Study of prevalence of sexually transmitted infections/human immunodeficiency virus and condom use among male-to-female transgender: A retrospective analysis from a tertiary care hospital in Chennai

Abstract

Context:

A “Transgender” person is one who dresses as, desires to be, has undergone surgery to become or identifies with opposite sex. They have a higher risk of sexually transmitted infection (STI) due to a combination of biological and social reasons. They have risky sexual behaviors but low-risk perception.

Aims:

The aim of this study is to determine the prevalence of STI/human immunodeficiency virus (HIV) in transgender (TG) and association with condom use.

Settings and Design:

A retrospective study of 82 male-to-female TGs attending our sexually transmitted disease (STD) clinic from 2011 to 2014 was undertaken.

Subjects and Methods:

Detailed history including sexual exposure, high-risk practices, and condom usage was obtained, and clinical examination for any evidence of STI was done. They were screened for the presence of STI/HIV and other appropriate investigations were done whenever required.

Statistical Analysis Used:

Retrospective analysis was used.

Results:

In our study, the total prevalence of STI/HIV in the studied population was 48.8% which was considerably higher than the prevalence in the general population which was 5.4%. Promiscuity rate of TGs studied was 45%, 33% of them were male sex workers. Syphilis was the most common STD, followed by HIV, genital warts, and gonorrhea. The prevalence of condom use was 45.1%, and the prevalence of STI/HIV in the condom used TGs was 14.6%.

Conclusion:

Based on the above findings, the TG group is found to have a higher prevalence of HIV/STI despite the higher use of condoms which is mostly attributable to the lack of correct and consistent use of condoms. This stresses upon the importance of promoting the condom usage and knowledge, and also this group should be the focus of intensive intervention programs aimed at STI screening and treatment, reduction of risky sexual behavior, and promotion of HIV counseling and testing.

INTRODUCTION

A “Transgender”[1] person is one who dresses as, desires to be, has undergone surgery to become or identifies with opposite sex. Male-to-female transgenders (TGs) are biological males who dress and socially behave as females. TGs are an important emerging risk group in India that requires extensive evaluation of sexual behavior and sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) infection. This group is often stigmatized and may sell sex for a living, thus putting them at a higher risk for acquiring STIs and HIV.

The aim of this study is to determine the prevalence of STI/HIV and condom use in male-to-female TG. The information could be used to design relevant and effective intervention programs among TGs, who are at risk for acquiring infections.

TGs are one of the risk groups targeted by the National AIDS Control Organization (NACO) to reduce HIV transmission. The number of targeted interventions for this community is being increased tremendously, and nongovernmental organizations (NGOs) working with TGs have initiated outreach programs. Relatively higher number of studies on STI profile of TGs are present from the Western world. However, these cannot be applied for the Indian population because of the difference in social and cultural behavior. Henceforth, we carried out this study to delineate the clinical patterns of sexually transmitted diseases (STDs) in TG coming to the STD clinic of our tertiary hospital.

SUBJECTS AND METHODS

A retrospective study of 82 male-to-female TGs was conducted from 2011 to 2014 in the STD clinic of our tertiary care hospital. Details of demographics (age, marital status, and native place), socioeconomic conditions (job, income, and living conditions), and health-seeking behaviors, history including past sexual behavior, type of sexual activity, condom use during the sexual acts, high-risk practices, and attitude and knowledge toward condom and STI were obtained. The prevalence of STI/HIV in the general population attending the STD clinic such as the people coming with complaints specific to venereal diseases, those coming for regular screening, those coming for screening before invasive procedures or surgeries, and those who come accompanied by the NGOs, among others was ascertained and it was used in comparison with TGs.

Careful examination of participants for the presence of STIs was done. Blood was collected for venereal disease research laboratory (VDRL) testing, Treponema pallidum hemagglutination assay, hepatitis B surface antigen, herpes simplex virus 2 IgG and IgM ELISA, anti-hepatitis C virus, and HIV tests (NACO Strategy 3). Urethral discharge, if present, was evaluated with Gram stain to identify pus cells and the presence of Gram-negative intracellular diplococci. Additional investigations such as dark ground microscopy to look for T. pallidum in syphilis, Tzanck smear to look for multinucleated giant cells in herpes genitalis, KOH mount to look for pseudohyphae in candidiasis, and wet mount with normal saline to look for Trichomonas vaginalis were carried out when required. Biopsy was done whenever and wherever needed.

RESULTS

The average age of TGs was 27, the youngest being 18 years and the oldest being 55 years. Education wise 46.3% of them had a high school education, 29.2% of them had a primary school education, 15.8% were illiterates, and 7.3% had a degree qualification. The occupation varied from begging, private offices, laborers, and sex workers. Disproportionately high number (32.9%) was found to have indulged in sex work. Substance abuse (including alcohol) was present in 18.3%.

Most of them were unmarried (87.1%) and 45.1% exhibited promiscuous behavior. The incidence of oro-receptive sex was 86.8% and anoreceptive sex was 66.5%. A sexual practice of placing the partner's penis between their thighs (nonpenetrative form, sometimes referred to as cuissage) was 12.1% and is seen commonly in TGs than other groups. Sexual reassignment surgery was found to be done in 47.5%.

