Barriers to Accessing Sexual Health Services for Transgender and Male Sex Workers: A Systematic Qualitative Meta-summary

  • Samuel BrookfieldEmail author
  • Judith Dean
  • Candi Forrest
  • Jesse Jones
  • Lisa Fitzgerald
Substantive Review


Access to safe and effective sexual healthcare services for transgender and male sex workers (TMSW) is a human right. Globally, TMSW experience a higher prevalence of human immunodeficiency virus (HIV) and sexually transmitted infections than the general population or other sex workers, suggesting the existence of unique challenges for this group when accessing healthcare. A systematic database search identified 22 qualitative papers addressing barriers to accessing sexual healthcare services for TMSW. These papers were critically evaluated for adherence to best practice standards for qualitative research and research with sex workers. A coding process identified five themes. Stigma was the predominant barrier, and was divided into stigma related to sexuality, gender identity, HIV status, sex worker status, and internalised stigma. Other barriers were confidentiality concerns, sexual health literacy, fatalism, and structural barriers. Each of these themes were informed by the wider context of stigma. The literature presents a complex syndemic of social disadvantage and exclusion acting to produce and reinforce health disparities related to sexual health and access to screening and treatment for TMSW.


Sex work Transgender Male sex work Sexual health Systematic review 



All funding for this review was provided by the HIV Foundation, Queensland.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

This research received ethical approval under the University of Queensland Human Research Ethics Committee (Approval Number #2016001287).


  1. 1.
    Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT, et al. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up. Lancet. 2015;385(9963):172–85.Google Scholar
  2. 2.
    Decker MR, Crago A, Chu SKH, Sherman SG, Seshu MS, Buthelezi K, et al. Human rights violations against sex workers: burden and effect on HIV. Lancet. 2015;385(9963):186–99.Google Scholar
  3. 3.
    Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviours, healthcare use, and mental health status of transgender persons: implications for public health intervention. Am J Public Health. 2001;91:915–21.Google Scholar
  4. 4.
    Operario D, Soma T, Underhill K. Sex work and HIV status among transgender women: systematic review and meta-analysis. J Acquir Immune Defic Syndr. 2008;48(1):97–103.Google Scholar
  5. 5.
    Tang W, Mahapatra T, Liu F, Fu G, Yang B, Tucker JD, et al. Burden of HIV and syphilis: a comparative evaluation between male sex workers and non-sex-worker men who have sex with men in urban China. PLoS ONE. 2015;10(5):e0126604.Google Scholar
  6. 6.
    UNAIDS. Global report 2012: UNAIDS report of the global AIDS epidemic. Joint United Nations Programme on HIV/AIDS. UNAIDS; 2012.Google Scholar
  7. 7.
    Poteat T, Wirtz AL, Radix A, Borquez A, Silva-Santisteban A, Deutsch MB, et al. HIV risk and preventive interventions in transgender women sex workers. Lancet. 2015;385(9964):274–86.Google Scholar
  8. 8.
    Myers T, Allman D, Xu K, Remis RS, Aguinaldo J, Burchell A, et al. The prevalence and correlates of hepatitis C virus (HCV) infection and HCV-HIV co-infection in a community sample of gay and bisexual men. Int J Infect Dis. 2009;13(6):730–9.Google Scholar
  9. 9.
    Nguyen TA, Nguyen HT, Le GT, Detels R. Prevalence and risk factors associated with HIV infection among men having sex with men in Ho Chi Minh City, Vietnam. AIDS Behav. 2008;12(3):476–82.Google Scholar
  10. 10.
    Oldenburg CE, Perez-Brumer AG, Reisner SL, Mimiaga MJ. Transactional sex and the HIV epidemic among men who have sex with men (MSM): results from a systematic review and meta-analysis. AIDS Behav. 2015;19(12):2177–83.Google Scholar
  11. 11.
    Baral SD, Friedman MR, Geibel S, Rebe K, Bozhinov B, Diouf D, et al. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet (Lond Engl). 2015;385(9964):260–73.Google Scholar
  12. 12.
    Sperber J, Landers S, Lawrence S. Access to health care for transgendered persons: results of a needs assessment in Boston. Int J Transgend. 2005;8(2–3):75–91.Google Scholar
  13. 13.
