A Mixed Methods Study of the Sexual Health Needs of New England Transmen Who Have Sex with Nontransgender Men

Article (PDF Available)inAIDS patient care and STDs 24(8):501-13 · August 2010with182 Reads
DOI: 10.1089/apc.2010.0059 · Source: PubMed
Abstract
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 interventions. 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] = 11.1; 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 nontransgender 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.
ORIGINAL ARTICLE
A Mixed Methods Study of the Sexual Health Needs
of New England Transmen Who Have Sex
with Nontransgender Men
Sari L. Reisner, M.A.,
1,2
Brandon Perkovich,
1,3
and Matthew J. Mimiaga, Sc.D., M.P.H.
1,2,4
Abstract
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] ¼ 11.1; 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.
Introduction
T
he sexual health of transmen—individuals who
were born or assigned female at birth and who identify as
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
have consistently found high rates of HIV infection and sexual
risk behaviors among transgender women, particularly
among transwomen who engage in sex work.
1–11
However,
the inclusion of transmen in studies of HIV sexual risk
behavior remains uncommon.
1,2,4,11–15
The current state of
knowledge of HIV and STD risk among transgender men may
be influenced by a common assumption that transmen only
engage in sexual behavior with nontransgender women
(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.
12,14,16–26
To 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 risk and 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
1
The Fenway Institute, Fenway Health, Boston, Massachusetts.
2
Harvard School of Public Health, Boston, Massachusetts.
3
Harvard College, Cambridge, Massachusetts.
4
Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts.
AIDS PATIENT CARE and STDs
Volume 24, Number 8, 2010
ª Mary Ann Liebert, Inc.
DOI: 10.1089/apc.2010.0059
1
role of psychosocial factors in sexual risk behaviors. A recent
study conducted by Sevelius
26
with a national sample of
TMSM (n ¼ 45) 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 sex and drug use in the context 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 epidemic
27
and other viral and bacterial STDs,
28–30
it is likely TMSM who
partner with gay or bisexual nontransgender men may be at
increased risk for HIV and STDs
12,23,26
and additional re-
search is needed to elucidate the risk and protective factors
among TMSM.
In addition, situating the sexual health of transmen within
the context of gender transition using a life course perspec-
tive
31,32
may allow for further consideration of the inter-
relationships between sexuality and gender identity
development, including the timing, duration, and context of
health behaviors. Simon and Gagnon
33(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,’
17
the
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.
Methods
Design and setting
Between May and September 2009, 16 transmen completed a
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 transgender community in the greater Boston area.
34,35
The
Fenway Health Institutional Review Board approved the study
and each participant completed an informed consent process.
Sample
Eligibility criteria. Prospective participants were screened
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.
Recruitment. A combination of venue-based recruitment
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
Data collection and measures
Participation in this study took, on average, 1.5 h. Partici-
pants were remunerated $50 for their participation in the
study.
Quantitative survey. Demographics, sexual behavior, and
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 Surveillance Survey, MSM cycle.
38
Questions were
also adapted from prior Fenway Health studies.
9,23,39,40
Sex-
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
goods and services) in their lifetime and in the past 12 months.
Depressive symptoms. Clinically significant depressive
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 a ¼ 0.84).
41
The 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.
2 REISNER ET AL.
Generalized anxiety symptoms. The Beck Anxiety Inventory
(BAI) was used to assess physiologic and cognitive symptoms
of anxiety.
42
Originally developed to reliably discriminate
anxiety from 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
prior research to assess internalized homophobia
43
: (1) ‘I wish
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
reverse scored.
Qualitative interview. The qualitative interview guide
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-
terview was digitally recorded and then transcribed verbatim.
Researchers and staff with experience and competency
working in transgender health were included at all levels of
study design, development, implementation, and analysis.
Analytic approach
Qualitative analysis. Qualitative data were analyzed
using content analysis,
37,44–48
broadly defined as a ‘‘technique
for making inferences by objectively and systematically
identifying specified characteristics of messages.’
45(p14)
An
emergent coding approach
37
was 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 cleaned to focus on the content of what was said. NVivo
software
49
was 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.
37
The following steps were implemented to
systematically evaluate the content of the data: (1) research
staff independently reviewed the material and came up with a
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
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.
