Substance Use & Misuse, 49:1049–1053, 2014 C 2014 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2013.855787
ORIGINAL ARTICLE
The Interaction of Drug Use, Sex Work, and HIV Among Transgender Women Beth R. Hoffman
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Public Health, California State University, Los Angeles, USA however, rates of testing are higher for those who engage in risky sexual behavior, which means testing rates for transgender women are likely higher than for transgender men (Xavier et al., 2005). Rates of drug use are much higher for transgender women than for the general population. Studies indicate lifetime alcohol use as high as 88%, marijuana use at 63%, and 30% for cocaine use (Wilson et al., 2009). These rates contrast starkly against general population lifetime alcohol use of alcohol of 69.7% by adults 21 to 25, and marijuana use of 19% and cocaine use of 1.4% for adults 18 to 25 (SAMHSA, 2012). These alarmingly high rates of HIV prevalence and drug use should be a clarion call for research into the factors driving these negative health outcomes. Such factors include the relationship between known predictors of HIV incidence such as sex work and drug use, as well as the interaction of interpersonal variables with these predictors. Further, programs are needed that address sex work and drug use in order to reduce HIV rates.
Transgender women have a higher prevalence of drug use, HIV, drug use, and sex work than the general population. This article explores the interaction of these variables and discusses how sex work and drug use behaviors contribute to the high rates of HIV. A model predicting HIV rates with sex work and drug use as well as these behaviors in the transgender woman’s social network is presented. Challenges to intervening with transgender women, as well as suggestions and criteria for successful interventions, are discussed. Keywords substance use, drug use, HIV, sex work, prostitution, transgender
INTRODUCTION
Transgender is a term describing a diverse group of people who cross the boundaries of gender defined by culture (Bockting, Robinson & Rosser, 1998). Transgender women are people who were born male but identify as female for at least part of the time. Methods of female presentation vary, from makeup, clothing, jewelry, and wigs to use of feminizing hormones and surgeries such as breast implantation, genital reconstruction, and feminizing facial surgeries to alter jawlines, cheeks, brows, and hairlines. The prevalence of HIV is higher among transgender women than among the general population (ClementsKnolle, Marx, Guzman & Katz, 2001; Edwards, Fisher & Reynolds, 2007), with prevalence rates as high as 19%–32% self-reported in some samples (Wilsonet al., 2009; Xavier, Bobbin, Singer & Budd, 2005). A metaanalysis of HIV rates among transgender women in the United States indicates an HIV prevalence rate of 27.7%, with a rate of HIV prevalence for transgender males of 0%–3% (Herbst et al., 2008). This rate is higher than the rate of HIV infection among MSM (9.1% Xu, Sternberg & Markowitz, 2010), a group considered to be most severely affected by HIV in the United States. As many as one in five transgender people do not know their HIV status;
Drug Use and HIV
Drug use increases the likelihood of HIV in several ways: the sharing of needles when drugs are injected as well as lowered inhibitions, which leads to more unsafe sexual behavior (such as sex with multiple partners and less condom use). As many as half of transgender women participate in sex while under the influence of drugs or alcohol (Xavier et al., 2005). Intoxication with drugs or alcohol is associated with more receptive anal sex and unprotected anal sex, whether that sex is with a primary partner (Operario, Nemoto & Iwamoto, 2011) or a casual partner, and for receptive (but not necessarily unprotected) anal sex with commercial partners (Nemoto, Operario, Keatley & Soma, 2004A). While it may seem less risky to engage in unprotected sex with a primary partner, almost half of transgender women with primary partners were engaging in sex with other sex partners, as were their partners (Nemoto et al., 2004A). Further, 32%
Address correspondence to: Dr Beth Hoffman, Public Health, California State University Los Angeles, 5151 State University Drive, Los Angeles, 90032 USA. E-mail: [email protected]
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of participants in one study were involved in an HIVdiscordant relationship (i.e., one partner was HIV positive and one was negative), which means that unprotected sex is particularly risky (Operario et al., 2011).
