Gender Abuse,Depressive Symptoms,and HIV and Other Sexually Transmitted Infections Among Male-to-Female Transgender Persons: A Three-Year Prospective Study

Objectives. We examined gender abuse and depressive symptoms as risk factors for HIV and other sexually transmitted infections (HIV/STI) among male-to-female transgender persons (MTFs).Methods. We conducted a 3-year prospective study of factors associated with incident HIV, syphilis, hepatitis B, chlamydia, and gonorrhea among 230 MTFs from the New York Metropolitan Area. Statistical techniques included Cox proportional hazards analysis with time varying covariates.Results. Among younger MTFs (aged 19–30 years), gender abuse predicted depressive symptoms (Center for Epidemiologic Studies Depression score ≥ 20), and gender abuse combined with depressive symptoms predicted both high-risk sexual behavior (unprotected receptive anal intercourse) and incident HIV/STI. These associations were independent of socioeconomic status, ethnicity, sexual orientation, hormone therapy, and sexual reassignment surgery.Conclusions. Gender abuse is a fundamental distal risk factor for HIV/STI among younger MTFs. Interventions for younger MTFs are needed to reduce the psychological impact of gender abuse and limit the effects of this abuse on high-risk sexual behavior. Age differences in the impact of gender abuse on HIV/STI suggest the efficacy of peer-based interventions in which older MTFs teach their younger counterparts how to cope with this abuse.Extremely high rates of HIV have been detected among male-to-female transgender persons (MTFs). Community-based studies using nonprobability sampling have observed an HIV prevalence of 22% to 35%, with yearly incidence rates ranging from 3.5% to 7.8%.1–9 Established risk factors for HIV in this population include ethnicity (African Americans and Hispanics compared with Whites) and sexual orientation (those attracted to men only compared with other categories of sexual attraction).1,4The dominant behavioral mode by which MTFs contract HIV and transmit the virus to others, including the general population,10 is unprotected receptive anal intercourse (URAI) with committed, casual, or commercial partners.11 MTFs report frequencies of high-risk sexual behavior (including URAI) with noncommercial and commercial sex partners that are much higher than those for the general population12 and higher than for sexual minorities.13A potentially significant proximal risk factor, which may combine with URAI to cause HIV in this population, is depressed affect. MTFs report levels of depressive symptomatology that are much higher than in the general population,14,15 and some previous studies suggest that depressive symptoms are intertwined with high-risk sexual behavior.16–20A more fundamental distal risk factor, which may cause depressive symptoms and ultimately high-risk sexual behavior and HIV among MTFs, is abuse associated with an atypical presentation of gender. Because they transgress basic gender norms, many MTFs are taunted or beaten by family members, neighbors, coworkers, strangers, or the police,21 and a recent study showed that this abuse is linked to depressive symptomatology.22 For some MTFs, gender abuse may be highly traumatizing and intertwined with depressed affect, which may erode prevention consciousness and the use of condoms to prevent HIV in particular.23–27We present the findings of a community-based prospective study designed to evaluate social, psychological, and behavioral risk factors for incident HIV and other sexually transmitted infections (HIV/STI) among MTFs. We tested 3 interrelated hypotheses, reflecting the literature reviewed here: (1) gender abuse is associated with depressive symptoms as measured by the Center for Epidemiologic Studies Depression scale (CES-D); (2) gender abuse is associated with URAI with committed, casual, and commercial partners, with the effects partially mediated by depressive symptoms; and (3) gender abuse is associated with incident HIV/STI, with the effects partially mediated by depressive symptoms and URAI.Psychological or physical abuse associated with an atypical presentation of gender (gender abuse) is the result of a binary gender system in which all individuals are expected to conform to a single gender role (male or female) consistent with their sexual anatomy at birth.23 Although it is subjectively experienced, this abuse is ultimately the product of social forces beyond the perceptions of individuals28; following the Institute of Medicine’s conceptualization,29 we posited that it was a distal social risk factor for HIV/STI in this population. We conceptualized depressive symptoms as a proximal psychological risk factor for URAI. We included URAI as a behavioral risk factor that directly causes HIV/STI. We hypothesized that gender abuse and depressive symptoms affect HIV/STI via their effects on URAI.We further hypothesized that these associations are modified by age. Some studies suggest that younger MTFs are particularly vulnerable to gender abuse and victimization.30–33 Other studies suggest that older MTFs, after years of coping to this adversity, develop attitudes and skills to better cope with it.29,34 Age differences in vulnerability to gender abuse were demonstrated in a recent retrospective study by our research team: gender abuse was strongly associated with depressive symptomatology during adolescence and early adulthood, but the strength of this association declined markedly during later stages of life.22 Building on this finding, we examined age differences in the effects of gender abuse on depressive symptom longitudinally in this study, with further predictions of age differences in the effects of gender abuse on URAI and HIV/STI.An analysis of HIV among MTFs must also recognize the fact that this is a diverse population with regard to socioeconomic status (SES) and stage of gender transition,29 both of which could confound observed associations between gender abuse and HIV/STI. Because of this potential confounding, we included indicators of SES (education and income) and variation along a spectrum of gender transition (hormone therapy, preoperational transsexual identity, and sexual reassignment surgery) in the analysis.