Intersectional barriers to HIV/STI healthcare among Washington State transgender and nonbinary communities

From the Seattle Trans and Non-binary Sexual Health (STARS) Advisory Board and the Duerr HIV Outcomes, Prevention and Epidemiology (HOPE) Group

“Transgender people experience a large number of barriers to accessing healthcare as a result of institutional erasure and systemic transphobia,” explained Dr. Diana Tordoff, a previous graduate student in Dr. Ann Duerr’s HIV Outcomes, Prevention and Epidemiology (HOPE) research group and now a postdoctoral scholar with The PRIDE Study at Stanford School of Medicine. She continued, “trans people often do not have access to trans-competent providers, experience challenges with insurance coverage (even for routine, preventative care), and delay or avoid care due to very real fears of mistreatment and discrimination in healthcare settings.” According to Tordoff, these barriers to healthcare access are “particularly true for gendered health service, like sexual and reproductive health.” Consequently, limited access to HIV/STI testing and to preventative tools like pre-exposure prophylaxis (PrEP) have resulted in increased susceptibility and acquisition of HIV/STI among the transgender community. Tordoff emphasized the importance of taking an intersectional research approach “for identifying and addressing inequities for communities that live at these intersections,” especially in relation to HIV/STI prevalence and prevention where data are often limited. In a recent Epidemiology study led by Tordoff, researchers utilized quantitative intersectionality methods to demonstrate the impact of racialized and genderized experiences on HIV/STI prevalence and healthcare access for Washington State transgender and nonbinary communities. Importantly, Dr. Tordoff highlighted that this work was a community engaged research study conducted in “close collaboration with the STARS (Seattle Trans and Nonbinary Sexual Health) Advisory Board, a group of trans and nonbinary people from the Seattle area with a wide range of expertise, including social work, nursing, public health, journalism, law, advocacy, community organizing, and performance arts.”

To understand the barriers faced by the local Washington State trans community, Tordoff and colleagues examined five HIV/STI surveillance data sources across Washington state from 2019-2021. This pooled dataset provided the researchers with a large and diverse sample group which included over 1,600 transgender and nonbinary participants. The research team examined differences in insurance, HIV/STI prevalence, testing and pre-exposure prophylaxis use among participants living in Washington State, accounting for race and ethnicity. The authors then calculated how the intersection of gendered and racialized experiences were associated with increased incidence or prevalence of HIV/STIs, beyond that expected from gender or race and ethnicity alone. The authors observed high levels of poverty and structural barriers to accessing healthcare among all trans and nonbinary participants. However, certain groups were disproportionately uninsured and impacted by HIV/STIs, especially transgender women of color. Dr. Tordoff explained that “a large proportion (50%–85%) of the higher HIV/STI prevalence among transgender women of color was explained by intersectional synergism of racialized and gendered experiences. At the same time, there were significant inequities in PrEP access among trans men and nonbinary participants assigned female at birth: only one in five had ever discussed PrEP with a provider. This points to missed opportunities for providers to discuss PrEP with trans and nonbinary patients.”

Four friends of varying gender identity
Four friends of varying gender identity Image taken from Vice’s Gender Spectrum Collection

Collectively, this work highlights “the need to expand access to trans-inclusive models of HIV/STI prevention and PrEP delivery that address multilevel barriers rooted in cissexism and structural racism,” Dr. Tordoff stated. The article also underscores the pervasive impact of structural racism and cissexism, enacted across various social and institutional levels, leading to both socioeconomic disparities and adverse health outcomes among transgender individuals. Brian Minalga, Deputy Director of the Office of HIV/AIDS Network Coordination (HANC) at Fred Hutch and coauthor on this study, reviewed 41 milestone HIV clinical trials over the last 30 years to understand how these inequities are perpetuated more broadly through the healthcare system. Despite trans communities having increased incidence of HIV, they have largely been excluded from clinical trials. Brian found that of the 171,062 study participants, <1% were transgender (1,340), 94% of those 1,340 people were trans women, 3% were trans men, and 3% were nonbinary. As a result, trans people do not have the same access to evidence-based interventions or data with which to inform their clinical care compared to cisgender people. Brian explained that “for example, many transgender people have questions about how HIV treatment and prevention drugs might affect gender-affirming hormone therapy. But doctors are largely unable to answer these questions due to research study designs that fail to meaningfully include trans people and address these kinds of research questions.”

Dr. Tordoff goes on to explain that “transgender communities are diverse and heterogeneous. Intersectional research approaches, and disaggregating data by gender, race, and ethnicity is critical for learning how to better serve these communities.” She added, “In order to improve the overall health and wellbeing of transgender communities, it is important to meaningfully include transgender individuals who have been historically excluded from research. This includes expanding the definition of ‘MSM’ (men who have sex with men) to include both cisgender and transgender men who have sex with cisgender and transgender men.”

Dr. Tordoff concluded by highlighting that this research was a community-based collaboration with the STARS advisory board which includes coauthor Brian Minalga. Community advisory boards such as STARS can play important roles “addressing power imbalances in secondary data analysis, since research findings still have the potential to influence clinical encounters and public health decisions that impact trans people (in Seattle or elsewhere).” Additionally, their participation in this work enables transgender and non-binary communities to have a voice in how data is interpreted to raise awareness of the important healthcare issues trans people face.


For HIV researchers interested in better aligning HIV research agendas with the priorities and needs of the trans community, check out the recent report: “No Data No More: Manifesto to Align HIV Prevention Research with Trans and Gender Diverse Realities.”

This work was supported by the National Institutes of Health, the American Sexually Transmitted Disease Association and the University of Washington’s Northwest Center for Public Health Practice.

Fred Hutch/ UW/ Seattle Children’s Cancer Consortium member Dr. Ann Duerr contributed to this work.

Tordoff DM, Fernandez A, Perry NL, Heberling WB, Minalga B, Khosropour CM, Glick SN, Barbee LA, Duerr A; Seattle Trans and Non-binary Sexual Health (STARS) Advisory Board. 2023. A Quantitative Intersectionality Analysis of HIV/STI Prevention and Healthcare Access Among Transgender and Nonbinary People. Epidemiology. 34(6):827-837.