Transgender women sex workers’ experiences accessing sexual health care in Iran: a qualitative study
Mina Saadat
A , Afsaneh Keramat B , Ali Mohammad Nazari C , Hadi Ranjbar D , Shayesteh Jahanfar E and Zahra Motaghi C *
A
B
C
D
E
Abstract
This study aimed to examine the experiences of transgender women who work in the sex industry regarding their access to health care facilities for sexual health. Transgender women sex workers are recognised worldwide as a high-risk group for HIV and sexually transmitted infections (STIs).
In Iran, between January and May 2022, we employed a snowball sampling technique to recruit a diverse group of 22 transgender women sex workers aged 19–42 years. Semi-structured interviews were conducted with these participants to provide insights into their experiences with accessing sexual health care.
The data was analysed using thematic analysis, revealing four overarching themes: experiences of violence, contextual barriers to health, socioeconomic challenges and HIV/STI risk practices, and 11 sub-themes. The results demonstrate that many participants experienced difficulties in accessing sexual health services due to violence, discrimination, financial difficulties and lack of awareness about STIs.
Sex workers face extraordinarily challenging occupational risks, including sexual and physical abuse, mental health issues, and HIV and STIs. Targeted public intervention programs and research for this group are urgently needed. Outreach programs engaging with underserved transgender women sex workers have the potential to enhance access to healthcare services, and contribute to the reduction of HIV transmission rates.
Keywords: discrimination, HIV prevention, public health, sex workers, sexually transmitted infections, stigma, transgender women, qualitative.
References
2 Ferguson A, Shannon K, Butler J, Goldenberg SM. A comprehensive review of HIV/STI prevention and sexual and reproductive health services among sex Workers in Conflict-Affected Settings: call for an evidence- and rights-based approach in the humanitarian response. Confl Health 2017; 2017 11: 25.
| Crossref | Google Scholar |
4 Ssekamatte T, Isunju JB, Naume M, et al. Barriers to access and utilisation of HIV/STIs prevention and care services among trans-women sex workers in the greater Kampala metropolitan area, Uganda. BMC Infect Dis 2020; 20: 932.
| Crossref | Google Scholar |
5 Moayedi-Nia S, Taheri L, Hosseini Rouzbahani N, et al. HIV prevalence and sexual behaviors among transgender women in Tehran, Iran. AIDS Behav 2019; 23: 1590-1593.
| Crossref | Google Scholar | PubMed |
6 Gama A, Martins MRO, Mendão L, et al. HIV infection, risk factors and health services use among male-to-female transgender sex workers: a cross-sectional study in Portugal. AIDS Care 2018; 30: 1-8.
| Crossref | Google Scholar | PubMed |
7 Septarini NW, Hendriks J, Maycock B, et al. Methodologies of stigma-related research amongst men who have sex with men (MSM) and transgender people in Asia and the Pacific Low/Middle Income Countries (LMICs): a scoping review. Front Reprod Health 2021; 3: 688568.
| Crossref | Google Scholar | PubMed |
8 Cheng FK. Sex work, health, and human rights: global inequities, challenges, and opportunities for action. Int J Hum Rights Healthc 2022; 15: 499-500.
| Crossref | Google Scholar |
9 Peitzmeier SM, Malik M, Kattari SK, et al. Intimate partner violence in transgender populations: systematic review and meta-analysis of prevalence and correlates. Am J Public Health 2020; 110: e1-e14.
| Crossref | Google Scholar | PubMed |
10 Evens E, Lanham M, Santi K, et al. Experiences of gender-based violence among female sex workers, men who have sex with men, and transgender women in Latin America and the Caribbean: a qualitative study to inform HIV programming. BMC Int Health Hum Rights 2019; 19: 9.
| Crossref | Google Scholar |
11 Nemoto T, Operario D, Keatley J, Villegas D. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care 2004; 16: 724-735.
| Crossref | Google Scholar | PubMed |
12 Armstrong L. Stigma, decriminalisation, and violence against street-based sex workers: changing the narrative. Sexualities 2019; 22: 1288-1308.
| Crossref | Google Scholar |
13 Hawkes S, Collumbien M, Platt L, et al. HIV and other sexually transmitted infections among men, transgenders and women selling sex in two cities in Pakistan: a cross-sectional prevalence survey. Sex Transm Infect 2009; 85: ii8-ii16.
| Crossref | Google Scholar | PubMed |
14 Ogden SN, Harris MT, Childs E, et al. “You need money to get high, and that’s the easiest and fastest way:” A typology of sex work and health behaviours among people who inject drugs. Int J Drug Policy 2021; 96: 103285.
| Crossref | Google Scholar |
15 Karamouzian M. Characterizing the relationship between incarceration and structural risks among female sex workers in Iran: findings of a nationwide biobehavioral surveillance survey. Ann Epidemiol 2019; 35: 29-34.
