Barriers and facilitators to HIV and sexually transmitted infections testing for gay, bisexual, and other transgender men who have sex with men

ABSTRACT

Transgender men who have sex with men (trans MSM) may be at elevated risk for HIV and other sexually transmitted infections (STI), and therefore require access to HIV and STI testing services. However, trans people often face stigma, discrimination, and gaps in provider competence when attempting to access health care and may therefore postpone, avoid, or be refused care. In this context, quantitative data have indicated low access to, and uptake of, HIV testing among trans MSM. The present manuscript aimed to identify trans MSM’s perspectives on barriers and facilitators to HIV and STI testing. As part of a community-based research project investigating HIV risk and resilience among trans MSM, 40 trans MSM aged 18 and above and living in Ontario, Canada participated in one-on-one qualitative interviews in 2013. Participants described a number of barriers to HIV and other STI testing. These included both trans-specific and general difficulties in accessing sexual health services, lack of trans health knowledge among testing providers, limited clinical capacity to meet STI testing needs, and a perceived gap between trans-inclusive policies and their implementation in practice. Two major facilitators were identified: access to trusted and flexible testing providers, and integration of testing with ongoing monitoring for hormone therapy. Based on these findings, we provide recommendations for enhancing access to HIV and STI testing for this key population.

KEYWORDS:

• Transgender
• men who have sex with men
• HIV testing
• sexually transmitted infections
• health services

Introduction

In North America, approximately two-thirds of transgender (trans) men (female-to-male transgender persons) persons identify as sexual minorities (Bauer, Redman, Bradley, & Scheim, 2013; Grant et al., 2011). A smaller proportion are sexually active with cisgender (non-trans) men; in Ontario, Canada, 21% of trans men reported at least one past-year cisgender male sex partner (Bauer et al., 2013).

As these partners are often gay or bisexual men, HIV risk among trans men who have sex with men (trans MSM) is of concern (Rowniak, Chesla, Rose, & Holzemer, 2012). A recent international review identified 10 laboratory-confirmed HIV seroprevalence data points for trans men in high-income countries, ranging from 0–4% (Reisner & Murchison, 2016). In Ontario, a respondent-driven sampling survey found no self-reported HIV infections among trans MSM, but 43% had never been tested (Bauer et al., 2013; Scheim, Bauer, & Travers, 2016). Barriers to access likely contribute to low uptake; in a global survey of MSM, trans men reported lower access to HIV testing than their cisgender counterparts (Scheim et al., 2016).

Trans MSM may be affected by general and MSM-specific barriers to testing such as low risk perception, HIV-related and anti-gay stigmas, and concerns regarding confidentiality; and general facilitators including shorter wait times, less invasive testing methods, and normalization as part of routine care (Deblonde et al., 2010; Lorenc et al., 2011). Further, trans-specific barriers to healthcare may limit accessibility of HIV and other sexually transmitted infections (STI) testing. Trans people have traditionally been invisible in healthcare education and policy (Bauer et al., 2009; Obedin-Maliver et al., 2011), and therefore, healthcare providers often feel ill-prepared to provide care (Poteat, German, & Kerrigan, 2013; Snelgrove, Jasudavisius, Rowe, Head, & Bauer, 2012). Trans people frequently report negative experiences in healthcare settings, ranging from insensitive language to refusal of care (Bauer, Scheim, Deutsch, & Massarella, 2014; Grant et al., 2011). As a result, they may avoid both preventative and urgent care (Bauer et al., 2014; Cruz, 2014; Socías et al., 2014).

Accessing HIV and STI testing may be additionally challenging for trans MSM due to reluctance to discuss their sexual behaviour and risks with healthcare providers, particularly as some providers may consider same-gender sexual behaviour or vaginal intercourse inconsistent with trans male identity (Reisner, Perkovich, Perkovich, & Mimiaga, 2010). In addition, some trans MSM prefer to access sexual health services tailored to MSM, but such services can be unprepared to provide them care (Sevelius, 2009).

