Transgender women (i.e. male-to-female transgender persons) are individuals whose gender identities are discordant with the male sex they were assigned at birth. During the developmental period from early adolescence through young adulthood, many young transgender women struggle to develop a coherent sense of self while addressing feelings of guilt and shame about their identities, pressures to conform to familial, peer, and gender norms, and often the need for secrecy, either to “pass” in their chosen gender, or to hide their true feelings to avoid rejection and discrimination.1 Instead of support and understanding from family, friends and other adults, these women often experience social rejection and marginalization due to their gender identity and expression, as well as perceived sexual orientation.2-4 This rejection and marginalization is particularly salient during this period of developmental vulnerability and often results in severe consequences, as evidenced by high rates of homelessness, trading sex for food and other basic needs, and incarceration.5-9 A growing body of literature suggests that the marginalization experienced by these young women contributes to a wide range of negative health outcomes including psychological distress, substance abuse, and victimization, including verbal, physical, and sexual abuse. All of these outcomes are related to sexual risk behavior and HIV infection.5-8
The prevalence of HIV infection among transgender women is equal to or greater than among other traditionally high risk groups, such as men who have sex with men (MSM).10 In a review of 29 studies of HIV incidence, prevalence, and related risk behavior among transgender individuals completed between 1990 and 2003, the average laboratory confirmed HIV prevalence for transgender women across age groups was 27.7% (four studies) and the average self-reported HIV prevalence was 11.8% (18 studies, i.e., that included prevalence estimates).10 More recent data from local testing of over 500 transgender women with no known prior positive HIV test results in Miami Beach, Florida, San Francisco, and Los Angeles found 12% HIV infection, which suggests a high percentage of unrecognized HIV infection in this population.11 In an analysis by age, the highest number of new HIV infections, representing 45% of all cases, were detected among those ages 20-29.11
Estimates of HIV prevalence among young transgender women are scarce and based on very small, non-probability samples. A community-based study of ethnic minority young transgender women (ages 16-24; N=51) found 22% self-reported HIV-positive status.6 A prior analysis of study data from young transgender women, ages 15-24 (N=151, data further analyzed herein), found a comparable rate of 19% self-reported HIV infection.7 The higher rate of self-reported HIV-infection among young transgender women, in comparison to transgender women more generally, may be a result of relatively high rates of HIV testing. A total of 87% of young transgender women in this study had been tested for HIV infection at least once.7 However, self-reported prevalence of HIV-infection among these young women is still likely to be underestimated given evidence of unrecognized infection among those ages 20-29.11
High rates of unprotected receptive anal intercourse in this population,10 place them at risk of both acquiring and transmitting HIV infection. In the review of 29 studies referred to above, 31.7% of transgender women reported multiple, primarily male, sex partners and 48.3% reported having sex with casual partners. The average proportion of any unprotected receptive anal intercourse (URAI) was 44.1%, and the proportion of unprotected insertive anal intercourse (UIAI) was 27.4% (assessed across various recall periods).10 Estimates of sexual behavior among young transgender women in the community-based study referenced above (N=51) documented a rate of 59% self-reported unprotected anal intercourse (UAI, receptive or insertive) in the past 12 months.6
Multiple psychosocial health problems, including psychological distress, substance use, violence and victimization are common among transgender women. For example, community surveys suggest rates of depression and suicidality that are up to three times higher than the general population.3,12-14 Likewise, evidence indicates substance use is common (i.e., prior 30-day use of alcohol and marijuana of 50% and 38% respectively)15 with high prevalence of sex under the influence of drugs and alcohol.15-17 Studies of violence and victimization among transgender women estimate that between 21% to 68% have experienced forced sex9,18 and between 37% and 65% have experienced physical abuse9,15,18 either as a child or an adult.18
