Forms of Safety and Their Impact on Health: An Exploration of HIV/AIDS-Related Risk and Resilience Among Trans Women in Lebanon

Abstract

Using minority stress theory, the authors investigated risk behaviors of transgender women (trans women) in Lebanon. Using semistructured interviews, the authors explored six areas: relationships with family and friends; openness about gender and sexuality; experiences with stigma; sexual behavior; attitudes and behaviors regarding HIV testing; and perceived HIV-related norms among transgender peers. Participants voiced the importance of different forms of safety: social/emotional, physical, sexual, and financial. Strategies for obtaining safety were negotiated differently depending on social, behavioral, and structural factors in the environment. In this article, we provide study findings from the perspectives of trans women, their exposure to stigma, and the necessary navigation of environments characterized by transphobia.

INTRODUCTION AND BACKGROUND

In this article, we explore the lived experiences of transgender women (hereafter trans women) in the greater Beirut area as part of a larger mixed methods study on the social networks and risk behavior of populations whose members are at elevated risk for HIV infection in Lebanon. Despite high rates of HIV incidence and prevalence internationally, trans women’s health behavior and experiences, to the best of our knowledge, had yet to be examined rigorously in the Middle East.

Trans women, due largely to transphobia, stigma, and discrimination, experience extreme health disparities and are therefore at increased risk for a range of negative health outcomes (Clements-Nolle, Marx, Guzman, & Katz, 2001). For example, transphobia can have a deleterious impact on mental health (Nemoto, Operario, Han, & Nguyen, 2004) with more than half of the trans women in one study reporting depressive symptoms (Clements-Nolle et al., 2001). Further, suicide attempts among transgender individuals have been reported to be as high as 31% (Clements-Nolle, Marx, & Katz, 2006; Herbst et al., 2008). Transphobic life events, such as being treated unfairly by an employer because of being transgender or transsexual, have been associated with depression, anxiety, and lower income among transgender individuals (Lombardi, 2009). Due to gender identity and gender presentation, 77% of transgender individuals in one U.S.-based study reported feeling unsafe in public settings, and 43% and 21% had been affected by physical abuse and forced sexual intercourse, respectively (Herbst et al., 2008).

Similar to in other most-at-risk-populations, the rates of actual HIV seropositivity are higher than self-reported seropositivity among transgender individuals (28% versus 12%; Herbst et al., 2008), indicating the possibility of an alarming proportion of trans women who are unknowingly living with HIV/AIDS. High rates of sex work, unprotected sex, and substance use place trans women at increased risk for contracting HIV as well as for developing mental health problems (Garofalo, Deleon, Osmer, Doll, & Harper, 2006; Silva-Santisteban et al., 2011). Trans women experiencing higher levels of transphobia are more likely to engage in unprotected receptive anal intercourse (Sugano, Nemoto, & Operario, 2006). Results from research in 2008 indicate that contextual factors of HIV/AIDS risk among transgender individuals were likely to include mental health concerns, physical abuse, social isolation, economic marginalization, and unmet healthcare needs specific to the population (Herbst et al., 2008). More recent research confirms the link between gender-based violence and HIV risk among trans women; researchers emphasize the integral role of interventions that mitigate the psychological impact of gender abuse and sexually high-risk behavior (Nuttbrock et al., 2012). Further, trans women with a history of sex work report very high rates of suicidal ideation (about 33%), suicide attempts (64%), having been physically assaulted (50%), and having been raped or sexually assaulted (38%; (Nemoto, Bödeker, & Iwamoto, 2011). More than two-thirds of transgender youth report having experienced verbal abuse by their parents or peers about their gender identity and gender nonconformity (Grossman, D’Augelli, & Frank, 2011).

Although much of the health research among trans women has been conducted in the United States, researchers in Peru recently found that trans women are the most vulnerable group to HIV infection in the country (Silva-Santisteban et al., 2011). In El Salvador, trans women were more likely to engage in sex work, report high-risk behavior, and have lower HIV-related knowledge compared with men who have sex with men (MSM; Barrington, Wejnert, Guardado, Nieto, & Bailey, 2012).