50,51
Analyses were
focused on the contextual issues surrounding HIV and STD
risk and intervention development with TMSM.
Quantitative analysis. Survey data were used to provide
a more comprehensive portrait of occurring themes, as well as
to support qualitative results, and are integrated with the
interview findings below. Descriptive analyses were con-
ducted using SPSS statistical software.
52
Results
Demographic characteristics of the study sample (n ¼ 16)
are outlined in Table 1.
Table 1. Sample Demographics (n ¼ 16)
Mean (SD) age 32.5 (11.1)
n%
Race/ethnicity
White 14 87.5
Mixed race/ethnicity (Asian, NH/PI,
black, Hispanic/Latino)
2 12.5
Education
Some college 5 31.3
College degree 6 37.5
Some graduate work 3 18.8
Graduate degree 2 12.5
Annual income
$11,999 or less 6 37.5
$12,000 or more 10 62.5
Employment
Full-time 9 56.3
Part-time 4 25.0
Unemployed 3 18.8
Disabled 1 6.3
Student 5 31.3
Health insurance
No health insurance 4 25.0
Gender identification
Male 8 50.0
Female-to-male (FTM) 9 56.3
Transgender 9 56.3
Transsexual 4 25.0
Genderqueer 3 18.8
Other 1 6.3
Access to transgender specific services
Testosterone at time of study 14 87.5
Surgery ever for transgender-related purposes 11 68.8
Sexual identification
Queer 12 75.0
Gay 2 12.5
Bisexual 2 12.5
Heterosexual 1 6.3
Unsure 1 6.3
Disclosure of transgender and MSM identities
Out about being transgender 15 93.8
Out about MSM 5 31.3
SD,standarddeviation;NH/PI,MSM,menwhohavesexwithmen.
SEXUAL HEALTH NEEDS OF NEW ENGLAND TRANSMEN 3
Participants had a mean age of 32.5 (standard deviation
[SD] ¼ 11.1), 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 males regularly and for whom HIV and STDs
were ranked at #1, HIV and STD concerns most often ranked
at #4 or #5. For some participants sexual health needs were not
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 even on the radar. When we were talking about top
five [health concerns]—it’s like oh, no, it’s not in the top five.
Consistently reported as more important health issues were
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
thinking.
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
nontransgender female partner, and 56.3% with a transgender
partner (56.3% transmen, 12.5% transwomen, and 12.5% both
transmen and transwomen). Overall, participants reported
sex with a mean 6.4 (SD ¼ 10.1) unknown HIV serostatus sex
partners of any gender in the past 12 months. A mean number
of 5.4 (SD ¼ 8.7) nontransgender male sex partners with un-
known HIV serostatus were reported in the past 12 months.
Number of unprotected sexual acts with HIV unknown
status partners. Overall, a mean number of 9.9 (SD ¼ 17.4)
unprotected sex acts (transmission risk episodes) were re-
ported with unknown HIV serostatus partners: 43.8% re-
ported a mean of 4.0 (SD ¼ 9.0) unprotected receptive vaginal
sex acts with nontransgender males, 25.0% reported a mean
number of 4.5 (SD ¼ 15.0) unprotected vaginal or anal sex acts
with nontransgender females, and 18.8% reported a mean
number of 1.4 (SD ¼ 3.4) unprotected sexual acts with trans-
gender sex partners.
