Mariko Iwamoto

Social Support, Exposure to Violence and Transphobia, and Correlates of Depression Among Male-to-Female Transgender Women With a History of Sex Work

OBJECTIVES We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW). METHODS A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire. RESULTS More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression. CONCLUSIONS For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.

Social factors related to risk for violence and sexually transmitted infections/HIV among Asian massage parlor workers in San Francisco

AbstractAsian women who work at massage parlors in San Francisco have high levels of riskfor sexually transmitted infections (STIs), including HIV, and being victims of violence, which jeopardizes their health and wellbeing. On the basis of mapping, the targeted districts in San Francisco where massage parlors were located, 23 massage parlors were identified where commercial sex activity took place. Using snowball-sampling methods, 43 Asian female massage parlor workers were recruited for focus groups; 21 participants were Vietnamese and 22 were Thai. Qualitative analyses revealed frequent exposure to violence including verbal or physical abuse from customers and gang members, as well as persistent HIV risk behaviors associated with multiple daily sex partners, inconsistent condom use with customers, and forced sex. Social factors related to gender, immigration status, and socioeconomic status appeared to be closely tied to the health and wellbeing of Asian masseuses. Study findings suggest that individualized as well as community-level interventions are necessary to improve these women’s health and decreasetheir prolonged exposure to risks for STIs and violence.

HIV-related risk behaviors among female sex workers in Ho Chi Minh City, Vietnam.

This study quantitatively and qualitatively described HIV risk behaviors among Vietnamese female sex workers (FSWs) who work at three distinct venues in Ho Chi Minh City: street, massage parlors, and bars/clubs. Although 35% of the participants had never been tested for HIV, 18% of street and 7% of bar/club FSWs reported being positive. Almost all massage parlor FSWs had never used a condom for oral sex. Inconsistent condom use for vaginal sex with customers was more prevalent among bar/club FSWs (85%) than massage parlor (72%) and street FSWs (68%). Many participants reported difficulties in negotiating condom use with customers because of economic pressure, maintaining relationships, and lack of bargaining power. Bar/club FSWs revealed a difficult situation where drinking is part of their work. Thirty percent of street FSWs had injected drugs and reported addiction to heroin in relation to their helpless condition as FSWs. Street FSWs had the lowest levels of self-esteem and norms toward practicing safe sex and the highest levels of economic pressure. This study recommends future HIV prevention programs for FSWs in Vietnam that target their specific risk behaviors and work environments.

HIV-related risk behaviors among kathoey (male-to-female transgender) sex workers in Bangkok, Thailand.

Based on combined methods, this study investigated substance use and HIV risk behaviors among kathoey sex workers (KSWs) in Bangkok, Thailand. The study found that only half of the KSW participants reported having been tested for HIV, and that except for one participant, all others had not seen health care providers in the past 12 months. About one third of the participants reported having engaged in unprotected anal sex with customers in the past six months. Almost all participants reported alcohol use, as well as having had sex with customers under the influence of alcohol. The prevalence of marijuana and ecstasy use in the past 12 months was high (32 and 36%, respectively); as was for ketamine (20%) and non-injecting methamphetamine (yaba) use (10%). A multiple regression analysis showed that the participants who were post-operative status, had used illicit drugs, or had been abused by their father and brothers were less likely to use condoms for anal sex with customers. Three quarters of the participants sent money to their families and 35% of the participants expressed their willingness to engage in unsafe sex when customers offer extra money. The qualitative interviews revealed that many identified as girl or kathoey in early age and had been exposed to transphobia and violence from father and brothers. Some reported support for gender transition from their mothers. More than half of the participants currently had difficulties in living as kathoey, such as challenges in the job market and relationship with family members. Family obligation for sending money and the Buddhist concept of karma were discussed in relation to risk behaviors among KSWs. The study provided implications for facilitating HIV testing and developing future HIV prevention intervention programs for KSWs in Thailand.

Practices of receptive and insertive anal sex among transgender women in relation to partner types, sociocultural factors, and background variables

It is urgent to develop efficacious HIV prevention programs to curb the reported extremely high HIV prevalence and incidence among transgender women (male-to-female transgender persons) who reside in large cities in the USA. This study aimed to describe unprotected receptive anal sex (URAS) and unprotected insertive anal sex (UIAS) among high-risk transgender women in relation to partner types, psychosocial factors, and background variables. Based on purposive sampling from the targeted communities and AIDS service organizations in San Francisco and Oakland, a total of 573 transgender women who had a history of sex work were recruited and individually interviewed using a structured survey questionnaire. Significant correlates with URAS with primary, casual, and commercial sex partners were found (e.g., needs for social support, frequency of social support received, exposure to transphobia, self-esteem, economic pressure, norms toward practicing healthy behaviors, and self-efficacy toward practicing safe sex). Multiple logistic regression analyses revealed that transgender women who had engaged in URAS with commercial partners were more likely to have higher levels of transphobia or lower levels of the norms or self-efficacy to practice safe sex. Among the participants who did not have vaginoplasty (preoperative transgender women), 16.4% had engaged in insertive anal sex (IAS) with commercial partners in the past 30 days. The participants who were HIV positive and had engaged in IAS were more likely to be African-American or Caucasians, coinfected with sexually transmitted infections, or identified themselves as homosexual. Practices of IAS among transgender women have not been thoroughly investigated in relation to sexual and gender identity. UIAS with homosexual and bisexual men in addition to URAS may be a cause for high HIV incidence among transgender women. An HIV prevention intervention study must be developed and evaluated, which aims to reduce HIV-positive and -negative transgender womens URAS and UIAS.