There is a dearth of HIV/AIDS research that focuses exclusively on transgender individuals in the Middle East and North Africa (MENA) region. Very few studies in the region differentiate between MSM and transgender populations (Mumtaz et al., 2011). Despite being regarded as one of the populations most at risk for HIV infection, transgender women in MENA are still not understood for the risks and experiences they face.

In order to understand the experiences and risk behaviors of transgender women in Beirut, Lebanon, and to inform the second stage of a two-phase mixed-methods project, we conducted qualitative semistructured interviews as part of a larger study in which we examined sexual health, risk behavior, and HIV testing among MSM, male sex workers (MSWs), and trans women. Through the lens of minority stress theory, we sought to examine the unique perspectives of trans women, exposure to stigma, and how they navigate a stressful social environment characterized by stigma, prejudice, and discrimination based on minority status and gender identity (Meyer, 2003; Pascoe & Smart Richman, 2009). According to minority stress theory, being a member of one or more minority group(s) can cause elevated levels of environmental stress, which can lead to negative health sequelae (Meyer, 2003). The ultimate purpose of the study was to inform strategies for intervention development to improve the overall health of individuals in these understudied populations and communities.

METHODS

Data Collection and Analysis

As part of a larger study with MSM, MSW, and trans women, we interviewed 10 trans women living in Beirut, Lebanon, in the fall of 2011. Participants were recruited through referrals from Helem, a nonprofit organization that serves the lesbian, gay, bisexual, and transgender (LGBT) community in Lebanon, and from study participants. Following the informed consent process for voluntary participation and for digital audio recording, the interviews were conducted by a social worker who provides social support services to the transgender community and with whom the participants were familiar. The social worker was experienced in working with trans women and had been trained in qualitative interviewing prior to administering the interviews. Nine out of the 10 interviews took place in a private room at Helem. One interview took place in the participant’s home at her request. The interviews were conducted in Arabic, were digitally audio-recorded, and typically lasted from 60–to 90 minutes. The interviewer transcribed the recorded interviews from Arabic into English transcripts. All audio recordings were deleted and destroyed following completion of the transcription process. Confidentiality was further protected by avoiding the use of participants’ names or other potentially identifying information in transcripts and all other study documents. Each participant was paid U.S. $30 for completing the interview. Institutional Review Boards reviewed and approved the study prior to the initiation of the data collection process.

Interviews followed the structure of an interview guide that was developed by the research team to assess the influence of social factors on sexuality and HIV risk behavior. The interview guide consisted mostly of open-ended questions to allow for the expression of individual experiences that could be compared across the sample. Participants were asked for some basic demographic information provided in Table 1. The interview then focused on six main topic areas: (a) relationships with family and friends; (b) comfort with sexual orientation, level of disclosure, and openness about sexuality; (c) experiences of stigma and mechanisms for coping with stigma; (d) sexual behavior including type and number of sexual partners and engagement in sexual risk behavior including condom use; (e) attitudes and behaviors regarding HIV testing and discussion of sexually transmitted infections (STIs) and HIV risk with sexual partners; and (f) perceived norms among transgender peers regarding condom use and HIV testing behavior and attitudes.

TABLE 1.

Demographics of Study Participants

Item	N (%)
Age (SD)	26.7 (9.3)
Born in Lebanon	47 (87.0)
Legal in Lebanon	53 (98.1)
No current income	28 (51.9)
Sex for income	36 (66.7)
Earn <$500 per month	22 (41.5)
In a committed relationship	19 (35.2)
Living with someone	37 (68.5)
Living with parents or family	22 (59.5)
Highest education level
Didn’t complete grade school	31 (57.4)
Completed grade school	14 (25.9)
Some college	6 (11.1)
Graduated college	3 (5.6)
Currently in school	8 (14.8)

