A Mixed Methods Study of the Sexual Health Needs
of New England Transmen Who Have Sex
with Nontransgender Men
Sari L. Reisner, M.A.,1,2Brandon Perkovich,1,3and Matthew J. Mimiaga, Sc.D., M.P.H.1,2,4
The sexual health of transmen—individuals born or assigned female at birth and who identify as male—remains
understudied. Given the increasing rates of HIV and sexually transmitted diseases (STDs) among gay and
bisexual men in the United States, understanding the sexual practices of transmen who have sex with men
(TMSM) may be particularly important to promote sexual health or develop focused HIV prevention inter-
ventions. Between May and September 2009, 16 transmen who reported sexual behavior with nontransgender
men completed a qualitative interview and a brief interviewer-administered survey. Interviews were conducted
until redundancy in responses was achieved. Participants (mean age, 32.5, standard deviation [SD]¼11.1; 87.5%
white; 75.0% ‘‘queer’’) perceived themselves at moderately high risk for HIV and STDs, although 43.8% reported
unprotected sex with an unknown HIV serostatus nontransgender male partner in the past 12 months. The
majority (62.5%) had used the Internet to meet sexual partners and ‘‘hook-up’’ with an anonymous non-
transgender male sex partner in the past year. A lifetime STD history was reported by 37.5%; 25.0% had not been
tested for HIV in the prior 2 years; 31.1% had not received gynecological care (including STD screening) in the
prior 12 months. Integrating sexual health information ‘‘by and for’’ transgender men into other healthcare
services, involving peer support, addressing mood and psychological wellbeing such as depression and anxiety,
Internet-delivered information for transmen and their sexual partners, and training for health care providers
were seen as important aspects of HIV and STD prevention intervention design and delivery for this population.
‘‘Embodied scripting’’ is proposed as a theoretical framework to understand sexual health among transgender
populations and examining transgender sexual health from a life course perspective is suggested.
male—remains understudied. No national behavioral sur-
veillance data are currently available on the incidence or
prevalence of HIV or sexually transmitted diseases (STDs)
among transgender populations in the United States. Studies
risk behaviors among transgender women, particularly
among transwomen who engage in sex work.1–11However,
the inclusion of transmen in studies of HIV sexual risk
behavior remains uncommon.1,2,4,11–15The current state of
be influenced by a common assumption that transmen only
engage in sexual behavior with nontransgender women
he sexual health of transmen—individuals who
wereborn orassigned femaleat birth andwho identify as
(i.e., presumed heterosexual orientation), and not with non-
transgender men. However, transmen have diverse sexual
identities, desires, and behaviors, including being attracted to
and engaging in sexual behavior with nontransgender men,
nontransgender women, and other transgender individuals,
including transmen and transwomen.12,14,16–26To fully un-
derstand the sexual health needs of transmen, research
must foreground and anticipate the diverse sexual identities,
attractions, and sexual behaviors that transmen may engage
in, including sex with nontransgender men.
Little is known about HIV and STD riskand broader sexual
health needs among transmen who have sex with non-
transgender men (TMSM), and a dearth of literature to date
has documented the individual and contextual factors—both
risk and protective—associated with HIV and STD risk be-
haviors among this subpopulation of transmen, including the
1The Fenway Institute, Fenway Health, Boston, Massachusetts.
2Harvard School of Public Health, Boston, Massachusetts.
3Harvard College, Cambridge, Massachusetts.
4Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts.
AIDS PATIENT CARE and STDs
Volume 24, Number 8, 2010
ª Mary Ann Liebert, Inc.
role of psychosocial factors in sexual risk behaviors. A recent
study conducted by Sevelius26with a national sample of
TMSM (n¼45) found high rates of risky sexual behaviors
among TMSM with their nontransgender male partners, with
only 31% who reported ‘‘always’’ using condoms during
vaginal sex and 40% ‘‘always’’ using condoms during anal
sex. Although only 2% of the sample was HIV-infected, 91%
had been diagnosed with an STD at some time in the past.
Other risk factors were also observed for HIV and STDs, in-
cluding transactional sexand drugusein thecontext of sexual
behavior. These data suggest that although HIV prevalence
among TMSM may be low, current risk behaviors, and high
rates of STD could augment rates of HIV in the near future
among TMSM. Given that men who have sex with men con-
tinue to be disproportionately affected by the HIV epidemic27
and other viral and bacterial STDs,28–30it is likely TMSM who
partner with gay or bisexual nontransgender men may be at
increased risk for HIV and STDs12,23,26and additional re-
search is needed to elucidate the risk and protective factors
In addition, situating the sexual health of transmen within
the context of gender transition using a life course perspec-
tive31,32may allow for further consideration of the inter-
development, including the timing, duration, and context of
health behaviors. Simon and Gagnon33(p118)describe devel-
opmental periods of ‘‘transition,’’ ‘‘disjuncture,’’ and ‘‘some-
times crisis’’ as being important to consider in sexuality across
the life course: ‘‘A potential crisis of the self process and
production of scripts—sexual and nonsexual—is occasioned
by change [life course transitions] not merely because some
aspect of the self is under pressure to change, but also because
the very ecology of the self has been disturbed; a moment
requiring renegotiation of aspects of the self involved in or
related to change.’’33(p111)Sexual experimentation, explora-
tion, and change may be part of the gender transition process
for transgender men, as the very ‘‘ecology’’ of the self is being
negotiated during different developmental periods. More-
over, and consistent with prior research suggesting ‘‘trans-
gender sexual scripts’’ and a ‘‘transgender sexuality,’’17the
fluidity and specificity of a transgender sexuality may have
important implications for the sexual health of transmen, and
warrants additional exploration.
The purpose of this formative mixed methods study was to
gain a deeper understanding of the sexual health concerns
and needs of transmen, including but not limited to HIV and
STD risk, and to explore the influence of gender dynamics in
sexual encounters with nontransgender men. The aims of the
study were twofold: (1) to gather preliminary data to design
and develop effective sexual health programming and inter-
ventions aimed at holistically improving the sexual health of
transmen who partner with nontransgender men, including
intervening on HIV and STD sexual risk and (2) to consider a
life course perspective in understanding the complex and
dynamic relationship between human sexualities and gender
identities among this group.
