- What programs, services or interventions have been shown to be effective in improving the sexual health and well-being of transgender people?
Key take-home messages
- There are a lack of high-quality interventions that demonstrate positive impacts on the health of transgender women (1).
- A small number of interventions have had a positive effect on HIV risk among transgender women and men, however many of these projects were pilot studies that used convenience sampling techniques and small sample sizes. Future interventions should continue to have multiple components that address the complexities of HIV risk for transgender men and women (2-4).
- HIV prevention efforts need to be tailored to the unique needs of the transgender community (4;5) while addressing multiple health issues (2;6).
The issue and why it’s important
Transgender is an umbrella term used to identify persons whose gender expression and identity is different from the sex they were assigned at birth (7-10). A transgender woman is one whose gender identity differs from a male sex assignment at birth; similarly, a transgender male refers to a person who does not identify with a female sex assignment at birth (7). Gender expression in transgender women and men is diverse, occurring in masculine, feminine and androgynous forms (10). Transgender individuals may wish to alter their identity and appearance by changing their name, wearing different clothing, adopting new grooming techniques and through medical intervention (9).
Because current surveillance systems traditionally collect data on gender in binary categories, it is difficult to obtain data for the transgender community (6;11;12). As a result, research with transgender communities has been limited to smaller convenience samples (12). However, estimates of HIV prevalence in transgender women and men do exist. In the United States, transgender women are 34 times more likely to be HIV-positive compared to the adult population (13). According to meta-analyses, the prevalence of HIV and risk behaviours is low in transgender men (14;15).
Transgender individuals face unique interrelated individual, interpersonal and structural issues that may be associated with increased risk of acquiring HIV (5;8;12;14-16). These factors include but are not limited to: stigma and discrimination (5;6;8;17;18), limited access to health care (8;15), marginal housing (10;19), sexually transmitted infections (8;14), substance use (8;14;16;20), mental health issues (11;14;15;21), violence (8;15;16;22;23), sex work (1;8;11;16) and low levels of familial support (6;11).
What we found
Few programs and services in the literature demonstrated a positive effect on transgender communities. These studies were primarily small-scale, HIV risk-reduction interventions that lacked control groups. All the interventions were developed and piloted in the United States and mostly targeted transgender women.
Through meta-analysis, HIV prevalence rates among transgender women in the United States has been estimated to be over 25% (14;15). Despite this fact, the U.S. Centers for Disease Control and Prevention’s (CDC) Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention does not contain any interventions specific to transgender communities.
The interventions we identified consisted mainly of group-level sessions that focused primarily on HIV risk-reduction. Preintervention focus groups and surveys with transgender women identified relevant issues as well as intervention content, such as sexual health, relationships, substance use, and empowerment. Some studies used frameworks from evidence-based interventions intended for other populations to guide the development of their project.
Small-group level sessions
LifeSkills (24) is an intervention for young transgender women. Developed at the Howard Brown Research Centre in Chicago, this small group-based intervention examined HIV-related risk behaviours among 51 transgender women aged 16-24. The LifeSkills curriculum included six peer-led sessions that covered transgender pride, communication and respect, skills building, sexual healthincluding HIV/AIDS, and partner negotiation. Participants also had the opportunity to attend individual sessions in order to develop a personalized HIV-risk reduction plan. Evaluation at baseline and at three-month follow-up found statistically significant decreases in unprotected receptive anal sex with casual partners (p<.01) and the number of male sexual partners (p<0.5).
LifeSkills for Men (LS4M)
LifeSkills for Men (LS4M) (25), adapted from the LifeSkills intervention, was pilot-tested (n=18) and evaluated with transgender men who have sex with men in Boston. LS4M is a small group-based HIV and STI prevention intervention for transgender men aged 18-29. Its design and curricular content was informed through three focus groups where transgender men who have sex with men discussed their sexual health needs and concerns. The final sessions included identity recognition and affirmation, communication and partner negotiation, and HIV/STIs. At four month follow-up, participants described their experience with LS4M as positive, suggesting that it was fun and informative. Furthermore, outcome measures suggested that the intervention could reduce risk behaviours associated with HIV and STIs, and improve mental health.
