Objectives Trans people remain an understudied population in the UK, with unmet sexual health needs. The aim of this research was to identify possible barriers and facilitators for sexual health clinic attendance and HIV testing among trans people.
Methods Lesbian, gay, bisexual and transgender (LGBT) participants from across the UK were invited to take part in a cross-sectional online survey through Facebook advertising (April–June 2018). Psychosocial and sexual factors associated with recent sexual health clinic attendance, and ever having an HIV test were examined using multivariate logistic regression.
Results A total of 3007 cisgender and 500 trans participants completed the survey. Trans participants were less likely to attend a sexual health clinic than cisgender participants (27% vs 36%, p<0.001) and report ever having an HIV test (49% vs 64%, p<0.001). One trans participant reported living with HIV and three reported currently taking pre-exposure prophylaxis. Factors associated with trans sexual health clinic attendance were: living in London, having a relationship with multiple partners, engaging in condomless anal intercourse, greater life satisfaction, and having alcohol and/or drugs before sex. Being a person of colour, aged 25–49 years, in a relationship with multiple partners, condomless anal intercourse, lower body dissatisfaction, and having drugs before sex were associated with ever having an HIV test among trans participants.
Conclusions Trans people were less likely to attend sexual health services than cisgender people, and half of trans participants who reported condomless anal intercourse had never had an HIV test. Further research is needed to understand and improve uptake of sexual health services among trans people.
- genitourinary medicine
- human immunodeficiency virus
- service delivery
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Uptake of sexual health services by trans people in the UK is low, suggesting trans people's sexual health needs are not currently being met.
Over half of trans participants that had recent condomless anal intercourse had not attended a sexual health service in the same time period.
Trans participants were more likely to report experiences of discrimination in healthcare and other settings, and poorer psychological well-being compared with cisgender participants.
The factors affecting trans people’s use of sexual health services are poorly understood, even though this group has need for such services.1 A global review estimated the HIV prevalence among trans women worldwide to be 19.1%, although this may reflect elevated risks (eg, antiretroviral therapy access, survival sex work) in the countries included (USA, Asia-Pacific region, Latin America and three European countries).1 However, outreach testing among trans women in the USA indicated a high prevalence (12%) of undiagnosed HIV.2 Research into trans people’s sexual health has been limited by the historic grouping of trans women with men who have sex with men (MSM), as well as the limited inclusion of trans people in health programmes, and HIV epidemiological research.3 4
Trans is an umbrella term, referring to anyone whose current gender differs from the gender assigned them at birth, such as transgender, trans male, trans female, genderqueer and non-binary people (as well as anyone’s identity that differs from the traditional cultural male-female binary).5 The term cisgender refers to anyone whose current gender is the same as that assigned at birth.
Studies that have examined sexual risk and HIV testing among trans people indicate significant risks and HIV testing uptake problems. In Ontario, Canada over half of trans men surveyed identified as MSM, with around 10% engaging in high-risk sexual behaviours, and 40% never having an HIV test.6 HIV testing was more common among those accessing a community outreach project in London, although 15% of trans people had never tested, and 25% had not tested in the past 3 years, while over half reported unprotected sex, and knowledge of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) was low.7
Reasons suggested for trans sexual health inequalities include mental health issues, stigma and discrimination, social isolation, economic difficulties, and unmet needs for trans-specific healthcare services.8 Trans people in the UK have a high incidence of mental health issues, with one study indicating half may have mild to major depression.9 It was also found that high levels of body dissatisfaction have been reported among trans people and this influenced how they viewed themselves and sex, although transition was related to improved body satisfaction.9
Stigma that trans people face include structural (eg, gender conformity, healthcare access barriers), interpersonal (eg, discrimination, hate crimes) and individual (eg, internalisation of stigma, avoidance behaviours) factors, and contribute to the health inequalities they experience.10 Research investigating the stigma experienced by people living with HIV found that being trans was a predictor of receiving different treatment or healthcare being delayed or refused compared with cisgender participants, and more likely to report avoiding healthcare.11 The UK National LGBT Survey conducted in 2017 found fewer trans participants (17%) had accessed sexual health services than cisgender participants (29%), and they were less likely to report these services as easy or very easy to access, and more likely to report a negative experience when accessing services.12
Qualitative interviews with Canadian trans men who identify as MSM found that trans-specific and general barriers, low perceived risk, and a lack of knowledge of trans healthcare needs were barriers to HIV and sexually transmitted infection (STI) testing.13 Conversely, a USA study found gender-specific discrimination was associated with sexual risk behaviours, but not HIV testing among trans people.14 A literature review on trans women and HIV identified a lack of UK data and research,15 which is concerning considering trans people in England are twice as likely to be diagnosed with HIV at a late stage than cisgender people.16 Research into barriers and psychosocial factors affecting access to sexual healthcare and HIV testing for trans people is needed to inform health promotion.
