Transphobia: Impact
on HIV & Health Care
Lydia A. Sausa, Ph.D., M.S. Ed., C.S.E.
University of California, San Francisco
Department of Family and Community Medicine
Overview
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It’s 2007! Updating Our Lens and Language
HIV in the Trans Community
Different Levels of Transphobia
Impact of Transphobia on Health Care & HIV
Copyright 2007 Lydia A. Sausa
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Moving Beyond A Binary
View of Trans
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Most historical and medical literature categorized
Transgender/Transsexual people into only 2 boxes:
 Male to Female (MTF)
 Female to Male (FTM)
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Today we know that Trans includes a wide variety of different
gender identities (over 100 have been documented).¹²³
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Let’s talk about trans people in more inclusive ways than simply
re-creating another 2 box system.
Reference:
¹ Grossman & D’Augelli (2006).
² Vade (2005).
³ National Center for Transgender Equity (2005).
Kreative Korporation (2006).
Copyright 2007 Lydia A. Sausa
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Quick Question!
Have you ever had a gay man
come out to you?
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Did he say…
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A) Hi, I’m gay.
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B) Hi, I am Hetero-to-Gay. I was assigned
heterosexual at birth, though I identify as a gay
male now.
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C) I’m fabulous…need I say more!
Copyright 2007 Lydia A. Sausa
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Updating Our Language
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Let’s stop using language that forces trans people to state
what others assigned them at birth, and may no longer be
relevant to them now.
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Focus on a person’s present identity
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Cheat sheet for the “special people”:
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Male to Female (MTF) = Transwoman or woman or female
Female to Male (FTM) = Transman or man or male
Copyright 2007 Lydia A. Sausa
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True or False?
The rate of HIV reported among
transwomen is lower than that
reported among men who have sex
with men (MSM) in San Francisco.
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False!
HIV prevalence among transwomen is
higher than estimates from studies with
gay men, as well as injection drug users
of the same age in San Francisco. ¹
Reference:
¹Clements, K., Marx, R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status
of transgender persons: Implications for public health intervention. American Journal of Public Health, 91(6), 915-921.
Copyright 2007 Lydia A. Sausa
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MSM & Transwomen
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In 2005, the San Francisco Department of Public Health reported
that based on estimated population size for 2006 that about 1 in 4
MSM (24.3%) and transwomen (22.8%) are living with HIV. ¹
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Caveat: Population size for trans people is often underestimated, since
many trans people do not feel comfortable coming out
Most striking, the incidence for new infections estimated for 2006
is higher for transwomen (3.78%) vs. MSM (1.75%), and
especially for transwomen IDU (6.08%) vs. MSM IDU (2.58%). ¹
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Thus, transwomen are 2 times (2.16- 2.35) more likely to contract HIV
compared to MSM.
References:
¹ San Francisco Department of Public Health (2005).
Copyright 2007 Lydia A. Sausa
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HIV Among Trans People
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Estimated 1 in 250 people are living with HIV/AIDS in the United States, and
24-27% are undiagnosed or unaware of their HIV infection.¹²
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The trans community is disproportionately affected by HIV.
 For transwomen is estimated about 1 in 4, mostly transwomen of color.
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 African-American (35-47%) and Latina (23-28%) transwomen have the
highest prevalence in San Francisco, compared to other racial/ethnic
groups.³
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For transmen is estimated 1 in 50, mostly transMSM and transmen who
engage in sex work and/or injection drug use.
References:
¹ Centers for Disease Control and Prevention (CDC) (2006).
² Glynn & Rhodes (2005).
³ San Francisco Department of Public Health (2005).
Bemis, Simon, Reback, & Gatson (2000).
Clements, Marx, Guzman & Katz (2001).
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Nemoto, Operario, Keatley, Han, & Soma (2004).
Xavier (2005).
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Transphobia
A discomfort with or fear of trans
people, or an inability to accept a
person’s gender identity and/or
gender expression
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Transphobia on Many Levels
Self - internalized transphobia, low-self-esteem and self efficacy.
For example: “I can’t leave an unhealthy
relationship/employment because I won’t find
someone/something else since I am trans.”
Interpersonal Level - specific acts of discrimination, bias, lack
of acceptance. For example: A family member telling you to
hide who you are or that you are confused; A person being
hostile toward you about using the bathroom, dressing
room, or other gender segregated space; A health care
provider refusing you service.
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Transphobia on Many Levels
Community/Societal Level – norms, resources, access to
services or events. For example: Deaths of Tyra Hunter in
DC and Robert Eads in Georgia due to lack of health care
access; Michigan Women’s Music Festival not allowing
transwomen to attend; Stating that trans people are all MTF
or FTM.
Systemic/Institutional Level - legal, policy, religion. For
example: Shelters not allowing trans people; The “transpanic defense” as a legal defense to killing a trans person as
was allowed in the Gwen Araujo Murder Trial.
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Impact of Transphobia on Health
Care & HIV
Impact on the Patient/Client:
 Lower self-efficacy and self esteem¹
 Higher rates of depression, sucidality, self-mutilation²³
 Lower adherence to HIV medication
 Higher rates of violence, drug use, HIV risk
behaviors² 6
 Avoiding care for preventive and urgent/life-threatening
References: conditions
¹ Clements, Wilkinson, Kitano & Marx (2001).
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² Sugano, Nemoto, & Operario (2005)
³ Newfield, Hart, Dibble, & Kohler (2006).
Clements, Marx, Guzman & Katz (2001).