Girlfriends (26) is an intervention for transgender women that was developed at Hudson Pride Connections in New York City, a community-based organization that offers services to the lesbian, gay, bisexual and transgender community. Qualitative interviews with transgender women (n=20) guided intervention development, as did input from an Advisory Panel of transgender women. Intervention content included transgender stress, stigma, drugs and alcohol, and social support, with an overarching emphasis on empowerment. Sessions were held over the course of four weeks in four 90-120 minute blocks and were facilitated by a transgender female and the Project Director. Of the 63 women enrolled in the study, 76% (n=48) attended all four sessions. At three-month followup, participants reported having fewer sexual partners (p=.043) and fewer instances of unprotected anal sex with male partners (p=0.013).
Transgender Resources and Neighborhood Space (TRANS)
TRANS is a community intervention project that provides a “safe space” for transgender women and facilitates health education workshops throughout the year (27). Informed by focus groups and a survey, TRANS was developed with the goal of creating an environment for transgender women that was socially acceptable, supportive and inclusive (28). Located in San Francisco’s Tenderloin district, an area where transgender women live and socialize, the venue has a living room, conference rooms, shower facilities and a resource closet containing clothing and accessories (28). Workshops are facilitated by health educators in both Spanish and English and are organized into three domains: sex, relationships and health; reducing drug use and improving coping skills; and general life needs, which include topics like job searching, meditation, acculturation and legal issues (27). Preliminary data from participants (n=109) who completed 10 sessions showed that sexual risk behaviour within the past 30 days decreased, as did perceived barriers to treatment programs for substance use (27).
Transgender Sisters Informing Sisters about Topics on AIDS (T-SISTA)
In response to the lack of interventions available to transgender women, the Center for Excellence in Transgender Health at the University of California in San Francisco developed the Transitions Project to assist community-based organizations in tailoring HIV prevention interventions to transgender communities (29). One intervention the Transitions Project developed for AfricanAmerican transgender women, T-SISTA, was adapted from SISTA (Sisters Informing Sisters about Topics on AIDS), a group-level intervention shown to increase condom use among African American women (29;30). The T-SISTA resource guide provided information on how community-based organizations can adapt the program. It included a five-session curriculum that covers transgender culture, HIV and STIs, and communication skills (31). While T-SISTA was developed with support from the U.S. CDC and has been executed in various community-based organizations within the United States, we did not find any evidence in the literature that assessed T-SISTA as an effective HIV prevention intervention.
Intensive day-long seminars
South Beach AIDS Project: Educational Program
One paper described a six-hour pilot HIV prevention workshop for transgender women (n=50) at a community-based organization in Miami (32). The seminar was informed by previous interventions with transgender women (e.g. TRANS) and an intervention developed by the organization for black men who have sex with men. The workshop consisted of several presentations given by transgender advocates and health care specialists. It covered a variety of topics, from transgender history to HIV epidemiology. Evaluation was informal, based on anecdotal feedback from participants and a review of program goals by staff members. Participants found the workshop primarily positive although they identified additional topics for inclusion, such as stigma and relationship issues. After reviewing workshop objectives, which primarily involved educating transgender women and building community through networking, staff concluded that the workshop’s goals had been achieved.
All Gender Health
All Gender Health at the University of Minnesota Medical School (33) – a two-day seminar (16 hours) – is an HIV and STI prevention intervention for transgender women and men that focuses on sexual health in the context of prevention. The seminar was held in local venues familiar to members of the transgender community, such as health centres and night clubs. Topics including sexual identity, sexual health, body image and relationships were presented in a variety of formats (e.g. lectures, videos and panel discussions). Eight seminars were held over a period of five years; participants were invited to complete a pre- and post-seminar evaluation, in addition to a three-month follow-up. Of the 235 individuals that completed the pre-test, 101 completed the three-month follow-up. They reported improved attitudes towards condom use from pre-test to post-seminar (p<.001) and from pre-test to follow-up (p=0.01). In addition, 92% of participants found the seminar to be a positive experience.
