AIDS and Behavior

, Volume 22, Issue 7, pp 2056–2067 | Cite as

Syndemic Conditions, HIV Transmission Risk Behavior, and Transactional Sex Among Transgender Women

  • Jeffrey T. Parsons
  • Nadav Antebi-Gruszka
  • Brett M. Millar
  • Demetria Cain
  • Sitaji Gurung
Original Paper


This study examined the effect of four syndemic conditions—namely, polydrug use, depression, childhood sexual abuse, and intimate partner violence—on rates of HIV transmission risk behavior (TRB) and separately, transactional sex among transgender women. TRB was defined as the number of condomless penetrative sex events with a casual or main partner of discordant or unknown HIV status. Using data from 212 transgender women in New York City, multivariable analyses revealed that, compared to those with no syndemic conditions, dramatically higher rates of recent HIV TRB events (ARR = 8.84, p < 0.001) and recent transactional sex events (ARR = 8.32, p < 0.001) were reported by participants with all four syndemic conditions. These findings highlight the importance of considering the role of syndemic conditions in HIV risk among transgender women, and the need for comprehensive psychosocial interventions to improve sexual health among this population.


Syndemics HIV transmission risk behavior Transactional sex Transgender women 


Este estudio examinó el impacto de cuatro condiciones sindémicas—principalmente, el uso de múltiples drogas, depresión, abuso sexual en la infancia, y violencia domestica, y cómo ellas impactan el comportamiento riesgoso en relación a la transmisión de VIH (CRT), y adicionalmente, el sexo transaccional entre mujeres transgénero. CRT se definió como el número de eventos en la cual se tuvo sexo penetrativo sin condón con una pareja casual o principal con estatus de VIH discordante o desconocido. Utilizando data de 212 mujeres transgénero en la ciudad de Nueva York, análisis multivariados mostraron tasas dramáticamente altas de eventos recientes de CRT (ARR = 8.84, p < 0.001) y eventos recientes de sexo transaccional (ARR = 8.32, p < 0.001) en el grupo de mujeres transgénero que reportaron sufrir de las cuatro condiciones sindémicas comparado con el grupo que reportó no sufrir de las cuatro condiciones. Los resultados enfatizan la importancia de considerar el rol de las condiciones sindémicas en mujeres transgénero que están en riesgo de contraer VIH, y la necesidad de las intervenciones psicosociales para mejorar la salud sexual en esta población.



We would like to acknowledge other members of the T-Talk Study Team (H. Jonathon Rendina, Tyrel Starks, Ana Ventuneac, Ruben Jimenez, and Jonathan López Matos) and other current staff from the Center for HIV/AIDS Educational Studies and Training (Chris Hietikko, Tina Koo, Carlos Ponton) who were integrally involved in the development, implementation, and reporting of this study. We would also like to thank the staff at Callen-Lorde Community Health Center (Asa Radix, Linda Li, Makada Bernard), and the LGBT Center in New York City (Carrie Davis and Cristina Herrera). Finally, special thanks to Drs. Richard Jenkins and Pamela Goodlow at NIDA. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.


T-Talk was funded by the National Institutes of Health (R01 DA 034661: Jeffrey T. Parsons, Principal Investigator).

Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical Approval

All study protocols were approved by the City University of New York (CUNY) Institutional Review Board.

Informed Consent

All participants provided their consent to take part in the study.


