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A journal club style critical review of current publications in evidence-based transgender medical care.

Wednesday, May 30, 2012

Transgender Men and HIV

Of 59 transmen presenting for HIV screening at public health clinics in San Francisco, none tested positive.  However the sample may not be representative of the population. (1)    

     Transgender men (transmen) may be at risk for HIV infection.  Transmen may have male sexual partners and therefore be identified as men who have sex with men (MSM).  Transmen may also have sex with transgender women (transwomen).  HIV prevalences in San Francisco, USA have been found to be 24% among MSM and 35% among transwomen.  Historically only a few cases of HIV in transmen have been reported in San Francisco.  The authors aimed to identify the prevalence of HIV among those transmen presented to one of 17 public health clinics in San Francisco during 2009.  These sites perform 25% of all HIV tests in the city.

     A total of 64 HIV tests were performed on 59 unique self-identified transmen in 2009 at these sites, representing 0.4% of all tests performed.  Median age was 27, with 79% ages 18-37.  Whites comprised 73% of the sample and 64% identified as gay/lesbian/queer.  With respect to sexual practices in the prior 12 months, 61% had a male sexual partner (51% vaginal receptive, 19% anal insertive, 39% anal receptive), 63% had female partners (55% vaginal or anal sex) and 47% had transgender partners (42% vaginal or anal sex); 44% had 6 or more sexual partners in the prior year.  Unprotected vaginal or anal sex was reported by 63% in the past 12 months, with 10% reporting having had vaginal or anal sex with a known HIV+ person.  None of the subjects tested positive for HIV (98% negative, 2% missing).


     This study demonstrates a number of interesting findings.  First it confirms what is already anecdotally well known; that transmen have a range of sexual partners, practices and orientations.  It also demonstrates an absence of HIV in a population of transmen who are actively engaging in a variety of high risk behaviors.  This absence suggests that transmen are still in a “pre-epidemic” phase with respect to HIV and that there is substantial opportunity to develop HIV prevention measures targeting this population.  It also raises the question if there are factors (anatomical, functional, behavioral) that alter transmale succeptability to HIV infection to a level lower than that of other populations. 

     The study also has a number of limitations.  The study population was primarily white transmen between the ages of 18-35, and only comprised of 25% of all HIV tests performed in San Francisco during the study period.  Barriers may exist for younger transmen or transmen of color to accessing HIV testing at any location.  Older transmen may be more likely to have insurance and a primary care provider and seek testing at a private office.  Some transmen may not self-identify themselves when completing a survey.

     The study demonstrates the complexities and pitfalls of data collection on transgender populations.  The survey used contains numerous flaws and oversights with respect to demographics and sexual practices.  For example, sexual activity with a transgender person is not broken down by transmale/transfemale.  It is unclear if respondents identified transgender partners by their affirmed gender, their transgender status, or both.  It is assumed that by “man” and “woman” the researchers intended to refer to cisgender men and women – such assumptions are counter to the “two-step” recommendation for data collection (Step 1: “What was the sex you were assigned at birth?”; Step 2: “What is your gender identity?”) which allows a more complete and culturally sensitive collection of data.  Anal and vaginal sex with a transgender person or a woman (presumably cisgender) were grouped together and not qualified by insertive or receptive relative to the subject.  Further study with a greater level of detail with respect to demographics and sexual practices as well as a wider catchment of age ranges and ethnicities is essential to identify and manage HIV risks in transgender men.


1) Chen S, McFarland W, Thompson HM, Raymond HF. Transmen in San Francisco: What do We Know from HIV Test Site Data? AIDS and Behavior. 2010 Dec 9;15(3):659–62

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