Underrepresented: HIV Prevalence Among Transgender Men
At the United States Conference on HIV and AIDS in September of 2022, Sybastian Smith from the National Center on Transgender Equality and I talked with one another after a session focusing on trans masculine representation, data collection, and policy leadership development. We reflected on years of what we understood to be significant under-representation of transgender men and masculine persons in HIV – in research, in data collection and surveillance activities, in advocacy…everywhere.
There are complex intersections of experience that lead to this under-representation, in no small part because an unspoken assumption of transgender men is we transition from being cis-gender women who have sex with cis-gender women to being transgender men who have sex with cis-gender women. Therefore, our “risk” of acquiring HIV by way of sexual activity is astronomically low. However, that’s not always true. At the intersection of survival, the fluidity in sexuality that might occur was we transition (some people are same-sex attracted, therefore changing gender identity might also mean a change in who someone chooses to have sex with). Gay transgender men exist. Indeed, there’s a whole segment of the porn industry which is exploding in popularity that’s dedicated to transgender men who have sex with cis-gender men. And, anecdotally, gay transgender men tend to have the kinds of sex their cis-gender counterparts have and for the same reasons, rather than the kinds of sex cis-gender women have or for those reasons.
An added layer is the discrimination transgender men face in accessing health care. This includes public health activities which do not capture our data. Many “risk” assessment forms focus exclusively on identity and make assumptions as to what behaviors someone might engage in based on their identity. For example, when a cis-gender woman fills a form or discusses with an outreach worker, they’re generally asked about the identity of who they have sex with and if they engage in injection drug use. But discussion of what kinds of sex they have or what body parts their sexual partners have aren’t necessarily accounted for. And that lens is applied to transgender men. In fact, the Take Me Home screener questions ask what a requestor’s gender identity and assigned sex at birth are but only ask the identity of sex partners. For someone who is a transgender man who has receptive penetrative sex with a transgender woman, the “risk” assessment will miss essential behavioral data because of this.
This is just one of many ways in which transgender men are disregarded as men.
This isn’t significantly different from how transgender women have historically been “grouped” with men who have sex with men based on assumptions of behavior. However, transgender men have almost no representation in HIV data, despite this close mirror of considerations. Indeed, the Center for Disease Control and Prevention’s (CDC) webpages under “HIV by group” for “transgender people” only mention information about transgender women (prevalence and prevention challenges).
So it comes as no surprise for transgender men working and living in HIV spaces when two studies, one from New York and one from Germany, found that transgender men who have sex with men had a higher rate of HIV prevalence than the general population (at 2.5%). For good reason, some might suggest this could be an undercount. The data also found that only 24% of transgender men who have sex with men have ever had an HIV test and only 45% have ever had a STI screening, both significantly lower than their cis-gender counterparts.
If we are to address HIV in the transgender community, we need to include all of the transgender community. Resources should be allocated appropriately but not in a fashion which excludes highly affected, marginalized populations.
We need to include both identity and sufficient assessment of detailed behavior to design effective education and interventions.
