Trans Men Are Being Erased from HIV Prevention

AMSTERDAM, Netherlands — Preventing the spread of HIV among gay and bisexual transgender men has hit one huge snag: many countries and health departments don’t know how to categorize transgender men, and they fall through the cracks. Transgender activists from all around the world gathered at the 2018 International AIDS Conference to share personal stories related to how their respective health systems left them behind in conversations about sexual health as well as spaces meant for male-identified queer people.

The panel was led by Teddy Cook, an Australian trans man who works at ACON, an Australian LGBT HIV prevention organization. Trans men, Cook stressed, often begin behind the 8-ball when it comes to HIV prevention because their level of risk isn’t taken seriously.

“Trans men, particularly HIV-positive and vulnerable trans men and transmasculine populations, our risk is largely invisible or misrepresented, met with discrimination, hostility and violence within our own trans communities and within settings of research, health, judicial systems, policy frameworks, across sociocultural and across the entire political landscape,” Cook said.

Cook said that globally trans men continue to be “profoundly erased” as a group in need of HIV prevention outreach, even though many trans men are gay and bisexual men who are having both anal and vaginal sex.

Cook said the biggest problem was that researchers often don’t know where to place transgender men within their HIV prevention research. Similarly with clinics, if they have programs for gay and bisexual men, that usually just means gay and bisexual cisgender men.

“We’ve been erased and invisible for the entire length of the epidemic,” Cook said. Preliminary data in Australia shows that as much as 5 percent of the transgender male population is living with HIV, though little research has been done around trans male bodies.

Cianan Russell, a transgender man and the UN officer for Transgender Europe, spoke about his own experiences at a trans clinic in Thailand, where he lived before moving to Europe.  Both he and his cisgender male partner accessed care at this clinic. According to Russell, the only options for sexual partners given to his partner were “cis man,” “trans woman” and “cis woman,” and each time his partner accessed care, Russell was put in a different box.

“Quite frankly, that’s the norm,” Russell said. “Counselors don’t know how to deal with us or our partners.”

Additionally, Russell said he had been denied several PrEP studies because he is a transgender man, even though he identified as gay. He had to lie about his identity to get on PrEP. Even if he were able to access PrEP more easily, due to a lack of research among trans men, he’d have no idea how useful the drugs would be in preventing HIV acquisition.

“I honestly don’t have any idea about the efficacy of any of these drugs with my body,” he said. “How long is the waiting in vaginal tissue that has atrophied? You don’t know, I don’t know. What is the risk prevalence with vaginal tissue that’s atrophied? We don’t know.”

Researcher Ayden Scheim, a postdoctoral research fellow at the University of California, San Diego, spoke about his own experience trying to start a working group on trans male sexual health in Toronto in 2006, which he described as an “uphill battle” in queer cis male spaces.

“Every time there was a space set aside in gay men’s sexual health meetings for [trans men], people asked why that was happening,” he said. “People were pretty confused as to why we were there and would come to the session.”

GATE executive director Mauro Cabral Grinspan, who earlier at AIDS2018 presented on how badly underfunded trans organizations really are, spoke about his experiences as a trans man who wanted to date men and how people categorized him as mentally ill. Cabral Grinspan also noted that just because a country might have good legal conditions for transgender people, that doesn’t mean they understand trans sexuality well.

“There’s a sense that, ‘OK, I respect you as a guy, but why do you want to date gay people?'” he said. “There’s a reaction like, ‘Well, actually you want too much. First, you want to be a guy and now you want to come to our spaces?” Cabral Grinspan also spoke about how queer male spaces are often dictated by erotic desire and that trans male bodies are often rejected in those spaces.

“The idea is that we are foreigners and [cis gay men] can be welcoming to us, but it’s not our space,” he said. “We are still strangers trying to enter a space that makes an explicit decision to be open to us.” Often, Cabral Grinspan said, trans men are not consulted about their ability to be in these queer male spaces.

“There’s an idea that trans men need special permission, special space, special night decided upon by cis people,” he said.

Finally, Cook added a personal anecdote about working with Australian public health officials — without pay — to make their national guidelines for HIV prevention and treatment inclusive of transgender men.

“They did not take any of our recommendations,” Cook said. “They stuck with what they had proposed in the draft, which we had said, ‘If you do this, you are putting trans men at risk of HIV.'”

Cook said that it all comes back to a false perception of being low risk.

“We are considered to be low risk unless we’re having anal sex,” Cook said, pointing out a contradiction. “However, het couples having vaginal sex with someone’s who is HIV positive is apparently high risk. So it’s like if I’m trans, it means I can no longer get HIV. It’s some sort of vaccine — unless I’m getting fucked in my ass.”