Design and setting
qualitative interview and a brief interviewer-administered
demographic, sexual risk, substance use, and psychosocial
survey. Study activities took place at Fenway Health, a free-
standing health care and research facility specializing in HIV/
AIDS care and serving the needs of the lesbian, gay, bisexual,
and each participant completed an informed consent process.
by trained study staff on the telephone or via email to deter-
mine eligibility. Individuals were eligible for the study if they:
(1) were born or assigned female at birth; (2) self-identified as
male or along the transmasculine spectrum; (3) self-reported
oral, anal, or vaginal sex with a nontransgender man in the
12 months prior to study enrollment; (3) were age 18 years or
older; and (5) lived in New England.
Prospective participants were screened
strategies (including the use of the Internet) and snowball/
chain referral sampling methods were used to recruit partic-
ipants. Venue-based recruitment strategies consisted of direct
outreach and posting of study flyers at Fenway Health, local
community-based organizations, Internet partner meeting
websites, bars/clubs, and community events. Snowball/
chain referral sampling, in which enrolled participants re-
ferred potentially eligible peers, was also used. As is typical in
qualitative methods, interviews continued until redundancy
in responses was achieved.36,37
A combination of venue-based recruitment
Data collection and measures
Participation in this study took, on average, 1.5 h. Partici-
pants were remunerated $50 for their participation in the
drug use questions. Questions examining demographics, sex-
ual behavior, and drug use during sex were adapted from the
Centers for Disease Control and Prevention’s National HIV
Behavioral SurveillanceSurvey,MSMcycle.38Questions were
also adapted from prior Fenway Health studies.9,23,39,40Sex-
ual risk behaviors such as frequency of unprotected sex in the
prior 12 months, sexual risk behavior (i.e., oral, anal, frontal/
vaginal), partner gender (i.e., male, female, transgender
partners) and type (i.e., casual, regular, etc.), and venues
where they met sexual partners (including Internet use for
sexual partner meeting) were assessed. Substance use during
sex in the past 12 months was queried, including substances
used and frequency of substances used during sex with
nontransgender men. The survey captured self-reported HIV
status and STD history, including history of HIV testing and
STD screening. Participants were also asked about transac-
tional sex (i.e., exchanging sex for money, drugs, or other
Demographics, sexual behavior, and
symptoms were assessed with the Center for Epidemiologic
Studies Depression Scale (CES-D), a validated screener of
clinically significant distress as a marker for possible clinical
depression (Cronbach a¼0.84).41The 20-items were scored
on a 4-point Likert scale from 0 to 3. A score of 16 or greater
was indicative of depressive symptoms.
symptoms.Clinically significant depressive
2REISNER ET AL.
Generalized anxiety symptoms. The Beck Anxiety Inventory
(BAI) was used to assess physiologic and cognitive symptoms
of anxiety.42Originally developed to reliably discriminate
anxietyfrom depression while displaying convergent validity,
the validated scale consists of 21 items, each describing a
common symptom of anxiety. The respondent was asked to
rate how much he had been bothered by each symptom over
the past week on a 4-point scale ranging from 0 to 3. The items
were summed to obtain a total score ranging from 0 to 63,
indicating the severity of anxiety. Scores were further broken
down and classified as ‘‘no anxiety’’ (score 0 to 7), ‘‘mild’’ (8 to
15), ‘‘moderate’’ (16 to 25), and ‘‘severe’’ (score 26 to 63).
Internalized homophobia. Two items were adapted from
I was not attracted to men’’ and (2) ‘‘I am extremely com-
fortable with being very open about my sexual relationships
with men.’’ Responses were scored on a 4-point Likert scale
from ‘‘strongly agree’’ to ‘‘strongly disagree’’; item two was
was developed by conducting a thorough literature review to
identify gaps in knowledge and gathering input from trans-
gender health specialists at Fenway Health. The interview
included four broad topic areas: (1) gender transition and
sexuality development across transition; (2) experiences with
nontransgender men in the past 12 months, including most
recent sexual encounter with a nontransgender male; (3)
perception of HIV and STD risk and social networks; (4) ideas
for HIV prevention interventions with this group. Each in-
Researchers and staff with experience and competency
working in transgender health were included at all levels of
study design, development, implementation, and analysis.
The qualitative interview guide
using content analysis,37,44–48broadly defined as a ‘‘technique
for making inferences by objectively and systematically
identifying specified characteristics of messages.’’45(p14)An
emergent coding approach37was used to categorize the data
in which thematic categories were established following
preliminary examination of the data.
Transcripts were first reviewed for errors and omissions,
and cleanedtofocus onthecontentofwhat wassaid.NVivo?
software49was used to aid with the coding, organization, and
searching of narrative sections from each interview, as well as
to facilitate the systematic comparison and analysis of themes
across interviews.37The following steps were implemented to
systematically evaluate the content of the data: (1) research
checklist of a set of preliminary features and codes; (2) re-
searchers compared preliminary checklists and reconciled
any differences that showed up on an initial pass through the
data; (3) a consolidated checklist was created and a structured
codebook was developed that contained the code mnemonic,
a brief code definition, definition of inclusion criteria, defini-
tion of exclusion criteria, and sample passages that illustrated
how the code concept might appear in natural language; (4)
the coding scheme was independently applied to several
transcripts by research staff; (5) percent coder agreement was
Qualitative data were analyzed
checked to ensure acceptable reliability (>90%); (6) once re-
liability was established, the coding scheme was broadly ap-
plied to analyze all transcripts; (7) a quality control procedure
was followed whereby coded transcripts were regularly re-
viewed by members of the research team, ongoing discussion
helped resolve coding inconsistencies, and ensure consistency
of code application and text segmentation.50,51Analyses were
focused on the contextual issues surrounding HIV and STD
risk and intervention development with TMSM.
amore comprehensive portraitofoccurring themes, as wellas
to support qualitative results, and are integrated with the
interview findings below. Descriptive analyses were con-
ducted using SPSS? statistical software.52
Survey data were used to provide
Demographic characteristics of the study sample (n¼16)
are outlined in Table 1.
Table 1. Sample Demographics (n¼16)
Mean (SD) age 32.5 (11.1)
Mixed race/ethnicity (Asian, NH/PI,
Some graduate work
$11,999 or less
$12,000 or more
No health insurance
Access to transgender specific services
Testosterone at time of study
Surgery ever for transgender-related purposes 11
Disclosure of transgender and MSM identities
Out about being transgender
Out about MSM
SD, standard deviation; NH/PI, MSM, men who have sex with men.
