Sex Roles

, Volume 68, Issue 11–12, pp 675–689 | Cite as

Gender Affirmation: A Framework for Conceptualizing Risk Behavior Among Transgender Women of Color

  • Jae M. SeveliusEmail author
Original Article


Experiences of stigma, discrimination, and violence as well as extreme health disparities and high rates of sexual risk behavior and substance use have been well-documented among transgender women of color. Using an intersectional approach and integrating prominent theories from stigma, eating disorders, and HIV-related research, this article offers a new framework for conceptualizing risk behavior among transgender women of color, specifically sexual risk behavior and risky body modification practices. This framework is centered on the concept of ‘gender affirmation,’ the process by which individuals are affirmed in their gender identity through social interactions. Qualitative data from 22 interviews with transgender women of color from the San Francisco Bay Area in the United States are analyzed and discussed in the context of the gender affirmation framework.


Transgender identity Gender affirmation Stigma Race Risk behavior Sexuality 



The research described was supported by the National Institute of Mental Health, Award #K08MH085566. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health. The author would like to express gratitude to Mallory O. Johnson, PhD, for his invaluable mentorship, to Angel Ventura for her skilled assistance, and to the participants for their courage, time, and candor.


  1. Ainsworth, T., & Spiegel, J. (2010). Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Quality of Life Research, 19, 1019–1024. doi: 10.1007/s11136-010-9668-7.PubMedCrossRefGoogle Scholar
  2. Ålgars, M., Santtila, P., & Sandnabba, N. (2010). Conflicted gender identity, body dissatisfaction, and disordered eating in adult men and women. Sex Roles, 63, 118–125. doi: 110.1007/s11199-11010-19758-11196.CrossRefGoogle Scholar
  3. Barrientos, J., Silva, J., Catalan, S., Gómez, F., & Longueira, J. (2010). Discrimination and victimization: Parade for Lesbian, Gay, Bisexual, and Transgender (LGBT) pride, in Chile. Journal of Homosexuality, 57, 760–775. doi: 10.1080/00918369.2010.485880.PubMedCrossRefGoogle Scholar
  4. Bauer, G., Hammond, R., Travers, R., Kaay, M., Hohenadel, K., & Boyce, M. (2009). “I don’t think this is theoretical; this is our lives”: How erasure impacts health care for transgender people. The Journal of the Association of Nurses in AIDS Care, 20, 348–361. doi: 10.1016/j.jana.2009.07.004.PubMedCrossRefGoogle Scholar
  5. Bockting, W. (2008). Transgender identity and HIV: Resilience in the face of stigma. Focus: A Guide to AIDS Research and Counseling, 23(2), 1–4.Google Scholar
  6. Bockting, W., Robinson, B., & Rosser, B. (1998). Transgender HIV prevention: A qualitative needs assessment. AIDS Care, 10, 505–526. doi: 10.1080/09540129850124028.PubMedCrossRefGoogle Scholar
  7. Bockting, W., Knudson, G., & Goldberg, J. (2006). Counseling and mental health care of transgender adults and loved ones Trans Care Project. Vancouver: Transgender Health Program.Google Scholar
  8. Branscombe, N., Schmitt, M., & Harvey, R. (1999). Perceiving pervasive discrimination among African Americans: Implications for group identification and well-being. Journal of Personality and Social Psychology, 77, 135–149. doi: 10.1037/0022-3514.77.1.135.CrossRefGoogle Scholar
  9. Clements-Nolle, K., Marx, R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health, 91, 915–921. doi: 10.2105/AJPH.91.6.915.PubMedCrossRefGoogle Scholar
  10. Cochran, S. D., Stewart, A. J., Ginzler, J. A., & Cauce, A. M. (2002). Challenges faced by homeless sexual minorities: Comparison of gay, lesbian, bisexual and transgender homeless adolescents with their heterosexual counterparts. American Journal of Public Health, 92, 773–777. doi: 10.2105/AJPH.92.5.773.PubMedCrossRefGoogle Scholar
  11. Crabtree, B., & Miller, W. (1999). Using codes and code manuals: A template organizing style of interpretation. In B. Crabtree & W. Miller (Eds.), Doing qualitative research (2nd ed.). Newbury Park, CA: Sage.Google Scholar
