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Lifetime Risk Factors for HIV/Sexually Transmitted Infections Among Male-to-Female Transgender Persons

Nuttbrock, Larry PhD*; Hwahng, Sel PhD*; Bockting, Walter PhD; Rosenblum, Andrew PhD*; Mason, Mona; Macri, Monica MPH; Becker, Jeffrey MPH, MSW

JAIDS Journal of Acquired Immune Deficiency Syndromes: November 2009 - Volume 52 - Issue 3 - p 417-421
doi: 10.1097/QAI.0b013e3181ab6ed8
Brief Report: Epidemiology and Social Science

Objectives: To describe and evaluate risk factors for HIV/sexually transmitted infections (STIs) among male-to-female (MTF) transgender persons.

Methods: Using the life chart interview, potential lifetime risk factors for HIV/STIs among MTFs were measured and evaluated in conjunction with lifetime exposures for HIV, syphilis, hepatitis B, and hepatitis C. The participants were 517 MTFs between the ages of 19 and 59 years from the New York metropolitan area.

Results: HIV/STIs were low among white Americans and very high among Hispanics and African Americans. In the latter groups, HIV and hepatitis B were associated with an androphilic sexual orientation, lifetime number of commercial sex partners (sex work), and the social expression of transgender identity; syphilis was associated with lifetime number of casual sex partners; and hepatitis C was associated with injection drug use, unemployment, and social expression of transgender identity. In multivariate models, the social expression of transgender identity was the strongest and most consistent predictor of HIV/STIs. Consistent with their lower levels of infections, white Americans reported significantly lower levels of the risk factors found to be predictive of HIV/STI among Hispanics and African Americans.

Conclusions: HIV/STI prevention in this population should be targeted at Hispanic and African Americans. Prevention programs should incorporate multiple components designed to address the diverse issues confronting ethnic minority transgender persons, with an emphasis on the social expression of transgender identity.

From the *National Development and Research Institutes, New York, NY; and †Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN.

Received for publication November 14, 2008; accepted March 6, 2009.

Supported by a grant from the National Institute of Drug Abuse (1 R01 DA018080) (L.N., principal investigator) and by a National Institute of Drug Abuse administrative research supplement to promote diversity in health related research (S.H., Investigator).

Correspondence to: Larry Nuttbrock, PhD, National Development and Research Institutes, 71 W, 23rd St, 8th Floor, New York, NY 10010 (e-mail:

Previous studies have reported very high levels of HIV and other sexually transmitted infection (STIs) among male-to-female (MTF) transgender persons. Surveys of MTF sex workers detected levels of HIV antibodies ranging from 62% to 74% with syphilis and hepatitis B exceeding 75%.1-3 HIV among MTFs recruited from the streets ranged from 22% to 35%.4-6 Follow-up studies of MTFs receiving social services observed yearly incidence rates of HIV ranging from 3.5% to 7.8%.7-8

Several risk factors have been suggested for HIV/STIs in this population. More than one-half of MTFs report a history of commercial sex partners (sex work), which is widely thought to put them at risk for HIV/STIs.9 Because of difficulties in maintaining employment in the legitimate economy, MTFs may be financially compelled to pursue sex work, which then puts them at risk for HIV/STIs.9 Lifetime numbers of noncommercial sex partners are much higher among MTFs compared with general population, and these partnerships may likewise contribute to HIV/STIs.10-11 Noninjection substance use may broadly increase HIV/STI vulnerability and lead to illicit psychoactive drug injection, which is a well-established risk factor for HIV, hepatitis B, and especially hepatitis C.12

Significant numbers of MTFs have used feminizing hormones to enhance their presentation of sex.13 The accepted medical practice is to prescribe hormone pills to be taken orally, but many doctors prescribe and many patients prefer intramuscular shots (injections are thought by patients to produce quicker results). The reuse of unsterilized needles for intramuscular injections, as with intravenous injections, poses a potential risk for HIV/STIs.13

Because of their failure to conform to conventional sex roles, MTFs may experience psychological and physical abuse, which is proclaimed to be a fundamental cause underlying many of the issues confronting sex-variant individuals, including HIV infection.14 Social expressions of transgender identity may be psychologically beneficial in important respects, but “coming out” to others may also expose sex-variant individuals to increased abuse and discrimination and ultimately increase their odds of HIV/STI infections.15

The subset of MTFs sexually attracted only to men (androphilic) may have an elevated risk for HIV/STI because of their comparatively frequent sexual contacts with high-risk partners (MSMs).16 The prevalence of HIV among Hispanics and African American MTFs has been shown to be much higher than the prevalence of HIV among white American MTFs.4

Empirical research bearing on these potential HIV/STI risk factors among MTFs is, in fact, limited and methodologically weak. Previous studies typically relied on recollections of risk factors in the recent and distant past in conjunction with narrowly defined samples of MTFs. This study examines potential HIV/STI risk factors using an innovative methodology for the collection of retrospective data (described below) and a diverse and broadly recruited sample of MTFs from the New York metropolitan area.

