HIV research and monitoring has historically excluded transgender men, creating blind spots in understanding this group’s sexual well-being and happiness. Two recent studies—one out of New York and the other from Germany—suggest that transgender men who have sex with other men have a higher prevalence of HIV than the general population. The German analysis further finds that transgender men who have sex with other men face a host of inequities compared to cisgender gay and bisexual men, including reduced access to sexual healthcare and less satisfying sex lives.
Max Appenroth from the Robert Koch Institute and colleagues used data from the European Men Who Have Sex with Men Survey (EMIS) to compare the sexual health, mental health, and socioeconomic factors of 122 trans men in Germany who have sex with other men (trans MSM) to more than 22,000 cisgender gay and bisexual men. The trans men who participated were generally younger, with a median age of about 29 years, while the cisgender group had a median age of 39. (Cisgender or cis refers to a person whose gender identity matches their sex at birth).
Almost three quarters of trans MSM reported their income was insufficient for them to live comfortably, compared to about half of cis MSM. The researchers note that the income disparity could be due to the trans MSM participants being younger on average, but they also suggest discrimination could play a role.
In terms of mental health, survey scores indicated both groups experienced various degrees of depression and anxiety from mild to severe. However, trans MSM were almost four times as likely to suffer from severe anxiety and depression compared to cis MSM (15% vs 5%). Furthermore, trans MSM indicated far more suicidal ideation than their cisgender counterparts (41% versus 16%).
The survey results also pointed to gaps in sexual satisfaction, with more trans MSM being unhappy with their sex life than cis MSM (34% versus 22%). Trans men more often disagreed that sex was as safe as they wanted (18% versus 11%) and indicated less ability to say no to unwanted sex (23% to 12%). Trans MSM reported fewer sexual partners than cis MSM, and the study authors propose that difficulties in finding partners due to stigma may contribute to less happiness in their sex lives.
On the whole, trans MSM also had poorer access to healthcare compared to cis MSM. Fewer had ever received either an HIV test (41% versus 24%) or an STI test (55% versus 45%). Drawing on other research, the authors suggest that one reason for this may be discrimination in healthcare settings, which may cause trans men to avoid seeking sexual health services. The authors go on to say that stereotypes, such as assuming trans men only have sex with cisgender women, may also interfere with providing adequate care. Finally, although trans MSM had higher rates of HIV than the general population, this was lower than amongst cis MSM (2.5% versus 10.7%).
A different study conducted in New York City by Dr Asa Radix and colleagues of the Callen-Lorde Community Health Center also found that HIV prevalence is higher in transgender men. In this retrospective analysis, the authors identified a racially diverse group of 577 transgender men who sought care at the facility between 2009 and 2010. Among this group of men (mean age 32 years), less than half (n=250) had ever had an HIV test. Out of the 250 individuals who had, 2.8% (n=7) tested positive for HIV, a significantly higher rate of HIV than the current US national prevalence of 0.41%. Of the 18 trans men who had sex exclusively with cis men and tested for HIV, two (11.1%) were positive.
Radix and colleagues state that their results underscore the need to include trans men in HIV prevention research, which has historically excluded them. Appenroth and colleagues conclude their results indicate that trans MSM could benefit from programmes integrating mental and sexual health services; The European researchers acknowledge that a small sample size limits conclusions that can be drawn from their work, but they argue it’s a much needed step to begin understanding and addressing the sexual health needs of this frequently neglected group.
Appenroth M et al. Sexual happiness and satisfaction with sexual safety among German trans men who have sex with men: results from EMIS-2017. Journal of the International AIDS Society 25: 11-18, 2022 (open access).
Radix A et al. HIV prevalence among transmasculine individuals at a New York City Community Health Centre: a cross-sectional study. Journal of the International AIDS Society 25: 5-10, 2022 (open access).