Transgender and Gender Diverse Persons
Transgender persons often experience high rates of stigma and socioeconomic and structural barriers to care that negatively affect health care usage and increase susceptibility to HIV and STIs (326–332). Persons who are transgender have a gender identity that differs from the sex that they were assigned at birth (333,334). Transgender women (also known as trans women, transfeminine persons, or women of transgender experience) are women who were assigned male sex at birth (born with male anatomy). Transgender men (also known as trans men, transmasculine persons, or men of transgender experience) are men who were assigned female sex at birth (i.e., born with female anatomy). In addition, certain persons might identify outside the gender binary of male or female or move back and forth between different gender identities and use such terms as “gender nonbinary,” “genderqueer,” or “gender fluid” to describe themselves. Persons who use terms such as “agender” or “null gender” do not identify with having any gender. The term “cisgender” is used to describe persons who identify with their assigned sex at birth. Prevalence studies of transgender persons among the overall population have been limited and often are based on small convenience samples.
Gender identity is independent of sexual orientation. Sexual orientation identities among transgender persons are diverse. Persons who are transgender or gender diverse might have sex with cisgender men, cisgender women, or other transgender or gender nonbinary persons.
Clinical Environment Assessment
Providers should create welcoming environments that facilitate disclosure of gender identity and sexual orientation. Clinics should document gender identity and sex assigned at birth for all patients to improve sexual health care for transgender and gender nonbinary persons. Assessment of gender identity and sex assigned at birth has been validated among diverse populations, has been reported to be acceptable (335,336), and might result in increased patients identifying as transgender (337).
Lack of medical provider knowledge and other barriers to care (e.g., discrimination in health care settings or denial of services) often result in transgender and gender nonbinary persons avoiding or delaying preventive care services (338–340) and incurring missed opportunities for HIV and STI prevention services. Gender-inclusive and trauma-guided health care might increase the number of transgender patients who seek sexual health services, including STI testing (341), because transgender persons are at high risk for sexual violence (342).
Primary care providers should take a comprehensive sexual history, including a discussion of STI screening, HIV PrEP and PEP, behavioral health, and social determinants of sexual health. Clinicians can improve the experience of sexual health screening and counseling for transgender persons by asking for their choice of terminology or modifying language (e.g., asking patients their gender pronouns) to be used during clinic visits and history taking and examination (343). Options for fertility preservation, pregnancy potential, and contraception options should also be discussed, if indicated. For transgender persons who retain a uterus and ovaries, ovulation might continue in the presence of testosterone therapy, and pregnancy potential exists (https://transcare.ucsf.eduexternal icon).
A systematic review and meta-analysis of HIV infection among transgender women estimated that HIV prevalence in the United States is 14% among transgender women, with the highest prevalence among Black (44%) and Hispanic (26%) transgender women (344). Data also demonstrate high rates of HIV infection among transgender women worldwide (345). Bacterial STI prevalence varies among transgender women and is based largely on convenience samples. Despite limited data, international and U.S. studies have indicated elevated incidence and prevalence of gonorrhea and chlamydia among transgender women similar to rates among cisgender MSM (346–348). A recent study using data from the STD Surveillance Network revealed that the proportions of transgender women with extragenital chlamydial or gonococcal infections were similar to those of cisgender MSM (349).
Providers caring for transgender women should have knowledge of their patients’ current anatomy and patterns of sexual behavior before counseling them about STI and HIV prevention. The majority of transgender women have not undergone genital-affirmation surgery and therefore might retain a functional penis; in these instances, they might engage in insertive oral, vaginal, or anal sex as well as receptive oral or anal sex. In the U.S. Transgender Survey, 12% of transgender women had undergone vaginoplasty surgery, and approximately 50% more were considering surgical intervention (350). Providers should have knowledge about the type of tissue used to construct the neovagina, which can affect future STI and HIV preventive care and screening recommendations. The majority of vaginoplasty surgeries conducted in the United States use penile and scrotal tissue to create the neovagina (351). Other surgical techniques use intestinal tissue (e.g., sigmoid colon graft) or split-skin grafts (352). Although these surgeries involve penectomy and orchiectomy, the prostate remains intact. Transgender women who have had a vaginoplasty might engage in receptive vaginal, oral, or anal sex.
