Interviewers:
Nikki Calma, Carla Clynes, Matt Rice, Nashanta Stanley, Doan Thai

Field Coordinators:
Rob Guzman, Vince Guilin, Scott Ikeda

Referral Coordinator:
Ari Bachrach

Investigators:
Kristen Clements, MPH, Mitchell Katz, MD, Rani Marx, PhD, MPH

Community Advisory Committee Members:
Connie Amarthitada, Nadia Cabezas, Crystal Catamco, Tamara Ching, Patrick Forte, Sage Foster, Liz Highleyman, Russell Hilkene, Carry Kissel, Jade Kwan, Yosenio Lewis, Lauren Michaels, Margaret Morvay, Major, Chenit Ong-Flaherty, Elise Shiver-Russell, Zak Sinclair, Claire Skiffington, Tammy Jean Spirithawk, Viny Tango, Gina Tucker, Adela Vasquez, Kiki Whitlock, and Willy Wilkinson

Collaborating Interview Sites:
Asian & Pacific Islander Wellness Center, Center for Special Problems, Glide-Goodlett HIV/AIDS Program, Instituto Familiar de la Raza, New Village, Proyecto ContraSIDA Por Vida, and Tom Waddell Clinic

Other Collaborators:
FTM International, Motherload Bar, San Francisco Department of Public Health Laboratory, Southeast Asian Community Center, Tenderloin AIDS Resource Center, and Filipino Task Force on AIDS

A Special Thanks to Our Participants!!!

The Transgender Community Health Project (TCHP) is a quantitative study designed to assess HIV risk among Male-To-Female (MTF) and Female-To-Male (FTM) transgendered persons in San Francisco. From July 1, 1997 to December 31, 1997 we conducted an anonymous survey and HIV testing with 392 MTF and 123 FTM transgendered individuals. All participants were counseled and referred to appropriate health and prevention services.

MTF individuals reported high levels of lifetime HIV risk behaviors including: sex work (80%), unprotected receptive anal sex (85%), and injection drug use (34%). In addition, there is potential for continued HIV transmission among MTF participants and their partners because current risk behaviors (past 6 months) were commonly reported: sex work (48%), unprotected receptive anal sex (34%), and injection drug use (18%). Over one third (35%) of MTF participants were infected with HIV and among African Americans, almost two thirds (63%) were HIV positive.

For FTM participants, HIV prevalence was low (<2%) and current risk behaviors were infrequent. However, a history of unsafe receptive anal sex was reported by 28% of FTM participants, and among those who reported a history of injection drug use (18% of the sample), 91% shared syringes.

Based on our findings, we believe there is an urgent need for effective HIV prevention and harm reduction interventions for MTF transgendered individuals. Such interventions should make a special attempt to reach MTF African American individuals because this population had extremely high HIV prevalence. Currently, there are no HIV prevention interventions in San Francisco for FTM transgendered persons; such interventions will be most effective if they specifically target individuals who have sex with men and those who inject street drugs.

From July 1, 1997 to December 31, 1997 we conducted the Transgender Community Health Project (TCHP). We surveyed 392 MTF and 123 FTM transgendered individuals who were at least 18 years of age and lived, worked, or socialized in San Francisco. Results from qualitative focus groups conducted with 100 transgendered persons in 19961 and several months of formative research and neighborhood mapping guided the development of TCHP. In addition, members from both the MTF and the FTM transgender communities were involved in all planning, implementation, and evaluation activities.

Six transgendered individuals were hired as interviewers to conduct recruitment, interviewing, counseling and referrals. We used targeted sampling strategies2 to recruit MTF and FTM individuals from various street settings, bars, and social gatherings where transgendered persons were known to congregate. Flyers and posters were also placed at critical venues, agencies, clinics, and in the FTM International quarterly newsletter. In addition, agency/clinic staff who worked with transgendered clients referred individuals to the study. Eligibles who completed the survey referred other transgendered individuals to the study (snowball or chain-referral recruitment). All individuals who were recruited or referred to the study were given a 1-800 number that they called to find out more about the study, complete the eligibility screening, and set-up or reschedule an interview.