To inform efforts to improve access to and uptake of testing among trans MSM, the current analysis draws on data from a qualitative study of trans MSM in Ontario, Canada to identify perceived barriers and facilitators to HIV and other STI testing.

Method

The Trans MSM Sexual Health Study was a community-based qualitative research project investigating HIV risk among trans MSM. Data were collected in 2013 from 40 participants recruited through social media, lesbian, gay, bisexual, transgender or HIV organizations, and trans-related events. Eligible participants identified as trans men or trans masculine, had sex with a man in the previous year, were 18 or older, and lived in Ontario. Quota sampling was employed to oversample Indigenous/Aboriginal and racialized trans men, and to ensure representation of those living outside the province’s largest urban centre, Toronto. Participants were provided with a $40CAD honorarium. Research ethics boards at the University of Windsor and Wilfrid Laurier University approved the study.

Participants completed a brief demographic questionnaire before participating in semi-structured interviews conducted in person, by phone, or by Skype. This analysis focuses on responses to a set of questions pertaining to HIV/STI testing history and barriers to testing services. Interviews were audio-recorded, transcribed, and coded in NVivo10. Employing template analysis (King, 1998), an initial coding template was based on questions in the interview guide. Next, author RT and a transgender-identified graduate student organized participant responses thematically to develop a hierarchical coding template, which the authors continually refined. In this manuscript, we report on results under the high-level themes of “barriers to” and “reasons for” testing. Participants are identified by their age and whether they resided in Toronto or elsewhere in the province.

Results

Participants

Participant characteristics are described in Table 1. Participants were young (73% were between the ages of 18–34, n = 29) and racially diverse (43% Indigenous and/or racialized, n = 17). None reported being HIV-positive, but 15% (n = 6) did not know their HIV status. Most (70%, n = 28) lived in Toronto and described themselves as having completed medical transition (49%, n = 19) or being in process of transitioning (41%, n = 16).

Table 1. Characteristics of Trans MSM Sexual Health Study participants in Ontario, Canada (n = 40).

	n	%
Gender identity^a
Male	27	68
Trans man	32	80
Genderqueer, genderfluid, non-binary	7	18
Two spirit	2	5
Age^b
18–24	10	25
25–34	19	48
35–44	9	23
45+	2	5
Cisgender male sex partners, past 6 months^b,c
None	4	10
One	9	23
2–4	12	30
5–9	8	20
10+	7	18
Sexual orientation^a
Heterosexual	2	5
Gay/homosexual	13	33
Bisexual or pansexual	12	30
Queer	29	73
Two spirit	2	5
Race/ethnicity^b
Aboriginal/Indigenous	4	10
Racialized, non-aboriginal	13	33
White	23	58
Live in Toronto	28	70
Self-reported medical transition status^b
Medically transitioned (hormones and/or surgery)	19	49
In process	16	41
Planning but not begun	2	5
Concept doesn’t apply to me or not sure	2	5
HIV status^b
Negative	34	85
Positive	0	0
Don’t know	6	15

^aParticipants could check all that apply; proportions will sum to greater than 100%.

^bProportions may sum to greater than 100% because of rounding.

^cPast-year sex with a cisgender or transgender man was an inclusion criterion.

Barriers to HIV and STI testing

Barriers to HIV and STI testing included fear of positive results, difficulties accessing sexual healthcare in general, provider perceptions of low risk, lack of provider knowledge, and limited clinic capacity to meet STI testing needs. Most reported barriers were situated in the context of Ontario’s sexual health clinics, which are mandated to provide low-barrier access to testing for communities at high HIV and STI risk, including gay and bisexual men.

Fear of receiving a positive result

Concerns about the ramifications of testing positive for HIV led some participants to avoid or delay testing. A few participants explicitly connected these fears to being trans MSM, with one worrying that “[…] if I somehow contracted HIV, that it would prevent my transition” (23, Toronto).

