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. Author manuscript; available in PMC: 2022 Jul 1.
Published in final edited form as: J Sex Res. 2021 Mar 28;58(6):743–753. doi: 10.1080/00224499.2021.1892575

Social Networks and Exchange Sex among Transgender Women

Anne E Fehrenbacher a,b,*, Jesse B Fletcher c, Kirsty Clark d,e, Kimberly A Kisler c,f, Cathy J Reback a,b,c
PMCID: PMC8273090  NIHMSID: NIHMS1679231  PMID: 33779427

Abstract

Transgender women are more likely to exchange sex than cisgender individuals. This study investigated how social networks were associated with exchange sex among transgender women in Los Angeles County. From July 2015 to September 2016, transgender women (N=271; “egos”) reported their sexual and substance use behaviors and perceptions of the same behaviors among their peers (N=2,619; “alters”). Clustered logistic and negative binomial regressions were used to model odds of exchange sex and number of exchange sex partners in the past six months, respectively. Transgender women who perceived that any of their peers were engaged in exchange sex were approximately four times more likely to exchange sex themselves and reported three times as many exchange sex partners as those who did not perceive any peers engaged in exchange sex. Perceived ecstasy use among peers was associated with higher odds of exchange sex and more exchange sex partners, whereas perceived marijuana use among peers was associated with lower odds of exchange sex and fewer exchange sex partners. Peer behaviors were strongly associated with both transgender women’s likelihood and rate of engagement in exchange sex. Risk reduction interventions with transgender women should attend to network dynamics that are often overlooked in existing programs.

Keywords: transgender, social networks, exchange sex, substance use, behavioral homophily

Introduction

Transgender women are more likely to engage in exchange sex (e.g., sex work, transactional sex, or sex in exchange for money, food, housing, or other needs) than cisgender individuals (McMillan et al., 2018; Poteat et al., 2015). One meta-analysis suggested that up to 3 out of 4 transgender women in the United States (U.S.) engage in exchange sex in their lifetime (Herbst et al., 2008), a rate which is further elevated among transgender women of color (Poteat et al., 2015). According to the National Transgender Discrimination Survey, African American/Black and Hispanic/Latina transgender women are approximately 5–7 times more likely to engage in exchange sex compared to their white counterparts, and they also report higher rates of poverty, unemployment, homelessness, and incarceration (Fitzgerald et al., 2015).

Although exchange sex is not inherently harmful, transgender women of color are exposed to risk environments that both set the stage for the initiation of exchange sex and limit their ability to exchange sex safely (Baral et al., 2013; Poteat et al., 2016). Risk environments refer to structural and social factors outside of the individual (Rhodes, 2002), such as widespread transphobia, discrimination, and overpolicing of transgender women engaged in exchange sex, particularly transgender women of color who exchange sex in street-based environments (Poteat et al., 2017; Rhodes et al., 2012; Sausa et al., 2007). Syndemic theory posits that risk environments and epidemics mutually reinforce each other to exacerbate health disparities and limit access to resources, a process that might explain the disproportionate co-occurrence of HIV and substance use experienced by transgender women of color engaged in exchange sex (Brennan et al., 2012; Glynn et al., 2018; Operario & Nemoto, 2010; Parsons et al., 2018).

Across the life course, transgender women are subjected to multiple forms of marginalization including social exclusion and rejection by family; verbal, physical, and sexual violence; and lack of institutional protections in education, employment, and housing – disparities which are further amplified by racism against transgender women of color (Poteat et al., 2016; Poteat et al., 2017; Raiford et al., 2016; Reback, Clark, & Fletcher, 2019). These intersecting inequities contribute to elevated levels of housing instability, poverty, substance use, and incarceration among transgender women of color, factors that have been shown to influence engagement in exchange sex (Grant et al., 2015; Reback et al., 2005). Indeed, previous evidence suggests that transgender women exposed to four syndemic conditions prevalent among transgender populations – polysubstance use, depression, childhood sexual abuse, and intimate partner violence – demonstrated over eight times the rate of recent exchange sex events and nine times the rate of recent condomless sex events compared to those who did not experience any of these syndemics (Parsons et al., 2018). Additionally, transgender women of color reported exposure to twice as many syndemic conditions as white transgender women, as well as significantly higher rates of both exchange sex and condomless sex than white transgender women.

Exchange sex among transgender women, particularly street-based exchange sex, has been associated with a host of negative health outcomes including heightened exposure to violence, adverse mental health outcomes, substance use, and HIV transmission (Operario et al., 2008). Among transgender women engaged in exchange sex, estimated HIV prevalence ranges from 26–40% globally (Baral et al., 2013; Beyrer et al., 2015; Reback et al., 2018), compared to 15% among transgender women not engaged in exchange sex (Operario et al., 2008; Poteat et al., 2016). Transgender women engaged in exchange sex also demonstrate elevated risk for substance use, which can serve as a strategy to cope with structural and social stressors endemic to criminalized exchange sex risk environments (Hoffman, 2014; Rhodes, 2012). One study with a large sample of transgender women of color (N=2,136) – of whom 75% reported exchange sex – indicated high rates of methamphetamine use (21.5%), and injection drug and non-prescribed hormone use (66.3%) (Reback & Fletcher, 2014). Substance use among transgender women engaged in exchange sex has been associated with increased risk of HIV transmission by reducing inhibitions to sexual risk-taking, decreasing consistent condom use, and for stimulants, rapid disease progression via impaired immune response (Passaro et al., 2015; Poteat et al., 2017).

