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Abstract
Objective Literature surrounding the healthcare needs of transgender individuals is limited in Australia. This study aimed to investigate the demographic characteristics, risk behaviours and HIV/STI positivity among male-to-female (MTF) and female-to-male (FTM) transgender individuals attending Melbourne Sexual Health Centre (MSHC), Australia, between 2011 and 2014.
Method A retrospective cohort analysis for 133 transgender individuals was conducted based on the first visit of individuals to MSHC during the study period. Demographic characteristics, sexual behaviours and HIV/STI positivity were examined.
Results The majority of transgender individuals were single or never married (74%; n=99). Almost half of the individuals (47%; n=62) had ever engaged in sex work during their lifetime. The median number of male sexual partners (MSP) reported in the last 3 months was 1 (IQR: 1–2) and with female sexual partners (FSP) was 2 (IQR: 1–4). For those who reported having sexual partners in the previous 3 months, always using condoms with MSP was 31% (n=22), and that with FSP was 18% (n=2). HIV/STI positivity during the study period was 7% (n=8) for chlamydia, 5% (n=6) for gonorrhoea, 5% (n=5) for syphilis and 1% (n=1) for HIV. Hormone use for reassignment was reported by 63% (n=90) of individuals and reassignment surgery was reported by 27% (n=29+6=35).
Conclusions Transgender individuals in this study were found to be a diverse group, with a history of sex work being a common feature. These findings indicate that transgender individuals' sexual healthcare needs differ substantially from those in other countries, including the US and Canada. Attention to differences in MTF and FTM transgender persons must be considered in healthcare settings in Australia.
- TRANSSEXUAL
- SEXUAL BEHAVIOUR
- SEXUAL HEALTH
- PUBLIC HEALTH
- CONDOMS
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Introduction
Transgender individuals are generally a socially marginalised group who are at a high risk of HIV/STIs.1 Previous research has found that transgender individuals commonly report high levels of sexual and other behaviours which are considered to put them at risk of HIV and other STIs1–3 due to high rates of sex work, drug abuse, multiple sexual partners and condomless sex. Most research has been conducted on male-to-female transgender individuals (MTF), with the research surrounding female-to-male transgender individuals (FTM) being more limited, possibly due to the smaller sample size. Previous studies have investigated the differences between MTF and FTM risk behaviours; however, results are inconclusive.1 ,2 Despite being a reportedly high-risk group, rates of accessing healthcare among transgender individuals are reported to be low,1 ,2 with an Australian study reporting transgender individuals as representing 0.06% of all sexual health consultations.2
Numerous studies have examined HIV and STI prevalence among transgendered persons, but this varies across studies.2 ,3 In Australia, research on transgender individuals has been very limited. Only one study, published almost 10 years ago, reported the sexual behaviour and sexual health needs of 40 transgender individuals (36 MTF and 4 FTM) between 1990 and 2006 in Sydney, Australia.2
Due to the lack of research on transgender individuals, particularly in Australia, as well as the suggestion that transgender individuals are a high-risk group for HIV and STIs in the research available, further research is needed in this area. This study aimed to investigate the demographic characteristics, risk behaviours and positivity rates of HIV and STIs among MTF and FTM transgender individuals attending a large urban sexual health service in Melbourne, Australia, between 2011 and 2014.
Method
A retrospective analysis was undertaken to investigate the demographic characteristics, sexual behaviours, reasons for attendance and HIV/STI positivity of transgender individuals attending Melbourne Sexual Health Centre (MSHC), the largest sexual health clinic in Victoria, Australia, between 1 January 2011 and 31 December 2014. MSHC provides a free walk-in service for approximately 35 000 consultations per year, with approximately 0.4% of these with transgender clients during the study period. Transgender was defined as an individual who self-identified as transgender, and who have had sex reassignment surgery and/or hormonal treatment.
Individuals attending MSHC are asked to record their demographic details when attending their first visit. The clinical diagnoses and laboratory test results for each clinical visit are recorded electronically in the Clinical Practice Management System (CPMS). For individuals identified as transgender, CPMS-extracted data included the laboratory diagnoses of HIV and STIs including chlamydia, gonorrhoea and syphilis. A chart review was performed on all transgender individuals to identify whether they were MTF or FTM, and had any history of surgical or hormonal intervention.
This study was approved by the Alfred Hospital Human Ethics Committee (number 369/15).
Statistical analyses
Descriptive and frequency analyses were conducted using the data from an individual's first visit of the study period (N=133). To determine differences on a range of demographic and sexual behaviour characteristics, individuals were stratified into two groups, MTF (n=77) and FTM (n=28), and Pearson's Fischer's exact methods or Mann-Whitney U tests were used to compare the differences in proportions and medians of the study variables across groups.
HIV and STI (chlamydia, gonorrhoea and syphilis) positivity was calculated among individuals who had tested for the infection. All analyses were conducted using Stata V.13.1.
Results
Characteristics of transgender individuals
A total of 133 transgender individuals attended 558 consultations representing a median of two (IQR 1–5) visits per person between 2011 and 2014. Fifty-eight per cent (n=77) of individuals were MTF, 21% (n=28) were FTM and for 21% (n=28) this was unreported. Table 1 summarises the demographic characteristics and sexual behaviours among 133 transgender individuals.
