HIV is the modern gay story. “The gay disease” wiped out large numbers of gay and bisexual men. Lesbian and bisexual women took the traditional gendered roles of caring for their queer brothers dying in “The Plague”. In the post-gay marriage age of assimilated white cis gay men, HIV is the starkest possible reminder of the extreme vulnerabilities sexual minorities face. Yet as ever, the group most excluded from this narrative are transgender people.
The infection rate for transgender people in the UK is unclear, but estimates of the rate across Europe range from 11.5-57%. This compares to a UK rate of 5% of gay and bisexual men living with HIV and 0.15% of the general population living with HIV. Only recently have HIV/AIDS organisations like the Terence Higgins Trust realised the need for specific resources for trans women. The idea of HIV as disease of the bathhouse, of the gay movement being wiped out and then rebuilt to achieve civil equality over three decades, is ingrained into queer and non-queer understandings. HIV in many ways was the death of the gay liberation movement, but the birth of the civil equality movement. The vulnerability of the communal experience for LGB people made civil rights necessary for survival, namely official recognition in marriage and hospital visitation rights, pensions, and inheritance. Trans people do not have the luxury of survival through civil equality and recognition alone. Their vulnerability to HIV is linked to a whole variety of issues ranging from poverty to criminalisation.
There has been more comprehensive research on infection rates for trans people in the US. A National Transgender Discrimination Survey report found transgender health outcomes linked to intersections with class, race, gender, employment, and even immigration status: at least 2.64% were HIV+ overall (88% of whom are trans women), four times the rate of infection in the general population. For black trans people, this rose to just under 25%. Undocumented trans immigrants had a positive rate of around 7%, and 17% did not know their status. 61% of trans people with HIV had done sex work. 10% who had been sexually assaulted were HIV positive. 13.5% of those without a high-school diploma were positive, and 13% did not know their status.
Trans women are up to 49 times more likely to experience infection worldwide than the general population. As is the case for middle-class cis women and black people, economic prosperity is not enough. To be ‘middle-class’ and trans is very different from being middle-class and cis, or white, or male. Trans experiences with healthcare, housing, or employment are not made ‘secure’ with economic prosperity alone. Trans people are constantly reminded their security can be removed at any moment. Even in Brighton, ‘the gay capital’ of the UK, 26% of trans people are unemployed and 60% are earning under £10,000 annually. In this context the criminally ‘insecure’ job of sex work becomes more secure for trans women. It at least guarantees enough money for food and heating, as well as the clothes and make-up needed to ‘pass’ as cis. In the US, where the lack of universal healthcare particularly impacts trans people, many contract HIV by turning to needles for necessary hormones. Healthcare outcomes in the US are linked to the mass criminalisation and stigmatisation of trans people, especially trans people of colour who face additional burdens of criminalisation and stigmatisation.
Significantly, 21% of US trans women, and at least 47% of black US trans women, are incarcerated at some point in their lifetime. Such a rate of mass incarceration has a wider impact on communities. In the same way the US prison system acts as ‘The New Jim Crow’ for black communities by removing large numbers of their community and resources, removing a quarter of all trans women and half of black trans women from communities creates an inescapable cycle of criminalisation and stigma. JoAnne Keatley, director of the Center of Excellence for Transgender Health at the University of California, says “Once a trans person becomes part of that cycle of criminal injustice, it’s hard to break out of that.” It helps to explain why trans sex workers are 4 times more likely than cis sex workers to contract HIV. When trans people are made homeless and jobless, forced on to the streets which is paradoxically ‘insecure’ but offers the hope of ‘secure’ sex and/or drug work, trans people have to ‘pass’ not just as cis, but to avoid criminalisation. In the choice between unsafe sex and possessing condoms used as evidence they are selling sex, trans sex workers often choose the former. Here in the UK, trans sex workers face the same choices when condoms are seized as evidence in sauna raids. In the choice between hormones and anti-retroviral medication for HIV, the former is chosen, the immediate safety of ‘passing’ over protection via condoms and HIV medication.
The most direct correlation between criminalisation and HIV infection is ironically, laws that criminalise non-disclosure of HIV status before sex. The laws are selectively enforced: they place the burden of informing authorities and individuals on criminalised and stigmatised communities. 58% of the US transgender population believe it is justified to avoid testing and treatment for fear of criminalisation. This also translates to Europe where such laws selectively target trans women, gay and bisexual men, sex workers, and black men. Testing and treatment is stigmatised when marginalised communities face additional barriers of criminalisation in accessing healthcare. The cycle of mass criminalisation and incarceration only worsens the HIV pandemic by making these communities more vulnerable to infection. Trans women are labelled as MSM (Men who have sex with men), making them more likely to experience abuse and stigmatisation. They are placed in male prisons and are assaulted and abused by male prisoners and guards alike.
The addition of the trans narrative to HIV policy responses is a fundamental task. ACT UP, the pioneering HIV group who helped gay and bisexual men to “survive a plague”, are once again bringing the fight for anti-retroviral affordability to the public arena. In the US, Senator Bernie Sanders is seeking to establish a government ‘prize fund’ for HIV drugs to promote drug affordability instead of leaving it to the free market. However, it is clear adding the trans narrative requires an understanding of other material vulnerabilities faced in employment and housing, and of the various healthcare choices (namely around hormones) made by trans people daily. Most important is tackling the mass criminalisation, in drug use, immigration status, and sex work, that destroys trans communities by separating trans people from the resources and security needed to access treatment: it has created a devastating vacuum that HIV has filled.