Sexual Behaviors and Vulnerability to Sexually Transmitted Infections in Transgender Women

Background: It is essential to pay special attention to sexual health of transgender women. The aim of this study was to assess sexual behaviors and vulnerability of transgender women to sexually transmitted infections (STIs) including AIDS. Method: A cross-sectional study was conducted using convenient sampling from August 2019 to march 2020 in Iran. 127 transgender women participated in this study .A researcher-made questionnaire was applied for evaluating sexual behaviors, STIs and HIV. Results: The mean age of participants and their age of sexual debut were 27.6 and 16.9, respectively. 92.1% of participants were single with experience of sex and 59.3% had one sex partner in the last 2 years. 96.9% of the participants were heterosexual with 67.2% reporting experiencing orgasm in at least 50% of their sexual intercourse. However, 42.5% reported dyspareunia and the same percentage reported low or very low sexual satisfaction. The majority of participants had little knowledge of the symptoms (33.9%) and complications (44.1%) of STIs. Although 87.4% and 72.4% of participants had never been tested for a STI and HIV, 1.6% were infected with HIV and 18.1% with STIs. Conclusion: Sexual interests of Iranian transgender women were aligned with those of cisgender women.

50% of their sexual intercourse. However, 42.5% reported dyspareunia and the same percentage reported low or very low sexual satisfaction. The majority of participants had little knowledge of the symptoms (33.9%) and complications (44.1%) of STIs. Although 87.4% and 72.4% of participants had never been tested for a STI and HIV, 1.6% were infected with HIV and 18.1% with STIs.
Conclusion: Sexual interests of Iranian transgender women were aligned with those of cisgender women.
In terms of sexual function, despite the higher rate of orgasm in transgender women, sexual satisfaction was lower in them compared to that of cisgender women due to dyspareunia and body dissatisfaction, which highlights the need to investigate for more effective surgeries and speci c sexual counseling interventions in this group.

Background
Transgender women feel uncomfortable with their biological male gender and identify themselves as female [1]. Few studies have been conducted on sexual behaviors and preferences of transgender people [2][3][4]. Transgender people may face signi cant challenges in the type and frequency of sexual activities, pleasure, and sexual satisfaction due to the psychological effects of gender dysphoria, body dissatisfaction, and improper functioning of sex organs [5,6].
Studies conducted in 2013-14 in Europe indicated that 46 to 80% of transgender people are sexually active [4,7], most of them are heterosexual [2], prefer anal sex and have multiple sex partners [8]. On the other hand, sexually-active transgender women were less inclined to use condoms during receptive anal sex with their main partner [9] because they wanted to feel intimate with him [10].
Many transgender women are unemployed due to discrimination and stigma and live below the poverty line. Financial problems sometimes make these people involved in high-risk sexual behaviors [11] such as having multiple sex partners, unprotected sex and prostitution [12]. As a result, they are subject to more health problems than the general population [13].
Transgender individuals are at serious risk for AIDS and other STIs, and according to the Centers for Disease Control and Prevention, they are four times more likely to experience HIV infection than the general population [14]. Unsafe hormonal or silicone injections for sex adaptation or drug injections may also put them at risk for HIV infection [12,15,16]. As reported by the National Center for Transgender Equality in 2012, about one-third of transgender people and 48% of transgender men in the United States failed to undergo or delayed preventative care, such as pelvic exams and STI screening test due to fear of discrimination or insulting behavior of health care providers [17].
According to o cial statistics, the prevalence of gender reassignment surgery (GRS) has signi cantly increased in Iran in recent decades [18]. Although any sexual relationship without marriage is legally prohibited in Iran, some studies suggest that 60% of Iranian transgender individuals have sex while they are single. The high prevalence of sexual activity, having sex with multiple partners [19] and a high percentage of transgender women being involved in high-risk sexual behaviors, including anal sex without condoms, expose this group to serious risk of STIs including AIDS [20].
In order to promote health in this vulnerable group, it is necessary to have accurate information on their sexual behavior, function and STIs. This study is part of a larger project on the reproductive and sexual health needs of transgender women. The frequency of violence, suicide and discrimination [21], as well as their quality of life, anxiety, depression and stress [22] are expressed in separate articles. In this study, sexual behavior of transgender women and their vulnerability to sexually transmitted infections were assessed.

Participants
Participants were selected from "Support center for Iranian transgender (MAHTAA)" and "Shiraz Forensic Medicine" by convenient sampling. 185 transgender women who were led in the above-mentioned centers were called. Forty-ve women did not answer. Eight individuals failed to meet inclusion criteria and 5 women were not willing to participate in the study. Written informed consent was obtained from 127 transgender women who opted to participate in the study. All questionnaires were completed in the presence of a researcher aware of the subject of the research at the relevant center. Inclusion criteria were all transgender women who had started treatment (hormone therapy or surgery).