In addition to the AIDS Office, seven agencies that provided health or social services for transgendered persons were used as interview sites: Asian & Pacific Islander Wellness Center, New Village, Projecto ContraSIDA Por Vida, Tom Waddell Clinic, Glide-Goodlett HIV/AIDS program, Instituto Familiar de la Raza, and the Center for Special Problems. Using a standardized face-to-face interview, we assessed:

1. sociodemographics;
2. medical history and health status;
3. HIV prevention service access;
4. sexual behaviors; 5) drug use behaviors; and
5. psychosocial factors.

Interviews were conducted in English, Spanish, Vietnamese, Tagalog, and American Sign Language. After completing the interview, participants received HIV/STD education, harm reduction counseling, and referrals and were anonymously tested for HIV using the OraSure method.

At the end of the interview and HIV test, participants were scheduled for a follow-up appointment with the same interviewer who conducted the initial interview. At the follow-up appointment, participants who chose to do so received their HIV test results and further counseling and referrals. Participants were compensated $40.00 for the interview and $10 for the follow-up appointment.

We screened 645 individuals for eligibility, of whom, 586 (91%) were eligible. Of the eligibles, 523 (89%) completed the interview and HIV test. Eight intersexed individuals were excluded for this analysis because they could not be classified as either MTF or FTM, resulting in a final sample size of 515. Over two thirds (70%) of the participants returned for their follow-up appointment HIV test results. There were no demographic differences between those interviewed and those who did show up for the interview or between those who returned for their follow-up appointment and those who did not.

Table 1.1 - Sociodemographic Profile of 392 MTF Individuals

Characteristic MTF=392 Median Age 34 yrs (18-67) Race/Ethnicity African American 104 (27%) Latino/a 106 (27%) White 106 (27%) Asian & Pacific Isl. 49 (13%) Native American 24 (6%) Born Outside the United States 126 (32%) Gender Identity Transgender 145 (37%) Female 135 (34%) Transsexual 100 (26%) Other (i.e. bigender, cross-dresser) 12 (3%) Sexual Orientation Heterosexual 263 (67%) Bisexual 82 (21%) Gay/Homosexual 15 (4%) Lesbian 21 (5%) Asexual 10 (3%) Current Housing Status Stable Housing 207 (53%) Unstable Housing: SRO 105 (27%) Unstable Housing: Streets/Shelters 51 (13%) Unstable Housing: Crashing 29 (7%) Median Monthly Income (range) $744 ($55-7,346) Education < High School 112 (29%) High School/GED 110 (28%) Some College 117 (30%) College Degree + 52 (13%) History of Incarceration 255 (65%) Incarcerated Past Year 121 (31%)

The median age of MTF respondents was 34 years (range: 18-67 years) and 91% were currently living in San Francisco (Table 1.1). The MTF sample was racially/ethnically diverse: 27% African-American, 27% Latina, 27% White, 13% Asian or Pacific Islander, and 6% Native American. About one third (32%) were born outside the United States (usually in Central American or Southeast Asian counties). The majority of participants stated that their primary gender identification was transgender (37%), female (34%) or transsexual (26%); very few individuals identified as a transvestite, cross-dresser, drag queen, or a bigendered person. Most MTF individuals reported their sexual orientation as heterosexual (67%) or bisexual (21%).

The median monthly income for MTF participants was $744 (range: $55-7,346). The most common (nonmutually exclusive) ways that MTF participants obtained money in the past 6 months included part- or full-time employment (40%), sex work (32%), and SSI/SSDI (29%). Twenty nine percent of this sample had less than a high school education, 28% a high school degree, 30% some college education, and 13% a college or professional degree.

Almost two thirds (65%) of MTF participants reported a history of incarceration and 31% had been jailed in the past 12 months. Over half (53%) were currently living in a house or apartment (stable housing), 27% lived in Single Room Occupancy Hotels (SROs), 7% moved from place to place staying with friends and family members, and 13% were living on the streets and in shelters (homeless).