This study examined the sexual and psychosocial factors associated with recent sexual health clinic attendance and HIV testing among trans people in the UK, to identify barriers to access.
The LGBT Sex and Lifestyles Survey was a national UK online cross-sectional study conducted in 2018, recruiting a convenience sample using Facebook advertising and community organisations’ social media accounts,17 18 approved by the Liverpool John Moores University Research Ethics Committee (18/PHI/011). Four adverts were run on Facebook during the period April–June 2018, targeting MSM, women who have sex with women (WSW), trans people, or LGBT (lesbian, gay, bisexual and transgender) people generally. Participants were invited to take part in the survey if they had ever had a same-gender sexual partner and/or they identified as trans. Screening questions asked if participants were aged 18 years or over and currently living in the UK. A prize draw for a £50 or one of two £25 Amazon vouchers was offered as an incentive.
The questionnaire covered three areas: demographics, sexual health and drug use, and psychological well-being. An adapted version of a two-stage gender monitoring question was used to identify participants’ gender, which was revised through discussions between Public Health England and community organisations for HIV monitoring in England.16 Participants were asked which of the following best describes how you think of yourself: male (including trans man); female (including trans woman); non-binary; in another way, please specify; and prefer not to say. This was followed by asking if their gender identity is the same as the gender they were assigned at birth. Participants were classified as trans if they specified that their current gender was different to the gender they were assigned at birth. Participants were grouped as cisgender if they stated their current gender was the same as the gender they were assigned at birth.
Sexual health questions were adapted from research on similar topics.19 20 Participants were asked if they had attended a sexual health/genitourinary medicine clinic in the past 12 months and when they last had an HIV test. Those who reported ever having an HIV test were compared with those who had never tested. Participants were asked if they had taken any of 14 drugs in the past 12 months. They were then asked if they had been under the influence of these during sex or had taken them immediately before or during sex, with use of any substance, other than alcohol, grouped as sex under the influence of drugs.
Internalised transphobia (referred to as self-stigma), the negative attitudes a trans person may hold towards themselves and other trans people due to internalising society’s male/female gender norms,21 was measured using an adapted version of the Internalised Transphobia Scale, where higher scores indicate higher levels of self-stigma.21 Trans participants were asked if they had experienced discrimination because of their gender in various settings in the past 12 months, using established questions adapted to account for more modern situations of discrimination, and for use with LGBT people.22 If a participant did not identify as heterosexual, they were asked if they had experienced discrimination because of their sexuality in the same settings. The Objectified Body Consciousness scale was used to measure body image satisfaction,23 where higher scores indicate higher body dissatisfaction. A three-item loneliness scale,24 the Satisfaction With Life Scale (SWLS),25 and the Kessler Psychological Distress Scale,26 were used to assess psychological well-being.
All analyses were conducted using SPSS 25 (IBM Corp., Armonk, NY, USA). Forward stepwise multivariate logistic regression analyses were used to explore factors associated with recent sexual health clinic attendance, and reporting ever having an HIV test (entry p<0.05, removal p>0.10).Factors significant at the univariate level (p<0.05) were included in the multivariate analysis.
Patient and public involvement
LGBT organisations were involved in the survey design, participant recruitment, and interpretation of the findings.
Of the 4690 people who started the survey, 96 did not meet the inclusion criteria, and 1087 did not sufficiently complete the questionnaire (completion rate 75%, n=3507). There were 500 (14%) trans participants. Trans participants were younger, had lower educational achievement, and were less likely to live with a partner or in London than the cisgender participants (table 1). A minority of trans participants identified as straight/heterosexual (6%), the majority were of white ethnicity (95%), and mean age was 27.1 (SD 9.6, range 18–71) years. One participant reported living with HIV (trans man), and three were taking PrEP (trans man, trans woman, and non-binary trans man (self-identified)).
Of the trans participants, 81% reported psychological distress levels rated as high/very high. Trans participants were more likely to have poor/very poor perceived health, greater psychological distress, higher loneliness scores, body dissatisfaction, and lower satisfaction with life than cisgender participants (table 2). Trans participants were also more likely to experience discrimination in a medical setting, and in other settings.
Trans participants were significantly less likely to have attended a sexual health clinic in the past 12 months than cisgender participants (table 1). There was no significant difference in sexual health clinic attendance of trans participants by gender. Table 3 presents the bivariate and multivariate analyses of factors associated with sexual health clinic attendance. Due to the strong correlation between loneliness and satisfaction with life (R=0.48, p<0.001), and the association between anal intercourse with a man, and condomless anal intercourse with a man, only satisfaction with life and condomless anal intercourse were included in the multivariate analysis. Factors associated with sexual health clinic attendance among trans participants were: having a relationship with multiple partners, living in London, condomless anal intercourse with a man in the past 12 months, having sex under the influence of alcohol, having sex under the influence of drugs, and having greater life satisfaction. Being unemployed was not associated with sexual health clinic attendance.
