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The Invisible War on Transgender Women

Transgender women are no strangers to abuse, stigma, and violence, but one of the greatest perils they encounter is HIV infection. Globally, nearly one in five trans women lives with HIV, and they have an even higher chance of acquiring the virus than other susceptible groups, including sex workers, gay men, and drug abusers, according to the Joint United Nations Program on HIV and AIDS (UNAIDS). The national incidence of HIV among trans women is 27.7 percent – even higher among African American trans women – and exceeds the 19 percent HIV prevalence in men who have sex with men. Alarmingly, the likelihood of a trans woman becoming HIV positive rises considerably with each year of life.

A recent study in the journal, AIDS and Behavior, shines a light on the often hidden challenges trans women face, including the odds of becoming HIV-positive, which are 34.2 times higher than for the general United States adult population. The study reveals the dynamics that make trans women so much more vulnerable to HIV infection than any other group.

Several key factors contribute to the problem. Transgender women often drop out of school, thereby restricting their employment prospects. They undergo discrimination in housing and employment and are rejected by their families. These circumstances leave them susceptible to violence, along with drug and alcohol abuse. Because of rampant discrimination, many trans females see few options other than sex work for survival, increasing their risk of infection. If they are arrested, imprisonment can result in rape. More than 32 percent of trans women have been incarcerated at some point in their lives.

To cope with the emotional anguish and punishing physical demands of sex work, trans women often resort to substance abuse, resulting in high rates of alcohol abuse (43.7 percent of trans women), marijuana use (20.2 percent), and illegal drug use (26.7 percent). Drug and alcohol use during sex or sex work also can reduce consistent condom use. And of course, sharing needles is a very effective way to transmit HIV.

The misuse of injectable hormones is another problem. According to a 2001 Los Angeles Transgender Health Study, 69 percent of high-risk trans women in Los Angeles have injected hormones, and 33 percent have injected substances such as silicone or oils to improve their gender presentation. Many purchase hormones from questionable sources, including the black market.

An added burden: Trans women often face discrimination by the very health care system that is designed to support them. Almost 50 percent lack health insurance coverage. Health care and social service workers often offend transgender people by using incorrect language when addressing them. More importantly, many providers are ill-equipped to meet their health needs and sometimes even refuse to treat them. This kind of transphobic behavior leads many trans women to give up on the health care system altogether or to wait until they have a symptomatic STI to seek care. Untreated STIs substantially raise the risk of HIV infection and transmission.

Imagine being transgender, with all the stigma and confusion that goes with it. Now imagine that your family just threw you out. Where will you sleep tonight? Unstable housing is another painful stop on the road to HIV infection. Many live in poverty, which limits housing choices. Stigma and bias make finding reliable housing extremely problematic. For trans women, changeable housing situations result in inconsistent condom use and substance use during sex, according to the authors of the recent study.

The federal government has recognized the relationship between violence and HIV infection. In 2012, an official memorandum from President Obama prompted the foundation of an interagency federal working group to explore the intersection of HIV/AIDS, violence against women and girls, and gender-related health disparities. The group’s 2013 report confirmed that violence and HIV are particularly prevalent among transgender women.

“A systematic review found a mean of 58 percent of transgender women reported violence at home, with a mean HIV prevalence of 28 percent,” concluded the group’s participants.

Action steps resulting from this report include the development of transgender sensitive campaigns to promote HIV testing among women and girls, with a focus on African-American and Latina women. This material will soon become available to the public, along with a list of domestic violence shelters and rape crisis centers through the website, VetoViolence.cdc.gov, and through social media.

The Health and Human Services Office on Women’s Health will also release “Addressing the Link Between Violence Against Women and Increased Risk of HIV: A Skills Enhancement Guide,” to educate and train violence-prevention providers about the link between violence and HIV. The contents will be used to promote HIV testing and risk reduction during violence-prevention services.

On a hopeful note, more services have become available to transgender people, according to Cathy J. Reback, Ph.D., Research Sociologist in the UCLA Integrated Substance Abuse Programs, Executive Director of the Friends Community Center in Los Angeles, and author of the AIDS and Behavior study. “I do believe that trans health issues have received more and more attention lately,” she says. “There are more resources available than previously. Although a tremendous amount still needs to be done to eradicate discrimination, stigma, and prejudice, and culturally competent HIV prevention interventions still need to be developed and evaluated for efficacy, there are also more services available today than in previous years.  Finally, there is forward movement, albeit ever so slightly.”

Dr. Reback believes that getting at-risk transwomen into trans-affirming health and social service programs is the most effective way of reducing the spread of HIV within this population. The good news is that these programs are becoming more widely available than ever before.