SEXUAL HEALTH NEEDS OF NEW ENGLAND TRANSMEN3
Participants had a mean age of 32.5 (standard deviation
[SD]¼11.1), and the majority (87.5%) were white. Most
(87.5%) were taking testosterone for transgender-related
purposes at the time of the study, and 68.8% reported trans-
gender-related surgery (68.8% ‘‘top’’/chest surgery, 18.8%
hysterectomy, 12.5% oopherectomy). The majority (75.0%)
self-identified as ‘‘queer.’’
Do HIV and STDs matter?
When asked about their top five health concerns, 87.5% of
participants reported that sexual health issues were not
ranked among their top three health concerns. With the ex-
ception of one participant who reported doing sex work with
nontransgender malesregularly andforwhom HIV andSTDs
were ranked at #1, HIV and STD concerns most often ranked
on the list of health concerns at all:
I think, at least in this area, to most people that I spend time
with and who live in Western Mass or in New England in
general, I don’t think it’s [HIV] on the radar.
It’s just not evenon the radar.Whenwewere talkingabouttop
five [health concerns]—it’s like oh, no, it’s not in the top five.
access to hormones, surgery, health insurance (i.e., getting
transgender-related procedures covered by insurance), diet,
exercise, weight management, and help quitting cigarette
smoking. Access to culturally competent counseling services
was described by several participants as key to their overall
mental and emotional health, with a particular focus on body
image. Moreover, several participants were more concerned
about pregnancy than about HIV or STDs in the context of
considering sexual health concerns.
Perceptions of HIV and STD risk
Although not a prioritized health issue for them, when
asked about their perceptions of sexual risk among TMSM,
participants generally perceived transmen as a group at
moderately high risk for HIV and STDs:
By and large, I think among the group of people that have sex
with men, transmen fall higher than non-trans women. So I
think it’s like transwomen as most risky, then non-trans gay or
bi men, then FTMs, and then non-trans heterosexual women. I
think transmen who have sex with men have elevated risk
compared to heterosexual women. But probably not as high as
gay or bi men.
If they’re doing what I’m doing, then I feel FTMs are at high
risk. I think transmen and transwomen are at the highest risk
for HIV and STDs. Then straight women. Then probably men.
This self-perception of elevated risk was often interestingly
juxtaposed against not prioritizing sexual health issues in
relation to overall health concerns, since competing issues,
such as obtaining hormones, was often times foremost in their
HIV and STDs
While the vast majority (93.8%) of the sample had been
tested for HIV at some time in the past, 25.0% reported not
having been tested for HIV in the 2 years prior to study en-
rollment (Table 2). Despite not recently being tested for HIV,
all participants self-reported as HIV-negative. The majority
(81.3%) of participants had been screened for STDs in their
lifetime. A lifetime history of one or more STDs was reported
by 37.5% of participants (18.8% herpes, 12.5% trichomonas,
6.3% bacterial vaginosis). Overall, 31.1% had not received
gynecological care or a Pap smear (i.e., including STD
screening) in the past 12 months.
Sexual behavior and sexual risk
in the past twelve months
Table 2 summarizes participants’ sexual behavior in the
past 12 months and Table 3 details the most recent sexual
encounter participants reported with a nontransgender man
in the past 12 months.
Number of male, female, and transgender partners of
unknown HIV status.
In the past 12 months 100% of partic-
ipants reported sex with a nontransgender male (this was
required to enroll in the study), 68.8% also reported sex with a
partner (56.3% transmen, 12.5% transwomen, and 12.5% both
transmen and transwomen). Overall, participants reported
sex with a mean 6.4 (SD¼10.1) unknown HIV serostatus sex
partners of any gender in the past 12 months. A mean number
of 5.4 (SD¼8.7) nontransgender male sex partners with un-
known HIV serostatus were reported in the past 12 months.
Number of unprotected sexual acts with HIV unknown
Overall, a mean number of 9.9 (SD¼17.4)
unprotected sex acts (transmission risk episodes) were re-
ported with unknown HIV serostatus partners: 43.8% re-
ported a mean of 4.0 (SD¼9.0) unprotected receptive vaginal
sex acts with nontransgender males, 25.0% reported a mean
number of 4.5 (SD¼15.0) unprotected vaginal or anal sex acts
with nontransgender females, and 18.8% reported a mean
number of 1.4 (SD¼3.4) unprotected sexual acts with trans-
gender sex partners.
Knowledge of sexual health
Many transmen were knowledgeable about sexual health
issues, particularly TMSM whoweregay-identified, and were
transmen who had not had ovaries removed or hysterecto-
my). Some transmen just beginning to have sex with non-
transgender men demonstrated inconsistent knowledge of
sexual health information. Participants often mentioned
having heard about or seen a TMSM sexual health website
from Ontario, Canada (www.queertransmen.org/).
The general level of knowledge around sexual health risks
exhibited by participants suggested that informal channels of
knowledge flow around sexual health exist for many trans-
men. Several participants narrated how they learned about
safer sex through friends. For example, after being diagnosed
with herpes, one participant described how he learned about
safer sex through a female friend:
The first time I slept with my current partner, it was my first
time inmy life havingsafe sex. Youknow, using barriers,and I
didn’t even know how it worked. I have a friend who is really
into safe sex and she was just showing me like all this stuff
trying to prep me.
