Budhwani Henna, Hearld Kristine R, Hasbun Julia, Charow Rebecca, Rosario Santo, Tillotson Louise, McGlaughlin Elaine, Waters John
Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, United States of America.
Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States of America.
PLoS One. 2017 Nov 2;12(11):e0186457. doi: 10.1371/journal.pone.0186457. eCollection 2017.
Not only do transgender female sex workers have some of the highest rates of sexually transmitted infections (STI), human immunodeficiency virus (HIV), and experienced stigma, they also have higher likelihood of early sexual debut and some of the lowest levels of educational attainment compared to other stigmatized populations. Some of the most common interventions designed to reduce transmission of HIV and STIs seek to educate high-risk groups on sexual health and encourage condom use across all partner types; however, reaching stigmatized populations, particularly those in resource-limited settings, is particularly challenging. Considering the importance of condom use in stopping the spread of HIV, the aim of this study was two-fold; first to characterize this hard-to-reach population of transgender female sex workers in the Dominican Republic, and second, to assess associations between their HIV knowledge, experienced stigma, and condom use across three partner types.
We analyzed self-reported data from the Questionnaire for Transgender Sex Workers (N = 78). Respondents were interviewed at their workplaces. Univariate and bivariate analyses were employed. Fisher Chi-square tests assessed differences in HIV knowledge and experienced stigma by condom use across partner types.
HIV knowledge was alarmingly low, condom use varied across partner type, and the respondents in our sample had high levels of experienced stigma. Average age of first sexual experience was 13.12 years with a youngest age reported of 7. Dominican Republic statutory rape laws indicate 18 years is the age of consent; thus, many of these transgender women's first sexual encounters would be considered forcible (rape) and constitute a prosecutable crime. On average, respondents reported 8.45 sexual partners in the prior month, with a maximum of 49 partners. Approximately two thirds of respondents used a condom the last time they had sex with a regular partner. This was considerably lower than condom use reported with coercive partners (92.96%) and clients (91.78%). Bivariate analyses revealed two trends: experienced stigma was associated with lower rates of condom use, and lower HIV knowledge was associated with lower rates of condom use. The former provides additional evidence that experienced stigma may become internalized, affecting individual-level behaviors-lowering self-confidence and resilience-making it more difficult to negotiate condom use due to lack of self-efficacy and desire to show trust in one's partner. The latter supports public health research that suggests gaps in HIV knowledge persist and are pronounced in highly stigmatized populations.
The vulnerabilities experienced by transgender persons, particularly in environments that vehemently adhere to conservative ideologies related to sex and gender, are significant and harm this population. These vulnerabilities could potentially be addressed through critically examining of impact of policies that indirectly promote or allow victimization of transgender citizens and subsequently diminish the effectiveness of public health and educational interventions. By taking action through the revocation of such laws, the Dominican Republic has the opportunity to improve overall population health, to protect some of its most stigmatized citizens, and to become the flag bearer of enhanced human rights in the Caribbean and Latin America.
变性女性性工作者不仅有着一些最高的性传播感染（STI）、人类免疫缺陷病毒（HIV）感染率，且遭受着污名化，与其他受污名化群体相比，她们也更有可能过早开始性行为，且受教育程度极低。一些旨在减少HIV和性传播感染传播的最常见干预措施试图对高危群体进行性健康方面的教育，并鼓励在与所有类型伴侣的性行为中使用避孕套；然而，要接触到受污名化群体，尤其是那些资源有限环境中的群体，极具挑战性。鉴于使用避孕套对于阻止HIV传播的重要性，本研究有两个目的；其一，描述多米尼加共和国这个难以接触到的变性女性性工作者群体的特征，其二，评估她们在三种伴侣类型中的HIV知识、所遭受的污名化与使用避孕套之间的关联。
我们分析了来自《变性性工作者调查问卷》的自我报告数据（N = 78）。在她们的工作场所对受访者进行了访谈。采用了单变量和双变量分析。费舍尔卡方检验评估了在不同伴侣类型中因使用避孕套而在HIV知识和所遭受污名化方面的差异。
HIV知识水平低得惊人，避孕套的使用因伴侣类型而异，且我们样本中的受访者遭受着高水平的污名化。首次性经历的平均年龄为13.12岁，报告的最小年龄为7岁。多米尼加共和国的法定强奸罪法律规定18岁为同意性行为的年龄；因此，这些变性女性的许多首次性接触会被视为强迫性行为（强奸），并构成可被起诉的罪行。平均而言，受访者报告在前一个月有8.45个性伴侣，最多有49个伴侣。大约三分之二的受访者在最后一次与固定伴侣发生性行为时使用了避孕套。这大大低于与强迫性伴侣（92.96%）和客户（91.78%）发生性行为时报告的避孕套使用率。双变量分析揭示了两个趋势：遭受污名化与较低的避孕套使用率相关，较低的HIV知识水平与较低的避孕套使用率相关。前者提供了额外的证据，表明所遭受的污名化可能会内化，影响个人层面的行为——降低自信心和恢复力——由于缺乏自我效能感以及想要表现出对伴侣的信任，使得协商使用避孕套变得更加困难。后者支持了公共卫生研究，该研究表明HIV知识方面的差距依然存在，并且在受高度污名化的群体中尤为明显。
变性者所经历的脆弱性，尤其是在那些坚决秉持与性和性别相关的保守观念的环境中，是巨大的，并对这一群体造成伤害。通过批判性地审视那些间接促进或允许对变性公民进行伤害并随后削弱公共卫生和教育干预效果的政策的影响，这些脆弱性有可能得到解决。通过采取行动废除此类法律，多米尼加共和国有机会改善总体人口健康状况，保护一些最受污名化的公民，并成为加勒比地区和拉丁美洲加强人权的旗手。
