Discussing your sexual history with a doctor, or anyone for that matter, can be an uncomfortable experience.
But for many transgender people, the conversation never takes place because they aren't seeking health care, according to Adrian Juarez, PhD, a public health nurse and assistant professor in the University at Buffalo School of Nursing.
Through a preliminary study examining HIV testing access and heath-based decision making in urban, transgender populations, Juarez found that social stigma, as well as a lack of affordability, keep many transgender people from pursuing needed care.
"There is evidence that health care providers do tend to be judgmental, and it's unwelcoming," says Juarez. "People will refrain from going to health care providers if they have to deal with stigma and discrimination."
The study, "Examining the Role of Social Networks on Venue-Based HIV Testing Access and Decision Making in an Urban, Transgendered Population," is partially funded through a Junior Investigator Award from the American Public Health Association.
The results are troubling considering nearly a third of transgender Americans are HIV-positive, according to a 2009 report from the National Institutes of Health (NIH). Transgender women of color are at even greater risk for HIV infection; the NIH study found more than 56 percent of black transgender women are HIV-positive.
"We don't know enough about communities of color," says Juarez. "Most trans research is done on the Euro-American population. While we have made some inroads at looking at African Americans, there is almost nothing coming out for Hispanic communities."
Juarez's study is examining HIV-risk data from the New York State Department of Health AIDS Institute, Evergreen Health Services in Buffalo and International AIDS Empowerment in El Paso, Texas, a largely Latino community.
Juarez also conducted interviews with members of the Buffalo and El Paso transgender communities.
Among the factors keeping transgender patients away from doctors is the inability to afford care. According to a 2011 report from the National Center for Transgender Equality, transgender people were four times more likely than the general population to live in extreme poverty - with a household income of less than $10,000 per year - and more than twice as likely to be homeless.
Finding work is yet another challenge. According to the National Center for Transgender Equality, 90 percent of more than 6,000 transgender people surveyed nationwide reported being the target of harassment, mistreatment and discrimination at work.
"Imagine someone applies for a job and the employer isn't accepting of their identity. They're not going to get the job," says Juarez. "But as human beings, we need to eat and shelter ourselves. So they turn to sex work. The risk factors just add on."
In addition to gender discrimination, if a transgender patient of color does meet with a doctor for care, they also face the social stigma associated with being HIV-positive, where the victim is often blamed or judged for their actions, says Juarez.
He also adds that some health care providers are ill informed on how to treat transgender patients.
"It puzzles me how doctors will still refer to trans individuals by their biological name. That's their identity," says Juarez.
But in health care treatment, the line between biological and identifying gender are not always clear.
Transgender women still require prostate screenings, and transgender men need a Pap smear, although a cautious health care provider may not offer the testing to avoid suggesting treatment that goes against the patient's identity.
To improve the care of transgender patients, Juarez stresses the need to address stigmatization nationally on a social level and to provide education on proper treatment to health care providers.