Sexual Health in Transgender People

Sexually transmitted infections (STIs) affect all population groups, including transgender people. In the context of previous gender-affirming surgery or gender affirming hormone therapy, diagnosis of STIs can be different to that in the cisgender population with different presenting signs and symptoms.

Key points of infections sexually transmitted

• STIs can occur to people of any age or gender, with adolescents and young adults being most affected.
• Most STIs are asymptomatic, so can be unknowingly transmitted.
• STIs can affect individuals, their partners and may also be transmitted from mother to child.
• Some STIs can increase the risk of cancer. For example, certain strains of human papilloma virus (HPV) can cause cervical cancer, genital cancer, and rectal cancer in both cisgender and transgender people.
• STIs can be prevented by a number of ways, such as risk behavior reduction and condom use. Some can be prevented by vaccines, such as for hepatitis A virus, hepatitis B virus, and human papilloma virus (HPV).
• Some STIs are curable, such as those caused by bacteria (e.g. syphilis, gonorrhea, and chlamydia).
• Some STIs can result in chronic conditions, such as viral diseases (e.g. HIV, herpes, and genital warts). However, their severity and complications can be reduced.

Risks associat ed with STIs There are several risk factors associated with STIs in transgender people, including sexual behavior or techniques used on genital gender-affirming surgery. These factors can be divided as follows:

Transgender women

1. Transgender women who have not undergone genital gender-affirming surgery have a similar risk of STIs to the cisgender population.
2. Transgender women who have undergone genital gender-affirming surgery are at varying levels of risks of gonorrhea and chlamydia infection, depending on tissue used to construct their neovagina as follows:
   1. neovagina constructed from penile skin using a graft technique can be infected with gonorrhea
   2. neovagina using urethral tissue, peritoneum or the intestinal wall can be infected with gonorrhea and/or chlamydia.
   3. It has been reported that transgender women whose neovagina is constructed from colon mucosa, if infected with gonorrhea, can bleed during or after sex.

Transgender men

1. Transgender men who have not undergone genital gender-affirming surgery and have used testosterone long-term may have thinner vaginal mucosae. Sexual intercourse with male partners may cause abrasion or bleeding, which may increase the risk of STI and HIV infection.
2. It is very rare for transgender men who have undergone genital gender-affirming surgery to have gonorrhea in their neopenis.

Signs and symptoms of STIs in transgender people

Generally, STIs can be classified into those that are symptomatic and asymptomatic. The signs and symptoms of STIs in transgender people are not different from those in the cisgender population.

Specimen collection and screening

for STI diagnosis in transgender people

Symptomatic

1. Gonorrhea and chlamydia: Collect specimens from symptomatic sites for gram stain, culture and/or NAAT (nucleic acid amplification testing).
   1. Gram stain is not recommended for oral sites as it may produce false positive results.
   2. A speculum or anoscope can be used for neovagina examination as well as specimen collection for gram stain or culture.
   3. A small speculum with sufficient lubrication should be applied when collecting vaginal specimens for gram stain or culture from transgender men who receive gender affirming hormone treatment. This is because testosterone thins vaginal mucosa, which can cause pain or bleeding during the examination.
   4. For NAAT, a speculum or anoscope is not needed.
2. Syphilis: Blood testing is recommended.
3. Genital warts: Generally diagnosed by appearance. A biopsy may be necessary. HPV testing is not recommended.
4. Genital and rectal lesions: Generally diagnosed based on symptoms. If diagnosis uncertain, swabs for NAAT/PCR (polymerase chain reaction) from lesions are recommended.

Asymptomatic

Most STIs are asymptomatic. As asymptomatic STIs are a major cause of ineffective disease control, asymptomatic STI screening should be available to provide rapid treatment to reduce complications and onward transmission. While STIs screening is recommened, types of screening can be considered on an individual basis depending on risk activity. It is recommended the following are screened for: HIV, syphilis, hepatitis B, hepatitis C, gonorrhea, and chlamydia. For asymptomatic gonorrhea and chlamydia, NAAT is recommended at all sites with the following considerations:

• Clients can carry out self-collection as this has been shown to be equally as effective as healthcare provider collection.
• Neovaginal specimens can be collected from either urine or neovaginal swabs.
• For transgender men who have undergone genital gender-affirming surgery, urine collection is recommended.
• For transgender men who have not undergone genital gender-affirming surgery, vaginal swab collection is recommended.
• Herpes and HPV screening are not recommended. Treatment should be symptom- based.
  • Neovaginal HPV screening and pap smears are not recommended. However, an annual examination is recommended to screen for STIs and other abnormalities.
  • For transgender men who have not undergone hysterectomy or who have undergone a supracervical hysterectomy, HPV screening and pap smear can be performed in accordance with Thai National Guidelines for cervical cancer screening.

STIs screening time frame

Frequency of STI screening should be based on individual risk.

• Those with high risk (e.g. multiple sex partners, inconsistent condom use, sex work, chemsex), should be screened for STIs every three months.
• Transgender individuals with occasional risk exposure should be tested at their visit. Repeat testing should be performed where needed after the window period.

Refer: Sexual Health in Transgender People: Sexually Transmitted Infections - The Thai Handbook of Transgender Healthcare Services, Center of Excellence in Transgender Health, Chulalongkorn University