HIV Prevention Case Management
HIV Prevention Case Management (34) is an intervention for highrisk transgender women living in Los Angeles County. The aim of the intervention is to reduce sociocultural factors such as sex work, homelessness and psychological distress that contribute to HIV risk behaviours. In ten 60-minute sessions, participants would assess their own personal risk, developing an individual plan to change high-risk behaviours. Of the 60 transgender women enrolled, 97% (n=58) completed follow-up evaluations. When compared to baseline, the follow-up data revealed that homelessness decreased by 21% (p<.01) as did reliance on sex work for income (41% at baseline compared to 22% at follow- up; p<.05). While some interventions had a positive effect on HIV risk among transgender women and men, many of these projects were pilot studies that used convenience sampling techniques and small sample sizes. Future interventions should continue to have multiple components that address the complexities of HIV risk for transgender men and women (2-4).
What we did
We searched Medline using a combination of [text terms transgender or (trans* adj men) or (trans* adj women) or transsexual or (trans* adj5 gender) or (trans* adj sex*) or MeSH terms (Transgender Persons or Transsexualism)] and [text terms HIV or Hepatitis C or Sexually Transmitted or sexual health or MeSH terms (Sexually Transmitted Diseases or Sexually Transmitted Infections)]. The search was conducted on January 29, 2016. Thirty four articles were included in this review. Articles were limited to those from highincome countries, published since 2005 in English. Reference lists of identified studies were also reviewed. A grey literature search using Google was also conducted using a combination of the terms above.
Factors that may impact local applicability
All studies included in this review were conducted with transgender populations in the United States. Regional differences between transgender communities in both the American and Canadian context must be considered when interpreting this review. .
- Poteat T, Wirtz AL, Radix A, Borquez A, Silva-Santisteban A, Deutsch MB et al. HIV risk and preventive interventions in transgender women sex workers. Lancet 2015 January 17;385(9964):274-86.
- Operario D, Nemoto T. HIV in transgender communities: Syndemic dynamics and a need for multicomponent interventions. Journal of Acquired Immune Deficiency Syndromes 2010;55:Suppl-3.
- Poteat T, Reisner SL, Radix A. HIV epidemics among transgender women. Current Opinion in HIV & AIDS 2014 March;9(2):168-73.
- Sevelius JM, Reznick OG, Hart SL, Schwarcz S. Informing interventions: The importance of contextual factors in the prediction of sexual risk behaviors among transgender women. AIDS Education & Prevention 2009 April;21(2):113-27.
- Kosenko KA. Contextual influences on sexual risk-taking in the transgender community. Journal of Sex Research 2011 March;48(2-3):285-96.
- Centers for Disease Control and Prevention. HIV among transgender people. http://www.cdc.gov/hiv/group/gender/ transgender/ (accessed on February 22, 2016). 2015.
- Institute of Medicine Committee on Lesbian, Gay Bisexual and Transgender Health Issues and Research Gaps and Opportunities. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press; 2011.
- amfAR. Trans populations and HIV: Time to end the neglect. http://www. amfar.org/issue-brief-trans-populationsand-hiv-time-to-end-the-neglect/ (accessed February 17, 2016). 2014.
- American Psychological Association. Answers to your questions about transgender people, gender identity, and gender expression. http://www.apa.org/ topics/lgbt/transgender.pdf (accessed February 16, 2016). 2014.
- Keatly, J and Bockting, W. What are male-to-female transgender persons’ (MtF) HIV prevention needs? http://caps. ucsf.edu/uploads/pubs/FS/pdf/revMtFFS. pdf (accessed February 18, 2016). 2008.
- Keller K. Transgender health and HIV. Bulletin of Experimental Treatment for AIDS 2009;21(4):40-50.
- American Psychology Association. Module Nine: HIV and the transgender population. https://www.apa.org/pi/aids/ programs/hope/training/hiv-transgender. pdf (accessed February 22, 2016). 2010.
- Baral SD, Poteat T, Stromdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: A systematic review and meta-analysis. Lancet Infectious Diseases 2013;13(3):214-22.
- Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health 2001;91(6):915-21.
- Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS & Behavior 2008;12(1):1-17.
- Reback CJ, Fletcher JB. HIV prevalence, substance use, and sexual risk behaviors among transgender women recruited through outreach. AIDS & Behavior 2014 July;18(7):1359-67.