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Sampling and Data Collection

A total of 517 MTFs were recruited for the baseline component of a large cross-sectional/longitudinal study of MTFs in the New York metropolitan areas. All study participants were assigned as male at birth but subsequently did not regard themselves as “completely male” in all situations or roles (transgender identity). Eligibility criteria included transgender identity (as defined above), age of 19 years or older, and the absence of psychotic ideation (2 were screened out). Because of the small numbers, respondent's older than 59 years and those indicating an ethnicity other than white American, African American, or Hispanic were not included in this report. Study participants were broadly recruited from the streets, clubs, newspaper advertisements, transgender organization in the New York metropolitan area, the Internet, and referrals of other transgender persons by study participants. They were paid $30 for the baseline interview. Transgender or sex-variant individuals were actively involved in all aspects and phases of the research design (instrument construction, interviewing, data analysis, and dissemination of the findings). The interviewers, all but 1 of whom was transgender or sex variant, were fully trained (including mock and observed interviews) with an ongoing monitoring of their performance (including interviewer drift).

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Face-to-face interviews were conducted with the Life Review of Transgender Experiences (LRTE), which adopts and extends the protocols and format of the life chart interview (LCI),17 which was developed in conjunction with the National Comorbidity Survey.18 The LCI (and the LRTE) uses time-focused interviewing (all questions are referenced with regard to a particular time frame) and multiple sets of personal and social memory cues or anchors to improve the accuracy of symptom recall. The LCI has now been implemented and validated in mental health surveys around the world.19 Versions of this methodology have been used to study changes in relationships over the life course.20 The LRTE is designed specifically for an MTF population and includes a broad range of social, behavioral, economic, and psychiatric assessments. The Institutional Review Board of the National Development and Research Institutes, Inc, approved all the research protocols.

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Biological Assays (Bendiner & Schlesinger Laboratories, New York City, NY)

The presence of HIV antibodies was determined by an enzyme immunoassay screen with a Western blot confirmation. Syphilis was assayed with a rapid plasma reagin screen and a fluorescent treponemal antibody confirmation. Hepatitis B was determined by the presence of core antibodies. Hepatitis C was assessed with a third-generation enzyme immunoassay with a polymerase chain reaction confirmation. By design, all these viral assessments reflect lifetime exposures.

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Lifetime HIV/STI Risk Factors

The LRTE incorporates reporting intervals corresponding to stages of the life course. Adolescence was divided into early adolescence (ages 10-14 years) and late adolescence (ages 15-19 years) for all the respondents. For the younger respondents with a current age of 19-39 years, adulthood was indicated as early adulthood (ages 20-24 years), young adulthood (ages 25-29 years), and early middle age (ages 30-39 years). For the older respondents with a current age of 40-59 years, adulthood was indicated more broadly as early/young adulthood (ages 20-29 years), early middle age (ages 30-39 years), and later middle age (ages 40-59 years). These differences in the duration of the post-adolescent life stages for the younger and older respondents necessitated a statistical control for current age in much of the analysis below.

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Lifetime Numbers of Sex Partners

Respondents were asked about the total numbers of different commercial (paying), casual (short-term or “1 night stands”), and committed (long-term relationships including marriage) sex partners. Item responses were added across the stages of life to form a lifetime count of these 3 types of sexual partners. The raw counts of commercial, casual, and committed sexual partners will be divided by 10 in the logistic regression modeling below (ie, each unit of measurement equals 10 partners).

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Drug Injections

Months of injecting psychoactive drugs were assessed across stages of life to form a lifetime measure of nonhormonal drug injection. Due to the low numbers, this distribution was trichotomized (0 = never; 1 = less than 5 years; and 2 = 5 years or more). Injection of feminizing hormones was measured on a continuous scale as the years of injection.

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Substance Use

Months of using alcohol heavily (5+ drinks/d) or using 10 illicit drugs were added across the stages of life and divided by 12 to form a composite lifetime assessment of substance use years.

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Sex Abuse

Durations of time the respondents were “verbally abused or harassed and thought it was because of their sex identity or sex presentations” (psychological abuse) were assessed. A parallel item referred to durations of time respondents were “physically abused or beaten” (physical abuse). Durations of the 2 types of abuse, at given stages of life, were trichotomized (0 = never abused; 1 = abused less than once a month; and 2 = abused at least once a month). Categorized responses for the 2 types of abuse during each of the 5 stages of life were added to form a composite measure of lifetime sex abuse, which theoretically ranged from 0 to 10.

