DRAFT: Background for mini-project
I.
Transmen are individuals who have been assigned a female gender at birth but do not feel this
accurately describes their gender. Some, but not all, have identifiable intersex conditions. Many
transmen transition to become men, but not all transmen who transition identify as men. Transmen
may identify their gender as transgender, queer, genderqueer, transmale, male, or other. Transmen
may transition socially or medically (with hormones and/or surgeries) for extrinsic or intrinsic reasons,
such as to be perceived by others as the gender they identify as, or to achieve a body that better fits
their own self-image. A social transition can occur in many ways, such as by changing the pronouns one
goes by, changing one’s clothes, or changing legal identification. Social transition can be a linear or fluid
process involving re-socialization and identity development. It is influenced by one’s identity, as well as
by beliefs and valuation of identities. For example, someone identifying as genderqueer may elect to
change the gender marker on their ID to male not because they identify as male, but because they feel a
male ID would be more accurate for them than a female ID. Another person may identify strongly as
male, and not identify as part of the transmale community because such identification conflicts with his
gender. Some transmen are out about their transgender identity or past throughout and after
transition. Other transmen prefer to keep this information private, and live stealth. Any individual may
also choose to sometimes be out, and sometimes be stealth. For instance, one may be stealth at work,
but out among close friends. Being stealth may be contextual decision, a response to anticipated
stigma, or simply a matter of personal preference.
Previously one had to identify as a heterosexual man to access hormones, surgeries, or legal changes.
This is no longer the case and an increasing number of transmen are coming out as gay, bi, or queer.
Some transmen who don’t identify as gay, bi, or queer also have sex with trans or non-trans
(cisgendered) men. Few studies have examined the complexity and meaning of gender and sexual
orientation identity among transmen. Few data exist also on health measures among transmen who
have sex with men (TMSM). Not surprisingly, many TMSM have expressed difficulty finding and
accessing health services. These difficulties impact HIV testing for TMSM by creating test barriers, and
by reducing the accuracy of existing test data on TMSM. Provider insensitivity, stigma, and fear of
denied testing access are examples of barriers to testing TMSM experience. When TMSM test, the
existence of these barriers influences some to not disclose their trans status. These men may be
counted subsequently as cisgendered men or women in test site data. Other TMSM may prefer to not
disclose a trans status because they don’t identify as transgender. Systematic barriers reduce the
accuracy of TMSM HIV data because test sites do not routinely include transmen in the data they collect;
many test sites do not include a transmale gender option on intake sheets, and few test sites look at
transmen and transwomen separately. Given these barriers and problems with systematic data, a closer
look at TMSM and HIV risk is warranted.
Kevin Jefferson (Kevinaje@gmail.com; kevinaje@umich.edu) 10-12-11
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DRAFT: Background for mini-project
II.
Existing needs assessments on transmen and HIV have found low prevalence but high risk behavior
among participants. Three studies are particularly relevant to note: a 2008 rapid needs assessment of
transmen in San Francisco commissioned by the HIV Prevention Planning Council, a 2009 study of TMSM
recruited nationally by Sevelius, and a 2010 study of TMSM in New England by Reisner, Perkovich, and
Mimiaga. The Rapid Needs Assessment (Thompson, Wall, & Roebuck 2008, abc) primarily found risk
behaviors among transmen of sex with men (64%), multiple sex partners (45-75%), unprotected
receptive sex (11% anal and 34% frontal/vaginal within 12 months of the study), elevated drug use (70%
current regular alcohol use, 15% injection drug use ever), and high rates of sex work (32% since
transition). This assessment reported a 2% prevalence of HIV. Sevelius (2009) found participants had a
median of 3 cisgender male partners within the last year; that 69% reported inconsistent frontal
condom use generally; 40% reported heavy drinking within the last month; and 18% reported doing sex
work within the last year. Similarly, Reisner, Perkovich, and Mimiaga (2010) found participants had a
mean of 5.4 unknown serostatus cisgender male partners within the last year; that 44% had
unprotected receptive frontal sex within the last year; 63% had sex while drunk within the last year; and
19% reported doing sex work within the last year. HIV prevalence in Sevelius’s study was 2% whereas
no TMSM reported seropositivity in the Reisner et al study. All three assessments found TMSM often
used the internet to meet male sex partners (Reisner et al 2010; Sevelius 2009; Thompson 2008 abc);
while Sevelius suggests the internet may facilitate safer sex, Reisner et al found more TMSM had unsafe
sex during internet facilitated encounters than not.