Demographics and sexual behaviours among 133 transgender individuals from the first visit attended between 2011 and 2014
Surgery and hormone therapy
Of the 22 MTF individuals who had received any sexual reassignment surgery, this included breast augmentation (64%, n=14), and neovaginal construction (36%, n=8). For the 13 FTM individuals who had received any sexual reassignment surgery, this included mastectomy (38%, n=5), hysterectomy (31%, n=4), both mastectomy and hysterectomy (23%, n=3) and one was awaiting metoidioplasty (8%, n=1). Hormone therapy was oral or intramuscular therapy including androgen-blocking hormones for MTF and testosterone therapy for FTM.
Discussion
Transgender individuals were found to have low numbers of sexual partners, and among those reporting sexual partners in the last 3 months, rates of consistent condom use were also reported to be low. Almost half of the transgender individuals had worked as sex workers in their lifetimes. A majority of individuals were using hormones for transition, and around one-fifth had undergone any type of reassignment surgery. MTF individuals were found to be more likely to report ever having done sex work and attending routine sex work check than FTM individuals.
This study had a number of limitations including that the data were collected from one urban sexual health clinic in Melbourne and therefore is unlikely to represent the broader population of transgender individuals in Victoria or Australia. The sample of FTM individuals was relatively small, especially compared with MTF individuals; however, the population of FTM individuals is smaller than MTF individuals in the wider population.2 The data were derived largely from self-report information, which may be biased due to the social desirability of certain questions, or interpreted differently by different individuals. A further limitation was the substantial number of cases in which we were unable to identify if individuals were MTF or FTM, due to the lack of identification in the clinical notes, and the nature of the self-reporting. Finally, a substantial percentage of transgender individuals in this study had a history of sex work and therefore may be more likely to attend for routine sex worker certificates under the Victorian Sex Work Regulations, requiring sex workers to have STI testing and obtain a certificate to work every 3 months.4 The sexual behaviour information of these individuals with their clients was also not captured in this analysis.
This study also has a number of strengths, as it highlights some important considerations for transgender individuals, and is the first study of this nature to be conducted in Victoria, Australia. The last Australian study of transgender individuals was conducted by Hounsfield et al2 in Sydney 9 years ago, with a small sample of 40, covering 16 years, and the demographics of the sample may have changed during this time and in a different location. This study also focused on both MTF and FTM individuals, unlike many prior studies which were largely only focused on MTF individuals. This was also a relatively large sample of 133 individuals over a 4-year period, especially compared with another study of transgender individuals in a similar context.2
Low rates of condom use with both male and female sexual partners were found in our study which is consistent with the finding in Sydney;2 however, the median numbers of sexual partners in the last 3 months were low, suggesting individuals may have had regular sexual partners they were not using condoms with. In contrast, this study also had much lower rates of IDU (12%) than that of the study of Hounsfield and colleagues (40%), suggesting that rates of injecting drug use may be falling in this population.2 Yet, these rates still remain much higher compared with the national data estimating IDU as 1.2% in Australia.5 Similar rates of chlamydia were found in this study (7%), as in the study of Hounsfield and colleagues (10%), as well as gonorrhoea (5% and 8%, respectively) and syphilis (5% and 3%, respectively).2
In a worldwide systematic review conducted by Baral et al6 as well as another systematic review of the US conducted by Herbst et al,1 much higher rates of HIV (19% and 28%, respectively) were found in MTF transgender individuals than that was found in our study (3%). Incidence rates of HIV in the general population in Australia, however, are only one-fifth of the rate of HIV in the US.7 Sexual risk behaviours, including multiple sexual partners, unprotected sex and sex while affected by drugs, were also found to be quite high in a systematic review by Herbst et al,1 while numbers of sexual partners and rates of IDU were found to be lower in this study. The Australian context for HIV infection and sexual risk behaviours may be quite different to other low/middle income countries and first world countries, and therefore the sexual healthcare needs of transgender individuals will also be different in varying contexts. In low/middle income countries, transgender individuals are less likely to have access to healthcare services and HIV and STI testing, as well as knowledge of sexual health and safe sex practices.8
Hounsfield et al2 found a similar percentage of individuals had a history of sex work (47%) as in the current study (47%); however, this was much higher than other studies conducted in the US (11%)1 and Canada (15%).9 The high proportion of sex workers in this study may also have influenced the lower incidence of high-risk sexual behaviour, and certain STIs, due to this mandatory screening, along with mandatory condom use with clients. Sex workers in Melbourne have been shown to have very high rates of condom use with clients, with a recent study reporting 96% of sex workers always using condoms with clients.10
Transgender individuals in this study were found to be a diverse group, with a history of sex work being a common feature, which may have influenced the results. It is also important to consider the differences between MTF and FTM transgender individuals in healthcare settings. The findings in this study were largely consistent with the results obtained by Hounsfield and colleagues.2
Footnotes
Handling editor Jackie A Cassell
Contributors EPFC and CKF designed the study. CSB performed the chart review and wrote the first draft of the manuscript. SW performed data analysis. All authors contributed to the interpretation of the study findings and contributed to the drafting of the manuscript.
Funding This work was supported by the National Health and Medical Research Council (NHMRC) programme grant (number 568971). EPFC is supported by the Early Career Fellowships from the Australian NHMRC (number 1091226).
Competing interests None declared.
Ethics approval Alfred Hospital Human Ethics Committee (number 369/15).
Provenance and peer review Not commissioned; externally peer reviewed.