4 REISNER ET AL.
Table 2. HIV and STD Testing, HIV Serostatus, Sexual Behavior in the Past 12 Months,
and Other Psychosocial Factors of the Study Sample (n¼16)
HIV testing and status
Ever had an HIV test
No HIV test in 2 years prior to study enrollment
STD testing and STD history
Ever had STD test
Pap smear in past 12 months
STD history (18.8% herpes, 12.5% trichomonas, 6.3% bacterial vaginosis)
In past 12 months sex with:
Transmen and transwomen
Relationship status at time of study
Sex work (exchange of sex for money, drugs, or other goods and services)
Sex work ever
Sex work past 12 months
Unprotected sex with partners of unknown HIV serostatus in past 12 months
Nontransgender males: Unprotected receptive vaginal sex
Nontransgender females: Unprotected vaginal or anal sex
Transgender: Unprotected vaginal or anal sex
Substance use during sex at least monthly in past 12 months
Alcohol (‘‘sex while drunk’’)
Where met sex nontransgender male partners in past 12 months
Bar or club
Private sex party
History of sex with nontransgender men
Had sex for the first time with a nontransgender man after gender transition
(‘‘I wish I was not attracted to men’’ and ‘‘I am not comfortable with being very open about
my sexual relationships with men’’)
Number of sex partners in past 12 months
Number of unknown HIV serostatus sex partners (nontransgender male,
nontransgender female, and transgender)
Number of nontransgender male partners
Anonymous nontransgender male partners
Number of transactional (sex work) nontransgender male partners
HIV risk episodes—number of times engaging in sexual behavior
with an unknown HIV status partner in past 12 months
Total number of transmission episodes with males, females, transgenders
Nontransgender males: Unprotected receptive vaginal sex acts
Nontransgender females: Unprotected vaginal or anal sex acts
Transgender: Unprotected vaginal or anal sex acts
Self-perceived HIV and STD risk (scale 1 to 10)
STD, sexually transmitted disease.
Themes associated with sexual risk
unsafe sex among TMSM during interviews.
Lack of information.
noted the lack of adequate information regarding sexual
health for TMSM:
Nearly every participant (93.8%)
I have not been able to find any information on any type of
penetration or protection or risks. Nobody is thinking about
that, and I haven’t heard like a lot of guys talk about it. If I like
put my clit in a penetrative way in another tranny boy’s
vagina, am I at risk? What am I at risk for?
Most felt that what little information was out there for
TMSM was inadequate or often times not relevant, having
been simply adapted from materials for traditional hetero-
sexual sex as opposed to tailored to the sexual lives, bodies,
and desires of transgender men:
withbio[logical]guys,it was really hardto findstuff. I didfind
Participants commonly mentioned wanting sexual health
particular, participants wanted information that was ‘‘by and
it, like what are the risks? I have not been able to find any type
ofinformationon penetrationandprotectionandrisks.It’s like
nobody seems to be thinking of that.
The importance of recognizing transgender-specific sexual
practices wasunderscored bymany participants indescribing
quantitative data where 93.8% of the sample reported recep-
that in the context of sexual health, sensitivity and attention
needs to be paid to the specificity of transgender men’s sexual
experiences, including the recognition that some men enjoy
frontal/vaginal receptive sex:
I had a really hard time identifying as a gay male because I
didn’t fit that and I was always, in the back of my head, saying
men the way men have sex with men, and I don’t want to.
Normalizing the sexual practices of transmen, including
the experience of receptive frontal sex, was thought to be an
important element of sexual health information tailored to
meet the needs of TMSM.
mentioned the early stages of gender transition as a time of
‘‘heightened risk’’ and described it as being a period of bound-
ary pushing and sexual experimentation:
There’s a re-socialization that happens.You have to learn what
it means to be a man. And it’s like when you’re growing up,
part of self-discovery—you have to see how far you’ll go to see
how far you won’t go. It can definitely put some guys at risk.
A number of participants used the metaphor of ‘‘adoles-
cence’’ to describe transmen younger in their gender transi-
tion (e.g., not necessarily younger in age):
I worry about the kids. Kids in terms of being young in
transition. It’s that time between realizing you have to do
something about your gender and getting back into a normal
cycle of life where gender is not the most important thing in
your life anymore. Adolescence is a good metaphor for it. But
you have all the adult stuff there too. Plus, throw in hormone-
induced menopause just for fun. I mean, puberty and men-
opause were never designed to take place in the same body!
Take all that and throw in intense social anxiety about ne-
gotiating gender in work, family, partnerships. I think all that
together, puts you in a really good position to get in some bad
Several participants expanded on the nature of their own
sexual boundary pushing, suggesting that sexual fulfillment
could be elusive for many TMSM and that some transgender
men might be more willing to engage in risky behavior in
search of sexual fulfillment:
I don’t think I’ve ever had a sexually fulfilling experience.
Because of the biological body I have. To me—that’s reality. I
think that’s where some of the confusion and the experimen-
tation comes in.
The ‘‘gender role trigger’’. The risks associated with experi-
mentation were not only concerning HIV and STD acquisition
or transmission, but also about the risk of ‘‘being taken ad-
vantage of,’’ getting into abusive or manipulative relation-
ships and situations, and generally being pushed past sexual
boundaries that might be comfortable. Many participants
talked about standards and stereotypes in the gay male
community and among men more generally, as well as how
these inform and affect transgender men’s risk for HIV
and STDs. One participant felt that transgender men were
Table 3. Characteristics of the Most Recent Sexual
Encounter with a Nontransgender Male in the
Past 12 Months Among the Study Sample (n¼16)
HIV status of male partner
Unknown HIV status male partner
HIV sexual risk behaviors
Unprotected receptive anal or vaginal sex
Unprotected insertive anal sex
Unprotected receptive oral sex
with ejaculate (performed)
Unprotected oral sex (received)
Talked about safer sex before
or during sex
Participant substance use before or during encounter
Sex partner’s substance use before or during encounter
6REISNER ET AL.
especially vulnerable to a ‘‘gender role trigger’’ associated
with these stereotypes:
I think transguys have a gender role trigger. You can push
them to do almost anything by questioning their gender ro-
le...When I was first coming out, I got pressured into a lot of
stuff that I didn’t want to do because I was told ‘‘real gay men
do it.’’ I had bad experiences with safer sex etiquette because
people pressured me, and said, ‘‘gay men don’t do that.’’
Another participant felt the potential for similar pressures
around gender roles, but felt that sex with nontransgender
men could threaten or call into question his transgender
I think sometimes there’s this weird, not-trans enough thing
that a lot of people encounter when hooking up with men.
Participants often contrasted their experiences as transmen
with their perceptions of the nontransgender gay male expe-
rience. Specifically, participants felt that transmen often come
out later in life than many gay men. Respondents reported
first coming out to themselves as transgender at a mean age
23.6 (SD¼8.7) and nearly half (43.8%) reported having sex
with a nontransgender male for the first time only after be-
ginning gender transition. Participants perceived that trans-
men in the early stages of coming out or transitioning may be
more vulnerable to the pressure associated with gender ste-
reotypes than gay men of the same age group:
I kind of feel like men who came out as gay in their teens build
up the self-esteem to just say, I don’t have to live up to your
stereotype bullshit. But I feel like transmen, especially the
young, coming out college age transmen, haven’t developed
immunity to macho bullshit yet. And it’s really important for
them to get accepted as men and I think that’s a real danger.