Although exchange sex is often a function of economic need due to exclusion from other forms of employment, some transgender women also report engaging in exchange sex for gender affirmation, intimacy, or as a rite of passage within transgender communities (Nuttbrock et al., 2009; Sevelius, 2013). Previous research has suggested that exchange sex networks among transgender women can provide social solidarity in the wake of rejection from family and buffer the impacts of stigma and discrimination from society at large (Sausa et al., 2007; Wilson et al., 2009). In addition, transgender women frequently draw on support from peers to navigate challenges associated with gender expression or transition (Clark et al., 2018; Trujillo et al., 2017). Transgender community connectedness has been shown to improve mental health among transgender women by reducing symptoms of anxiety and depression (Pflum et al., 2015).

How transgender women’s social and sexual networks are formed, and how risk and protective behaviors proliferate within such networks is an area of growing interest for HIV prevention research (Nieto et al., 2020; Poteat et al., 2016; Reback et al., 2005; Reback, Clark, Fletcher & Holloway, 2019). The principle of social network homophily posits that individuals with similar attributes are more likely to share social bonds with each other compared to more dissimilar individuals (McPherson et al., 2001). Furthermore, people become more behaviorally similar to their social network peers over time (Centola, 2011). Transgender women’s networks are likely neither inherently protective, nor inherently risky. Rather, the structure and composition of transgender women’s social networks likely interact with universal principles of social network dynamics to create greater or lesser risk for the inhabitants of each network (McPherson et al., 2001). For example, a study with transgender women engaged in exchange sex in Boston described how more experienced transgender “mothers” often initiated young transgender women into exchange sex and provided advice and safety tips for working in the sex industry (Reisner et al., 2009). However, another study found that transgender women with a greater number of social network peers who used hormones for gender confirmation – either prescribed or non-medically monitored – were more likely to misuse hormones (e.g., injecting “street hormones” or non-prescribed silicone “fillers”), indicating the potentially complex effects of social network connections on transgender women’s behaviors (Clark et al., 2018).

Social network analyses investigating the propagation of sexual behaviors within networks have focused primarily on HIV risks among men who have sex with men (MSM) (Amirkhanian, 2014; Choi et al., 2007; Veinot et al., 2016). One of the few studies to investigate social network influences on sexual behaviors among transgender women of color compared the network characteristics of African American/Black transgender women to African American/Black MSM (Ezell et al., 2018). Results showed that transgender women’s networks hewed closely to the principle of social network homophily; their networks were populated with a significantly higher proportion of other transgender women even when compared to, for example, the proportion of MSM commonly seen in MSM networks (Ezell et al., 2018). In addition, transgender women and their social networks both demonstrated elevated rates of exchange sex relative to MSM, suggesting the strong influence of behavioral homophily on the architecture of transgender women’s social and sexual networks (Ezell et al., 2018; McPherson et al., 2001).

A greater understanding of how transgender women’s networks influence their engagement in exchange sex can generate insights on how risk reduction interventions can abrogate harmful aspects of exchange sex risk environments (Rhodes et al., 2012) such as higher likelihood of co-occurring homelessness and substance use, while maximizing benefits, such as opportunities for income generation, sharing of safety and resistance strategies, and avenues for social solidarity and connectedness in a community of peers with similar experiences and behaviors (Hoffman, 2014; Laidlaw, 2017). Although few social network interventions have been tested with transgender women, a review of network-level interventions in HIV prevention research indicates that successful models have been implemented with MSM, injection drug users, methamphetamine users, and cisgender female sex workers (Amirkhanian, 2014). Critical to understanding how transgender women’s social networks can be leveraged to reduce HIV risk is examining the impact of network dynamics on behaviors among transgender women who are engaged and not engaged in exchange sex (Reback, Clark, Fletcher, & Holloway, 2019).

The current study utilized egocentric social network analysis to quantify the extent to which exchange sex behaviors clustered within the networks of a racially and ethnically diverse sample of transgender women in Los Angeles County (LAC). The parent study for this analysis examined the structure of transgender women’s social networks to estimate how network alters’ perceived HIV risk and protective behaviors influenced transgender women’s own HIV risk and protective behaviors (Holloway et al., 2020; Reback, Clark, Fletcher, & Holloway, 2019). For this analysis, we sought to identify how perceptions of exchange sex and substance use behaviors among peers within one’s social network were associated with engagement in exchange sex and number of exchange sex partners in the past six months. Drawing on the principle of behavioral homophily within social networks (Centola, 2011; McPherson et al., 2001), we hypothesized that perceiving a higher number of social network peers (i.e., “alters”) engaged in exchange sex within one’s social network would be associated with higher odds of engagement in exchange sex among study participants (i.e., “egos”), as well as a higher number of exchange sex partners within the past six months. A higher number of exchange sex partners could indicate either higher or lower risk for transgender women (e.g., by increasing opportunities for HIV/STI transmission through more potential exposures, or conversely, by improving income security and reducing incentives to engage in condomless sex for additional money) (Fehrenbacher et al., 2016). Of particular interest in this analysis was whether perceived use of certain substances within social networks was associated with a higher likelihood and rate of exchange sex whereas perceived use of other substances was associated with a lower likelihood and rate of exchange sex, such as stimulants vs. depressants (Glynn et al., 2018; Reback & Fletcher, 2014). We hypothesized that perceptions of exchange sex and substance use behaviors among alters would be associated with both egos’ probability and rate of engagement in exchange sex, and that these social network determinants would persist when controlling for common individual correlates of exchange sex among transgender women such as race/ethnicity, housing instability, education level, and income.

