Addressing the Sexual Health and HIV Prevention Needs of Same-Sex Attracted Transgender Men
How can medical care providers, social workers and community outreach workers ensure they are addressing the needs and desires of transgender (trans) men who have sex with men (TMSM)? At a community skills development workshop at the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia, 50 community members led by Budi Sudarto and Jez Pez explored the realities, concerns and questions of TMSM, as well as resources for providers.
Sudarto, who self-identifies as a cisgender (non-transgender) gay man, led the workshop by invoking "not leaving anyone behind" when it comes to discussing HIV prevention and treatment -- a major theme of the conference -- pointing out that TMSM are often still left out of conversations about gay men and transgender individuals. He used a myth-busting exercise to debunk common myths about trans men, including: all transgender individuals are gay or lesbian, all transgender individuals want genital reconstruction surgery, transgender men are not at risk for HIV and all transgender men hate their body and their genitalia. After the denouncing of the myth that transgender individuals are "simply confused about their gender identity," one participant yelled, "They're no more or less confused than anybody else!"
Trans Men: Identity, Sexuality and Community
Pez, a queer trans man, illuminated the diversity and nuance of the TMSM community and pointed out the "huge lack of HIV prevention education targeting our communities." To frame the conversation, he referenced Primed: A Back Pocket Guide, a Canadian guide to TMSM sexual behavior created in 2010. It reads:
How can we make a sexual health resource dealing explicitly with fucking, sexually transmitted infections, hepatitis and HIV while at the same time, using language that is clear and respectful to the wide range of trans men who will read it?
Pez emphasized the importance of discussing trans men's sexuality in terms of specific behaviors, rather than by using language rooted in gender binary terms like male or female, making it more inclusive and relatable. For example, "Do you practice anal sex?" might be a better question to ask a TMSM than "Do you have sex with men?"
Globally, little to no research has been done on trans men, contributing to the scarcity of funding for their communities. One estimate cited by Pez shows that anywhere from 0.03% to 5% of the population might be considered a trans man depending on the definition used. Pez cited issues with the vast array of gender identities and how they don't translate well to data collection as reasons why it may be hard to lock down a number. Because there is no clear estimate of the demographic, he explained, there are few sexual health education messages geared specifically toward TMSM and a lack of dedicated peer-led services that are funded.
Pez shared many nuances that come with discussing trans men's gender, and the importance of making sure that service providers discuss gender identity with their patients -- without forcing disclosure. While a person may be a transgender man, the person may not identify as a man or transgender; the person may not identify within the binary of male/female at all. Medical professionals must also understand that gender transitioning is not a wholly medicalized process, with multiple social and cultural factors to it that patients may or may not want to discuss. Yet, there are issues that should be respectfully probed in order to get a client's full history.
The longest discussion of trans men's gender and sexuality centered around the concept of passing, which is when a person's perceived gender matches the gender by which the person wants to be perceived. If a trans man is perceived to be a man by those around him, he is considered passing. However, many in the audience pointed out the problematic nature of the term.
For many trans people, passing as another gender is not the ultimate goal -- the person may want to look a certain way, but not have any prescribed cultural and social gender norms attached to that look. Also, many trans people are often unfairly discriminated against for failing to pass or for not adhering to a certain sociocultural idea of beauty. While passing is something that can happen, there are those for whom passing is not a priority, or even an option, and that must be respected.
I'd say passing to me isn't essential. The piece that's essential to me is, if I come out to you and you continue to treat me as male. Can I play in my body as a guy and be perceived and responded to as a guy? That matters. If someone is going to make me into a girl in their mind with their behavior, it's not happening. -- Primed: A Back Pocket Guide
For providers working with trans men, even those who identify as gay, it is important to understand the fluid, nuanced sexuality of many trans individuals. There is a diverse array of sexual identities and sexuality must be understood as separate from gender identity. Some trans men will have multiple partners and some will have relationships with people of various genders. Service providers should be comfortable asking their clients about their level of sexual health knowledge and how they deal with issues around body image, disclosure of their gender identity, negotiating safer sex, and sexual rejection.
Same-Sex Attracted Trans Men and Sexual Health
In response to an encounter in the past with a prominent professional in the HIV community who said, "the stats don't really show that trans men are that affected, so why is it a priority to focus on HIV prevention for trans men," Pez cited recent studies (Riesner et al, 2010; Sevelius 2009) showing that 44% to 69% of TMSM reported unprotected sex or inconsistent condom use with cisgender men in the past year as evidence for the need for HIV prevention education.
TMSM often experience stigma from several communities -- including cis communities, trans communities and gay communities -- and people who experience stigma often engage in risky behaviors in order to seek acceptance. Because many trans men were labelled female at birth and lived at least part of their lives presenting as female, they may not have been raised in a culture that emphasizes HIV testing. Once they begin to live as TMSM, they enter a culture with a high HIV prevalence, yet are often not well-versed in the facts regarding HIV. Also, many professionals often lack knowledge around the sexual practices of TMSM and fail to educate them properly about their own bodies -- Pez noted that the diversity of trans men's sexual activities "range from vanilla to very kinky sexual activities, including oral, anal and front hole, vaginal sexual activities."
According to Pez, many issues disproportionately impact trans men and the care they receive, including: lack of representative research; stigma and discrimination; issues surrounding disclosure of gender identity with partners or medical professionals; power imbalance with sexual partners (which can lead to coercion into unsafe sexual situations); issues negotiating safe play, boundaries and consent; fear of violence and rejection; lack of sexual health knowledge; and issues with service delivery. Service providers should be aware of all of these issues when dealing with trans men.
While many MSM are knowledgeable when it comes to proper condom usage, such as needing to change condoms when switching partners, Pez emphasized that such strategies are not "familiar for trans men." One self-identified trans participant added that many care providers and community members also assume that trans men are receptive sexual partners and only address them as such, but that they must also be looked at as insertive partners. Finally, Pez noted that practitioners should speak to trans men about their use of lube, as they may not be as naturally lubricated as is necessary for safe penetration.
In conclusion, Pez emphasized that trans men need respectful and safe access to testing and sexual health information; spaces that are welcoming and friendly to trans men; clear language that includes gay/queer trans men -- especially messages that don't only explicitly reference cis genitalia; education about boundaries and negotiating sex with cis, gay, and bi men; and appropriate, representative research that looks into the sexual health, risk behaviors and STI/HIV burden of trans men.
Some resources for trans men, which may not be safe for viewing while at work or in public areas:
Terrence Higgins Trust Guide for Trans Men
Mathew Rodriguez is the community editor for TheBody.com and TheBodyPRO.com.
Follow Mathew on Twitter: @mathewrodriguez.