Factors associated with condom use with non-commercial partners among sexually-active transgender women in Cambodia: findings from a national survey using respondent-driven sampling

Transgender women, individuals who self-identify as female despite being assigned as male at birth, are a vulnerable population globally. They experience a high degree of social marginalization that results in mental health challenges, substance abuse, and exposure to violence—all risk factors for HIV and other sexually transmitted infections (STIs) [1‐6]. As a result of these risk factors, they have higher rates of HIV and STIs than cisgender individuals, those whose gender identity corresponds with sex assigned at birth. A 2013 global systematic review found the probability of HIV infection among transgender women to be 48.8 times [95% confidence interval (CI) 21.2–76.3] higher than that in the general adult population [7].

Along with the psychological challenges that frequently lead transgender women to engage in sexual risk behaviors, such as condomless sex, they face societal judgment related to their gender identity. They are often discriminated against when applying for jobs and accessing health services [8, 9]. With the lack of employment opportunities, many transgender women turn to sex work [10]. The double stigmatization of gender identity and prostitution makes this population even less likely to access health services [7, 9, 10]. This lack of access has serious consequences, as the risk of HIV and other STIs is also higher among transgender women who are engaging in transactional sex [10, 11]. Sex workers may be less able to negotiate condom use because of weakened bargaining power, economic instability, low self-esteem, and other psychological problems [6, 9, 12]. Because of stigmatization, many transgender women experience financial isolation or destitution, and have had to make the difficult decision to engage in sex without a condom as an economic survival strategy [5, 10, 13].

Condomless anal intercourse is an important risk factor for HIV and STI transmission [14, 15]. In a 2016 HIV prevalence study among transgender women in Cambodia, respondents who reported not using a condom at last anal intercourse had 3.8 times the odds of HIV infection [16]. Transgender women are more likely to be the receptive partner in a sexual encounter, increasing their risk of HIV and STIs if their rate of condomless anal intercourse is high [2, 8]. Multiple factors have been shown to be correlated with inconsistent condom use among men who have sex with men (MSM) and transgender women globally: HIV risk perception [17], drug and alcohol use [4, 10, 18, 19], depressive symptoms [4, 9, 18, 20, 21], history of abuse [21‐23], low levels of education [18], and having sex with a commercial partner [12, 20, 24]. In these studies, condom use is treated as a binary variable: consistent users were participants who reported always using condoms during anal intercourse, whereas inconsistent users did not.

Results from the few studies conducted on condom use among MSM and transgender women in Southeast Asia are consistent with the global findings. Having a higher perceived risk of HIV was associated with inconsistent condom use among MSM and transgender women in Thailand [17]. MSM and transgender women in Indonesia who reached a higher educational level, had fewer depressive symptoms in the past week, and had no history of abuse as a child were more likely to report consistent condom use [18]. Drug use and commercial sex decreased the likelihood of condom use [18]. These studies, however, did not differentiate factors based on type of sexual partners (commercial vs. non-commercial). They also mostly include both transgender women and MSM, not focusing on transgender women specifically.

Cambodia is an important context in which to explore factors associated with condom use among transgender women. The prevalence of HIV among transgender women in Cambodia is between 4.6 to 5.9% [11, 16]. This is double the rate among MSM (2.3%) [25], and about 20 times that of the general adult population (0.3%) [26]. Transgender women in Cambodia also report inconsistent condom use more frequently than MSM, have engaged in sex work at higher rates, and admit to sexual intercourse with both men and women [16, 27]. Despite their higher risk profile and unique characteristics, until 2012, transgender women were not recognized as a separate group from MSM [16]. Therefore, public health interventions targeted specifically at transgender women are less developed than those for other key populations [28, 29].

In this population, consistent condom use with commercial and non-commercial partners varies widely. Weissman et al. (2016) found that 84% of participants used a condom during last sex, whereas Yi et al. (2017) reported 62% [11, 16]. Unlike other studies that show decreased condom use among non-commercial partners, in Weissman et al. (2016), consistent condom use among commercial and non-commercial male partners in the last six months was equal, at around 45% [16]. On the other hand, participants surveyed in Yi et al. (2017) were more likely to consistently use condoms with commercial partners in the last three months [11].

Like these two studies, most research focuses on condom use generally, or specifically with commercial partners [4, 5, 16]. There is a paucity of research on factors associated with condom use in non-commercial relationships. Past studies identified that an important gap in the literature is to understand condom use based on partner types and sexual acts [16]. This study was therefore conducted to explore factors associated with consistent condom use among sexually-active transgender women in Cambodia, specifically with their non-commercial partners.

In this study, 41.5% of participants reported always using condoms in anal intercourse with male non-commercial partners in the past three months. The two previous studies of Cambodian transgender women’s sexual behaviors, which also used RDS method, reported on condom use with commercial and non-commercial partners. Weissman et al. (2016) found that condom use was about the same—around 45%—with both kinds of partners over the previous six months [16]. On the other hand, participants surveyed in Yi et al. (2017) were more likely to consistently use condoms with commercial partners in the past three months (60% vs. 38% with non-commercial) [11]. These variations could indicate that some transgender women are better able to negotiate condom use with commercial partners. There are also structural elements to condom use within sex work: some employers may provide, or even require condoms, and some may not. Since these studies were conducted in different provinces, the location of the sex work (venue-based, street-based, etc.) could influence condom use.