Trans participants were significantly less likely to report ever having an HIV test than cisgender participants (table 1). There was no significant difference in reporting ever having an HIV test between trans participants by gender. Factors associated with ever having an HIV test among trans participants were: being aged 25–49 years, being a person of colour, being in a relationship with multiple partners, engaging in condomless anal intercourse with a man, having sex under the influence of drugs, and lower body dissatisfaction score (table 4).
Understanding how psychological, social and sexual characteristics impact on trans people's use of sexual health clinics and uptake of HIV testing is important for reducing inequalities in service access. Similar to previous research, we found trans people were less likely to report recent sexual health clinic attendance than cisgender people who are lesbian, gay or bisexual.12 While those engaging in sexual risk-taking behaviours are more likely to attend a sexual health clinic, over half of trans participants who had recently engaged in condomless anal intercourse had not attended a sexual health clinic.
Unlike previous qualitative research,13 but similar to quantitative research from the USA,14 no directly trans-specific barriers to attending sexual health services such as experiences of discrimination or self-stigma were observed when controlling for other variables. However, in the bivariate analysis, trans people who had experienced discrimination in a healthcare setting were more likely to have reported sexual health clinic attendance, though it is possible that this was where they experienced the discrimination, this may have been experienced elsewhere.11 12 Similarly, self-stigma was negatively associated with sexual health clinic attendance and HIV testing in bivariate, but not the multivariate, analyses. Future research is needed to explore these issues and their implications.
Unemployment appeared to be a barrier to sexual health clinic attendance for trans participants, possibly reflecting the higher levels of social and economic isolation they experience, as well as the lack of trans-specific services.8 Similarly, participants living in London were more likely to report clinic attendance, probably reflecting an inequality in the distribution of trans-specific services, as London has one of the UK’s few trans specific sexual health services.27 Those with higher life satisfaction were more likely to report sexual health service attendance, but 80% of trans people had high or very high psychological distress levels, and high levels of mental health issues have been previously reported among trans people in the UK,9 which may contribute to trans people not engaging with sexual health services.
Previous research has suggested trans women have a high HIV prevalence compared with other at-risk groups.1 Only one participant, a trans man, reported living with HIV in this study. Over half the participants reported never being tested for HIV, which may indicate a number of trans people living with undiagnosed HIV, similar to the high level of undiagnosed HIV observed in the USA.2 The proportion of participants never tested for HIV was higher than in a previous UK study,7 which looked at community-based HIV testing at sex-on-premises venues, where people may be more likely to have had an HIV test. Additionally, trans people aged 25–49 years were more likely to report having an HIV test than younger participants, suggesting a possible HIV risk knowledge gap among younger trans people, or that younger trans people are less likely test due to a possible perceived lack of need. Three trans participants reported being on PrEP; this might reflect a lack of PrEP knowledge,7 or issues with access to PrEP for trans people, who have only recently been included in the UK PrEP provision guidelines.28
Although people may attend sexual health services for reasons other than STI testing, this is the first UK study to investigate factors associated with trans people’s sexual health service engagement. Facebook advertising and using community organisations social media aided recruitment of trans people, including those not engaged with sexual health services. A limitation of this method is that only people using social media can be reached; this is possibly reflected in the sample, as this was slightly younger relative to the UK general population, and people of colour were underrepresented. Participants were also self-selected, which may have biased the findings. Even so, being a trans person of colour was a predictor for HIV testing. A lack of representation of people of colour is a common critique of LGBT research in the UK.9 Future research should aim to better represent trans people of colour.
Our study was aimed at all LGBT people, so it was not possible to explore sexual behaviours in as much detail as could be achieved in a trans-specific survey (eg, other types of intercourse). Nevertheless, it has highlighted inequalities in sexual health service access and HIV testing uptake among trans people, as well as suggesting PrEP uptake is low. Possible reasons for these include trans people historically not being included in sexual health campaigns, and a lack of confidence in healthcare professionals’ treatment of trans people,11 with these possibly limiting sexual health knowledge and perceived risk among trans people.
In conclusion, uptake of sexual health services among trans people should be improved, and international guidance for implementing effective HIV prevention programmes with trans people suggests this can be achieved by engaging trans people in the design and delivery of interventions,3 and by training sexual health workers on trans sexual health needs so as to remove barriers. Additionally, to fully understand trans people’s sexual health needs it is important that they are included in the development of both sexual health programmes and research.
The researchers would like to thank everyone who participated in the survey, as well as CliniQ, COAST, GALOP, the Gay Men’s Health Collective, London Friend and The National LGB&T Partnership for their contribution to the design and recruitment of the survey.
Contributors MH conducted the literature review and drafted the manuscript. Design of the survey, data collection and statistical analysis was conducted by MH with input and supervision from CB, LP and VH. Community members AW, HW and MR contributed to the design and interpretation of the study. All authors contributed to and approved the final draft.
Funding This study was funded as a PhD project from Liverpool John Moores University.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.