Speaking to gay and bisexual trans men, the word “invisibility” comes up a lot. Invisibility in the bathhouse and on dating apps, invisibility among cisgender people, straight people, trans people and gay people. And, too often, invisibility in the doctor’s office.
“I have tried just going to walk-in clinics and stuff like that to ask questions or request tests,” one trans man recently told researchers in Vancouver. “And I just found the doctors were generally confused about me and my body. And I had to go into great detail. That made me not so comfortable talking to them about it because they were just kind of sitting there confused.”
“People have tried to talk me out of testing . . . saying I was low-risk behaviour,” another man told the researchers. “They didn’t understand my behaviour really. . . I’ve had practitioners as well say they don’t know what to do; they don’t know what to look for.”
Both men were speaking to researchers for a new study on the sexual health of trans men who have sex with men — a group social scientists know remarkably little about. Many of the men spoke about being on the margins of mainstream culture, gay culture and of the healthcare system.
It should be no surprise, then, that the study happened almost by accident. When PhD student Ashleigh Rich started work with the Momentum Health Study — a five-year, in-depth research project on the sexual health of men who have sex with men (MSM) conducted out of the BC Centre for Excellence in HIV/AIDS — she never intended to write a paper about trans MSM.
But a small group of trans men volunteered for the study, some pointing out ways the Momentum researchers could change their surveys to be more inclusive.
There were too few for quantitative research — only 14 — but Rich asked if they would sit down for an hour and talk about their experiences. Eleven agreed.
The result is a slim, 11-page paper that hints at a world of things we don’t yet know about transgender gay and bisexual men. We do know they form a large part of the trans population; nearly two thirds of trans men say they are not straight. We also know trans MSM participate in the same rich world of sexuality as other men who have sex with men — from dating apps to anonymous sex to sex work and a broad range of sexual behaviour.
We don’t know much about trans MSM risk for HIV; estimates range from much less than cisgender gay and bi men to somewhat more. We also don’t know much about how a combination of stigma, invisibility and limited healthcare options may be affecting trans men’s health.
Rich is cautious about drawing any broad conclusions from her study. Not only is it a tiny sample, but the men she spoke to are also mostly urban, white and educated. This study was less about answering questions, and more about figuring out which questions to ask.
A few themes, though, emerge clearly. One is that trans MSM often find themselves falling through the cracks when it comes to sexual health. Doctors are increasingly aware of how to talk to gay men, but don’t always see trans gay men as “real” MSM. They assume trans men are heterosexual, or fail to bring up sexual health altogether.
Some doctors give trans men information on PrEP — a preventative anti-HIV medication that can drastically reduce the risk of contracting HIV if taken every day — based on studies on cisgender men, without checking to see if different anatomy requires different doses. When trans men come in for HIV tests, they are sometimes urged to get pap smears instead.
“We come in with specific issues we want to talk about in a health care consult, and sometimes once people discover we’re trans they’ll want to do a pregnancy test or something,” says Kai Scott, a trans inclusivity consultant who collaborated on the study with Rich. “And we’re not there for that. They’re giving us things we don’t want, and not telling us the things we do need to know.”
Sam Larkham, a trans man who organizes sexual health clinics across Metro Vancouver with the Health Initiative for Men (HIM), says he was once referred by his doctor to a trans health care clinic that had been closed for years. Experiences like that make him think the best path for trans MSM is to rely on queer-focused health care providers like HIM.
“It would be ideal if it were the whole medical system, but that’s impossible,” Larkham says. “I think we have to look at what we can do, and that’s have specific places where we have nurses who are well trained to handle trans MSM. I think that’s the more doable thing. I would love to have every clinic be culturally competent, but that’s not the reality and never will be.”
Scott is more sanguine. He points to Trans Care BC, a provincial health program that has pushed for more education for doctors. Education needs to happen on both fronts, Scott says, among MSM organizations and in the health care system at large.
