Sexual and Mental Health Among Trans Feminine People in the Middle East: HIV Prevalence and Risk Behavior in Lebanon (WITHDRAWN)

Background: Transgender women are among the most-at-risk of populations for becoming HIV-infected globally. Due to stigma, discrimination, and violence, transgender women face other negative health sequelae. This study explored the lived experiences and measured risk factors related to HIV transmission among trans feminine individuals in Beirut, Lebanon. As the first study to include transgender women in the Middle East and North Africa (MENA), the findings and results demonstrate dramatic health disparities in this high-risk and marginalized community.

Methods: This mixed methods study utilized the Gender Affirmation Framework. Through referrals from a local NGO, 10 participants were recruited for in-depth interviews on topics including relationships and social support, “openness” about gender identity, experiences of stigma, sexual behavior, attitudes about HIV testing, and perceived norms about HIV among transgender peers (Phase 1). Long chain referral sampling was used to recruit 53 participants for an optional free rapid HIV test and completion of a behavioral survey including questions about demographics, sexual behavior, HIV testing and healthcare access, Gender Affirmation, stigma and discrimination, trauma, and mental health (Phase 2). The constant comparative method was used to analyze the qualitative data; the quantitative data were analyzed using bivariate and multivariable analyses.

The mean age of participants in Phase 1 was 27 years. Participants used a range of different words to describe their gender identities and had undergone a variety of feminizing procedures. All participants reported having ever had an HIV test and negative test results.  The median age of participants in Phase 2 was 22 years. Over half of the participants (57%) had not completed high school and only three had graduated from university. Forty percent of the participants reported having never had an HIV test.

Results: A complex constellation of overlapping and multi-directional factors that impact participants’ health risk and resilience emerged through data analysis in Phase 1. Four forms of safety were described as both important and threatened due to transgender identity: social / emotional, physical, sexual, and financial safety; these safety risks in turn impacted HIV risk. Fifty-seven percent of participants in Phase 2 reported condomless receptive anal intercourse (CRAI) in the last three months; 40% did not know the HIV status of the partner. HIV prevalence was found to be 10% in this sample. Surprisingly, “outness” about transgender identity was significantly associated with CRAI in the regression analysis. 

Conclusions and Implications: These findings and results highlight important health challenges that members of this understudied population face and provide the first measurements of HIV prevalence and risk behavior among trans feminine people in MENA. Future research in Lebanon will determine the feasilibty and acceptability of an adapted intervention to improve sexual and mental health and explore the meaning of “outness” and its relationship to HIV risk. Contextual understanding and cultural humility are essential for research and practice in the global setting. Trans-inclusive data collection methods should be used in research and practice.