Difficulties in accessing sexual healthcare

Both trans-specific and general barriers (e.g., hours of operation) to sexual health services were described. For instance, a participant described how moving to another city – with fewer trans-friendly health resources – led to an interruption in his history of regular HIV and STI testing:

I prefer actually to go to a clinic like [clinic], but that’s mainly because I haven’t really felt that comfortable with doctors that I’ve seen […] before I left [city] I had a habit of getting tested about every six months, and then while I was away I didn’t get tested because there wasn’t a place that I felt comfortable asking for testing. (37, Toronto)

In contrast, a few trans men indicated that they largely avoided preventative care altogether due to medical mistrust. A 23-year-old in Toronto explained:

I mean, there’s a lot of things like health-wise that I should probably deal with. […] I just have an aversion to doctor things. I’m sick, I’m not gonna go to the doctor cause I’ve had such issues […]

In addition to avoiding testing due to fears of mistreatment, there were reported instances of health care providers outright refusing care. For example, one participant reported being refused testing by multiple clinics catering to MSM:

In [major city outside Ontario] it was actually quite difficult because I lived in the village and there was a lot of places to get tested, but a lot of them don’t take trans guys […] they cannot understand that trans guys have sex with cis dudes. (31, Toronto)

Low perceived risk

As the participant above noted, reluctance or refusal to provide sexual health services to trans men may be related to misperceptions that they are at low HIV and STI risk. In line with this observation, some trans MSM described being explicitly discouraged from testing by healthcare providers. A 34-year-old trans man in Toronto said: “I had gone for an HIV test and um, and a slew of other STI testing, and the nurse tried to talk me out of it. She said I wasn’t at risk.”

Lack of knowledge among testing providers

In addition to assumptions about the types of sexual behaviours and risks that trans men may engage in, participants often felt that HIV/STI testing providers lacked knowledge of trans identities and health-related concerns. As a 37-year-old in Toronto described: “The person who did the HIV test […] was asking me questions about terminology and stuff that I kind of feel like someone who’s working there should know.” Similarly, providers sometimes used inappropriate language, reflecting limited awareness of the different terms trans men may use to describe their gendered histories and anatomy:

She [doctor] was actually pretty decent but then she was like “okay, so you”re still biologically a woman, then” and I was like “No!” […] Went for the butt swab and I was like “dammit, I don’t want to take my pants off in front of you.” (25, outside Toronto)

Institutional and provider capacity to meet STI testing needs

In general, trans men faced more barriers accessing testing for STIs other than HIV because these tests generally necessitate disclosure of trans status and discussion of genital status (particularly for those who might otherwise be perceived as cisgender men). Moreover, in requesting STI tests, trans men uncovered “cisnormative” (Bauer et al., 2009) assumptions among testing providers. For example, a 25-year-old outside Toronto described difficulty obtaining rectal swabs that would be indicated based on his sexual behaviour:

I was like, “what do you do for cis gay men?” And they were like “oh, well for men who have sex with men we do an anal swab and a urethral swab” … and I was like “why did you never offer any of those to me?” and they were like “well, you're not a man who has sex with men” … and I was like “who do you think I fuck? Straight guys?”

At the institutional level, services that were gender-segregated – even if nominally trans-inclusive – posed unique barriers, particularly for STI testing. Some trans men were uncomfortable with the binary division of services and therefore avoided such services. Yet even when trans men felt that a men’s-only environment was suitable and decided to attend, they sometimes encountered clinics that were unready to provide culturally and clinically competent care. Describing his experiencing of visiting a men’s sexual health clinic, a 25-year-old Toronto trans man related:

They call me by my birth name to go in. […] And then the doctor didn’t know if she could do a pap smear, and she didn’t know if she had the equipment […] [a speculum] was hanging out of me for a while, she was running around the room trying to figure out where all the things were.