Neovaginal STIs have infrequently been reported in the literature and include HSV and HPV/genital warts in penile-inversion vaginoplasty, C. trachomatis in procedures that involved penile skin and grafts with urethra mucosa or abdominal peritoneal lining (353), and N. gonorrhoeae in both penile-inversion and colovaginoplasty (354–359). If the vaginoplasty used an intestinal graft, a risk also exists for bowel-related disease (e.g., adenocarcinoma, inflammatory bowel disease, diversion colitis, and polyps) (360–362).
The few studies of HIV prevalence among transgender men indicated that they have a lower prevalence of HIV infection than transgender women. A recent estimate of HIV prevalence among transgender men was 2% (344). However, transgender men who have sex with cisgender men might be at elevated risk for HIV infection (332,363,364). Data are limited regarding STI prevalence among transgender men, and the majority of studies have used clinic-based data or convenience sampling. Recent data from the STD Surveillance Network demonstrated higher prevalence of gonorrhea and chlamydia among transgender men, similar to rates reported among cisgender MSM (365).
The U.S. Transgender Survey indicated that the proportion of transgender men and gender diverse persons assigned female sex at birth who have undergone gender-affirmation genital surgery is low. Providers should consider the anatomic diversity among transgender men because a person can undergo a metoidioplasty (a procedure to increase the length of the clitoris), with or without urethral lengthening, and might not have a hysterectomy and oophorectomy and therefore be at risk for bacterial STIs, HPV, HSV, HIV, and cervical cancer (366). For transgender men using gender-affirming hormone therapy, the decrease in estradiol levels caused by exogenous testosterone can lead to vaginal atrophy (367,368) and is associated with a high prevalence of unsatisfactory sample acquisition (369). The impact of these hormonal changes on mucosal susceptibility to HIV and STIs is unknown.
Transgender men who have not chosen to undergo hysterectomy with removal of the cervix remain at risk for cervical cancer. These persons often avoid cervical cancer screening because of multiple factors, including discomfort with medical examinations and fear of discrimination (338,370). Providers should be aware that conducting a speculum examination can be technically difficult after metoidioplasty surgery because of narrowing of the introitus. In these situations, high-risk HPV testing using a swab can be considered; self-collected swabs for high-risk HPV testing has been reported to be an acceptable option for transgender men (371).
The following are screening recommendations for transgender and gender diverse persons:
- Because of the diversity of transgender persons regarding surgical gender-affirming procedures, hormone use, and their patterns of sexual behavior, providers should remain aware of symptoms consistent with common STIs and screen for asymptomatic infections on the basis of the patient’s sexual practices and anatomy.
- Gender-based screening recommendations should be adapted on the basis of anatomy (e.g., routine screening for trachomatis and N. gonorrhoeae) as recommended for all sexually active females aged <25 years on an annual basis and should be extended to transgender men and nonbinary persons with a cervix among this age group.
- HIV screening should be discussed and offered to all transgender persons. Frequency of repeat screenings should be based on level of risk.
- For transgender persons with HIV infection who have sex with cisgender men and transgender women, STI screening should be conducted at least annually, including syphilis serology, HCV testing, and urogenital and extragenital NAAT for gonorrhea and chlamydia.
- Transgender women who have had vaginoplasty surgery should undergo routine STI screening for all exposed sites (e.g., oral, anal, or vaginal). No data are available regarding the optimal screening method (urine or vaginal swab) for bacterial STIs of the neovagina. The usual techniques for creating a neovagina do not result in a cervix; therefore, no rationale exists for cervical cancer screening (368).
- If transgender men have undergone metoidioplasty surgery with urethral lengthening and have not had a vaginectomy, assessment of genital bacterial STIs should include a cervical swab because a urine specimen will be inadequate for detecting cervical infections.
- Cervical cancer screening for transgender men and nonbinary persons with a cervix should follow current screening guidelines (see Human Papillomavirus Infections).