Knowledge of sexual health
Many transmen were knowledgeable about sexual health
issues, particularly TMSM who were gay-identified, and were
aware of HIV and STD risk as well as pregnancy risk (for those
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 in my life having safe sex. You know, 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 (n ¼ 16)
n%
HIV testing and status
Ever had an HIV test 15 93.8
No HIV test in 2 years prior to study enrollment 4 25.0
HIV-negative (self-report) 16 100.0
STD testing and STD history
Ever had STD test 13 81.3
Pap smear in past 12 months 11 68.8
STD history (18.8% herpes, 12.5% trichomonas, 6.3% bacterial vaginosis) 6 37.5
In past 12 months sex with:
Nontransgender males 16 100.0
Nontransgender females 11 68.8
Transmen 9 56.3
Transwomen 2 12.5
Transmen and transwomen 2 12.5
Relationship status at time of study
Single 8 50.0
Monogamous 2 12.5
Nonmonogamous 6 37.5
Sex work (exchange of sex for money, drugs, or other goods and services)
Sex work ever 7 43.8
Sex work past 12 months 3 18.8
Unprotected sex with partners of unknown HIV serostatus in past 12 months
Nontransgender males: Unprotected receptive vaginal sex 7 43.8
Nontransgender females: Unprotected vaginal or anal sex 4 25.0
Transgender: Unprotected vaginal or anal sex 3 18.8
Substance use during sex at least monthly in past 12 months
Alcohol (‘‘sex while drunk’’) 10 62.5
Marijuana 10 62.5
Downers 3 18.8
Painkillers 2 12.5
Hallucinogens 1 6.3
Ecstasy 1 6.3
Where met sex nontransgender male partners in past 12 months
Internet 10 62.5
Through friends 9 56.3
Social gathering 3 18.8
Bar or club 2 12.5
Private sex party 2 12.5
On street 2 12.5
History of sex with nontransgender men
Had sex for the first time with a nontransgender man after gender transition 7 43.8
Internalized homophobia
(‘‘I wish I was not attracted to men’ and ‘I am not comfortable with being very open about
my sexual relationships with men’’)
6 37.5
Mean (SD)
Number of sex partners in past 12 months
Number of unknown HIV serostatus sex partners (nontransgender male,
nontransgender female, and transgender)
6.4 (10.1)
Number of nontransgender male partners 5.4 (8.7)
Anonymous nontransgender male partners 4.5 (8.8)
Number of transactional (sex work) nontransgender male partners 2.4 (7.6)
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 9.9 (17.4)
Nontransgender males: Unprotected receptive vaginal sex acts 4.0 (9.0)
Nontransgender females: Unprotected vaginal or anal sex acts 4.5 (15.0)
Transgender: Unprotected vaginal or anal sex acts 1.4 (3.4)
Self-perceived HIV and STD risk (scale 1 to 10)
Nontransgender males 3.8 (2.7)
Nontransgender females 1.3 (1.1)
Transgender 1.4 (1.9)
STD, sexually transmitted disease.
5
Themes associated with sexual risk
A number of interrelated themes emerged as risk factors for
unsafe sex among TMSM during interviews.
Lack of information. Nearly every participant (93.8%)
noted the lack of adequate information regarding sexual
health for TMSM:
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:
When I started looking up information to trans guys having sex
with bio[logical] guys, it was really hard to find stuff. I did find
some stuff for trans guys. But it was basically like they just took
hetero[sexual] female and changed the words for like anatomy.
Participants commonly mentioned wanting sexual health
information that would be tailored to their bodies and lives. In
particular, participants wanted information that was ‘‘by and
for’’ transmen:
We need information from transguys for transguys. Like I have
this new clit that’s like longer and I can do different things with
it, like what are the risks? I have not been able to find any type
of information on penetration and protection and risks. It’s like
nobody seems to be thinking of that.
The importance of recognizing transgender-specific sexual
practices was underscored by many participants in describing
needed sexual health information. This was also supported by
quantitative data where 93.8% of the sample reported recep-
tive frontal/vaginal sex in the past 12 months. Participants felt
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
well, but, I’m not really a gay guy because I don’t have sex with
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.
Transition-related experimentation. Several participants
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,
you have to figure things out for yourself. Boundary pushing is
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
situations.
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 (n ¼ 16)
n %
HIV status of male partner
Unknown HIV status male partner 8 50.0
HIV sexual risk behaviors
Unprotected receptive anal or vaginal sex 5 31.3
Unprotected insertive anal sex 2 12.5
Unprotected receptive oral sex
with ejaculate (performed)
3 18.8
Unprotected oral sex (received) 9 56.3
Communication
Talked about safer sex before
or during sex
10 62.5
How met
Internet 9 56.3
Through friends 6 37.5
Social gathering 3 18.8
Participant substance use before or during encounter
Alcohol 6 37.5
Marijuana 2 12.5
Sex partner’s substance use before or during encounter
Alcohol 5 31.3
Marijuana 2 12.5
6 REISNER 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
identity:
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 (SD ¼ 8.7) 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-
ported an increased interest in sex in general and awareness of
their own sexual desires specifically compared to their expe-
riences prior to taking hormones. In interviews, the majority of
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
always had, but had not felt comfortable expressing until after
transition:
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
interactions.
