to 30 years of age relative to 41 to 60 years of age, having an income less than $500 relative to $500 to $999 during the past 30 days, and ever having had sex while under the influence of drugs during the past 30 days. Significant predictors of receptive anal sex with casual partners were being Latina relative to API, not having had sex reassignment surgery, and ever having had sex while under the influence of drugs during the past 30 days. Significant predictors of receptive anal sex with commercial partners were being Latina, having an STD in the past year, and ever having had sex while under the influence of drugs during the past 30 days.
URAS.
Of the participants who had engaged in receptive anal sex with each respective partner during the past 30 days, 47% had URAS with a primary partner, 26% had URAS with a casual partner, and 12% had URAS with a commercial partner. Table 3 shows bivariate associations between these 3 sexual behaviors and demographics, STD history, HIV status, and sexual risk factors in the past 30 days.
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). Models for casual and commercial sex partners showed adequate goodness of fit. The only predictor of URAS with a primary partner in the past 30 days was having sex while under the influence of drugs during the past 30 days. Significant predictors of URAS with a casual partner were being HIV-positive and having had sex while under the influence of drugs during the past 30 days. Significant predictors of URAS with a commercial partner were being African American and having an income of less than $500 during the past 30 days relative to $1000 or more. |
DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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MTF transgender persons of color in this study reported high levels of HIV and STDs. Self-reported HIV rates in this study were very similar to findings reported in a previous study that used serological HIV testing. Self-reported prevalence here was 41% African American, 23% Latina, and 13% API; serological prevalence in another study in San Francisco was 63% African American, 29% Latina, and 25% others (two thirds of which were APIs).2 These prevalence estimates are comparable to HIV levels among gay men at the height of the epidemic in the 1980s.12
Rates of URAS were highest with primary partners and less so for casual partners and commercial partners, further confirming previous study findings2 and reports on relationship intimacy as a barrier to condom use and risk reduction.19 Earlier focus group findings suggested that social and psychological factors contribute to sexual risk behaviors with different partner types.14,15 In the context of sex with primary partners, focus group participants described intense need for affection and personal connection, and stated that condoms undermined feelings of intimacy and threatened the connection with primary partners. In the context of sex with casual partners, participants described feelings of gender validation and attractiveness associated with receiving sexual attention from men. Most participants endorsed 100% condom use rules with customers, whom they viewed as business clientele rather than intimate partners. However, economic pressures compelled many to compromise their condom rules and engage in unsafe sex for increased money. Quantitative findings thus corroborate the need for prevention strategies to target the relationship context of sex—whether with a primary partner, with a casual date or 1-night stand, or with a partner who pays for sex.
Ethnic differences in HIV-related sexual risk behaviors corroborated previous epidemiological research.2 African Americans in our sample had the highest rates of HIV and also reported frequently engaging in multiple risk behaviors including sex under the influence of drugs and unprotected sex with commercial sex partners. Latinas were most likely to engage in sex work, reported high rates of having sex while under the influence of drugs, and reported the highest rates of receptive anal sex with all partner types (although this sexual behavior is not risky when condoms are used). It is worth noting that African Americans and Latinas also reported particularly adverse socioeconomic conditions, which should be considered when designing HIV prevention interventions.8 In an expected finding, APIs showed a protective factor for HIV: they were the least likely among the ethnic groups to report any receptive anal sex with primary, casual, or commercial partners as well as having sex under the influence of substances. Furthermore, only 1 API sex worker reported recent URAS. Lower rates of risk behaviors, HIV, and STDs among APIs may be attributable in part to their higher education and income and lower likelihood of engaging in sex work.
Previous research on MTF transgender persons has shown that African American race was a significant predictor of HIV seroconversion (adjusted relative hazard ratio = 5.0).12 Our findings suggest that this seroconversion rate may be associated with URAS with commercial partners. Although a minority of our study participants reported engaging in URAS with commercial partners, African Americans were disproportionately likely to do so. In addition, low income was independently correlated with URAS with commercial partners. This corroborates our focus group finding that economically disadvantaged MTF transgender persons engage in unprotected sex for survival15 and confirms that commercial sex clients offer to pay extra for sex without condoms.20 HIV education programs that address the specific needs of African American MTF transgender persons, such as job training, housing, and substance abuse treatment and mental health services, are critically needed.16
Urgent Need for Transgender-Sensitive HIV and Substance Use Interventions
Although MTF transgender persons of color may represent an extremely high-risk strata and a subpopulation within a minority group, practical steps toward addressing these health outcomes are currently underway. Several community-based programs in San Francisco have launched culturally sensitive, transgender-specific HIV/AIDS prevention and care programs and substance abuse treatment programs. Several ethnic-specific community-based agencies (e.g., African American, Latino, and Asian/Pacific Islander AIDS service organizations) have enhanced their transgender-specific outreach, support groups, and educational training programs conducted by transgender staff. Local substance abuse treatment organizations and public health clinics have also increased their sensitivity to transgender health and social issues, and some have hired transgender service providers and counselors to offer transgender-specific programs. Another evidence-based transgender HIV prevention intervention in Minnesota has been well documented.21,22
MTF transgender-specific health intervention programs should be implemented in other metropolitan areas (e.g., Los Angeles, New York, Washington, DC, Boston, Chicago). It is important to train health service providers on transgender sensitivity and health issues.11,16 This might be particularly important for public health clinics and social service agencies, where transgender persons of color may feel uncomfortable using services because of previous racial and gender insensitivity toward transgender persons.16 Hiring qualified transgender staff can provide a critical link to the community and enhance trust for transgender clients.