Minority Stress, Smoking Patterns, and Cessation Attempts: Findings From a Community-Sample of Transgender Women in the San Francisco Bay Area.

INTRODUCTION Research has demonstrated associations between reports of minority stressors and smoking behaviors among lesbian, gay, and bisexual populations; however, little is known about how minority stressors are related to smoking behaviors and cessation attempts among transgender women. The purpose of this study was twofold: (1) to examine the associations between transgender-based discrimination and smoking patterns among a sample of transgender women; and (2) to identify barriers to smoking cessation in a sample of transgender women with a history of smoking. METHODS A community sample of 241 transgender women completed a one-time survey. Binary and multinomial logistic regression models examined associations between minority stressors and (1) smoking behaviors and (2) cessation attempts. Both models adjusted for income, education, race/ethnicity, recent sex work, HIV status, depression, alcohol use, and current hormone use. RESULTS Overall, 83% of participants indicated that they had smoked a cigarette in the last month. Of these women, 62.3% reported daily smoking and 51.7% reported an unsuccessful quit attempt. Discrimination was positively associated with currently smoking (adjusted odds ratio [AOR] = 1.04, 95% confidence interval [CI]: 1.01, 1.08). Discrimination was positively associated with unsuccessful cessation (AOR = 1.03, 95% CI: 1.01, 1.18) and never attempting (AOR = 1.04, 95% CI: 1.01, 1.11) compared to successful cessation. Discrimination was also positively associated with never attempting compared to unsuccessful cessation (AOR = 1.01, 95% CI: 1.00, 1.03). CONCLUSIONS Smoking cessation may be driven by unique transgender-related minority stressors, such as discrimination. Future research is warranted to address unique stigmatizing contexts when understanding and providing tailored intervention addressing smoking among transgender women.

Social and cultural contexts of HIV risk behaviors among Thai female sex workers in Bangkok, Thailand

Abstract Recently, the number of indirect female sex workers (FSWs) who work at bars/clubs and massage parlors is substantially increasing in Thailand; however, there are huge gaps in knowledge about HIV risk behaviors among indirect FSWs. This study aimed to describe and understand HIV risk behaviors among Thai FSWs in Bangkok in relation to sociocultural factors and work environment (e.g., bars/clubs, massage parlors, brothels, and street). Based on venue-based purposive sampling methods, Thai FSWs were recruited for qualitative interviews (n=50) and survey interviews (n=205). Based on mixed methods, the study revealed that HIV risk and substance use behaviors among FSWs significantly differed depending on work venues, although there were no significant differences between work venues on some key risk behaviors (e.g., inconsistent condom use with primary partners and customers; willingness to engage in unsafe sex with customers). A multiple linear regression analysis revealed that FSWs who had used illicit drugs, were young, had low levels of self-esteem, or reported STIs had frequently engaged in unprotected vaginal sex with customers. Also, FSWs who worked at bars/clubs, were young, had higher income, or reported STIs had frequently engaged in sex with customers under the influence of alcohol. Qualitative interviews illustrated FSWs’ alcohol and drug use due to their stressful life (e.g., long working hours and a large number of customers) and easy access to alcohol and drugs. FSWs had shown inaccurate knowledge about HIV prevention methods and engaged in risky behaviors, such as washing vagina with water or toothpaste after having had sex with customers. The HIV prevention strategies in Thailand need to be re-structured through implementing evidence-based HIV prevention intervention programs for FSWs, which must address sociocultural factors (e.g., self-esteem) and alcohol and drug use specific to work venues.

TARGETED EXPANSION PROJECT FOR OUTREACH AND TREATMENT FOR SUBSTANCE ABUSE AND HIV RISK BEHAVIORS IN ASIAN AND PACIFIC ISLANDER COMMUNITIES

Access to culturally competent HIV/AIDS and substance abuse treatment and prevention services is limited for Asian and Pacific Islanders (APIs). Based on the intake data for a community outreach project in the San Francisco Bay Area (N = 1,349), HIV risk behaviors were described among the targeted API risk groups. The self-reported HIV prevalence was 6% among MSM. Inconsistent condom use for vaginal sex with casual partners in the past 6 months was reported among substance users (43%) and incarcerated participants (60%), whereas 26% of men who have sex with men reported inconsistent condom use for anal sex with casual partners. Overall, 56% and 29% had engaged in sex with casual partners under the influence of alcohol and drugs in the past 6 months, respectively. Although API organizations in the Bay Area have spearheaded HIV prevention, future programs must address substance use issues in relation to sexual risk behaviors, specific to API risk groups.

Contexts of HIV-Related Risk Behaviors among Male Customers at Asian Massage Parlors in San Francisco

Based on focus groups for male customers who frequented Asian massage parlors in San Francisco, the present study described their sexual and drug use behaviors and attitudes toward practicing safe sex with Asian masseuses. A pervasive view among patrons was that they could engage in sex with masseuses without using a condom if they offered extra money. Their sexual behaviors with Asian masseuses were influenced by perceptions about vulnerability toward HIV/STIs, substance use behaviors, and masseuses’ initiation of condom use, which was often governed by unspoken rules at parlors. Customers perceived massage parlors as being a safe place compared with street sex venues. Some customers sought emotional attachment with Asian masseuses and expressed stereotypical views toward them as being docile and submissive. Culturally appropriate HIV/STI prevention programs (e.g., communication about and practicing 100% condom use) are needed to target both customers and Asian masseuses at multiple levels (individual, owner/manager, work environment, and community levels). Also, customers’ and masseuses’ perceptions toward relationships at massage parlors and power dynamics need further investigation to promote safe work environments and 100% condom use at massage parlors.