Transgender sex workers

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.[9] 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.[10]

Despite engaging in higher risk activity, transgender sex workers are more likely to receive lower pay than other sex workers.[8] 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.[11]

In the United States, there are no explicit legal protections on a federal level for transgender workers based on gender identity or expression.[12] This lack of legal protection places transgender workers in a position to have higher rates of unemployment and greater risk of poverty.[13]

Unemployment rates reported by transgender sex workers were twice those of transgender non-sex workers based on data from the National Transgender Discrimination Survey.[6] A main cause of unemployment among the transgender sex worker population is the compounded stigma of being transgender and being involved in sex work, as both of these populations are unlikely to access health services or job opportunities due to social discrimination.[14] Transgender sex workers of color experience higher rates of unemployment than white sex workers, in addition to being at higher risk for HIV and other STDs.[6]

Transgender sex workers often request, and also have difficulty accessing, job training and placement services.[15] Rates of accessing health care, temporary shelter, and financial assistance are all higher than rates of accessing job placement or job trainings. These rates are also affected by race; for example, African American transgender sex workers were less likely to have access to job programs than Latina transgender sex workers.[15]

Sex workers as a population experience higher risk for various health conditions, including HIV and other sexually transmitted infections (STIs).[16] 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.[11][17] 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.[8] 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.[11]

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.[11] 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.[18] Transgender sex workers, especially transgender women, have a higher risk of carrying or contracting HIV.[8] 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.[16]

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 five times the rates of cisgender male sex workers and syphilis rates almost 10 times the rates present in the cisgender male sex worker community.[19] 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.[19] Sex workers in China are often detained in "re-education through labor" (RTL) centers that focus on moral and vocational training.[20] The number 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.[20]

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.[1] Insensitivity from health care professionals has been cited as a reason that sex education and medical services are not accessed.[21] 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.[22]

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.[8] 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.[8] 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.[8]

Pre-exposure prophylaxis, or PrEP, is an effective method of preventing HIV contraction when taken regularly and used in combination with condoms. However, barriers to accessing general health care prevent transgender sex workers from accessing PrEP and other HIV-preventing medications as well.[23] Demand for PrEP exists within the transgender sex worker community but low awareness of the drug, cost of the medication, and confusion about where to get PrEP create an environment in which sex workers cannot effectively access it.[23] A study on PrEP usage in the men who have sex with men and transgender women sex worker communities recommended increasing access to PrEP by spreading more accurate information about PrEP as well as providing ways to get PrEP for a cheaper price.[23]