Towards ‘reflexive epidemiology’: Conflation of cisgender male and transgender women sex workers and implications for global understandings of HIV prevalence

Abstract

The HIV epidemic has had a widespread impact on global scientific and cultural discourses related to gender, sexuality, and identity. ‘Male sex workers’ have been identified as a ‘key population’ in the global HIV epidemic; however, there are methodological and conceptual challenges for defining inclusion and exclusion of transgender women within this group. To assess these potential implications, this study employs self-critique and reflection to grapple with the empiric and conceptual implications of shifting understandings of sexuality and gender within the externally recreated etic category of ‘MSM’ and ‘transgender women’ in epidemiologic HIV research. We conducted a sensitivity analysis of our previously published meta-analysis which aimed to identify the scope of peer-reviewed articles assessing HIV prevalence among male sex workers globally between 2004–2013. The inclusion of four studies previously excluded due to non-differentiation of cisgender male from transgender women participants (studies from Spain, Thailand, India, and Brazil: 421 total participants) increased the overall estimate of global HIV prevalence among “men” who engage in sex work from 10.5% (95% CI 9.4–11.5%) to 10.8% (95% CI 9.8–11.8%). The combination of social science critique with empiric epidemiologic analysis represents a first step in defining and operationalizing ‘reflexive epidemiology’. Grounded in the context of sex work and HIV prevention, this paper highlights the multiplicity of genders and sexualities across a range of social and cultural settings, limitations of existing categories (i.e., ‘MSM’, ‘transgender’), and their global implications for epidemiologic estimates of HIV prevalence.

‘It all dials back to safety’: A qualitative study of social and economic vulnerabilities among transgender women participating in HIV research in the USA

“…Medicine has historically pathologised and stigmatised TW health needs. In HIV research, the legacy of mistrust is specific to TW having been categorised as MSM 18–20. TW did not trust researchers to consider their specific safety and confidentiality concerns such as their physical safety in terms of geographic location of research sites (potential exposure to violence) and emotional safety and confidentiality (concerns of being ‘outed’).…”

Sensitive Health Topics With Underserved Patient Populations: Methodological Considerations for Online Focus Group Discussions

“…For example, it is possible that our results may be more generalizable, compared with data obtained from in-person face-to-face focus groups, in that they reflect the views of more marginalized as well as more geographically diverse subgroup of the population. In addition, transgender people are often excluded from research and/or historically have been collapsed with other population groups (Perez-Brumer, Oldenburg, Reisner, Clark, & Parker, 2016), rather than have their distinct and specific health needs assessed and considered. Equitable access to research participation and the ability to contribute data on health care needs to improve health care service delivery and responsiveness represent important dimensions of inclusion in population health (Deutsch, Radix, & Reisner, 2016).…”

Transgender health in India and Pakistan

“…In Pakistan the HIV incidence among transgender people contributes up to 17.5% of the entire HIV population. 3,4 Moreover, in Pakistan, approximately 71% of the transgender sex worker-cum-injected drug users have sexual relationship with other drugusers and up to 33.7% of them did not use condom in the last coitus with their clients. 5 Similarly in India, the use of condom during anal sex remains low and almost two thirds of transgender people have no access to treatment of STI.…”