  1. 1.
    Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis. 2013;13(3):214–22.Google Scholar
  2. 2.
    Centers for Disease Control and Prevention. HIV among transgender people. Updated 3 Aug 2017. Accessed 10 Sep 2017.
  3. 3.
    Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. Am J Public Health. 2001;91(6):915–21.PubMedCentralGoogle Scholar
  4. 4.
    Neumann MS, Finlayson TJ, Pitts NL, Keatley J. Comprehensive HIV prevention for transgender persons. Am J Public Health. 2017;107(2):207–12.Google Scholar
  5. 5.
    Reisner SL, Poteat T, Keatley J, et al. Global health burden and needs of transgender populations: a review. Lancet. 2016;388(10042):412–36.Google Scholar
  6. 6.
    Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav. 2007;12(1):1–17.Google Scholar
  7. 7.
    Singer MC, Erickson PI, Badiane L, et al. Syndemics, sex and the city: understanding sexually transmitted diseases in social and cultural context. Soc Sci Med. 2006;63(8):2010–21.Google Scholar
  8. 8.
    Mustanski B, Garofalo R, Herrick A, Donenberg G. Psychosocial health problems increase risk for HIV among urban young men who have sex with men: preliminary evidence of a syndemic in need of attention. Ann Behav Med. 2007;34(1):37–45.PubMedCentralGoogle Scholar
  9. 9.
    Parsons JT, Grov C, Golub SA. Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: further evidence of a syndemic. Am J Public Health. 2012;102(1):156–62.PubMedCentralGoogle Scholar
  10. 10.
    Parsons JT, Rendina HJ, Moody RL, Ventuneac A, Grov C. Syndemic production and sexual compulsivity/hypersexuality in highly sexually active gay and bisexual men: Further evidence for a three group conceptualization. Arch Sex Behav. 2015;44(7):1903–13.PubMedCentralGoogle Scholar
  11. 11.
    Parsons JT, Millar BM, Moody RL, Starks TJ, Rendina HJ, Grov C. Syndemic conditions and HIV transmission risk behavior among HIV-negative gay and bisexual men in a U.S. national sample. Health Psychol. 2017;36(7):695–703.Google Scholar
  12. 12.
    Stall R, Mills TC, Williamson J, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003;93(6):939–42.PubMedCentralGoogle Scholar
  13. 13.
    Nuttbrock L, Bockting W, Rosenblum A, et al. Gender abuse, depressive symptoms, and substance use among transgender women: a 3-year prospective study. Am J Public Health. 2014;104(11):2199–206.PubMedCentralGoogle Scholar
  14. 14.
    Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS. 2017;28(11):1059–66.Google Scholar
  15. 15.
    Bauermeister JA, Goldenberg T, Connochie D, Jadwin-Cakmak L, Stephenson R. Psychosocial disparities among racial/ethnic minority transgender young adults and young men who have sex with men living in Detroit. Transgend Health. 2016;1(1):279–90.PubMedCentralGoogle Scholar
  16. 16.
    Garofalo R, Deleon J, Osmer E, Doll M, Harper GW. Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health. 2006;38(3):230–6.Google Scholar
  17. 17.
    Raiford JL, Hall GJ, Taylor RD, Bimbi DS, Parsons JT. The role of structural barriers in risky sexual behavior, victimization and readiness to change HIV/STI-related risk behavior among transgender women. AIDS Behav. 2016;20(10):2212–21.Google Scholar
  18. 18.
    Reisner SL, Vetters R, White JM, et al. Laboratory-confirmed HIV and sexually transmitted infection seropositivity and risk behavior among sexually active transgender patients at an adolescent and young adult urban community health center. AIDS Care. 2015;27(8):1031–6.PubMedCentralGoogle Scholar
  19. 19.
    Taylor RD, Bimbi DS, Joseph HA, Margolis AD, Parsons JT. Girl friends: evaluation of an HIV-risk reduction intervention for adult transgender women. AIDS Educ Prev. 2011;23(5):469–78.Google Scholar
  20. 20.
    Gilbert L, Raj A, Hien S, Stockman J, Terlikbayeva A, Wyatt G. Targeting the SAVA (substance abuse, violence, and AIDS) syndemic among women and girls: a global review of epidemiology and integrated interventions. J Acquir Immune Defic Syndr. 2015;69(Suppl 2):S118–27.PubMedCentralGoogle Scholar
  21. 21.
    Operario D, Soma T, Underhill K. Sex work and HIV status among transgender women. J Acquir Immune Defic Syndr. 2008;48(1):97–103.Google Scholar
  22. 22.
    Brennan J, Kuhns LM, Johnson AK, et al. 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.PubMedCentralGoogle Scholar
