By Matthew Hibbert and Aedan Wolton
The sexual health needs of trans people remain understudied in the UK and internationally. It is estimated that the worldwide prevalence of HIV among trans women is around 19%, but there is currently no research in the UK regarding HIV prevalence among trans people.
Previous research into trans sexual health and HIV has focused mostly on trans women and little is known about trans men and non-binary people, who may be at risk of HIV if having condomless sex with cisgender men. Societal stigma faced by trans people can be in the form of barriers to healthcare access and discrimination, with internalised self-stigma also contributing to the health inequalities experienced by trans people.
The UK National LGBT Survey undertaken by the Government Equalities Office found that 17% of trans people had attended a sexual health clinic, compared to 29% of cisgender people. Among those that had attended a sexual health clinic, trans people were more likely to report a negative experience when accessing the service.
For those living with HIV in the UK, accessing healthcare is vital. HIV care in the UK is excellent; the vast majority of people living with HIV have an undetectable viral load and therefore cannot transmit HIV.
The LGBT+ Sex and Lifestyles Survey
The aim of The LGBT+ Sex and Lifestyles Survey was to further understand uptake of sexual health services in the UK and the sexual health needs of LGBT+ people. An online survey recruited participants between April-June 2018 using Facebook advertising. Community organisations also promoted the survey on social media. The survey was divided into three sections: “about you”, “sexual health and drug use”, and “psychological wellbeing”.
Two questions were used to collect gender data, which was adapted from Public Health England’s HIV monitoring system with input from community organisations:
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
- prefer not to say
Is this the same gender you were assigned at birth?
- Yes
- No
- Prefer not to say
Participants who responded that their current gender was not the same as the gender they were assigned at birth (and did not respond prefer not to say for the first question) were grouped as trans. Participants who responded that their current gender was the same as the gender they were assigned at birth were grouped as cisgender.
What we found
3,507 participants completed the survey (3,007 cisgender and 500 trans people; 147 trans men, 88 trans women, 244 non-binary people, 21 in another way). Among trans participants, only one participant, a trans man, reported living with HIV, and only three participants reported taking PrEP (preventative medication that significantly reduces the likelihood of contracting HIV), despite trans people recently being included in national guidelines to be considered eligible for PrEP. It was also found that trans people were more likely to report experiencing discrimination in a medical setting in the past 12 months (23% vs. 4%), and over four fifths of trans participants had high or very high levels of psychological distress.
Sexual Health Clinic Attendance
Similar to the UK National LGBT Survey, we found that trans people were less likely to have attended a sexual health clinic in the past 12 months compared to cisgender people (27% vs. 36%). When controlling for multiple factors, we found that trans people were more likely to attend a sexual health clinic if they had engaged in sexual risk behaviours such as condomless anal sex or reported taking alcohol or drugs before sex. It was also found that trans people who had greater life satisfaction and those who lived in London were more likely to attend a sexual health clinic, and those who were unemployed were less likely to have attended a sexual health clinic.
HIV Testing
Additionally, we found that trans people were less likely to report ever having had an HIV test compared to cisgender participants (49% vs. 64%). When controlling for multiple factors, we found that trans people were more likely to report ever having an HIV test if they had engaged in sexual risk taking, were older, were a person of colour and were in a relationship with multiple partners.
Although it appears positive that those engaging in sexual risk behaviours were more likely to have attended a sexual health clinic and to report ever having an HIV test, over 50% of those that had engaged in condomless anal sex in the past 12 months had not attended a sexual health clinic in the same period, and 32% had never had an HIV test. We were surprised not to find more trans people living with HIV. This could be due to a low prevalence in the UK because of excellent HIV care, or there could be a high level of undiagnosed HIV, as over half of trans participants had never had an HIV test. Future research is needed to understand this further.
Discrimination
Trans people were more likely to report experiencing discrimination in healthcare compared to cisgender people. Whilst it was not measured if this took place in a sexual health clinic, training should be provided to sexual health workers, and health professionals more generally, to help remove barriers to accessing care. Trans people who lived in London were more likely to report attending a sexual health clinic, which may reflect London having some of the UK’s only trans specific sexual health clinics. Trans people who were unemployed were less likely to attend a sexual health clinic, which could be because local services are not as inclusive for trans people, and therefore trans people need to travel further for care.
In conclusion, uptake of sexual health services among trans people requires significant improvement. 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, and by training sexual health workers on trans sexual health needs. Additionally, to fully understand the community’s sexual health needs, it is important that trans and non-binary people are included in the development of both sexual health programmes and research.
We would like to thank the participants who took part in the survey, and the community organisations involved in the design, recruitment and promoting of the survey.