Transcripts in English were analyzed according to the constant comparative method to identify salient themes both within and across transcripts (Glaser & Strauss, 1967). Commonalities and differences within and among participants’ experiences were identified and then organized according to theme. Qualitative analysis through the use of questioning the data; analyzing a word, phrase, or sentence; and further analyzing through comparisons (Strauss & Corbin, 1998) facilitated the process of identifying the most important concepts both according to existing concepts of health and to the participants’ voices and experiences. Analytical rigor was ensured through conscientiously staying close to the data during analysis to guarantee that themes and conclusions were grounded in the data (Gioia, Corley, & Hamilton, 2013). Further, the research team was comprised in part of both Lebanese LGBT cultural insiders and outsiders, thus providing unique insight and critical perspectives (Gioia et al., 2013). Quotations in this article were selected for their representation of themes and concepts within the interviews.

FINDINGS

Sample Description

The mean age of the participants was 27 (range = 18–54). Participants’ education attainment ranged from the equivalent of high school completion or less to a college degree. At the time of data collection, three participants lived with their parent(s), while two lived with other family member(s), and five lived on their own or with friends. The participants used a range of different words to describe their identities (e.g., female, girl, woman, ladyboy, gay, transgender, shemale transgender); the interviewer used feminine pronouns with the participants per their preference.¹ Participants had undergone a variety of feminizing procedures ranging from previous hormone use (N = 3) to current hormone use (N = 3) and procedures including botox (N = 2), plastic surgeries (N = 3), breast augmentation (N = 2), and gender confirmation surgery (N = 1). Some participants had not undergone any of these procedures (N = 4); among them, some did not want to do so while others planned to in the future.

Everyone in the sample expressed the preference or practice of having exclusively nontransgender male sexual partners. Of the eight participants who responded to the question, they reported a broad range of the number of sexual partners in the last year from 4 to 400. Five participants reported currently engaging in sex work. All of the participants had been tested for HIV and reported being HIV negative; three of the participants answered that they had had an STI in the past.

Themes

Data analysis revealed a complex constellation of factors that seemed to impact the participants’ health risk and resilience in an often overlapping and multidirectional process. Participants in the sample voiced the importance of different forms of safety, including: social/emotional safety, physical safety, sexual safety, and financial safety, and how these forms of safety influenced engagement in and exposure to health risks. Strategies for obtaining and maintaining these forms of safety, however, were negotiated differently depending on social, behavioral, and structural factors in the participants’ environments.

The women in the sample spoke at length about their families’ reactions and levels of support about their gender identity. Although data collection occurred at one point in time, therefore limiting our ability to theorize about causality, familial support seemed to play an important and pivotal role in the way in which participants negotiated many facets of their lives, most notably their gender expression. Familial support comes in the form of both social/emotional care and financial stability. Typically, if a participant was living with her parents, value on familial harmony was placed as a high priority that trumped gender expression if necessary. Conversely, if a participant was living more independently or with an extended family member, gender expression freedom seemed more attainable and was one of the main motivators to do so. Many participants spoke about living apart from their families as a necessary step in order to be able to live the way they felt comfortable. Participants who were living “at home” experienced the tension and frustration of a “double life” because they were restricted from expressing their gender identity. Financial security, however, was a high price to pay for the increased freedom that independence allowed. Some participants also left their parents’ residences in attempts to ensure physical and emotional safety and to avoid abuse within the family. Sex work was viewed by some of the participants as the only way to ensure financial safety, thus posing a threat to sexual safety.

Social and emotional safety

Securing social and emotional safety through means of social support was an important theme throughout all the interviews. Reactions from parents about gender identity were an integral part of most participants’ experiences. The majority of the women in the sample described their parents’ reactions to the news of having a transgender child as negative, but some cited a process of change toward acceptance that had taken place. One participant’s explanation highlights the tensions that occur when maintaining an unusually close relationship with her parents, who do not fully embrace her as a woman but provide what she describes as invaluable emotional support:

My mother’s support is the most important for me. I can tell her anything I want and she would advise me. I even tell her about my sexual relationships and my clients. I feel safe to speak to her, and her moral support is very important to me. … My parents refer to me as a guy, but they know all about what I do. They are all supportive. I started to put on makeup at the age of 16 and my mother saw me putting on makeup and dressing feminine. She knew I was transgender and she was very supportive. My sister had a friend who was gay and my mother knew his mother who was also very accepting. I think my Mom was used to the idea. She loves me and supports me a lot. I never had to tell her. She noticed that I was transgender and she just let me be what I am. I once went with her to buy a dress! We share clothes, me, her, and my sister. When she is asked why your son is like this, she would answer, “He is this way and it’s none of your business.” My older brother sometimes nags my Mom about me, but my Mom defends me.