Increased interest in sex. All participants who reported
hormone use (15/16; i.e., being on testosterone or ‘‘T’’) re-
their own sexual desires specifically compared to their expe-
participants (75.0%) mentioned or joked about the connection
between testosterone and attraction to non-transgender men,
using phrases like ‘‘T makes you gay’’ or ‘‘turning gay on T’’:
I heard about people liking men after testosterone before I
started, and I was just like, oh, yeah, sure...I have one trans
friend that I talk with pretty regularly and I told him, I’m like,
‘‘Dude, I think I am turning gay or something. I don’t know.
What the fuck.’’ And he’s like, ‘‘Why, you want to fuck men?’’
And I’m like, ‘‘Yeah.’’ And he’s like, ‘‘You’re not gay, dude,
you’re just horny.’’ And I’m like, ‘‘Well, that’s true!’’
Most commonly, the connection between testosterone and
‘‘being gay’’ was invoked as being a dominant ‘‘myth’’ in the
transmale community, and participants often talked about
how their experiences were different, particularly among
transmen who reported sexual attraction and engagement
with nontransgender men prior to gender transition. Others
connected their interest in sex to an improved sense of con-
fidence they felt that allowed them to act on desires they had
It’s hard to say that, like, it [testosterone] enhanced my sexual
desire in general or—I think it probably had more to do with
me just looking like a guy and feeling more confident and
having that opportunity. I’m more comfortable having gay
interactions with men than I am having, like, woman on man
Language. Many transmen described the challenge of talk-
ing about their bodies, especially with nontransgender male
I haveahard timetalkingaboutsexwithsomeoneI’mgoingto
havesexwith, inthatreally specific,‘‘Here’swhatI want’’ kind
Participants identified difficulty with language and words
to talk about their bodies and ‘‘parts’’ to be a potential barrier
to negotiating sexual safety. Difficulties negotiating the lan-
guage transmen feel best respects their gender identity might
also translate into difficulty negotiating and establishing
comfortable sexual riskboundaries and limits moregenerally.
I’ve been in uncomfortable situations in the sense that even
your gender identity. Like they refer to your body parts in
ways that are not respectful.
Internalized transphobia. For several participants, internal-
ized feelings about how their transgender identity and body
might negatively affect their sexual and romantic lives were
common themes. In early transition, participants often re-
were further along in transition reflected back on their expe-
riences in early transition and remarked on the uncertainty
they felt about being able to find sexual partners who would
think their body was ‘‘hot’’ or ‘‘sexy’’:
I was worried when I first transitioned that I would have
trouble finding people who were interested in dating someone
like me. I have learned that I can be picky. I have enough good
to make more refusals than I really enjoy making. Which is
For a number of participants, fears that their transgender
unworthy of sexual experiences and, when they did find po-
tential sexual partners, ‘‘lucky to get laid.’’ One participant
talked about how this might influence safer sex practices for
I thinkin general some trans guys might have that internalized
fear that they can’t get someone. And so they need to make
concessions for them, like they might need to do something
they’re not comfortable with just because they need to find
someone. This guy wants to have sex with me. But he doesn’t
want to use a condom. But, you know, he wants to have sex
with me. So, maybe I should make a concession because, you
know, I’m lucky that he wants me.
Participants also suggested that anxieties about sexual
performance and attractiveness might put transmen at a
greater risk of consenting to otherwise unacceptable sexual
There’s an ugly phase in early transition where you feel like no
one’s going to hook-up with you. And you accept conditions
that you might not accept normally because you think you
SEXUAL HEALTH NEEDS OF NEW ENGLAND TRANSMEN7
going to have to accept this because no one is going to want to
sleep with a freak. Then you get through that phase and real-
ize, actually, kind of a lot of people want to sleep with you!
Internet. The Internet played a prominent role in the sexual
behaviors of TMSM in this sample, particularly with non-
transgender male sex partners. The majority of participants
(81.3%) made explicit reference to the Internet as a means of
meeting nontransgender male sexual partners. Most (62.5%)
reported having met an anonymous nontransgender male sex
partner in the past 12 months online, and 56.3% reported
meeting their most recent casual nontransgender male sex
partner using the Internet:
The Internet is kind of how I figure I’ll meet anyone, any po-
tential partner. They will already know I’m trans and every-
thing will be out there and it won’t be an issue.
For many TMSM in the sample, the Internet appeared to
facilitate anonymous sexual encounters. Participants reported
an average of 4.5 (SD¼8.8) anonymous nontransgender male
sex partners in the past 12 months, the majority of which they
met online. During the most recent encounter with a non-
transgender man, a higher proportion of TMSM who met sex
partners online reported unprotected receptive vaginal or
anal sex (55.6%) compared to TMSM who did not meet their
most recent partner via the Internet (28.6%).
Although the Internet appeared to be a risk factor for some
participants, it also appeared to serve a protective function for
others. Some participants mentioned using the Internet as a
tool to help screen out partners who might be uninterested or
hostile to asexual encounter with a transman. Specifically, the
nature of online sexual networking allowed for TMSM to
disclose sensitive information, including but not limited to
their transgender identity, relationship status, and STD his-
tory, without risk of face-to-face rejection:
Oh my God, the Internet is so awesome. I love the Internet
more than TV. I mean I could get that tattooed ‘‘The Internet is
so awesome.’’ The Internet gives me access to literally hun-
dreds of people who meet the basic criteria I need. I can put up
a boyfriend, and anybody who contacts me after that knows.
And then I’m not seeing people’s negative reactions. Anyone
who contacts me after that is interested. I don’t have to deal
with all that rejection—and that is huge to my staying sane.
Additionally, several participants mentioned the Internet
as a useful tool in negotiating safer sex. Participants could
establish their own comfort boundaries around sex acts and
barrier usage prior to a sexual encounter in much the same
way that the Internet allows transmen to disclose their
transgender status. One participant described using the In-
ternet in a similar manner to negotiate boundaries around sex
interests and comfortable boundaries prior to an encounter.