    Singh GK, Azuine RE, Siahpush M. Widening socioeconomic, racial, and geographic disparities in HIV/AIDS mortality in the United States, 1987–2011. Adv Prev Med. 2013;2013:657961.Google Scholar
  14. 14.
    Newman PA, Philbin MM, Hirsch JS, Wilson PA, Ly AT, Giang LM, et al. Structural barriers to HIV prevention among men who have sex with men (MSM) in Vietnam: diversity, stigma, and healthcare access. PLoS ONE. 2018. Scholar
  15. 15.
    White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222–31.Google Scholar
  16. 16.
    Beattie TSH, Bhattacharjee P, Suresh M, Isac S, Ramesh BM, Moses S. Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka State, South India. J Epidemiol Community Health. 2012;66(Suppl 2):42–8.Google Scholar
  17. 17.
    Chakrapani V, Newman PA, Shunmugam M, McLuckie A, Melwin F. Structural violence against Kothi-identified men who have sex with men in Chennai, India: a qualitative investigation. AIDS Educ Prev. 2007;19(4):346–64.Google Scholar
  18. 18.
    Earnshaw VA, Bogart LM, Dovidio JF, Williams DR. Stigma and racial/ethnic HIV disparities: moving toward resilience. Am Psychol. 2013;68(4):225–36.Google Scholar
  19. 19.
    Arnold EA, Rebchook GM, Kegeles SM. ‘Triply cursed’: racism, homophobia and HIV-related stigma are barriers to regular HIV testing, treatment adherence and disclosure among young Black gay men. Cult Health Sex. 2014;16(6):710–22.Google Scholar
  20. 20.
    Lazarus L, Deering KN, Nabess R, Gibson K, Tyndall MW, Shannon K. Occupational stigma as a primary barrier to health care for street-based sex workers in Canada. Cult Health Sex. 2012;14(2):139–50.Google Scholar
  21. 21.
    Logie CH, James L, Tharao W, Loutfy MR. HIV, gender, race, sexual orientation, and sex work: a qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med. 2011;8(11):e1001124.Google Scholar
  22. 22.
    Ngo AD, Ratliff EA, McCurdy SA, Ross MW, Markham C, Pham HT. Health-seeking behaviour for sexually transmitted infections and HIV testing among female sex workers in Vietnam. AIDS Care. 2007;19(7):878–87.Google Scholar
  23. 23.
    Levesque J, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12(18):18.Google Scholar
  24. 24.
    Harcourt C, Donovan B. The many faces of sex work. Sex Transm Infect. 2005;81(3):201–6.Google Scholar
  25. 25.
    Jobson GA, Theron LB, Kaggwa JK, Kim HJ. Transgender in Africa: invisible, inaccessible, or ignored? SAHARA-J J Soc Asp HIV/AIDS. 2012;9(3):160–3.Google Scholar
  26. 26.
    Bungay V, Oliffe J, Atchison C. Addressing underrepresentation in sex work research: reflections on designing a purposeful sampling strategy. Qual Health Res. 2016;26(7):966–78.Google Scholar
  27. 27.
    Bonevski B, Randell M, Paul C, Chapman K, Twyman L, Bryant J, et al. Reaching the hard-to-reach: a systematic review of strategies for improving health and medical research with socially disadvantaged groups. BMC Med Res Methodol. 2014;14(1):42.Google Scholar
  28. 28.
    Dudwick N, Kuehnast K, Jones VN, Woolcock M. Analyzing social capital in context: a guide to using qualitative methods and data. Washington, DC: World Bank Institute; 2006.Google Scholar
  29. 29.
    Choy LT. The strengths and weaknesses of research methodology: comparison and complimentary between qualitative and quantitative approaches. IOSR J Humanit Soc Sci. 2014;19(4):99–104.Google Scholar
  30. 30.
    Chakrapani V, Newman PA, Shunmugam M, Dubrow R. Barriers to free antiretroviral treatment access among Kothi-identified men who have sex with men and Aravanis (transgender women) in Chennai, India. AIDS Care. 2011;23(12):1687–94.Google Scholar
  31. 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. 2016;18(1):1–14.Google Scholar
  32. 32.