Regardless of location, higher consistent condom use with commercial partners relative to non-commercial partners is consistent with the overall literature [12, 13, 18, 34]. The reasons for differential condom use by partner have been explained in multiple ways in other studies—because of discrimination they have faced, transgender women may want to affirm their gender identity, and their partner’s desire for them by having condomless intercourse [13, 34]. Condoms can also undermine the feelings of intimacy with romantic partners, a factor not unique to transgender relationships [12]. We also found that participants were more likely to use condoms with non-commercial partners if they did not always use condoms with commercial partners. This introduces an element of risk calculation into the condom use decision-making. If transgender women use condoms with commercial partners, they may feel that they are protected from HIV and other STIs, so they are freer to engage in condomless intercourse with their non-commercial partners. This interpretation is consistent with our findings related to perceived HIV risk. Although these studies mostly recruited participants through word-of-mouth outreach, they did not employ RDS analyses to correct for the non-random sample. Therefore, their conclusions must be interpreted as not fully comparable with our RDS-adjusted estimates.

In this study, we found a dose-response effect in the relationship between self-perceived HIV risk and condom use with non-commercial partners. The lower the participant’s perceived risk of HIV, the lower the odds of consistent condom use with non-commercial partners. This means that our participants’ condom use with non-commercial partners matched their risk perception. A 2017 study in Thailand found the opposite—that increased HIV risk perception was associated with inconsistent condom use [17]. The Thai data reflected that the participants may not have taken their perceived HIV risk into account when practicing condomless intercourse. On the other hand, our participants could assess their HIV risk more accurately and act accordingly. However, this is only perceived risk—transgender women in our sample could be assuming that, in engaging in condomless intercourse with their non-commercial partners, they are safe from HIV and other STIs.

Although not all of the results were statistically significant, we found a trend that the more alcohol consumption within the past three months, the higher the odds of consistent condom use with non-commercial partners. This finding is inconsistent with numerous other studies that demonstrated a decreased likelihood of condom use with drug and alcohol use [6, 12, 18]. We assessed alcohol intake by asking the number of days they drank on a given week. We did not specifically ask participants when they drank alcohol, however, so the alcohol consumption could have been during sexual encounters with commercial partners, or unrelated to sexual intercourse in general. Future studies should employ more accurate alcohol measures that take into account alcohol dependence or problematic alcohol use.

Finally, we found that participants who had been reached by community-based HIV services in the past three months had a lower odds of consistent condom use with non-commercial partners, as compared to participants who did not receive the services. This may reflect a failure of community-based HIV programs to teach HIV prevention behaviors adequately. However, there is not enough data to jump to this conclusion. Perhaps the participants who were not reached by the programs were not very sexually active or engaged less in sexual risk behaviors such as multiple sexual partners, for instance. Moreover, some service seeking behaviors, such as HIV testing or searching for online HIV services may indicate a higher risk profile, which is consistent with a lower rate of consistent condom use.

Some limitations of the study should be noted. This study included only the capital city and 12 provinces with a large population size of transgender women and higher burden of HIV. These city and provinces are prioritized sites for HIV intervention programs. Therefore, findings from this study may not be generalized at a national level. Specific to our RDS methodology, the initial seeds of participants were identified and recruited by outreach workers working for community-based NGOs, which could be biased towards transgender women who are participants in their programs and therefore more educated on sexual health. In addition, participants were more likely to be more socially connected than non-participants and were more likely to recruit people who were like themselves, and therefore, non-independence may be an issue. However, we have tried to account for some of these limitations by accounting for networks in our analyses. Furthermore, with RDS, after a certain number of waves, the characteristics of the participants would become independent from those of the seeds. Another limitation is the self-reporting measures on sensitive issues such as sexual behaviors and substance abuse that may have encountered over- and under-reporting biases. Finally, the monetary incentive given to the participants to recruit seeds may have affected their genuine motivation to partake in the study to certain extent and influence their responses. Nevertheless, sufficient due measures were taken in data collection procedures to minimize these potential effects.

This study confirms the persistently low rates of condom use, particularly in non-commercial relationship among transgender women in Cambodia. It showed that lower perceived risk of HIV was associated with lower condom use rates, regardless of the actual risk. This is confirmed by the relationship between consistent condom use with commercial vs. non-commercial sexual partners. Participants were more likely to consistently use condoms with non-commercial partners if they inconsistently used condoms with commercial partners. This risk assessment behavior may have exacerbated vulnerability to HIV and other STIs and explain the increase of HIV prevalence among this population, despite the substantial reduction of new HIV infections in the general population. However, this study demonstrates the complexity of the factors that influence condom use with non-commercial partners among this population, including alcohol and drug use, and use of various health services. To address these concerns, efforts towards education about harmful effects of multiple, concurrent relationships, and inconsistent condom should be reinforced among transgender women.