Method

Participants

Transgender women in LAC (N=271) were recruited and enrolled in the study from July 2015 to September 2016. Study participants (“egos”) were eligible if they were: (1) 18 years of age or older; (2) currently identified as a transgender woman or any term along the trans feminine spectrum, regardless of their stage of social or medical gender transition; (3) assigned male sex at birth on original birth certificate; and (4) self-reported any alcohol or substance use (including non-medically prescribed marijuana) in the past six months, or self-reported condomless anal intercourse (either insertive or receptive) in the past six months. Individuals were excluded if they did not meet all eligibility criteria or were unable to understand the informed consent form.

Procedure

Prior to implementation, formative work was conducted to help modify the Social Network Interview (described below under Measures), identify recruitment venues, and provide overall input on the study development (Holloway et al., 2020). Five focus groups (N=39) were conducted, four with transgender community members and consumers of trans-related social services (n=31), and one focus group comprised of transgender women service providers (n=8). Following the development of the Audio Computer-Assisted Self-Interview (ACASI) survey instrument, a feasibility pilot test (N=7) was conducted to identify any problems, concerns, or glitches with the functionality of the ACASI. Additionally, all outreach and recruitment locations were approved by a trans-specific Community Advisory Board (CAB) prior to study implementation. Input from these various modalities was critical in forming the final study. The study was approved by the Institutional Review Boards at the University of California, Los Angeles and Friends Research Institute, Inc.

To recruit a sample of transgender women engaged in recent sexual and substance use behaviors, a two-pronged recruitment strategy was utilized: (1) street- and venue-based outreach to recruit transgender women not likely to be connected with service providers; and (2) community-based organization outreach to recruit transgender women who were likely to be receiving health and social services. In order to sample from as many diverse and discrete social networks as possible, recruitment sites varied throughout LAC. Two transgender women served as peer research assistants and conducted recruitment at street locations and venues throughout the county where transgender women were known to socialize, work, or congregate based on previous research and guidance from the CAB (e.g., bars and clubs, cruising areas, exchange sex strolls, hotels, beauty salons, wig stores, and electrolysis offices). The research assistants were trained on how to protect the privacy and confidentiality of the participants in a public venue. Participants were also recruited in agencies serving transgender women through recruitment flyers and via word-of-mouth referrals from transgender women.

The two research assistants conducted confidential screenings at recruitment sites, enrolled eligible participants, and facilitated the tablet-based ACASI surveys. A self-administered ACASI assessment was utilized to minimize social desirability bias and non-response to sensitive questions about stigmatized behaviors. Participants (N=271) were asked about their socio-demographic characteristics and sexual and substance use behaviors, as well as their perceptions of the same characteristics and behaviors among their social network alters (N=2,619). Upon completion of the assessment, all participants were compensated $50. Additional details on study procedures were previously reported elsewhere (Clark et al., 2018; Holloway et al., 2020; Reback, Clark, Fletcher, & Holloway, 2019).

Measures

Los Angeles Transgender Health Survey (LATHS).

The LATHS was originally developed by Cathy Reback and colleagues in 1997, in consultation with members of transgender communities in LAC and updated as community needs changed (Reback et al., 2001). LATHS socio-demographic variables used in this analysis as control variables included: race/ethnicity (African American/Black, Hispanic/Latina, or Non-Black/Non-Hispanic), age (in years), educational attainment (in years and highest degree attained), income (dichotomized at $500/month), and housing status (owns or rents own home, staying with someone, transitional housing such as a hotel/motel or treatment facility, homeless/on the streets, or don’t know/refused/other). Health-related variables included HIV status (positive, negative, or unknown status), any lifetime hormone use (yes/no) and any injection hormone use (yes/no), exchange sex in the past six months (yes/no), number of exchange sex partners in the past six months (count), and any substance use in the past six months (each of the following substances: alcohol, marijuana, methamphetamine, cocaine, crack, and ecstasy). The outcomes for the current study were: (1) any self-reported engagement in exchange sex in the past six months; and (2) rate of engagement in exchange sex measured by the number of exchange sex partners in the past six months. Exchange sex partner was defined as “someone with whom you exchange sex for things you need or they need such as money, drugs, shelter, or food.”

Social Network Interview (SNI).

The SNI, originally developed by Eric Rice and colleagues for a social network study with homeless youth, was modified by the investigators for this study in consultation with Rice and members from LAC transgender communities (Rice et al., 2007; Rice et al., 2011). The SNI asked participants to name their social network alters and then answer questions about each alter, including their perceived socio-demographic characteristics, exchange sex, and substance use behaviors in the past six months. Socio-demographic variables included race/ethnicity, gender identity, sexual identity, educational attainment, and housing status. Health-related variables included perceived exchange sex, substance use, HIV status, and hormone use, with all health variables operationalized in the same way as described above for study participants. Participants’ overall network size, density, and other structural characteristics were reported elsewhere (Reback, Clark, Fletcher, & Holloway, 2019).