Similarly, evidence suggests that psychosocial health problems are also prevalent among young transgender women. Garofalo and colleagues, in a community-based study of 51 ethnic minority young transgender women cited above found that while self-esteem and depression were within the normal range on average, both were independently associated with UAI.5 With regard to substance abuse, past-year alcohol and marijuana use were reported by 65% and 71% of participants, respectively.6 Wilson and colleagues reported that over 90% of young transgender women in the study sample had used substances in their lifetime (alcohol 88%, marijuana 63%, cocaine 30%, ecstasy 32%, and methamphetamine 30%).7 Sex under the influence of alcohol or drugs was reported to be 50% and 53% in these separate studies 5,8 and was significantly associated with unprotected anal sex.5 With regard to violence and victimization, Garofalo and colleagues reported that over half of participants reported a history of forced sex, which was significantly associated with sexual risk behavior.5 Reported fear of partner anger and rejection were also noted as reasons young transgender women engaged in unsafe sex.6
We conclude that psychological distress and substance abuse, as well as frequent experiences of violence and other forms of victimization may contribute to HIV risk in this population, potentially fueling heightened rates of HIV infection. In light of the high HIV prevalence rates and the complexity of risk factors associated with risk behaviors and HIV acquisition, it may be appropriate to examine HIV risk among these young women within the framework of syndemic theory, as has been suggested by a leading group of experts in transgender health.19 Merrill Singer coined the term, “syndemic” in reference to the health crisis among poor and underserved inner-city women in the early 1990s, which included the co-occurrence of substance use, AIDS, and violence.20 As described by Singer, a syndemic involves “a set of enmeshed and mutually enhancing health problems that, working together in a context of deleterious social and physical conditions that increase vulnerability, significantly affect the overall disease status of a population” (p.15).21 Thus, a syndemic describes more than the interaction of diseases, but rather the mutually reinforcing interaction of disease and social conditions.21-23 Singer describes syndemics as occurring in “noxious social conditions” and are often produced by “structural violence of social inequality.”22
Stall and colleagues applied syndemic theory to the study of HIV-related sexual risk among urban men who have sex with men (MSM). They found that an increasing number of psychosocial health problems, including poly-substance use, depression, partner violence and childhood sexual abuse was significantly and positively associated with high-risk sexual behavior and HIV infection.24 Similarly, in an urban sample of ethnically diverse young MSM, ages 16-24, Mustanski and colleagues found that an increasing number of psychosocial health problems, including binge drinking, street drug use, regular marijuana use, psychological distress, intimate partner violence and sexual assault increased the odds of multiple anal sex partners, unprotected anal sex, and HIV-positive status.25
To our knowledge, syndemic theory has not previously been applied to the study of HIV risk among young transgender women; however given their marked social and economic marginalization and high prevalence of psychosocial health problems and HIV infection, the principles underlying this theory may well apply. The syndemic model, therefore, serves as a framework guiding the analysis described herein. We chose specific psychosocial health problems for inclusion in our syndemic model, as the data would allow, that are similar to factors examined among both urban poor and underserved women and urban MSM, and which reflect the life circumstances of young transgender women.
Based upon the evidence of the health disparities among young transgender women,5-8 we hypothesize that a syndemic of co-occurring health and psychosocial factors: low self-esteem, poly-substance use, victimization related to transgender identity (i.e., verbal threats and insults; being chased, followed or having property damaged; and being physically assaulted), and intimate partner violence (i.e., partner controlling activities; verbal harassment; threatening physical safety; sexual violence; and being pressured/forced to hide female gender identity) are additive and associated with HIV-infection and sexual risk for HIV infection. That is, the more psychosocial health problems reported, the greater the risk for both unsafe sexual behavior and HIV infection would be expected. In addition, Singer specified that a syndemic develops in a context of deleterious social conditions that increase vulnerability. Thus, we further test indicators of social marginalization as correlates of this clustering of psychosocial factors. Specifically, the objectives of this study were to: 1) assess whether or not multiple psychosocial factors are additive in their relationship to sexual risk behavior and self-reported HIV status among young transgender women (i.e., can be characterized as a syndemic) and 2) assess the relationship of indicators of social marginalization, such as a history of commercial sex work, homelessness, and incarceration to these psychosocial factors.