HEALTH VULNERABILITIES OF TRANSGENDER SEX WORKERS: AN INTEGRATIVE REVIEW

an integrative review conducted in July 2020 in the PubMed, Web of Science, SCOPUS, CINAHL, IBECS and LILACS databases, with no language or time restrictions. The following descriptors indexed in DeCS and MESH and their respective synonyms were used: “Transgender persons”, “Sex workers” and “Health vulnerability”. The data were analyzed based on thematic analysis.

Results:

a total of 547 articles were retrieved and, after the selection and analysis process, 34 were included in this review. Four thematic classes emerged: “Knowledge, prevention and exposure to STIs in sex work”; “Use (and abuse) of illegal substances and alcohol”; “The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies”; and “Psychosocial diseases, discrimination and challenges of transgender sex workers”.

Conclusion:

the health vulnerabilities experienced by transgender sex workers are marked by discrimination, social exclusion, stigma, incarceration contexts, physical, psychological and sexual violence and use of illegal substances and alcohol, in addition to difficulties in accessing essential services such as health, education and leisure.

DESCRIPTORS:
Transgender persons; Sex workers; Health vulnerability; Sexual and gender minorities; Nursing

Database	Strategy
PUBMED, SCOPUS	(((("transgender persons") OR transgenders) OR "Person, Transgender") OR Persons, Transgender OR Transgenders) OR Transgender) OR Transsexual Persons AND (((("Health Vulnerability") AND ((Sex Work") OR Work, Sex) OR Sex Industry) OR Prostitution)
CINAHL WEB OF SCIENCE	#1“transgender persons” OR transgender OR “Person, Transgender” OR “Persons, Transgender” OR “Transgenders” OR “Transsexual Persons” #2: “Health Vulnerability” #3: “Sex Work” OR “Work Sex” OR “Sex Industry” OR “Prostitution” Strategy: #1 AND #2 AND #3
LILACS, IBECS	“Pessoas transgênero” OR “Pessoa trans” OR “Pessoas transexuais” OR “Transexual” OR “Transgênero” OR “Transgêneros” OR “personas transgénero” OR “transgender persons” OR “transgenders” OR “Person, transgender” OR “Transsexual Persons” AND “Vulnerabilidade em Saúde” OR “Vulnerabilidad en Salud” OR “Health Vulnerability” AND “Profissionais do sexo” OR “Trabajadores Sexuales” OR “Sex Workers” OR “Sex Industry” OR “Prostitution”

