AIDS CARE (2002), VOL. 14, NO. 1, pp. 127–134
HIV among transgendered people
G. P. KENAGY
Jane Addams College of Social Work, University of Illinois at Chicago, USA
Abstract This study explores HIV status and HIV-related risk factors among transgendered
people. A needs assessment survey developed with the help of transgendered people was used to
conduct face-to-face interviews with 81 transgendered persons, 49 male-to-females (MTFs) and 32
female-to-males (FTMs). The bullet5 ndings indicate that HIV/AIDS is a serious health concern facing
the transgender community. The majority of respondents engaged in at least one high risk sexual
activity during the past three months, were willing to have high risk sex in the future and did not
believe they were susceptible to infection. FTMs have a signibullet5 cantly lower level of AIDS knowledge
than MTFs (p, 0.01). Over half (56.7%) of FTMs have not been tested for HIV/AIDS. Efforts
to prevent the spread of HIV/AIDS among the transgender community are urgently needed.
HIV/AIDS prevention must specibullet5 cally target transgendered people, including FTMs who, despite
being at risk, have been largely ignored.
Introduction
Societal discrimination of transgendered people is not new (MacKenzie, 1994) and such
discrimination has resulted in adverse public health outcomes, including HIV/AIDS, facing
the transgendered community. ‘Transgender” has been used as an umbrella term to describe
people who do not follow traditional gender norms and may include transgenderists, drag
queens, cross-dressers, intersex persons and transsexuals (Green & Brinkin, 1994; Lombardi
et al., 1998). Transgendered people commonly use the terms male-to-female (MTF) and
female-to-male (FTM) to describe their gender identity. MTFs are people who are assigned
a male gender at birth, but identify as female. FTMs are people who are assigned a female
gender at birth, but identify as male. Available research, though limited, seems to indicate
that there is a high HIV seroprevalence rate among transgendered people and that transgen-
dered people are at high risk for HIV infection (Clements et al., 1998; Elifson et al., 1993;
Gattari et al., 1991; Kok et al., 1990; Modan et al., 1992; Pang et al., 1994).
Gattari et al. (1991) reported that among 22 transgendered prostitutes (11 transvestites
and 11 transsexuals) who were attending a drug dependency unit in Rome, 86% tested
positive for HIV. Elifson et al. (1993) found that 68% of a sample of 53 male transvestite
prostitutes in Atlanta, Georgia were HIV-1-positive. In another study, almost half (47.6%) of
25 MTFs were HIV-positive (Nemoto et al., 1999). Additionally, higher seroprevalence rates
were found among transgendered people than among non-transgendered groups, including
IV drug users (Gattari et al., 1991), female prostitutes (Modan et al., 1992) and male sex
workers (Elifson et al., 1993).
Address for correspondence: Gretchen P. Kenagy, PhD, Assistant Professor, Jane Addams College of Social Work
(MC 309), University of Illinois at Chicago, 1040 West Harrison Street, Chicago, Illinois 60607–7134, USA. Tel: 1 1
312 996 0038; Fax: 1 1 312 996 2770; E-mail: kenagy@uic.edu
ISSN 0954-0121 print/ISSN 1360-0451 online/02/010127-08 Ó Taylor & Francis Ltd
DOI: 10.1080/09540120220098008
128 G. P. KENAGY
There is evidence that HIV infection among transgendered people may be the result of
high risk sexual activity including lack or inconsistent use of protection (Clements et al.,
1998; Gattari et al., 1991; Kok et al., 1990) and high numbers of sexual partners (Clements
et al., 1998; Nemoto et al., 1999). In addition, high levels of sexually transmitted diseases
(STDs) among transgendered people have been reported (Clements et al., 1998; Elifson et
al., 1993; Kok et al., 1990).
Transgendered people’s risk for HIV/AIDS from IV drug use is also a concern; however,
the extent to which IV drug use is a factor in the transmission of HIV in the transgender
community is not clear. For example, Gattari et al. (1991) found that about 73% of their
sample (n 5 22) occasionally used IV drugs. Nemoto et al. (1999), on the other hand, found
that about one-bullet5 fth (22.2%) of 25 MTFs used IV drugs, while Elifson et al. (1993) found
that only 6% of 53 transvestite sex workers had injected drugs. Additionally, among a sample
of 392 MTFs and 123 FTMs, Clements et al. (1998) found higher levels of IV drug use
among MTFs (34%) than FTMs (18%). Gattari et al. (1991) suggest that HIV infection
might be the result of a combination of IV drug use and sexual activity. It is very likely that
alcohol and drugs are being used to decrease one’s inhibition to engage in high-risk sexual
activity (Bockting et al., 1998).