Another participant’s parents were unable at first to accept the news that their child is transgender. She explained that it took them some time to accept her, and although she is grateful for their support, she regrets that it did not come sooner:

My father was shocked [when he was told I am transgender]. His first words in the car were, “What were the wrong things I did so this would happen?” He felt it was his fault. My parents were not violent people, but it was hard for them to accept the reality. My parents, after 4 years, now consider me a girl. It took me 4 years to convince them that I am a girl. Now they are very accepting and supportive. I blame my family because they were not there when I was going through all this during my teenage years. I told my Mom, and the solution she always mentioned was to change schools. I was terrified of changing schools. I was used to the agony in this school; I was afraid it would be worse in another school.

Unfortunately, the above-described parental support was more the exception than the norm among the participants interviewed. Another participant described an extreme reaction from her parents, which led her to leave her parents’ home and go to live with a relative who was more accepting:

When my parents found out, they didn’t know how to deal with it. Instead of trying to understand me, they pushed me to change. They locked me home. They started beating me and stopped letting me go to school. They also started listening to my phone conversations. They thought that this would make me change, but it just made the situation worse. … My relations with my family members are not good at all. They were not supportive when I most needed them. I am considered an unnatural being. When your parents know that you’re transgender and have this problem, they should be closer to you and support you. Instead, my parents did the opposite. My relationship with them is not good. We don’t spend time with each other anymore.

Other participants also faced violence at home because of their transgender identity. One participant described the lack of physical and emotional safety she encountered:

Since I was very young, I used to feel that I was a girl. My parents never treated me as a girl. They were very violent with me. They wanted me to become a man. They used to beat me to force me to change my behavior. … My Mom always nags me to stop pursuing the sex change procedure and to stay as a male. They don’t want me to have the operation. I need to do the operation to feel better. … My family hurt me a lot, especially emotionally. My Dad used to beat me a lot when I would say that I am a girl. He used to burn the female clothes I used to buy and I always used to buy more. One time he hurt me badly. He started to cry because he felt guilty.

Another participant described her family as a prison and said that her uncle threatened to kill her and put a pistol to her head due to her gender expression. She explained that she thinks the only reason her family members tolerate her is because she provides financial support to them. She described her family as viewing her as gay, not understanding what transgender means, and being embarrassed to be seen with her.

Few participants cited receiving emotional or social support from the transgender community. In fact, the reverse was true for most of the women in the study. They described members of the transgender community as mean and jealous of one another. Other trans women were viewed as competition either in regards to the number of feminizing procedures undertaken or for potential sex work clients. One participant, who had a more positive attitude toward the transgender community, explained that her transgender friends might provide logistical or functional assistance, but not emotional support:

The support from my transgender friends and community is a simple kind, because each one of us lives the same situation and faces a lot of problems. I might ask them for money to buy some food if I spent the day out and couldn’t go back home to eat. They might lend me a dress if I have a customer or take care of my makeup. This is the support I usually get from them. I also have a friend that would let me sleep at her house if I was out late and was wearing female clothes. I don’t have emotional support from them.

Nine out of 10 participants answered affirmatively about having had some kind of mental health problem either currently or in the past. The only woman, notably, who reported that she had never been down or depressed was the participant who described her family’s support as wholly positive. Although the interview guide included questions about self-esteem, depression, and mental health service utilization, we did not inquire directly about suicide ideation or suicide attempts. It would be remiss, however, not to note that five out of the 10 participants volunteered that they had considered or attempted suicide in the past.

