3 things to keep in mind about trans (men’s) inclusion in HIV prevention research
In response to mounting evidence of the prevention benefits of pre-exposure prophylaxis (PrEP) use by HIV-negative gay and bisexual men, a discussion recently emerged on social media about the perceived exclusion of trans men1 who have sex with men from PrEP research studies.
In fact, trans men participate in many HIV prevention research studies, whether or not they are identified as trans when results are reported. Some do not identify as trans, but rather as men of trans experience or transitioned men, and are happy to check the “male” box without qualification. Other studies have explicitly included trans men and allowed them to self-identify. Regardless, some were upset that when results were reported, PrEP effectiveness among trans men was not addressed. In response, a number of well-intentioned non-trans men voiced their support for greater inclusion of trans men in biomedical and other HIV prevention research. While these statements are a testament to the progress gay and bisexual men’s communities are making in embracing men of trans experience, I feel compelled to offer a reality check about the inclusion of trans men in HIV prevention research.
- According to a recent estimate,2 about one in 200 people are trans. Therefore, unless greatly oversampled, trans men will never represent a large enough subgroup of a study to allow for well-powered comparisons of efficacy or effectiveness between trans and non-trans men. Further complicating matters is that we would likely see lower incidence rates among trans men overall, requiring even larger numbers to detect an effect.
- Trans people are not unicorns! We can cautiously infer from research on non-trans people. For instance, we can look to basic science research showing lower concentrations of tenofovir (one of the two drugs in Truvada) in vaginal and cervical versus rectal tissues to learn about how PrEP may work differently for trans men who have vaginal intercourse (e.g. requiring more frequent dosing, or a longer period to become efficacious at the beginning of use). Where we do need to find out more about prevention issues specific to trans people, studies that are trans-specific provide better opportunities to ask targeted questions, and to explore heterogeneity within trans communities. Inclusion of trans people in broader studies is important for identifying disparities, but is often less useful for identifying potential remedies for such disparities.
- While some gay, bi, and queer trans men are at risk for, or living with HIV, the impact of HIV in trans communities is largely experienced by trans women, who are at incredibly high risk of infection in many regions.3 At the moment, we don’t have evidence to suggest a similar HIV epidemic among trans men, in any setting. While we need more, and better-quality, data on HIV prevalence and incidence in trans populations,4 we can safely conclude that trans women should be prioritized in prevention research. Yet, trans women represented a pitiful 0.2 per cent of participants in PrEP trials that had reported results as of 2013.5
Moving forward, prevention research and interventions (e.g., PrEP demonstration projects) that focus on trans women are needed, rather than problematically lumping them in with men who have sex with men. While prevention, treatment, and care efforts for gay and bisexual men must accommodate the experiences and needs of trans men affected by HIV, gay and bisexual men (trans and non-trans) should be raising our voices to ensure that increased resources are dedicated to HIV prevention for trans women.
Ayden Scheim is a PhD Candidate, Trudeau Foundation Scholar, and Vanier Scholar in epidemiology and biostatistics at Western University in London, Ontario. Over the past decade, he has been involved in a number of community-based trans health research, promotion and education initiatives, including work with the Trans Men’s Working Group of the Ontario Gay Men’s Sexual Health Alliance.
1 I use trans men here to refer to those who are assigned a female sex at birth, but identify as male or masculine. Similarly, I use trans women as shorthand to refer to those who were assigned male at birth, but identify as female or feminine. These are imperfect terms, as many trans people do not necessarily identify as “men” or “women.”
2 Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender health in Massachusetts: results from a household probability sample of adults. American Journal of Public Health. 2012;102(1):118–22.
3 Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TT, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infectious Diseases. 2013;13(3):214–22.
4 As trans status is not captured in HIV testing data and other surveillance data sources, seroprevalence estimates for trans women rely almost exclusively on convenience sampling, often from venues where we would expect higher prevalence (e.g. sexual health clinics and HIV prevention programs). In addition, we are not able to estimate HIV prevalence for trans people in Canada.
5 Escudero DJ, Kerr T, Operario D, Socías ME, Sued O, Marshall BDL. Inclusion of trans women in pre-exposure prophylaxis trials: a review. AIDS care. 2015;27(5):637–41.
Gay/bi trans men are still MSM, having sex in that high risk pool, and should be included on that basis alone. We “don’t have evidence” because almost no (if not entirely no) studies separate out trans men by orientation. If you didn’t separate cis MSM from cis men who don’t have sex with men, this over-category would appear to be at less risk too.
Thanks for commenting, Jessie.
First of all, I hope I made it clear that I wholeheartedly support inclusion of trans MSM in broader studies of MSM. However, we don’t need to misrepresent the current evidence to advocate for that inclusion.
