Post submitted by Enzo Patouhas, Luis Gutierrez-Mock, JoAnne Keatley & Jae Sevelius, UCSF Center of Excellence for Transgender Health
Transgender men (or trans men) is a term used to refer to people who were assigned a female sex at birth and now identify as male (sometimes referred to as female-to-male or “FTM” individuals). A subset of trans male populations includes trans men who have sex with men (trans MSM), a group that is often overlooked and underrepresented in research.
Trans MSM have diverse sexual identities and engage in a range of sexual behaviors that may or may not align with their sexual identities. Sexual identities, attractions, and behaviors of trans men may shift, change, or evolve with gender transition. Some trans men who are on cross-sex hormone therapy (i.e., testosterone, or “T”) self-report a correlation between testosterone use, increased sex drive, increased interest in engaging in sexual activity, and exploration of sexual behaviors that may include sex with non-trans men. For trans men on testosterone, the masculinization of the body may lead to increased access to non-trans MSM partners, and a willingness to take sexual risks could potentially place trans MSM at risk for STI and HIV infection.
Trans MSM may face barriers to negotiating safer sex. Several studies have identified unique gender related risks, such as affirming gender identity through sexual encounters with non-trans MSM, and complex gender role-related power dynamics that can affect condom negotiation (Reisner et al., 2010, Sevelius, 2009). Receiving gender affirmation in any context can temporarily lessen feelings of gender dysphoria for transgender people. Potential barriers to negotiating safer sex for trans MSM may include gender dysphoria, dissociation with their bodies, a lack of terminology to comfortably describe their bodies, and fear of partner rejection should they disclose their trans status.
These potential barriers may all contribute to the vulnerability of trans MSM to STI and HIV acquisition. While some sexual encounters with non-trans MSM may be gender-affirming, non-trans MSM partners inexperienced with trans bodies may confuse gender role expectations and invalidate gender identities for trans MSM.
In addition, a significant proportion of trans MSM report using alcohol and/or drugs to alleviate anxiety related to their bodies. Drug and alcohol use may affect decision-making, which may reduce inhibitions and contribute to increased willingness to engage in unprotected receptive vaginal and or anal intercourse for trans MSM. This in turn increases trans men’s risk for HIV, STDs, and pregnancy. Some trans men may not be aware that they may still be able to get pregnant even while taking testosterone.
Sexual health resources for non-trans MSM are often not inclusive of trans MSM. Accurate and culturally appropriate sexual health information for trans men is scarce. Reduced safer sex knowledge among trans MSM and non-trans MSM and/or misinformation may influence low risk perceptions and a lack of testing initiative. The marginalizing practice of excluding trans MSM in relevant sexual health discourse contributes to structural health inequities.
The U.S. healthcare system often perpetuates this marginalizing practice by not acknowledging transgender bodies and identities on pertinent medical forms,and not requiring healthcare providers to be competent to provide healthcare to transgender people. As a result, transgender men may avoid seeking medical services, especially gynecological and sexual health prevention services.
It is important to note that few trans men have access to genital surgeries, sometimes because of the very high cost of these procedures, sometimes due to a lack of trained surgeons or perceived less-than-optimal surgical outcomes. In addition, some trans men do not desire genital surgeries.
Trans MSM face many of the same social factors that place non-trans MSM at risk for HIV, such as stigma and discrimination. In addition, trans MSM face intersecting oppressions in terms of sexuality and identity. The consequences of these social factors for both trans and non-trans MSM are often psychological distress and predisposition to high-risk sexual behavior. Low self-esteem has been cited as a primary reason for sexual risktaking among trans men. Rates of depression, substance abuse, and suicidal ideation are disproportionately high in transgender populations compared to their heterosexual, lesbian, gay, and bisexual non-trans peers.
To date, there are few studies of HIV incidence among trans MSM in the literature. Those that have been conducted have found relatively high levels of reported risk behavior, but lower levels of HIV prevalence. A review of the literature from 2001-2011 was recently conducted in a technical report on the global health needs of transgender populations (Reisner, S.L., Lloyd, J., Baral, S.D., 2013), and found that HIV prevalence ranged from 0-3%.
High -risk sex among trans MSM has not been fully explored nor yet fully understood. There are significant gaps in the literature regarding the sexual practices, relationships, and sexual networks of trans MSM. Future research should examine the social determinants affecting the health of trans MSM in order to better understand HIV risk and factors of resilience and inform sexual health education, prevention practices, and programs.