Closely linked with the next theme of physical safety, women experienced transphobia in different ways that seemed to impact their views of themselves as well as their decisions about feminizing procedures. One participant described the effect of stigma and discrimination:

This [stigma and discrimination] affected me on the personal level. I felt hurt. Offensive words I hear affect me a lot and push me to hate myself for what I am. I try my best to overcome the depression and the feelings of being down caused by discrimination and offensive attitudes toward me.

Another participant described the struggle for self-acceptance that she viewed as a common experience among all trans women, likely indicating her efforts to normalize her feelings:

I try to forget sometimes that I am transgender and try to think that I am a girl, a female. Whatever transgender individuals do, they always have the dream of being born as biological girls. Our happiness is never complete. Even if we grow breasts and have the sex change operation, we always feel that there is something missing; [that something missing] is being born as females. I wish I were born as a female in order not to have all these complications.

The desire for social support seemed to challenge many of the women’s self-acceptance and their decisions about changing their appearance, highlighted by one participant’s explanation:

I identify myself as a ladyboy, sometimes as gay. I like to look feminine. [I’d like] to have a whole body hair removal, but I don’t want to have breasts or have any operation to change sex. If I want to go to my parents’ house, I can’t be dressed as a full woman. If my parents and my family were not there, I would have nothing to lose. … I don’t like being this way. I would prefer if I were born like the others. I never go to weddings. It makes me sad because I can never get married.

Thus, the need for social support and emotional safety was at odds with considering the possibility of pursuing feminizing procedures for many participants.

Physical safety

Although the interview guide did not include questions directly about experiences of physical and sexual violence, nine out of the 10 participants reported having experienced some form of violence. In the same way that participants volunteered accounts of suicide ideation and attempts, threats to physical safety were commonly described across and throughout many interviews. This theme, which includes mobility and space, emerged as an important construct that highlights the complex interplay between gender expression and physical safety. Participants described different ways of negotiating public spaces to maximize both physical and social safety. The extent to which the participants are able to express their gender identity impacts the ability to move in and out of different spaces and venues safely.

Some participants explained that safety and acceptance in cafés, night-clubs, or restaurants is dependent on the make-up of the group:

We never go to heterosexual cafes or nightclubs. We tried to go to some of the cafés together, but the owner told us to leave the place because of our look or we would start hearing criticism and mockery from people sitting in the café. There are a few cafés where we would feel accepted; these are gay friendly—this is why they would let us in. If I go to a café with heterosexual friends, no one would bother me, but if we are in a group of transgender friends, they won’t let us in.

This same participant also distinguished the difference between negotiating venues versus moving from one location to another: “The situation on the streets is different. Sometimes people follow me to beat me when they see my look.” Another participant described a decrease in the problems she faced following the steps she had taken to change her appearance:

I used to hear a lot of insults in the streets from guys and girls. This was the most hurtful. I had no real friends then. I was suffering in silence. … Now after I had my breast operation and botox, people see me as a woman, so I face less problems in the street.

Participants frequently expressed fear, frustration, anger, and shame about how they were treated “in the streets.” One participant explained how she deals with the verbal harassment and the shame associated with her appearance:

In the street, I always hear people insulting and mocking me. In the street, I always put on a headset and some music not to hear some offensive comments from people. … When I’m with a member of my family, and people insult me in the street, it is very shameful.

On the other hand, the same participant who described being mocked in the street also explained that some people view her as a woman. She described appreciating it when this takes place. Her description, at the same time, highlights the restrictions she and other participants experience and the caution they must use for making choices about transportation and appearances:

I like when society looks at me as a girl or an attractive person that just passes in front of them. Many people in the streets think that I’m a girl. The taxi driver that brought me here today thought I was a girl! He started looking at me. Many people, when they look at me from behind, think that I’m a girl. When I am out with a customer or sex partner, I wear a dress, hide my dick, and wear some female underwear. I won’t do that if I’m going on the street. If I had a car, I wouldn’t mind wearing this every day. I have to walk at night when I finish work to go home. This is also why I don’t wear feminine clothes [all the time].

