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Providing appropriate STI care for transgender and gender-diverse clients
Aug 6, 2014 by Andrea Szewchuk, MD, CCFP, Centre Organizer, Catherine White Holman Wellness Centre
Transgender people have unique health needs, particularly in regards to sexual health and HIV care. When combined with barriers to care, including fear of disclosure and real or perceived discrimination within social and health settings, extra care and knowledge is necessary to provide appropriate and culturally-competent sexual health care and screening.
There is evidence showing that trans people face increased risk of STI and HIV. Trans women, and especially trans women of colour, may have HIV prevalence as high as 19.1% in some populations. This can be due to lack of appropriate sexual health information, minority stress, and experiences of violence or discrimination. Social stigmas leading to poverty and involvement in sex work may further influence rates of HIV.
The TransPULSE study of 433 trans Ontarians found that experiences of depression and violence amongst trans people were correlated with increased challenges with condom negotiation. Furthermore, trans clients were more likely to avoid testing and delay care. Transphobia leads to systemic barriers in care, prevention, follow-up, and large scale prevention and tracking studies for STI and HIV.
Providing appropriate care
Knowing why and how we ask questions is important when creating safe spaces. Avoid assumptions about sexuality based on someone’s gender identity. For example, many trans men identify as queer or gay, and therefore may have similar STI and HIV risks as cis-males engaging in MSM sex. A significant percentage of trans men engage in receptive vaginal sex. Similarly, trans women who have not had surgery may engage in penetrative sex.
Ask permission to discuss sensitive areas, and make sure your client knows why you are asking. Trans people are often faced with inappropriate questions about their bodies that may not relate to the presenting issue, and it’s important to clarify why we ask certain questions.
Language is important! At the most basic level, knowing what name and pronoun (such as he, she, or they) your patient prefers is key.
When taking sexual history, using general language can help to increase comfort. For example, say “genitals” rather than naming body parts, as this may trigger dysphoria.
Let your clients know that you are open to using language they feel comfortable with. For example, “frontal hole” is a term sometimes used among trans men. Similarly, you can say “chest exam” rather than “breast exam.”
Base sexual health screening on the body parts that your client has, and know the ways in which hormone therapy and surgery affect sexual health.
Trans women will require prostate exams, and trans men will require cervical screening. In the latter, hormone therapy can often cause dryness and vaginal changes that can make exams more uncomfortable. For those on testosterone, it’s especially important to talk about barrier protection, as micro-tears may increase risk for STI.
For those accessing surgery, sexual health needs will further change. Neo-vaginal tissue in trans women has less elasticity than natal-vaginal tissue and requires extra lubrication. Post-operative information on STI risk for folks of all genders is lacking from current literature.
Look for resources that are appropriate for your client. Many sexual health guidelines are notably lacking in gender-diversity, and clients can have difficulty accessing information appropriate to their needs.
The below list has recommendations for gender-inclusive primary care, sexual health, and HIV information.
- Transgender Health Information Program (Vancouver Coastal Health, BC)
- Guidelines and Protocols for Comprehensive Primary Care for Trans Clients (Sherbourne Health Centre, Ontario)
- University of California San Francisco Centre of Excellence for Transgender Health (San Francisco, USA)
- Trans PULSE Research Project
- Primed: The back pocket guide for trans men and the men who dig them (2006)
- Brazen: Trans women’s safer sex guide (2013)
- Baral, S et al. Worldwide Burden of HIV in transgender women: Systematic Review and Meta-analysis. The Lancet Infectious Diseases. 13:3, 214-222. 2013.
- Bauer GR, Redman, N, Bradley K, Scheim AI. Sexual Health of Trans Men Who Are Gay, Bisexual, or Who Have Sex with Men: Results from Ontario, Canada. International Journal of Transgenderism 2013;14(2):66-74.
Categories: Current practice