  23. 23.
    Chakrapani V, Newman PA, Shunmugam M, Logie CH, Samuel M. Syndemics of depression, alcohol use, and victimisation, and their association with HIV-related sexual risk among men who have sex with men and transgender women in India. Glob Public Health. 2017;12(2):250–65.Google Scholar
  24. 24.
    Poteat T, Wirtz AL, Radix A, et al. HIV risk and preventive interventions in transgender women sex workers. Lancet. 2015;385(9964):274–86.Google Scholar
  25. 25.
    Clements-Nolle K, Guzman R, Harris SG. Sex trade in a male-to-female transgender population: psychosocial correlates of inconsistent condom use. Sex Health. 2008;5(1):49–54.Google Scholar
  26. 26.
    Hill BJ, Rosentel K, Bak T, Silverman M, Crosby R, Salazar L, Kipke M. Exploring individual and structural factors associated with employment among young transgender women of color using a no-cost transgender legal resource center. Transgend Health. 2017;2(1):29–34.PubMedCentralGoogle Scholar
  27. 27.
    Dowshen N, Lee S, Franklin J, Castillo M, Barg F. Access to medical and mental health services across the HIV care continuum among young transgender women: a qualitative study. Transgend Health. 2017;2(1):81–90.PubMedCentralGoogle Scholar
  28. 28.
    Nemoto T, Bödeker B, Iwamoto M. Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work. Am J Public Health. 2011;101(10):1980–8.PubMedCentralGoogle Scholar
  29. 29.
    Wilson EC, Garofalo R, Harris RD, et al. Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS Behav. 2009;13(5):902–13.PubMedCentralGoogle Scholar
  30. 30.
    Harcourt C, Donovan B. The many faces of sex work. Sex Transm Infect. 2005;81(3):201–6.PubMedCentralGoogle Scholar
  31. 31.
    Badgett MV, Lau H, Sears B, Ho D. Bias in the workplace: consistent evidence of sexual orientation and gender identity discrimination. 2007. Accessed 30 June 2017.
  32. 32.
    Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the national transgender discrimination survey. Washington, DC: The National Gay and Lesbian Task Force and the National Center for Transgender Equality; 2011. Accessed 10 Sep 2017.
  33. 33.
    Harcourt C, Beek I, Heslop J, McMahon M, Donovan B. The health and welfare needs of female and transgender street sex workers in New South Wales. Aust N Z J Public Health. 2001;25(1):84–9.Google Scholar
  34. 34.
    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(6):724–35.Google Scholar
  35. 35.
    Nadal KL, Davidoff KC, Fujii-Doe W. Transgender women and the sex work industry: roots in systemic, institutional, and interpersonal discrimination. J Trauma Dissociation. 2014;15(2):169–83.Google Scholar
  36. 36.
    Sausa LA, Keatley J, Operario D. Perceived risks and benefits of sex work among transgender women of color in San Francisco. Arch Sex Behav. 2007;36(6):768–77.Google Scholar
  37. 37.
    Sevelius JM, Keatley J, Gutierrez-Mock L. HIV/AIDS programming in the United States: considerations affecting transgender women and girls. Women Health Issues. 2011;21(6):S278–82.Google Scholar
  38. 38.
    Silva-Santisteban A, Raymond HF, Salazar X, Villayzan J, Leon S, McFarland W, Caceres CF. Understanding the HIV/AIDS epidemic in transgender women of Lima, Peru: results from a sero-epidemiologic study using respondent driven sampling. AIDS Behav. 2012;16(4):872–81.Google Scholar
  39. 39.
    UNAIDS. Global report: UNAIDS report on the global AIDS epidemic. 2012. Accessed 30 June 2017.
  40. 40.
    Solomon MM, Nureña CR, Tanur JM, Montoya O, Grant RM, McConnell JJ. Transactional sex and prevalence of STIs: a cross-sectional study of MSM and transwomen screened for an HIV prevention trial. Int J STD AIDS. 2015;26(12):879–86.Google Scholar
  41. 41.
    Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, Kerrigan D. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. Lancet. 2012;12(7):538–49.Google Scholar
  42. 42.
    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.PubMedCentralGoogle Scholar
  43. 43.
    Nemoto T, Cruz T, Iwamoto M, Trocki K, Perngparn U, Areesantichai C, et al. Examining the sociocultural context of HIV-related risk behaviors among Kathoey (male-to-female transgender women) sex workers in Bangkok, Thailand. J Assoc Nurses AIDS Care. 2016;27(2):153–65.Google Scholar