Other participants described verbal harassment that became physically violent and the expense that is required to ensure safety:

I also face a lot of discrimination in the street and hear a lot of insults. I have to take a taxi and pay 10,000 LBP [~U.S.$6.70] in order not to confront the guys that gather in our street near my house. Once a guy stopped me in the street and screamed at me: “How can you come to this region wearing these clothes?!” I am afraid that these guys would try to hurt me again.

The same participant went on to explain how important it is for her to be able to stand up for herself despite the safety risk:

I am a very stubborn person. I don’t like to run away. If someone insults me, I would insult him back. I was beaten once by a guy because he gave me the finger and I gave mine back! I don’t run away. My dignity is very important to me. I don’t want anyone to take it from me.

One participant explained that even though she had changed her name and official identification, she still faces discrimination in the streets of her neighborhood because some of the people in the transgender community disclosed her transgender status.

Sexual safety

The lack of safety that many of the participants described experiencing in the streets extended to a lack of safety within the context of sexual encounters. One participant illustrated such risk:

I feel stigmatized in the street. I hear a lot of insults and people laughing at the way I look. I was beaten once by a policeman because of how I look. … Stigma and discrimination have caused me to go through a lot of risky situations. I was kidnapped once by a taxi driver. Some people followed me in their cars and tried to assault me. I had risky sex and unsafe sex several times. I had sex with partners I didn’t want to have sex with but because they threatened me or because of money, I had sex with them.

Coercive sex was a common experience among the participants, as were other forms of violence. Although many of the participants who were engaging in sex work described using or not using condoms as an individual choice that they were able to make, one participant cited access to condoms as a problem for many transgender women:

Transgender individuals wouldn’t go into a pharmacy to ask for a condom. They would be ashamed to do so. Condoms are not available to them. Only about 10% of transgender individuals I know use condoms. They don’t have access to them. When I take boxes of condoms with me, they don’t last for more than a few hours.

This same participant also explained that when she has sex at home, she always has safe sex; however, when she is out, she never has safe sex. Many of the participants described scenarios in which physical and sexual safety are linked. For example, one participant acknowledged the risk of having sex in public, but she explained that her partner had nowhere to take her:

Sometimes I take risk in my sexual encounters. I have sex with some customers in public places because he has no place for sex. We could easily be caught and I would have serious problems. The guy I went with yesterday had no hotel room; he was on a motorcycle. We went to some dark corners in the streets to have sex. I was really afraid.

Another participant recounted an experience she had with sexual violence:

Last month a guy that I met took me to his village house far away. He wanted to force me into having sex with him. He beat me. I had to run away. I was very scared. All the guys I meet want me for sex, not for love or a relationship.

The participant’s words above also echo a commonly expressed view among many of the participants: If long-term loving sexual partnerships were possible, sexual risk would decrease. Other reasons participants gave for engaging in risky sex include not using a condom if the partner was good-looking, muscular, or “clean.” Still other explanations for unprotected sex suggested poor self-esteem or mental health, as illustrated by one participant’s comment:

I know I am taking risks, but sometimes I say to myself that I don’t really care anymore. Sometimes I wish I would have HIV and die of AIDS because I feel like I’m worth nothing. I am only 19; I have so many responsibilities. … Sometimes I also feel that in this life nothing is really worthwhile.

Another participant highlighted this sense of shame and a lack of deservedness:

I only used condoms if the guy asked for it. I didn’t use condoms because I was ashamed about asking the guy to use a condom. … Most of the transgender people I know are ashamed to ask the guy to bring condoms with him. They feel it’s not their right to ask for protection. We feel like saying, “Thank God, he agreed to have sex with us and not be with a girl. Why ask him for condoms and complicate things for him?”

Despite a fear of being infected with HIV, consistent condom use was rare among the women in the sample, highlighted by the above quotation. The same participant, however, described the anticipated impact of seroconverting:

I would rather die than have HIV. This would hurt my family so much. My Dad would die of a heart attack. My Mom, when she knew about my last sexual intercourse, she said to me that if you get any disease, I would let you go and forget about you. I am very afraid of the social stigma that being HIV positive would cause.