Language. Many transmen described the challenge of talk-
ing about their bodies, especially with nontransgender male
partners:
I have a hard time talking about sex with someone I’m going to
have sex with, in that really specific, ‘Here’s what I want’’ kind
of way.
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 risk boundaries and limits more generally.
I’ve been in uncomfortable situations in the sense that even
though you’ve told someone, they still sometimes don’t respect
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-
ported seeking validation from men. Several participants who
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
offers that I can turn down the ones that aren’t great. I still have
to make more refusals than I really enjoy making. Which is
great.
For a number of participants, fears that their transgender
identity might negatively affect their sex lives left them feeling
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
some TMSM:
I think in 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
risk limits:
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
don’t have a better option. It’s like, well, if I want to get laid I’m
SEXUAL HEALTH NEEDS OF NEW ENGLAND TRANSMEN 7
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 (SD ¼ 8.8) 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 a sexual 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 profile and say, by the way, I’m an FTM, I have herpes, I have
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
work. In each case, partners are screened on the basis of sexual
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 (SD ¼ 7.6)
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
of what’s put in your head by the people around you in society.
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
behavior.
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
participants with higher anxiety symptom scores described an
‘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
going to get them? You know? Like how many hot guys versus
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
of exciting.
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
sexual decision-making:
I don’t always take cum in the mouth. I don’t always take cum
inside of me. To my knowledge, there’s not any blood involved
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.
The reason I don’t tell my female partners now [about sex work
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
fairly low.
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
boundaries:
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
encounter:
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
initiating sex:
I’m very clear beforehand what I want. I’m very clear that if
you’re going to put me at risk, to just not even engage with me.
Potential educational and sexual health intervention
components and programs
Peer support. Several participants reported difficulty
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:
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
about this stuff. It would make me feel like I’m not the only one
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-identified
53
) 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 they transition and like girls. When I go online it’s great to
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
trans guy. Now I know that it is happening more and more and
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
(http://tribes.tribe.net/gayftmandtheirmen), Village Voice ar-
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 the number of
participants who reported going online to find sexual partners
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
mentioned the potential of the Internet to reach nontransgender
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-
gram delivery. Access to HPV vaccination was also highlighted.
Focus on pleasure and ‘hot sex.’ Focusing on pleasure
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.
TrannyWood Pictures (www.trannywoodpictures.com/) and
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’’:
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 TRANSMEN 9
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. Participants identified a variety
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.
When I signed the informed consent and started testosterone
therapy, it said ‘this shouldn’t be used as birth control,’ but it’s
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
experience:
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
trans aware.
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
pregnant ...it’s just having to go through the services and stuff
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. Culturally competent
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
‘women’s clinic’’:
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 men as a barrier to him getting an HIV test and screening
for STDs:
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
first, before you can really talk about sexual behavior and risks.
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.
Discussion
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
among this community. Overall, 43.8% of the sample reported
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 that recent increases
in HIV and other viral and bacterial STDs have been noted
among MSM in the United States.
27–30
Sexual health programs
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
perspective
31,32
offers 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’
31,32
of 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,
and negotiating sexual safety upfront and prior to engaging in
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,
54,55
may
represent an important next step in recruiting a diverse
sample, and understanding and improving the sexual health
of transmen.
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,
56,57
it 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).
26
Similarly, 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-
ical approaches are needed to conceptually understand sexual
health among transmen, particularly examining gender roles
in safer sexual practices across the life course. Aspects of being
embodied that are transgender-specific—such as the effects of
long-term use of testosterone on anatomy
58,59
—warrant the-
oretical consideration in sexual health. Integrating a social
epidemiologic framework of embodiment
60
with a social
psychological framework of sexual scripting
33
—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.
Acknowledgments
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 &
Public Health: Theories of Disease Distribution’’) and Dr. Bryn
Austin (fall 2009 SHH297 ‘Sexuality and Public Health’’) to
Sari Reisner (doctoral student at Harvard School of Public
SEXUAL HEALTH NEEDS OF NEW ENGLAND TRANSMEN 11
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
of Health.
Author Disclosure Statement
No competing financial interests exist.
