HIV Risk and Social Networks Among
Male-to-Female Transgender Sex Workers
in Boston, Massachusetts
Sari L. Reisner, MA
Matthew J. Mimiaga, ScD, MPH
Sean Bland, BA
Kenneth H. Mayer, MD
Steven A. Safren, PhD
engage in sex work constitute a group at high risk
for HIV infection in the United States. This mixed-
methods formative study examined sexual risk among
workers (N 5 11) in Boston. More than one third
of the participants were HIV-infected and reported
a history of sexually transmitted diseases. Partici-
pants had a mean of 36 (SD 5 72) transactional
male sex partners in the past 12 months, and
a majority reported at least one episode of unpro-
tected anal sex. Qualitative themes included (a)
sexual risk, (b) motivations for engaging in sex
work, (c) consequences of sex work, (d) social
networks (i.e., ‘‘trans mothers,’’ who played a pivotal
role in initiation into sex work), and (e) potential
intervention strategies. Results suggest that interven-
tions with transgender male-to-female sex workers
must be at multiple levels and address the psychoso-
cial and environmental contexts in which sexual risk
(Journal of the Association of Nurses in AIDS Care,
20, 373-386) Copyright ? 2009 Association of
Nurses in AIDS Care
Key words: HIV, intervention development, sexually
transmitted diseases, transgender, trans mothers
researchers are now beginning to substantiate what
the transgender community has been experiencing:
HIV remains a serious public health crisis for the
itivity rates ranging from 8% to 35% (Clements-
Sari L. Reisner, MA, is Epidemiology Projects Manager,
The Fenway Institute, Fenway Health, Boston, Massachu-
setts. Matthew J. Mimiaga, ScD, MPH, is Research Scien-
tist, The Fenway Institute, Fenway Health, Boston; and
Instructor, Psychiatry, Harvard Medical School/Massa-
chusetts General Hospital, Boston. Sean Bland, BA, is
Research Associate for Epidemiology and Behavioral
Science Studies, The Fenway Institute, Fenway Health,
Boston. Kenneth H. Mayer, MD, is Co-Director, The Fen-
way Institute, Fenway Health, Boston; Director, Brown
University AIDS Program, Providence, Rhode Island;
Professor of Medicine and Community Health, Brown
University Medical School, Providence; and Professor of
Medicine and Community Health, Brown University, Prov-
idence. Brandon Perkovich is an undergraduate student,
Harvard College, Cambridge, Massachusetts. Steven A.
Safren, PhD, is Senior Research Scientist, The Fenway
Institute, Fenway Health, Boston; Director of Behavioral
Medicine, Massachusetts General Hospital, Boston; and
Associate Professor of Psychology, Department of Psychi-
atry at Harvard Medical School, Boston.
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 20, No. 5, September/October 2009, 373-386
Copyright ? 2009 Association of Nurses in AIDS Care
Nolle, Marx, Guzman, & Katz, 2001; Herbst et al.,
2008; Kellogg, Clements-Nolle, Dilley, Katz, &
McFarland, 2001; Kenagy, 2002; Nemoto, Operario,
Keatley, Nguyen, & Sugano, 2006; Operario, Soma,
& Underhill, 2008; Reback & Lombardi, 1999;
Simon, Reback, & Bemis, 2000). Rates of HIVinfec-
tion among transgender women have been reported to
be significantly elevated compared with rates in the
general population and other groups with high-risk
behaviors, including men who have sex with men
(MSM) (California Department of Health Services,
2006). Epidemiologic studies have attributed high
rates of HIV infection in transgender women to
a variety of risk behaviors including unprotected sex
with male partners and injection drug use (Elifson
et al., 1993; Operario et al., 2008; Simon et al.,
2000). In addition, contextual factors such as sex
work may influence HIV risk behaviors (Mimiaga,
Reisner, Tinsley, Mayer, & Safren, 2009). Given
that as many as 44% of transgender women engage
in high-risk behaviors (i.e., unprotected anal sex)
and 24% to 75% participate in sex work (Herbst
et al., 2008), advances in HIV prevention strategies
are needed to reduce sexual risk taking among
transgender populations (Bockting & Avery, 2005;
Bockting, Robinson, Forberg, & Scheltema, 2005;
Lombardi, 2001; Mason, Connors, & Kammerer,
Sex work (i.e., transactional sex) has been consis-
tently associated with HIV seropositivity among
et al., 1993; Operario et al., 2008; Simon et al.,
2000). A recent metaanalysis estimated HIV preva-
lence to be 27.3% in transgender sex workers
(TGSW) compared with 15.1% in male sex workers
and 4.5% in female sex workers (Operario et al.,
2008). Operario et al. (2008) also reported that
TGSW experience significantly higher HIV risk
than transgender women who do not engage in sex
work, but additional research is needed to understand
both the risk factors that increase HIV infection and
possible protective factors that reduce risk behaviors
among transgender individuals.