  12. Diaz, R. (1998). Latino gay men and HIV: Culture, sexuality, and risk behavior. New York: Routledge.Google Scholar
  13. Diaz, R., Ayala, G., Bein, E., Henne, J., & Marin, B. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from 3 US cities. American Journal of Public Health, 91, 927–931. doi: 10.2105/AJPH.91.6.927.PubMedCrossRefGoogle Scholar
  14. Diaz, R., Ayala, G., & Bein, E. (2004). Sexual risk as an outcome of social oppression: Data from a probability sample of Latino gay men in three US cities. Cultural Diversity & Ethnic Minority Psychology, 10, 255–267. doi: 10.1037/1099-9809.10.3.255.CrossRefGoogle Scholar
  15. Elifson, K., Boles, J., Posey, E., Sweat, M., Darrow, W., & Elsea, W. (1993). Male transvestite prostitutes and HIV risk. American Journal of Public Health, 83, 260–262. doi: 10.2105/AJPH.83.2.260.PubMedCrossRefGoogle Scholar
  16. Fredrickson, B., & Roberts, T. (1997). Objectification theory. Psychology of Women Quarterly, 21, 173–206. doi: 110.1111/j.1471-6402.1997.tb00108.x.CrossRefGoogle Scholar
  17. Garofalo, R., Deleon, J., Osmer, E., Doll, M., & Harper, G. (2006). Overlooked, misunderstood, and at-risk: Exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. Journal of Adolescent Health, 38, 230–236. doi: 10.1016/j.jadohealth.2005.03.023.PubMedCrossRefGoogle Scholar
  18. Gerhardstein, K., & Anderson, V. (2010). There’s more than meets the eye: Facial appearance and evaluations of transsexual people. Sex Roles, 62, 361–373. doi: 10.1007/s11199-010-9746-x.CrossRefGoogle Scholar
  19. Grant, J., Mottet, L., Tanis, J., Harrison, J., Herman, J., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force.Google Scholar
  20. Herbst, J., Jacobs, E., Finlayson, T., McKleroy, V., Neumann, M., & Crepaz, N. (2008). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior, 12, 1–17. doi: 10.1007/s10461-007-9299-3.PubMedCrossRefGoogle Scholar
  21. Kenagy, G. (2002). HIV among transgendered people. AIDS Care, 14, 127–134. doi: 10.1080/09540120220098008.PubMedCrossRefGoogle Scholar
  22. King, N. (1998). Template analysis. In G. Symon & C. Cassell (Eds.), Qualitative methods and analysis in organizational research (pp. 118–134). London: Sage.Google Scholar
  23. Koken, J., Bimbi, D., & Parsons, J. (2009). Experiences of familial acceptance-rejection among transwomen of color. Journal of Family Psychology, 23, 853–860. doi: 10.1037/a0017198.PubMedCrossRefGoogle Scholar
  24. Kraemer, B., Delsignore, A., Schnyder, U., & Hepp, U. (2008). Body image and transsexualism. Psychopathology, 41, 96–100. doi: 10.1159/000111554.PubMedCrossRefGoogle Scholar
  25. Lombardi, E. (2009). Varieties of transgender/transsexual lives and their relationship with transphobia. Journal of Homosexuality, 56, 977–992. doi: 10.1080/00918360903275393.PubMedCrossRefGoogle Scholar
  26. Lombardi, E., Wilchins, R., Priesing, D., & Malouf, D. (2001a). Gender violence: Transgender experiences with violence and discrimination. Journal of Homosexuality, 42, 89–101. doi: 10.1300/J082v42n01_05.PubMedCrossRefGoogle Scholar
  27. Lombardi, E., Wilchins, R., Priesing, D., & Malouf, D. (2001b). Gender violence: Transgender experiences with violence and discrimination. Journal of Homosexuality, 42, 89–101.PubMedCrossRefGoogle Scholar
  28. Lowery, S., Kurpius, S., Befort, C., Blanks, E., Sollenberger, S., Nicpon, M., & Huser, L. (2005). Body image, self-esteem, and health-related behaviors among male and female first year college students. Journal of College Student Development, 46, 612–623. doi: 10.1353/csd.2005.0062.CrossRefGoogle Scholar
  29. Major, B., & O’Brien, L. (2005). The social psychology of stigma. Annual Review of Psychology, 56, 393–421. doi: 10.1146/annurev.psych.56.091103.070137.PubMedCrossRefGoogle Scholar
  30. Mallon, G., & De Crescenzo, T. (2006). Transgender children and youth: A child welfare practice perspective. Child Welfare: Journal of Policy, Practice, and Program. Special Issue: LGBTQ Youth in Child Welfare., 85, 215–241.Google Scholar
  31. Marecek, J., Fine, M., & Kidder, L. (2001). Working between worlds: Qualitative methods and social psychology. Journal of Social Issues, 53. doi: 10.1111/j.1540-4560.1997.tb02452.x.
