Having receptive anal sex carries the greatest HIV risk compared to other sexual behaviours (such as insertive anal sex, and insertive and receptive vaginal sex).

Unless a transgender woman has had gender reassignment surgery, she will not have a vagina so she will not be able to have receptive vaginal sex. If she has sex with men she will only be able to have anal sex – and this may be insertive or receptive. If she struggles to use condoms with partners or access PrEP she is at high risk of HIV. 

Just like other women, transgender women also experience gender-based violence and gender inequality, both of which increase HIV risk. In some circumstances, if a trans women doesn’t ‘pass’ as female, violence (including sexual violence) can be even worse than other women experience as a form of punishment for not acting and behaving like a man.

Transgender women need the same non-judgemental, easily accessible HIV services as any other at-risk group. This means providing HIV prevention services, such as condoms and lubricants, plus PrEP and PEP if available. It means providing HIV and STI testing and good links to treatment, adherence support and treatment monitoring. 
 

It is essential to ensure such services treat transgender women as women – using their chosen names and correct pronouns (such as ‘she/her’) – not as men who have sex with men.

Other support to consider includes:

- gender-based violence services, particularly in relation to rape and intimate partner violence, tailored to the experiences of transgender women, not gay men

- needle and syringe programmes for trans women who inject hormones or drugs (if legal) 

- tailored livelihood support for trans sex workers interested in other employment

- safe housing plus food support for trans women who have been made homeless

- tailored counselling and support to improve mental health and well-being. 

The best way to provide transgender women with services is to work with community representatives who can advise on what trans women want and need, and how best to deliver this support.

Respect people’s dignity, treat them with kindness, and ensure their privacy and confidentiality. Do not assume that every transgender person will have the same lifestyle, experiences or issues. Take time to understand who they are as a person and what support they need from you. Do not judge people for being who they are.

Use the name they call themselves, even if it is different from the name on their record. Use the gender-neutral pronoun ‘they’ (instead of ‘he’ or ‘she’) until you know what pronoun the person likes to use. If you are using English, say ‘your partner’ instead of ‘your husband/wife’. If they use a certain term to describe themself, such as ‘male’, female’, ‘trans’, ‘queer’ or ‘non-binary’, use it too. 

Only ask questions that are relevant to whatever issue they have come to you with. It is not okay to ask them questions to satisfy your curiosity or to infer blame. Your body language, facial expressions, and the tone and pitch of your voice can suggest surprise or disapproval, so try to keep these things neutral. And remember that you are only human – if you make a mistake, apologise and move on.

Transitioning describes the changes that some transgender and non-binary people make so they can live in a way that better reflects their gender identity.

Gender dysphoria are feelings of unease that some people get if their gender identity and their body don’t match up. This unease can also come from being treated as a certain gender by others when they do not identify this way.

Not every transgender and non-binary person gets gender dysphoria or wants to transition. It is important to be led by the person you are supporting. Ask them non-judgemental questions about how they are feeling. Let them know that exploring how they feel, and learning to love and accept it, can be hard. But it’s one of the best things they can do for themselves. 

It is important to understand the facts on transgender people’s sexual health, including on HIV, STIs, gender dysphoria, transitioning and sexual pleasure. Communicate these facts clearly, without judgement. 

Research if there are LGBT+ support groups in your area or online that they can join. This is a good way to show them they are not alone in what they are feeling. It is also useful to research the laws in your country on gender identity and recognition and find out whether gender-affirming healthcare is available. If they want to find out more, you can then let them know what their options and rights are.

Yes, PrEP is safe for transgender women on hormone replacement therapy (HRT). Research shows that PrEP does not interfere with the effectiveness of gender-affirming hormones. This means you can reassure transgender women that PrEP is compatible with HRT.

It is advisable for transgender women on HRT to speak to a health provider before starting PrEP. To look up interactions between PrEP and other medications, visit www.hiv-druginteractions.org. 

Stigma is when people feel, think and talk negatively about LGBT+ people. It relates to people’s attitudes and views. Self-stigma is when someone has internalised negative stereotypes, public stigma and shame about themselves - this can often be around their sexuality, gender identity or HIV status. 

Discrimination is when stigmatising views cause LGBT+ people to be treated unfairly. Discrimination can happen in many different circumstances, including at home, in school, at work and in healthcare. It also includes discriminatory laws, such as the criminalisation of homosexuality.

The stigma, discrimination and criminalisation that transgender people face stops many from accessing sexual health services, including HIV and STI prevention, testing, treatment and care. Transgender people may be too scared to test for HIV, use PrEP or take treatment if they need it. 

Stigma and discrimination can cause some transgender people to feel anxious or depressed, to misuse alcohol and drugs and to increase the sexual risks they take. Some of these things can increase the risk of getting HIV. Stigma and discrimination can also stop transgender people from getting the mental health support they need to cope with what they are experiencing.

You can try the following things to provide support:

• arrange to meet them somewhere discreet and private
• let them know you are not here to judge or report on them: you are here to support their health
• tell them that whatever they tell you will be kept private.