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Mental Health
Transgender women experience mental illness at rates higher than the general population. Over half of transgender women report depression during their lifetimes (Budge, Adelson & Howard, 2013; Nuttbrock et al., 2010) compared with a lifetime depression rate of less than 20% for the general population (Gonzalez, Tarraf, Whitfield & Vega, 2010). Approximately 40% of transgender women reported anxiety, according to Budge and colleagues (2013). Body image dissatisfaction and eating disorders occur at higher rates than among nontransgender females (Vocks, Stahn, Loenser & Legenbauer, 2009). Qualitative research with transgender women reveal that some transgender women engaged in substance use to cope with mental health problems and stress (BithMelender et al., 2010; Nemoto, Operario, Keatley & Villegas, 2004B), which in turn can exacerbate the mental health problems. There are high rates of attempted suicide among LGBT populations in general and transgender groups in particular (especially among victims of physical violence; Testa et al., 2012), and studies indicate an association between a history of problematic substance use (as indicated by participation in substance user treatment) and attempted suicide (Clements-Nolle, Marx & Katz, 2006). Kammerer and colleagues (1999) attribute the high rates of mental illness to the social stigma transgender women face from an early age. Recent studies are finding a lack of support for the self-medication theory in general populations (Lembke, 2012). It remains to be seen whether this theory holds for transgender populations or if another theory is more valid in explaining the associations of drug use and mental illness in this group. Sexual Violence and Sex Work
Transgender women are prone to high rates of sexual violence: as many as 59% of transgender participants in one study reported being victims of sexual assault (ClementsNolle et al., 2006). A history of sexual assault is associated with drug and alcohol use among transgender women (Testa et al., 2012). The relationship between general violence and drug/alcohol use was not significant in this study, indicating that there is something specific to sexual assault that is particularly traumatic for its victims. Sex work is common among transgender women. Transgender women engage in sex work to earn a living in the face of workplace discrimination, to pay for expensive feminization procedures, or to validate their value as a sexually desirable female (Bith-Melender et al., 2010; Clements, Wilkinson, Kitano & Marx, 1999; Nemoto et al., 2004B; Thukral & Ditmore, 2003). Given high rates of unemployment and low earning levels for many transgender women, sex work is often an economic necessity (Badget, Lau, Sears & Ho, 2007). Rate of engagement in sex work has been measured to be as high as 67% in a sample of young transgender women aged 15
to 24. Thirty five percent of this sample had engaged in sex work in the past month (Wilson et al., 2009). Researchers and transgender women agree that there is a clear relationship between drug use and sex work (Bith-Melender et al., 2010; Clements et al., 1999; Nemoto et al., 2004B; Operario & Nemoto, 2005; Wilson et al., 2009). This is true across ethnicities; for example, Asian/Pacific Islander transgender women were more likely to have engaged in sex while under the influence of alcohol or drugs, and to have used drugs at all, if they had engaged in sex work in the past month (Operario & Nemoto, 2005). Some transgender women sex workers use drugs to escape the trauma of prostitution; others become involved in sex work to pay for their drug use (BithMelender et al., 2010; Sausa, Keatley & Operario, 2007). Some use drugs with clients who will pay the women (or pay them more than they would otherwise) to use drugs with them (Bith-Melender et al., 2010; Sausa et al., 2007). Some use drugs because of perceived pressure from other transgender women further along in the transitioning process (Nemoto et al., 2004B). Drug use during sex work puts transgender women at greater risk for STIs and HIV, as intoxication lowers their ability to negotiate condom use (Sausa et al., 2007). Unlike injection drug users in the general population, transgender women may be injecting drugs both for intoxication (Clements-Nolle et al., 2001) and to achieve feminization via injection of nonmedically obtained hormones or silicone (Garofalo, Deleon, Osmer, Doll & Harper, 2006). Hormones are available in pill form, but many transgender women feel the efficacy of injected hormones is greater (Nemoto, Luke, Mamo, Ching & Patria, 1999). Nonhormonal drug injection is associated with HIVpositive status among transgender women (ClementsNolle et al., 2001). High-risk injection drug use behaviors included needle sharing and backloading, a process by which drugs are squirted from one hypodermic needle to another (Clements-Nolle et al., 2001; Nemoto et al., 1999). Hormone injection needles are longer than needles for injecting psychoactive drugs and are not available at needle exchange locations, which increases the likelihood that needles will be shared (Nemoto et al., 1999). Sex workers using hormones may be less likely to use condoms. Feminizing hormones often affect the ability to get and maintain erections; condoms intensify this effect. Transgender sex workers who use their penises to engage in sex work may avoid condoms in order to enhance sexual performance (Bockting et al., 1998), thus greatly increasing risk of HIV and STD transmission. Networks of Support
Friends are often primary sources of support for transgender women. Often a transgender woman loses the support of her family of origin as she transitions (Gagne & Tewksbury, 1996). As a result, friendships become important sources of information and support; these networks of friends are often very cohesive (Barrington, Wejnert, Guardad, Nieto & Bailey, 2012). Unfortunately, these friendship networks often provide models of sex work and drug use behaviors; transgender women new to the
DRUG USE, SEX WORK, HIV IN TRANSGENDER WOMEN
network often feel pressured to start using drugs and engaging in prostitution in order to become a part of the group (Sausa et al., 2007).