Previous research has suggested that many trans-
gender individuals enter into sex work because of
structural-level factors such as social stigma and
employment discrimination (Clements-Nolle et al.,
2001; Kaufman, 2007; Melendez, 2007; Nemoto
et al., 2006; Sausa, Keatley, & Operario, 2007). Sex
work can provide transgender women an opportunity
to make a living (Bockting, Robinson, & Rosser,
1998; Nemoto et al., 2006; Nemoto, Operario, Keat-
ley, & Villegas, 2004; Sausa et al., 2007) as well as
allow them to sustain ongoing drug dependence
(Clements-Nolle, Guzman, & Harris, 2008; Reback
& Lombardi, 1999). High levels of substance use
and psychological distress (e.g., depression, earlier
suicide attempts, history of sexual abuse) have been
observed among transgender women, including
TGSW, which may contribute to elevated HIV sexual
risk behavior (Clements-Nolle et al., 2001; Clements-
Nolle, Marx, & Katz, 2006; Garofalo, Deleon,
Osmer, Doll, & Harper, 2006; Kenagy, 2005; Kenagy
& Bostwick, 2005; Stall et al., 2003). Results from
other studies have suggested that sex work may allow
transgender women to feel part of both a community
and social network (Sausa et al., 2007) and even feel
safety, affection, and validation from transactional
sex partners (Bockting et al., 1998; Melendez &
The purpose of this mixed-methods formative
research study was to examine sexual risk among
workers in Boston, Massachusetts, including the
role of social networks in relation to sexual risk.
Understanding the role of risk and protective factors
underlying sexual behavior may inform providers
and researchers regarding how to tailor HIV preven-
tion interventions to this unique and high-risk
Design and Setting
Between August and November 2008, 11 partici-
pants completed a one-on-one, in-depth, semistruc-
tured qualitative interview and brief quantitative
survey. Study activities took place at Fenway Health
(FH), a freestanding health care and research facility
specializing in HIV care and serving the needs of the
lesbian, gay, bisexual, and transgender community in
the greater Boston area (Mayer et al., 2001). The FH
institutional review board approved the study
374 JANAC Vol. 20, No. 5, September/October 2009
Individuals were eligible for the study if they:
(a) were born biologically male, identified as trans-
gender, and were preoperative; (b) were 18 years of
age or older; (c) lived in Massachusetts; and (d)
reported they had engaged in sex work with a biolog-
ical male in the 12 months before study enrollment.
Sex work was defined as the exchange of sex for
money, drugs, housing, protection, or other services.
Participants were recruited via word-of-mouth
referrals and study flyers that were distributed in the
clinical and medical areas at FH, in known public
sex cruising areas, at community events frequented
community-based organizations in the Boston area.
& Huberman, 1994). All participants were compen-
sated $50 for their participation in the study.
Data Collection and Measures
After an informed consent process with one of
two trained interviewers, each study participant
completed a semistructured qualitative interview
and a brief interviewer-administered quantitative
psychosocial assessment battery of questionnaires.
Data collection lasted approximately 1.5 hours.
guide was developed after a thorough literature review
and after gathering input from former sex workers as
well as transgender health specialists at FH to ensure
cultural relevance of interview questions and survey
instruments. The interview included four broad topic
areas: (a) experiences with sex work in the past 12
months (e.g., ‘‘Tell me about your experiences doing
sex work in the past 12 months.’’), (b) the impact of
sex work (e.g., ‘‘How, if at all, do you feel that sex
work has affected you?’’), (c) HIV/ sexually trans-
mitted disease (STD) risk (e.g., ‘‘What types of sexual
practices do you engage in during sex work encoun-
individuals who engage in sex work (e.g., ‘‘If we
were to develop an intervention or program for male-
to-female transgender persons who perform sex work,
what do you see as the most important areas on which
The qualitative interview
transcription company. Interviewers were trained
together and regularly met with the research team to
discuss emerging themes and issues as well as to mini-
mize bias caused by differential interviewer methods.
included on the quantitative survey instrument to
assess background and HIV risk factors. Questions
that addressed demographic characteristics, sexual
behavior, and drug use during sex were adapted from
the Centers for Disease Control and Prevention’s
National HIV Behavioral Surveillance Survey (San-
chez et al., 2006). Items also captured self-reported
HIV status and testing history as well as STD history.
Depressive symptoms were assessed with the
Center for Epidemiologic Studies Short Depression
Scale (CES-D 10) (Andresen, Malmgren, Carter, &
bach’s a5 .84). The 10 items were scored on a four-
point Likert scale ranging from 0 (rarely or none of
the time) to 3 (most or all of the time). Items 5 (‘‘I
felt hopeful about the future’’) and 8 (‘‘I was happy’’)
The CAGE questionnaire, a four-item clinical
screening instrument for alcoholism (Cronbach’s
a5 .69), was used to assess alcohol use (Ewing,
1984; Knowlton, McCusker, Stoddard, Zapka, &
Mayer, 1994; Mayfield, McLeod, & Hall, 1974).
Items included the following (italicized words form
the CAGE acronym):
survey. Several measureswere
1. Have you ever felt you should cut down on your
2. Have people annoyed you by criticizing your
3. Have you ever felt bad or guilty about your
4. Have you ever had a drink first thing in the
morning to steady your nerves or get rid of
a hangover (eye-opener)?
