The prevalence of sexually transmissible infections in transgender people

Transgender people may have a higher burden of both medical and mental health problems

The rates of sexually transmissible infections (STIs) in transgender people are reported to be far higher than for cisgender individuals,1,2,3 but the factors underlying the higher numbers are not known. Possibilities include lack of access to quality health care4 and greater assumption of risk by transgender people because of their relatively precarious life circumstances.5

In this issue of the MJA, Callander and his colleagues report the most systematic analysis to date of STI prevalence among transgender people in Australia.6 Their study is notable because it mined a defined and broad database. The network reporting the analysed data included forty‐six sexual health clinics across Australia in both urban and more remote locations. Other large studies of transgender people have suffered from the absence of good control groups, often relying upon large scale survey methods without detailed understanding of how the participants might differ from the general population. The database approach adopted by Callander and colleagues allowed them to include the non‐transgender people in the database as a control group. It is naturally likely that the patients of sexual health clinics which identify their transgender patients have different characteristics to the general Australian population. Nevertheless, by analysing data for a defined cohort the authors have established a good basis for future comparisons.

Although STI rates were higher for transgender women than heterosexual cisgender people, the reported differences were smaller than reported by others.2 This may be attributable to the fact that the Australian data refer to a broad cross‐section of transgender individuals, whereas previous studies sampled narrower populations at greater risk. Alternatively, the lower STI rates might reflect improved access to care and treatment achieved by increased attention to transgender health care in general.7

The study by Callander and his co‐authors carefully documents differences in STI rates in a defined context. However, the underlying reasons for these differences, and interventions that could reduce them, remain to be identified. For example, stratification by characteristics other than gender identity, including high risk behaviours, should be undertaken. The lack of such stratification may have hidden differences between cisgender and control people that cause confounding, and this is a substantial weakness of the study. While some characteristics associated with higher risk behaviours or greater vulnerability seem correlated with STI risk, more direct connections have not been established.

Transgender people have a significantly higher burden of medical and mental health problems than cisgender individuals.4 This greater morbidity might be attributable to barriers to quality transgender health care, together with the stigma attached in most societies to being transgender. Leinung and colleagues noted that both the age of patients presenting to their New York endocrinology practice for transgender hormone therapy and their mental health morbidity have declined with time, suggesting that at least some of the morbidity may be alleviated by improved access to care.8 Further, Callander and colleagues found that the STI risk for transgender women corresponded to that of gay men, for whom access to care has been better than for transgender people in recent years. The similarity might therefore be explained by similar rates of high risk behaviour rather than by lack of access to care for transgender people.

In any case, the data presented by Callander and his co‐authors show that work remains to be done, but they have provided a more useful baseline for evaluating such efforts than has previously been available.