“You don’t fit into any of the boxes”: trans men’s experiences with PrEP

Transgender men in France had to make a case for why they needed PrEP, by distinguishing their needs from cisgender gay men. There was often a feeling that they did not fit neatly into a box regarding who can benefit from taking PrEP, according to recent qualitative research.

Background

While not often acknowledged as being at a higher risk for getting HIV, transgender men – people assigned female at birth who identify and live as men – have a seven times higher risk of HIV than the general population. Still, it is rare to see public health campaigns directed towards trans men about HIV or protective measures, such as PrEP.

Many trans men also identify as a sexual minority, choosing to have sex mainly or exclusively with other men. The use of testosterone during medical gender transitioning may lead to an increase in sexual desire and risk-taking behaviour. This may increase their chances of contracting HIV and means they have a greater need for PrEP.

However, the very limited research with trans men regarding PrEP indicates lower levels of uptake and experiences of transphobia in healthcare. Providers often have limited understanding of trans men’s sexual expression, vulnerability to HIV and need for comprehensive sexual health services that include contraceptive and reproductive services.

The study

Ten qualitative interviews were selected from two studies, carried out between 2019 and 2023 in France with trans men. The ten interviews relate specifically to experiences with PrEP or the decision not to take PrEP. This research was conducted by Dr Clark Pignedoli and Paul Rivest from Université d’Aix-Marseille and published in Social Science and Medicine.

The participants ranged in age from 21 to 36, lived mostly in large urban centres (60%) and had both regular and occasional partners (70%). Six participants were on PrEP at the time of the interview. All participants identified as being on the masculine spectrum, with most identifying as trans men. All reported relationships with other men, while three stated that they were attracted to all genders and engaged in relationships with both cisgender men and other trans people.

All participants were French citizens, and could access PrEP freely through the public health system. Of the six on PrEP, four received it through sexual health units at public hospitals, while the others accessed it through community sexual health centres. Some participants reported starting PrEP without a prescription and bypassing official healthcare systems.

All participants were medically transitioning and receiving testosterone, and most had previously had top surgery (breast removal). Two participants reported previous or current sex work, and two had no stable accommodation.

The interviews revealed the following unique perspectives regarding vulnerability to HIV, PrEP access and deciding whether to use PrEP or not.

Trans men feel invisible when it comes to sexual health services

Participants reported that they were often mistaken for cisgender men by their providers, and thus inappropriate recommendations would be made, such as event-based PrEP – which is only approved for cisgender gay men and trans women.

“[T]hey assume that I’m a cisgender gay guy, which is problematic. Because in the end, if I don’t out myself [as a trans person], they’re not necessarily going to provide me with proper care.”

This often led to awkward interactions, where questions pertaining to vaginal sexual health and contraception were glossed over:

“The doctors would say: ‘You need this test, that test’, and I’d say: ‘I’m going to need a third one, the vaginal swab.’ I said it every time. At one point he said to me: ‘Fine, we’ll try to modify the form.’ He was reading me a follow-up form and clearly, we weren’t included in it whatsoever.”

There was a strong feeling that PrEP services were tailored to the needs of cisgender gay men. Not fitting neatly into a biomedical box would lead to embarrassment and the occasional avoidance of services.

“It’s silly, but one of my fears when I first called to make an appointment for PrEP was that they’d say ‘No, you don’t fit into any of the boxes [ …]’. I imagined they’d say, I don’t know, ‘You’re not a real faggot! You don’t need PrEP.’”

Some participants stated that it was easier to present themselves as a sex worker to ensure easy PrEP access. This would mean that they would not have to convince healthcare workers that they needed PrEP as trans men, as they could automatically qualify as sex workers.

“I don’t want to have to convince the person in front of me that I’m legitimate to have the treatment because I’m a trans guy, and so he thinks I’m less at risk, basically.”

PrEP, sexual pressure and gender-based violence

Some participants reported previous sexual assault or challenges negotiating sexual boundaries with cisgender men. In these instances, PrEP was viewed as an important form of protection against getting HIV, especially when condom use could not easily be negotiated.

"At least I’ll know that if I get assaulted, the worst risk, namely HIV, will be avoided.”

However, using PrEP could be a double-edged sword: when sexual partners knew PrEP was being used, they often used it as a reason to pressure participants into condomless sex.

“I discussed this topic with the [PrEP] peer navigator, and he said to me: ‘Maybe it’s better if you don’t actually put on your [Grindr] profile that you’re on PrEP.’ And I think he’s right, because then it’s an excuse to say: ‘Fine, let’s go ahead and do it.’

Some participants spoke about gendered power imbalances that arose with cisgender gay men. This would often result in undue pressure – often to engage in condomless sex, which was viewed as a gay norm.

“Potentially there are things that cisgender men can use [ ….] to have unequal relationships. It’s the fact that I have less sexual experience because I started my sex life later, which for me is also related to my transition…”

Four of the six participants taking PrEP started off by taking post-exposure prophylaxis (PEP). Thus, there had been unplanned risk (non-consensual removal of a condom or accidental breakage) and several participants felt drawn to PrEP because of challenges negotiating consistent condom use.

“I started because… there were like a few situations that scared me. I took the [PEP treatment] twice… three times… I don’t know. Hmm, I was there ‘Uh, well. Maybe I can do something.’ And I heard people talking about [PrEP], and it’s free.”

Changing desires and the need for new forms of biomedical protection

Gender transition and starting testosterone often resulted in unanticipated changes not just regarding amount of sexual desire, but also a distinct desire to have sex with cisgender men, to have more casual sex or to engage in gay cruising.

This was accompanied by a need for PrEP. For some participants, this meant moving from sexual relationships with females to exclusively having sex with cisgender men, and the adoption of new cultural sexual practices, often revolving around gay condomless sex.

“When I started going on Grindr and really meeting guys, and seeing how difficult it is for them to just put on a condom, I said: ‘Maybe it’s time [to start PrEP].’”

However, this also raised questions regarding what could be seen as an excessive need for biomedical intervention:

“I didn’t know how lucky I was before. I feel like I’ve been married to the medical profession ever since I became a fag. I mean, I find that my relationship with the medical profession is kind of constant… vaccinations, tests for hormone levels, blood tests, PrEP appointments, and all that…”

Choosing not to take PrEP

While most participants felt safer because of PrEP, two said PrEP reminded them of oral contraceptive pills, which was a negative association. Contraceptives were seen as conferring gender: a gender that participants no longer identified with.

“[PrEP] seemed to me to be a bit of a heavy thing to take, every day and all that. It reminded me of the pill, I really didn’t want to take it.”

“I’d tried [the] pill… very restrictive, mental burden, etcetera. And in fact, before the IUD [intra-uterine device], I had an implant. The implant was really horrible. They put it in after I had an abortion. And it was really… no more libido, I cried every day, I had my period 3 weeks a month…”

Conclusion

Despite having a small sample size, this study sheds light on experiences that are rarely represented in research and public health discussions. The prevailing narrative that only cisgender gay men and trans women need PrEP often works to exclude trans men, who feel that they need to convince healthcare providers that they are at risk for getting HIV and that they too need PrEP.

Additionally, this study captures complex shifts in desire that often accompany the medical gender transition process for trans men. This process may result in both stronger sexual desire and heightened vulnerability in sexualised spaces – and thus a greater need for the protective benefits conferred by PrEP.