Transactional sex. For several participants, transactional sex
(i.e., exchanging sex for money, drugs, or other goods and
services) emerged as a potential source of HIV risk. Nearly
half (43.8%) of the sample reported having ever engaged in
sex work, and 18.8% reported engaging in transactional sex in
the past 12 months with a mean number of 2.4 (SD¼7.6)
transactional nontransgender male sex partners. All partici-
pants who reported transactional sex in the past 12 months
reported not using barriers or condoms in one or more
transactional encounters with nontransgender men due to
being able to earn more money:
I don’t use any barriers or condoms. Sex work-wise with guys,
I can do better without using them. Part of me is ok with it and
part of me is not. I guess because of the work I do and because
I mean in this day in age, there’s HIV. That part of me feels
guilty. The other part of me says I gotta do what I gotta do.
Substance use. Alcohol and marijuana, reported by 62.5% of
participants, were the most frequently reported substances
during sex. Two participants reported unprotected vaginal
intercourse during their most recent sexual encounter with an
anonymous male sex partner and while using alcohol and
marijuana. Where substance use around sex was reported,
participants often attributed its use to a need to lower inhi-
bitions, and to reduce anxieties and fears of not finding a
sexual partner who could respect and validate their identity:
A lot of my heavy drinking was so I could engage in sexual
I know some trans guys who might not be as comfortable with
their bodies, and use drugs or alcohol to disassociate them-
selves from certain experiences during sex, or as a way to
loosen themselves up.
Mood triggers. Mood as triggers to engaging in risky sexual
behavior represent an important area to consider further in
understanding HIV risk among transmen. Several partici-
pants described seeking out sex with nontransgender men as
connected to their feelings and mood. More than half (56.3%)
of participants met criteria for clinically significant depressive
symptoms (CES-D score 16þ) at the time of the study. Most
often, these participants described ‘‘feeling down’’ or ‘‘anx-
ious,’’ in connection with their search for male sexual partners
on the Internet.
Sometimes I feel lonely so I go online. It distracts me from
feeling bad. I mean, looking for casual sex can be time con-
suming. It gives me something to do.
Anxiety was also commonly observed among this sample,
with 56.3% meeting criteria for ‘‘mild’’ or ‘‘moderate’’ and
18.8% for ‘‘severe’’ anxiety related symptoms. Several of
‘‘obsessive’’ or ‘‘compulsive’’ quality to seeking sex with
nontransgender men on the Internet:
It’s kind of obsessive. A lot of it is just about the attention. It’s
like how many responses am I going to get. How fast am I
goingtoget them?Youknow?Like howmanyhot guysversus
like creepy scary guys. Like, how many are actually going to
want to follow through. And sometimes I don’t even follow
through. But there’s something about that process that is kind
I think my compulsive behavior and need around it [sex with
nontransgender men] is actually the biggest risk. Because so
many times I’ve almost engaged with someone and then
I jerked off and like was over it, you know.
Risk reduction. Some participants reported engaging in
sexual behaviors with the intent to reduce their risk of
HIV and STD acquisition or transmission. Intentional risk
8 REISNER ET AL.
reduction practices were reported and appeared to inform
I don’t always take cum in the mouth. I don’t always take cum
at least in a sexual way, unless I’m doing BDSM [bondage and
discipline, sadism and masochism] but I only do that with
people I know well.
I will insist on a condom and that’s something I make sure
I have a ton of.
with nontransgender men] is because I consider them to have
no risk because I’m strictly a top with them. When I do sex
work I’ll bottom, but I’m not at risk of passing to my main
female partners because there is no body fluid exchange.
I’ve never used a condom in oral sex. But then the risks are
Many participants distinguished between regular and ca-
sual nontransgender male sexual partners in their sexual risk
reduction decision-making. In general, most participants re-
ported being willing to use less or no protection only with
regular partners with whom the participants had established
When I was hooking up with my partner’s partner, that was a
time that I wasn’t sleeping with anybody else but him, and I
knew his status, and we didn’t use condoms.
The timing of barrier negotiation emerged as another risk
reduction technique. Participants reported having difficulty
regularly using barriers during a sexual encounter when they
were feeling ‘‘in the moment.’’ As such, many participants
reported attempting to reduce their risk of unprotected sex
by establishing expectations of barrier usage prior to the
If there’s any negotiation, it’s usually before we meet
up...because generally when I’m hooking up, it’s just that.
Similarly, several participants described asking about a
partner’s STD history and current HIV serostatus prior to
I’m very clear beforehand what I want. I’m very clear that if
you’regoing to put me at risk, to just not evenengage with me.
Potential educational and sexual health intervention
components and programs
talking openly about their sexual health and/or having sex
with non-transgender men. This was particularly true for
several participants who reported regular female partners:
Several participants reported difficulty
It’s just not something that comes up. I mean, being with
women is such a low risk thing. And I don’t talk about being
with men when I’m with other people so the topic [sexual
health] doesn’t really come up. I wish I had other guys to talk
sorting through these issues.
Programs that foster a sense of community and an ex-
change of information among TMSM may represent an im-
portant potential area of future intervention. Internet-based
interventions: The Internet was thought to be essential in
reaching TMSM and disseminating information within the
transgender community. Several participants talked about
online communities for ‘‘trannyfags’’ (defined as a transman
who is attracted to males and gay-identified53) as critical
spaces for TMSM to connect with one another and share in-
formation, including information on coming out:
When I finally came out as trans, you know, years later,
through all of this online research that I’m doing, I’m realizing
that there’s an entire community of trans men that also date
other men and it was just this, like, burden that was lifted.
It feels like most trans men stereotypically are lesbians and
then theytransitionand like girls.WhenI go onlineit’s greatto
be able to talk to other people that have had the same experi-
ence that I have had because I definitely felt like I was the only
person. Because I wanted to date men and at that point I didn’t
think it would ever be possible for a non-trans guy to date a
it like blows my mind and I think it’s amazing.
Websites commonly mentioned when discussing commu-
nity websites were Gay FTMs and the men who love them
ticle called ‘‘Introducing: Trannyfags’’ (www.villagevoice
.com/2004-03-30/columns/introducing-trannyfags/), the Ca-
nadian website Queertransmen.org (www.queertransmen.
org/), and XX Boys (www.xxboys.net/). Given thenumber of
and/or information about TMSM, the Internet seems partic-
ularly well-suited as an intervention delivery mechanism
surrounding safer sex. The Internet has the potential to not
only foster more formal peer support structures, but also to
create channels for the dissemination of more accurate infor-
mation on sexual health. Moreover, a number of participants
male sex partners of transmen with intervention efforts.
