Socioeconomic marginalization, social exclusion, and engagement in transactional sex among transgender women living with HIV: the role of multidimensional gender affirmation

Gender affirmation (GAF) is a multidimensional (psychological, social, medical, administrative) social determinant of health for transgender individuals. Transactional sex (TS) is prevalent among transgender women living with HIV (TWLH), who face intersectional discrimination. GAF's relationship with TS is understudied. ANRS-Trans&HIV(2020-2022) was a French cross-sectional, community-based, life-event study of TWLH. We used clustering analyses to identify patterns of GAF among TWLH and compared TS engagement across clusters. 331/506 (65%) were currently engaged in TS. Most reported income <1000€/month. Three clusters were identified: "Sparse engagement with medical and administrative dimensions" (s-MA) - less likely to report lifetime feminizing hormone-use, gender-affirming surgery, or a gender-concordant identity document, "Past and predominant engagement with medical dimension" (p-M) - lifetime but not current feminizing hormone use, and feminizing-but-not-genital surgery, and "Current and comprehensive engagement with all dimensions" (c-MAPS) - current feminizing hormone use & genital surgery, gender-concordant identity documents, infrequent misgendering, and less frequently envisioning gender-affirming care. S-MA (aPR = 1.60, CI = 1.15-2.22) and p-M (aPR = 1.60, CI = 1.17-2.20) had higher TS engagement than c-MAPS. We identified diverse GAF experiences, though some may forego hormone use or genital surgery because they interfere with TS (e.g., erectile dysfunction). Findings underscore improving access to formal employment, reducing socioeconomic marginalization, and offering person-centered care.Trial registration: ClinicalTrials.gov identifier: NCT04849767.