Data Analysis

Descriptive statistics were computed for participants’ socio-demographic characteristics, exchange sex, and substance use behaviors, as well as for their perceptions of alters’ socio-demographic characteristics, exchange sex, and substance use behaviors. In all cases, variables were chosen based on their relevance to transgender women’s engagement in exchange sex based on prior literature (Fitzgerald et al., 2015; Glynn et al., 2018; Operario et al., 2008; Poteat et al., 2015; Poteat et al., 2016; Reback et al., 2005; Wilson et al., 2009). Chi-squared tests (for categorical variables) and t-tests (for continuous variables) were used to test for significant differences in socio-demographic characteristics of egos by self-reported ego engagement in exchange sex (Table 1), differences in socio-demographic characteristics of alters by perceived alter engagement in exchange sex (Table 2), and differences in substance use behaviors within and between egos and alters by both self-reported ego and perceived alter engagement in exchange sex (Table 3). In the case of cell sizes below five, a Fisher’s Exact Test was used instead of the chi-squared test. Z-tests for the equality between proportions were used to contrast proportions between groups in Table 1.

Table 1.

Participant (i.e., “Ego”) Characteristics Stratified by Self-Reported Engagement in Exchange Sex Among Transgender Women in Los Angeles, CA, 2015–2016

Ego Self-Reported Exchange Sex, Past 6 Months
No (n = 146; 53.9%)
N (%) or Mean [SD]		 Yes (n = 125; 46.1%)
N (%) or Mean [SD]		 Total (N = 271)
N (%) or Mean [SD]		 p
Racial/Ethnic Identity 0.66
Hispanic/Latina 59 (40.4%) 56 (44.8%) 115 (42.4%)
African American/Black 44 (30.1%) 38 (30.4%) 82 (30.3%)
Non-Hispanic/Non-Black 43 (29.5%) 31 (24.8%) 74 (27.3%)
Age 0.15
Years 36.0 [12.9] 33.9 [10.8] 35.0 [12.0]
Educational Attainment 0.01
Years 12.0 [2.7] 11.2 [2.4] 11.6 [2.6]
Income (Past 30 days) 0.26
Less than $500 87 (59.6%) 63 (50.4%) 150 (55.4%)
$500 or More 51 (34.9%) 51 (40.8%) 102 (37.6%)
Refused 8 (5.5%) 11 (8.8%) 19 (7.0%)
Current Housing Status 0.04
Owns or Rents a House/Apt 60 (41.1%) 52 (41.6%) 112 (41.3%)
Staying with Someone 29 (19.9%) 13 (10.4%) 41 (15.5%)
Transitional Housing 35 (24.0%) 29 (23.2%) 64 (23.6%)
Homeless/On the Streets 14 (9.6%) 26 (20.8%) 40 (14.8%)
Other/Don’t Know/Refused 8 (5.5%) 5 (4.0%) 13 (4.8%)
HIV Status (Self-Report) 0.18
HIV Positive 48 (32.9%) 48 (38.4%) 96 (35.4%)
HIV Negative 86 (58.9%) 73 (58.4%) 159 (58.7%)
Don’t Know/Refused 12 (8.2%) 4 (3.2%) 16 (5.9%)
Hormone Use (Lifetime)
Used 119 (81.5%) 101 (80.8%) 220 (81.2%) 0.99
Injected 97 (81.5%) 89 (88.1%) 186 (84.6%) 0.18
Perceived Alters Engaged in Exchange Sex
% of Total in Social Network 8.6% [16.8%] 22.3% [26.0%] 14.9% [22.6%] 0.002
At Least One 51 (34.9%) 81 (64.8%) 132 (48.7%) <0.001
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Table 2.

Social Network (i.e., “Alter”) Characteristics, Stratified by Perceived Engagement in Exchange Sex Among Transgender Women in Los Angeles, CA, 2015–2016

Alter Perceived Exchange Sex, Past 6 Months
No (n = 2,279; 87.0%)
N (%) or Mean [SD]		 Yes (n = 340; 13.0%)
N (%) or Mean [SD]		 Total (N = 2,619)
N (%) or Mean [SD]		 p
Racial/Ethnic Identity < 0.001
Caucasian/White 435 (19.1%) 23 (6.8%) 458 (17.5%)
African American/Black 625 (27.4%) 128 (37.7%) 753 (28.8%)
Hispanic/Latina 946 (41.5%) 166 (48.8%) 1,112 (42.5%)
Mixed/Other/Don’t Know 273 (12.0%) 23 (6.8%) 296 (11.3%)
Gender Identity < 0.001
Transgender 613 (26.9%) 248 (72.9%) 861 (32.9%)
Sexual Identity < 0.001
Lesbian/Gay/Bisexual/Queer 732 (35.1%) 167 (54.1%) 899 (37.5%)
Educational Attainment*
High School Diploma/GED Equivalent 1,248 (59.2%) 101 (35.6%) 1,349 (56.4%) < 0.001
4-Year College Graduate 539 (26.6%) 23 (8.2%) 562 (24.2%) < 0.001
Current Housing Status < 0.001
Homeless/On the Streets 247 (13.0%) 119 (41.8%) 366 (16.8%)
HIV Status < 0.001
HIV Positive 174 (9.3%) 80 (26.9%) 254 (11.7%)
Hormone Use (Lifetime)
Used 81 (3.6%) 71 (20.9%) 152 (5.8%) < 0.001
Injected 52 (2.3%) 52 (15.3%) 104 (4.0%) < 0.001
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Notes.