Items were dichotomously scored as 0 (no) or 1
(yes), and a score of 2 or more indicated a problem
with alcohol abuse.
Reisner et al. / HIV Risk and Social Networks Among Transgender Sex Workers375
Questions taken from the EXPLORE study (Ches-
ney et al., 2003; Koblin et al., 2003) were adapted to
examine early childhood sexual experiences and their
association with HIV-related sexual risk. Questions
included age at first sexual experience, sexual experi-
ences with someone 5 or more years older before age
13, sexual experience with someone 10 or more years
older between the ages of 13 and 17, self-reported
sexual abuse, and nonconsensual sex (i.e., rape) as
analyzed using content analysis (Strauss & Corbin,
1990, 1997). Using a process of allowing concepts
and themes to emerge from the data, analysis
continued until saturation was reached (Glaser,
1978). Analyses were focused on HIV sexual risk
and intervention development and concentrated on
emerging themes that were relevant to HIV preven-
tion interventions with TGSW.
Transcripts were reviewed for errors and omis-
sions, including context and content accuracy, and
cleaned to focus on the content of what was said.
Coding was used as the analytic process through
which datawere ‘‘fractured, conceptualized, and inte-
grated’’ (Strauss & Corbin, 1990, p. 3), and intercon-
structured codebook was developed that contained
the code mnemonic, a brief code definition, definition
of inclusion criteria, definition of exclusion criteria,
and example passages that illustrated how the code
concept might appear in natural language (Mac-
Queen, McLellan, Kay, & Milstein, 1998; Silverman,
2000). NVivo qualitative data analysis software,
version 7, was used to assist with the coding, organi-
zation, and searching of narrative sections from each
interview as well as to facilitate the systematic
comparison and analysis of themes across interviews.
Coded transcripts were regularly reviewed by
members of the research team, and data reexamina-
tion and ongoing discussion helped resolve coding
inconsistencies, further define coding categories,
ensure consistency of code application and text
segmentation, and make interconnections between
used to support qualitative results. Univariate and
descriptive analyses were conducted for the present
report using SPSS (Statistical Package for the Social
Sciences) software, version 15.0.
Quantitative data were
Tables 1 through 3 outline the demographic
characteristics, sexual and substance use risks, and
psychosocial characteristics of the study sample
(N5 11). Participants ranged in age from 21 to 52
years andhada mean
(SD510.6). Persons of color represented almost
two thirds (63.7%) of the sample. A total of 4 partic-
ipants (36.4%) were infected with HIV. Other
demographic and risk variables will be discussed in
the context of qualitative results.
ageof 34.6 years
Sexual Risk Behavior and Condom Use
Inconsistent condom use was reported by the
a mean of 39.4 (SD571.9) male sex partners in
the past 12 months; the mean number of transac-
tional male sex partners was 36.1 (SD5 72.3). All
but one participant (90.9%) reported unprotected
anal sex, and most of these episodes (72.7%) were
with a serodiscordant partner. Almost half (45.5%)
of the participants reported unprotected insertive
anal sex, and over a third (36.4%) of these episodes
were with a serodiscordant partner. A total of 5
participants (45.5%) reported unprotected oral sex
with ejaculation in the mouth. Despite these results
on sexual risk behaviors and inconsistent condom
use, participants had relatively low perceived risk
for contracting HIV infection (M 53.9, SD51.0
on a 0 to 10 scale), perhaps because more than
one third (n5 4, 36.4%) were already infected.
Likewise, despite the fact that the same number of
participants (n54, 36.4%) reported a history of
one or more STDs, participants perceived them-
selves to be at only moderate risk for acquiring an
STD (M5 4.6, SD52.5).
Communicating about HIV/STDs in sex work
encounters. When asked whether or not and how
376 JANAC Vol. 20, No. 5, September/October 2009
often the topics of HIVor STDs come up in sex work
encounters, participants reported that they rarely dis-
cussed sexual healthwith paying male partners. A 26-
year-old Latina participant whowas not infected with
HIV responded, ‘‘Normally, nine times out of ten,
clients don’t ask about HIV status. Like, every once
and a while, you’ll get a client that will say, ‘Are
you clean?’ In other words, are you HIV-positive?’’
Another uninfected 21-year-old Latina participant
elaborated, ‘‘Sometimes they’ll react, like, ‘Why
are you asking that question? Are you positive?’’’
Fear of losing a date and not getting paid were
reported to be the most common reasons that partic-
ipants did not ask a transactional sex partner about
his serostatus. A 26-year-old Latina participant who
was not infected with HIVexplained as follows:
I asked one person one time because he looked
likea total AIDSvictim, and hegot soextremely
So I decided against doing it from there on out.
A 52-year-old Black HIV-infected participant
described her difficulty negotiating safer sex with
transactional sex partners.
I try to negotiate, but sometimes you just do
what you got to do. I have this thing inside of
me when I do things that I don’t want to
do—intercourse without rubbers and stuff.
And I’m saying, I shouldn’t be doing this
because he might contract AIDS.
