What are male-to-female transgender persons’ (MtF) HIV prevention needs?
what does being transgender mean?
Transgender is an umbrella term for persons whose gender identity and expression does not conform to norms and expectations traditionally associated with their sex assigned at birth. Transgender persons may self-identify as transgender, female, male, trans-woman or -man, transsexual, crossdresser, bigender, gender queer, gender questioning, MtF, FtM or one of many other transgender identities, and may express their genders in a variety of masculine, feminine and androgynous ways. Transgender persons may prefer and identify with certain terms and not others, so it is best to ask participants and clients what they prefer. For this fact sheet, we use the term MtF for male-to-female transgender individuals.
The transgender community is complex and not enough research has been conducted with transgender persons. From what we know, MtFs have higher rates of HIV and HIV-related risks than female-to-male transgender persons (FtMs). While this fact sheet focuses on MtFs, we are developing other fact sheets on FtMs and the general transgender population.
is HIV a concern?
Unfortunately, yes. HIV is certainly not the only concern of MtFs, who face many physical, mental, social and economic disparities besides HIV. The stigma and discrimination experienced by many people merely for being transgender heightens risk behavior for MtFs. It is greater for MtFs of color, who experience stigma and discrimination due to ethnicity as well.
A recent review of 29 studies of MtFs in the US, found they have been greatly impacted by the HIV epidemic. In four of the studies, 27.7% of MtFs tested HIV+, compared to 11.8% who self-reported HIV+ in the remaining 25 studies. This suggests that many MtFs may not be aware of their HIV status. Highest HIV rates were among African American MtFs (56.3%). In this review, a large percentage of MtFs reported engaging in unprotected receptive anal intercourse, multiple casual partners and sex work.
Stigma, discrimination and racism, as well as the social isolation and alienation from family that some MtFs encounter, can lead to anxiety, depression as well as thoughts of and attempts at suicide. Stigma and abuse also make MtFs vulnerable to dropping out of school and homelessness at a young age, disrupting their education and employment careers. Some MtFs turn to sex work for survival, and some MtFs turn to substance use to cope with all of these life stresses.
It is important to note that not all MtFs are at risk for HIV. Like with many populations, those at greatest risk are more likely to be poor, homeless, young, people of color and sex workers. There are many MtFs who do not face the same degrees of risk.
Substance use immediately before and during sexual activity increases HIV risk. One study of MtFs in San Francisco, CA, found that their male sexual partners often use crack cocaine before sex to ease inhibitions and to maintain their fantasy, particularly during anal sex.
who are partners of MtFs?
MtFs may have sex with men, women and other transgender persons. Like many other women, MtFs face complicated power and gender dynamics in their sexual relationships. There is a perception that there are few people who are willing to be in committed relationships with MtFs, which compromises disclosure of HIV status, sexual negotiation and condom use. Some MtFs have sexual partners who provide a sense of love and acceptance, but who also request unsafe sexual behaviors.
While MtFs have been considered a bridge group for transmission to men, it appears that the opposite could be true. In one online survey, Latino men who have sex with a transgender partner were more likely to be HIV+, reported a higher number of sexual partners, and were almost three times more likely to have had unprotected sex than Latino men who have sex with men who did not report sex with a transgender person.
Men who have sex with MtFs challenge traditional sexual orientation categories often used in HIV prevention. These men may have sex with women, men and MtFs and may describe themselves as straight, bisexual or gay. Few have sex solely with MtFs.
how are challenges addressed?
Education and employment. Finding and keeping jobs is a key step in reducing risk for MtFs. The Transgender Economic Empowerment Initiative (TEEI) provides training, employment and support for transgender individuals in San Francisco, CA. TEEI helps build job skills such as interviewing, coaching and resume building and has hosted job fairs. TEEI has a mentoring program for newly placed employees, and legal and technical services for employers to help make workplaces safe for transgenders.
Training for healthcare providers. Quality, sensitive healthcare is important for MtFs. Despite their sincere concern to serve patients effectively, providers may have very little knowledge, experience, skills and therefore comfort with transgender patients. The Center of Excellence for Transgender HIV Prevention provides free training and consultations for health professionals.