  44. 44.
    Hoffman BR. The interaction of drug use, sex work, and HIV among transgender women. Subst Use Misuse. 2014;49(8):1049–53.Google Scholar
  45. 45.
    Logie CH, Wang Y, Lacombe‐Duncan A, Jones N, Ahmed U, Levermore K, et al. Factors associated with sex work involvement among transgender women in Jamaica: a cross‐sectional study. J Int AIDS Soc. 2017;20(1):21422.PubMedCentralGoogle Scholar
  46. 46.
    Siembida EJ, Eaton LA, Maksut JL, Driffin DD, Baldwin R. A comparison of HIV-related risk factors between Black transgender women and Black men who have sex with men. Transgend Health. 2016;1(1):172–80.PubMedCentralGoogle Scholar
  47. 47.
    Wilson EC, Chen YH, Arayasirikul S, et al. Differential HIV risk for racial/ethnic minority trans*female youths and socioeconomic disparities in housing, residential stability, and education. Am J Public Health. 2015;105(S3):e41–7.PubMedCentralGoogle Scholar
  48. 48.
    Miner MH, Bockting WO, Romine RS, Raman S. Conducting internet research with the transgender population: reaching broad samples and collecting valid data. Soc Sci Comput Rev. 2011;30(2):202–11.PubMedCentralGoogle Scholar
  49. 49.
    Parsons JT, Vial AC, Starks TJ, Golub SA. Recruiting drug using men who have sex with men in behavioral intervention trials: a comparison of internet and field-based strategies. AIDS Behav. 2013;17(2):688–99.PubMedCentralGoogle Scholar
  50. 50.
    Sobell LC, Sobell MB. Timeline follow-back. In: Measuring alcohol consumption. New York: Springer; 1992. p. 41–72.Google Scholar
  51. 51.
    Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.Google Scholar
  52. 52.
    Greenwood GL, Relf MV, Huang B, Pollack LM, Canchola JA, Catania JA. Battering victimization among a probability-based sample of men who have sex with men. Am J Public Health. 2002;92(12):1964–9.PubMedCentralGoogle Scholar
  53. 53.
    Straus MA, Hamby SL, Boney-McCoy S, Sugarman DB. The revised conflict tactics scales (CTS2): development and preliminary Psychometric data. J Fam Issues. 1996;17(3):283–316.Google Scholar
  54. 54.
    Bancroft J, Janssen E, Carnes L, Goodrich D, Strong D, Long JS. Sexual activity and risk taking in young heterosexual men: the relevance of sexual arousability, mood, and sensation seeking. J Sex Res. 2004;41(2):181–92.Google Scholar
  55. 55.
    Millar BM, Starks TJ, Grov C, Parsons JT. Sexual risk-taking in HIV-negative gay and bisexual men increases with depression: results from a US national study. AIDS Behav. 2017;21(6):1665–75.PubMedCentralGoogle Scholar
  56. 56.
    Garofalo R, Kuhns LM, Reisner SL, Mimiaga MJ. Behavioral interventions to prevent HIV transmission and acquisition for transgender women: a critical review. J Acquir Immune Defic Syndr. 2016;72(Suppl 3):S220–5.PubMedCentralGoogle Scholar
  57. 57.
    Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender health in Massachusetts: results from a household probability sample of adults. Am J Public Health. 2012;102(1):118–22.PubMedCentralGoogle Scholar
  58. 58.
    Reisner SL, Bailey Z, Sevelius J. Racial/ethnic disparities in history of incarceration, experiences of victimization, and associated health indicators among transgender women in the U.S. Women Health. 2014;54(8):750–67.PubMedCentralGoogle Scholar
  59. 59.
    Poteat TC, Keatley J, Wilcher R, Schwenke C. Evidence for action: a call for the global HIV response to address the needs of transgender populations. J Int AIDS Soc. 2016;19(3 Suppl 2):21193.PubMedCentralGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Center for HIV/AIDS Educational Studies & TrainingHunter College of the City University of New York (CUNY)New YorkUSA
  2. 2.Department of PsychologyHunter College of the City University of New York (CUNY)New YorkUSA
  3. 3.Health Psychology and Clinical Sciences Doctoral ProgramThe Graduate Center of the City University of New York (CUNY)New YorkUSA
  4. 4.Mental Health Counseling, Department of PsychologyCity College of the City University of New York (CUNY)New YorkUSA
  5. 5.Community Health SciencesUniversity of Illinois-Chicago School of Public HealthChicagoUSA
  6. 6.CUNY School of Public Health and Health PolicyNew YorkUSA

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