*

Categories not mutually exclusive.

Table 3.

Participant (i.e., “Ego”) Self-Reported Substance Use and Perceptions of Social Network (i.e., “Alter”) Substance Use in the Past 6 Months, Stratified by Ego Self-Reported and Alter Perceived Engagement in Exchange Sex in the Past 6 Months Among Transgender Women in Los Angeles, CA, 2015–2016

Ego (N = 271)
Self-Reported Exchange Sex,
Past 6 Months 		Alter (N = 2,619)
Perceived Exchange Sex,
Past 6 Months
No (n = 146) Yes (n = 125) No (n = 2,279) Yes (n = 340)
Substance N (%) N (%) N (%) N (%) p
Binge Alcohol 63 (43.2%) 46 (36.8%) 343 (15.1%) 80 (23.5%) b, c, d
Marijuana 73 (50.0%) 74 (59.2%) 450 (19.8%) 122 (35.9%) b, c, d
Methamphetamine 26 (17.8%) 48 (38.4%) 152 (6.7%) 84 (24.7%) a, b, c, d
Cocaine 10 (6.9%) 17 (13.6%) 40 (1.8%) 10 (2.9%) c, d
Crack 4 (2.7%) 7 (5.6%) 29 (1.3%) 3 (0.9%) d
Ecstasy 6 (4.1%) 13 (10.4%) 44 (1.9%) 15 (4.4%) a, b, d
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Notes.

a

= Difference within Participant Egos is significant (p < 0.05)

b

= Difference within Social Network Alters is significant (p < 0.05)

c

= Difference between Participant Egos not engaged in exchange sex and Social Network Alters not engaged in exchange sex is significant (p < 0.05)

d

= Difference between Participant Egos engaged in exchange sex and Social Network Alters engaged in exchange sex is significant (p < 0.05)

To build the multivariable models in Table 4, the primary independent variable for all models was each alter’s perceived “engagement in exchange sex,” which was a binary variable (1=yes, 0=no) indicating whether the ego who nominated that alter perceived the alter to be engaged in exchange sex. Coefficients related to this independent variable indicated the estimated change in the relative odds (Models 1–2) or relative rate (Models 3–4) of ego’s engagement in exchange sex for each additional alter within their social network perceived to be engaged in exchange sex (i.e., as an alter’s “engagement in exchange sex” went from a “0” to a “1”). To accomplish this, Models 1 and 2 included all data points (i.e., each ego was included once for each alter they nominated) and were thus estimated as clustered logistic regressions, with each cluster representing a participant’s social network. Results were reported as unadjusted odds ratios (OR: Model 1) and adjusted odds ratios (aOR: Model 2). Models 3 and 4 again included all data points and were thus estimated as clustered negative binomial regressions, with each cluster again representing a participant’s social network. Results were reported as unadjusted incidence rate ratios (IRR; Model 3) and adjusted incidence rate ratios (aIRR; Model 4). All variables pertaining to socio-demographic characteristics of egos from Tables 1 and substance use behaviors of both egos and alters from Table 3 were included as controls in the multivariable Models 2 and 4. Socio-demographic characteristics of alters were included in Table 2 to characterize the social networks descriptively, but they were not included in the multivariable models because we had no a priori hypotheses based on existing literature to assume that such alter characteristics would be associated with ego engagement in exchange sex. The significance level was set at p<0.05, and tests were two-tailed, wherever possible.

Table 4.

Unadjusted and Adjusted Odds of Participant (i.e., “Ego”) Engagement in Exchange Sex and Number of Exchange Sex Partners in the Past 6 Months on Social Network (i.e., “Alter”) Characteristics Among Transgender Women in Los Angeles, CA, 2015–2016