Several participants brought up the importance of risk re-
duction information about how to reduce overall risk in
anonymous Internet sexual encounters, not just risk reduction
focused on sexual health. Participants suggested that pam-
phlets about how to be smart and reduce their risk while
hooking up online with men should include information on
communication and disclosure issues, and tips for meeting a
guy for the first time (i.e., meet in the hallway or lobby of his
building or a more public space, etc.).
Another aspect of risk reduction that emerged was regular
access to healthcare related to sexual health. Access to cul-
turally competent HIV testing and STD screening were most
commonly mentioned as important to incorporate into pro-
Focus on pleasure and ‘‘hot sex.’’
and enjoyment in sexuality was thought to be an important
dimension of any sexual health information designed for
transgender men. Pornography was thought to serve as an
important source of information for TMSM about sex and
their bodies, as well as being with non-transgender men.
Buck Angel (www.buckangel.com/) were mentioned. It was
suggested that any safer sex materials and pamphlets also be
‘‘hot,’’ in that the material should be erotic and a ‘‘turn on’’:
Focusing on pleasure
It has to be hot. I don’t want to look at boring stuff. It’s a turn
off. Like, I want to see people having a good time, having hot
sex, and also taking care of themselves sexually.
SEXUAL HEALTH NEEDS OF NEW ENGLAND TRANSMEN9
Incorporating erotica and/or pornography into the circu-
lation of relevant sexual health-related information was
thought to be one way of increasing the uptake of information
on sexual risk reduction.
Content of information.
of sexual health-related concerns around the physiologic
changes associated with hormone therapy and how those
changes in their bodies might affect sexual risk and HIV or
STDs, highlighting them as areas of particular interest for
TMSM. Several participants expressed concern over the lack
of information on exactly what types of protective barriers
(e.g., latex condoms, ‘‘female’’ condoms, gloves, etc.) pro-
vide what levels of HIV and STD protection for the kinds
of sex TMSM engage in with non-transgender male, non-
transgender female, transmen, and transwomen partners.
Pregnancy, in particular, emerged as an arena where
TMSM felt that more information and programming should
be offered. Most participants were aware of the risks of
pregnancy while on hormone therapy.
Participants identified a variety
When I signed the informed consent and started testosterone
like, does that mean there is risk of pregnancy?
Condoms are not a question. Yes, we’re using condoms be-
cause I don’t want to be pregnant.
Several participants knew of TMSM who had had
pregnancy scares and one participant described his own
I didn’t think much about it [pregnancy], but then I had a scare
where a condom broke and like [the doctor and nurse] came in
and they’re like, ‘‘Well, we really don’t think there’s a good
chance.’’ It freaked me out.
Another participant reported an experience he had prior to
taking testosterone and had accessed abortion services:
I did get pregnant at one point. That was pre-hormones. That
was a nice little trip to Planned Parenthood. But thankfully,
they were very good—I was impressed—they were very like
Several participants also expressed an interest in possibly
getting pregnant and having their own child at some time in
the future; however, felt that no information was available to
them about doing this and/or wanting to do this. Concern
about navigating pregnancy-related healthcare services as a
transman was especially noted:
I guess my concern with pregnancy is not so much getting
being a trans guy.
Additional areas that were thought to be especially salient
sexual health arenas without sufficient or available pools of
information were structural and anatomic changes (particu-
larly changes to the vagina and clitoris during hormone use),
including its effects on HIV and STD transmission, and
information about hysterectomy.
Training for health care providers.
medical providers were commonly reported by participants
as an area in need of improvement with respect to consid-
ering sexual health services for transmen. Many participants
described the general tone of healthcare providers as rela-
tively uninformed about the particular needs of transmen, in
particular those who report sex with non-transgender men.
Several participants talked about having to educate their
care providers about their specific health needs and gener-
ally found that experience to be frustrating. Culturally
competent gynecological services were commonly men-
tioned as an area of particular need. One participant re-
ported avoiding returning to the gynecologist for years
because he perceived that competent and comfortable med-
ical services were unavailable and because of it being a
I’ve avoided getting the Pap for the last three years because I
don’t want to go into a women’s clinic. And there is no great
place to go.
However, several other participants shared stories of pos-
itive experiences with a healthcare provider who were not
necessarily knowledgeable about transgender health, but
who were open and responsive to learning and understand-
ing their transgender patients’ sexual health needs.
In the context of HIV and STD testing, participants often
described the difficulty of disclosing their sexual behavior
with men to a health care provider. One participant described
disclosure of both transgender status and sexual behavior
with menas abarrier tohim getting anHIV test and screening
It’s hard to talk about our bodies. I mean, how do you tell a
counselor who you’ve never met that you recently hooked up
with some dude you didn’t know and you let him fuck your
boy pussy without a condom? You have to disclose being FTM
And you have to be comfortable coming out about being with
men. I think this is a barrier for a lot of guys—thinking that
providers will not understand why they are transmen and
want to be with men.
To our knowledge, this study represents the first formative
mixed methods examination of the sexual health needs of
transmen who have sex with nontransgender men on the East
Coast, including a discussion of risk and protective factors
that are likely associated with HIV and STD sexual risk
unprotected receptive vaginal sex with nontransgender males
of unknown HIV serostatus in the past 12 months. Consistent
with previous research from a national sample of TMSM,26
the current findings suggest that TMSM may be at elevated
risk for HIV and STDs,particularly given thatrecent increases
in HIV and other viral and bacterial STDs have been noted
and interventions that are culturally competent and address
the transgender-specific sexual health needs of TMSM and
their nontransgender male sexual partners are needed. In-
tegrating sexual health information ‘‘by and for’’ transmen
into other healthcare services, involving peer support, ad-
dressing mood triggers such as depression and anxiety,
Internet-delivered information and services for transmen and
their sexual partners, making safer sex materials ‘‘hot’’ (i.e.,
erotic) and pleasure-focused, and training for healthcare
providers were seen as important aspects of intervention de-
sign and delivery for this population.