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Model of Factors Predicting HIV in Transgender Women
Figure 1 presents a model of factors leading to HIVpositive status in transgender women. Risky sexual behavior and drug use are direct predictors of HIV. Risky sexual behavior is measured by the composite of number of sexual partners, participation in sex work (physical interaction with people in exchange for money, drugs, food, or shelter), and not using condoms. Both noninjection drug use and injection drug use (including hormones and silicone) are included in the drug use construct. Noninjection drug use includes regular use of any substance, whether illicit or not, as any substance use may result in lowered negotiations for condom use and lowered inhibitions when choosing partners. However, it is expected that injection drug use will provide increased risk of HIV infection as well, whether due to high-risk sexual behavior or to infection due to needle sharing. Secondary factors consist of friendship-related factors. The percentage of a transgender woman’s network, which is transgender, is predicted to influence participating in sex work as well as the percentages of friends that are sex workers and drug users, given the high rates of sex work and drug use among transgender women. Percentage of friends, who are sex workers, is predicted to affect sex work, and the percentage of friends who are drug users will predict drug use. Based on past research, several factors are predicted to serve as moderators to the model. Since transgender women often engage in sex work due to a lack of financial opportunities and sex work is associated with increased drug use, socioeconomic status should affect the model, with lower SES resulting in stronger predictive values. Race ethnicity is likely a moderate as well, given the high prevalence of HIV in African American and Latina transgender females as compared to white transgender
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females (Clements-Nolle et al., 2001; Nuttbrock et al., 2009). Racial/ethnic differences are likely interacting with several aspects of the model, as differences are seen across a variety of variables, including numbers of both sex work and recreational sex partners, lifetime employment, and injection of female hormones (Nuttbrock et al., 2009). Substance Use Treatment for Transgender Women
Transgender women require and are requesting more transgender-specific support systems, including substance abuse treatment (Bith-Melender et al., 2010; Clements et al., 1999). While services may be designated for “LGBT” populations, some service providers worry that a transgender person, who identifies as such based on her gender identity, may not feel that her needs are met at a facility where programs are geared more to populations identifying by sexual orientation (Travers et al., 2010). Services at such a facility may not be geared toward her needs, or she may feel discriminated against by lesbian, gay, and bisexual clients or service providers (Clements et al., 1999; Kammerer et al., 1999). Transgender women who inject hormones and silicon may not consider themselves to be drug users (Bockting et al., 1998; Kammerrer et al., 1999) and therefore may be missed by programs targeting transgender substance users. A program that wishes to serve transgender clients must overcome several barriers in order to treat this population. The first barrier will be funding a program in a difficult financial climate. Given the high rates of HIV among transgender women, programs that seek to address substance use and/or sex work in this community should qualify for HIV-related funding, given the links between HIV, drug use, and sex work. Programs that already deal with substance use or sex work rehabilitation may wish to expand their client base by providing services related to transgender women. Recruitment of clients will require different strategies than those used to engage nontransgender clients due to the alienation many transgender women feel from these groups. Connections with agencies already serving transgender populations will provide a pipeline
FIGURE 1. Model of factors predicting HIV in transgender women.
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both for new clients and for resources needed to aid clients in transitioning to sober lives in legal jobs. Prisons and the court systems are also good sources of clients, as some jurisdictions allow those convicted of drug-based offenses to complete substance use rehabilitation instead of jail time. Programs may need to meet requirements of the justice system in order to interact in this capacity. A restructuring of preexisting programs, including physical facility features, may be warranted. Transgender women are getting more attention in the media but many people do not know how to address a transgender person, let alone interact with one in close quarters where people are expected to cooperate and share details of their lives. Clients as well as staff will need sensitivity training to learn about transgenderism and how to interact respectfully with transgender clients. Facilities may need to be reconfigured to provide transgender-only residence areas or to alter restrooms, either to increase the number of women’s facilities or to transform all restrooms into unisex facilities. Oggins and Eichenbaum (2002) describe five components of a successful substance use treatment program for transgender women in a facility for both transgender and nontransgender patients. These components consist of transgender staff, acceptance of transgender clients, sensitivity training for staff and clients, developing a social support network among clients, and developing community ties (Oggins & Eichenbaum, 2002). While their findings reflect only a small number of transgender women, the successful completion rates of transgender women in this program are encouraging and suggest that the methods may indeed be effective. Many transgender women are living on the fringes of society, as evidenced by their high rates of sex work, substance use, and HIV prevalence. The relationships between these health issues is complex and a substance use treatment program that does not address the centrality of sex work to the lives of many clients will not be successful. It remains to be seen whether programs aimed at providing former prostitutes with more socially accepted jobs will be effective in reducing rates of substance abuse and HIV, though existing information suggests that such programs would be efficacious. Clearly there is a health crisis in this community, and funding for substance use and prostitution rehabilitation programs could be justified as HIV-reduction programs. Resources for transgender women are limited, even in areas with relatively high transgender populations. The issues of sex work, drug use, and HIV status are inextricably linked (Clements et al., 1999); it is possible that reducing sex work by providing job training and resources to adapt to living in a “mainstream” world would reduce the prevalences of both substance use and HIV in the community of transgender women. Conversely, substance user rehabilitation problems that address problems related to sex work and provide services for obtaining legal work upon release would address both issues and could result in less sex work, substance use, and ultimately HIV, given enabling necessary conditions.