Over half (52%) of the MTF participants did not have health insurance, one third (34%) were publicly insured, and 14% were privately insured (table 1.2). Prior STD diagnosis was reported by 53% of participants; the most common STDs were gonorrhea (24%), syphilis (20%) and Hepatitis B (18%). One third of MTF participants stated that they had been prescribed medication for a mental health condition (excluding Gender Identity Disorder), 22% had been hospitalized for a mental health condition, and 32% reported a past suicide attempt. Over three fourths (78%) of the MTF participants received health care at a doctor's office or clinic in the past six months (usually associated with hormone therapy).

Table 1.2 - Physical and Mental Health Characteristics of 392 MTF Individuals

Characteristic MTF=392 Health Insurance None 202 (52%) Public 132 (34%) Private 56 (14%) Diagnosed with STD (ever) 207 (53%) Prescribed Medication for Mental Health 130 (33%) Hospitalized for Mental Health 87 (22%) Attempted Suicide 127 (32%) Received Health Care (past 6 months) 306 (78%)

As shown in Table 1.3, most (91%) MTF participants reported past hormone use and 65% reported hormone injection. Recent hormone use (past six months) was reported by 73% of individuals. MTF participants who recently used hormones typically obtained their hormones from a clinic or private doctor (71%), although 20% bought hormones off the streets and 9% obtained them from friends. About one third (31%) of MTF participants reported injecting their hormones in the past 6 months. Most (85%) participants who injected hormones in the past 6 months obtained their needles from reliable and safe sources such as a clinic, private doctor, pharmacy or needle exchange site. Recent hormone syringe sharing was rare (only three individuals).

Some type of sexual reassignment or gender confirmation surgery was reported by 22% of MTF individuals. The most common (nonmutually exclusive) types of surgery were breast augmentation or implants (16%), followed by vaginoplasty (9%), hip enlargement (7%), and facial plastic surgery (7%). Almost three fourths (72%) of MTF participants planned to have some type of sexual reassignment or gender confirmation surgery in the future.

Table 1.3 - Hormone Use & Sexual Reassignment Surgery among 392 MTF Individuals

Characteristic MTF=392 Hormone Use (ever) 357 (91%) Hormone Injection (ever) 256 (65%) Hormone Use (past 6 months) 286 (73%) Hormone Injection (past 6 months) 121 (31%) Sexual Reassignment Surgery (SRS) 86 (22%) Plan to have SRS in the future 282 (72%)

All MTF participants reported some type of abuse and discrimination because of their gender identity or gender presentation, including: verbal abuse (83%), employment discrimination (46%), physical abuse (37%), housing discrimination (27%), and problems obtaining health care (13%). In addition, recent physical abuse (past 12 months) was reported by 37% of MTF participants; 44% of those recently abused were abused by a boyfriend, husband, domestic partner, or sex partner.

Over one third (35%) of MTF participants tested positive for HIV infection and prevalence among African Americans was more than double that of other racial/ethnic groups (Figure 1.2). Of the HIV-infected MTF participants, 65% already knew they were infected, 20% found out their status for the first time while participating in TCHP, and 15% did not return and/or chose not to be told their test results. Of the participants who knew they were infected, 78% were receiving HIV health care and 58% were receiving some type of drug therapy. However, 28% of HIV infected MTF individuals with a self-reported T-Cell count less than 200 were not receiving any form of HIV drug therapy.

A history of participation in an alcohol treatment program was reported by 16% of MTF subjects and 23% had been in a drug treatment program. Lifetime noninjection drug use was frequent: marijuana (90%), cocaine (66%), speed (57%), LSD (52%), poppers (50%), crack (48%) and heroin (24%). The drugs used most frequently in the past 6 months were marijuana (64%), speed (30%), and crack (21%) (figure 1.3).

A third of MTF participants (34%) reported a history of injection drug use (excluding hormone injection) and 63% of this group shared syringes. The drugs most commonly injected were speed (84%), heroin (58%), and cocaine (54%). Recent injection (past 6 months) was reported by 18% of the MTF sample and speed was the most commonly used drug by recent injectors (83%). Almost half (47%) of the MTF participants who injected drugs in the past 6 months reported sharing syringes, 49% used one syringe to load another (backloading), and 29% shared cookers (figure 1.4).