References
1. Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prev-
alence, risk behaviors, health care use, and mental health
status of transgender persons: Implications for public health
intervention. Am J Public Health 2001;91:915–921.
2. Herbst JH, Jacobs ED, Finlayson TJ, et al. Estimating HIV
prevalence and risk behaviors of transgender persons in
the United States: A systematic review. AIDS Behav 2008;12:
1–17.
3. Kellogg TA, Clements-Nolle K, Dilley J, et al. Incidence of
human immunodeficiency virus among male-to-female
transgendered persons in San Francisco. J Acquir Immune
Defic Syndr 2001;28:380–384.
4. Kenagy GP. HIV among transgendered people. AIDS Care
2002;14:127–134.
5. Nemoto T, Operario D, Keatley J, et al. Promoting health for
transgender women: Transgender Resources and Neigh-
borhood Space (TRANS) program in San Francisco. Am J
Public Health 2006;95:382–384.
6. Operario D, Soma T, Underhill K. Sex work and HIV status
among transgender women: Systematic review and meta-
analysis. J Acquir Immune Defic Syndr 2008;48:97–103.
7. Reback CJ, Lombardi EL. HIV risk behaviors of male-to-
female transgenders in a community-based harm reduction
program. Int J Transgenderism 1999. www.symposion.com/
ijt/hiv_risk/reback.htm. (Last accessed May 26, 2010).
8. Reback CJ, Simon PA, Bemis CC, Gatson B. The Los Angeles
Transgender Health Study: Community Report. Los An-
geles, CA: 2001.
9. Reisner SL, Mimiaga MJ, Bland S, Mayer KH, Perkovich B,
Safren SA. HIV risk and social networks among male-to-
female transgender sex workers in Boston, Massachusetts.
J Assoc Nurses AIDS Care 2009;20:373–386.
10. Simon P, Reback C, Bemis CC. HIV prevalence and inci-
dence among male-to-female transsexuals receiving HIV
prevention services in Los Angeles County. AIDS 2000;14:
2953–2955.
11. Xavier J, Bobbin M, Singer B, Budd E. A needs assessment of
transgender people of color living in Washington DC. Int J
Transgenderism 2005;8:31–47.
12. Adams A, Lundie M, Marshall Z, et al. Getting primed:
Informing HIV prevention with gay/bi/queer trans men in
Ontario. Ontario Ministry of Health and Long-Term Care,
2008. Ontario: AIDS Bureau. www.queertrans men.org/
images/gettingprimed.pdf (Last accessed January 20, 2010).
13. Bockting W, Avery E, eds. Transgender Health and HIV
Prevention: Needs Assessment Studies from Transgender
Communities Across the United States. Binghamton, NY:
The Hayworth Press, 2005.
14. Kenagy GP, Hsieh CM. The risk less known: Female-to-male
transgender persons’ vulnerability to HIV infection. AIDS
Care 2005;17:195–207.
15. Schulden J, Song B, Barros A, et al. Rapid HIV testing in
transgender communities by community-based organiza-
tions in three cities. Public Health Rep 2008;123:s101–s114.
16. Blanchard R, Clemmensen LH, Steiner BW. Heterosexual
and homosexual gender dysphoria. Arch Sex Behav 1987;
16:139–152.
17. Bockting W, Benner A, Coleman E. Gay and bisexual iden-
tity development among female-to-male transsexuals in
North America: Emergence of a transgender sexuality. Arch
Sex Behav 2009;38:688–701.
18. Chivers ML, Bailey JM. Sexual orientation of female-to-male
transsexuals: A comparison of homosexual and nonhomo-
sexual types. Arch Sex Behav 2000;29:259–278.
19. Coleman E, Bockting WO, Gooren L. Homosexual and bi-
sexual identity in sex-reassigned female-to-male transsexu-
als. Arch Sex Behav 1993;22:37–50.
20. Cromwell J. Transmen and FTMs: Identities, Bodies, Gender,
and Sexualities. Chicago, IL: University of Illinois Press, 1999.
21. Devor H. FTM: Female-to-Male Transsexuals in Society.
Bloomington, IN: Indiana University Press, 1997.
22. Lev AI. Transgender Emergence: Therapeutic Guidelines for
Working with Gender-Variant People and their Families.