A 31-year-old in Toronto found his experience at a men’s sexual health clinic more gender-affirming, but faced similar obstacles to STI testing:

They were really friendly. They were like, super perky. But like, I didn’t get the feeling that they knew what they were doing, necessarily. […] They were really clear about telling me how affirming they were, but also they didn’t seem to know how to go about the swabbing that would need to have been done.

Disconnect between trans-inclusive policy and practice

Trans men observed that while sexual health clinic staff were friendly and oriented toward inclusivity, they were not necessarily successful in implementing inclusive practices. Participants commented on a discrepancy between trans-inclusive intake forms and less inclusive practices in waiting and examination rooms:

They asked me at the front desk whether or not I was a woman or a trans woman. […] I hadn’t even marked it [the intake form] off yet. […] The reason there’s a paper that has check boxes means you don’t ask! (21, Toronto)

I guess he didn’t actually look at it [intake form] because then he started talking to me about my dick, and whether I use condoms when I’m topping … it was hilarious cause the form had all these [gender] options. (27, Toronto)

Trans men reported that uncomfortable clinic experiences, even if not overtly discriminatory, impacted willingness to access testing in the future:

 … was I ever denied access? No. But was it a cumbersome thing that leaves me not wanting to go back to [clinic]? Yes. (25, Toronto)

Facilitators of testing

Among those who regularly accessed HIV and STI testing, motivations included testing as part of a general healthcare routine, a sense of responsibility to partners, or recent HIV risk behavior. Specific to participants’ experiences as trans MSM, key facilitators of HIV testing were access to trusted testers and integration of testing with gender-affirming primary care.

Trusted testers

For trans men who expressed mistrust of the healthcare system, access to testing was facilitated by trusted providers who offered low-barrier services. When concerned about the possibility of a positive HIV test result, a 31-year-old in Toronto sought out testing with a friend who was also a testing provider, who was open to an alternative process for delivering results:

I went for the rapid test, but I was actually really nervous because I had had unprotected sex with several people […] It was making me feel really panicked to get a result so quickly, so the worker, who was a friend of mine, sealed it for three days and let me come back.

Prior negative healthcare experiences related to both injection drug use and trans status led one 24-year-old Toronto trans man to avoid health services. However, he felt able to access HIV testing when offered by a mobile service, without need for an appointment or interaction with physicians:

Hep C day at the health centre. The bus was there, and I was like hey, since I’m not seeing doctors and you guys are right here taking, walk on the bus and get your blood taken, I was like, I’m gonna do this.

Integration with gender-affirming healthcare

Engagement with ongoing gender-affirming healthcare provided an opportunity to routinize HIV testing. Most participants were on testosterone hormone therapy (80%, n = 32), and many of those individuals had HIV testing incorporated into their visits with a physician providing transition-related care, often concomitant with bloodwork for monitoring hormone safety and effectiveness. A 29-year-old trans man in Toronto expressed a common sentiment when he said, “I usually just get the test done whenever I get tested for testosterone. So it’s not like a major deal to me.”

Multiple narratives, however, drew attention to potential limitations of seamlessly integrating HIV testing into hormone monitoring, in the absence of pre-test counselling. Some trans men, knowing that an HIV test had been included in their laboratory requisitions at some point, assumed – but had not verified – that HIV testing was carried forward for subsequent blood tests.

Discussion

To our knowledge, this represents the first study to examine barriers and facilitators to HIV and STI testing services for trans men who have sex with men. We found that it was sometimes more difficult for trans MSM to access STI testing, as compared to HIV testing. Among cisgender MSM, inadequate receipt of rectal STI tests has been noted (Siconolfi et al., 2013), and trans men may not receive indicated screening for similar reasons, such as not being directly offered screening. However, some participants specifically requested genital and/or rectal swabs and yet encountered barriers, including providers who were unprepared to examine their genitals. Another distinct theme was a gap between sexual health clinic policies and practices. Participants appreciated the efforts clinics had made to implement trans-inclusive intake forms and organizational mandates, yet were sometimes exasperated by the disjuncture between those efforts and their experiences accessing services. As one participant exclaimed: “I was like, ‘really? Your organization is trying so hard to be trans positive and inclusive and … this is happening.’”

