Ask AI
Back Back
The Transgender Odyssey
Beyond the Clinic Walls: The Transgender Odyssey 

Released: December 16, 2025

Amanita Calderon Cifuentes
Amanita Calderon Cifuentes
Activity Information

Activity

Progress
1
Course Completed
Continue
Key Takeaways
  • Elevated HIV risk for transgender people isn't about identity, it’s about systems that punish, stigmatize, or neglect certain identities.
  • The best way to reduce HIV risk is dismantling structural barriers to care, and no one is better positioned to do this than the community members themselves.

When trans people walk into clinics, we bring every experience of discrimination, every time someone dead-named us (used our birth name instead of our chosen name), every moment we've had to choose between rent and hormones, and every police encounter that made us question whether seeking care was worth the risk.

Healthcare professionals often fail to understand this: for trans people living with HIV, accessing care becomes an act of trust that many of us have learned, through painful experience, to ration carefully. 

Trans-feminine people are 66 times more likely to acquire HIV than the general population, with an estimated prevalence of 19.9%, while trans masculine people face 6.8 times the risk, with a prevalence of 2.6%. Statistics alone don't explain why. What they do tell us is who. Those of us living at the intersections of specific sociodemographic characteristics—particularly gender, race, and migration status—face dramatically elevated HIV risk. Understanding why requires looking beyond individual identities to the systems that create this exposure in the first place.

The answer also requires healthcare systems to do something they're deeply uncomfortable with: admit that they've been part of the problem.

The Real Barriers Healthcare Systems Don't See
Healthcare systems remain fundamentally structured around the assumption that trans people don't exist. When we can't access legal gender recognition, we become invisible in medical records. When our IDs don't match our lived reality, we face interrogation at every intake desk. When trans-specific healthcare isn't covered, we're forced to choose between gender-affirming care and HIV prevention.

These legal barriers directly increase HIV exposure by amplifying minority stress. Chronic psychological strain creates cognitive overload, making it genuinely harder to remember to take pre-exposure prophylaxis (PrEP), to schedule appointments, and to navigate byzantine healthcare bureaucracies. Violence, discrimination, and harassment fuel chronic stress, leading to higher rates of depression, anxiety, and substance use disorders. Without legal protections, many of us are forced into informal economies, including sex work, which increases exposure to HIV without protective labor rights or access to healthcare.

Understanding Intersectionality Beyond Hierarchies
When people hear "intersectionality," they often imagine a hierarchy that ranks suffering. That's a fundamental misunderstanding. Intersectionality describes how different social, political, legal, and economic conditions shape lived experiences depending on context. A Black trans woman in Denmark may access higher education more easily than a white cisgender man in the United States—not because of her race, but because of her nationality and the Danish welfare system that protects her right to education. But when facing police violence, the power dynamics shift entirely: her race becomes the factor exposing her to brutality. Those of us who are priority populations experience dramatically higher risk, not because we're "vulnerable by nature," but because structural violence, stigma, criminalization, poverty, discrimination, and social exclusion expose us to harm. 

Our elevated HIV risk isn't about identity itself. It's about systems—patriarchal and capitalistic—that punish, stigmatize, or neglect certain identities. For that reason, the best way to reduce HIV risk isn't only through biomedical tools, it's by also dismantling those structural barriers. And nobody is better positioned to do this than communities ourselves, who understand those experiences first-hand and have already built effective models to respond. This is what the nongovernmental organization delegation UNAIDS calls community-led integrated services.

What Actually Works
Research with trans-led clinics like Trans United Europe in Amsterdam and the Tangerine Clinic in Bangkok reveals something critical: the most effective HIV services integrate gender-affirming care with HIV care, because that's how we experience our bodies and our lives.

At Tangerine Clinic, trans women come for hormone therapy and leave with PrEP. Between November 2015 and May 2023, the clinic served 5939 trans women, with 91% receiving HIV testing and 98% viral suppression among those on antiretroviral therapy (ART). And a 2021 systematic review found that integrated service delivery resulted in 67% higher uptake of HIV testing, 42% higher ART initiation rates, and 68% better retention in care. These sorts of community-led services build trust because they're led by people who share lived experiences and design services around real needs.

What Healthcare Professionals Can Do Tomorrow

Stop gatekeeping. Parental consent requirements for young trans people accessing PrEP create barriers that increase risk. Extensive documentation requirements before offering gender-affirming care constitute structural violence.

Integrate services. HIV care should include mental health screening, harm reduction services, comprehensive sexuality education, gender-based violence programs, legal support, and trans-specific care as part of the same pathway, as directed by the World Health Organization guideline on HIV service delivery. Every additional door we have to walk through becomes an opportunity to be turned away. 

Trust community expertise. Hire trans people—especially those with lived experience of sex work, drug use, migration, incarceration—as decision-makers who shape how services operate and as providers who deliver them. We know what we need.

Recognize that confidentiality means survival. For criminalized populations, breaches of confidentiality threaten freedom and safety. This requires zero-disclosure dispensing, anonymous testing options, and immediate access to legal advice.

The Bottom Line
Trans-specific healthcare functions as HIV prevention infrastructure. People receiving gender-affirming hormone therapy had a 37% lower chance of acquiring HIV. We cannot end HIV while pretending trans people don't exist. What's needed is healthcare that recognizes our full humanity, and that funds, protects, and centers the community-led models that have always done this work best. The infrastructure exists. The evidence is clear. What's missing is political will. 

Your Thoughts
What are some ways, big or small, that you reduce intersectional barriers to care for transgender people in your practice? Leave a comment to join the discussion!

Continue