Ego Engagement in Exchange Sex,
Past 6 Months (Logistic) 		Ego Number of Exchange Sex Partners,
Past 6 Months (Count)
Model 1 Model 2 Model 3 Model 4
OR (95% CI) aOR (95% CI) IRR (95% CI) aIRR (95% CI)
Social Network (Alters)
  Engaged in Exchange Sex 3.95***
(2.55; 6.12)		 3.83***
(2.45; 5.97)		 2.57***
(1.86; 3.55)		 2.92***
(1.88; 4.56)
  Substance Use
    Binge Alcohol - 1.00
(0.60; 1.68)		 - 0.74
(0.52; 1.07)
    Marijuana - 0.51**
(0.31; 0.85)		 - 0.66*
(0.44; 0.98)
    Meth - 1.18
(0.60; 2.29)		 - 1.71
(0.98; 2.98)
    Cocaine - 2.25
(0.84; 6.07)		 - 1.65
(0.87; 3.16)
    Crack - 0.20
(0.03; 1.52)		 - 0.41
(0.13; 1.30)
    Ecstasy - 11.00***
(3.29; 36.75)		 - 2.21*
(1.03; 4.78)
Participant (Ego)
  Racial/Ethnic Identitya
    African American/Black - 0.41*
(0.18; 0.96)		 - 0.27**
(0.11; 0.67)
    Non-Hispanic & Non-Black - 0.43*
(0.19; 0.98)		 - 0.20***
(0.08; 0.50)
  Educational Attainment (yrs) - 0.88*
(0.77; 0.99)		 - 0.94
(0.83; 1.06)
  Incomeb
    ≥$500 - 1.05
(0.52; 2.12)		 - 1.59
(0.82; 3.11)
  Housing Statusc
    Staying with Someone - 0.49
(0.18; 1.34)		 - 0.47
(0.19; 1.18)
    Transitional Housing - 0.78
(0.31; 1.97)		 - 1.40
(0.48; 4.12)
    Homeless - 0.96
(0.28; 3.32)		 - 2.25
(0.68; 7.45)
    Other/Don’t Know/Refused - 1.19
(0.25; 5.66)		 - 3.49
(0.46; 26.26)
  HIV Statusd
    HIV Negative - 1.10
(0.56; 2.17)		 - 1.25
(0.62; 2.51)
  Substance Use
    Binge Alcohol - 0.40**
(0.20; 0.79)		 - 0.76
(0.38; 1.55)
    Marijuana - 1.71
(0.87; 3.37)		 - 1.53
(0.77; 3.04)
    Meth - 3.10**
(1.31; 7.36)		 - 1.76
(0.73; 4.21)
    Cocaine - 1.76
(0.41; 7.66)		 - 9.22**
(1.81; 46.98)
    Crack - 1.78
(0.43; 7.33)		 - 0.97
(0.29; 3.22)
    Ecstasy - 2.86
(0.52; 15.81)		 - 0.47
(0.08; 2.60)
n = 2,619
(269 clusters)		 n = 2,289
(236 clusters)		 n = 2,619
(269 clusters)		 n = 2,289
(236 clusters)
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Notes.

a

Reference Category: Hispanic/Latina

b

Reference Category: Less than $500

c

Reference Category: Own or Rent House/Apt

d

Reference Category: HIV Positive

*

p < 0.05;

**

p < 0.01;

***

p < 0.001

OR: Odds Ratio

aOR: Adjusted Odds Ratio

IRR: Incidence Rate Ratio

aIRR: Adjusted Incidence Rate Ratio

CI: Confidence Interval

Results

Table 1 provides participants’ (i.e., egos’) socio-demographic characteristics. Participants were predominantly Hispanic/Latina (42%) or African American/Black (30%), earned less than $500/month (55%), owned or rented their own house/apartment (41%) or were staying in transitional housing (24%), were HIV-negative (59%), and averaged 35 years of age. Approximately half of the participants (46%) self-reported exchange sex in the past six months, and about the same proportion (49%) perceived that at least one alter in their social network engaged in exchange sex. Participants who reported exchange sex were overrepresented in the homeless category (21% vs. 10%; p=0.04) and had significantly lower educational attainment (11 vs. 12 years; p=0.01). Participants who reported exchange sex were more likely than those who did not report exchange sex to perceive that at least one alter in their social network was engaged in exchange sex (65% vs. 35%; p<0.001). They also perceived that a higher proportion of alters in their social network was engaged in exchange sex (22% vs. 9%; p=0.002).

Table 2 demonstrates that most social network alters were perceived to be Hispanic/Latina (43%) or African American/Black (29%), to have completed high school (56%), and to be HIV-negative (88%). African American/Black and Hispanic/Latina alters were more likely to be perceived by egos as engaged in exchange sex (p<0.001). Approximately one-third of alters (33%) were identified as transgender and slightly over one-third (38%) as lesbian, gay, bisexual, or queer (LGBQ); alters who were perceived to be transgender and those perceived to be LGBQ were both significantly more likely to be perceived to be engaged in exchange sex than their cisgender and heterosexual counterparts (73% vs. 27% and 54% vs. 35%, respectively; both p<0.001). Alters who were perceived to be engaged in exchange sex were also more likely to be identified by egos as homeless (42% vs. 13%; p<0.001) and having ever used hormones (21% vs. 4%; p<0.001).

Table 3 provides egos’ self-reported substance use in the past six months and their perceptions of alters’ substance use, arrayed by self-reported (egos’) and perceived (alters’) engagement in exchange sex. Participants who reported exchange sex in the past six months were more likely to report methamphetamine use (39% vs. 18%; p<0.001) and ecstasy use (10% vs. 4%; p=0.04). Participants were more likely to report use of every measured substance relative to alters, irrespective of engagement in exchange sex. Alters perceived to be engaged in exchange sex were also more likely to be perceived as using alcohol, marijuana, methamphetamine, and ecstasy relative to alters who were not perceived to be engaged in exchange sex.

Table 4 demonstrates that perceiving any alters to be engaged in exchange sex in one’s social network significantly increased both the odds of egos engaging in exchange sex (aOR: 3.83; 95% CI: 2.45–5.97; p<0.001) as well as their number of exchange sex partners in the past six months (aIRR: 2.92; 95% CI: 1.88–4.56; p<0.001), regardless of socio-demographic controls, individual and network substance use behaviors, or other network characteristics. Specifically, the confidence intervals implied between 2.5 to 6.0 times the odds of engagement in exchange sex and 1.9 to 4.6 times the rate of exchange sex partner acquisition in the past six months for each social network alter perceived to be engaged in exchange sex.

