Hello, everyone. My name is Joseph Cherabie. I use they and he pronouns. I am an assistant professor in the Division of Infectious Diseases at Washington University in St. Louis. I also am a clinical ambassador for the CDC Let’s Stop HIV Together Campaign and am a board member for the HIVMA.
Today we get to talk about a topic that is near and dear to my heart—and a topic that’s making a lot of headlines lately—which is transgender health care and gender-affirming care in HIV prevention settings.
I want to say that this talk is going to give you some basics of how to provide transgender and gender-affirming care within any health care setting, but especially catered towards HIV prevention settings. What we’re going to do today is: We’re going to discuss Terminology 101; discuss some trans health disparities; go over gender-affirming care in HIV treatment and prevention settings; and provide you all with some resources that you can use within your work practice on a daily basis.
Terminology 101: Sex and Gender
Without further ado, let’s start by defining sex and gender. Terminology is important because, oftentimes, some of these terms get conflated with one another.
First, let’s define sex. Sex is typically referred to as sex assigned at birth, and it is exactly that: It is assigned at birth based off the appearance of your external genitalia, or your anatomy.
We know that there are certain individuals with differences in sexual development; there are certain individuals who are intersex. Those individuals are not as uncommon as we tend to think. They’re as common as redheads, in fact. And we know that just because you have a certain genotype does not mean you have a certain phenotype, or expression of those genes. So, while we like to view sex as a binary, it’s oftentimes actually a spectrum.
Then we get into gender: Gender identity is what your internal sense of what your gender is. And we have to remember: What people have defined to be masculine and feminine [has] changed over time. In fact, if you look at history, what was once masculine is now, in modern day, deemed quite feminine. So the way that I like to think about it is: Remove your anatomy; remove every physical attribute about yourself. What is it that makes you feel like a man? What is it that makes you feel like a woman? What is it that makes you feel like neither? That is your gender identity. And then how you express that to the world, how you externalize that, how you share that: That’s your gender expression.
All of this is separate from sexual attraction, sexual behavior and practices, and sexual orientation. Sexual attraction is whom you’re physically and emotionally attracted to. Sexual practices are actually just that: [For example,] I am a queer person who has sex with cisgender men and transgender individuals. And then sexual orientation is how you identify your sexuality. I identify as queer; oftentimes I identify as gay. Sexual orientation does not necessitate what your sexual practices are, nor vice versa.
Defining Key Facets of Gender-Affirming Care
So: What do we mean when we say gender-affirming care? And I want to be very clear here, because gender-affirming care has made a lot of headlines lately and we want to make sure that we are clearly defining it. I personally like this framework: The four facets of gender affirmation are as such [i.e., social, psychological, medical, and legal]. This is not a checklist of what it means to be trans or what it means to be cisgendered.
You have the social aspect, which is what you externalize. “Hi. My name is Joe. I use they and he pronouns.”
Then you have the psychological, internal, felt self. That might be different from what you externalize or what you express outside; it may take time for you to externalize it and share it socially.
The medical aspect is what oftentimes we view as all gender-affirming care: The stuff of taking gender-affirming hormone therapy; surgery; or body modifications. But I want to emphasize this: Trans people sometimes don’t want the medical aspect of gender-affirming care. And sometimes cisgender people—or people whose sex assigned at birth aligns with their gender identity—they actually do want gender-affirming therapy. Example[s] of this [are] breast modification; low testosterone treatment in men; or post-hormonal replacement therapy in menopausal women.
The last aspect is legal gender markers or name change. And that is where an individual changes their designation on their birth certificate and/or other forms of identification.
I do want to say, straight from the get-go, that this is a survey from the Trans Equality Group. And you can see here that there is a high amount of satisfaction with gender-affirming hormone therapy, especially hormone replacement therapy, and gender-affirming surgery. And so, without any controversy here, I just want to say evidence-based medicine shows that there is a high amount of satisfaction, especially among trans and gender-diverse folks who receive this care.
So, why are we talking about this? Because we happen to live in a world and in a time in which we are seeing record numbers of anti-LGBT bills being introduced and passed. In fact, 26 states ban best practice care for transgender youth; these are the ones highlighted in the orange here.
