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Male-to-female transgender women (TGW) experience high rates of substance use and HIV. A recent substance use trend is the use of prescription medication without a doctor's consent. No research to date has examined the associations between this non-medical use of prescription drugs and HIV risk behaviour in TGW. In the present study, TGW recruited from community venues (N = 104) in the Mid-Atlantic region of the United States completed surveys assessing demographic information, non-medical use of prescription drugs, other substance use, injection practices and sexual risk behaviour. Twenty-four per cent of the sample reported lifetime non-medical use of prescription drugs across the following categories: analgesics (21.2%), anxiolytics (14.4%), stimulants (12.5%) and sedatives (8.7%). Participants reporting non-medical use of prescription drugs were more likely to report other substance use, needle use to inject drugs, injecting silicone and sharing needles. In multivariable analyses, non-medical use of prescription drugs was associated with unprotected sex, sex after engaging in substance use, and commercial sex work, after controlling for demographic factors. Self-esteem and social support from family served as protective factors for non-medical use of prescription drugs. HIV-prevention programmes focused on TGW in the United States may wish to expand their assessment of substance use to include the use of prescription medications without a physician's consent.

Discrimination and victimization are very common experiences of transgender women. Social marginalization is often linked to poor mental health, substance use, and risky sexual behaviors. HIV prevalence in transgender women in the USA may be as high as 27.7%, and has been estimated at nearly 50 times that of the overall adult population globally. It is in this context that we test structural equation models for the relationships among perceived gender-identity discrimination, internalized anxiety about being transgender (transphobia), mental health problems, illicit substance and alcohol use, and HIV risk behaviors. We tested two mediational models: one that proposes mental health, alcohol, and other substance use as key mediators of sexual risk behaviors, and the other that posits the exchange of sex for money or goods as a key mediator linking mental health and substance use with other risky sexual behaviors. Our results suggest that perceived gender-identity discrimination and internalized transphobia are both significantly related to mental health problems. In turn, in the first model, mental health problems were marginally related to number of sexual partners and sex under the influence of drugs. In addition, alcohol use played a key role in risky sexual behaviors in both models and having sex in exchange for money or goods also played a significant role in the second model. We discuss some of the limitations in the data and analyses that require further research to explore these relationships more carefully.

The purpose of this study was to examine the use of the internet to meet sexual partners among transgender individuals and examine correlates of this use, including sexual risk behavior, discrimination experiences, and mental health. A sample of 166 transgender adults (112 male-to-female transgender women and 54 female-to-male transgender men) were recruited in community venues and anonymously completed measures assessing these variables. Most participants (64.5 %) were HIV-negative, 25.2 % were HIV-positive, and 10.3 % did not know their HIV status. Overall, 33.7 % of participants reported having met a sexual partner over the internet, which did not differ significantly between transgender women and men. Among these individuals, transgender women reported significantly more lifetime internet sexual partners (median = 3) than transgender men (median = 1). Use of the internet to meet sexual partners was associated with lower self-esteem but not with depression, anxiety, somatic distress or discrimination experiences. Among transgender women, use of the internet to meet sexual partners was associated with each of the 11 sexual risk behaviors examined, including having multiple partners, sex under the influence of drugs, number of unprotected anal or vaginal sex acts, and history of commercial sex work. The use of the internet to meet partners was not associated with sexual risk behavior among transgender men (0/11 variables assessed). Although the internet is a common mode of meeting sexual partners among some transgender adults, it may also be a potential venue for prevention interventions targeting transgender individuals at particularly high risk for HIV acquisition.

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