- Grant, JM, Mottet, LA, Harrison, J, Herman, JL, and Keisling, M. Injustice at every turn: A report of the national transgender disrcimination survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.
- Logie CH, James L, Tharao W, Loutfy MR. “We don’t exist”: A qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. Journal of the International AIDS Society 2012;15(2):17392.
- Fletcher JB, Kisler KA, Reback CJ. Housing status and HIV risk behaviors among transgender women in Los Angeles. Archives of Sexual Behavior 2014 November;43(8):1651-61.
- Rowe C, Santos GM, McFarland W, Wilson EC. Prevalence and correlates of substance use among trans female youth ages 16-24 years in the San Francisco Bay Area. Drug & Alcohol Dependence 2015 February 1;147:160-6.
- Rotondi NK, Bauer GR, Travers R, Travers A, Scanlon K, Kaay M. Depression in male-to-female transgender Ontarians: Results from the Trans PULSE project. Canadian Journal of Community Mental Health 2016;30(2):113-33.
- Stotzer RL. Violence against transgender people: A review of United States data. Aggression and Violent Behavior 2007;14(3):170-9.
- Nuttbrock L, Bockting W, Rosenblum A, Hwahng S, Mason M, Macri M et al. Gender abuse, depressive symptoms, and HIV and other sexually transmitted infections among male-to-female transgender persons: A three-year prospective study. American Journal of Public Health 2013 February;103(2):300-7.
- Garofalo R, Johnson AK, Kuhns LM, Cotten C, Joseph H, Margolis A. LifeSkills: Evaluation of a theory-driven behavioral HIV prevention intervention for young transgender women. Journal of Urban Health 2012;89(3):419-31.
- Reisner SL, Hughto JM, Pardee DJ, Kuhns L, Garofalo R, Mimiaga MJ. LifeSkills for Men (LS4M): Pilot evaluation of a gender-affirmative HIV and STI prevention intervention for young adult transgender men who have sex with men. Journal of Urban Health 2016.
- Taylor RD, Bimbi DS, Joseph HA, Margolis AD, Parsons JT. Girlfriends: Evaluation of an HIV-risk reduction intervention for adult transgender women. AIDS Education & Prevention 2011;23(5):469-78.
- Nemoto T, Operario D, Keatley J, Nguyen H, Sugano E. Promoting health for transgender women: Transgender Resources and Neighborhood Space (TRANS) program in San Francisco. American Journal of Public Health 2005 March;95(3):382-4.
- Nemoto T, Sausa LA, Operario D, Keatley J. Need for HIV/AIDS education and intervention for MTF transgenders: responding to the challenge. Journal of Homosexuality 2006;51(1):183-202.
- Center of Excellence for Transgender Health. Transitions Project http://transhealth.ucsf.edu/trans?page=programstransitions (accessed February 15, 2016). 2016.
- DiClemente RJ, Wingood GM. A randomized controlled trial of an HIV sexual risk-reduction intervention for young African-American women. Journal of the American Medical Association 1995 October 25;274(16):1271-6.
- Gutierrez-Mock L, Thomas-Guess Y, Sevelius J, Cotten P, and Kegeles S. T-SISTA: A resource guide for adapting SISTA for transwomen of color. http:// transhealth.ucsf.edu/pdf/TSISTAResourceGuide.pdf (accessed February 16, 2016). 2016.
- De Santis JP, Martin CW, Lester A. An educational program on HIV prevention for male-to-female transgender women in south Miami beach, Florida. Journal of the Association of Nurses in AIDS Care 2010 May;21(3):265-71.
- Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/ STD risk in the transgender community. AIDS Care 2005 April;17(3):289-303.
- Reback CJ, Shoptaw S, Downing MJ. Prevention case management improves socioeconomic standing and reduces symptoms of psychological and emotional distress among transgender women. AIDS Care 2012;24(9):1136-44.
Rapid Response Service. Programs to improve the sexual health and well-being of transgender individuals. Toronto, ON: Ontario HIV Treatment Network; April, 2016.
Danielle Giliauskas and Jason Globerman