Links between intimate partner violence and HIV risk among transgender women require trans-affirming health and social services

Transgender women are more than 32 times more likely than cisgender adults to be living with HIV and twice as likely to experience physical and sexual violence from their intimate partners. According to recent research conducted with transgender women living in the United States, published in the journal Culture, Health & Sexuality, transgender women’s high rates of HIV and intimate partner violence are due to a number of factors.

One is their historical exposure to abuse from family members and partners and their consequent normalising and even expecting violence in their intimate relationships. Another, connected factor is emotional and financial dependence on intimate partners. This dependence is directly linked to their relatively low access to traditional employment opportunities: many transgender women rely on sex work and/or intimate relationships to meet their financial needs. The authors conclude that intimate partner violence among transgender women, and their related HIV risk behaviours, is experienced in trans-specific ways. These important intersections demand changes in how health and social services interact with members of the trans community.

The authors conducted three focus groups with eleven transgender women aged 18 and over who had reported at least one instance of intimate partner violence. The focus groups were held in the state of Rhode Island. Half of the participants were Black, and half were unemployed. The goal of the research was to develop an intervention designed to tackle transgender women's overlapping risks of HIV infection and intimate partner violence.

Experiencing and normalising violence

Participants’ understandings of intimate partnership differed from standard definitions. In addition to a current sexual and romantic partner, they also considered more casual sexual connections and, in the case of sex work, regular paying sexual partners with whom they had established trust and rapport to be intimate partners. One participant said:

“Queer intimacy is inherently different than heterosexual intimacy by sheer culture alone ... I now have a lot of friends that are trans sex workers, and you know they have experienced violence, and they would call the people that they were with – aside from maybe a client – as an intimate partner, because they were intimate.”

Participants distinguished between intimate partner violence and childhood sexual abuse, which several had also experienced. Childhood violence, trauma and abuse (witnessing domestic violence at home, being sexually, physically, or verbally abused, and/or being abused by family members as punishment for openly expressing their gender identity) was often the beginning of a lifetime of abuse.

“It’s our relationships with our parents and family that leads us to having those kind of partners.”

Focus group members described coming to view violence and abuse from family members as a normal, expected part of living as a transgender woman. They spoke of modelling their expectations of intimate relationships on the abusive ones they had witnessed and/or experienced as children and accepting a level of violence and abuse in their intimate relationships as a result.

“I’ve been in relationships where I tolerated a lot because my mother was very abusive growing up. And being in a relationship, like I said, I tolerate. I guess you get programmed in your head, you don’t develop properly. You’re raised [with] your ideas of how relationships are supposed to be, because of your role models … So, then you get [in] these relationships and it’s almost like I put myself in that position. I almost find a partner to continue the abuse.”

Participants were fearful of disclosing their transgender identity to partners, expecting their partners to react with verbal and physical violence, as many had already experienced. Many felt that given the dual threats of violence from family and partners, and of transgender women having normalised receiving violence and abuse, transgender women may not recognise violence against them when it occurred, may feel that they deserved it, or saw it as the cost of having an intimate relationship. Some participants recalled receiving this message from others in their social networks.

“Sometimes we don’t know if we’re getting abused. We think it may be normal because we’ve been pushed to the side or been abused by our relatives for just being who we are … I might be being sex trafficked and don’t even know it, because we’re just so excited to be in a relationship, and think that it’s okay…”

Several participants spoke of needing tools to help them recognise when they are being victimised and advocate for better treatment from their partners.

“At least give us knowledge on how to deal with things, like tools on how to know that we’re being abused or being sexualised or being used.”

Intersecting vulnerabilities: violence, risk of HIV infection, and mistrust

Transgender women linked the heightened risk of acquiring HIV from intimate partners to their own willingness to remain with an abusive partner and engage in unprotected sex for fear of losing them. For these participants, the desire to be loved was stronger than the desire to leave the relationship or the risk of abuse or HIV.

“I don’t even know if he got fuckin’ tested [for HIV] or not. But he’s acknowledging me, and he’s accepting me. So, honey, fuck me. And I wanna feel it because I don’t fuckin’ feel it that often.”

“Well, my boyfriend used to always tell me no one else is going to want me because I’m trans and that he’s the only one that I’m going to be with… So, I think if he leaves me I’m not going to find nobody to treat me like he does and treat me good and all that stuff. So, I have to put up sometimes with the bad for the good.”

Many described needing to remain in these relationships because it was the only way they could feel loved or access food, housing, and financial support. This dependence on potentially abusive partners was exacerbated by the general lack of independent employment opportunities and appropriate housing due to wide-spread discrimination.

Participants felt that these intersecting vulnerabilities and dangers, directly linked to living as transgender women, were not recognised by health and social service professionals. They felt that these professionals prioritise their own agendas over the transgender community’s distinctive needs. They stated that more trans-affirming and empowering health and social services were crucial to increase transgender women’s safety and service engagement.

“It starts with a team in a safe environment where people can really feel comfortable to let that down, and for somebody of knowledge that’s been through some shit to speak on it.”

More specifically, they called for training on the trans community, including on trans-specific experiences of violence, and better representation of trans people in service delivery sites.

“Trying to hire trans people to do some of this stuff – that would make me feel comfortable. Because when I went to the clinic and the trans woman was taking my blood, I just wanted to sit there and chat.”

Participants spoke of health and social services needing to devote more time to their encounters with trans women to allow them to build the trust necessary for them to open up about their experiences of violence and abuse, and to provide them with the tools they needed to identify and respond to intimate partner violence.

“Hopefully, in the future, there will be providers who help the young people navigate through the abuse and just start off with the basic tools to know how to deal with a situation, to know if you’re being abused, to know if it’s right or wrong to accept it.”

Recommendations

The authors stress that standard questions regarding intimate partner violence may miss the different ways that transgender women understand and experience intimate partnerships. Given the high rates of intimate partner violence and HIV among transgender women, they also recommend introducing gender-affirming approaches to health and social service delivery to increase engagement by transgender women who experience intimate partner violence, as this population is often made to feel distrustful, unsafe, and marginalised when interacting with these services.