Sexual health care barriers and HIV/STI prevention for transgender people in Japan

Summary

Primary care and sexual health services for transgender people in Japan are lacking. We surveyed 233 transgender patients (57 [24.5%] assigned male at birth [AMABs] and 176 [75.5%] assigned female at birth [AFABs]) at the Personal Health Clinic to collect data on sexually transmitted infections (STI) and human immunodeficiency virus (HIV) risk, as well as lifestyle, stigma, and health literacy. Among respondents, 55% reported a sexual intercourse history, and 7.6% noted a previous STI. Only 62.2% underwent free STI testing. Current smoking rates were 19.3% higher in AFABs. Hospital visit hesitation was reported by 59.6%, and 83.3% experienced daily mental struggles. Awareness of post-exposure prophylaxis and pre-exposure prophylaxis was low. Our findings highlight the urgent need for improved primary care and sexual health services for transgender people in Japan, emphasizing the necessity to increase sexual health care facilities, reduce primary care access barriers, and improve knowledge among health care providers.

Introduction

By 2022, 12,000 transgender people with Japanese citizenship had undergone a legal gender change. While the actual number is unknown, as many transgender people do not legally change their gender. Primary care and sexual health care for transgender people in Japan are poorly developed. Health providers may lack knowledge about transgender people due to shortcomings in medical education (1). Consequently, transgender people who are ill may hesitate to seek care because physicians often do not understand the concept of gender.

We conducted a survey on sexual health care and examined lifestyle, stigma, and health literacy in the transgender population.

Current situation in Japan and overseas regarding transgender medical care

Few physicians in Japan have received specialized training in transgender-affirming care, and data on primary or sexual health care for transgender people remain limited (1). One gap of particular concern is the lack of comprehensive data on the risk of sexually transmitted infections (STI) and human immunodeficiency virus (HIV) infection among transgender individuals. Previous research showed that transgender individuals in Asia, including Japan, face stigma and poor understanding among health care providers. Additionally, the number of certified specialists in gender incongruence remains low in Japan (2). According to the World Professional Association for Transgender Health Standards of Care, there is a pressing need to improve gender-affirming care globally, including primary care and sexual health (3). To address this gap, we conducted a survey on sexual health care, and examined lifestyle, stigma, and health literacy in the Japanese transgender population.

Several countries have already implemented specific measures to provide comprehensive transgender-affirming health care. For example, the Fenway Institute in Boston has developed a successful, integrative model of transgender healthcare that includes primary care, mental health services, and gender-affirming treatments. Their approach, which emphasizes patient-centered care and provider training, has significantly improved health outcomes and reduced disparities among transgender patients (4). Japan could follow these successful models to improve access to transgender-affirming care.

Questionnaire survey

This study conforms to the provisions of the Declaration of Helsinki (as revised in 2013). We surveyed 233 transgender patients who visited the gender outpatient department at the Personal Health Clinic between June 2023 and April 2024 (10 months). The main purpose of the clinic visits was treatment consultation and gender-affirming hormone therapy (GAHT). At the initial visit, patients whose informed consent was obtained were given free STI/HIV testing and surveyed using online questionnaires.

Response options to the survey questions were yes, no, don't know, and refuse to answer. Only patients who answered with a yes or no response and were able to complete the online questionnaire were included in the study. We excluded respondents who did not answer eight mandatory questions. Sex assigned at birth was a required response; respondents were divided into transgender individuals assigned male at birth (AMABs) and transgender individuals assigned female at birth (AFABs). Gender identity was freely reported: responses included transgender female or male, male to female, female to male, non-binary, and genderqueer.

Characteristics of survey respondents

Of 233 respondents, 57 (24.5%) were AMABs and 176 (75.5%) were AFABs. The mean age of transgender patients was approximately 32.7 years. The mean age of AMABs was 34.5 years, with 27 (47.4% of AMABs) under age 30 years, 13 (22.8%) between age 31 and 40 years, and 17 (29.8%) over age 41 years. The average age of AFABs was 32.1 years; 76 (43.2% of AFABs) were under age 30 years, 80 (45.5%) were between age 31 and 40 years, and 20 (11.4%) were aged 41 years or older.