These findings suggest a need for clinics to implement training and procedures to ensure that respectful language is used throughout the clinic visit (Hagen & Galupo, 2014). In addition, they indicate that efforts focused on respectful communication are necessary but not sufficient. Sexual healthcare providers also require the clinical competence to comfortably attend to trans people’s bodies and specific needs vis-à-vis STI testing, including for trans men who have had genital surgery. In particular, gender-specific clinics should assess internal capacity to provide sex-specific screening for trans men, and clearly communicate any limitations to potential patients.

Among trans women, integration with hormone therapy has been identified as a facilitator to HIV treatment and adherence (Melendez & Pinto, 2009; Sevelius, Patouhas, Keatley, & Johnson, 2013). By logical extension, co-provision of hormones and HIV testing has been recommended (Reisner, Radix, & Deutsch, 2016), but these findings are, to our knowledge, the first to demonstrate support for co-provision among trans people themselves. Future integration of these services should address some of the limitations highlighted in participant narratives, including lack of informed consent or pre- and post-test counselling, limited provision of other STI tests, and miscommunication about the frequency with which HIV testing was included in laboratory requisitions.

On the other hand, some trans MSM avoid healthcare settings, and these participants preferred to access outreach or peer testing. For these men, both formal peer testing programmes and self-testing may be viable options for increasing testing uptake. As home HIV tests have not yet been licenced for sale in Canada, they were not addressed in the interviews, but we would recommend future evaluation of their potential utility for trans MSM.

This study had strengths and limitations that should be noted. We drew on data from a community-based research project in which the majority of the research team members were themselves trans MSM. Therefore, we were able to engender trust on the part of participants, and collect rich narratives regarding sensitive experiences. While these qualitative findings from a convenience sample cannot be generalized beyond the sample, a number of the barriers identified are consistent with previous studies of sexual and gender minority populations and may have broader applicability. However, most participants lived in Canada’s largest city, where existing trans-friendly healthcare services are concentrated. Trans MSM living in smaller communities may face different challenges in accessing testing than did the participants in our study. Finally, while our study sample was intentionally very diverse with respect to race/ethnicity, no participants discussed barriers or facilitators related to race, Indigeneity, or other identities that may intersect with trans status to impact healthcare access.

In conclusion, within this sample of trans MSM in Ontario, Canada, we identified a number of barriers to accessing HIV and STI testing which were heightened for (non-HIV) STI testing, and when accessing specialized sexual health clinics. Many of these barriers are likely amenable to change through expanded medical education and staff training. Uptake of HIV and STI testing among trans MSM may also be enhanced through co-provision of HIV testing with trans healthcare, and through outreach testing initiatives.

Acknowledgements

We are grateful to the 40 study participants who generously shared their experiences. The Trans MSM Sexual Health Study Team was: Barry Adam, Alex Adams, Zack Marshall, James Murray, Caleb Nault, Nik Redman, Ayden Scheim, Robb Travers, and Syrus Marcus Ware. Thank you to Lauren Munro and Charlie Davis for assistance with data analysis. The authors wish to acknowledge the contributions of our late colleague, Kyle Scanlon, to the development of this study.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This research was supported by the Canadian Institutes of Health Research (CIHR), HIV/AIDS Community-Based Research Initiative [Funding Reference # 272849]. Ayden Scheim is supported by Pierre Elliott Trudeau Foundation and Vanier Canada Graduate Scholarships. Robb Travers is supported by a CIHR New Investigator Award, Population Health/Health Services (HIV/AIDS).