Declaration of Interest
The author reports no conflict of interest. The author alone is responsible for the content and writing of the article. THE AUTHOR Beth R. Hoffman, Ph.D., M.P.H., is an Assistant Professor of Public Health at California State University, Los Angeles. She received her Ph.D. in Health Behavior Research and her M.P.H. in Preventive Nutrition from the University of Southern California. She has studied social influences on drug and sexual behaviors in several populations, including adolescents, gang members, and transgender women. Her other research interests include vaccination education and public health pedagogy.
GLOSSARY
Sex work: The exchange of money, drugs, food or shelter for sexual stimulation. Transgender: Description of people who cross the boundaries of gender defined by culture. Transgender women: People who were born male but who identify and express themselves as female. REFERENCES Badgett, M. L., Lau, H., Sears, B., & Ho, D. (2007). Bias in the workplace: Consistent evidence of sexual orientation and gender identity discrimination. Los Angeles, CA: The Williams Institute, UCLA School of Law. Barrington, C., Wejnert, C., Guardad, M. E., Nieto, A. I., & Bailey, G. P. (2012). Social network characteristics and HIV vulnerability among transgender persons in San Salvador: Identifying opportunities for HIV prevention strategies. AIDS Behavior, 16, 214–224. Bith-Melander, P., Sheoran, B., Sheth, L., Bermudez, C., Drone, J., Wood, W., et al. (2010). Understanding sociocultural and psychological factors affecting transgender people of color in San Francisco. Journal of the Association of Nurses in AIDS Care, 21(3), 207–220. Bockting, W. O., Robinson, B. E., & Rosser, B. R. S. (1998). Transgender HIV prevention: A qualitative needs assessment. AIDS Care, 10(4), 505–525. Budge, S. L., Adelson, J. L., & Howard, K. A. S. (2013). Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Consulting and Clinical Psychology, 81(3), 545–557. Clements, K., Wilkinson, W., Kitano, K., & Marx, R. (1999). HIV prevention and health service needs of the transgender community in San Francisco. International Journal of Transgenderism, 3(1–2). Clements-Nolle, 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.
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DRUG USE, SEX WORK, HIV IN TRANSGENDER WOMEN
Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51(3), 53–69. Edwards, J. W., Fisher, D. G., & Reynolds, G. L. (2007). Male-tofemale transgender and transsexual clients of HIV service programs in Los Angeles County, California. American Journal of Public Health, 97(6), 1030–1033. Gagne, P., & Tewksbury, R. (1996). No man’s land: Transgenderism and the stigma of the feminine man. Advances in Gender Research, 1, 115–155. Garofalo, R., Deleon, J., Osmer, E., Doll, M., & Harper, G. W. (2006). Overlooked, misunderstood and at-risk: Exploring the lives and HIV risk of ethnic minority male-tofemale transgender youth. Journal of Adolescent Health, 38, 230–236. Gonzalez, H. M., Tarraf, W., Whitfield, K. E., & Vega, W. A. (2010). The epidemiology of major depression and ethnicity in the United States. Journal of Psychiatric Research, 44, 1043–1051. Herbst, J. H., Jacobs, E. D., Finlayson, T. J., McKleroy, V. S., Neumann, M. S., & Crepaz, N.(2008). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior, 12, 1–17. Kammerer, N., Mason, T., & Connors, M. (1999). Transgender health and social service needs in the context of HIV risk. International Journal of Transgenderism, 3, 1–2. Lembke, A. (2012). Time to abandon the self-medication hypothesis in patients with psychiatric disorders. American Journal of Drug and Alcohol Abuse, 38(6), 524–529. Nemoto, T., Luke, D., Mamo, L., Ching, A., & Patria, J. (1999). HIV risk behaviors among male-to-female transgenders in comparison with homosexual or bisexual males and heterosexual females. AIDS Care, 11(3), 297–312. Nemoto, T., Operario, D., Keatley, J., & Soma, T. (2004A). 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., Operario, D., Keatley, J., & Villegas, D. (2004B). Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care, 16(6), 724–735. Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., et al. (2009). Lifetime risk factors for HIV/sexually transmitted infections among male-to-female transgender persons. Journal of Acquired Immune Deficiency Syndrome, 52(3), 417–421.
