Caught between different worlds: how transgendered women may be "forced" into risky sex

Journal of Sex Research, Feb, 2007 by Richard A. Crosby, Nicole L. Pitts

Evidence suggests that HIV incidence among transgendered women (biological males who have adopted the gender-role identity of a woman) is exceptionally high (Clements-Noelle, Marx Guzman, & Katz, 2001; Elifson et al., 1993; Kellog, Clements-Noelle, Diley, Katz, & McFarland, 2001; Kenagy, 2002; Nemoto, Operario, Keatley, Han,& Soma, 2004). Incidence may be greatest among African American transgendered women (Clements-Noelle, Marx Guzman, & Katz, 200; Nemoto et al., 2004). For example, in a study of nearly 400 transgendered women, the overall prevalence of HIV was 35%, with the African Americans being nearly six times more likely than their White counterparts to be infected (Clements-Noelle et al., 2001).

Clearly, transgendered women are a marginalized population in the United States. The associated stigma and loss of economic opportunity may place many transgendered women in circumstances that lead to commercial sex work (Bockting, Robinson, & Rosser, 1998; Elifson et al., 1993; Nemoto, Operario, Keatley, Han,& Soma, 2004; Nemoto, Operario, Keatley, Villegas, 2004). Further, economic deprivation may preclude transgendered women from medical care thereby necessitating they obtain injections of silicone and hormones from street vendors (Wiessing, van Roosmalen, Koedijk, Bielman, & Houweling, 1999). Lack of condom use during sex work combined with potential exposure to HIV from contaminated needles/syringes magnify HIV risk for this population.

Prevalence of HIV risk behavior among transgendered women may be greater than that of gay men, bisexual men, and heterosexual women (Nemoto, Luke, Mamo, Ching, & Patria, 1999). From a psychosocial perspective, the search for effective HIV intervention strategies is dependent upon improved understanding of life circumstances experienced by transgendered women. The required depth of this understanding may best be achieved by qualitative research. Unfortunately, only a few such studies have been published. A recent study found that transgendered women had unprotected sex with primary partners to feel emotionally connected and to validate their gender identity. Transgendered women reported using drugs to cope with stress pertaining to sex work, transphobia, and economic deprivation (Nemoto et al., 2004). A less recent study found that transgendered women experienced a host of issues ranging from sexual identity conflict, shame, and isolation to compulsive sexual behavior, sex work, and shared needles for hormone injections (Bockting et al., 1998). Given the magnitude of HIV risk and the potential to develop effective intervention strategies for transgendered women, expanded qualitative research efforts are warranted.

Accordingly, the purpose of this study was to qualitatively explore potential reasons why transgendered women may engage in sexual risk behavior that could lead to their acquisition of HIV infection. Specifically, we conducted this investigation with a sample comprised predominately of transgendered women who identified as Black or African American and who resided in a large metropolitan area of the Southern United States.

Method

Study Sample

In late 2004 through early 2005, 17 transgendered women were enrolled in this qualitative study. The study co-investigator (Nicole L. Pitts) actively solicited the participation of transgendered women through gay, lesbian, bisexual, and transgender (GLBT) groups and through organizations that provided support group meetings specifically for transgendered women. Persons were also recruited from two venues known to attract transgendered women (a cafe and coffee house). Referrals were also used (i.e., transgendered woman who completed an interview may have referred another transgendered woman to the study). Potential volunteers were asked whether they would be willing to answer three questions: (1) Do you consider yourself to be a transgendered woman?, (2) Are you knowingly HIV positive?, and (3) Are you between the ages of 18 and 45 years? Women who identified as transgendered, who stated they were not knowingly HIV positive, and who indicated being 18 years of age or older, but not more than 35, were asked for their willingness to volunteer in a study designed to investigate HIV risk behavior of transgendered women. To preserve anonymity, a waiver of written informed consent was obtained. The Institutional Review Board at the University of Kentucky approved the study protocol. A $25 incentive was provided to all study participants.

Data Collection

Interviews occurred in a private area agreeable to study participants. Because recruitment occurred in public places, private areas were most often nearby restrooms, stairwells, or in eating establishments. Interviews lasted, on average, about 30 min. The interviewer was trained by investigators at Emory University and the Centers for Disease Control and Prevention and she possessed ample experience interviewing people (mostly gay men) about their sexual behavior. She also openly identified as a transgendered woman. All interviews were recorded on audiotape.