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Try out PMC Labs and tell us what you think. Learn More. Background: Research has shown that sexual risk behavior, as well as transition-related risk behavior, such as uncontrolled hormone use, auto-medication, and silicone injections, may lead to several adverse health outcomes for transgender persons.

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Transgender sex workers are a vulnerable group within the transgender population, who are at increased risk for these health risk behaviors. However, European research into this topic and risk population remains largely absent. Aim: This study explores the prevalence of uncontrolled gender-affirming hormone use, silicone injections, and inconsistent condom use among transgender sex workers working in Antwerp, Belgium. Methods: A descriptive analysis of a survey sample of 46 transgender sex workers, supplemented with nine in-depth interviews with transgender sex workers.

Transition-related and sexual risk behaviors are prevalent. Access to health care and social services should be ensured, and culturally tailored health interventions that take into their social context as well as their gender identity should be developed. Research indicates that HIV prevalence and sexual risk behavior are estimated to be high for transgender persons. Especially among transgender women, who were ased male at birth but identify more on the female spectrum, HIV rates appear to be high: a systematic review based on 39 studies calculated a global HIV prevalence rate of In the USA, a meta-analysis of 29 studies showed that Sexual risk behaviors such as inconsistent condom use with primary as well as non-primary or commercial partners or sex in serodiscordant relationships are frequently reported among transgender populations Guadamuz et al.

However, some transgender persons also engage in other kinds of health risk behavior. These hormones are sometimes obtained via friends, street vendors or through the internet Mepham et al. Because of the relatively low cost compared to standard options for transition e. Indeed, for some transgender persons, gender-affirming healthcare is unavailable, difficult to access or impossible to afford Winter et al.

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Studies have demonstrated that transgender women are disproportionally represented in the sex industry Logie et al. Transgender persons frequently face discrimination on the labor and housing market, which may lead to economic marginalization and in turn facilitate engagement in sex work.

Moreover, an US-based study showed that transgender women who had ever used gender-affirming hormones without medical supervision were also more likely to be engaged in sex work, face financial hardship, and have no health insurance Nuttbrock et al.

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Because of the financial hardship they frequently face, transition-related risk behavior might indeed be more prevalent within populations of transgender sex workers. Most of the studies that involve transgender sex workers are conducted in large urban areas in North-America, such as New York and San Francisco, or Asian countries e. These studies show that HIV risk behaviors are indeed common among transgender sex workers Gama et al.

Transgender sex workers also appear to experience more discrimination and exclusion compared to transgender persons not involved in sex work Ballester-Arnal et al. However, social contexts for transgender persons as well as for sex workers differ greatly globally, and even within Europe ILGA Europe, ; Weitzer, However, transition-related health risk behavior within this vulnerable population of transgender sex workers has not yet been studied.

Therefore, this study aims at exploring uncontrolled hormone use and silicone injections as well as sexual risk behavior in a population of transgender sex workers working in Antwerp, Belgium. The city of Antwerp has a close concentration of window-based prostitution that was historically developed alongside the Antwerp harbor, which expanded increasingly towards the end of the 19th century and as such created a high demand for sex workers De Koster, In Belgium, third-party involvement in prostitution is illegal, but not prostitution itself, although some local governments tolerate third-party involvement.

In Antwerp, transgender sex workers are present in window prostitution, whereas in red light districts in other Belgian cities, like Brussels or Ghent, this is not the case. Although health care services for sex workers are present and easily accessible in the Antwerp red light district, transition-related risk behavior and sexual risk behavior of this subpopulation of sex workers, as well as their need for healthcare remain unknown.

As such the nature of this study is descriptive and exploratory, aiming at providing first insights in the risk behavior of transgender sex workers in Belgium. The authors opted for a face-to-face survey method in close co-operation with two outreach organizations providing healthcare and assistance for sex workers that are located in or nearby the red light district. Therefore, one trained Spanish-speaking peer expert identifying as gender variant, who had been working in the Antwerp sex industry before getting involved with the outreach organization and held Woman want real sex Antwerp New York contact with the transgender sex worker population working in the Antwerp red light district, was included as part of the research team.

Their role was essential in gaining access to this hard-to-reach population. For the outreach organizations, the primary focus of the study was to explore the use of gender-affirming hormones in the population of transgender sex workers reached by them, in order to develop an intervention aiming at harm reduction of uncontrolled hormone use. Because of this primary focus on hormone use, ever having used gender-affirming hormones was required to participate in the study.

The face-to-face survey was supplemented afterwards by in-depth interviews with transgender sex workers working at the red light district in Antwerp. The in-depth interviews were part of a larger study looking in the lives and discourses of transgender sex workers in Antwerp, but only data related to hormone use and risk behavior was used for this article, to supplement the initial findings resulting from the survey.