I want to also highlight the experience of transgender folks. This is from the Center for American Progress survey in 2022. The first one that I want to highlight is that more than 1 in 3 LGBT adults faced some kind of discrimination in the last year since they took the survey.
But I want to highlight the statistics in the box:
- Nearly 4 in 5 LGBT adults reported that they took at least one action to avoid experiencing discrimination based off of their sexual orientation, gender identity, or intersex status.
- More than 1 in 3 reported postponing or avoiding medical care in the past year due to cost issues.
- And more than 1 in 5 reported postponing or avoiding medical care due to disrespect or discrimination from providers.
That is on us, y’all. That is on us as health care providers, in terms of not making a safe, healthy environment for people to obtain health care.
It goes even further than that. This is the Kaiser Family Foundation/Washington Post survey in 2023. They noticed a widespread discrimination and harassment of trans individuals: -
- One-quarter have been physically attacked due to their gender identity, gender expression, or sexual orientation.
- That goes up to 1 in 3 trans people of color.
- Sixty-four percent report verbal attacks or harassment.
- Forty-seven percent say health care providers know little—sorry, they know not much or nothing—about how to provide care for trans people.
- Thirty-one percent have to teach their doctor or other provider to get appropriate care.
- And 31% say their provider refused to acknowledge their gender identity.
So, not only are they experiencing historic and record numbers of stigma and discrimination from the health care providers; then they have to advocate for themselves, for their own health care. That’s not necessarily fair here. We, as health care providers, need to do better to educate ourselves on how to provide this level of care.
Guidelines for Clinicians When Interacting With Transgender Patients
So, what can we do for our trans and gender-diverse population? These are some guidelines that me and some of my colleagues have come up with.
We have to understand that the need to affirm one’s gender identity can supersede other critical health concerns. I have had patients not want to be admitted to the hospital because of bad experiences they have had in that hospital. And that’s perfectly valid; many of our patients carry their negative experiences and trauma with them. So, we need to understand that. We need to validate that and try our best to avoid repeating those traumas in the future.
We need to avoid asking questions out of curiosity, and only ask what you need to know. Reassure patients about confidentiality. Respect concerns regarding potentially sensitive physical exams and tests. And address health concerns related to hormone interventions and surgeries.
I always use the term, “Is it OK if I,” if I ask a question or if I’m about to do a physical exam. The reason why is: I want to give the power back to the patient. And it’s OK to ask how they want their body parts referred to as, and avoiding gendered language overall. The more that you normalize this for all of your patients, the more you realize how easy it is to do.
Avoid the terms “male-to-female” or “female-to-male” trans individuals, and use instead “trans women,” “trans men,” or “individuals of transgender experience.” The reason to say that is when you say “male-to-female” or “female-to-male,” you’re using their previous gender and not their current gender. When we say “trans woman,” this is a woman. When we say “trans man,” this is a man. If we say this is a “man of trans experience,” then this is a man. And it leaves nothing to be questioned.
Familiarize yourself with they/them pronouns. We use them all the time. One of the little tips and tricks that I learned from an elementary school teacher, actually, was [to] try to imagine that the person has a mouse in their pocket, and it’s always there. And try to say they/them whenever that person happens to be in the room.
Never assume the sexual partners of a patient based off of their gender identity. In other words, trans men can have cis male partners. Just because they are trans does not necessarily mean that they automatically have cisgender women partners, as is commonly the assumption.
Barriers and Facilitators Regarding HIV PrEP Usage Among Trans Individuals
We also need to understand that there is a lack of data on transgender health due to historic stigma, discrimination, and neglect. A perfect example of this is we don’t have much data on Descovy, or TAF/FTC [i.e., emtricitabine/tenofovir alafenamide], in transgender men, especially, and in cisgender women—anyone assigned female at birth, basically. We are getting preliminary data from the PURPOSE trials, so you should stay tuned for that. [Editor’s note: Early PURPOSE 1 results revealed high efficacy for injectable, long-acting PrEP with lenacapavir in cisgender women. Early PURPOSE 2 results found similar findings in cisgender men, transgender people, and non-binary people who have sex with men.]