Binghamton, NY: Haworth Press, Inc., 2004.
23. Reisner SL, Mimiaga MJ, Mayer KH. STD and HIV risk be-
haviors and psychosocial concerns among female-to-male
transgender men at an urban community health center,
Boston, MA, 2007. Poster #P1267 presented at the 2010 Na-
tional STD Prevention Conference, Atlanta, GA, March 2010.
24. Rubin H. Self-Made Men: Identity and Embodiment among
Transsexual Men. Nashville, TN: Vanderbilt University
Press, 2003.
25. Schleifer D. Make me feel might real: Gay female-to-male
transgenderists negotiating sex, gender, and sexuality. Sex-
ualities 2006;9:57–75.
26. Sevelius J. ‘There’s no pamphlet for the kind of sex I have’’:
HIV-related risk factors and protective behaviors among
transgender men who have sex with non-transgender men.
J Assoc Nurses AIDS Care 2009;20:398–410.
27. Centers for Disease Control and Prevention. HIV/AIDS
Surveillance Report, 2007. Volume 19. Atlanta, GA: U.S.
Department of Health and Human Services, 2009.
28. Centers for Disease Control and Prevention. Trends in Re-
portable Sexually Transmitted Diseases in the United States,
2007: National Surveillance Data for Chlamydia, Gonorrhea,
and Syphilis. Atlanta, GA: U.S. Department of Health and
Human Services; 2009. www.cdc.gov/std/stats07/trends.
pdf (Last accessed December 15, 2009).
29. Centers for Disease Control and Prevention. Sexually
Transmitted Disease Surveillance, 2007. Atlanta, GA: U.S.
Department of Health and Human Services, 2008.
30. Centers for Disease Control and Prevention. Trends in
primary and secondary syphilis and HIV infections in men
who have sex with men—San Francisco and Los Angeles,
California, 1998–2002. MMWR Morb Mortal Wkly Rep
2004;53:575–578.
31. Ben-Shlomo Y, Kuh D. A life course approach to chonic dis-
ease epidemiology: Conceptual models, empirical challenges,
12 REISNER ET AL.
and interdisciplinary perspectives. Int J Epidemiol 2002;
31:285–293.
32. Kuh D, Ben-Shlomo Y, Lynch J, Hallqvist J, Power C. Life
course epidemiology. J Epidemiol Community Health. 2003;
57:778–783.
33. Simon W, Gagnon JH. Sexual scripts: Permanence and
change. Arch Sex Behav 1986;15:97–120.
34. Mayer KH, Mimiaga MJ, VanDerwarker R, Goldhammer H,
Bradford JB. Fenway Community Health’s model of inte-
grated community-based LGBT care, education, and re-
search. In: IH Meyer and ME Northridge, eds. The Health of
Sexual Minorities: Public Health Perspectives on Lesbian,
Gay, Bisexual, and Transgender Populations. New York:
Springer Science & Business Media, LLC., 2007:693–715.
35. Mayer K, Appelbaum J, Rogers T, Lo W, Bradford J, Boswell
S. The evolution of the Fenway Community Health model.
Am J Public Health 2001;91:892–894.
36. Glaser BG. Theoretical Sensitivity. Mill Valley: CA: Sociol-
ogy Press, 1978.
37. Miles MB, Huberman AM. Qualitative Data Analysis, 2nd
ed. Newbury Park, CA: Sage, 1994.
38. Sanchez T, Finlayson T, Drake A, et al. Human Im-
munodeficiency Virus (HIV) risk, prevention, and testing
behaviors—United States, National HIV Behavioral Sur-
veillance System: Men who have sex with men, November
2003–April 2005. MMWR Surveill Summ 2006;55:1–16.
39. Mimiaga MJ, Reisner SL, Cranston K, et al. Sexual mixing
patterns and partner characteristics of Black MSM in Mas-
sachusetts at increased risk for HIV infection and transmis-
sion. J Urban Health 2009;86:602–623.
40. Mimiaga MJ, Goldhammer H, Belanoff C, Tetu AM, Mayer
KH. Men who have sex with men: Perceptions about sexual
risk, HIV and sexually transmitted disease testing, and
provider communication. Sex Transm Dis 2007;34:113–119.