Participants were recruited by the two outreach organizations between January and June Structured face-to-face survey interviews were conducted in person by three Spanish-speaking social workers of the outreach organizations, as well as the peer expert, who contacted possible participants during their outreach work in and around the red light district in Antwerp.

Because most transgender sex workers were at work during outreach, usually an appointment was made for the survey interview, and the actual interview was conducted by the social workers or the peer expert later on in one of the locations of the outreach organizations.

After the survey data collection and analysis, additional in-depth interviews with transgender sex workers were conducted by one of the researchers A. The researcher who conducted the in-depth interviews was a Belgian Spanish-speaking cisgender woman from a Latin-American background, which created a feeling of familiarity without actually being part of the transgender sex worker community, and as such proved to be very useful for the data collection.

Recruitment for the in-depth interviews was conducted in the same way as for the face-to-face survey interviews. An interview with the peer expert was conducted after the Woman want real sex Antwerp New York collection and analyses for feedback on the. Written informed consent was obtained from all survey and interview participants. Pseudonyms were chosen for the interview participants to ensure privacy.

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Spanish in-depth interviews were transcribed, translated, and coded in Dutch. Of the 65 transgender sex workers working in the Antwerp red light district that were contacted during the outreach phase for the quantitative survey, 46 persons agreed to participate in the face-to-face survey. Fifteen transgender sex workers were contacted for the additional in-depth interviews, of which nine agreed to participate.

Some of them already participated in the survey. Reasons for dropout were distrust of researchers, which is common among sex workers Sanders, band the sex worker having a client at the moment of the recruitment or the appointment. For the face-to-face survey, a questionnaire was developed by the research team.

The questionnaire was first reviewed by the outreach organizations and tested by two key informants of Woman want real sex Antwerp New York population, and translated in Spanish after adjustments were made. Sociodemographic measures included age, educational level, country of origin, current nationality, legal gender, permission of permanent residence, and having a health insurance.

Gender identity was measured with the options: 1 female, 2 between male and female, 3 sometimes male, sometimes female, and 4 male. This classification was chosen in correspondence with the outreach organizations, to be understandable for all participants and match their lived experiences, because the cultural conceptualization of gender identity might vary. Information about past gender-affirming hormone use included age at first use, continuity of past hormone use, where the hormones were obtained, whether there was medical supervision, and whether hormonal treatment was ever interrupted or stopped due to complications.

Highest dose ever, brand name, duration of past hormone use, and possible complications were open-ended questions that were coded later on by one of the researchers J. To explore present gender-affirming hormone use brand names and doses were asked as open-ended questions that were coded later on by the researcher in the same way as for past hormone use. Questions on present hormone use also included where the current hormonal treatment was obtained, whether there was medical supervision for this treatment and whether the participant was taking additional hormones without medical supervision.

All of these questions were open ended and coded later on. For the in-depth interviews, a semi-structured topic list was used based on the analysis of the quantitative survey data, covering the topics past and present hormone use, sex work, migration trajectory, discrimination experiences, and gender identity experiences. Descriptive analyses were used to describe the socio-demographic characteristics of the study population, their past and present hormone use, their silicone use, and sexual risk. Qualitative data was transcribed ad verbatim. The in-depth interviews were double coded during and after the data collection process by two researchers independently A.

Quotes are used where possible to illustrate the findings; however, because of the primary focus on hormone use for the outreach organizations, topics such as silicone use and sexual health were not explored extensively during the in-depth interviews. All survey participants were ased male at birth and had a history of using gender-affirming hormones as required to participate. One person identified as male: this person self-identified as a cross-dresser and had a history of hormone use.

All sociodemographic characteristics of the survey sample are summarized in Table 1. All of the nine interview participants were ased male at birth and identified as female. Of the nine interview participants, seven were from Ecuadorian origin. Furthermore, six of them had lived in Spain. A variety of migration pathways is found among the interview participants, with the Netherlands, France, Germany, Italy, and Spain mentioned as first destination countries. Table 2 shows migration pathways for all interview participants.

The economic crisis in Spain is cited by a lot of the interview participants as the reason for eventually migrating to Belgium or the Netherlands. All interview participants worked in the Antwerp red light district, but four of them did not live in Antwerp: two of them were living in Amsterdam NL but work in Antwerp because they had to pay taxes to work in the Amsterdam red light district.

One participant lived in Spain and occasionally traveled to Antwerp to work, and one participant lived in Brussels and also worked in Brussels in street-based sex work. Socio-demographic characteristics of the interview participants are summed up in Table 2.

Complications cited were depression and mood Woman want real sex Antwerp New York, weight gain, and erection problems. A variety of brand names and doses is found in the survey sample, in the past as well as in the present. Furthermore, a lot of the transgender sex workers in the survey sample cited injectable estrogens which are not available in Western Europe.

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