But we have to understand that it’s OK to say you don’t know; give the information that you do have; and to make shared decisions based off of informed consent.
We know that combining gender-affirming hormone therapy and HIV treatment in one setting is great for people living with HIV—in fact, [it] has created a great amount of viral suppression. But what about HIV PrEP? There’s this review looking at the barriers and facilitators of HIV PrEP uptake, adherence, and persistence amongst transgender populations in the U.S. What they found were five trends:
- That PrEP concentrations tended to be lower amongst individuals taking feminizing hormones. But this was not statistically clinically significant.
- There was concern over the interaction between PrEP and gender-affirming hormone therapy. And this remains a large barrier.
- PrEP initiation may facilitate increased self-advocacy and self-acceptance.
- There is a lack of trust in medical institutions, and this oftentimes impacts PrEP uptake.
- And social networks have a significant influence on PrEP knowledge, interest, and adherence.
Additional research, though, is really necessary, especially among transgender men and nonbinary persons.
The major question is: Do hormones interact with HIV antiretroviral therapy? And the answer is that there [have] been multiple studies—all of those conducted on TDF/FTC [i.e., emtricitabine/tenofovir disoproxil fumarate, originally sold under the brand name Truvada]—have shown no effect on hormone levels.
Some studies have shown that high dose of feminizing hormones in trans women result in lower tenofovir levels in certain tissues, like rectal tissues. But other studies do not show lower levels. So, we have conflicting data here.
We also know that the FEM-PrEP study—that looked at PrEP TDF/FTC in cisgender women—it took around 21 days for PrEP, taking PrEP daily, to reach therapeutic levels. But this was in 2012. And we know that uptake of PrEP amongst that study population was quite low.
There was a recent study done by Marazzo, et al., in 2024, that showed the same effectiveness in individuals assigned female at birth—90%, versus 88% for those assigned male at birth—for individuals taking TDF/FTC. What this means is that individuals assigned female at birth and individuals assigned male at birth had the same level of effectiveness if they were taking Truvada daily.
That is amazing. And that is important information, because it goes against this idea that hormones—or certain things about especially feminizing hormones or estrogen—can affect the level of tenofovir in certain tissues.
What is important is daily adherence. And we have to understand that both TDF/FTC and cabotegravir are approved [for PrEP] in sexually active adults. And PURPOSE 2 is on the way for lenacapavir, in which they’re studying it amongst individuals assigned [male] sex at birth and gender-diverse folks.
The Importance of Taking a Good Sexual History
So, what is the best practice in sexual health clinical settings? Making sure to go back to taking a good sexual history. This is the guide to taking a sexual history from the CDC:
- Understanding that professional language is oftentimes preferred by transgender and gender-diverse folks.
- Never assume what an individual’s anatomy is, what their sexual practices are. Let them tell you.
- Open-ended questions work much better here, as well, saying things like, “Tell me about your sex partners,” or “What are the genders of your sex partners?” This is, of course, in comparison to saying, “Do you have sex with men, women, or both?” That doesn’t capture gender-diverse folks. And so, saying, “What are the genders of your sex partners?” allows individuals to answer that a little bit more openly.
- Asking what type of sex you have and “What does sex mean to you?” and allowing them to explain that to you and share that. Sometimes you may not understand some of the terms, but it’s OK to ask and to learn.
There’s also, in the newest iteration of the STI Treatment Guidelines, a whole list of screening processes for transgender and gender-diverse folks, and recommendations. This is a great step in the right direction. And this is available, again, on the STI Treatment Guidelines, and in the STI Treatment Guidelines app.
Remember That Trans Joy Is Real
The last thing that I want to impart on you all, though, is that trans joy is real.
We’ve highlighted a lot of trans health disparities and highlighted a lot of negative experience of transgender people. But what I can say is that I have many trans friends. I myself am part of the transgender community. And I will also say that I get to take care of these patients every day. And their joy is real; it is valid. And we, as health care providers, need to do our part in order to make sure that we continue to provide health care that ensures that this joy continues.
I will be providing resources that I have listed above in the bottom part of this interview and this video. But I just want to thank you all for listening and working on trying to provide the best care for all of our patients.