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Employment was gauged by whether (0 or 1) respondents were typically employed full or part time (sex work not included). These responses were reverse coded and added across 3 adult stages of life to form a measurement of unemployment with a theoretical range from 0 to 3.

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Disclosure of Transgender Identity

Whether the respondent's transgender identity was known to parents, siblings, friends, coworkers, and fellow students was determined. For each of these 5 interpersonal contexts, transgender identity disclosure was coded as 0 (known to no others), 1 (known to some but not all others), or 2 (known to all others). A lifetime summary of transgender identity disclosure was computed by adding these scores across the 5 interpersonal contexts and the 5 stages of life with a theoretical range of 0-50. Because of differences in the extent to which these interpersonal contexts, such as school or work, were applicable or available during given stages of life, an additional measurement of the availability of these interpersonal contexts was obtained and will be used as a covariate in some of the analysis below. This covariate reflects the availability of the above 5 interpersonal contexts across 5 stages of the life course with a theoretical range from 0 to 25.

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Dressing in the Female Role in Public

This was scored as 0 (never), 1 (part time), or 2 (full time) and summed across the 5 life stages to provide a lifetime summary of dressing in female attire in public, with a theoretical range of 0-10.

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Description of the Study Participants

The 517 respondents included in this report ranged in age from 19 to 59 years with a mean age of 37 years. Hispanic identification was 47.6%, with 23.4% and 29.4% classified as non-Hispanic African American, and non-Hispanic white American, respectively. More than half (58.1%) of the included respondents were high school graduates (12 years of education), about one-fifth (18.2%) were college graduates (at least 16 years of education). About two-thirds of the respondents (64.2%) were sexually attracted to males only (androphilic), 17.8% were only attracted to females (gynephilic), 14.8% were attracted to both males and females (bisexual or androphilic/gynephilic), and 3.2% were not attracted to either males or females (asexual). For the analysis below, sexual orientation will be dichotomized as androphilic (64.2%) or nonandrophilic (35.8%).

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Lifetime HIV/STI Infections Across Ethnic Groups

HIV was 3.5% among white Americans compared with 49.6% and 48.1% among the Hispanics and African Americans, respectively. Syphilis was 1.4% among the white Americans compared with 21.6% and 14.7% among the Hispanics and African Americans, respectively. Hepatitis B was 6.5% among the white Americans compared with 36.0% and 35.5% among the Hispanics and African Americans, respectively. Hepatitis C was 3.6% among the white Americans compared with 15.7% and 7.4% among the Hispanics and African Americans, respectively.

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Potential Lifetime HIV/STI Risk Factors Across Ethnic Groups

Because of the extremely low numbers of HIV/STIs among the white American, the effects of risk factors on these infections within this ethnic group, or across ethnic groups, cannot be estimated. A description of HIV/STI risk factors within and across ethnic groups is possible however and will be broadly informative about HIV/STI etiology in this population.

Adjusted for age, no differences across the 3 ethnic groups were observed with regard to lifetime psychoactive drug injections. No age-adjusted differences between the Hispanics and the African Americans were observed for the remaining risk factors described above. Compared with the Hispanics and African Americans (considered as a group), the white Americans reported fewer commercial and causal lifetime sex partners, fewer years of injecting female hormones, less sex-related abuse (physical or psychological), less lifetime unemployment, less sex identity disclosure, and less dressing in the female role in public.

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Modeling of HIV/STIs Among MTFs of Color

Bivariate Modeling

The associations of the above lifetime HIV/STI risk factors with lifetime HIV/STI infections were estimated using logistic regression (Table 1). These associations include current age as a covariate (coefficients not displayed). Statistical significance was determined by the Wald test with 2-sided P values indicated for significance at the 0.05 and 0.01 levels.



Number of lifetime commercial sex partners was associated with HIV. The odds ratio (OR) of 1.02 indicates that an increase in 10 lifetime commercial sex partners, controlling for age, is roughly associated with a 2% increase in the likelihood of HIV (OR of 1.02). Number of lifetime commercial sex partners was also associated with hepatitis B and hepatitis C. Number of lifetime casual sex partners was associated with syphilis but not with HIV, hepatitis B, or hepatitis C. Number of committed sex partners was not associated with any of the HIV/STIs.

Years of psychoactive drug injection were strongly associated with hepatitis C but not the other HIV/STIs. Years of hormone injection were not associated with any of the HIV/STIs. Hispanic identification (compared with African American) was associated with hepatitis C. Sexual orientation (androphilic compared with nonandrophilic) was associated with HIV and hepatitis B. Substance use was associated with hepatitis B and hepatitis C.

Sex abuse was not associated with the HIV/STIs. Unemployment was associated with HIV, hepatitis B, and hepatitis C. Sex identity disclosure was associated with HIV, hepatitis B, and hepatitis C. The above analysis included number of available interpersonal contexts as a covariate (coefficients not displayed). Female dressing in public was associated with HIV, hepatitis B, and hepatitis C.