41. Radloff LS. The CES-D scale: A self-report depression scale
for research in the general population. Appl Psychol Meas
1977;1:385–401.
42. Beck AT, Steer RA. Beck Anxiety Inventory Manual. San
Antonio, TX: The Psychological Corporation Harcourt Brace
& Company, 1993.
43. O’Leary A, Fisher HH, Purcell DW, Spikes PS, Gomez CA.
Correlates of risk patterns and race/ethnicity among HIV-
positive men who have sex with men. AIDS Behav 2007;
11:706–715.
44. Denzin NK, Lincoln YS, eds. Handbook of Qualitative
Research. Thousand Oaks, CA: Sage Publications, 1994.
45. Holsti OR. Content Analysis for the Social Sciences and
Humanities. Reading, MA: Addison-Wesley, 1969.
46. Krippendorff K. Content Analysis: An Introduction to its
Methodology. Newbury Park, CA: Sage, 1980.
47. Joffe H, Yardley L. Content and thematic analysis. In:
Marks DF, Yardley L, eds. Research Methods for
Clinical and Health Psychology. Sage Publications Ltd.,
2003:56–68.
48. Weber RP. Basic Content Analysis, 2nd ed. Newbury Park,
CA: Sage, 1990.
49. QSR International Pty Ltd. QSR NVivo qualitative data
analysis software, Version 7. Cary, NC: 2006.
50. MacQueen KM, McLellan E, Kay K, Milstein B. Codebook
development for team-based qualitative analysis. Field
Methods 1998;10:31–36.
51. Silverman D. Doing Qualitative Research: A Practical
Handbook. Thousand oaks, CA: Sage Publications, 2000.
52. SPSS Inc. SPSS 15.0 for Windows, Release 15.0.1, 2006.
53. Urban Dictionary. ‘Trannyfag’’. http://www.urbandictionary.
com/define.php?term¼trannyfag (Last accessed January 27,
2010).
54. Heckathorn DD. Respondent-driven sampling: A new ap-
proach to the study of hidden populations. Soc Prob
1997;44:174–199.
55. Salganik MJ, Heckathorn, DD. Sampling and estimation in
hidden populations using respondent-driven sampling. So-
ciol Methodol 2004;34:193–239.
56. JSI Research & Training Institute. Access to health care for
transgendered persons in greater Boston. Boston, MA: GLBT
Health Access Project, JSI Research & Training Institute,
2000. www.glbthealth.org/documents/transaccessstudy.pdf
(Last accessed April 14, 2008).
57. Kenagy GP. Transgender health: Findings from two needs
assessment studies in Philadelphia. Health Soc Work 2005;
30:19–26.
58. Perrone AM, Cerpolini S, Maria Salfi NC, et al. Effect of
long-term testosterone administration on the endometrium
of female-to-male (FtM) transsexuals. J Sex Med 2009;6:3193–
3200.
59. Makadon HJ, Mayer KH, Potter J, Goldhammer H, eds.
Fenway Guide to Lesbian, Gay, Bisexual & Transgender
Health. Philadelphia, PA: American College of Physicians,
2008.
60. Krieger N. Embodiment: A conceptual glossary for epide-
miology. J Epidemiol Community Health 2005;59:350–355.
Address correspondence to:
Sari Reisner, M.A.