The median number of lifetime sexual partners for MTF participants was 150 (range: 1-9,020 sex partners); most of these sex partners were male (Table 1.4). Over three fourths (80%) of the MTF population reported a history of sex work and 59% reported a history of forced sex or rape. Rates of unprotected sex were also high: unsafe receptive anal intercourse (85%), unsafe insertive anal intercourse (64%), and unsafe vaginal receptive intercourse (6%).

Table 1.4 - Lifetime Sexual Behaviors of 392 MTF Participants

Lifetime Sexual Behaviors MTF=392 # Sexual Partners, median (range) 150 (1-9,020) Sex Work/Survival Sex 313 (80%) Forced Sex/Rape 231 (59%) Receptive Anal Intercourse (no condom) 334 (85%) Insertive Anal Intercourse (no condom) 249 (64%) Receptive Vaginal Intercourse (no condom) 23 (6%)

As shown in table 1.5, MTF participants reported a median of 8 sexual partners (range: 1-2201 partners) in the past six months. Almost half (48%) of MTF participants had sex with a main partner, 53% with a casual partner, and 48% with a paying partner. Almost two thirds of the sample (63%) participated in receptive anal intercourse, of whom, 54% had sex without a condom. About one third (30%) had insertive anal intercourse, with 38% of this group having unprotected sex. Only 4% of MTF individuals had receptive vaginal intercourse (few had vaginal construction surgery), but 65% of those who had vaginal sex did so without using a condom. Three fourths of the MTF population participated in receptive oral sex; 80% of this group had unprotected sex.

Table 1.5 - Recent Behaviors of 392 Sexually Active MTF Participants

Sexual Behaviors (past 6 months) MTF=392 # Sexual Partners, median (range) 8 (1-1201) Sex With a Main Partner 187 (48%) Sex With a Casual Partner 209 (53%) Sex With a Paying Partner 190 (48%) Receptive Anal Intercourse 248 (63%) Unprotected 133/248 (54%) Insertive Anal Intercourse 119 (30%) Unprotected 45/119 (38%) Receptive Vaginal Intercourse 17 (4%) Unprotected 11/17 (65%) Receptive Oral Intercourse 294 (75%) Unprotected 234/294 (80%)

The median age of the FTM participants was 36 years (range: 19-61 years) and 58% were currently living in San Francisco (Table 2.1). Over two thirds (67%) of the FTM sample were White, 12% Latino, 10% African American, 7% Asian or Pacific Islander, and 3% Native American. Only 14% of FTM participants were born outside the United States. The majority of FTM participants stated that their primary gender identification was transgender (37%), male (33%), or transsexual (21%). Over one third (35%) of the sample identified as heterosexual, 33% as bisexual, 18% as gay/homosexual, and 12% as lesbian.

The median monthly income for FTM participants was $1,100 (range: $100-6,000). Their primary source of income was employment (81%), followed by SSI/SSDI (13%), and family support (12%). High education levels were reported by FTM participants: college/professional degree (46%), some college (39%), high school degree (11%), and less than high school (4%). Past incarceration was reported by 29% of FTM individuals and 5% had been jailed in the last year. Over three fourths (79%) of participants had stable housing (house or apartment), 6% lived in SROs, 8% crashed with friends and relatives, and 7% were currently living on the streets or in shelters.

