Transgender sex workers

A transgender sex worker is a transgender person who works in the sex industry or performs sexual services in exchange for money or other forms of payment. The term transgender refers to a diverse population whose gender identity or expression differs from their assigned sex at birth. Transgender women are defined as natal males with female identification or expression and transgender men are natal females with male identification or expression. In general, sex workers appear to be at great risk for serious health problems related to their profession, such as physical and sexual assault, robbery, murder, physical and mental health problems, and drug and alcohol addiction. Though all sex workers are at risk for the problems listed, some studies suggest that sex workers who work on the street have a higher risk for experiencing these issues. Transgender people are likely to experience high degrees of discrimination and carry the risk of facing higher rates of contracting HIV and experiencing poverty or violence during their work.

Health issues

Sexually transmitted infection risk

Sex workers as a population experience higher risk for various health conditions, including HIV and other sexually transmitted infections (STIs). People engaging in sex exchange services are likely to receive or transmit HIV or other STIs because of the likelihood of engaging in risky sexual behaviors (e.g., sex without a condom, sex with multiple partners) and substance use. The Centers for Disease Control and Prevention (CDC) reports that because data for transgender people are not uniformly collected there is a major lack of information about HIV-positive transgender people in the United States. The dearth of information regarding transgender people does not exist solely in the United States, however. There is an urgent need for HIV data for transgender sex workers all around the world, especially in Africa, eastern Europe, and central Asia. This worldwide gap in available information is a result of structural barriers created by the legal structures of different countries and continued criminalization of sex work.

According to the CDC, data collected by local health departments and scientists studying transgender communities have shown high levels of HIV and disparities between racial groups. In a systematic review of HIV infection in the United States, African-American transgender women were most likely to test HIV-positive. 56% of African-American transgender women had positive HIV test results compared to 17% of white transgender women and 16% of Hispanic transgender women. Transgender sex workers, especially transgender women, have a higher risk of carrying or contracting HIV. From the data collected it has been estimated that as many as 1-in-4 transgender female sex workers are HIV-positive. HIV testing programs and HIV prevention programs for transgender individuals could potentially reduce the risk for infection while also helping HIV-positive transgender sex workers access health care.

Transgender sex workers worldwide are at higher risk of contracting HIV and other STIs as well. In a study on sex workers in Jakarta, Indonesia, waria, or third gender people, were found to have HIV rates over 5 times the rates of cisgender male sex workers and syphilis rates almost 10 times the rates present in the cisgender male sex worker community. The results of this study have implications for the wider population in Jakarta as well, as many of the sex workers interviewed reported bisexual activity. Sex workers in China are often detained in "re-education through labor" (RTL) centers that focus on moral and vocational training. The numbers of detained sex workers has been on the rise due to the recent uptick in HIV rates among heterosexual men. However, incarceration in an RTL center makes accessing information about HIV and STIs difficult, mostly due to social stigma of imprisonment and sex work in general, which only further increases rates of HIV and STIs in sex workers.

Health care services

Experiences of discrimination in a health care setting can delay a sex worker's willingness to seek medical care in the future. Refusing to seek medical treatment for seemingly minor medical issues may lead to initially innocuous issues becoming more serious and more difficult to treat. Insensitivity from health care professionals has been cited as a reason that sex education and medical services are not accessed. Reports of insensitive behavior among health care providers (e.g., misgendering, using the wrong name, etc.) suggest that some services are lacking in terms of provision of culturally sensitive interactions and possible provisions of trans health care. In addition to the health care problems experienced by transgender men and women, traditional health care plans do not always cover the costs relative to transitioning, which may lead to men and women resorting to alternative methods to pay for transitioning or force them to seek out unsafe methods of making these changes such as using hormones bought off the street or sharing needles while injecting hormones.

Various methods have been implemented to help transgender sex workers gain information about HIV and safe sex practices. The use of mobile outreach units in Lima, Peru was effective in reaching transgender women and identifying HIV-positive transgender women who did not previously know their status. The Sisters program in Thailand, which primarily serves kathoeys, emphasizes the use of peer support networks and outreach efforts and has increased condom usage in kathoey sex worker populations with clients. Despite this success, however, there was no increase in condom usage with casual or long-term partners. While there has been success with implementing HIV prevention programs in different countries around the world, a lack of information about HIV programs for lesbian, gay, bisexual, and especially transgender sex workers limits the extent to which effective, long-term solutions can be produced.

Causes and effects

Poverty

Poverty works both as a cause and an effect of sex work. Sex workers as a whole are a vulnerable population due to obstacles like poverty, poor health, and legal and social barriers. A study that collected information on sex work from transgender women of color in San Francisco reported that for some transgender women sex work is a necessary means of survival. For these women, sex work is a way to get food, shelter, or income in a society that precludes them from many other lines of work.

Despite engaging in higher risk activity, transgender sex workers are more likely to receive lower pay than other sex workers. Transgender sex workers with history of homelessness, unemployment, incarceration, mental health issues, violence, emotional, physical, or sexual abuse, or drug use are further at risk of being trapped in a cycle of poverty. Lack of economic opportunities outside of the sex work industry and discrimination may lead to transgender people entering sex work in order to generate income for rent, drugs, medicines, hormones, or gender-related surgeries.

In addition to the laws used against male and female sex workers, laws prohibiting cross-dressing or impersonation of another sex are used to suppress their activity. In the United States, there are no explicit legal protections on a federal level for transgender workers based on gender identity/expression. This lack of legal protection places transgender workers in a position to have higher rates of unemployment and greater risk of poverty.

Discrimination

Physical and sexual violence

Transgender people are likely to experience high levels of violence and harassment from strangers, people in the home, or people they know. They are also at a higher risk of being victims of sexual or physical assault multiple times. There is also a high prevalence of sexual assault and rape starting at a young age. In the United States, the most common finding across self-surveys and needs assessments is that about 50% of transgender people report unwanted sexual activity. The majority of perpetrators of sexual violence are people who are known to the victim, including partners and family members.

Participating in the sex industry comes with a higher risk of experiencing violence. Sex workers work in a variety of settings and are often open to exploitation, harassment, and physical and sexual abuse from clients, managers, and police. According to self-reported surveys from sex workers in the U.S. most unwanted sexual violence has come from clients. This violence may be motivated by perpetrators hatred or negative attitudes toward transgender people. Self reported surveys have become a major form of data collection on sex worker violence in part due to research by Departments of Health or social service organizations. Since these institutions have a large focus on data pertaining to sexual activity there are more reports relative to sexual violence in comparison to other forms of violence. These experiences are not always reported to the police which can affect crime reporting rates, which may be due to mistrust of the police or fear of discrimination.

Legal discrimination

Transgender and sex worker populations have difficulty accessing health care services due to social stigma. This difficulty is further compounded at the intersection of these two populations. A survey of sex workers, which included transgender responses, in four African countries, Kenya, Zimbabwe, Uganda, and South Africa, reported that denial of treatment for injuries associated with physical or sexual assault as well as general public services was common. Recent legal moves have been made to legalize this kind of discrimination within the health care sector with the First Amendment Defense Act (FADA).