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Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., et al. (2010). Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. Journal of Sex Research, 47(1), 12–23. Oggins, J., & Eichenbaum, J. (2002). Engaging transgender substance users in substance use treatment. The International Journal of Transgenderism, 6(2). Operario, D., & Nemoto, T. (2005). Sexual risk behavior and substance use among a sample of Asian Pacific Islander transgendered women. AIDS Education and Prevention, 17(5), 430–443. Operario, D., Nemoto, T., & Iwamoto, M. (2011). Unprotected sexual behavior and HIV risk in the context of primary partnerships for transgender women. AIDS Behavior, 15, 674–682. Sausa, L. A., Keatley, J., & Operario, D. (2007). Perceived risks and benefits of sex work among transgender women of color in San Francisco. Archives of Sex Behavior, 36, 768–777. Substance Abuse and Mental Health Services Administration (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of national findings. NSDUH Series H44, HHS Publication No. (SMA) 12–4713. Rockville, MD: Substance Abuse and Mental Health Services Administration. Testa, R. J., Sciacca, L. M., Wang, F., Hendricks, M. L., Goldblum, P., Bradford, J., et al. (2012). Effects of violence on transgender people. Professional Psychology Research and Practice, 43(5), 452–459. Thukral, J., & Ditmore, M. (2003). Revolving door: An analysis of street-based prostitution in New York City, USA. New York, NY: Urban Justice Center. Travers, R., Guta, A., Flicker, S., Larkin, J., Lo, C., McCardell, S., et al. (2010). Service provider views on issues and needs for lesbian, gay, bisexual, and transgender youth. The Canadian Journal of Human Sexuality, 19, 191–198. Vocks, S., Stahn, C., Loenser, K., & Legenbauer, T. (2009). Eating and body image disturbances in male-to-female and female-tomale transsexuals. Archives of Sexual Behavior, 38, 364–377. Wilson, E. C., Garofalo, R., Harris, R. D., Herrick, A., Martinez, M., Martinez, J., et al. (2009). Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS Behavior, 13, 902–913. Xavier, J. M., Bobbin, M., Singer, B., Budd, E. (2005). A needs assessment of transgender people of color living in Washington, D.C. International Journal of Transgenderism, 8(2–3), 31–47. Xu, F., Sternberg, M. R., & Markowitz, L. E. (2010). Men who have sex with men in the United States: Demographic and behavioral characteristics and prevalence of HIV and HSV-2 infection. Sexually Transmitted Diseases, 37(6), 399–405.
ORIGINAL ARTICLE
The Interaction of Drug Use, Sex Work, and HIV Among Transgender Women Beth R. Hoffman
Subst Use Misuse Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
Public Health, California State University, Los Angeles, USA however, rates of testing are higher for those who engage in risky sexual behavior, which means testing rates for transgender women are likely higher than for transgender men (Xavier et al., 2005). Rates of drug use are much higher for transgender women than for the general population. Studies indicate lifetime alcohol use as high as 88%, marijuana use at 63%, and 30% for cocaine use (Wilson et al., 2009). These rates contrast starkly against general population lifetime alcohol use of alcohol of 69.7% by adults 21 to 25, and marijuana use of 19% and cocaine use of 1.4% for adults 18 to 25 (SAMHSA, 2012). These alarmingly high rates of HIV prevalence and drug use should be a clarion call for research into the factors driving these negative health outcomes. Such factors include the relationship between known predictors of HIV incidence such as sex work and drug use, as well as the interaction of interpersonal variables with these predictors. Further, programs are needed that address sex work and drug use in order to reduce HIV rates.