Sometimes multiple factors converged that resulted in having risky sex, as one participant described:

I sometimes had unsafe sex although I knew about HIV. When you are with an attractive person you forget to use condoms. I also used to think that I deserve to be HIV positive. Now I don’t think this way anymore. … I usually ask [sexual partners] before having sex with them if they usually use a condom and if they had the HIV test. I might not ask the person if he is my style and he is very handsome, then I might have unsafe sex with him.

Financial safety

Many participants in the sample described the challenge of finding employment because of physical external appearance. For example, one of the participants explained, “I can’t find a job easily because I am male according to my identity card although I look more like a female.” Another participant was told directly by potential employers that they would not hire her because of the way she looks. Other participants explained that they were paid less than their nontransgender counterparts. Still others described verbal and sexual harassment and physical violence in the workplace. Exceptions to these challenges that most of the participants in the sample faced include one participant who had undergone gender confirmation surgery who said that she had never faced discrimination at work. Another participant (aged 19 years) explained the compromises that trans women face in Lebanon:

I was never affected by stigma and discrimination [at work]. … Still it is true that I don’t dare go and register to continue my studies, and I know it won’t be easy for me to find a job. Now I am happy living with my parents.

Participants also described experiencing stigma and discrimination from peers and instructors in school. Poor treatment from others was the main reason that one participant cited as the impetus for leaving school. Another participant described how others responded to her, which captures the experiences that were common among other participants:

There was a lot of discrimination at school from both my teachers and my classmates. Some of my teachers used to lower my marks so I would fail their classes because they didn’t like the way I look and act. They find it girly for a boy. Some of my classmates used to insult and mock me.

Another participant detailed the painful effects that stigmatization at school had on her:

The school years destroyed me from the inside. The social reaction of people through my teen years—the rejection I faced—broke me down. During my teens in school, I would compare myself to the class ashtray. Those years destroyed my life and my personality. I was beaten and insulted in school. I was nothing. They used to spit on me. I was the victim of bullying. I was dead. Those school years hurt me deep inside. I am trying to come back to life. It is very hard now. … My friends at the university used to treat me as their slave: “Go bring us Nescafe. Hold my bag.” I only used to hear orders from them. I would do anything they asked just to keep them as my friends. I used to feel that I was lower than them. I changed a lot during the past 2 years. Sometimes now they say to me, “We miss the little pussy that you were when we started university.” … During the school years, I had no real life. I used to be afraid to participate in class. They used to make fun of me because I looked feminine. In school I was the first student in my class, but this didn’t matter to them. They used to sit on me on the bus, pretending I didn’t exist and that they didn’t see me.

For many participants who were not living with their parents, financial safety was their motivation for engaging in sex work. Of the participants who had received payment for sex, most explained that exchanges of sex for money was necessary for financial stability. A major theme voiced within and throughout many interviews was money as a main motivator for unsafe sex. One participant described balancing her monetary needs with her health needs:

I would have anal sex with someone without a condom if he pays more. Most of the time I don’t have anal sex with people I don’t really like, but recently my life has been upside down, so I am taking risks in many of my sexual encounters. … I didn’t used to have sex before as much as I do now. I have sex more now because I need money. I have sex four to five times per week with different customers. I don’t have sex with people I don’t know anymore because I went with a guy who turned out to be from the police. So now I take more precautions. … If a customer pays more than $200, I would accept having sex with him without using a condom.

Similarly, other participants explained that if customers would pay more for sex without condoms, then they were willing to agree to unsafe sex.

DISCUSSION

This study is the first of its kind designed to explore HIV/AIDS-related risk among trans women in Lebanon. The findings of this study contribute to our understanding of social, behavioral, and contextual factors of health risk that are both common across settings internationally as well as specific to the Lebanese and Middle Eastern environment. Through this study, we mark the first step in an effort to understand experiences and improve health within a population that is at high risk for becoming HIV positive but that has received limited attention.