Condom use related to earning potential.
ipants reported being offered more money to have
unprotected anal sex with paying male clients. One
33-year-old Latina HIV-infected participant said she
often had unprotected sex for more money, both as
the receptive and insertive partner.
I usually carry condoms on me, you know. It’s
just that when you’re out there trying to turn
tricks and you finally get a trick, if he’s going
to give you more money for not putting on
a condom, it’s almost as if you’ve got to do it.
Similarly, a 26-year-old Latina participant who
was not infected with HIV admitted that she would
do just about anything she had to for money,
including having unprotected anal sex: ‘‘It’s all about
how much they’re willing to pay me. If you’re willing
to pay me $5,000 to put a noose around your neck and
strangle you, then that’s what I’m going to do.’’ An
uninfected 43-year-old White participant expressed
succinctly what seemed to be the predominant
attitude among participants about having unsafe sex
for more money when she replied, ‘‘You do what
you have to do and get it over with.’’
Condom use related to need for validation.
Several participants reported that they engaged in
unprotected anal sex with transactional male partners
out of a need to feel validated and accepted. For
example, a 43-year-old White participant who was
not infected with HIV discussed self-validation as
her reason for having unsafe sex and said, ‘‘Having
unprotected anal sex just proved to me that I was
woman enough to do it. I proved to myself I was
a real woman. It was just an ego boost to me.’’ An
uninfected 30-year-old Black participant admitted
to looking for love and acceptance in transactional
sex encounters and commented, ‘‘Sometimes I feel
dirty afterwards. Like, God, why did I do this? You
know. It’s like sometimes for me at that time I wanted
to be loved, but I was looking for love in the wrong
Table 1. Demographic Characteristics of theTransgender
Male-to-Female Sex Worker Sample (N511)
AgeM5 34.6 (SD 510.6)
High school diploma/GED or less
Earn , $12 K annually
NOTE: GED 5 general educational development.
Reisner et al. / HIV Risk and Social Networks Among Transgender Sex Workers377
Motivations and Reasons for Engaging in Sex
Structural-level factors such as low socioeconomic
status, financial need, and discrimination along with
individual-level factors such as drug and alcohol
addiction were commonly cited by participants as
reasons for engaging in transactional sex.
a marginalized group of transgender women: all 11
participants (100%) had a high school diploma/
General Educational Development or less, 10
(90.9%) earned less than $12,000 annually, 9
(81.8%) were disabled or unemployed, 8 (72.7%)
reported unstable housing in the previous 12 months,
and 10 (90.9%) had a history of incarceration. More
than half of the sample (n5 6, 54.5%) had run
away from or been kicked out of their home because
of being gay or transgender or having a violent or
abusive family, and 2 (18.2%) reported having
experienced childhood sexual abuse. A 43-year-old
White participant who was not infected with HIV
explained as follows:
I grew up in the state of Maine. You’d never
think that they would grow me up in the state
of Maine! But I don’t know. I come from mental
abuse. I come from domestic violence. I come
from alcoholism. One day, I just jumped in
a car and left my family.
Another uninfected 36-year-old White participant
described the following:
Growing up in Charleston was horrid. They
used to beat me up. They used to throw rocks
and break my mother’s windows and every-
thing. The word is gay bash. I could only take
so much of the beating, so I had to leave.
motivation or reason for having engaged in sex work
in the past 12 months was financial need. All partici-
pants mentioned the need for money and ‘‘surviving’’
old Latina participant who was not infected with HIV
explained, ‘‘I don’t want to do it, but when you don’t
have anywhere to live and you don’t want to live on
the street, you can’t quit because you’ve got to make
money to put a roof over your head.’’
The most commonly reported
a job contributed most strongly to participants’
financial needs. Inability to obtain or maintain
a job was often explicitly tied to actual and/or
perceived discrimination resulting from being trans-
gender. For example, a 34-year-old Latina partici-
pant who was not infected with HIV described
having to work the streets because of gender-based
The reason why a lot of transsexuals are sex
workers is because we have to do it. It’s hard
for us to go out in society and get jobs and
not be discriminated against. A heterosexual
Table 2.Sexual and Substance Use Risks of the
Transgender Male-to-Female Sex Worker
Sample (N 511)
Sexual or Substance Use RiskN%
History of one or more STDs
Sexual risk behavior in past 12 Months
Number male sex partners
male sex partners
Unprotected receptive anal sex
receptive anal sex
Unprotected insertive anal sex
insertive anal sex
Unprotected receptive oral
sex with ejaculation in mouth
Self-perceptions of HIV/STD risk
Self-perceived risk for
HIV (scale 0 to 10)
for STDs(scale 0 to 10)
Substance use during sex in past 12 Months
Alcohol (while drunk) ‘‘some’’
or ‘‘most’’ of the time
Sildenafil citrate (Viagra)
M 539.4 (SD5 71.9)
M 536.1 (SD5 72.3)
M53.9 (SD5 1.0)
M54.6 (SD5 2.5)
NOTE: STD 5 sexually transmitted disease.