The thing is, many gay/bi trans men are *not* having sex with cisgender MSM- among gay/bi trans men overall, the proportion who have recently had sex with a cis man is lower than among cis gay/bi men (soon-to-be-published data from a few studies bear this out). So, what we actually need are data focussing on trans men who have sex with cis men, to address your valid concern about comparability. And again, even in that subgroup, data suggest lower levels of HIV-related sexual risk than among cis MSM (less condomless sex, most of which is vaginal sex). Less does NOT mean none, however. I conduct research on sexual health of gay/bi trans men, so I obviously think the topic is worthy of study.
Finally, when I said we “don’t have evidence”, I was explicitly referring to evidence of relatively high HIV prevalence or incidence. Documented HIV prevalence among trans men overall is low enough (0-3% in all existing studies, almost all closer to 0%) that even assuming that all of those cases are among trans MSM, HIV prevalence in that group would still be low relative to cis MSM.
For a published (open access) study that addresses some of what I mentioned above, see: Bauer GR, Redman N, Bradley K, Scheim AI. Sexual Health of Trans Men Who Are Gay, Bisexual, or Who Have Sex with Men: Results from Ontario, Canada. The International Journal of Transgenderism. 2013;14(2):66-74. doi:10.1080/15532739.2013.791650.
Thanks again for taking the time to comment, and I hope this helped to clarify what I was getting at!
1. “In fact, trans men participate in many HIV prevention research studies, whether or not they are identified as trans when results are reported.”
This is actually untrue. I’ve had one-on-one conversations with many of these researchers, including the team from iPrEx, IPERGAY, and PROUD, and they have all confirmed for me that the criteria for “MSM” explicitly stated participants must be “assigned male gender at birth”. Trans men have in fact been systematically excluded — not merely overlooked — from every single clinical efficacy trial for PrEP to date.
2. “Some do not identify as trans, but rather as men of trans experience or transitioned men, and are happy to check the “male” box without qualification.”
Researchers have noticed this and begun to account for it by asking two questions now: What is your current gender? What sex were you assigned at birth? This keeps trans men from being able to merely “check the male’ box without qualification” and serves to segregate trans men from cisgender men across the field of research.
3. “We can cautiously infer from research on non-trans people.”
Unfortunately, most medical professionals — who are not providing trans men with consistent, competent healthcare to begin with — are not cautious in the inferences they make. I know many trans men who have been prescribed PrEP and told by their doctors that as long as they take it at least 4 times a week they won’t get HIV, because that’s what the data show in MSM populations. The pervasive presumption of ciscentricity in our medical system is putting us at greater risk, and if researchers would be clear about saying “cisgender MSM” instead of merely “MSM” when they know they don’t have a representative sample of MSM in their data, these assumptions on the part of people applying the research in real-world clinical settings would be greatly reduced.
4. “While some gay, bi, and queer trans men are at risk for, or living with HIV, the impact of HIV in trans communities is largely experienced by trans women, who are at incredibly high risk of infection in many regions.”
We don’t know that trans women are at higher risk for HIV infection than trans men as trans men’s integration into predominantly cisgender gay cultural spaces improves. Studies actually suggest trans men may be at higher risk (81%) than trans women (55%) strictly in terms of reduced condom use (Kenagy & Hsieh, 2005, The Risk Less Known: Female to Male Transgender Persons’ Vulnerability to HIV infection) but that the only reason trans men’s HIV prevalence appears to be so low is that cisgender gay men have stigmatized and discriminated against trans men so extensively that trans men weren’t having enough sex to be at risk. As social awareness increases and trans MSM integration into gay community improves, we can expect to see HIV prevalence change accordingly (Rowniak, 2011, Transmen: The HIV Risk of Gay Identity), unless we intervene with safer sex education and tools like PrEP.
Moreover, I do not feel that it is useful to set up the false dichotomy of “trans women are at higher risk so we need to focus on them instead of trans men.” You don’t hear people saying “Gay men are at higher risk so let’s not talk about or study heterosexual Black women in the American South.” Where there’s a risk for HIV, there’s a risk for HIV. That risk is exceptionally prevalent among gay men, where half or more trans men are engaging in sexual activity. Dividing the trans community into finger-pointing over who deserves adequate medical care and who doesn’t is not useful for our progress as a community. We ALL deserve to be better-represented in the data. We ALL deserve not to be excluded or turned away when we show up to participate in research studies. We ALL deserve to know how a medication works in our body and how effective it is. We ALL deserve access to that resource.
Please do not undermine the struggles of trans men for our desperately-needed visibility just to appease those who have convinced you we’re not worthy of equality.
I know this was written quite a while ago, but i am wondering if the author (or other people!) would be open to chatting with me about this topic. i work for an organization under a contract that is brand new and working specifically with “msm of color.” there are obviously many issues that come up with this branding, and i would love to nerd out with someone and problem-solve/brainstorm alleys to inclusion.
please please feel free (anyone!) to email me. hopefully someone will see this.