10 REISNER ET AL.
Findings also suggest that understanding the sexual health
needs of transmen, including HIV and STD risk and protec-
tive factors, necessitates that sexuality be contextualized
within the broader process of gender transition. A life course
perspective31,32offers a framework to begin conceptualizing
the broader developmental context in which sexual risk be-
havior occurs for TMSM. For example, transmen might be
especially vulnerable to experiencing depression and anxiety
during ‘‘sensitive periods’’31,32of developmental transition
and change. Gender transition, whether it involves body
modification (i.e., hormones, surgeries, etc.) or not, represents
a time when many transmen explore and discover what it
means for them to be embodied differently in the world as
men. Thus, mood triggers may be more salient in sexual risk
behaviors during certain periods of gender transition than
others. Additional research with larger samples is needed to
further elucidate, test, and advance a life course framework to
understand the sexual health of transgender populations.
A dominant theme that emerged in this study was the
paucity of culturally relevant and accurate sexual health in-
formation tailored to the sexual health needs of TMSM. This
lack of information may put TMSM at risk for HIV and STDs
due to misinformation or inaccurate information, limited
support, lack of access to sexual health resources (i.e., STD
testing) and/or sexual partners who are knowledgeable and
respectful of their bodies, preferred sexual practices, and
identities. Safer sex education materials are needed that are
tailored to meet the needs of TMSM, including differentiating
by partner genders (i.e., male, female, transmen, trans-
women), type (i.e., casual, anonymous, monogamous, etc.),
and sexual behaviors (i.e., frontal/vaginal or anal sex; oral
sex; body contact with exchange of body fluids; sex toys, etc.).
Also needed is information about sexual health more broadly,
including information about pregnancy and how to navigate
pregnancy-related health care services as a transman.
The Internet, in particular, appeared to play an important
role in the lives of many TMSM, not only in facilitating sexual
partnerships with nontransgender men, but also in reducing
risk of violence or rejection from potential sexual partners,
a sexual encounter. Protective factors included using the
Internet as a way to screen potential sex partners and risk
reduction practices, including type of partners, timing of safer
sex negotiation, and evidence of science-based decision
making. The Internet also appeared to be pivotal in connect-
ing individual transmen with one another and forming com-
munities that provide social support for TMSM. Getting
accurate information into online networks may be one po-
tential strategy to improve the sexual health of transmen, and
involving nontransgender male sexual partners was thought
to be important. Additional research examining the social and
sexual networks of transmen, using methodological recruit-
ment methods shown to be effective at recruiting ‘‘hidden’’
populations, such as respondent-driven sampling,54,55may
represent an important next step in recruiting a diverse
sample, and understanding and improving the sexual health
Some limitations pertain to the current study and should
be considered in interpreting findings. First and foremost,
sexual risk behaviors and prevention needs may vary by
gender of transgender partner and represents a significant
omission in the present study. Although participants were
queried as to whether they had engaged in any sexual ac-
tivity with nontransgender men, nontransgender women,
transmen, and/or transwomen in the past 12 months, HIV
and STD sexual risk episodes were not differentially as-
sessed by gender vector of transgender partners (e.g.,
transmen compared to transwomen). Future research on
sexual health should include transgender gender vector (i.e.,
transmen, transwomen, genderqueer, etc.) and attend to the
nuances of sexual identities, behaviors, and bodies which are
likely important in designing HIV and STD prevention and
sexual health information.
Second, as a formative investigation of sexual health needs
of TMSM, the study enrolled a small convenience sample of
primarily white transmen, many of whom reported access to
health care and economic resources (i.e., health insurance,
stable housing, employment, education, and transgender-
related hormones and surgery). Given that previous research
has shown that transmen of color are less likely than their
white counterparts to have access to primary care ser-
vices,56,57it possible that sexual behaviors and healthcare
needs of transmen of color, TMSM of lower socioeconomic
position, and/or those lacking access to economic and social
resources may differ than results reported from this sample
(i.e., limitation of nongeneralizability).26Similarly, a large
proportion of the current sample self-identified as ‘‘queer’’
(75.0%); thus, it is possible that findings may not be general-
izable to gay or bisexual transmen. Research is needed with
larger and more diverse samples of transgender men that
contextualizes sexual health within broader issues of access to
health care, other health-related concerns such as psycholog-
ical health (e.g., depression and anxiety), and further consid-
ers the role of identity (e.g., gay, bisexual, queer), all of which
may affect risk-taking behavior.
The current study suggests that more nuanced theoretical
understandings of the dynamics that affect sexual health
among TMSM is necessary, including the influence of gender
roles and identities within sexual partnerships. New theoret-
health among transmen, particularly examining gender roles
embodied that are transgender-specific—such as the effects of
long-term use of testosterone on anatomy58,59—warrant the-
oretical consideration in sexual health. Integrating a social
epidemiologic framework of embodiment60with a social
psychological framework of sexual scripting33—i.e., an ‘‘em-
bodied scripting’’ approach—may allow for more sophisti-
cated understandings of the pathways of sexual risk among
this population, especially the biologic aspects of HIV and
STD transmission risk, and should be further developed.
For assistance with recruitment and study implementation:
Rubin Hopwood, Thomas Lewis, Gunner Scott and Massa-
chusetts Transgender Political Coalition, Rodney Vander-
warker, D’hana Perry, Sean Bland, and the Medical and
Behavioral Health Departments at Fenway Health. For in-
spiring new thinking about transgender sexual health:
Dr. Nancy Krieger (fall 2009 SHH215 ‘‘History, Politics &
Austin (fall 2009 SHH297 ‘‘Sexuality and Public Health’’) to
Sari Reisner (doctoral student at Harvard School of Public
SEXUAL HEALTH NEEDS OF NEW ENGLAND TRANSMEN11
Health). For insightful comments that strengthened a prior
version of the manuscript: An anonymous peer-reviewer.
The project described was supported by The Center for
Population Research in LGBT Health at The Fenway Institute
and by the Eunice Kennedy Shriver National Institute of Child
Health and Human Development (NICHD) under Award
Number R21HD051178 (PI: J. Bradford). Some of the investi-
gator time on this project was also support by grant number
R03DA023393 from the National Institute on Drug Abuse
(NIDA; PI: M. Mimiaga). The content is solely the responsi-
bility of the authors and does not necessarily represent the
official views of the NICHD, NIDA, or the National Institutes
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Sari Reisner, M.A.
The Fenway Institute
1340 Boylston Street, 8th Floor
Boston, MA 02215
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