  32. McKinley, N., & Hyde, J. (1996). The objectified body consciousness scale. Psychology of Women Quarterly, 20, 181–215. doi: 10.1111/j.1471-6402.1996.tb00467.x.CrossRefGoogle Scholar
  33. Melendez, R., & Pinto, R. (2007). ‘It’s really a hard life’: Love, gender and HIV risk among male-to-female transgender persons. Culture, Health and Sexuality, 9, 233–245. doi: 10.1080/13691050601065909.PubMedCrossRefGoogle Scholar
  34. Moradi, B. (2010). Addressing gender and cultural diversity in body image: Objectification theory as a framework for integrating theories and grounding research. Sex Roles, 63, 138–148. doi: 110.1007/s11199-11010-19824-11190.CrossRefGoogle Scholar
  35. Moradi, B., & Huang, Y. (2008). Objectification theory and psychology of women: A decade of advances and future directions. Psychology of Women Quarterly, 32, 377–398. doi: 10.1111/j.1471-6402.2008.00452.x.CrossRefGoogle Scholar
  36. Nemoto, T., Iwamoto, M., Perngparn, U., Areesantichai, C., Kamitani, E., & Sakata, M. (2011). HIV-related risk behaviors among kathoey (male-to-female transgender) sex workers in Bangkok, Thailand. AIDS Care, 24, 210–219. doi: 10.1080/09540121.2011.597709.PubMedGoogle Scholar
  37. Nemoto, T., Operario, D., Keatley, J., Han, L., & Soma, T. (2004). HIV risk behaviors among male-to-female transgender persons of color in San Francisco. American Journal of Public Health, 94, 1193–1199. doi: 10.2105/AJPH.94.7.1193.PubMedCrossRefGoogle Scholar
  38. Nemoto, T., Operario, D., Keatley, J., & Villegas, D. (2004). Social context of HIV risk behaviors among male-to-female transgenders of color. AIDS Care, 16, 724–735. doi: 10.1080/09540120413331269567.PubMedCrossRefGoogle Scholar
  39. Newfield, E., Hart, S., Dibble, S., & Kohler, L. (2006). Female-to-male transgender quality of life. Quality of Life Research, 15, 1447–1457. doi: 10.1007/s11136-006-0002-3.PubMedCrossRefGoogle Scholar
  40. Nuttbrock, L., Rosenblum, A., & Blumenstein, R. (2002). Transgender identity affirmation and mental health. International Journal of Transgenderism, 6(4).Google Scholar
  41. Nuttbrock, L., Bockting, W., Hwahng, S., Rosenblum, A., Mason, M., Macri, M., & Becker, J. (2009). Gender identity affirmation among male-to-female transgender persons: A life course analysis across types of relationships and cultural/lifestyle factors. Sexual and Relationship Therapy, 24, 108–125. doi: 110.1080/14681990902926764.CrossRefGoogle Scholar
  42. Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., & Becker, J. (2009). Lifetime risk factors for HIV/sexually transmitted infections among male-to-female transgender persons. JAIDS Journal of Acquired Immune Deficiency Syndromes, 52, 417–421. doi: 10.1097/QAI.0b013e3181ab6ed8.CrossRefGoogle Scholar
  43. Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., & Becker, J. (2010). Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. Journal of Sex Research, 47, 12–23. doi: 10.1080/00224490903062258.PubMedCrossRefGoogle Scholar
  44. Operario, D., & Nemoto, T. (2005). Sexual risk behavior and substance use among a sample of Asian Pacific Islander transgendered women. AIDS Education and Prevention, 17, 430–443. doi: 10.1521/aeap.2005.17.5.430.PubMedCrossRefGoogle Scholar
  45. Operario, D., Nemoto, T., Iwamoto, M., & Moore, T. (2011). Unprotected sexual behavior and HIV risk in the context of primary partnerships for transgender women. AIDS and Behavior, 15, 1–9. doi: 10.1007/s10461-10010-19795-10468.Google Scholar
  46. Reisner, S., Mimiaga, M., Bland, S., Mayer, K., Perkovich, B., & Safren, S. (2009). HIV risk and social networks among male-to-female transgender sex workers in Boston, Massachusetts. The Journal of the Association of Nurses in AIDS Care, 20, 373–386. doi: 10.1016/j.jana.2009.06.003.PubMedCrossRefGoogle Scholar
  47. Risser, J., Shelton, A., McCurdy, S., Atkinson, J., Padgett, P., Useche, B., & Williams, M. (2005). Sex, drugs, violence, and HIV status among male-to-female transgender persons in Houston, Texas. International Journal of Transgenderism, 8(2/3), 67–74. doi: 10.1300/J485v08n02_07.CrossRefGoogle Scholar
  48. Rodriguez-Madera, S., & Toro-Alfonso, J. (2005). Gender as an obstacle in HIV/AIDS prevention: Considerations for the development of HIV/AIDS prevention efforts for male-to-female transgenders. International Journal of Transgenderism, 8(2), 113–122. doi: 10.1300/J485v08n02_10.CrossRefGoogle Scholar