Transgender women have a higher prevalence of drug use, HIV, drug use, and sex work than the general population. This article explores the interaction of these variables and discusses how sex work and drug use behaviors contribute to the high rates of HIV. A model predicting HIV rates with sex work and drug use as well as these behaviors in the transgender woman’s social network is presented. Challenges to intervening with transgender women, as well as suggestions and criteria for successful interventions, are discussed. Keywords substance use, drug use, HIV, sex work, prostitution, transgender
INTRODUCTION
Transgender is a term describing a diverse group of people who cross the boundaries of gender defined by culture (Bockting, Robinson & Rosser, 1998). Transgender women are people who were born male but identify as female for at least part of the time. Methods of female presentation vary, from makeup, clothing, jewelry, and wigs to use of feminizing hormones and surgeries such as breast implantation, genital reconstruction, and feminizing facial surgeries to alter jawlines, cheeks, brows, and hairlines. The prevalence of HIV is higher among transgender women than among the general population (ClementsKnolle, Marx, Guzman & Katz, 2001; Edwards, Fisher & Reynolds, 2007), with prevalence rates as high as 19%–32% self-reported in some samples (Wilsonet al., 2009; Xavier, Bobbin, Singer & Budd, 2005). A metaanalysis of HIV rates among transgender women in the United States indicates an HIV prevalence rate of 27.7%, with a rate of HIV prevalence for transgender males of 0%–3% (Herbst et al., 2008). This rate is higher than the rate of HIV infection among MSM (9.1% Xu, Sternberg & Markowitz, 2010), a group considered to be most severely affected by HIV in the United States. As many as one in five transgender people do not know their HIV status;
Drug Use and HIV
Drug use increases the likelihood of HIV in several ways: the sharing of needles when drugs are injected as well as lowered inhibitions, which leads to more unsafe sexual behavior (such as sex with multiple partners and less condom use). As many as half of transgender women participate in sex while under the influence of drugs or alcohol (Xavier et al., 2005). Intoxication with drugs or alcohol is associated with more receptive anal sex and unprotected anal sex, whether that sex is with a primary partner (Operario, Nemoto & Iwamoto, 2011) or a casual partner, and for receptive (but not necessarily unprotected) anal sex with commercial partners (Nemoto, Operario, Keatley & Soma, 2004A). While it may seem less risky to engage in unprotected sex with a primary partner, almost half of transgender women with primary partners were engaging in sex with other sex partners, as were their partners (Nemoto et al., 2004A). Further, 32%
Address correspondence to: Dr Beth Hoffman, Public Health, California State University Los Angeles, 5151 State University Drive, Los Angeles, 90032 USA. E-mail: [email protected]
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of participants in one study were involved in an HIVdiscordant relationship (i.e., one partner was HIV positive and one was negative), which means that unprotected sex is particularly risky (Operario et al., 2011).
Subst Use Misuse Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
Mental Health
Transgender women experience mental illness at rates higher than the general population. Over half of transgender women report depression during their lifetimes (Budge, Adelson & Howard, 2013; Nuttbrock et al., 2010) compared with a lifetime depression rate of less than 20% for the general population (Gonzalez, Tarraf, Whitfield & Vega, 2010). Approximately 40% of transgender women reported anxiety, according to Budge and colleagues (2013). Body image dissatisfaction and eating disorders occur at higher rates than among nontransgender females (Vocks, Stahn, Loenser & Legenbauer, 2009). Qualitative research with transgender women reveal that some transgender women engaged in substance use to cope with mental health problems and stress (BithMelender et al., 2010; Nemoto, Operario, Keatley & Villegas, 2004B), which in turn can exacerbate the mental health problems. There are high rates of attempted suicide among LGBT populations in general and transgender groups in particular (especially among victims of physical violence; Testa et al., 2012), and studies indicate an association between a history of problematic substance use (as indicated by participation in substance user treatment) and attempted suicide (Clements-Nolle, Marx & Katz, 2006). Kammerer and colleagues (1999) attribute the high rates of mental illness to the social stigma transgender women face from an early age. Recent studies are finding a lack of support for the self-medication theory in general populations (Lembke, 2012). It remains to be seen whether this theory holds for transgender populations or if another theory is more valid in explaining the associations of drug use and mental illness in this group. Sexual Violence and Sex Work
