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Try out PMC Labs and tell us what you think. Learn More. Historically, HIV studies have conflated men who have sex with men MSM with transgender trans women, explicitly excluded trans individuals, or included sample sizes of trans people that are Women want sex Crabtree small to reach meaningful conclusions. Despite the heavy burden of HIV among trans women, conflation of this population with MSM has limited the information available on the social and behavioural factors that increase HIV vulnerability among trans women and how these factors may differ from MSM.

We conclude with implications for data collection and intervention development. Globally, transgender trans women are one of the most vulnerable populations to HIV. A recent meta-analysis of HIV prevalence among trans women Baral et al. This overwhelming disparity highlights the urgent need for research to inform effective and appropriate HIV prevention, care, and treatment interventions for this population. Historically, HIV studies have conflated men who have sex with men MSM and trans women, explicitly excluded trans individuals, or included sample sizes of trans people that were Women want sex Crabtree small to reach meaningful conclusions.

Leaders in the trans community have called for an end to this conflation and for the recognition of trans women as a unique population, different from MSM. The same critiques apply to gender minorities. These conflicting stances from well-respected health organisations raise not only issues of identity politics but also public health questions: What can currently available data tell us about the similarities and differences in HIV risk and vulnerabilities for trans women compared to non-transgender cisgender MSM? What data are missing? What does this mean for how data should be collected and for the appropriateness and effectiveness of current HIV interventions?

In order to address these questions, we conducted a secondary analysis of data from three sources in the United States: the — Baltimore National HIV Behavioral Surveillance Survey; the — Baltimore Transgender Supplement Questionnaire TSQand qualitative interviews with transgender adults, conducted as part of a larger study of gender, stigma, and HIV risk in Baltimore in We used Intersectionality and Syndemic Theory to interpret the findings from this analysis. Intersectionality is a theoretical approach that foregrounds the intersection of multiple social identities that result in multiple and interdependent structural inequalities Bowleg, Syndemic theory describes how multiple, co-occurring epidemics, concentrated within a specific population, interact and reinforce one another, giving rise to additional health problems Singer, Recruitment methods vary for each population, but standardised protocols and core questions are the same for each cycle.

Participating health departments may include locally specific questions to address local needs. Questionnaires collect information about demographics, sexual behaviour, injection and non-injection drug use, and HIV testing. In order to be eligible, participants had to report being ased male at birth natal malebe 18 years of age or older, reside in the city's metropolitan area, and have sex with a man in the 12 months.

Participants were recruited using venue-based, time-location sampling TLS. All participants provided verbal informed consent, and data were collected via face-to-face interviews using handheld devices. Structured quantitative interviews lasted approximately one hour.

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After the interview, HIV-1 testing was done on serum samples that were sent to the state laboratory for analysis. Eligibility criteria were the same as for the NHBS with the additional requirement of a transgender identity.

Data collection, HIV testing, and incentive payment were identical to NHBS with the exception of the use of paper questionnaires with several free lists and open-ended questions rather than completely structured questionnaires via handheld computers.

The TSQ collected data on sexual behaviour, gender identity, expression, and use of transition-related interventions.

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Questions about sexual partners included multiple options to describe the gender expression as well as the gender identity of those partners e. It did not include questions about condom use, drug use, or injections of soft-tissue fillers such as silicone. Forty respondents completed the TSQ. Because the of participants who completed both surveys was small with little overlap in the questions asked, the two samples were analysed separately. Sex-stratified purposive sampling was used to identify transgender participants for in-depth interviews IDIs about stigma and HIV risk.

Efforts were made to achieve variability along lines of race, engagement in medical care, and use of hormone therapy. Inclusion criteria for transgender participants included being 18 years of age or older, residing in the metropolitan area, and identifying as transgender or as a gender different from their birth sex. One IDI was conducted with each of the 30 trans women participants between January and July All participants provided verbal informed consent; all interviews were audio recorded and transcribed verbatim.

Women want sex Crabtree interview lasted between 45 and minutes with an average duration of 90 minutes. The interviews elicited detailed narratives of individual experiences and perceptions. Specifically, participants were asked about their family and social life, gender identity, sexual orientation and practices, health care experiences, as well as experiences of stigma and discrimination. Data were downloaded daily from handheld devices onto a password protected study computer.

Logistic regression modelling, controlling for demographic factors, was used to estimate odds ratios. Data from paper questionnaires were hand-entered into an Access database on a password protected study computer.

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No MSM were included in this sample, therefore no comparative tests of association were conducted. Data for analysis included transcripts of audio recordings from IDIs. The first author coded the transcripts Women want sex Crabtree the software program Atlas. Memos were used throughout analysis to organise and document the analytic process. Social and demographic characteristics of the sample are listed in Table 1. Compared to MSM, trans women were younger with an average age of 28 versus 34 years.