Table 2.1 - Sociodemographic Profile of 123 FTM Individuals

Characteristic MTF=123 Median Age 36 yrs (19-61) Race/Ethnicity White 82 (67%) Latino/a 14 (11%) African American 12 (10%) Asian & Pacific Isl. 9 (7%) Native American 4 (3%) Born Outside the United States 17 (14%) Gender Identity Transgender 46 (37%) Male 41 (33%) Transsexual 26 (21%) Other (i.e. bigender, cross-dresser) 10 (8%) Sexual Orientation Heterosexual 43 (35%) Bisexual 41 (33%) Gay/Homosexual 22 (18%) Lesbian 15 (12%) Asexual 2 (2%) Current Housing Status Stable Housing 97 (79%) Unstable Housing: SRO 7 (6%) Unstable Housing: Streets/Shelters 10 (8%) Unstable Housing: Crashing 9 (7%) Median Monthly Income (range) $1,100 ($100-6,000) Education College Degree + 57 (46%) Some College 48 (39%) High School/GED 13 (11%) < High School 5 (4%) History of Incarceration 36 (29%) Incarcerated Past Year 6 (5%)

As shown in table 2.2, 41% of FTM participants did not have health insurance, 47% were privately insured, and 11% were publicly insured. About one third (31%) of the FTM sample had been diagnosed with an STD, 48% had been prescribed medication for a mental health condition (excluding Gender Identity Disorder), 20% had been hospitalized for a mental health condition, and 32% reported a past suicide attempt. Most (83%) participants received health care at a doctor's office or clinic in the past 6 months (typically associated with hormone therapy).

Table 2.2 - Physical and Mental Health Characteristics of 123 FTM Individuals

Characteristic FTM=123 Health Insurance None 51 (41%) Private 58 (47%) Public 14 (11%) Diagnosed with STD (ever) 38 (31%) Prescribed Medication for Mental Health 59 (48%) Hospitalized for Mental Health 24 (20%) Attempted Suicide 39 (32%) Received Health Care (past 6 months) 102 (83%)

Over half (57%) of FTM participants reported a history hormone use and 54% stated that they injected hormones (table 2.3). Recent hormone use (past six months) was reported by 53% FTM individuals and almost all recent hormone users (97%) acquired their hormones from a medical source. Over half (51%) of FTM participants reported injecting hormones in the past six months. Most (92%) recent hormone injectors obtained their needles from reliable and safe sources such as a clinic, private doctor, pharmacy or needle exchange site. Recent hormone syringe sharing (past 6 months) was not reported by any FTM individuals.

One third of FTM participants had sexual reassignment or gender confirmation surgery. The most common type of surgery was breast removal or reduction (32%), followed by hysterectomy (11%), and penis construction or clitoral release (4%). Most (85%) participants planned to have some type of sexual reassignment or gender confirmation surgery.

Table 1.3 - Hormone Use & Sexual Reassignment Surgery among 123 FTM Individuals

Characteristic FTM=123 Hormone Use (ever) 70 (57%) Hormone Injection (ever) Hormone Use (past 6 months) 65 (53%) Hormone Injection (past 6 months) 63 (51%) Sexual Reassignment Surgery (SRS) 41 (33%) Plan to have SRS in the future 104 (85%)

Two FTM individuals (1.6%) tested positive for HIV infection; both subjects were aware of their HIV status and were receiving medical care.

Some form of discrimination and abuse related to gender presentation or gender identity reported all FTM participants: verbal abuse (85%), employment discrimination (57%), being denied or having difficulties obtaining health care (39%), physical abuse (30%), and housing discrimination (20%). Recent physical abuse (past 12 months) was reported by 27% of FTM participants; 30% of those recently abused were abused by a boyfriend/girlfriend, husband/wife, domestic partner, or sex partner.

A history of participation in an alcohol treatment program was reported by 23% of FTM subjects and one fifth of the sample reported a history of drug treatment. Lifetime noninjection drug use was common: marijuana (89%), LSD (67%), cocaine (52%), speed (50%), and "poppers" (42%) (figure 2.3). The only drug frequently used in the past 6 months was marijuana (43%).

Lifetime injection drug use (excluding hormone injection) was reported by 18% of the sample and 91% of this group shared syringes. The drugs most commonly used by FTM injectors were speed (77%), heroin (59%), and cocaine (59%). Only 4% of FTM individuals reported injection drug use in the past 6 months (excluding hormone injection). Unfortunately, small sample size limits the ability to assess recent injection behaviors among FTM participants.