All three assessments highlighted that a lack of appropriate language and sexual knowledge pertaining
to transmale bodies and sex acts created barriers to sexual health. For instance, many gay men
associate condoms with anal sex as safer sex, but might not necessarily think unprotected frontal
(vaginal) sex is unsafe sex. TMSM may not identify as having a “vagina,” and lacking an appropriate
term to refer to this body part may make condom negotiation difficult for some (Reisner et al 2010;
Sevelius 2009; Thompson 2008 abc). Further impacting condom negotiation, may be a perception
among TMSM that sex with non-trans MSM validates their gender; thus desire to be seen in an accurate
gender, and a lack of prior male socialization, may influence some TMSM to forgo condoms in sexual
encounters (ibid). Early transition in particular, when TMSM are navigating their new gender roles,
hormones, and changing bodies, was indicated as a time of potential heightened risk (ibid).
Given the discrepancy between risk behavior and prevalence rates found, researchers have mixed
opinions on the importance of transmale HIV prevention. Baring additional knowledge on the sexual
networks of TMSM, some question the relative HIV risk of TMSM (S. Hwang, personal communication,
April 9, 2011.) Others such as Chen, McFarland, Thompson, and Raymond (2011) believe intervening
now while risk behavior is high but HIV prevalence is low, could potentially prevent an HIV outbreak.
Because differing sexual networks might carry disparate risks among MSM (Petersen, Rothenberg, Kraft,
& Beeker, 2009), additional research into the sexual networks of TMSM could be a productive line of
inquiry. To date few studies consider the sexual networks of TMSM. Chen et al (2011) suggest that
because TMSM report a large number of other transgender sex partners -a small population- TMSM
sexual networks could carry more risk. Rowniak (2011) found TMSM and other MSM may share sexual
Kevin Jefferson (Kevinaje@gmail.com; kevinaje@umich.edu) 10-12-11
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DRAFT: Background for mini-project
networks; the TMSM in his study situated in San Francisco’s gay male community and partnered with
gay and bi men of diverse serostatus. Researchers believing TMSM HIV risk is low though ought to
support additional research on TMSM HIV incidence; we may find the prevalence is in fact higher than
that reported in the needs assessments. For instance, an analysis of visits from 2006-2009 at San
Francisco’s City Clinic reported approximately 10% of transmale and 11% of transfemale clients were
HIV positive (Stevens, Bernstein, & Philip, 2011). Likewise, a community based sample from 2009 to
2011 at STOP AIDS Project, a San Francisco HIV service organization, found that approximately 10% of
clients identifying as transmale reported HIV seropositivity (J. Hect, personal communication, July 21,
2011.) Given such variability in formal and informal data, along with the known existence of high risk
behavior, we should apply a precautionary principle when it comes to TMSM and HIV.
Future research could examine how HIV prevention needs might vary among TMSM according to race,
transition course, gender and sexual orientation identification. For example, a gay male identified
transman may value sex and perceived acceptance from non-trans gay men more than someone
embracing a queer sexuality or a transgender identity. Conversely, a transman who is in an open
primary relationship with a cisgendered female partner may feel a lack of familiarity with non-transmen
makes condom negotiation difficult for him. Racism within MSM circles may put TMSM of color at more
risk by reducing the size of an already small sexual network. Research exploring diversities of identity
and transition course could specifically explore early transition as a time of vulnerability, take a life
course perspective (as suggested by Reisner et al), examine identity development over time, and
consider the impact of community “situatedness” on HIV risk. Such research on intra-community
diversity ought not to contribute to creating a “risk hierarchy,” but should offer better understanding of
the risks, protective factors, and resiliency of TMSM in different social ecologies.
Kevin Jefferson (Kevinaje@gmail.com; kevinaje@umich.edu) 10-12-11
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DRAFT: Background for mini-project
III.
Our prior needs assessments highlight multiple partners, unprotected receptive sex, drug use, and sex
work as high risk behaviors among TMSM. Nonetheless we don’t know much about why transmen are
doing these behaviors, or if the behaviors are uniform across groups of transmen. Some may feel that
the risk behavior of TMSM mirrors that of other MSM, and has few distinct elements of its own.
Mention of gender affirmation in all three assessments though suggests a possible unique –or at least
unconsidered- driver of TMSM risk behavior from those of other MSM. Suggestions that early transition
is a particularly risky time especially reinforce the notion that gender affirmation need is a driver of risk.