378JANAC Vol. 20, No. 5, September/October 2009
or a homosexual man could go out and get a job
with no problem. But once transgender women
go out and apply, there’s discrimination. It’s
kind of like if they find out that you have
AIDS, they will treat you differently. It’s the
same thing when we walk up to a counter, and
we say we want a job. We don’t get jobs, so
that makes us go into the street-working
Another uninfected 26-year-old Latina participant
relayed that sex work was the most common ‘‘job’’
for trans women because of discrimination and
Sex work is like the main job for the trans
community. The main reason is because it’s
hard for us to go somewhere and get a job
where we’re not going to be judged, where
we’re not going to be made fun of, and we’re
going to be accepted. It just doesn’t happen
A 43-year-old White participant who was not in-
fected with HIV described the impact of structural-
level factors in a more personal way, in particular
how sex work can often seem like the only option,
when she said, ‘‘Some trans people can have
a courage or mental status to just walk out and apply
for a job. You’ve really got to believe inyourself to do
most commonly crack cocaine, was mentioned by
more than half of the participants as a reason for per-
forming sex work. A 44-year-old Black HIV-infected
participant elaborated as follows:
Having a drug habit,
I do sex work to more or less feed my habit.
Crack cocaine is my addiction, and I use crack
more just to hide away from the pain and all
the suffering and to deal with being homeless
and not having a job.
In the past 12 months, participants reported having
sex while using a variety of substances, most
commonly alcohol (‘‘while drunk’’ some or most of
the time) (n 57, 63.6%), marijuana (n5 7, 63.6%),
crack (n5 6, 54.4%), and cocaine (n5 4, 36.4%).
Individual participants also reported using crystal
methamphetamine, downers, ecstasy, and sildenafil
citrate (Viagra). More than half of the sample
(n5 6, 54.5%) reported having been in drug/alcohol
treatment at some time in the past. Several partici-
pants talked about how sex work was ‘‘fast money,’’
which made it appealing. For example, a 34-year-
old Latina participant who was not infected with
HIVexplained as follows:
In the sex work industry, we charge for a half an
hour, but once they ejaculate, you’re done.
You’re out the door. They don’t even get their
half an hour. That’s the good thing about sex
work—it’s $150 for half an hour, but it could
be for 5 or 10 minutes.
Another uninfected 26-year-old Latina participant
I want to quit all the time. I don’t want to do this
for the rest of my life. But the money’s really,
really good. I mean, I probably make in one
day what you make in 3 weeks on a paycheck.
Table 3. Psychosocial Risks of Transgender
Male-to-Female Sex Worker Sample (N5 11)
Current psychosocial issues
(CES-D 10 score $10)
CES-D 10 depressive
CAGE score $ 2
Currently enrolled in needle
Lifetime psychosocial issues
History of incarceration/jail
Self-report diagnosis of
Sexual abuse history
Age of first sexual experience
Before age 13, sexual experiences
Between 13 and 17, sexual
experiences with someone 10 years
or more older
Consider sexual abuse
Nonconsensual sex as adult (rape)
M513.5 (SD5 6.8)
M514.3 (SD5 2.9)
NOTE: CAGE 5clinical screening instrument for probable
alcohol dependence, CES-D 10 5 Center for Epidemiologic
Studies Short Depression Scale.
Reisner et al. / HIV Risk and Social Networks Among Transgender Sex Workers379
Consequences of Sex Work
Becoming infected with HIV or STDs.
participant mentioned the devastating impact of
HIV on transgender women, especially among the
transgender sex-working community both in the
past and currently. A 47-year-old White HIV-infected
participant said, ‘‘You know, everybody’s gone. I
can’t believe that all my friends are dead from the
virus. I’m still here. It’s undetectable.’’ Likewise,
lamented, ‘‘All of my girlfriends are dead that I
came from New York back to Massachusetts with.
They’re all dead except one, and I don’t know where
she’s at, but the rest of them all died from AIDS.’’
All four of the HIV-infected participants believed
that they had seroconverted during the time that
they engaged in sex work. As a 44-year-old Black
somehow, somewhere along the line, I wasn’t using
protection, and I contracted HIV.’’ Likewise, a history
of one or more STDs was reported by 4 participants
(36.4%). There were 4 reported cases of gonorrhea,
3 cases of syphilis, 3 cases of chlamydia, 2 cases of
herpes, and 1 case of hepatitis. However, participants
thought that STDs were ‘‘no big deal.’’
about the dangers and risks involved with sex work.
Almost half of the participants (n55, 45.5%)
reported having been raped in a sex work encounter.
Often, occupational violence was closely connected
to being a preoperative transgender woman and
being found out during a transactional sex encounter.
A 21-year old Latina participant who was not
infected with HIV reported as follows:
All participants talked
It’s kind of scary, because when I streetwalk as
a transgender, I don’t disclose what I am to
guys. I also make more money by doing it. But
it’s kind of scary for me, because I don’t tell
guys what I am, and if somebody finds out, I
can possibly get killed or something like that.
Participants also described specific situations in
which they experienced violence as a result of not
disclosing being transgender in a sex work encounter.