Lack of AIDS knowledge may also be a risk factor for HIV infection among transgen-
dered people. The amount of information available is limited, but research seems to suggest
that transgendered people have lower levels of AIDS knowledge than other non-transgen-
dered groups (Kok et al., 1990; Nemoto et al., 1999). Compounding the risks for HIV
infection are barriers to services. Research reports the difbullet5 culties transgendered people have
in accessing HIV services as due in part to the lack of service providers that are knowledge-
able about transgender issues (Kammerer et al., 1999).
In general, research on HIV among transgendered people focuses predominately on
MTFs. Only scarce attention has been given to FTMs and their risk for HIV/AIDS.
Therefore, information on a broader segment of the transgendered community including
FTMs is needed. In addition, there is a lack of information in the literature about the
racial/ethnic background of the study samples. This study aims to address some of the gaps
in the literature by exploring HIV status and HIV-related risk factors among both MTFs and
FTMs. Racial background of the study sample is reported. Differences between MTFs and
FTMs are explored.
Methods
Participants
The data presented in this paper are based on a needs assessment study conducted in
Philadelphia in 1997. A Philadelphia-based AIDS service agency was given funding to study
transgendered people. The agency, in collaboration with another social service agency and a
local university, conducted a needs assessment of a community-based sample of transgender
people in the Greater Philadelphia area. Snowball sampling was used to recruit respondents.
There were 81 transgendered persons in the sample, including 49 (60.5%) MTFs and
32 (39.5%) FTMs. Table 1 presents the demographic information of the respondents.
Among the 78 respondents who answered the question on race, 53 (67.9%) were African-
American, nine (11.5%) were multiracial, seven (9.0%) were biracial and nine (11.5%) were
‘other’, which included Hispanic and White. The average age of the respondents (n 5 62) was
28.0 years (SD 5 6.3), ranging from 19 to 67 years of age. The average number of years of
schooling among respondents (n 5 75) was 11.7 (SD5 1.5).
Sexual orientation was explored by asking respondents ‘Which of the following terms
HIV AMONG TRANSGENDERED PEOPLE 129
Table 1. Sample characteristics
MFT FTM Total
Variable (n5 49) (n5 32) (n5 81)
Age (M) 29.1 26.4 28.0
Race (%)
African-American 72.9 60.0 67.9
Multiracial 10.4 13.3 11.5
Biracial 6.3 13.3 9.0
Other (including Hispanic and white) 10.5 13.4 11.5
Highest grade attended (M) 11.4 12.1 11.7
Sexual orientation (%)
Homosexual 34.7 84.4 54.3
Heterosexual 36.7 12.5 27.2
Bisexual 16.3 3.1 11.7
Other (including asexual and don’t know) 12.2 0.0 7.4
best describes your sexual orientation right now?’ Forty-four (54.3%) of them were homosex-
ual; 22 (27.2%) heterosexual; nine (11.1%) bisexual; and six (7.4%) were ‘other’, which
included asexual and don’t know. More variability in sexual orientation was found among
MTFs than FTMs (see Table 1).
Instrument
The needs assessment survey instrument was developed with the help of transgendered
people, and was piloted before interviews were conducted. The perspectives of transgendered
people were the foundation of the survey instrument. The main topics, many of the questions
and the wording of questions were derived from two focus groups and two discussion groups
with MTF and FTM transgendered people. Questions on HIV/AIDS status, attitudes and
knowledge were adopted from the National Health Interview Survey, 1992: AIDS Knowl-
edge and Attitudes Supplement (US Department of Health and Human Services, 1993). The
needs assessment covered a wide variety of health and social service needs of transgendered
people. This paper reports results relevant to HIV/AIDS.
Procedure
Data were collected through face-to-face structured interviews by eight transgendered inter-
viewers (six MTF, two FTM) trained to administer the needs assessment survey. Interviews
lasted about one hour. Respondents were administered the needs assessment survey in places
of their choosing (e.g. apartments, boarding homes, restaurants) so they would feel as safe
and comfortable as possible.
Results
HIV status
HIV status was determined by the question, ‘As far as you know are you HIV-positive?’ Of
the 48 MTFs who answered the question, nine (18.8%) were HIV-positive, 37 (77.1%) were
HIV-negative and two (4.2%) said don’t know/no answer. Among HIV-positive MTFs, bullet5 ve
(55.6%) were taking medicine to treat the virus. All FTMs (n 5 32) reported they were
HIV-negative.
