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The Stigma-Sickness Slope: HIV Vulnerability in Asian Transgender Populations


As many as half of all transgender people in Asia may be living with HIV, according to a new report by the United Nations Development Programme and the Asia Pacific Transgender Network. The findings offer insight into the multifactorial drivers of high HIV seroprevalence and vulnerability among trans persons in the region.

Entitled Lost in Transition: Transgender People, Rights and HIV Vulnerability in the Asia-Pacific Region, the report -- released on May 17 to coincide with the International Day Against Homophobia and Transphobia -- was based on literature from 8 Asian-Pacific countries looking at the estimated 9.0 to 9.5 million trans people living in the region, restricted to papers published from 2000 through 2012.

Primarily, the report discusses the lack of adequate data and the need for trans-specific research into HIV seroprevalence and the sociocultural and legal factors contributing to health risks in trans people's lives. 

Author Sam Winter from Hong Kong University describes the "stigma-sickness slope" -- explaining how the effects of stigma and discrimination against Asian-Pacific trans people lead to high HIV prevalence, believed to be as high as 49% among trans women. Seroprevalence among trans men is unknown due to the complete lack of research into this population. Winter speculates that the risk is high, however, due to similar factors facing trans men, including the large number of trans men who work as female or male sex workers. 

The report details the ways trans people experience the "stigma-sickness slope" through patterns of discrimination, harassment, and verbal, sexual, and physical abuse in the family, at school, in the workplace, in medical services, in the legal system -- including interactions with law enforcement -- and in society more broadly.

The study also examines the physical and cultural factors that contribute to HIV risk among trans women -- such as the likelihood of women without bottom surgery (genital reconstruction) being receptive partners during anal sex, little or no education around HIV risk, and lack of access or unwillingness to use condoms or lubricant due to affordability concerns or fear that they will be used as evidence of prostitution.

The report provides recommendations to reduce the impact of factors leading to poor health outcomes among trans populations, including:

  • Research that is culturally competent and specifically focused on trans populations; this work needs to put trans people in key research positions to decrease cisgender (someone who identifies as the gender/sex they were assigned at birth) bias and to increase collaboration. 
  • Studies that estimate the number of trans people living in the region (including in rural settings), a complete count of transgender male and female sex workers, and accurate HIV seroprevalence estimates for trans women and men in the region. 
  • Research that goes beyond risk factors and instead looks at crucial shifts in legal and social frameworks that will confer resilience against the effects of stigma, prejudice, discrimination, harassment, and abuse, and their resulting marginalization.

In summary, these findings illuminate a need for widespread anti-stigma work and institutional change to improve the lives of trans people and empower them to make choices about their sexual health. A vital step in creating this social change is trans-specific research that institutionalizes categorization of trans people as a separate group in HIV-related and general population studies, and that includes trans people as equal partners. Implementation of these findings into programming may finally begin to derail the "stigma-sickness slope."

The full report is available online.



S Winter. United Nations Development Programme and Asia Pacific Transgender Network. Lost in Transition: Transgender People, Rights and HIV Vulnerability in the Asia-Pacific Region. May 2012.

United Nations Development Programme. New Asia-Pacific Report Focuses on Transgender Persons. Press release. May 17, 2012.