    Aunon FM, Wagner GJ, Maher R, Khouri D, Kaplan RL, Mokhbat J. An exploratory study of HIV risk behaviors and testing among male sex workers in Beirut, Lebanon. Soc Work Public Health. 2015;30(4):373–84.Google Scholar
  33. 33.
    Barmania S, Aljunid SM. Navigating HIV prevention policy and Islam in Malaysia: contention, compatibility or reconciliation? Findings from in-depth interviews among key stakeholders. BMC Public Health. 2016;16:524.Google Scholar
  34. 34.
    Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex. 2017;19(8):903–17.Google Scholar
  35. 35.
    Sevelius JM, Keatley J, Calma N, Arnold E. ‘I am not a man’: trans-specific barriers and facilitators to PrEP acceptability among transgender women. Glob Public Health. 2016;11(7–8):1060–75.Google Scholar
  36. 36.
    Shaver FM. Sex work research: methodological and ethical challenges. J Interpers Violence. 2005;20(3):296–319.Google Scholar
  37. 37.
    Beyrer C, Crago A, Bekker L, Butler J, Shannon K, Kerrigan D, et al. An action agenda for HIV and sex workers. Lancet. 2015;385(9964):287–301.Google Scholar
  38. 38.
    Abel G, Fitzgerald L, Brunton C. Christchurch School of Medicine study: methodology and methods. In: Abel G, Fitzgerald L, Healy C, Taylor A, editors. Taking the crime out of sex work: New Zealand sex workers’ fight for decriminalisation. Bristol: The Policy Press; 2010. p. 159–62.Google Scholar
  39. 39.
    Graça M, Gonçalves M, Martins A. Participatory action research with sex workers and an outreach team: a co-authored case study. Action Res. 2017. Scholar
  40. 40.
    Singh AA, Richmond K, Burnes TR. Feminist participatory action research with transgender communities: fostering the practice of ethical and empowering research designs. Int J Transgend. 2013;14(3):93–104.Google Scholar
  41. 41.
    Jeffreys E. Sex worker-driven research: best practice ethics. Dialogue e-J. 2010;8.Google Scholar
  42. 42.
    Baum F, MacDougall C, Smith D. Participatory action research. J Epidemiol Community Health. 2006;60(10):854–7.Google Scholar
  43. 43.
    van der Meulen E. Action research with sex workers: dismantling barriers and building bridges. Action Res. 2011;9(4):370–84.Google Scholar
  44. 44.
    Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7).Google Scholar
  45. 45.
    National Institute for Health and Care Excellence. Methods for the development of NICE public health guidance. London: National Institute for Health and Clinical Excellence; 2012.Google Scholar
  46. 46.
    Noyes J, Hannes K, Booth A, Harris J, Harden A, Popay J, et al. Qualitative research and Cochrane review. 2008. In: Cochrane handbook for systematic review of interventions (Internet). Cochrane Qualitative and Implementation Methods Group; p. 571.Google Scholar
  47. 47.
    Lui CW, Dean J, Mutch A, Mao L, Debattista J, Lemoire J, et al. HIV testing in men who have sex with men: a follow-up review of the qualitative literature since 2010. AIDS Behav. 2017. Scholar
  48. 48.
    Lorenc T, Marrero-Guillamon I, Llewellyn A, Aggleton P, Cooper C, Lehmann A, et al. HIV testing among men who have sex with men (MSM): systematic review of qualitative evidence. Health Educ Res. 2011;26(5):834–46.Google Scholar
  49. 49.
    Toye F, Seers K, Allcock N, Briggs M, Carr E, Barker K. Meta-ethnography 25 years on: challenges and insights for synthesising a large number of qualitative studies. BMC Med Res Methodol. 2014;14:80.Google Scholar
  50. 50.
    Restar AJ, Tocco JU, Mantell JE, Lafort Y, Gichangi P, Masvawure TB, et al. Perspectives on HIV pre- and post-exposure prophylaxes (PrEP and PEP) among female and male sex workers in Mombasa, Kenya: implications for integrating biomedical prevention into sexual health services. AIDS Educ Prev. 2017;29(2):141–53.Google Scholar
  51. 51.
    Scorgie F, Nakato D, Harper E, Richter M, Maseko S, Nare P, et al. ‘We are despised in the hospitals’: sex workers’ experiences of accessing health care in four African countries. Cult Health Sex. 2013;15(4):450–65.Google Scholar
  52. 52.