Lauren Goldman is a nurse educator for Trans Care BC. Since she was hired last fall, she’s been giving workshops to healthcare providers on how to treat trans patients. For now, though, the workshops are aimed at small groups of sexual health professionals, such as at the BC Centre for Disease Control or HIM. Goldman wants the program to expand to include everyone.
“We know trans patients are accessing care through a number of places all across the province,” she says. “We want everyone to have access to this information as soon as possible.”
Goldman says Trans Care is designing an online course that could bring trans cultural competency to primary care doctors everywhere as part of mandatory continuing education. Trans Care has also designed a primary care “toolkit” for doctors, and is in talks with UBC’s medical school about including trans-focused sexual health education for doctors in training.
Without specialized knowledge, Goldman says, there’s a lot doctors can miss. Testosterone can make vaginal tissue more sensitive and inflexible, for example, meaning trans men might have special difficulties with genital sex. Bacterial vaginosis is more common, and the usual antibiotics given to cis women may not solve the problem. Vaginal and rectal tissue may need different doses of PrEP to be effective.
And, most importantly, doctors need trans patients to know they will be heard.
“We need to be providing really obvious cues that show people that our services are trans inclusive,” Goldman says. “Including how we design our services, how we market our services, how we educate our clinicians, what signs we hang up, letting people know that our clinicians have a greater understanding of gender diversity.”
While Goldman is educating doctors, the trans men Rich studied were already very well educated about their own sexual health. They told Rich about careful risk assessments they make around sex, sharing information with other men, and advocating for STI screening to their reluctant doctors.
One man described slipping in HIV tests while getting regular testosterone-level screening: “Yeah, oh, I’m already getting blood drawn. I probably need to get tested, let’s just draw two more vials for HIV and syphilis.”
It’s not surprising that many trans men are so health-conscious, Scott says. “We’ve had to be champions of our own bodies for a while, and so that ethos carries through when it comes to health information.”
But it would be a mistake to overstate how safe trans MSM are, he adds. For one, the urban, white and well-educated men in Rich’s study may be more likely to have access to resources and care than less wealthy or more rural trans people. Also, the very reason trans MSM seem so safe might be because they aren’t getting the opportunities for sex they want.
“To some extent, we’re still on the sidelines,” Scott says. “I don’t think that systemic rejection should be the means of HIV prevention for trans and nonbinary people. We’re dealing with a lot of rejection, and so I don’t think we’ve really had the opportunity to be exposed to that risk.”
The theme of rejection is echoed frequently by the study subjects.
“I remember meeting this one guy at a friend’s party and we were flirting the whole time,” one participant recounted. “He was like, ‘Oh we should totally go for a beer’ and so we connected and then I told him I was trans and he was like, ‘Oh I’m not looking for anything.’”
“Cis men often shut down immediately, out of a sort of fear of the unknown, and being unaware of what can and can’t happen,” Scott says. “They can assume all trans guys are bottoms, which isn’t true.”
Constant rejection can wear trans men down, Larkham says. Not only does it damage mental health, but constant rejection can weaken trans men’s resolve to negotiate sexual safety.
Many trans men, the study notes, rely on online hookup sites, where they can be upfront about being trans, and avoid rejection by anyone who isn’t interested.
The burden of rejection is one reason trans MSM need better mental health services too, Larkham says. Too many men show up to sexual health clinics after being exposed to sexual risks. Mental health support, he thinks, could reach people earlier.
But again, Scott strikes a positive note. “It’s a source of celebration to me that despite huge barriers we’re still having the sex that we want,” he says.
In the end, the clearest message to emerge from Rich’s study is that there’s a lot more to learn. She hopes to get more answers from the next stage of the Momentum study, which will recruit a larger sample of MSM from across Canada. That study, she hopes, will be large enough to deliver the kind of precise, quantitative answers that this one couldn’t.
Scott is also eager to move forward.
“There’s so much you want to pack in and so much you want to report on,” he says. “There’s such a dire need to research these issues. People are really hurting, and I really feel that. But you’ve got to take it one step at a time.”