Limitations
This sample may not represent MTF transgender persons in general. Respondents were recruited in San Francisco, where a large transgender community might contribute to a higher prevalence of substance use and sexual activity (including sex work) than elsewhere. Although self-reports of sexual behaviors and drug use tend to be reliable,23,24 respondents may have minimized their reported risk behaviors. Nevertheless, these data from a large, diverse sample shed light on risk behaviors among a group about which little is known.
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CONCLUSIONS |
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Acknowledgments |
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The authors thank collaborating community-based organizations for their assistance and all research study participants who volunteered their time and personal information to this study.
Note. The contents of this article do not represent the opinions of the National Institute on Drug Abuse.
Human Participant Protection
This study was approved by the University of California, San Francisco, committee on human research.
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Footnotes |
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Accepted for publication January 4, 2004.
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References |
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2. Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. Am J Public Health. 2001;91:915–921.[Abstract]
3. Elifson KW, Boles J, Posey E, Sweat M, Darrow W, Elsea W. Male transvestite prostitutes and HIV risk. Am J Public Health. 1993;83:260–262.
4. Gattari P, Spizzichino L, Valensi C, Zaccarelli M, Rezza G. Behavioural patterns and HIV infection among drug using transvestites practicing prostitution in Rome. AIDS Care. 1992;4:83–87.[Medline]
5. Kenagy GP. HIV among transgendered people. AIDS Care. 2002;14:127–134.[ISI][Medline]
6. Modan B, Goldschmidt R, Rubinstein E, et al. Prevalence of HIV antibodies in transsexual and female prostitutes. Am J Public Health. 1992;82:590–592.
7. Nemoto T, Luke D, Mamo L, Ching A, Patria J. HIV risk behaviors among male-to-female transgenders in comparison with homosexual or bisexual males and heterosexual females. AIDS Care. 1999;11:297–312.[ISI][Medline]
8. Simon PA, Reback CJ, Bemis CC. HIV prevalence and incidence among male-to-female transsexuals receiving HIV prevention services in Los Angeles County. AIDS. 2000;14:2953–2955.[Medline]
9. Varella D, Tuason L, Proffitt MR, Escaleira N, Alquezar A, Bukowski RM. HIV infection among Brazilian transvestites in a prison population. AIDS Patient Care STDS. 1996;10:299–302.[Medline]
10. Feinberg L. Trans health crisis: for us it’s life or death. Am J Public Health. 2001;91:897–900.[ISI][Medline]
11. Lombardi E. Enhancing transgender health care. Am J Public Health. 2001;91:869–872.[Abstract]
12. Kellogg TA, Clements-Nolle K, Dilley J, Katz MH, McFarland W. Incidence of human immunodeficiency virus among male-to-female transgendered persons in San Francisco. J Acquir Immune Defic Syndr. 2001;28:381–384.
13. Bockting WO, Robinson BE, Rosser BRS. Transgender HIV prevention: a qualitative needs assessment. AIDS Care. 1998;10:505–526.[ISI][Medline]
14. Nemoto T, Sausa LA, Operario D, Keatley J. Need for HIV/AIDS education and intervention for MTF transgenders: responding to the challenge. J Homosex. In press.
15. Nemoto T, Operario D, Keatley J, Oggins J, Villegas D. Social context of HIV risk behaviors among male-to-female transgenders of color. AIDS Care. In press.
16. Nemoto T, Operario D, Keatley JG. Health and social services for male-to-female transgenders of color in San Francisco. Int J Transgenderism. In press.
17. National Institute of Drug Abuse (NIDA). Risk Behavior Assessment. Washington, DC: National Institute of Drug Abuse; 1993.
18. Hosmer DW, Lemeshow S. Applied Logistic Regression. New York, NY: Wiley; 1989.
19. O’Leary A. Women at risk for HIV from a primary partner: balancing risk and intimacy. Annu Rev Sex Res. 2000;11:191–234.[Medline]
20. Westhoff WW, McDermott RJ, Holcomb DR. HIV-related knowledge and behavior of commercial sex workers: a tale of three cities. Int Electronic J Health Educ. 2000;3:55–63.
21. Bockting WO, Rosser BRS, Scheltema K. Transgender HIV prevention: implementation and evaluation of a workshop. Health Educ Res. 1999;14:177–183.
22. Bockting WO, Rosser BRS, Coleman E. Transgender HIV prevention: a model education workshop. J Gay Lesbian Med Assoc. 2000;4:175–183.
23. James NL, Bignell CJ, Gillies PA. The reliability of self-reported sexual behaviour. AIDS. 1991;5:333–336.[ISI][Medline]
24. Weatherby NL, Needle R, Cesari H, Booth RE. Validity of self-reported drug use among injection drug users and crack cocaine users recruited through street outreach. Eval Program Plann. 1994;17:347–355.
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