HIV Risk and Safer Sex Practices
A number of recent studies have addressed the HIV prevalence and risk behaviors of trans people in North and South America, Europe and South Asia. While epidemiological studies in this area have been some of the largest studies of sexual behaviors among transpeople outside the field of clinical psychology, they do not provide a representative picture, as most have been limited to MTF sex workers (e.g. Modan et al 1992; Harcourt, van Beek, Heslop, et al 2001; Tsakris, Kyriakis, Chryssou & Papoutsakis 1997; Spizzichino et al 2001) or to the San Francisco area (Nemoto et al 1999; Clements-Nolle et al 2001; Kellogg et al 2001).
These studies have shown high rates of HIV risk behaviors and of HIV seroprevalence among trans people. While it is not known with any certainty what percentage of trans people engage in sex work, a high rate of participation in commercial sex may partially explain these phenomena; certainly the San Francisco studies have shown that a large number of MTFs engage in sex work, and that few practice safer sex consistently. The high medical costs of transitioning, family rejection, job discrimination, difficulty in passing may all contribute to transwomen entering sex work. Nemoto et al cite studies from Italy, Brazil, Israel and the United States showing that trans prostitutes have higher rates than both male and female non-trans prostitutes (298), which may be due to their making less money and being less likely to turn away clients who refuse to practice safer sex or offer more money for unsafe sex.
Not only sex workers but also the community at large may be at risk for a number of reasons. Citing focus groups conducted by the Minnesota Department of Health, Bockting and Kirk (1999) write that
Invisibility, poverty, shame, low self-esteem, loneliness, and sharing needles for hormone or silicone injection [are all risk factors affecting the trans community]. ... The chronic lack of HIV prevention efforts targeting the transgender community was seen as supporting a denial of risk already widespread in the community. Myths about HIV that predominate in society as a whole are reflected in the transgender community in unique ways. For example, some transexuals believe a change from a gay or lesbian to a heterosexual role, or a change from male to female, provides them with protection from HIV, without any concomitant behavior change.
It is not known just how many people have been infected by sharing needles for hormone injections, but use of street hormones is widespread and is suspected to be a significant route of transmission among transgendered people. San Francisco is the first city to respond to this problem with needle-exchange programs directed specifically at trans people injecting hormones.
Relatively little is known about the effects that physical processes of gender transition may have on HIV risk. Some have speculated (e.g. Modan et al 1992) that the inability of post-op transwomen's vaginas to self-lubricate may place these women at greater risk of vaginal transmission through abrasions in the vaginal walls, and HIV educators therefore advise post-op women to use added lubrication for vaginal intercourse.
While research thus far suggests that few (though definitely some) FTMs engage in sex work and that FTMs have much lower rates of HIV infection compared with MTFs, (e.g., 2% compared with 35% in Clements-Nolle et al 2001), they face many of the same risk factors and may be unlikely to see themselves as being at risk and to practice safer sex (Namaste 2001, Hein and Kirk 2001). Kammerer, Mason and Connors (2001) note "Contributing to female-to-male transgenders' risks ... is the sexual drive, sometimes both precipitous and strong, brought on by the use of male hormones to effect bodily transition, perhaps accentuated, as Griggs (1998: 34) notes, by "cultural reinforcement of masculine [sexual] expression."
Emotional and cognitive factors can and do impede the use of safer sex practices in all populations; specific factors may affect both MTFs and FTMs. Because, as discussed above, acceptance by sexual partners seems to be so important for many transpeople's self-esteem, especially during the transitioning process, some may not insist on safer sex practices, even if they would like to, for fear of rejection. Transsexual activist Riki Anne Wilchins suggests that, "You want to be accepted and sex feels like acceptance . . . even for a night, even for fifteen minutes . . . lots of Trans people will have unsafe sex to feel desirable, to feel loved, to be validated as a woman or a man . . ." (quoted in Warren 2001:145). And in Hein and Kirk's FTM workshops,
One participant related that simply being perceived as a man by potential male or female sexual partners predisposed him to emotional and physical risk. He described the profound validation he continues to feel being recognized as male, and the difficulty of asserting his needs when his gender identity is at stake; doing so might jeopardize his acceptability as a sexual partner, complicate the encounter, and end in rejection. (113)
Transmen and their partners may be unsure how to approach safer penetrative or oral sex, as they find that standard male condoms will not fit their genitals. Hein and Kirk (1999) reported of an FTM focus group that they
valued condoms because they provided male-identified options for safer intercourse and oral sex but found them difficult or impossible to use. When one group member related his struggles with safer sex, other participants raised the possibility of adapting dental dams for different sexual acts. He shuddered as he told the group that he associated dental dams with vaginal sex and being female; they were not an option, even if it meant contracting HIV. (113)
Questioned on this subject in her online advice column, Carol Queen (2001) suggested that finger cots and plastic kitchen wrap are appropriate alternatives for some.
Next Section: Sexual Violence Against Trans People