A lot of news reports this year have focused on murders of transgender women in the United States, particularly black transgender women. In fact, the American Medical Association just recently declared homicides of trans women an epidemic. And while many trans activists have called for men to stop murdering trans women (many of whom were killed by men they were dating or having sex with), little research is known about men who date or are attracted to trans women, and few resources exist to help men productively engage their feelings.
And given that transgender women of color are also at much higher risk of HIV acquisition than many other groups, what do we know about the lives and risk factors of their romantic and sexual partners? Very little. Cisgender men who have sex with trans women (MSTW) are likely at increased risk of HIV and may serve as a bridge population that transmits HIV to trans women from other vulnerable groups. Unfortunately, little is known about their specific risks because they might not self-identify, and research often lumps them into other sexual minority categories such as men who have sex with men. A new review published in AIDS Education and Prevention seeks to better understand the behavior and risk factors of this group of men by further analyzing published studies.
The authors used PubMed to find relevant research and did full text reviews of 24 articles. Some of these articles were excluded from the final analysis, however, because they relied exclusively on qualitative data, were not U.S. based, did not include HIV-related outcomes, or labeled sexual partners as transgender but did not specifically note whether they were trans women. Ultimately, 10 articles were included in this review, representing six unique studies, as some of the articles were based on data from the same study.
The sample was small, but the authors believe it provides important insight into this under-studied group of men.
"Currently, this group is overlooked in all U.S. public HIV surveillance systems, and if they are counted, they're likely to be miscategorized," said Arjee Restar, M.P.H., the study's lead author and a Ph.D. candidate at Brown University. "Without data about this group, it means that they are not included in many public health initiatives. Their invisibility is to the detriment of trans people's health -- given that the health of most trans people are interconnected with the partners they're with."
Overall, the analysis found that about one in three MSTW self-reported being HIV positive, and one in 10 were unaware of their status.
Three of the included studies measured substance use among MSTW. One found that 72% had used alcohol, 67% had used marijuana, 49% had used crack or other forms of cocaine, and 24% had injected drugs. Another study found lower alcohol (22%) and marijuana (11%) usage, but also found that 17% had used crack/cocaine, 17% had used methamphetamine, and 33% had used multiple substances. Only one study otherwise assessed the mental health of participants, finding that 60% of the MSTW participants exhibited signs of clinical depression.
The 10 reviewed studies show that MSTW have a wide array of partners. In one of the studies, for example, 14% reported engaging in sex with trans women and cisgender men; 37% reported sexual contact with transgender and cisgender women; and 23% reported intercourse with transgender women, cisgender men, and cisgender women. The proportion of MSTW who reported exclusively having sex with trans women ranged from 2% in one study to 50% in another. The analysis also found that 46.1% of the pooled overall sample reported engaging in condomless anal sex with trans women. These results suggest that this group of men has the potential to facilitate HIV acquisition for their transgender and cisgender women partners.
The analysis also revealed that MSTW across all of the included studies reported experiencing discrimination as a result of their relationships with transgender women. The authors note that stigma has been found to be a root cause of health disparities and to negatively impact communication with health care providers. Though the studies included in this meta-analysis did not ask about provider relationships, the authors believe that it is logical to assume that stigma faced by MSTW might be a barrier to proper health care and may be preventing them from accessing vital prevention and treatment tools like pre-exposure prophylaxis (PrEP) and HIV medications.
Restar believes the results provide an opportunity for "providers, clinicians, and researchers to start developing ways to screen for and address the health outcomes of this group, specifically in HIV and mental health."
"The results of this study can be leveraged for health equity, as it provides a different perspective -- a gateway -- to begin discussing and addressing not only MSTW's health needs, but also the consistently documented multitudes of sexual health outcomes that many transgender people, particularly trans women, are experiencing at the interpersonal level," she added.
Jasmine Tasaki of WeCare Tennessee, a group that provides supportive services, training, and advocacy for and by black transgender women in Memphis, Tennessee, thinks that MSTW will benefit from being represented in the research.
"I do have experience working with this demographic but haven't done much programming, because it's very hard for them to self-identify," she said. "They face discrimination, stigma, and judgement from all sides. These people are part of our community, but they're afraid to be part of the conversation."
"Seeing themselves in the research may help them feel engaged, which is important," she added. "We have a plan to end the epidemic by 2030, but we need everyone on board."