130 G. P. KENAGY
HIV test
Respondents were asked, ‘(Except for blood donations since March 1985) have you had your
blood tested for the AIDS virus infection?’ About three-quarters (77.8%) of the 45 MTFs
who answered the question said they had been tested. On the contrary, more than half
(56.7%) of the 30 FTMs who answered the question had not been tested.
Respondents who said they had been tested for HIV/AIDS were then asked when they
were last tested. The question was open-ended and was coded in months. Respondents who
said they were HIV-positive or said ‘no answer’ to the question on HIV status are not
included in order to explore testing among respondents who may be at risk for HIV infection.
The average time from last test to the interview among the 22 MTFs who answered this
question was 5.5 (SD5 3.3) months, ranging from a low of 0.5 months to a high of 12
months. The average time from last test to the interview among the 12 FTMs who answered
this question was 8.2 (SD5 13.0) months, ranging from a low of 0.25 months to a high of
48 months.
High-risk sexual activity
Current risk. A series of questions about sexual activities during the past three months was
asked. Respondents were considered to be at risk for HIV infection if they engaged in one or
more of the following activities without using a condom or a dental dam during the three
months prior to the interview: vagina-penis, anal-penis, oral-penis, oral-vagina, oral-anal
or vagina-vagina sex. In addition, they were considered to be at risk if they had sex while
drunk or high or sex with someone known to be HIV-positive during the three months prior
to the interview. Almost three-quarters (71.4%) of MTFs (n 5 49) and almost all (90.6%) of
FTMs (n 5 32) had engaged in at least one high risk sexual activity during the three months
prior to the interview (p , 0.05). Among 37 HIV-negative MTFs, 70.3% were at current risk
for HIV infection. Among nine HIV-positive MTFs, 77.8% were at current risk for reinfec-
tion.
Future risk. Respondents’ future risk was determined by their reported willingness to engage
in one or more of the following high-risk sexual activities in the future: sex without a latex
barrier such as a condom or dental dam; sex with multiple partners at the same time or
non-monogamous sex; sex while drunk or high; or sex with someone who was known to be
HIV-positive. Over half (59.2%) of MTFs (n 5 49) and more than three-quarters (78.1%) of
FTMs (n 5 32) said they would engage in at least one of these high-risk sexual activities in
the future. Over half (56.8%) of HIV-negative MTFs (n 5 37) and over two-thirds (66.7%)
of HIV-positive MTFs (n 5 9) would take this risk.
Specibullet5 cally, the willingness to engage in sex without a latex barrier, such as a condom
or dental dam, in the future was signibullet5 cantly higher among FTMs than MTFs (p, 0.05).
Almost two-thirds (62.5%) of FTMs (n 5 32) said they would have unprotected sex in the
future as opposed to only about one-third (35.6%) of MTFs (n5 45).
Drug and needle use
Respondents were asked ‘Have you ever injected any drugs?’ Among respondents who
reported injecting drugs, there was a follow-up question: ‘Do you think you have ever used
a needle that wasn’t new and clean?’
The majority (84.4%) of the 77 respondents who answered the question on IV drug use
had not injected drugs. Among the 12 respondents who reported injecting drugs at some
HIV AMONG TRANSGENDERED PEOPLE 131
point during their lifetime, 83.3% were MTF. Two-thirds (66.7%) of these 12 respondents
(all MTFs) said they had used a needle that wasn’t new and clean. In addition, all of the 12
respondents who reported a history of injecting drugs had engaged in at least one high-risk
sexual activity during the three months prior to being interviewed.
Respondents were also asked whether or not the needles used for hormones, silicone and
electrolysis were clean. Since none of the FTMs reported having hormone or silicone
injections or undergoing electrolysis, the data apply to MTFs only. Most (90.0%) of the 40
respondents who answered the question on hormones thought the needles used for hormone
injections were clean. Also, most (93.3%) of the 15 respondents who answered the question
on silicone thought the needles used for silicone injections were clean. More than two-thirds
(78.6%) of the 14 respondents who answered the question on electrolysis thought the needles
used for electrolysis were clean.
Sexually transmitted disease (STD)
Respondents were asked, ‘Have you ever been tested for a sexually transmitted disease
(STD), except HIV/AIDS?’ The majority (83.7%) of MTFs (n 5 49) and about one-third
(34.4%) of FTMs (n 5 32) had been tested for an STD other than HIV.
Respondents who said they had been tested for an STD were then asked when they were
last tested. The average time among the 30 MTFs who answered the question was 11.4
(SD5 21.8) months prior to the interview. The average time among the 11 FTMs who
answered the question was 8.4 (SD5 6.0) months prior to the interview.