Melendez, Exner, Ehrhardt, Dodge, Remien, Rotheram-Borus, Lightfoot, Hong, et al. (2005).
6 Sausa (2006).
Nemoto, Operario, Keatley, Han, & Soma (2004).
Shaffer (2005).
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Impact of Transphobia on Health
Care & HIV
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Impact on the Provider:
 Lack of knowledge, comfort, and skills to provide care
to trans people¹²³
 Disregarding health policies and laws that regulate
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health care access and service can lead to job loss
 Poor provider service can lead to negative reputation
of the clinic/organization and may jeopardize
funding
References:
¹ Nemoto, Sausa, Operario, & Keatley (2006).
² Clements, Wilkinson, Kitano & Marx (2001).
³ Grossman & D’Augelli (2006).
Shaffer (2005).
Mottet & Ohle (2003).
6 National Center for Transgender Equity (2005).
Hussey (2006).
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Impact of Transphobia on Health
Care & HIV
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Impact on the Health Care System:
 Higher rates of HIV transmission and AIDS
cases
 Higher rates of morbidity and mortality
 Additional financial burden on the system
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References
Bemis, C. C., Simon, P. A., Reback, C. J., & Gatson, B. (2000). Relationship between selfassessed HIV risk, self-reported risk behavior, and HIV seroprevalence in a male-to-female transgender
population. Los Angeles, CA: Health Research Association, Health Assessment and
Epidemiology, & Van Ness Recovery House.
Centers for Disease Control and Prevention (2006). HIV/AIDS Surveillance Report, 2005.
Vol. 17. Atlanta: US Department of Health and Human Services, CDC; 2006:1–46.
Clements, K., Marx, R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk behaviors,
health care use, and mental health status of transgender persons: Implications for public
health intervention. American Journal of Public Health, 91(6), 915-921.
Clements, K., Wilkinson, W., Kitano, K., & Marx, R. (2001). HIV prevention and health
service needs of the transgender community in San Francisco. In W. Bockting & S. Kirk
(Eds.), Transgender and HIV: Risks, prevention, and care (pp. 69-89). New York, NY: Haworth
Press.
Glynn, M. & Rhodes, P. (2005). Estimated HIV prevalence in the United States at the end
of 2003. National HIV Prevention Conference; June 2005; Atlanta. Abstract 595.
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References
Grossman, A. H. & D’Augelli, A. R. (2006). Transgender youth: Invisible and
vulnerable. Journal of Homosexuality, 51(1), 111-128.
Hussey, W. (2006). Slivers of the journey: The use of photovoice and storytelling to
examine female to male transsexuals’ experience of health care access. Journal of
Homosexuality, 51(1), 129-158.
Kreative Korporation (2006). Accessed June 1, 2007
http://www.kreativekorp.com/miscpages/gender/gender.pl
Melendez, R. M., Exner, T. A., Ehrhardt, A. A., Dodge, B., Remien, R. H., RotheramBorus, M., Lightfoot, M., Hong, D., and National Institute of Mental Health Healthy
Living Project Team (2005). Health and health care among male-to-female transgender
persons who are HIV positive. American Journal Public Health, 95(10), 5-7.
National Center for Transgender Equity (2005). California transgender bills signed. Retrieved
October 11, 2005, from http://www.nctequality.org/CaliforniaSept2005.pdf
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References
Nemoto, T., Operario, D., Keatley, J., Han, L., & Soma, T. (2004). HIV risk behaviors
among male-to-female transgender persons of color in San Francisco. American Journal of
Public Health, 94(7), 1193-1199.
Nemoto, T., Sausa, L.A, Operario, D., & Keatley, J. (2006). Need for HIV/AIDS
education and intervention for MTF Transgenders: Responding to the challenge. Journal
of Homosexuality, 51(1), 183-202.
Newfield, E., Hart, S., Dibble, S., & Kohler, L. (2006). Female-to-male transgender
quality of Life. Quality of Life Research, [Epublished ahead of print] PMID: 16758113.
Mottet, L. & Ohle, J. M. (2003). Transitioning our shelters: A guide to making homeless shelters
safe for transgender people. New York: The National Coalition for the Homeless and the
National Gay and Lesbian Task Force Policy Institute.
San Francisco Department of Public Health (2005). HIV/AIDS epidemiological annual
report. San Francisco, CA. Accessed June 1, 2007.
http://www.sfdph.org/PHP/RptsHIVAIDS/HIVAIDAnnlRpt2005.pdf
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References
Sausa, L. A. (2006). Translating research into practice: Trans youth recommendations for
improving school systems. Journal of Gay and Lesbian Issues in Education, 3(1), 15-28.
Shaffer, N. (2005). Transgender patients: Implications for emergency department policy
and practice. Journal of Emergency Nursing, 31, 405-7.
Sugano, E., Nemoto, T., & Operario, D. (2006). The impact of exposure to transphobia
on HIV risk behavior in a sample of transgendered women of color in San Francisco.
AIDS Behavior, 38(3), 230-236.
Vade, D. (2005). Expanding gender and expanding the law: Toward a social and legal
conceptualization of gender that is more inclusive of transgender people. Michigan Journal
of Gender and Law, 11, 253-316.
Xavier, J., Bobbin, M., Singer, T. B. & Budd, E. (2005). A needs assessment of
transgendered people of color living in Washington, DC. International Journal of
Transgenderism, 8(2/3), 31-47.
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Contact Information
Lydia A. Sausa, Ph.D., M.S. Ed., C.S.E.
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Web site: www.lydiasausa.com
Phone: 415-554-0130
E-mail: lydiasausa@hotmail.com
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