| Crossref | Google Scholar |
16 Brookfield S, Dean J, Forrest C, et al. Barriers to accessing sexual health services for transgender and male sex workers: a systematic qualitative meta-summary. AIDS Behav 2020; 24: 682-696.
| Crossref | Google Scholar | PubMed |
17 Alegria CA. Transgender identity and health care: implications for psychosocial and physical evaluation. J Am Acad Nurse Pract 2011; 23: 175-182.
| Crossref | Google Scholar | PubMed |
18 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77-101.
| Crossref | Google Scholar |
19 Decker MR, Lyons C, Billong SC, et al. Gender-based violence against female sex workers in Cameroon: prevalence and associations with sexual HIV risk and access to health services and justice. Sex Transm Infect 2016; 92: 599-604.
| Crossref | Google Scholar | PubMed |
20 Naderifar M, Goli H, Ghaljaie F, et al. Snowball sampling: a purposeful method of sampling in qualitative research. Stride Dev Med Educ 2017; 14: e67670.
| Crossref | Google Scholar |
21 Aggarwal NK, Consavage KE, Dhanuka I, et al. Health and health care access barriers among transgender women engaged in sex work: a synthesis of US-based studies published 2005–2019. LGBT Health 2021; 8: 11-25.
| Crossref | Google Scholar | PubMed |
22 Sun CJ, Anderson KM, Mayer L, et al. Findings from formative research to develop a strength-based HIV prevention and sexual health promotion mHealth intervention for transgender women. Transgend Health 2019; 4: 350-358.
| Crossref | Google Scholar | PubMed |
23 Boyce S, Barrington C, Bolaños H, et al. Facilitating access to sexual health services for men who have sex with men and male-to-female transgender persons in Guatemala City. Cult Health Sex 2012; 14: 313-327.
| Crossref | Google Scholar | PubMed |
24 Lazarus L, Deering KN, Nabess R, et al. Occupational stigma as a primary barrier to health care for street-based sex workers in Canada. Cult Health Sex 2012; 14: 139-150.
| Crossref | Google Scholar | PubMed |
25 Edmundson C, Heinsbroek E, Glass R, et al. Sexualised drug use in the United Kingdom (UK): a review of the literature. Int J Drug Policy 2018; 55: 131-148.
| Crossref | Google Scholar | PubMed |
26 Abelson A, Lyons C, Decker M, et al. Lifetime experiences of gender-based violence, depression and condom use among female sex workers in Cameroon. Int J Soc Psychiatry 2019; 65: 445-457.
| Crossref | Google Scholar | PubMed |
27 Eftekhar M, Mostafavi E, Gouya MM, et al. HIV prevention barriers in transgender women: a qualitative study. J Gay Lesbian Soc Serv 2020; 32: 133-147.
| Crossref | Google Scholar |
29 Fix L, Durden M, Obedin-Maliver J, et al. Stakeholder perceptions and experiences regarding access to contraception and abortion for transgender, non-binary, and gender-expansive individuals assigned female at birth in the U.S. Arch Sex Behav 2020; 49: 2683-2702.
| Crossref | Google Scholar | PubMed |
30 Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19: 903-917.
| Crossref | Google Scholar | PubMed |
31 Samudzi Z, Mannell J. Cisgender male and transgender female sex workers in South Africa: gender variant identities and narratives of exclusion. Cult Health Sex 2015; 18: 1-4.
| Crossref | Google Scholar |
32 Underhill K, Morrow KM, Colleran C, et al. A qualitative study of medical mistrust, perceived discrimination, and risk behavior disclosure to clinicians by U. S. male sex workers and other men who have sex with men: implications for biomedical HIV prevention. J Urban Health 2015; 92: 667-686.
| Crossref | Google Scholar | PubMed |
33 Fan X, Lau JTF, Cai Y, et al. Prevalence and associated factors of sexualized drug use in sex work among transgender women sex workers in China. AIDS Care 2020; 33: 1098-1106.
| Crossref | Google Scholar | PubMed |
34 Avila MM, Dos Ramos Farías MS, Fazzi L, et al. High frequency of illegal drug use influences condom use among female transgender sex workers in Argentina: impact on HIV and syphilis infections. AIDS Behav 2017; 21: 2059-2068.
| Crossref | Google Scholar | PubMed |
35 Bith-melander P, Sheoran B, Sheth L, et al. Understanding sociocultural and psychological factors affecting transgender people of color in San Francisco. J Assoc Nurses AIDS Care 2010; 21: 207-220.
| Crossref | Google Scholar |
36 Benoit C, Belle-Isle L, Smith M, et al. Sex workers as peer health advocates: community empowerment and transformative learning through a Canadian pilot program. Int J Equity Health 2017; 16: 160.
| Crossref | Google Scholar |