Table 1 shows the rate of yes responses and the yes/no ratio among AMABs and AFABs. Among 211 respondents who responded regarding their history of sexual intercourse, 55% answered yes, including 66.7% of AMABs and 49% of AFABs; a higher rate of sexual intercourse experience was observed in older respondents. Regarding STI history, 197 respondents gave valid answers (yes or no), with a surprisingly low proportion noting a previous STI history (7.6%).

Table 1. Sexual health literacy, medical care accessibility, and life difficulty among transgender people.

Characteristics			Transgender
			AMABs				AFABs
	n	Yes responses (%)	Average	Age (y)			Average	Age (y)
				≤ 30	31–40	≥ 41		≤ 30	31–40	≥ 41
Sexual intercourse experience	211	55.0	66.7	56.0	76.9	85.7	66.7	56.0	76.9	85.7
STI history	197	7.6	6.0	4.5	15.4	0.0	6.0	4.5	15.4	0.0
Accepts STI check	233	62.2	31.6	29.6	30.8	35.3	31.6	29.6	30.8	35.3
Current smoker	233	19.3	8.8	3.7	7.7	17.6	8.8	3.7	7.7	17.6
Hesitates to visit a hospital	194	58.8	52.1	47.8	63.6	50.0	52.1	47.8	63.6	50.0
Struggles mentally in daily life	205	82.4	77.1	82.6	63.6	78.6	77.1	82.6	63.6	78.6

AMABs, assigned male at birth; AFABs, assigned female at birth; STI, sexually transmitted infection.

All study participants (n = 233) gave valid answers about accepting free STI testing and current smoking. Only 62.2% of respondents underwent free testing for STI (syphilis, gonorrhea, chlamydia, hepatitis B virus, and HIV): 31.6% of AMABs and 72.2% of AFABs. More AFABs than AMABs underwent free STI testing in all age groups (≤ 30, 31-40, and ≥ 41 years), indicating that AFABs may be more aware of their own STI risk. Total smoking rate was 19.3% in the total: 8.8% of AMABs and 22.7% of AFABs, with higher rates among AFABs in all age groups.

A total of 194 and 205 transgender people gave valid answers regarding hesitation to visit a hospital and mental struggles in daily life, respectively. Specifically, 58.8% of AMABs and 61.0% of AFABs said they were hesitant about visiting a hospital when ill; 82.4% of AMABs and 84.1% of AFABs reported mental struggles in daily life. Higher proportions of AFABs reported these problems across all age groups.

As shown in Table 2, we surveyed respondents regarding their awareness about post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP); 87 transgender people (23 AMABs and 64 AFABs) gave valid answers to both questions. Among them, 20.7% and 10.3% of respondents knew about PEP and were interested in PrEP, respectively. A higher proportion of AMABs knew about PEP and were interested in PrEP compared with AFABs in all age groups. In particular, younger AMABs seemed to have greater awareness about PEP and interest in PrEP.

Table 2. PEP and PrEP awareness among transgender people.

Characteristics			Transgender
			AMABs				AFABs
	n	Yes responses (%)	Average	Age (y)			Average	Age (y)
				≤ 30	31–40	≥ 41		≤ 30	31–40	≥ 41
Knows about PEP	87	20.7	39.1	37.5	50.0	20.0	14.1	16.1	15.4	0.0
Interested in PrEP	87	10.3	13.0	25.0	10.0	0.0	9.4	9.7	11.5	0.0

AMABs, assigned male at birth; AFABs, assigned female at birth; PEP, post-exposure prophylaxis; PrEP, pre-exposure prophylaxis.

Experience of sexual intercourse

Few studies have investigated the rates of sexual intercourse among transgender individuals in Japan using comprehensive definitions of gender and sexuality. Available data often do not distinguish between cisgender and transgender populations (1). One survey reported that the age-standardized prevalence of never having had heterosexual intercourse among adults aged 18-39 years was 24.6% for "women" and 25.8% for "men" (5); however, it is unclear whether these categories were based on gender identity or sex assigned at birth. Overall, approximately 70% of respondents said they had had sexual intercourse. The rate of sexual intercourse among transgender people in our study was only 55%. Some transgender people may also have misconceptions about what constitutes sexual intercourse. It may be helpful to explore patients' understanding of sexual intercourse to address any potential misconceptions.

