1. Social Stigma, Marginalization, Injection Drug Use, and HIV Risk Among MTF Transgenders UCSF/CAPS Health Studies for People of Color 1145 Bush Street, 2nd Floor San Francisco, CA 94109 JoAnne G. Keatley, MSW Project Director

2. High Risk Because of their unique social context, male-to-female transgenders (MTF TGs) are at high risk for HIV infection and other adverse health outcomes.

3. Social Stigma Due to the social stigma attached to being transgender and the lack of employment opportunities, many feel forced to engage in commercial sex work.

4. Substance Use Substance use is also quite prevalent in this population, and helps MTF TGs cope with their oppressive environment.

5. Unprotected Sex  with commercial sex partners, who will often pay more to have unprotected sex.  with private partners who they trusted or with whom they were in a primary relationship.  with both types of partners while under the influence of substances. Instances of unprotected sex occur in the following three contexts:

6. Psychosocial Stressors Psychosocial stressors, including isolation, depression, and transphobia, can exacerbate HIV risk and drug using behaviors.

7. Cross-Sectional Study A cross-sectional study was carried out in San Francisco to learn more about this population and the issues they face.

8. Study Participants  African-American110  Latina110  API112 A total of 332 interviews were conducted with an ethnic minority sample, using a structured questionnaire reflecting the social context and life experiences of the MTF TG community.

9. TG Community Survey  Participants recruited from community sites, individual referrals, and referrals from collaborating ASOs  1.5 hr interviews, using structured questionnaire  Half the Latina interviews conducted in Spanish

10. Transphobia % ever (n)% daily (n) Made fun of/called names for being transgender or effeminate as a child79% (261)32% (105) Hit or beaten up for being transgender or effeminate as a child37% (122)4% (12) Made fun of/called names for being transgender or effeminate as an adult39% (131)8% (26) Hit or beaten up for being transgender or effeminate as an adult20% (65)0.3% (1) Told that transgenders were not normal as a child67% (224)24% (78)

11. Transphobia, con’t % ever (n)% daily (n) Told that transgenders were not normal as an adult63% (208)9% (31) Felt that being transgender hurts and embarrasses family58% (194)0% (0) Had to pretend not to be transgender in order to not hurt family46% (154)18% (61) Have lost a job or career opportunity for being transgender38% (126)0% (0) Had to move away from family or friends because of being transgender53% (177)0% (0) Have been harassed by police for being transgender61% (203)5% (18)

12. Violence and Victimization Ever physically assaulted% (n) Overall39% (128) African American39% (44) Asian/Pacific Islander36% (39) Latina41% (45) Ever raped as a minor Overall30% (99) African American40% (45) Asian/Pacific Islander12% (13) Latina37% (41) Ever raped as an adult Overall25% (82) African American35% (39) Asian/Pacific Islander16% (18) Latina23% (25)

13. Socioeconomic Hardship Housing situation% (n) Stable housing47% (157) Unstable housing44% (147) Homeless5% (16) Monthly income Less than $50019% (64) $500 to $1,00033% (110) $1,000 to $2,00021% (71) More than $2,00025% (84) Employment income, past 6 months Full time 28% (92) Part time or temp job18% (60) No employment income54% (180)

14. Mental Health Outcomes Depression (CES-D > 15)% (n) Overall40% (133) African Americans37% (41) Asian/Pacific Islanders24% (26) Latinas60% (66) Ever considered suicide Overall45% (149) African Americans61% (68) Asian/Pacific Islanders28% (31) Latinas46% (50) Ever attempted suicide Overall29% (95) African Americans41% (46) Asians/Pacific Islanders15% (16) Latinas45% (49)

15. Injection Drug Use IDU history% (n) Overall24% (78) African American37% (41) Asian/Pacific Islander12% (13) Latina22% (24) IDU, past month Overall7% (24) African American10% (11) Asian/Pacific Islander4% (4) Latina8% (9)

16. Unprotected Anal Intercourse, past month W/ primary private partnerAdjusted % (n / subsample) Overall36% (62 / 173) African American36% (24 / 67) Asian/Pacific Islander34% (19 / 56) Latina38% (19 / 50) W/ casual partners, past month Overall18% (22 / 119) African American31% (11 / 35) Asian/Pacific Islander11% (4 / 35) Latina14% (7 / 49) W/ commercial sex partner, past month Overall9% (12 / 131) African American16% (7 / 44) Asian/Pacific Islander3% (1 / 29) Latina7% (4 / 58)

17. Sex while under the influence, past month With private partnerAdjusted % (n / subsample) Overall72% (117 / 173) African American76% (51 / 67) Asian/Pacific Islander54% (30 / 56) Latina72% (36 / 50) With casual partner Overall68% (81 / 119) African American74% (26 / 35) Asian/Pacific Islander57% (20 / 35) Latina71% (49 / 25) With commercial sex partner Overall70% (92 / 131) African American68% (30 / 44) Asian/Pacific Islander66% (19 / 29) Latina74% (43 / 58)

18. HIV and STD Outcomes HIV % (n) Overall26% (86) African American42% (47) Asian/Pacific Islander13% (14) Latina23% (25) Tuberculosis Overall13% (42) African American12% (13) Asian/Pacific Islander3% (3) Latina24% (26) Hepatitis C Overall11% (38) African American22% (25) Asian/Pacific Islander2% (2) Latina10% (11)

19. HIV Testing HIV test, past year% (n) Overall55% (181) African American49% (55) Asian/Pacific Islander46% (51) Latina68% (75) HIV test, past 6 months Overall37% (123) African American38% (43) Asian/Pacific Islander22% (24) Latina51% (56)

20. TB Testing TB test, past year % (n) Overall43% (144) African American47% (53) Asian/Pacific Islander32% (35) Latina51% (56) TB test, past 6 months Overall30% (101) African American34% (38) Asian/Pacific Islander20% (22) Latina37% (41)

21. Conclusions As a result of pervasive transphobia Transgenders are denied access to social support, housing, employment, healthcare, education and other resources. HIV prevention efforts must focus on reducing social stigma and increasing access to much needed services.