Research Tools
Three researcher-made checklists on demographic data, sexual behaviors and STIs were used in this study. The demographic checklist included 6 items on age, marital status, education, employment, economic status, and history of vaginoplasty. Sexual behavior checklist included 10 items on sexual debut age, having sexual experience, number of sex partners, sex partner having sex with other people, sexual orientation, dyspareunia, sexual satisfaction, body satisfaction, effect of body satisfaction on sexual satisfaction and prioritizing sexual behaviors in order of performing them. Transgender women were asked to prioritize sexual behaviors performed during sex from 1 to 8 (including self-stimulation, sexual fantasies, touching the genitals, romantic touching and caressing, kissing, oral sex, anal sex, vaginal sex). Behaviors with the highest frequency were ranked the rst and those with lowest frequency were ranked eighth. The "not a priority" option included behaviors that had never been done before. To assess the status of STIs and HIV infection, 14 questions were designed on the knowledge on the ways of HIV transmission, recognizing the signs and symptoms of STIs, history of STIs, seeking treatment, considering oneself at risk for AIDS, the reasons for not being at risk, getting tested for STIs, rectal test, HIV test, reason for not doing HIV test, the feeling the need for condoms, the rate of condom use and the most important reason for condom nonuse. Some items were yes and no questions, some were multiple choice and some items were used to measure sexual satisfaction, body satisfaction and the effect of body satisfaction on sexual satisfaction using a 5-point Likert scale from very high to very low (in the tables, the answers are provided based on the type of question).
Validity of the questionnaires was assesed by content validity index (CVI) and content validity ratio (CVR) using opinions of 11 experts including psychiatrists, reproductive-sexual health, forensic practitioners, and psychologists. In the nal questionnaire, the CVR for each question was between 0.63 to 1 and the CVI for each question was above 0.79, which was considered acceptable. Reliability was measured with a test-retest procedure on 25 transgender women with 3 weeks interval. Interclass Correlation Coe cient (ICC) of questions ranged from 0.78 to 1 and the total Cronbach's alpha coe cient was 0.8.

Statistical Methods
Continuous variables were reported as mean and Sd, question's data were represented by number (%) for each of the questions. All statistical analysis was performed in STATA (StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP.)

Results
The mean and standard deviation of participants' age was 27.6 ± 7.3 and 48% were under 25 years old. 92.1% were single, 77.2% had high School degree and 62.2% were unemployed. 56.7% reported poor nancial conditions and 74% did not have vaginoplasty (Table 1). life. About 60% of women were moderately satis ed or dissatis ed with their appearance and believed that appearance had a high or very high effect on their sexual satisfaction ( Table 2). In order to better understand the sexual behaviors performed and preferred by transgender women during sex, these behaviors were prioritized and evaluated; behaviors with the highest frequency were ranked rst and behaviors with the lowest frequency were ranked eighth. In case of low frequency, some priorities were merged.
The most frequent sexual behavior in transgender women was romantic touching and caressing (53.1%) and then kissing (48.7%). Oral and anal sex had the lowest frequency among sexual behaviors and had never been tried in 54% and 47% of transgender women ; however, they were inevitably the third frequent sexual behavior (22.1% and 19.5% respectively) due to the lack of vaginoplasty in the majority of transgender women (74%). As a result, vaginal sex either did not exist or had the lowest frequency in 74.3% of transgender women. 85.8% had no self-stimulation and there was no sexual fantasies or touching genitals in 70.8% of participants (Table 3). The majority of participants con rmed the need to use condoms during all types of sex (about 45%) and about one third of participants mentioned it necessary only for vaginal sex (33%). About half of the participants used condoms occasionally during sex (48.7%) and the most important reason for not using condoms in most cases was not having a condom (37.9%) or their sexual partner not accepting to use one (33.7%) ( Table 4).