The multivariable results also indicated that Hispanic/Latina participants were more likely to report exchange sex and to acquire exchange sex partners at a higher rate than other racial/ethnic groups. Those with more years of education had lower odds of engagement in exchange sex. No other socio-demographic characteristics showed consistent patterns of association with exchange sex outcomes. Participants who self-reported methamphetamine use were more likely to report exchange sex, whereas those who self-reported cocaine use acquired exchange sex partners at a higher rate. Participants who self-reported binge alcohol use were less likely to report exchange sex. Participants who perceived that any social network alters used ecstasy were more likely to engage in exchange sex and acquired exchange sex partners at a higher rate, whereas the inverse was true among participants who perceived that any network alters used marijuana.

Discussion

This study investigated how perceptions of sexual and substance use behaviors within social networks were associated with exchange sex among transgender women. The findings demonstrated that transgender women who perceived that any of their social network alters were engaged in exchange sex were significantly more likely to engage in exchange sex themselves and acquired exchange sex partners at a higher rate than transgender women who did not perceive that any of their social network alters were engaged in exchange sex. The magnitude of these effects remained large and stable with the inclusion of socio-demographic controls, self-reported substance use, and perceptions of social network alters’ substance use, providing strong evidence of behavioral homophily among transgender women engaged in exchange sex (McPherson et al., 2001). Findings from this study demonstrated the robust influence of social ties on exchange sex among transgender women, consistent with a small but growing body of evidence demonstrating how sexual and substance use behaviors cluster together within transgender communities (Clark et al., 2018; Reback, Clark, Fletcher, & Holloway, 2019; Reisner et al., 2009).

Network alters who were perceived to exchange sex were also perceived to be more structurally and socially disadvantaged than alters perceived not to exchange sex. For example, alters perceived to exchange sex were more likely to be described as having intersecting racial/ethnic, sexual, and gender minority statuses; to have not completed high school; to be homeless; and to be living with HIV compared to alters perceived not to exchange sex. These findings are consistent with prior research demonstrating that transgender women engaged in exchange sex are exposed to greater marginalization than their transgender peers not engaged in exchange sex (Brennan et al., 2012; Operario & Nemoto, 2010; Parsons et al., 2018; Poteat et al., 2015; Reback, Fletcher, Fehrenbacher et al., 2019). A previous study found that young transgender women with a history of exchange sex reported significantly lower educational attainment, more homelessness, and greater likelihood of incarceration than young transgender women not engaged in exchange sex (Wilson et al., 2009). In the current study, a higher proportion of transgender women reporting exchange sex also reported current homelessness and lower educational attainment compared to those not engaged in exchange sex, replicating prior findings (Fletcher et al., 2014; Kattari & Begun, 2017). Patterns of co-occurring health disparities among transgender women who exchange sex may be explained by syndemic theory, which refers to the concentration of mutually reinforcing epidemics and forms of structural disadvantage within a population (Operario & Nemoto 2010; Reback, Clark, Rünger et al., 2019).

Race/ethnicity was associated with both the likelihood and rate of exchange sex among transgender participants. When controlling for other socio-demographic characteristics and both egos’ and alters’ substance use behaviors, African American/Black transgender women and non-Black/non-Hispanic transgender women were less likely to report exchange sex and acquired fewer exchange sex partners than Hispanic/Latina transgender women in the sample. The presence of large Hispanic/Latina transgender communities, many prominent cultural gatekeepers, and several Hispanic/Latina- and transgender-led service providers in Los Angeles might increase this group’s access to co-ethnic transgender peers and exchange sex resources (Hoefinger et al., 2020; Rodriguez, 2020). In addition, a previous analysis with the study sample indicated that Hispanic/Latina transgender women were more likely than other groups to use non-hormone soft tissue “fillers,” often injected to enhance one’s gender expression and presentation, which might accentuate feminine presentation and perceived desirability to male clients (Clark et al., 2018). In the current study, hormone use to enhance gender presentation was perceived to be more common among alters engaged in exchange sex consistent with previous research (Maschião et al., 2020). Further investigations on the intersections of race/ethnicity, hormone and filler use, and exchange sex might elucidate mechanisms driving disproportionate engagement in exchange sex among subpopulations of transgender women and provide particularly fruitful insights for communities with a high proportion of Hispanic/Latina transgender women, such as LAC (Clark et al., 2018; Rodriguez, 2020).

Substance use behaviors of both egos and alters were strongly associated with exchange sex among egos. At the individual level, substance use findings hewed closely to the extant literature (Hoffman, 2014; Reback & Fletcher, 2014). For example, recent self-reported stimulant use was associated with higher odds of exchange sex (methamphetamine) and a higher rate of acquiring exchange sex partners (cocaine), whereas binge alcohol use was associated with lower odds of exchange sex. These findings are consistent with previous studies on stimulant use among transgender sex workers as a safety strategy to stay awake and alert, particularly for those who live or work on the streets (Kattari & Begun, 2017; Reback & Fletcher, 2014). In contrast, binge drinking has the opposite effect and can impair a person’s ability to engage in exchange sex and see more clients (Reback et al., 2005).