An uninfected 26-year-old Latina participant vividly
recalled the following:
wasn’t looking for when he put his hand down
my pants, and really, really got angry. Now,
I’ve had a gun put to my head because I didn’t
the clients know. But unfortunately in this
episode, I didn’t. He put a knife to my throat.
Changes to intimacy.
reported that sex work made them feel differently
about having sex in general as well as in how they
connected or desired others. A 26-year-old Latina
participant who was not infected with HIVexplained.
Participants also often
I just do it [sex work], I’m like a robot. It used to
be a lot different, but now it’s to the place where
I’ve done it so much that I don’t need to think
about it. It just happens. I go into robot mode.
When I had my last boyfriend, he had to stop
me on a few occasions and tell me, ‘‘I’m not
a client. Treat me like your boyfriend.’’
Gay or Trans ‘‘Mothers’’: The Role of
Transgender Social Networks in Sex Work
For all participants, older and more experienced
transgender women played a pivotal role in intro-
ducing them to the world of transactional sex. In
describing her first transactional sex encounter after
leaving home at age 16, a 36-year-old White partici-
pant who was not infected with HIV described the
role of a more experienced trans woman she knew.
I went to Boston. I kind of knew one of the girls
already from being at her house a lot. She’s
and hard, but it’s notlike she didn’t teach me the
ropes. She taught me what to do and not to do.
Another uninfected 26-year-old Latina participant
described as follows an older transgender friend
helping her arrange her first date:
Well, she had run me an ad, and I got my first
client.I’ll never forget it. Mykneeswere knock-
ing. I was shaking like a leaf. I didn’t know
what was going on. I guess I was thrown in
head first. But that’s how it was for her, too.
380 JANAC Vol. 20, No. 5, September/October 2009
In the context of talking about social networks and
sex work, all participants used the terms gay mother
or trans mother to describe older and more experi-
enced transgender women, which illuminated the
central role that older trans women play in mentoring
and supporting younger girls. A 36-year-old White
participant who was not HIV-infected defined the
term when she asked, ‘‘You ever hear the term gay
mother? A gay mother is somebody who is up there,
like middle, late 50s, who has surely been through
what I’ve been through and somebody who takes
care of me.’’ Moreover, several participants described
being a gay or trans mother, explaining what it means
to have this relationship with other trans women.
Well, I’m a gay mother, and I’ve got a gay
daughter. And to me it’s like helping this boy
grow up to a woman and, you know, helping
to get his shots and get himself all prettied up
and stuff like that, you know. It’s just helping
somebody out. It’s like when you have a kid,
you help that kid to develop and grow up and
be a good person. (33-year-old Latina HIV-in-
What I have upstairs needs to be passed on. If
I don’t pass it on, then no one’s going to be
helped. A lot of trans women can be reached
through other trans women. I’m a trans mother
of two. Trans mother means that I’m over the
age where I’ve survived an epidemic, and these
are younger trans women that need an older
trans woman’s knowledge and experience and
guidance to go through this world. We adopt
younger children and we hope that we can
deal with them [laughs]. (43-year-old White
participant who was not infected with HIV)
Escorting: Setting up dates for other girls.
addition to engaging in transactional sex themselves,
many participants reported escorting (i.e., fixing up
other trans women, including their ‘‘daughters,’’ on
dates with paying male sex partners). Participants
ipant who was not infected with HIVexplained.
I was hustling, and then I went to escorting. I
would get paid for it. Whatever the girls paid
for their price—like, if it was $1,000—I would
get $500 just for bringing the men to them. It’s
easier than being out on the street.
However, participants had mixed feelings about
their role in fixing girls up on dates. This ambiguity
was particularly true when they felt they were putting
people at risk for HIV infection. For example, in the
context of talking about a man for whom she regu-
larly ‘‘scores’’ girls, an uninfected 43-year-old White
participant described setting him up with several
HIV-infected trans womenandfeelinglike sheshould
say something to him, but not knowing how.
This guy calls me up and wants me to get a hold
of a girl for him. He don’t care whether he’s
getting HIV or AIDS or whatever, just bang,
bang, bang. He calls me and asks me to score
for him, calls me to set him up with other girls.
He’s been with two of my friends that are HIV-
positive. Third one, she’s HIV-positive. I mean,
I just want to say something to him sometime.
That’s how we died. That’s how my community
died. Queens went with queens, johns and johns
hadthe disease. They passed it,passed it, passed
it. And some people caught it, and some didn’t.
These mixed feelings were even more present
when participants were talking about their own
‘‘daughters.’’ For instance, a 43-year-old White
participant who was not HIV-infected elaborated as
You want me to tell you something really bad,
something we haven’t discussed? It’s the simple
fact that you know when your trans son or
daughter is HIV-positive and they’re running
around with men having sex with no protection.
You know what’s going on—she’s passing HIV.
And just knowing it and then having to keep it
in your head, know that they’re going to pass
this HIV to these guys, it’s hard.
Potential Areas for Prevention Intervention
Participants were asked what they thought would
be helpful in terms of programs or interventions for
themselves or other transgenders who engaged in
sex work and were at risk for HIV and STDs.