History of an STD was determined by the question, ‘As far as you know, have you ever
had an STD?’ A large percentage (40.8%) of MTFs (n 5 49) said they had been diagnosed
with an STD as opposed to only 6.3% of FTMs (n 5 32).
Perceived AIDS knowledge
Respondents were asked, ‘How much would you say you know about AIDS—a lot, some, a
little, or nothing?’ Of the 79 who answered, 54.4% said a lot, 29.1% said some, 15.2% said
a little and 1.3% said nothing. FTMs felt they had a lower level of AIDS knowledge,
compared to MTFs. Almost three-quarters (74.5%) of MTFs (n 5 47) as opposed to only
one-quarter (25.0%) of FTMs (n 5 32) felt they knew a lot about AIDS.
AIDS knowledge
Respondents were read 11 statements about AIDS from the National Health Interview
Survey, 1992: AIDS Knowledge and Attitudes Supplement (see Table 2 for the list of
statements). After each statement, respondents were asked to indicate whether the statement
was true, false or that they didn’t know if the statement was true or false. Respondents’ AIDS
knowledge score was based on the number of correctly answered questions.
A signibullet5 cant difference (p , 0.01) in AIDS knowledge score was found between MTFs
(M5 8.8, SD5 1.7) and FTMs (M5 7.4, SD5 3.1). Overall, a higher percentage of MTFs
than FTMs answered each of the 11 questions correctly. In particular, signibullet5 cant differences
between MTFs and FTMs were found on two questions. First, MTFs seemed to have a
better understanding of the impact AIDS can have on their body. The majority (83.7%) of
the 49 MTFs said it was true that AIDS can damage the brain as opposed to only half
(50.0%) of the 32 FTMs (p , 0.01). Second, MTFs seemed to be more informed about the
meaning of AIDS than FTMs. Almost all (98%) of the 49 MTFs said it was true that AIDS
is an infectious disease caused by a virus as opposed to three-quarters (75.0%) of the 32
FTMs (p , 0.01).
132 G. P. KENAGY
Table 2. AIDS knowledge statements
Statement
AIDS can reduce the body’s natural protection against disease.
AIDS can damage the brain.
AIDS is an infectious disease caused by a virus.
A person can be infected with the AIDS virus and not have the disease AIDS.
Any person with the AIDS virus can pass it on to someone else through sexual intercourse.
A pregnant woman who has the AIDS virus can give it to her baby.
A person who has the AIDS virus can look and feel well and healthy.
There are drugs available which can lengthen the life of a person infected with the AIDS virus.
Early treatment of the AIDS virus infection can reduce symptoms in an infected person.
There is a vaccine available to the public that protects a person from getting the AIDS virus.
There is no cure for AIDS at present.
Note. From the National Health Interview Survey, 1992: AIDS Knowledge and Attitudes Supplement.
Perceived current HIV/AIDS risk
Respondents were asked, ‘What are your chances of having the AIDS virus; would you say
high, medium, low or none?’ Most MTFs and FTMs did not believe they were at high risk
for HIV/AIDS. Of the 35 MTFs who answered the question, only 5.7% thought their
chances of having AIDS were high. The rest thought their chances were low (51.4%),
medium, (22.9%), none (14.3%) and 5.7% refused to answer the question. Of the 31 FTMs
who responded to this question, none thought their chances were high. They thought their
chances were none (71.0%), low (35.5%), medium (16.1%) and 12.9% refused to answer the
question.
Perceived future risk
Respondents were asked, ‘What are your chances of getting the AIDS virus; would you say
high, medium, low or none?’ Most MTFs and FTMs did not seem to believe they were at
risk of getting AIDS in the future. Of the 27 MTFs who answered the question, only 7.4%
thought their chances of getting AIDS were high. The rest thought their chances were low
(48.1%), medium (25.9%), none (14.8%) and 3.7% refused to answer the question. Of the
16 FTMs who answered the question, only 6.3% thought their chances of getting AIDS were
high. The rest thought their chances were none (43.8%) or low (25.0%) and 25.0% refused
to answer the question.
Discussion
Before discussing the implications of these bullet5 ndings, several limitations of this study should
be addressed. First, the non-probability sampling method employed does not allow the
results of this study to be generalized beyond the study sample. Second, it should be noted
that this study asked about IV drug use and did not ask specibullet5 cally about injecting illicit
drugs. Therefore, the type of drug use (i.e. illicit or other) is unclear. Third, this study reports
whether or not respondents have been tested for an STD, average length of time since last
STD test, and incidence of an STD among the study sample, but information regarding the
specibullet5 c types of STD was not available. Future studies can provide respondents with a list
of STDs and ask them to check-off those for which they tested positive, as a means to
understanding the relationship between STDs and HIV infection.