Network dynamics also shed light on the social influence of perceived substance use behaviors on an individual’s engagement in exchange sex. Transgender women embedded in networks with perceived marijuana users were less likely to report exchange sex and had fewer exchange sex partners, and transgender women in networks with perceived ecstasy users were more likely to report exchange sex and had more exchange sex partners. Existing evidence has demonstrated that stimulant use, including both “street drugs” (e.g., methamphetamine) and “party drugs” (e.g., cocaine and ecstasy), have been associated with exchange sex among transgender women (Glynn et al., 2018; Hoffman, 2014; Reback & Fletcher, 2014). These findings are a novel extension of current literature, highlighting that perceived substance use in transgender women’s social networks also played a pivotal role in their engagement in exchange sex (Reback, Clark, Fletcher, & Holloway, 2019). Such results highlight that, among transgender women who exchange sex, multi-pronged risk reduction interventions targeting stimulant use at both the individual- and network-levels might be better suited than interventions attending to only one level of intervention, as substance use and exchange sex behaviors appear to reinforce one another within social networks (Operario & Nemoto, 2010).

An unexpected finding was that transgender women in the sample perceived themselves to be engaged in riskier substance use behaviors compared to their network alters, regardless of their engagement in exchange sex. Evidence from social network research with MSM and injection drug users suggests that individuals usually perceive themselves to be engaged in less risky behaviors than their peers (Hawkins et al., 1999; Peterson et al., 2009). However, the transgender women in this study perceived themselves to be engaged in riskier substance use behaviors than their alters. Although participants’ networks were populated with large numbers of both cisgender and transgender alters, with transgender women comprising approximately a third of the nodes, cisgender alters were numerically more prevalent within networks (Reback, Clark, Fletcher, & Holloway, 2019). As such, transgender women in the study might have perceived the “average” alter within their networks to be a cisgender person exposed to fewer syndemic risks and forms of marginalization associated with both exchange sex and substance use (Brennan et al., 2012; Parsons et al., 2018).

These findings must be interpreted with consideration of several limitations. First, recall and social desirability bias of personal behaviors and network characteristics might contribute to inaccurate reporting of exchange sex and substance use behaviors. Furthermore, egos’ perceptions of alters’ behaviors might not accurately reflect the true behaviors of others in the social network. Second, convenience sampling limits the ability to generalize the findings beyond transgender women engaged in the sexual and substance use behaviors used to determine study eligibility or transgender women outside of the LAC neighborhoods from which they were recruited. Third, the study was cross-sectional, so we are unable to draw causal inferences from the results. Fourth, because some substance use behaviors had few subgroup outcomes (e.g., crack cocaine and ecstasy use), some confidence intervals were imprecise. Although we are confident in the existence of an effect, we cannot with precision determine the effect size for these groups. Finally, evaluating motivations for engagement in exchange sex among transgender women or whether study participants perceived themselves to be sex workers was beyond the scope of this analysis. Understanding the complex interplay of structure and agency influencing transgender women’s engagement in exchange sex (Laidlaw, 2017; Sausa et al., 2007) and frequency of exchange sex (Benoit et al., 2017; Shaver, 2005) should be prioritized in future research. Despite these limitations, the novel social network methodology and wide range of measures on behaviors and social perceptions from a racially and ethnically diverse sample of transgender women provides a strong foundation for future analyses on social network dynamics in transgender communities, an area of research for which there is very little in the current literature (Clark et al., 2018; Ezell et al., 2018; Holloway et al., 2020; Reback, Clark, Fletcher, & Holloway, 2019).

Findings from this study with 271 transgender women in LAC demonstrated that social network dynamics, including alters’ perceived sexual and substance use behaviors, were strongly associated with both the likelihood of exchange sex and the rate at which transgender women acquired exchange sex partners. Risk reduction interventions with transgender women should attend to network dynamics that are often overlooked in existing programs to better understand how social networks influence engagement in exchange sex as well as how social networks could be harnessed to ensure the safety of those exchanging sex in criminalized risk environments (Fletcher, 2013; Holloway et al., 2020; Nieto et al., 2020; Reback, Clark, Rünger et al., 2019). Peer-led harm reduction strategies are well suited to meet the needs of transgender women engaged in exchange sex who often rely on other peers engaged in similar behaviors for support in coping with syndemics that increase risk for HIV, including housing instability, substance use, violence, and incarceration (Poteat et al., 2016; Reisner et al., 2009). Given the intersecting forms of marginalization and criminalization experienced by transgender women engaged in exchange sex (Hoefinger et al., 2020), public health programs that intervene at multiple social, structural, and policy levels are likely to be more effective than individual-level behavior change interventions (Operario & Nemoto, 2010; Reback, Clark, Fletcher, & Holloway, 2019).

Acknowledgements:

This study was supported by the National Institute on Drug Abuse, grant #R21DA037816. Dr. Fehrenbacher was supported by a grant from the National Institutes of Health Fogarty International Center awarded to the University of California Global Health Institute at the University of California, San Francisco (D43TW009343), as well as a National Institute of Mental Health grant awarded to the UCLA Semel Institute for Neuroscience and Human Behavior (T32MH109205). Drs. Reback and Fehrenbacher acknowledge additional support from a grant to the UCLA Center for HIV Identification, Prevention, and Treatment Services from the National Institute of Mental Health (P30MH58107). Dr. Clark acknowledges funding support from the Graduate Division, UCLA Fielding School of Public Health (Fellowship in Epidemiology, #104733842). We acknowledge editing support provided by Dhara Patel. We thank all study participants and research team members. The content is solely the responsibility of the authors and does not necessarily reflect the official views of the National Institutes of Health or other funders.

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