    Sandelowski M, Barroso J, Voils CI. Using qualitative metasummary to synthesize qualitative and quantitative descriptive findings. Res Nurs Health. 2007;30(1):99–111.Google Scholar
  53. 53.
    Underhill K, Morrow KM, Colleran CM, Holcomb R, Operario D, Calabrese SK, et al. Access to healthcare, HIV/STI testing, and preferred pre-exposure prophylaxis providers among men who have sex with men and men who engage in street-based sex work in the US. PLoS ONE. 2014;9(11):e112425.Google Scholar
  54. 54.
    Underhill K, Morrow KM, Colleran C, Holcomb R, Calabrese SK, Operario D, 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(4):667–86.Google Scholar
  55. 55.
    Boyce S, Barrington C, Bolanos H, Arandi CG, Paz-Bailey G. 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(3):313–27.Google Scholar
  56. 56.
    Okanlawon K, Adebowale AS, Titilayo A. Sexual hazards, life experiences and social circumstances among male sex workers in Nigeria. Cult Health Sex. 2013;15(Suppl 1):S22–33.Google Scholar
  57. 57.
    Reza-Paul S, Lorway R, O’Brien N, Lazarus L, Jain J, Bhagya M, et al. Sex worker-led structural interventions in India: a case study on addressing violence in HIV prevention through the Ashodaya Samithi Collective in Mysore. Indian J Med Res. 2012;135(1):98–106.Google Scholar
  58. 58.
    Xavier J, Bradford J, Hendricks M, Safford L, McKee R, Martin E, et al. Transgender health care access in Virginia: a qualitative study. Int J Transgend. 2013;14(1):3–17.Google Scholar
  59. 59.
    Giguere R, Frasca T, Dolezal C, Febo I, Cranston RD, Mayer K, et al. Acceptability of three novel HIV prevention methods among young male and transgender female sex workers in Puerto Rico. AIDS Behav. 2016;20(10):2192–202.Google Scholar
  60. 60.
    Jones JL, Rasch RFR, MacMaster S, Adams SM, Cooper RL. The experiences of African American male commercial sex workers at-risk for HIV: accessing outreach services. J Gay Lesbian Soc Serv. 2009;21(2–3):282–93.Google Scholar
  61. 61.
    Okal J, Luchters S, Geibel S, Chersich MF, Lango D, Temmerman M. Social context, sexual risk perceptions and stigma: HIV vulnerability among male sex workers in Mombasa, Kenya. Cult Health Sex. 2009;11(8):811–26.Google Scholar
  62. 62.
    Mimiaga MJ, Reisner SL, Closson EF, Perry N, Perkovich B, Nguyen T, et al. Self-perceived HIV risk and the use of risk reduction strategies among men who engage in transactional sex with other men in Ho Chi Minh City, Vietnam. AIDS Care. 2013;25(8):1039–44.Google Scholar
  63. 63.
    Reisner SL, Mimiaga MJ, Mayer KH, Tinsley JP, Safren SA. Tricks of the trade: sexual health behaviors, the context of HIV risk, and potential prevention intervention strategies for male sex workers. J LGBT Health Res. 2008;4(4):195–209.Google Scholar
  64. 64.
    Castaneda H. Structural vulnerability and access to medical care among migrant street-based male sex workers in Germany. Soc Sci Med. 2013;84:94–101.Google Scholar
  65. 65.
    Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex. 2009;11(2):125–37.Google Scholar
  66. 66.
    Collumbien M, Qureshi AA, Mayhew SH, Rizvi N, Rabbani A, Rolfe B, et al. Understanding the context of male and transgender sex work using peer ethnography. Sex Transm Infect. 2009;85(Suppl 2):ii3–7.Google Scholar
  67. 67.
    Morrell R, Jewkes R, Lindegger G. Hegemonic masculinity/masculinities in South Africa. Men Masc. 2012;15(1):11–30.Google Scholar
  68. 68.
    Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Soc Sci Med. 2010;71(12):2150–61.Google Scholar
  69. 69.
    Meyer-Weitz A. Understanding fatalism in HIV/AIDS protection: the individual in dialogue with contextual factors. Afr J AIDS Res. 2005;4(2):75–82.Google Scholar
  70. 70.