Transgender women are prone to high rates of sexual violence: as many as 59% of transgender participants in one study reported being victims of sexual assault (ClementsNolle et al., 2006). A history of sexual assault is associated with drug and alcohol use among transgender women (Testa et al., 2012). The relationship between general violence and drug/alcohol use was not significant in this study, indicating that there is something specific to sexual assault that is particularly traumatic for its victims. Sex work is common among transgender women. Transgender women engage in sex work to earn a living in the face of workplace discrimination, to pay for expensive feminization procedures, or to validate their value as a sexually desirable female (Bith-Melender et al., 2010; Clements, Wilkinson, Kitano & Marx, 1999; Nemoto et al., 2004B; Thukral & Ditmore, 2003). Given high rates of unemployment and low earning levels for many transgender women, sex work is often an economic necessity (Badget, Lau, Sears & Ho, 2007). Rate of engagement in sex work has been measured to be as high as 67% in a sample of young transgender women aged 15
to 24. Thirty five percent of this sample had engaged in sex work in the past month (Wilson et al., 2009). Researchers and transgender women agree that there is a clear relationship between drug use and sex work (Bith-Melender et al., 2010; Clements et al., 1999; Nemoto et al., 2004B; Operario & Nemoto, 2005; Wilson et al., 2009). This is true across ethnicities; for example, Asian/Pacific Islander transgender women were more likely to have engaged in sex while under the influence of alcohol or drugs, and to have used drugs at all, if they had engaged in sex work in the past month (Operario & Nemoto, 2005). Some transgender women sex workers use drugs to escape the trauma of prostitution; others become involved in sex work to pay for their drug use (BithMelender et al., 2010; Sausa, Keatley & Operario, 2007). Some use drugs with clients who will pay the women (or pay them more than they would otherwise) to use drugs with them (Bith-Melender et al., 2010; Sausa et al., 2007). Some use drugs because of perceived pressure from other transgender women further along in the transitioning process (Nemoto et al., 2004B). Drug use during sex work puts transgender women at greater risk for STIs and HIV, as intoxication lowers their ability to negotiate condom use (Sausa et al., 2007). Unlike injection drug users in the general population, transgender women may be injecting drugs both for intoxication (Clements-Nolle et al., 2001) and to achieve feminization via injection of nonmedically obtained hormones or silicone (Garofalo, Deleon, Osmer, Doll & Harper, 2006). Hormones are available in pill form, but many transgender women feel the efficacy of injected hormones is greater (Nemoto, Luke, Mamo, Ching & Patria, 1999). Nonhormonal drug injection is associated with HIVpositive status among transgender women (ClementsNolle et al., 2001). High-risk injection drug use behaviors included needle sharing and backloading, a process by which drugs are squirted from one hypodermic needle to another (Clements-Nolle et al., 2001; Nemoto et al., 1999). Hormone injection needles are longer than needles for injecting psychoactive drugs and are not available at needle exchange locations, which increases the likelihood that needles will be shared (Nemoto et al., 1999). Sex workers using hormones may be less likely to use condoms. Feminizing hormones often affect the ability to get and maintain erections; condoms intensify this effect. Transgender sex workers who use their penises to engage in sex work may avoid condoms in order to enhance sexual performance (Bockting et al., 1998), thus greatly increasing risk of HIV and STD transmission. Networks of Support
Friends are often primary sources of support for transgender women. Often a transgender woman loses the support of her family of origin as she transitions (Gagne & Tewksbury, 1996). As a result, friendships become important sources of information and support; these networks of friends are often very cohesive (Barrington, Wejnert, Guardad, Nieto & Bailey, 2012). Unfortunately, these friendship networks often provide models of sex work and drug use behaviors; transgender women new to the
DRUG USE, SEX WORK, HIV IN TRANSGENDER WOMEN
network often feel pressured to start using drugs and engaging in prostitution in order to become a part of the group (Sausa et al., 2007).