The median number of lifetime sexual partners for FTM participants was 27 (range: 1-2,014 sex partners); equal proportions of male and female sex partners were reported (Table 2.4). About one third (31%) of the FTM population had engaged in sex work in the past and 59% reported a history of forced sex or rape. Unprotected receptive anal intercourse was reported by 28% of FTM participants and almost two thirds (64%) had unprotected vaginal intercourse.

Table 1.4 - Lifetime Sexual Behaviors of 392 MTF Participants

Lifetime Sexual Behaviors FTM=123 Sexual Behaviors (lifetime) # (%) # Sexual Partners, median (range) 27 (1-2,014) Sex Work/Survival Sex 38 (31%) Forced Sex/Rape 72 (59%) Receptive Anal Intercourse (no condom) 34 (28%) Insertive Anal Intercourse (no condom) -------- Receptive Vaginal Intercourse (no condom) 79 (64%)

As shown in table 2.5, FTM participants reported a median of two sex partners in the past 6 months (range: 1-28 partners). Over half (58%) of the sample had sex with a main partner, 41% had sex with a casual partner, and 4% had sex with a paying partner. Only 7% of FTM participants had receptive anal intercourse in the past 6 months, but 56% of this group had unprotected sex. One fifth of the sample had receptive vaginal intercourse, 67% of whom did so without a using a condom. Receptive oral sex was reported by 21% of the FTM participants, with 73% of this group practicing unprotected sex.

Table 1.5 - Recent Behaviors of 123 FTM Participants

Sexual Behaviors (past 6 months) MTF=123 # Sexual Partners, median (range) 2 (1-18) Sex With a Main Partner 72 (58%) Sex With a Casual Partner 50 (41%) Sex With a Paying Partner 5 (4%) Receptive Anal Intercourse 9 (7%) Unprotected 5/9 (56%) Receptive Vaginal Intercourse 12 (10%) Unprotected 8/12 (67%) Receptive Oral Intercourse 26 (21%) Unprotected 19/26 (73%)

To our knowledge, this is the first study to quantitatively examine the level of HIV infection and risk behaviors in both MTF and FTM transgendered individuals. Using targeted and snowball sampling techniques, we were able to sample a large number of transgendered persons who typically are not eligible for studies or are excluded from analyses because their gender does not fit the male/female dichotomy. The importance of studying this population is underscored by the high levels of HIV prevalence and risk behaviors we found.

A history of engaging in HIV risk behaviors such as unprotected anal sex, injection drug use, and sex work were commonly reported by MTF participants. In addition, high levels of recent risk behaviors suggest continued transmission of HIV among MTF individuals and their sexual and drug using partners. We also found an alarmingly high level of HIV infection in MTF individuals, particularly among African Americans. Although it is difficult to compare our findings to other populations surveyed with different sampling strategies, it is clear that MTF transgendered individuals are one of the highest risk populations in San Francisco.

Overall, we found low HIV prevalence and few current risk behaviors among FTM participants. However, lifetime rates of unprotected receptive anal sex and needle sharing suggest that FTM individuals who have sex with men and those who inject street drugs may be at risk for acquiring HIV.

We believe there is an urgent need for effective HIV prevention and harm reduction interventions for MTF transgendered individuals. Such interventions need to emphasize both sexual and injection risk and should make a special attempt to reach African Americans because this population has extremely high HIV prevalence. Currently, there are no interventions in San Francisco for FTM transgendered persons; such interventions will be most effective if they specifically target FTM individuals who have sex with men and those who inject street drugs.

Regardless of the interventions implemented, hiring transgendered people to provide HIV prevention is probably the most effective way to reach those individuals most in need of services.

1. Clements, K., Wilkinson, W., Kitano, K., Marx, R. HIV Prevention and Health Service Needs of the Transgender Community in San Francisco. International Journal of Transgenderism. 1999 (In Press).
2. Watters JK, Biernacki P. Targeted sampling: options for the study of hidden populations. Social Problems. 1989; 36:416-430.

For more information contact: Kristen Clements, TCHP Project Director
San Francisco Department of Public Health
25 Van Ness, #500, San Francisco, CA 94102
(415) 554-9496 kristen_clements@dph.sf.ca.us