    Ma PHX, Chan ZCY, Loke AY. The socio-ecological model approach to understanding barriers and facilitators to the accessing of health services by sex workers: a systematic review. AIDS Behav. 2017;21(8):2412–38.Google Scholar
  71. 71.
    Stahlman S, Grosso A, Ketende S, Sweitzer S, Mothopeng T, Taruberekera N, et al. Depression and social stigma among MSM in Lesotho: implications for HIV and sexually transmitted infection prevention. AIDS Behav. 2015;19(8):1460–9.Google Scholar
  72. 72.
    Goffman E. Stigma: notes on the management of a spoiled identity. New York: Simon and Schuster; 1963.Google Scholar
  73. 73.
    Lacombe-Duncan A. An intersectional perspective on access to HIV-related healthcare for transgender women. Transgend Health. 2016;1(1):137–41.Google Scholar
  74. 74.
    Singer M, Bulled N, Ostrach B, Mendenhall E. Syndemics and the biosocial conception of health. Lancet. 2017;389(10072):941–50.Google Scholar
  75. 75.
    Biello KB, Colby D, Closson E, Mimiaga MJ. The syndemic condition of psychosocial problems and HIV risk among male sex workers in Ho Chi Minh City, Vietnam. AIDS Behav. 2014;18(7):1264–71.Google Scholar
  76. 76.
    Brennan J, Kuhns LM, Johnson AK, Belzer M, Wilson EC, Garofalo R. Syndemic theory and HIV-related risk among young transgender women: the role of multiple, co-occurring health problems and social marginalization. Am J Public Health. 2012;102(9):1751–7.Google Scholar
  77. 77.
    Dijkstra M, van der Elst EM, Micheni M, Gichuru E, Musyoki H, Duby Z, et al. Emerging themes for sensitivity training modules of African healthcare workers attending to men who have sex with men: a systematic review. Int Health. 2015;7(3):151–62.Google Scholar
  78. 78.
    van der Elst EM, Smith AD, Gichuru E, Wahome E, Musyoki H, Muraguri N, et al. Men who have sex with men sensitivity training reduces homoprejudice and increases knowledge among Kenyan healthcare providers in coastal Kenya. J Int AIDS Soc. 2013;16(Suppl 3):18748.Google Scholar
  79. 79.
    Reisner SL, Bradford J, Hopwood R, Gonzalez A, Makadon H, Todisco D, et al. Comprehensive transgender healthcare: the gender affirming clinical and public health model of Fenway Health. J Urban Health. 2015;92(3):584–92.Google Scholar
  80. 80.
    WHO. Guidelines: prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people: recommendations for a public health approach. Geneva: World Health Organisation; 2011.Google Scholar
  81. 81.
    Chillag K, Guest G, Bunce A, Johnson L, Kilmarx PH, Smith DK. Talking about sex in Botswana: social desirability bias and possible implications for HIV-prevention research. Afr J AIDS Res. 2006;5(2):123–31.Google Scholar
  82. 82.
    Kelly CA, Soler-Hampejsek E, Mensch BS, Hewett PC. Social desirability bias in sexual behavior reporting: evidence from an interview mode experiment in rural Malawi. Int Perspect Sex Reprod Health. 2013;39(1):14–21.Google Scholar
  83. 83.
    Perez-Brumer AG, Oldenburg CE, Reisner SL, Clark JL, Parker RG. Towards ‘reflexive epidemiology’: conflation of cisgender male and transgender women sex workers and implications for global understandings of HIV prevalence. Glob Public Health. 2016;11(7–8):849–65.Google Scholar
  84. 84.
    Dunkle KL, Wong FY, Nehl EJ, Lin L, He N, Huang J, et al. Male-on-male intimate partner violence and sexual risk behaviors among money boys and other men who have sex with men in Shanghai, China. Sex Transm Dis. 2013;40(5):362–5.Google Scholar
  85. 85.
    Shannon K, Crago A-L, Baral SD, Bekker L-G, Kerrigan D, Decker MR, et al. The global response and unmet actions for HIV and sex workers. Lancet. 2018;392(10148):698–710.Google Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.School of Public Health, Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
  2. 2.Respect Inc.BrisbaneAustralia

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