The Fenway Institute
Fenway Health
1340 Boylston Street, 8th Floor
Boston, MA 02215
E-mail: sreisner@fenwayhealth.org
SEXUAL HEALTH NEEDS OF NEW ENGLAND TRANSMEN 13
    • "Findings supported our hypothesis that trans MSM would report less access to basic HIV prevention services as compared to cisgender MSM, with the exception that while almost half of trans MSM had inadequate access to condoms, Table 2. Associations between stigma and access to HIV testing among transgender men (n069) in a global survey of men who have sex with men this proportion was quite similar to cisgender MSM. Our findings are consistent with trans men's qualitative reports of barriers to accessing sexual health services, particularly HIV and other sexually transmitted infections testing [10,23]. HIV testing is a pre-requisite for access to HIV treatment and preexposure prophylaxis, as well as for prevention of onwards transmission. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction Free or low-cost HIV testing, condoms, and lubricants are foundational HIV prevention strategies, yet are often inaccessible for men who have sex with men (MSM). In the global context of stigma and poor healthcare access, transgender (trans) MSM may face additional barriers to HIV prevention services. Drawing on data from a global survey of MSM, we aimed to describe perceived access to prevention services among trans MSM, examine associations between stigma and access, and compare access between trans MSM and cisgender (non-transgender) MSM. Methods The 2014 Global Men's Health and Rights online survey was open to MSM (inclusive of trans MSM) from any country and available in seven languages. Baseline data (n=3857) were collected from July to October 2014. Among trans MSM, correlations were calculated between perceived service accessibility and anti-transgender violence, healthcare provider stigma, and discrimination. Using a nested matched-pair study design, trans MSM were matched 4:1 to cisgender MSM on age group, region, and HIV status, and conditional logistic regression models compared perceived access to prevention services by transgender status. Results About 3.4% of respondents were trans men, of whom 69 were included in the present analysis. The average trans MSM participant was 26 to 35 years old (56.5%); lived in western Europe, North America, or Oceania (75.4%); and reported being HIV-negative (98.6%). HIV testing, condoms, and lubricants were accessible for 43.5, 53.6, and 26.1% of trans MSM, respectively. Ever having been arrested or convicted due to being trans and higher exposure to healthcare provider stigma in the past six months were associated with less access to some prevention services. Compared to matched cisgender controls, trans MSM reported significantly lower odds of perceived access to HIV testing (OR=0.57, 95% CI=0.33, 0.98) and condom-compatible lubricants (OR=0.54, 95% CI=0.30, 0.98). Conclusions This first look at access to HIV prevention services for trans MSM globally found that most reported inadequate access to basic prevention services and that they were less likely than cisgender MSM to have access to HIV testing and lubricants. Results indicate the need to enhance access to basic HIV prevention services for trans MSM, including MSM-specific services.
    Full-text · Article · Jul 2016
    • "TGNC people who had no interest in a medical transition began identifying as transgender and lived their lives with a renewed sense of pride about this identity. Since the 1990s, there has been a surge in research through other lenses, including public health, anthropology, sociology, and gender and sexuality studies (Hines, 2006; Reisner, Perkovich, & Mimiaga, 2010; Roen, 2001; Valentine, 2007). This broadening of the scientific literature has further illuminated the diversity in identities and experiences found within the TGNC communities. "
    [Show abstract] [Hide abstract] ABSTRACT: Psychological research with transgender and gender nonconforming (TGNC) people is a relatively new field with great promise to advance our understanding of this population’s needs and develop, implement, and evaluate corresponding interventions to reduce their health disparities and promote psychosocial adjustment, mental health, and well-being. After a brief review of the history of research with TGNC people, this article discusses several issues to ensure that research with this population is culturally competent and meaningful. This includes issues to consider for participant recruitment, data collection, working with institutional review boards, and distribution of research findings. We conclude with a discussion of gaps in the literature and corresponding opportunities for future psychological research with TGNC people.
    Full-text · Article · Jun 2016
    • "In one of these studies, transgender participants were four times less likely than cisgender MSM to have been tested for HIV even though attitudes towards condom use and self-reported condom use were similar (Bockting et al., 2007 ). Transgender men who have sex with cisgender men are at risk of HIV infection because of inconsistent condom use and receptive vaginal and anal sex (Reisner, Perkovich, & Mimiaga, 2010; Sevelius, 2009 ), frequently with gay-identified cisgender MSM (Rowniak, Chesla, Rose, & Holzemer, 2011). Estimates of the prevalence of HIV among transgender women vary widely due to sampling bias in this population (Baral, Poteat, Str€ omdahl et al., 2013). "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives:Sex with more than one gender is associated with higher substance use, and sexual HIV risk.Methods:We examined knowledge, motivation, and self-efficacy to engage in safer substance use and sexual behavior among methamphetamine-using U.S. men who have sex with more than one gender (N = 343).Results:Almost half(46.2%) of the men reported having sex with a man and a woman or transgender partner in the last 30 days.Compared to monosexual MSM, non-monosexual MSM reported greater condom use self-efficacy however, they reported more sexual partners who inject drugs.Conclusion:We observed distinct differences between men who do or do not have sex with more than one gender.
    Article · Apr 2016
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