Here, we identified one chlamydia-positive person among those who requested free STI/HIV testing, despite this individual claiming to never have had sexual intercourse. Without proper awareness, STI/ HIV infection rates among transgender people may increase undetected. Thus, measures to raise awareness about transgender-specific STI/HIV testing are urgently needed. In addition, Safer et al. (2016) discuss the barriers transgender individuals face in healthcare systems, noting that healthcare providers' lack of knowledge can be a significant challenge in STI/HIV care (6). The lack of guidelines addressing transgender-specific risks may contribute to these barriers, potentially limiting the provision of adequate healthcare.

Acceptance of free STI/HIV testing

Free STI/HIV testing is not mandatory for patients. In our study, slightly over half (62.2%) of participants sought free STI/HIV testing, mostly AMABs (31.6%). Reasons for not wanting to be tested included claims of never having had sexual intercourse, no possibility of being infected with an STI, and being uncomfortable discussing sexual matters.

International studies indicate a high prevalence of HIV and STI among transgender people globally (7). Physiologically, the risks for HIV and STI among AFABs who retain a vagina compared with those who do not remain unclear. Additionally, the distinct biological risks for HIV and STI among AMABs who have undergone penile inversion or sigmoid colostomy vaginoplasty require further investigation. There are scarce STI studies on transgender men, but the risk of STI and HIV among transgender men who have sex with men (MSM) is considered as high as that among cisgender gay men (8). Although the proportion of our study participants who underwent free STI/HIV testing was low, the close relationship between transgender people and STI/HIV suggests the need for regular screening, along with patient education.

Smoking rates among transgender people

The overall smoking rate in 2019 in Japan was 16.7%, with 27.1% in men and 7.6% in women (9). In this study, the overall transgender smoking rate was 19.3%, higher than the overall smoking rate in Japan, and the AFABs smoking rate (22.7%) was higher than the AMABs rate. Worldwide, smoking rates are reportedly high among transgender people, especially AFABs (10). Health providers should consider the higher burden of smoking-related health morbidities and mortality faced by AFABs when providing lifestyle guidance.

Barriers to health and sexual health care for transgender people

Many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor primary care (11). Barriers to accessing medical and health care are high for transgender people, and many do not visit a hospital if they have symptoms of illness (6). This may contribute to the exacerbation of health conditions and spread of STI/HIV infections. In this survey, more than half of all respondents felt hesitant to visit a hospital, and more than 80% said they struggle mentally each day. The term "struggle" here refers to problems or barriers experienced in daily life because of gender. Transgender people have a high suicide rate, and suicidal ideation is predicted by experiences of discrimination and struggle among transgender people (12). Improving access to care for transgender people therefore requires a multi-pronged approach, including clinician education in gender-affirming care, policy changes in primary care institutions, and advocacy to address social determinants of health. Health providers must have competent knowledge of transgender health problems and address these to provide truly equitable care for transgender people (13).

PrEP and PEP awareness among transgender people

PrEP and PEP research in transgender men is limited, but recent studies in transgender women reveal alarmingly high rates of HIV infection. According to a recent international analysis, transgender women are 49 times more likely to be HIV-positive than the general population. Although transgender men are less likely to be HIV-positive than transgender women, their infection rates still exceed those of the general population (14).

Transgender MSM do not have easier access to primary care than cisgender MSM, and barriers to HIV testing and PrEP intake are higher. Hence, there is an urgent need for HIV prevention education for transgender MSM (15).

Although there is a strong link between transgender people and HIV worldwide, policies to address this issue are lacking. Increasing the number of facilities that provide sexual health care along with GAHT for transgender people, reducing barriers to clinic visits, and improving health care providers' understanding of transgender people are issues to be resolved. Transgender people have the right to understand their own risk of HIV infection, as well as preventive methods such as PEP and PrEP.

Conclusion and suggestions

This study underscores the urgent need for improved primary care and sexual health services for transgender people in Japan. Comprehensive data on the health of this population, particularly concerning STI and HIV, remains scarce. Our survey highlights gaps in sexual health awareness, testing uptake, and overall primary care access.

Enhancing health care services for transgender people involves increasing the availability of primary care and sexual health care, reducing barriers to health care access, and improving knowledge among health care providers regarding transgender health issues. Future research should include more comprehensive data, particularly focusing on high-risk groups, to better inform and implement effective health care policies and practices. Raising awareness about the high risk of STI/ HIV infection among transgender people and promoting the use of PEP and PrEP are critical steps toward achieving equitable health care for all.