Discussion
This study was conducted to evaluate the sexual behaviors of transgender women and their vulnerability to STIs including HIV.
Results of the study on sexual behaviors of 127 transgender women showed that although 92% of them were single at the time of the study, about 93% had sex experience in their life. Although the majority of participants had sex with a single partner for the past 2 years, it is important to pay attention to the rest 40.7% who had more than 2 partners in the last 2 years. Considering the fact that in Iran, sex is legal only in marriage, these people are exposed to high-risk behaviors, and STIs including AIDS. This conclusion seems plausible by looking at demographic characteristics such as 62.2% unemployed and inappropriate nancial situation in 56.7% of participants. In a study by Clements-Nolle, 80% of transgender women had sex in the last 6 months and 37% had sex with more than 10 people [23]. In the study by Herbst, 31.7% of transgender women had multiple sex partners [24].
In the present study, sexual interests of transgender women were similar to those of Cisgender women in many ways. Romantic touching and caressing (53.1%) and then kissing (48.7%) were the rst and second sexual behaviors and preferences in transgender women. Naturally, due to the absence of vagina in 74% of the participants in this study, vaginal sex, despite their strong desire, was less prevalent in their sexual relations and oral and anal sex were inevitably the third sexual behavior with a frequency of 22.1% and 19.5%. The frequency of oral and anal sex in Iranian transgender women seems lower relative to other transgender women, which is consistent with the unpleasantness of these behaviors among most Iranian cisgender women [25]. By contrast, in the study by Sinha in India, all transgender participants had receptive anal sex and 73.3% had receptive oral sex [26]. In his study, 70% of participants had sex for money and therefore, they were willing to perform any type of sex even against their will. Other patterns of sexual behavior, such as very low preference for fantasy or masturbation, were consistent with patterns of sexual behavior among Iranian women [27].
Although transgender women had similar interests to Cisgender women, there were signi cant differences in their sexual function. In this study, about 67.2% of transgender women reached orgasm in at least 50% of sexual intercourse and only 8% of them did not experience orgasm, which is quite signi cant compared to the prevalence of orgasmic disorders (37%) [28] and anorgasmia (26%) in Iranian women [29] Experiencing a more pleasurable orgasm in transgender women compared to cisgender women may be due to the previous experience of orgasm owing to having a penis. In addition, the high ability to reach orgasm without vaginal penetration rea rms that orgasm in women is less dependent on vaginal intercourse.
It should be noted that despite reaching proper orgasm, transgender women did not report high sexual satisfaction and 41.6% of them reported low and very low satisfaction with their sex life. This nding is important from several perspectives. First, consistent with other studies, this nding shows that reaching orgasm does not necessarily imply high sexual satisfaction, and sexual satisfaction in women is largely in uenced by other factors such as satisfaction with husband [30,31] and body satisfaction [32,33] In this study, about 60% of people were moderately satis ed or dissatis ed with their appearance and believed that appearance has a great impact on their sexual satisfaction. Therefore, efforts should be made to nurture a positive body image in them.
Another reason for low sexual satisfaction in transgender women is the signi cant prevalence of dyspareunia in them. The frequency of dyspareunia in transgender women was 42.5% which is signi cant compared to the prevalence of severe (10.5%) and moderate dyspareunia (25.8%) in Iranian women [34]. At the same time, due to the absence of vaginoplasty in 74% of participants, they had to have anal sex which was described as painful and unpleasant. This shows that in order to improve the sexual health of transgender women, more useful and less complicated surgical methods are required, and special attention should be paid to sexual counseling, especially with their sex partner.
In addition, low sexual satisfaction in transgender women despite proper orgasm can be attributed to common sexual scripts in the society that generally consider sex to be penetration-based, and if absent, sexual satisfaction is overshadowed by dyspareunia or absence of vagina. With proper culture development and sexual counseling, however, their high potential for orgasm can be used to improve their sexual satisfaction.
This study showed that a signi cant portion of transgender women were not familiar with any STIs signs and symptoms and unfortunately 88.2% did not even consider themselves at risk for HIV infection. This nding is mostly related to cultural factors and lack of awareness on STIs in traditional societies. In India for instance, 88% of transgender people were not familiar with STIs(8) but in Canada 95% of transgender people were familiar with at least three main ways of HIV transmission [35].  [24,26,37]. In contrast to the present study, in most studies, the average prevalence of HIV infection in transgender women based on a positive laboratory test was between 14 and 41% [23,24,37,38], which is signi cant, because more than 72% of participants in this study had never undergone HIV test. Also, these people have been deprived of of other health services due to social stigma and discrimination [21].
In this study, about one-third of participants never used condoms during sex, and half of them used it occasionally. In addition, they mentioned that the most common reason for not using a condom was not having one, and given that the majority of participants in the study were in poor nancial conditions, it seems necessary to provide them with free condoms and give them necessary training for safe sex.
Results of other studies showed that the average condom nonuse in transgender people was low and between 34% and 48% [24,37,39].
To interpret the results of this study, it is necessary to consider its limitations such as data being selfreported and the lack of a cisgender group for comparison. However, this is the rst study in Iran that examines sexual behaviors and vulnerability to sexually transmitted diseases in transgender women in a signi cant sample size.

Conclusion
Results of this study indicated that sexual interests of transgender women were similar to cisgender women in any society in line with cultural patterns of their country. For example, in line with the preferences of Iranian cisgender women, transgender women were not interested in anal and oral sex, although they were forced to do so due to the lack of vagina or dyspareunia.
In addition, it seems that due to having penis at some point in life and experiencing previous orgasm, transgender women reach orgasm more easily and commonly compared to cisgender women, which emphasizes that women can reach orgasm without vaginal penetration. Despite having pleasurable orgasm, transgender women reported less sexual satisfaction than cisgender women for reasons such as dyspareunia and body dissatisfaction, which emphasizes the need for research on more effective surgeries. However, sexual dissatisfaction can be due to the great importance of vaginal sex in cultures, which indicates that speci c sexual counseling is necessary in this group.
Paying attention to job opportunities and nancial condition of transgender people, as well as raising their awareness on sexually transmitted diseases can be very effective in reducing high-risk behaviors and promoting their health. To maintain con dentiality and privacy, participants were assured that their information was con dential and their names or addresses will not be disclosed in the research. Written consent was obtained from all participants. This study was reviewed and approved by the Ethics Committee of Tehran University of Medical Sciences. All methods were performed in accordance with the relevant guidelines and regulations of the Research Ethics Committee.

Consent for publication
Not applicable Availability of data and materials