The total prevalence of STI/HIV in the TGs was found to be 48.8% (40 of 82). Syphilis was the most common STI present in 20.7% (17 of 82). Of the 17 patients with syphilis, seven had early syphilis and ten had late syphilis who were identified with VDRL testing which was then confirmed with T. pallidum hemagglutination assay. Genital warts were the next common STI present in 2.43% (2 of 85), and both of them had a history of unprotected anoreceptive sex. One patient had pharyngeal gonorrhea which was confirmed by culture. HIV infection was found to be present in 13.4% (n = 11). Out of the 82 patients, 14 (17%) were found to have nonvenereal genital dermatoses such as pearly penile papules, scabies, and folliculitis.

The total prevalence of STI/HIV in the general population attending our STD clinic was found to be 5.4%. HIV was the most common with a prevalence of 3.2%. The prevalence of syphilis was 2.2%.

The condom use was found to be 45.1% (37 of 82), and the prevalence of STI/HIV in the TGs who used condom was 14.6% (12 of 37). The rest did not give a history of ever using condoms. Most reported the use of condoms only for penetrative anal sex and not for other sexual acts. Most of them had a belief that condom decreases the sexual pleasure and that there was no need to use condoms while having intercourse with apparently healthy individuals. They also had little to no knowledge about the uses and benefits of condoms other than its role in the prevention of HIV.

DISCUSSION

Based on the above findings, TGs were found to have a higher prevalence of STI/HIV. There was significantly higher number of sex partners and high-risk behavior.[2] Syphilis was the most common STI followed by HIV. This is in concordance with the trend where there is reemergence of syphilis in the setting of HIV.[3] Health-seeking behaviors are often poor due to misconceptions about STI and fear of discrimination by health-care personnel and stigmatization in health-care settings. The stigma and discrimination they face make the bi-directional access to proper education, awareness, and health-care difficult. TGs remain a largely ghettoized, disempowered group in the country. Many have left their unsympathetic families to join others such as themselves, and together, they have built “closed” communities that eke out a living from begging and commercial sex work.

We found that disproportionately high number of TGs are employed in sex industry[4,5] due to difficulty in obtaining other jobs, discrimination in workplace, financial hardship, to earn money for survival, and also to afford the hormonal and surgical treatments. They are more likely to engage in high-risk practices[6] because of stigma within the sex industry forcing them to indulge in unprotected intercourse besides financial incentive to engage in risky sexual practices.[4]

Although the condom use was considerably higher, the correct and consistent use of condoms[7] was lacking which could explain the higher prevalence of STI among the studied male-to-female TGs even in the TGs who used condoms.[6] The fact that there is relatively increased condom use in the TGs group indicates that there is some awareness among them regarding the role of condoms in preventing STI/HIV which is an upside, but there is an increased prevalence of STI/HIV in this group and also among TGs in general which can be due multitude of reasons such as lack of correct and consistent use of condoms,[6] high-risk behavior including alcohol and substance abuse,[8] multiple sex partners, lack of awareness, lack of education, and lack of proper access to sex education and healthcare.

There is a combination of biological, social, and economic factors[9] responsible for the dearth of data regarding the TG population. In general, like all STI, marginalized groups are at the highest risk, and the TG individuals are some of the most marginalized members of the society with increased disease burden and they also act as a Bridge population[10,11] with potential for spread to others besides having a high impact on the social and economic factors affecting growth.

The problem can be tackled by increased access to health care and treatment, enacting laws and creating policies to decrease the discrimination against them, creating awareness in the society to clear the stigma, improved access to education and occupation, regular STI screening[11] and treatment, information about risk behavior, reduction in the number of partners, skill development to prevention of abuse, violence and exploitation, and condom negotiation skills with prospective clients along with addressing and alleviating misconceptions regarding condom use. Recent developments such as the passing of rights of TG persons 2014 Bill,[12] in Rajya Sabha which gives provision for reservation in education and jobs, financial aid, and social inclusion. Supreme Court Recognition of TG as a third gender[13] and directing the center and states to take steps to treat them as socially and educationally backward classes along with the formation of Welfare Board for TGs are steps in the right direction. Tamil Nadu is an example for a state making rapid strides in TG welfare by being the first state to form a TG Welfare Board and thereby according official recognition for the community with the issue of ration cards with a separate “third gender” category, free sex reassignment surgery (for male-to-female TG), free housing program and citizenship documents, scholarship for higher studies, and income generation programs.

The limitation of our study was that since this is a retrospective study of TGs attending our STD clinic, proctoscopy, rectal or pharyngeal swabs, or other investigations were not done to detect various STDs in asymptomatic patients, apart from routine screening done for HIV and syphilis. The diagnoses were clinically supported by investigations wherever indicated. Since the data were clinic based and only the male-to-female TGs were studied, they may not be representative of the population at large and a population-based study would be preferred to assess the risk behavior and HIV/STI prevalence among TGs. Despite the above-mentioned limitations, this study provided valuable insight into the STI/HIV profile and condom use in TGs attending a tertiary care hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.