  49. Sausa, L., Keatley, J., & Operario, D. (2007). Perceived risks and benefits of sex work among transgender women of color in San Francisco. Archives of Sexual Behavior, 36, 768–777. doi: 10.1007/s10508-007-9210-3.PubMedCrossRefGoogle Scholar
  50. Sevelius, J. (2009a). Incarceration among transgender women: Risk factors and impact on physical and mental health Paper presented at the American Psychological Association, Toronto, Ontario.Google Scholar
  51. Sevelius, J. (2009b). “There’s no pamphlet for the kind of sex I have”: HIV-related risk factors and protective behaviors among transgender men who have sex with non-transgender men. The Journal of the Association of Nurses in AIDS Care, 20, 398–410. doi: 10.1016/j.jana.2009.06.001.PubMedCrossRefGoogle Scholar
  52. Sevelius, J. (2011). Developing a quantitative measure of gender affirmation to examine its relationship to health risk behavior among transgender women. Paper presented at the World Professional Association for Transgender Health Symposium, Atlanta, GA.Google Scholar
  53. Sevelius, J., Grinstead, O., Hart, S., & Schwarcz, S. (2009). Informing interventions: The importance of contextual factors in the prediction of sexual risk behaviors among transgender women. AIDS Education and Prevention, 21, 113–127.PubMedCrossRefGoogle Scholar
  54. Sevelius, J., Carrico, A., & Johnson, M. (2010). Antiretroviral therapy adherence among transgender women living with HIV. The Journal of the Association of Nurses in AIDS Care, 21, 256–264. doi: 10.1016/j.jana.2010.01.005.PubMedCrossRefGoogle Scholar
  55. Silva-Santisteban, A., Raymond, H., Salazar, X., Villayzan, J., Leon, S., McFarland, W., & Caceres, C. (2011). Understanding the HIV/AIDS epidemic in transgender women of Lima, Peru: Results from a Sero-Epidemiologic Study using respondent driven sampling. AIDS and Behavior, 16, 872–881. doi: 10.1007/s10461-011-0053-5.CrossRefGoogle Scholar
  56. Sugano, E., Nemoto, T., & Operario, D. (2006). The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS and Behavior, 10, 217–225. doi: 210.1007/s10461-10005-19040-z.PubMedCrossRefGoogle Scholar
  57. Warner, L. (2008). A best practices guide to intersectional approaches in psychological research. Sex Roles, 59, 454–463. doi: 10.1007/s11199-008-9504-5.CrossRefGoogle Scholar
  58. Wiessing, L., van Roosmalen, M., Koedijk, P., Bieleman, B., & Houweling, H. (1999). Silicones, hormones and HIV in transgender street prostitutes. AIDS, 13, 2315–2316. doi: 10.1097/00002030-199911120-00022.PubMedCrossRefGoogle Scholar
  59. Wilson, E., Garofalo, R., Harris, R., Herrick, A., Martinez, M., Martinez, J., . . . and the Adolescent Medicine Trials Network for HIV/AIDS Interventions. (2009). Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS and Behavior, 13, 902-913. doi: 10.1007/s10461-008-9508-8.Google Scholar
  60. Wilson, E., Pant, S., Comfort, M., & Ekstrand, M. (2011). Stigma and HIV risk among Metis in Nepal. Culture, Health & Sexuality, 13, 253–266. doi: 10.1080/13691058.2010.524247.CrossRefGoogle Scholar
  61. Winter, S. (2010). Lost in transition: Transpeople, transprejudice and pathology in Asia. In P. Chan (Ed.), Protection of sexual minorities since Stonewall: Progress and stalemate in developed and developing countries (pp. 231–245): Routledge.Google Scholar
  62. Xavier, J. (1999). Passing as Privilege. Part Two of a Series on Transfeminism. Retrieved from
  63. Xavier, J., Bobbin, M., Singer, B., & Budd, E. (2005). A needs assessment of transgender people of color living in Washington DC. International Journal of Transgenderism, 8(2/3), 31–47. doi: 10.1300/J485v08n02_04.CrossRefGoogle Scholar
  64. Zierler, S., & Krieger, N. (1997). Reframing women’s risk: Social inequalities and HIV infection. Annual Review of Public Health, 18, 401–436. doi: 10.1146/annurev.publhealth.18.1.401.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Center of Excellence for Transgender Health, Center for AIDS Prevention Studies, Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA

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