Although gender affirmation and its relation to HIV risk receive little mention in existing literature
Melendez and Pinto (2007) have detailed a model of gender affirmation and HIV risk working with
transwomen. They suggest stigma and discrimination experienced by transwomen fuels a greater need
to feel accepted as women: in their model stigma and discrimination increases the need to feel
accepted/loved, elevating the role of a partner, which increases the risk of unsafe behavior (Melendez
and Pinto 2007). Quinn and Chaudoir (2009) may offer farther insight on how stigma and discrimination
could predicate gender affirmation need: researching the effects of stigma on health among individuals
with concealable stigmatized identities, they found that the more an individual anticipated stigma, the
more central and salient his or her identity became, and the more distress they felt.1
My proposed mini-project is to examine gender affirmation, and its relation to unsafe sex, among TMSM
using grounded theory. I seek to better understand the components of gender affirmation through
focus groups and individual interviews, so that I may examine the concept, and its relation to unsafe sex,
quantitatively in the future. It is my hope that my mini-project will contribute to our understanding of
TMSM risk, as well as to generalized knowledge on gender affirmation. I hope more effective
interventions can be informed in the future by looking at diversity among TMSM along with gender
affirmation need. Although my proposed mini-project focuses on transmen, I feel that understanding
more about gender affirmation could inform sexual health interventions for non-trans LGB populations,
and even cisgender heterosexual populations. I am particularly interested in how the scripting,
racialization, and classing of gender may create “places” or times of vulnerability, in which gender
affirmation may be more salient. For instance, the racialization of gender and stigma experiences may
operate through gender affirmation to heighten risk for racial minorities during adolescence. Perhaps
this mini project could ultimately support the development and subsequent testing of a generalized
model incorporating stigma, “places” or times of vulnerability, and gender affirmation need.
1
Anticipated stigma from Quinn and Chaudoir’s model could map onto stigma in Melendez’s model,
whereas distress in Quinn and Chaudoir’s model could map onto an increased need to feel
accepted/loved in Melendez’s model.
Kevin Jefferson (Kevinaje@gmail.com; kevinaje@umich.edu) 10-12-11
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DRAFT: Background for mini-project
References:
Chen, S., McFarland, W., Thompson, H., and Raymond, H. (2011). Transmen in San Francisco: What do
we know from HIV test site data? AIDS and Behavior. 15(3):659-62.
http://www.ncbi.nlm.nih.gov/pubmed/21153048
Hect, J. (2011, July 21). In person communication.
Hwang, S. (2011, April 9). In person communication.
Melendez, R., Pinto, R. (2007). ‘It’s Really a Hard Life’: Love, Gender and HIV Risk among Male-toFemale Transgender Persons. Culture, Health and Sexuality. 9(3): 233-245.
Petersen, J. L., Rothenberg, R., Kraft, J.M., Beeker, C. (2009). Perceived condom norms and HIV risks
among social and sexual networks of young African American men who have sex with men. Health
Education Research. 24 (1): 119-127
Quinn, D., Chaudoir, S. (2009). Living With a Concealable Stigmatized Identity: The Impact of
Anticipated Stigma, Centrality, Salience, and Cultural Stigma on Psychological Distress and Health.
Journal of Personality and Social Psychology. 97(4): 634-651.
Reisner, SL., Perkovich, B., Mimiaga, MJ. (2010). A mixed methods study of the sexual health needs of
New England transmen who have sex with nontransgender men. AIDS Patient Care STDS. 24(8):501-13.
http://www.ncbi.nlm.nih.gov/pubmed/20666586
Rowniak, S. (2011). Transmen: The HIV Risk of Gay Identity. Manuscript pending publication in AIDS
Education and Prevention. 23(6).
Sevelius, Jae. (2009). "There's no pamphlet for the kind of sex I have": HIV-related risk factors and
protective behaviors among transgender men who have sex with nontransgender men. J Assoc Nurses
AIDS Care. 20(5):398-410. http://www.ncbi.nlm.nih.gov/pubmed/19732698
Stevens, S., Bernstein, K., Philip, S. (2011). Male to Female and Female to Male Transgender Persons
have Different Sexual Risk Behaviors Yet Similar Rates of STDs and HIV. AIDS Behavior. 15: 683-686.
Thompson, H., Wall, S., Roebuck, C. (2008). A Rapid Needs Assessment Transgender Male
Risks for HIV in San Francisco 2008. Posted on San Francisco Department of Public Health
Community Programs HIV Prevention Section website:
http://www.sfhiv.org/documents/0312TransmaleRAP.pdf
Thompson, H., Wall, S., Roebuck, C. (2008). FTM Rapid HIV Risks Needs Assessment 2008.
Posted on San Francisco Department of Public Health Community Programs HIV Prevention
Section website: http://www.sfhiv.org/documents/AbbreviatedReport.pdf
Thompson, H., Wall, S., Roebuck, C. (2008). 2008 SF FTM Rapid HIV Risks Assessment
Preliminary Findings. Posted on San Francisco Department
of Public Health Community Programs HIV Prevention Section website:
http://www.sfhiv.org/documents/ExecutiveSummary.pdf
Kevin Jefferson (Kevinaje@gmail.com; kevinaje@umich.edu) 10-12-11
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