Through the interviews with the women in our study, we gained insight into the challenges they face due to a lack of acceptance from their families and communities. According to minority stress theory, trans women’s minority status leads to increased exposure to stressors, which in turn leads to adverse health outcomes (Meyer, 2003). Indeed, the women in our sample experienced exposure to stressors in the form of threats to their safety at multiple levels and described being targets of violence, harassment, and ridicule by all segments of society. This environment affects every aspect of life and threatens the ability to thrive and even to survive. The participants employed different strategies for obtaining and maintaining safety in the context of threats to social and emotional safety, physical safety, sexual safety, and financial safety.

The critical role that family support plays in the ability of these women to adjust and cope psychologically with this extreme stress and stigma is highlighted by the few women who felt supported by their families and who were the only women to express a level of psychological well-being. In fact, transgender youth with parental support report regular condom use, whereas those without this support report inconsistent condom use (Wilson, Iverson, Garofalo, & Belzer, 2012). Further, family acceptance favorably impacts transgender youths’ self-esteem, social support, and overall health including mental health, substance use, and suicide ideation (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). Conversely, the absence of support from both family and society highlights the grave reality of the struggle for acceptance from peers and the transgender community. It is interesting to note that trans women in other parts of the world, unlike the participants in our study, often find others in the transgender community as sources of acceptance, support, and care that extend beyond a basic logistical rapport (Pinto, Melendez, & Spector, 2008). It will be important to explore cultural and contextual underpinnings that may underlie these differences regarding peer community support.

Poor mental health including high rates of depression, suicide ideation, and suicide attempts characterize an alarming proportion of transgender individuals in different contexts (Clements-Nolle et al., 2006; Herbst et al., 2008). Transphobia can have a deleterious impact on individuals’ self-esteem via an internalization of stigma. Without support from family, friends, and community, members of this marginalized group are at great risk for vulnerability, both perceived and actual. In turn, these factors can lead to, cause an increase in, and fuel the circumstances that are most conducive to engaging in risky sexual behaviors.

Like other studies among transgender individuals in other regions of the world, our study participants provided striking accounts of the critical need for programs and services in order to begin to address the needs of this highly vulnerable population—not only in terms of sexual health and HIV prevention, but also including basic needs of everyday life, such as employment opportunities, advocacy of laws to prevent discrimination, and mental health treatment. Intervention efforts that are multicomponent are essential (Operario & Nemoto, 2010) and must also address economic independence and mental health so that trans women can make empowered decisions about their bodies, their lives, and their health.

Several factors indicate potential strategies for improving trans women’s health outcomes by reducing risk and improving resilience. Parental support has been associated with higher levels of regular condom use among young trans women (Pinto et al., 2008; Wilson et al., 2012). Social support in general has also been correlated with less unprotected sex among trans women (Golub, Walker, Longmire-Avital, Bimbi, & Parsons, 2010). Context-and culture-specific interventions that address structural barriers are essential for mitigating risk and increasing resilience among trans women (Sevelius, Reznick, Hart, & Schwarcz, 2009). So far, researchers have demonstrated intervention effectiveness in addressing socioeconomic and psychological problems among trans women utilizing an HIV prevention case management model; the intervention’s successful impact included decreased homelessness, decreased reliance on sex work for income, and decreased poor mental health symptoms (Reback, Shoptaw, & Downing, 2012). An intervention such as this, that addresses the complex interplay of safety and risk, may offer promise for affecting positive change among trans women in the Middle East and North Africa region.

The study has several limitations. Because of data collection time constraints, we were not able to seek to reach saturation. Ideally, the research team would have conducted interviews until novel themes and concepts were no longer raised during interviews with participants. Second, the interviews were conducted in Arabic and then translated and transcribed into English transcripts by the interviewer. This process may have introduced collection bias and limitations due to meaning and nuance being lost in the translation process. In order to address this language challenge, one of the authors who has some relevant cultural and linguistic knowledge communicated with the interviewer about language, expression, and meaning of specific concepts in the transcriptions during the data analysis process. Despite these limitations, these findings contribute to the first steps in understanding of the risk and resilience of trans women in Lebanon.