HIV AMONG TRANSGENDERED PEOPLE 133
Despite these limitations, bullet5 ndings from this study indicate that HIV/AIDS is a serious
health concern facing the transgender community. Both MTFs and FTMs are at risk for HIV
infection. MTFs were found to be at risk from high-risk sexual activities and a willingness to
engage in high-risk sexual activities in the future. Although MTFs were at risk for HIV
infection, the majority did not believe their chances of having, or getting, HIV/AIDS were
high.
Although the percentage of the sample that was HIV-positive was lower than reported by
previous studies, the majority of FTMs had not been tested. In addition to lack of testing,
FTMs were found to be at tremendous risk for HIV/AIDS through a combination of
high-risk sexual activities, willingness to engage in high-risk sexual activities in the future, lack
of knowledge about HIV, and a belief that they are not susceptible to the disease. These
bullet5 ndings are alarming due to the lack of attention to HIV risk among FTMs in the literature.
These bullet5 ndings also indicate the urgent need for HIV education and prevention efforts
targeting FTMs. For an example of an FTM-specibullet5 c HIV prevention programme, see Hein
and Kirk (1999).
Although this study supports the low levels of injection drug use found by Elifson et al.
(1993), the combination of IV drug use and high-risk sexual activities, particularly among
MTFs, indicates a need for strategies which target multiple high-risk behaviours. In addition,
although use of unclean needles for hormone and silicone injections and electrolysis among
respondents who were going through some degree of medical treatment was not found to be
a major problem in this study (most respondents had not used unclean needles as reported
in the Results section), it is still a concern. For example, in an effort to maintain or modify
their appearance, transgendered people without access to proper health care may resort to
sharing needles to inject hormones and risk HIV infection in the process.
Respondents’ risk for HIV infection from high-risk sexual activities demonstrates the
need for HIV prevention education targeted specibullet5 cally towards transgendered people.
Messages should take into account the uniqueness of transgendered people’s bodies (Bockt-
ing et al., 1998). For example, there may be an increased risk of HIV transmission for MTFs
who have had vaginoplasty to construct a new vagina, due to the vagina’s fragile lining
(Modan et al., 1992).
HIV risk assessments should not only take into account the uniqueness of transgendered
people’s bodies, but also their sexual experiences. This study (as well as many previous
studies) assessed HIV risk through questions of high-risk sexual activities that are based on
standard conceptions of female and male anatomy. As such, the breadth of information that
can be reported about the sexual activities experienced by the respondents may be limited.
For example, FTMs may answer the sexual activities questions based on having male
anatomy even if they had not undergone gender-related surgery. Additionally, these questions
fail to capture sexual activities among those whose bodies are changing due to hormone use
or gender-related surgery. HIV/AIDS risk based on sexual activities commonly associated
with non-transgendered people may not be applicable to transgendered people.
HIV prevention efforts must also take into consideration the complexity of their sexual
orientation. Sexual orientation of transgendered people is not well documented in the
literature and at times seems to be confused with gender identity. The term transgender
pertains to the gender, not the sexual orientation with which a person identibullet5 es, transgen-
dered people can be gay or lesbian, heterosexual, bisexual, asexual, etc. (MacKenzie, 1994).
Although traditional categories of sexual orientation that are based on anatomy are used to
discuss the sexual orientation of transgendered people, these categories may need to be
debullet5 ned differently when applied to this group. For example, some transgendered people may
base their debullet5 nition of sexual orientation on their gender identity, while others may identify
their sexual orientation based on their anatomy.
134 G. P. KENAGY
One unexpected benebullet5 t of the study was that some FTMs reported learning about
HIV/AIDS from participating in the survey. Interviewers reported that once the interview was
complete they would go over the correct answers to the 11-item AIDS knowledge test with
respondents who did not know all of the answers. Although the needs assessment survey was
not intended to be an HIV education tool, the fact that some FTMs learned from it was a
very positive aspect of the study.
In conclusion, this study demonstrates the need for HIV prevention interventions for
transgendered people. Intervention strategies need to address the needs of both MTFs and
FTMs. Furthermore, this study points out that in order to accurately assess HIV/AIDS risks
specibullet5 c to transgendered people, it is critical to develop questions about sexual activities that
are sensitive to the complexities of transgender identity.
Acknowledgements
This study would not have been possible without the hard work and dedication of the
interviewers—thank you. Thanks also to the respondents who gave their time to complete the
survey.
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