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Model of Factors Predicting HIV in Transgender Women
Figure 1 presents a model of factors leading to HIVpositive status in transgender women. Risky sexual behavior and drug use are direct predictors of HIV. Risky sexual behavior is measured by the composite of number of sexual partners, participation in sex work (physical interaction with people in exchange for money, drugs, food, or shelter), and not using condoms. Both noninjection drug use and injection drug use (including hormones and silicone) are included in the drug use construct. Noninjection drug use includes regular use of any substance, whether illicit or not, as any substance use may result in lowered negotiations for condom use and lowered inhibitions when choosing partners. However, it is expected that injection drug use will provide increased risk of HIV infection as well, whether due to high-risk sexual behavior or to infection due to needle sharing. Secondary factors consist of friendship-related factors. The percentage of a transgender woman’s network, which is transgender, is predicted to influence participating in sex work as well as the percentages of friends that are sex workers and drug users, given the high rates of sex work and drug use among transgender women. Percentage of friends, who are sex workers, is predicted to affect sex work, and the percentage of friends who are drug users will predict drug use. Based on past research, several factors are predicted to serve as moderators to the model. Since transgender women often engage in sex work due to a lack of financial opportunities and sex work is associated with increased drug use, socioeconomic status should affect the model, with lower SES resulting in stronger predictive values. Race ethnicity is likely a moderate as well, given the high prevalence of HIV in African American and Latina transgender females as compared to white transgender
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females (Clements-Nolle et al., 2001; Nuttbrock et al., 2009). Racial/ethnic differences are likely interacting with several aspects of the model, as differences are seen across a variety of variables, including numbers of both sex work and recreational sex partners, lifetime employment, and injection of female hormones (Nuttbrock et al., 2009). Substance Use Treatment for Transgender Women
Transgender women require and are requesting more transgender-specific support systems, including substance abuse treatment (Bith-Melender et al., 2010; Clements et al., 1999). While services may be designated for “LGBT” populations, some service providers worry that a transgender person, who identifies as such based on her gender identity, may not feel that her needs are met at a facility where programs are geared more to populations identifying by sexual orientation (Travers et al., 2010). Services at such a facility may not be geared toward her needs, or she may feel discriminated against by lesbian, gay, and bisexual clients or service providers (Clements et al., 1999; Kammerer et al., 1999). Transgender women who inject hormones and silicon may not consider themselves to be drug users (Bockting et al., 1998; Kammerrer et al., 1999) and therefore may be missed by programs targeting transgender substance users. A program that wishes to serve transgender clients must overcome several barriers in order to treat this population. The first barrier will be funding a program in a difficult financial climate. Given the high rates of HIV among transgender women, programs that seek to address substance use and/or sex work in this community should qualify for HIV-related funding, given the links between HIV, drug use, and sex work. Programs that already deal with substance use or sex work rehabilitation may wish to expand their client base by providing services related to transgender women. Recruitment of clients will require different strategies than those used to engage nontransgender clients due to the alienation many transgender women feel from these groups. Connections with agencies already serving transgender populations will provide a pipeline
FIGURE 1. Model of factors predicting HIV in transgender women.
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B. R. HOFFMAN
both for new clients and for resources needed to aid clients in transitioning to sober lives in legal jobs. Prisons and the court systems are also good sources of clients, as some jurisdictions allow those convicted of drug-based offenses to complete substance use rehabilitation instead of jail time. Programs may need to meet requirements of the justice system in order to interact in this capacity. A restructuring of preexisting programs, including physical facility features, may be warranted. Transgender women are getting more attention in the media but many people do not know how to address a transgender person, let alone interact with one in close quarters where people are expected to cooperate and share details of their lives. Clients as well as staff will need sensitivity training to learn about transgenderism and how to interact respectfully with transgender clients. Facilities may need to be reconfigured to provide transgender-only residence areas or to alter restrooms, either to increase the number of women’s facilities or to transform all restrooms into unisex facilities. Oggins and Eichenbaum (2002) describe five components of a successful substance use treatment program for transgender women in a facility for both transgender and nontransgender patients. These components consist of transgender staff, acceptance of transgender clients, sensitivity training for staff and clients, developing a social support network among clients, and developing community ties (Oggins & Eichenbaum, 2002). While their findings reflect only a small number of transgender women, the successful completion rates of transgender women in this program are encouraging and suggest that the methods may indeed be effective. Many transgender women are living on the fringes of society, as evidenced by their high rates of sex work, substance use, and HIV prevalence. The relationships between these health issues is complex and a substance use treatment program that does not address the centrality of sex work to the lives of many clients will not be successful. It remains to be seen whether programs aimed at providing former prostitutes with more socially accepted jobs will be effective in reducing rates of substance abuse and HIV, though existing information suggests that such programs would be efficacious. Clearly there is a health crisis in this community, and funding for substance use and prostitution rehabilitation programs could be justified as HIV-reduction programs. Resources for transgender women are limited, even in areas with relatively high transgender populations. The issues of sex work, drug use, and HIV status are inextricably linked (Clements et al., 1999); it is possible that reducing sex work by providing job training and resources to adapt to living in a “mainstream” world would reduce the prevalences of both substance use and HIV in the community of transgender women. Conversely, substance user rehabilitation problems that address problems related to sex work and provide services for obtaining legal work upon release would address both issues and could result in less sex work, substance use, and ultimately HIV, given enabling necessary conditions.
Declaration of Interest
The author reports no conflict of interest. The author alone is responsible for the content and writing of the article. THE AUTHOR Beth R. Hoffman, Ph.D., M.P.H., is an Assistant Professor of Public Health at California State University, Los Angeles. She received her Ph.D. in Health Behavior Research and her M.P.H. in Preventive Nutrition from the University of Southern California. She has studied social influences on drug and sexual behaviors in several populations, including adolescents, gang members, and transgender women. Her other research interests include vaccination education and public health pedagogy.
GLOSSARY
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