Reisner et al. / HIV Risk and Social Networks Among Transgender Sex Workers 381
Responses centered around the areas of HIV/STD
testing, condoms and education/information, mental
health services, and support groups and peer
the importance of accessible HIV/STD testing and
the need to make these services available for trans
women. A 44-year-old Black HIV-infected partici-
Several participants discussed
Having AIDS myself now, I know about the risk
of contracting HIV. I feel that it’s a must that
you should get yourself tested—make sure
you’re healthy and take care of yourself. The
girls need to always use condoms and stuff
like that to protect themselves.
Condoms, education, and information.
pants seemed to have good overall knowledge of
HIVand STDs. With respect to condoms, education,
and information, they most often mentioned the
importance of making condoms readily available
and free. Participants also emphasized the impor-
tance of the availability of detailed information about
sexual health and HIV/STD transmission. A 43-year-
old White participant who was not infected with HIV
commented, ‘‘I think that more details on diseases
would help. I had exposure to hepatitis C, and there
was no literature. We had no information.’’
Mental health services.
63.6%) of the sample screened positive for clinically
score $10) at the time of the study, and 9 (81.8%)
of the study participants reported that they had been
diagnosed with depression by a physician or other
health care or mental health professional in the
past. Many transgender sex workers mentioned expe-
riences of trauma and abuse as children and in adult-
hood, further underscoring the need for mental health
services including therapy and counseling to inter-
vene in sexual risk-taking behaviors. A 21-year-old
Latina participant who was not infected with HIV
conveyed the following:
A majority (n5 7,
Sometimes they do give out condoms in
outreach. But just because we’re in the sex
industry doesn’t mean that we don’t need
someone to talk to, especially someone that
we don’t know, so we kind of sometimes open
up to outreach workers more. We need to find
out more information on different places, like
different places that we can go get help and
talk to people.
Substance abuse treatment was also identified as
a mental health need, particularly among trans
women who connected engaging in sex work with
using drugs. As advised by a 44-year-old Black
HIV-infected participant, ‘‘Don’t do drugs. It’s not
worth it. And if you can get off the streets and the
commonly talked about the need for prevention
interventions focused on substance use to help trans-
gender women reduce the odds of becoming
addicted to substances while they were engaging in
your life.’’ Participants
Support groups and peer networks.
overwhelmingly discussed support groups or other
avenues of networking/meeting up with other trans-
gender women as an area of interest for interven-
tions. Involving peers and other sex workers in
interventions was frequently mentioned as an impor-
tant intervention component, especially because the
grapevine was described as being an integral part
of transgender social networks. A 43-year-old White
I hear a lot of stuff, as we call it, grapevine
news. It’s what we call it—trans community
grapevine news. Talk, talk, talk. Talk, talk,
talk. From me to Sophia to Rene to Erica to
whoever to whoever, whoever. And we’ll talk.
Grapevine. You have to get information into
One participant talked about having been involved
in outreach to TGSW including condoms, informa-
tion, and resource distribution and how this work
was mutually beneficial for both her and the individ-
uals she reached.
legal advice or counsel would be helpful to them in
understanding their rights and in determining what
Several participants indicated that
382 JANAC Vol. 20, No. 5, September/October 2009
was and was not legal. Moreover, several trans
women mentioned legalizing prostitution as being
an important structural change that would benefit
them. A 26-year-old Latina participant who was not
infected with HIV stated the following:
In the U.S.A., sex work is forbidden. So you
don’t get any help, you know? I mean, when
we go to jail for sex work, they put it under
prostitution or call it night walking. We’re just
trying to live our lives. I mean, the court
industry is not going to put money in our
pockets. So what do you expect us to do? We
can’t get jobs. So, I mean, they say that they
want to help us. If you want to help sex
workers, pass a law saying that it’s legal—and
Results from this study suggest that transgender
women who exchange sex for money, drugs, housing,
and other services are a population at high risk for
HIVacquisition and transmission. In qualitative inter-
views, inconsistent condom use with offers of more
money for unsafe sex and low rates of HIV status
disclosure were commonly reported. A majority of
the sample reported unprotected anal sex with trans-
actional male sex partners of unknownor different se-
rostatus in the past 12 months, and all participants
reported that HIV was not a topic of discussion in
sex work encounters. Financial need, gender-based
discrimination, lack of access to education and jobs,
and drug/alcohol addiction were the central motiva-
tions and reasons that participants engaged in sex
work. HIV seroconversion, occupational violence,
and changes to intimacy with nonpaying partners
were frequently reported as consequences of transac-
tional sex. In alignment with results from prior
studies with transgender women (Clements-Nolle
et al., 2001; Clements-Nolle et al., 2006; Kenagy,
2005), high levels of substance use and psychological
distress were observed among participants. Other risk
factors included depression, history of childhood
sexual abuse, gender-based discrimination, history
of incarceration, and history of psychiatric inpatient
hospitalization. Together, quantitative and qualitative
study results suggest that HIV sexual risk behaviors
among TGSWare occurring within the context of in-
tertwined syndemics (Singer & Snipes, 1992; Stall &
Purcell, 2000), and that interventions need to incor-
porate these multiple risk dynamics to be effective.
