Once relegated to the shadows, transgender and gender-nonconforming people are increasingly visible in movies, television, books, and other media. While depictions are gradually more positive than before, many still rely on the dated, stigmatizing tropes that most or all of us who are trans or gender nonconforming do sex work, or that all transgender people are HIV positive.
Unfortunately, it is true that rates of HIV and other sexually transmitted infections among trans people are exceptionally high. A National Institutes of Health report from 2009 documented that approximately one-third of all transgender people in the United States were HIV positive and that an overwhelming number had been unaware of their HIV status, positive or negative. Another study evaluated the rates of HIV in transgender women in New York City, finding that nearly half of the African American and Latina transgender women were HIV positive; this compares to just 3.5 percent of the Caucasian transgender female population. While trans men generally have lower rates of HIV infection (0–3 percent), those who sleep with cisgender men are at higher risk.
To put these elevated HIV rates in context, transgender people demonstrate a variety of health disparities compared to the general population and even compared to cisgender (nontransgender) members of lesbian, gay, bisexual, and queer communities. The rate of diabetes in transgender individuals is estimated at 25.9 percent compared to 13.7 percent in LGB individuals. Almost 40 percent of transgender and gender-nonconforming individuals are obese, compared to 24.6 percent of cisgender people. Smoking prevalence is 30.7 percent among transgender and gender-nonconforming populations versus 15.4 percent in the general population. And it has been found that up to 42.3 percent of transgender adults report a history of a suicide attempt.
These statistics clearly document the ongoing public health crises in transgender and gender-nonconforming populations.
The numbers of transgender and gender-nonconforming people engaged in sex work are also high and show similar ethnic divisions to the transmission rates of HIV. Those identifying as black or black/multiracial are most likely to practice sex work (39.9 percent). In Hispanic/Latinx individuals the rates are nearly as high (33.2 percent), while in white individuals they are significantly lower (6.3 percent).
Why are these numbers so elevated?
Many transgender people have been marginalized from a young age. Children and adolescents who demonstrate gender variance can be harassed by their peers simply for dressing in the “wrong” garment or for having a hairstyle that more closely matches norms for the “other” gender. Teachers often refuse to acknowledge students’ trans identities and insist on referring to individuals by their birth names and pronouns, something most transgender and gender-nonconforming people find to be an aching nullification of their identity. Very frequently, youth who do not conform are subject to ostracization, jeers, bullying, physical violence, and sexual assault. Many youth also face similarly unsupportive or hostile families.
These explicit and implicit attacks can become a chronic trauma individuals face daily. Lack of physical and emotional safety can lead to poor school performance, less access to higher education, fewer opportunities for stable and lucrative employment, and less safe living conditions.
Transgender people can also face discrimination in hiring due to their appearance, gaps in resumes due to the time spent in transition and possibly out of the workforce, difficulty using past employers as references, and potentially mismatching identity documents. The 2011 National Transgender Discrimination Survey found that transgender people are four times more likely than others to have a household income of less than $10,000 per year and are twice as likely to be unemployed. For black transgender people, the unemployment rate is four times the national average.
Many in our communities are so uncomfortable with their bodies that they take inadequate care of their general health. They may not seek or have access to regular health care, especially pretransition, and may lack sufficient food or shelter. Additionally, 26.3 percent report misusing drugs or alcohol to cope with transgender-related discrimination.
Not surprisingly, all this leaves transgender and gender-nonconforming people especially vulnerable to poorer health, riskier lives, and fewer professional opportunities beyond marginalized careers like sex work.
Sex work comes in countless forms, any of which can be done by people trans or cis. Though sex work is a last resort for many, it is not always done in desperation. Transgender sex workers have consistently been in high demand and often find this type of work lucrative. Transfeminine people engage in sex work at nearly twice the rate of transmasculine people. Transgender pornography—primarily transgender women with functioning penises, but also transgender men with vaginas—is among the most sought-after forms of pornography. The largest consumer demographic for transgender porn is heterosexual men.
Less common today are stereotypical miniskirt-clad, stiletto-heeled women or musclebound, shirtless men alongside avenues beckoning to passersby. Those streetwalkers who do exist are often transgender adolescents rejected by their families with no other means to raise money. Their youth and powerlessness make them especially vulnerable and among the most defenseless in our communities.
Sex work is increasingly negotiated via computer or cell phone. Sex workers list themselves online in subsections of Craigslist or on sites devoted to an individual worker or agency. Here, potential clients are free to explore body types, areas of expertise, likes, dislikes, and boundaries at their leisure.
Sex work may not involve direct exchanges of bodily contact for cash. Instead it might include acting in pornographic movies, having photos taken, or online “camming,” in which an individual performs as dictated by paying subscribers via webcam. Camming and online porn reach a wealthy and sometimes lonely demographic, often furtively watching at a safe distance from home or office, and well-designed cam websites facilitate the easy transfer of money from viewer to entertainer. Neither camming nor pornography involves actual human contact, and both provide a measure of safety for the sex worker.
Transgender people also function as escorts and “kept women.” These individuals are often quite elegant, accompanying their clients to professional or cultural events; they may have brief or long-term relationships with clients. Some clients provide apartments and a monthly cash “allowance,” essentially hiring these women as private mistresses available on demand.
Some transgender people turn to sex work when their financial situation becomes dire. “Survival sex” refers to an exchange of sex for basic needs: someone homeless might trade sex for a bed, or a substance addict might swap sex for drugs when unable to pay for another fix. Sex might be bartered for food, a rent payment, or as protection from violence. Similarly, transgender women in prison have historically been housed alongside cisgender male populations and may negotiate sex for food, privileges, or security.
Many in trans communities turn to sex work to raise the large sums of money necessary to transition. Though hormones may be covered by insurance companies, other necessary medical procedures, like hair removal and surgeries, generally are not. Many trans or gender-nonconforming people do not have health insurance at all.
Is the connection between sex work and HIV automatic? It generally depends on the level of risk people take when they engage in sex acts. Some sex workers have the ability to decide to use protection, or to say yes or no to proposals. Sex workers with the least power are essentially coerced because of desperation to agree to riskier sexual activities. Individuals performing survival sex, often those in marginalized communities due to race or socioeconomics and people who are incarcerated face additional pressures to engage in whatever the client demands.
The belief that sex work is inherently humiliating is not universal. Many trans and cisgender people involved in the industry report it to be a rewarding profession. Rather than finding the work demeaning or objectifying, many trans and cisgender people regard it as uplifting and sometimes approach the work believing they are providing moments of joy to lonely individuals who otherwise have few options for sexual or physical intimacy. Not everyone has the luxury of a partner. Some sex workers consider their trade akin to psychotherapy.
Sex workers who report a sense of empowerment also claim that this work provides body autonomy and sexual confidence. They feel desired and confident about their lives and bodies, and can raise large sums in short periods—money often needed for college or other expenses—leaving them free to pursue other activities without the drudgery of more time-consuming jobs. Many sex workers point out that our society has little difficulty with people who use their physicality for money in other ways (construction workers, dancers, athletes), and they feel that sex work is no different; they outright reject that sex work is morally wrong.
Organizations such as the Red Umbrella Project, the Sex Workers’ Project, and the Sex Workers’ Rights Advocacy Network center the experiences of sex workers and call for decriminalization of sex work and for additional services to aid sex-worker health and safety.
While the majority of trans people are neither sex workers nor HIV positive, there are higher rates of both in trans communities, especially among trans women of color. HIV rates correlate with marginalization, as do rates of sex work, although sex work is not always a sign of desperation. For some, it is even empowering.