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Multivariate Analysis

To clarify the effects of the above statistically significant HIV/STI risk factors, multivariate logistic regression models were estimated, which included them simultaneously in the equations. Multivariate models of lifetime syphilis exposure are not estimated because this infection is predicted from a single proximal risk factor (number of lifetime casual sex partners). In this modeling, HIV was predicted from androphilic sexual orientation (B = 0.81; SE = 0.40; OR = 2.27*) and dressing in the female role in public (B = 0.10; SE = 0.05; OR = 1.10*). Hepatitis B was similarly predicted from androphilic sexual orientation (B = 0.09; SE = 0.03; OR = 2.98*) and dressing in the female role in public (B = 0.16; SE = 0.06; OR = 1.17**). Hepatitis C was predicted from psychoactive drug injection (B = 1.54; SE = 0.45; OR = 4.54**), unemployment (B = 0.40; SE = 0.20; OR = 1.49*), and dressing as a female in public (B = 0.16; SE = 0.01; OR = 1.18*).

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A central finding of this study is the extremely high prevalence of HIV/STIs among Hispanics and African Americans MTFs combined with the surprising low prevalence of HIV/STIs among the white Americans MTFs.

It is unclear why syphilis, a classic STI transmitted only via sexual contact, was not associated with aspects of sexual behavior (androphilic sexual orientation, commercial sex partners, and committed sex partners) other than casual sex partners. It is likewise unclear why the lifetime number of committed sex partners had no impact on STIs efficiently transmitted via sexual contact (HIV, syphilis, and hepatitis B).

There has been some speculation that intramuscular injection of feminizing hormones might be a risk factor for HIV/STIs. Injection of feminizing hormones was not associated with HIV/STI in this study, and we conclude that the impact of intramuscular injections on HIV/STIs is either extremely weak or nonexistent among Hispanic or African American MTFs.

The extent to which hepatitis C is sexually transmitted is currently debated.21 In this study, lifetime number of commercial sex partners (sex work) was indeed associated with hepatitis C in bivariate models of theses 2 variables, but not in multivariate modeling with statistical controls for substance use and unemployment. We conclude that the impact of sex work on hepatitis C is either extremely weak or nonexistent among Hispanic and African American MTFs. The duration and extent of lifetime sex abuse (psychological and physical) was not associated with HIV/STIs among the Hispanic and African American MTFs in this study.

The most robust risk factor for HIV/STIs, among the Hispanic and African American MTFs in this study, was the social expression of transgender identity (measured as sex identity disclosure and dressing in female attire). Those MTFs who live out their social lives in the male role are apparently unlikely to contract HIV/STIs. In contrast, those who presented in the female sex role at an early age, and dress accordingly, were more likely to become infected with HIV or some other STI. This finding is consistent with previous research associating HIV infection with a greater involvement in the transgender community measured as a commitment to a transgender (transvestite) lifestyle and social interaction mostly within transgender (transvestite) networks.22 MTFs who do not socially express their sex identity are different from those who do so because of a combination of personal selection and societal forces. Because of dispositional factors or early socialization, some MTFs may have a greater need than others to express their sex identity at an early age. Once they are “out” to others and live their lives in the female sex role, they may become increasingly marginalized in a social world where transgenderism is condoned and often desired (sex work). The identification of unemployment in the bivariate and some of the multivariate models as a STI risk factor suggests that normative employment roles may be difficult to sustain for MTFs who are at high risk. MTFs may initially drift into sex work because it allows them to express themselves in the context of sexual practices and social roles highly symbolic of their sex identity.23

The risk factors associated with HIV/STIs among the ethnic minority MTFs were strikingly virtually absent among the white American MTFs in this study. Androphilic sexual orientation, commercial sex partners (sex work), and the social expression of transgender identity were consistently associated with HIV among the ethnic minority MTF, but infrequently reported by the white American MTFs. The differences in HIV across these ethnic groups may be largely attributable to ethnic differences in these risks.

The findings of this study indicate that improved HIV/STI prevention is urgently needed for Hispanics and African American MTFs. This prevention should be broadly formulated and incorporate multiple components designed to address the complex and diverse issues confronting ethnic minority transgender persons. This prevention should focus on a key risk factor for HIV/STI in this population-the social expression of transgender identity. The affirmation of sex identity is a dominant issue in the lives of transgender persons. Approaches to HIV prevention should be devised, which promote the affirmation of sex identity while simultaneously avoiding the high-risk behaviors too often associated with it.24

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We thank the participants of this study for sharing their “life stories.”

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life chart interview; male-to-female transgender persons; major depression; suicidality

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