Trans women were more likely to be Black and have a high school education or less. The two groups showed no statistically ificant difference in housing stability. Trans-identified respondents were not asked about condom use at last anal intercourse, and therefore no comparisons with MSM could be made. All respondents denied injecting drugs in the preceding 12 months. There was no difference between the two groups in frequency of non-injection use of amphetamines, crack, cocaine, downers, painkillers, hallucinogens, club drugs, heroin, or poppers.

In a multivariable logistic regression model that included race, age, gender identity and sexual orientation, transgender identity was not ificantly associated with HIV status. Demographic information for this sample can be found in Table 1. They are similar to the trans participants in the NHBS in age, race, and educational attainment.

Only one respondent reported having genital reconstruction surgery. Two-thirds of the respondents desired future gender transition. Only two participants preferred partners of a different race or ethnicity. HIV test were available for 21 of the 40 respondents, and one-third of them tested HIV-positive The average age of the trans women in the study was 39 years range 21— Two-thirds identified as Black or African-American, the remainder identified as white.

Most of the Black participants had exclusively male sexual partners, and most of the white participants had exclusively female sexual partners. Half had no more than a high school education. Twenty-six of the thirty trans women had a regular source for medical care. Two-thirds of them had been tested for HIV in the year. Of the five trans women who reported having HIV, all of them were Black and had been diagnosed for greater than 10 years.

Relationship challenges were a recurrent theme and were linked to HIV vulnerabilities. Participants described little problem finding sexual encounters but greater difficulty finding committed partners. When they found partners who accepted their gender identity, they feared being abandoned for a cisgender partner.

Several participants with male partners described engaging in insertive sex and in condomless sex in order to keep their partner in the relationship. Some participants felt that families were more likely to reject trans children than gay children. This family rejection with concomitant loss of emotional and financial support led many trans women to sex work.

Sex work was able to provide money for livelihood and as well as funds for gender affirming interventions, such as hormone therapy. Street-based sex Women want sex Crabtree, with its attendant risks of detention and incarceration, incurred additional vulnerabilities. One participant described being arrested while with a date who had picked her up in a stolen car. While incarcerated, she was raped by another prisoner and later learned that she had contracted HIV. Every participant reported using condoms with male partners.

Yet, it was unclear how consistently this happened. Trans sex workers asserted using condoms with all clients but were more vague about condom use with other partners. One person in particular expressed relief that she had been HIV-negative every time she was tested, even though she was aware of taking sexual risks.

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See Table 2 for illustrative quotes. Experiences of enacted stigma discrimination and violence were pervasive. Racial differences in narratives of discrimination were remarkable. Employment discrimination and rejection by former friends or partners were the most common themes in the narratives of white participants. Narratives of Black participants described routine public harassment from strangers as well as police; and reports of emotional and physical abuse were common.

Strategies to cope with these challenges ranged from using drugs to seeking social support. Sources of support and resilience included the trans community, accepting friends or family members, and spiritual faith. Using quantitative and qualitative data from one metropolitan area in the United States, we explored similarities and differences in data on HIV vulnerability among trans women compared to MSM. Intersectionality and Syndemic Theory provide useful frameworks to contextualise these findings and explore their implications for Women want sex Crabtree HIV among trans women in Baltimore.

Notably, in multivariable modelling that included both trans women and MSM, the strongest predictor of positive HIV status was Black race. Indeed, it is possible that the slightly higher prevalence of HIV among trans women compared to MSM in the NHBS study may have been related to the higher proportion of Black participants in the sample of trans women.

The ificant racial disparity in HIV suggests that experiences of race and racism intersect with homophobia and transphobia to compound existing disparities by risk group. In other ways, the two groups were similar. These similarities may be attributable to the use of a venue-based, time-location sampling strategy that was deed to recruit MSM. These venues may cater to individuals from the same community contexts, regardless of gender identity.

Trans women who frequent MSM-focused venues may also meet partners and share sexual networks with the men at these venues, leading to overlapping interpersonal risks and similar prevalence of STIs and HIV. Trans women from these venues were marginally more likely than MSM to report use of the free condoms they received. It is possible that trans women were more likely than MSM to use condoms overall.

Women want sex Crabtree, given ubiquitous employment discrimination against trans women Grant et al. The omission of questions about sexual practices and condom use at last sex among trans participants in the NHBS preclude a comparison between the two populations. Whereas most of the white trans women in the IDIs had female partners, all of the Black participants described male partners.

Since HIV acquisition is much more efficient from male partners, this androphilia may for some of the racial disparities seen among trans women.

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