Mentoring. Youth and others who are transitioning need role models to help them envision a successful life for themselves. Unfortunately, MtFs struggle with the loss of potential role models due to marginalization and pressure to “pass.” This invisibility often leaves young transgender people looking to find community on the street, one of the few places where MtFs are visible, yet risks are high. Fortunately, an increasing number of MtFs are more open about their transgender identity, and public awareness is growing due to transgender community organizing and coalitions with the gay, lesbian, bisexual and other allied communities.
what’s being done?
In Minnesota, All Gender Health incorporates HIV prevention efforts into comprehensive sexuality education for transgender persons. The program addresses HIV risk in context and covers topics such as coming out, resilience in the face of stigma and discrimination, dating and relationships, body image and sexual functioning, and community building and empowerment. The two-day, weekend workshops are led by MtF professional and trained peer educators, combining education with live entertainment. Participants reported improved attitudes toward condom use, increased monogamy and decreased high risk behavior at 3-month follow-up. All Gender Health is being adapted for online delivery.
In Hawaii, Kulia Na Mamo is a program developed and run by MtFs that provides job skills training, job referrals and a support group for working women. They developed an HIV, substance abuse and hepatitis prevention program for native Hawaiian MtFs.
Although the CDC currently has no interventions for transgender populations in their Diffusion of Effective Behavioral Intervention (DEBI) program, a few have been informally or formally adapted. The Transitions Project provides technical assistance to numerous agencies adapting the DEBI projects SISTA and Mpowerment across the US.
Bienestar in Los Angeles, CA, has adapted SISTA for Latina MtFs, as DIVAS (Destacadas Intervenciones Variadas Acerca del SIDA). The Life Foundation in Hawaii has another adaptation, TITA (T-girls Informing T-girls about Topics on AIDS).
what still needs to be done?
To address the devastating effects of stigma and discrimination on transgender persons, large scale anti-stigma campaigns as well as anti-discrimination laws should be implemented across the country. Sensitivity training should be provided for healthcare workers, employers, service providers and researchers working with MtFs. Education and training for school officials—including teachers, principals and administrators—is key.
Sexual partners of MtFs should not be ignored. Recent studies show that many male partners of MtFs are at high risk for HIV. More research is needed for them, as well as programs that work with MtFs and their partners together as a couple.
We need to do a better job counting and including MtFs in HIV surveillance. The CDC currently has plans to pilot a transgender category for HIV reporting as part of the National HIV Behavioral Surveillance System. Interventions that specifically address transgender persons should be added to the DEBI program. DEBIs that have been successfully adapted for the transgender population should be disseminated.
More research should be done with transgender youth to identify and develop strategies for HIV prevention for young adults coming out as transgender. Structural interventions such as job training, housing and anti-discrimination laws need to be studied to see if they are effective and make a difference in MtFs’ lives.
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6. Bockting W, Miner M, Rosser BR. Latino men’s sexual behavior with transgender persons. Archives of Sexual Behavior. 2007;36:778-786.
7. Operario D, Burton J, Underhill K, et al. Men who have sex with transgender women: challenges to category-based HIV prevention. AIDS and Behavior. 2008;12:18-26.
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11. Bockting WO, Robinson BE, Forberg J, et al. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care. 2005;17:289-303.
12. Kulia Na Mamo
14. Transitions Project Newsletter. Winter/Spring 2007.
15. Garofalo R, Deleon J, Osmer E, et al. Overlooked, misunderstood and at-risk: Exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. Journal of Adolescent Health. 2006;38:230–236.
- Center of Excellence for Transgender HIV Prevention
- Transgender Law Center
- National Center for Transgender Equality
- Transgender HIV/AIDS Services Best Practices Guidelines
- World Professional Association for Transgender Health
Prepared by JoAnne Keatley MSW* and Walter Bockting PhD**
*CAPS, Pacific AETC; **University of Minnesota
September 2008. Fact Sheet #41ER
Special thanks to the following reviewers of this fact sheet: Ashliana Hawelu-Fulgoni, Craig Hutchinson, Steve Levine, Micah Lubensky, Samuel Lurie, Rita Melendez, Don Operario, Jessica Xavier.
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