Today is World Aids Day, a time to remember those lost to HIV/Aids and to reflect on our responsibilities to those living with HIV/Aids and to educate ourselves and our communities about safer sex and harm reduction. Jess Bradley writes:
<content note: sex, sex work, drug use, medicalisation, injections, mental health, sexual assault>
Like a lot of trans healthcare issues, the research simply has not been done to solidly say how many trans people are living with HIV/Aids. This is a huge problem because without these statistics it essentially means we are invisible to service providers. Where people do want to carry out trans specific HIV/Aids work, the lack of empirical evidence means that there are less likely to be able to secure funding for their work.
It is possible to pick out a few studies which investigate the stats regarding HIV in the trans community. In a study of trans women across 15 different countries, Baral et al (2013), the global average HIV prevalence for the trans women studied was 19.1%, rising slightly to 21.6% in high income countries. In another international study, Operario et al (2008) found that the crude average HIV prevalence for trans women sex workers who had sex with men was 27.3%, compared to 14.7% for trans women in general, 15.1% in male sex workers, and 4.5% for female sex workers. Neither of those studies looked at data from the UK context. However it does suggest that UK trans women, especially those who engage in sex work, are likely to be at greater HIV risk than our cisgender peers. I have yet to find any specific prevalence data specifically looking at trans men or non-binary people, which is concerning.
Before my involvement in Action for Trans* Health, I used to work for Students for Sensible Drug Policy UK and Youth Organisations for Drug Action Europe. Primarily my interest in drug policy and harm reduction came from the higher incidence of drug use and drug harms within the LGBT community. Statistics for drug use in the trans community are scarce, particularly UK specific statistics. But for people such as myself who were working on LGBT drug use, the prevalence of drug use within the trans community, in particular types of drug use which are associated with more harms, was a red flag. Its worth noting here also that self-medicating trans people are also at risk of related harms with semi-legal supplies, access to needles, and inconsistent knowledge about safe injection practices.
There is very little data about HIV prevalence for trans men. However in a US study, Kenagy and Hsieh (2010) found that whilst trans people in general had much higher likelihood of engaging in risky sexual practices then their cisgender peers, the trans men in their study exhibited riskier sexual health practices than the trans women studied.
The trans community has higher risk factors for HIV. This is due to the higher rates of sex work, IV drug use within the trans community, and riskier sexual practices. Stated simply, this seems to locate the risk factors within the trans community itself. However, I think it is important to look at structural factors in place which are so often missing from the analysis when talking about these issues.
Trans people face significant discrimination in the workplace and as such are an under-employed population. At the same time we face significant objectification and fetishisation by cis people. Trans people’s higher engagement in sex work can be explained by the interaction between those two factors. As a former sex worker, I know its reductive to deny trans peoples agency in the face of structural issues in a way which argues that trans sex workers are forced into that line of work. Yet these structural factors are not irrelevant, we can only choose from the options available to us. It is clear that the trans community needs to build strong links with those fighting for sex workers rights, and that the voices of trans sex workers need to be raised up within our community. Building these links of solidarity between these communities can yield results in terms of HIV harm reduction. As Shannon et al. (2014) suggest, global decriminalisation of sex work is likely to cut 33-46% of HIV infection over the next decade, something that will certainly make an impact on the trans community.
Similarly, trans drug use and self-medication does not happen within a social vacuum. The stresses of living in a transphobic society can lead trans people to develop problematic drug habits, and the lack of trans- or even LGBT-specific drugs services can leave trans people out in the cold. The barriers to access services such as drugs counselling, mental health provision, or needle exchanges has a big structural impact on our lives. Similarly, long waiting times for transition related healthcare and inconsistent support from GPs lead many down the path of self medicating hormones and/or other substances. Whilst it is possible to responsibly manage the risks of self-medication and illegal drug use (either recreational or medicinal), the lack of official guidance and support doesnt help. Funding for trans-specific harm reduction work desperately needs to be found and put to good use, and the trans community needs to support calls for drug policies which are shown to reduce the health and social harms of drug use.
Trans people often engage in riskier sexual practices. I don’t know of anyone who has ever been taught about trans specific sexual health issues who hasn’t been at a workshop that we at Action for Trans Health have offered. Part of my role in Action for Trans Health involves talking to sexual health service providers about how to improve their services for trans people. Sometimes, I am pleasantly surprised by the doctors, nurses and administrative staff’s prior knowledge of trans issues (ie. knowing what a trans person is). Other times, its a uphill struggle simply starting a conversation. I have yet to go to a sexual health clinic where anyone working there has the knowledge of trans specific sexual health issues I would expect from those who will be working with trans patients on a regular basis. Clearly this lack of information and education is a significant contributing factor to why we engage in riskier sexual practices. Work in this area is urgent, and whilst us and other organisations are doing work in this area, it simply isnt enough to cover the work that needs to be done. You can help by doing a sexual health audit of your local service, or getting in touch with us at info[at]actionfortranshealth.org.uk to book us in for trans sexual health training (either for medical professionals or for trans people themselves).
However, I dont think that access to sexual health services is the only thing that should be considered here. Because of systemic transphobia in all areas of life, trans people often have low self esteem and low social equity. Sex and sexuality can be difficult for everyone to talk about, but particularly for trans people as sex is so gendered by society. Negotiating our sexual needs, especially discussions about safer sex, can be extremely difficult, something that many of our sexual partners may not realise. As a result, we often end up in situations where risky practices take place. Our partners need to be aware of our needs. The trans community needs to open itself up to a frank discussion of how we can negotiate for safe, consensual, and empowering sex. These discussions need to be had within a broader challenge to systemic transphobia.