Interviews with TGSW showed
networks play an especially vital role in the lives of
transgender women, many of whom are alienated
from their families of origin, face ongoing stigma
and discrimination in negotiating their identities,
and remain socioeconomically disadvantaged. The
trans or gay mother was highlighted in some of the
discussions and seems to occupy an important loca-
tion in the social networks of transgender women.
According to participants, elements essential to the
mother identity are older age, having been through
and survived what the younger generation is going
through, having knowledge and experience to share,
and taking care of or helping trans women on the
streets, which included escorting and fixing them up
with dates. Given that participants in the current
study as well as in prior studies of transgender
women (Nemoto, Operario, Keatley, Han, & Soma,
2004; Nemoto et al., 2004) believed that health
interventions for transgender women should be deliv-
ered by transgender peers, it seems that involving and
educating the system of trans and gay mothers that is
currently in place within the transgender community
may be important to successfully intervening and
reducing sexual risk among transgender women. In
fact, delivering information through the grapevine
may be shown to be an effective strategy for risk
reduction among this population. Additional research
is warranted with larger samples to examine the
social network characteristics of TGSW in greater
There are limitations of this study that bear
mention. First, HIV serostatus was self-reported by
participants. Because the study team did not conduct
HIV confirmatory testing to verify participants’ self-
reports, participants may have potentially been
unaware of having seroconverted since their last
test, or it is possible they had not been tested for
HIV at all. Second, the nonprobability sampling
method used means the possible introduction of
sampling bias, a nonrepresentative sample of the
population, and limited generalizability of results.
However, to the best of the authors’ knowledge,
Reisner et al. / HIV Risk and Social Networks Among Transgender Sex Workers 383
this study was the first of its kind conducted in
formative data to inform the development and imple-
mentation of HIV prevention programs for this
qualitative interviews were stopped after reaching
redundancy in responses, as typical in qualitative
research, the transgender women interviewed in
this study comprised only a subset of TGSW at
risk for HIV infection.
Limitations notwithstanding, study results suggest
that to be effective and intervene in the complex and
multifacetedissuesassociated with HIV riskbehavior
among transgender male-to-female individuals, inter-
ventions must address contextual and psychosocial
gender-based discrimination, and other aspects
surrounding HIV risk behavior such as condom use
and negotiated safety with transactional sex partners
among TGSW. Structural and financial issues, such
as being unable to refuse more money for unsafe
sex, also need to be taken into consideration. Results
can be used to generate hypotheses for designing and
providing tailored primary and secondary prevention
interventions for this at-risk population. Increased
research efforts aimed at effective intervention
development should not only continue to examine
HIV/STD risk but also recognize protective factors
and how individual characteristics and the social
environment affect sexual behaviors and transactions.
Multilevel interventions that focus on the individual
(e.g., mental health counseling, HIV/STD testing)
as well as the community (e.g., group level interven-
tions that incorporate peer health navigation and/or
peer support groups) may be effective in curbing
rising rates of infection among TGSW.
The project described in this article was supported
by The Center for Population Research in Lesbian,
Gay, Bisexual, and Transgender Health at The Fen-
way Institute and by the Eunice Kennedy Shriver
National Institute of Child Health and Human
R21HD051178. Some of the investigator time on
this project was also supported by grant number
R03DA023393 from the National Institute on Drug
Abuse (NIDA) and from the Lifespan/Tufts/Brown
University Center for AIDS Research grant P30
AI42853 from the National Institutes of Health.
Content is solely the responsibility of the authors
and does not necessarily represent the official views
of the NICHD, NIDA, or the NIH.
? Male-to-female transgender individuals who
exchange sex for money, drugs, housing, or
other services are a population at high risk for
HIVacquisition and transmission.
? Financial need, gender-based discrimination,
lack of access to education and jobs, and
drug/alcohol addiction may motivate TGSW
to engage in sex work (i.e., transactional sex).
? Inconsistent condom use with offers of more
money for unsafe sex and low rates of HIV
status disclosure are common among TGSW,
and HIV is rarely a topic of discussion in sex
? Engaging in transactional sex may result in
harmful consequences for transgender women,
including HIV seroconversion, occupational
violence (e.g., physical and sexual), and
changes to intimacy with nonpaying partners.
? Social networks play an especially vital role in
the lives oftransgender women,manyof whom
are alienated from their families of origin, face
ongoing stigma and discrimination in negoti-
ating their identities, and remain socioeconom-
access to clinical care and/or disclosure of
behavioral HIV risks to medical and mental
? Multilevel interventions that focus on the indi-
vidual (e.g., mental health counseling, HIV/
STD testing) as well as the community (e.g.,
group level interventions that incorporate peer
health navigation and/or peer support groups)
may be effective in curbing rising rates of
infection among TGSW.
384JANAC Vol. 20, No. 5, September/October 2009
The authors thank Benny Vega for contributing
time and energy to this project.
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