Authorship	Year of publication	Research design	Level of evidence
Russi JC et al.2424. Russi JC, Serra M, Vinõles J, Pérez MT, Ruchansky D, Alonso G, et al. Sexual transmission of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus type 1 infections among male transvestite commercial sex workers in Montevideo, Uruguay. Am J Trop Med Hyg [Internet]. 2003 [cited 2020 June 18];68(6):716-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12887033 https://www.ncbi.nlm.nih.gov/pubmed/1288...	2003	Quantitative - Epidemiological, descriptive	V
Sausa LA et al.2525. Sausa LA, Keatley JA, Operario D. Perceived risks and benefits of sex work among transgender women of color in San Francisco. Arch Sex Behav [Internet]. 2007 [cited 2020 June 20];36(6):768-77. Available from: https://doi.org/10.1007/s10508-007-9210-3 https://doi.org/10.1007/s10508-007-9210-...	2007	Qualitative	VI
Reisner SL et al.2626. Reisner SL, Mimiaga MJ, Bland S, Mayer KH, Perkovich B, Safren SA. HIV risk and social networks among male-to-female transgender sex workers in Boston, Massachusetts. J Assoc Nurses AIDS Care [Internet]. 2009 [cited 2020 June 18];20(5):373-86. Available from: https://doi.org/10.1016/j.jana.2009.06.003 https://doi.org/10.1016/j.jana.2009.06.0...	2009	Mixed	V, VI
Wilson EC et al.2727. Wilson EC, Garafalo R, Harris RD, Herrick A, Martinez M, Martinez J, et al. Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS Behav [Internet]. 2009 [cited 2020 June 18];13(5):902-13. Available from: https://doi.org/10.1007/s10461-008-9508-8 https://doi.org/10.1007/s10461-008-9508-...	2009	Quantitative - Cross-sectional, descriptive	V
Infante C et al.2828. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: Vulnerability of male, transvestite, transgender and transsexual sex workers. Cult Health Sex [internet]. 2009 [cited 2020 June 23];11(2):125-37. Available from: https://doi.org/10.1080/13691050802431314 https://doi.org/10.1080/1369105080243131...	2009	Qualitative	VI
Farias MSR et al.2929. Farías MS dos R, García MN, Reynaga E, Romero M, Vaulet MLG, Fermepín MR, et al. First report on sexually transmitted infections among trans (male to female transvestites, transsexuals, or transgender) and male sex workers in Argentina: high HIV, HPV, HBV, and syphilis prevalence. Int J Infect Dis [Internet]. 2011 [cited 2020 June 18];15(9)e635-640. Available from: https://doi.org/10.1016/j.ijid.2011.05.007 https://doi.org/10.1016/j.ijid.2011.05.0...	2011	Quantitative - Epidemiological, descriptive	V
Farias MSR et al.3030. Farías MS dos R, Picconi MA, García MN, González JV, Basiletti J, Pando ML, et al. Human Papilloma virus genotype diversity of anal infection among trans (male to female transvestites, transsexuals or transgender) sex workers in Argentina. J Clin Virol [Internet]. 2011 [cited 2020 June 18];51(2):96-9. Available from: https://doi.org/10.1016/j.jcv.2011.03.008 https://doi.org/10.1016/j.jcv.2011.03.00...	2011	Quantitative - Epidemiological, descriptive	V
Cortez FCP et al.3131. Cortez FCP, Boer DP, Baltieri DA. A psychosocial study of male-to-female transgendered and male hustler sex workers in São Paulo, Brazil. Arch Sex Behav [Internet]. 2011 [cited 2020 June 20];40(6):1223-31. Available from: https://doi.org/10.1007/s10508-011-9776-7 https://doi.org/10.1007/s10508-011-9776-...	2011	Quantitative - Cross-sectional, descriptive	V
Nemoto B et al.3232. Nemoto T, Bödeker B, Iwamoto M. Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work. Am J Public Health [Internet]. 2011 [cited 2020 June 22];101(10):1980-8. Available from: https://doi.org/10.2105/AJPH.2010.197285 https://doi.org/10.2105/AJPH.2010.197285...	2011	Quantitative - Cohort	VI
Altaf A et al.3333. Altaf A, Zahidie A, Agha A. Comparing risk factors of HIV among hijra sex workers in Larkana and other cities of Pakistan: an analytical cross sectional study. BMC Public Health [Internet]. 2012 [cited 2020 June 23];12:279. Available from: https://doi.org/10.1186/1471-2458-12-279 https://doi.org/10.1186/1471-2458-12-279...	2012	Quantitative - Cross-sectional, analytical	V
Nurena CR et al.3434. Nurena CR, Brown B, Galea JT, Sánchez H, Blas MM. HPV and genital warts among Peruvian men who have sex with men and transgender people: knowledge, attitudes and treatment experiences. PLoS One [Internet]. 2013 [cited 2020 June 1];8(3):e58684. Available from: https://doi.org/10.1371/journal.pone.0058684 https://doi.org/10.1371/journal.pone.005...	2013	Qualitative	VI
Nemoto T et al.3535. Nemoto T, Iwamoto M, Perngparn U, Areesantichai C, Kamitani E, Sakata M. HIV-related risk behaviors among kathoey (male-to-female transgender) sex workers in Bangkok, Thailand. AIDS Care [Internet]. 2012 [cited 2020 June 18];24(2):210-9. Available from: https://doi.org/10.1080/09540121.2011.597709 https://doi.org/10.1080/09540121.2011.59...	2013	Mixed	VI
Cai Y et al.99. Cai Y, Wang Z, Lau JT, Li J, Ma T, Liu J. Prevalence and associated factors of condom less receptive anal intercourse with male clients among transgender women sex workers in Shenyang, China. J Int AIDS Soc [Internet]. 2016 [cited 2020 June 18];19(3 Suppl 2):20800. Available from: https://doi.org/10.7448/IAS.19.3.20800 https://doi.org/10.7448/IAS.19.3.20800...	2016	Quantitative - Cross-sectional, descriptive	V
Giguere R et al.3636. Giguere R, Lopez-Rios J, Frasca T, Lentz C, Balán IC, Dolezal C, et al. Use of HIV self-testing kits to screen clients among transgender female sex workers in New York and Puerto Rico. AIDS Behav [Internet]. 2020 [cited 2020 June 22];24(2):506-15. Available from: https://doi.org/10.1007/s10461-019-02730-2 https://doi.org/10.1007/s10461-019-02730...	2016	Quantitative - Randomized clinical trial	II
Logie CH et al.1010. Logie CH, Wang Y, Lacombe-Duncan A, Jones N, Ahmed U, Levermore K, et al. Factors associated with sex work involvement among transgender women in Jamaica: a cross-section study. J Int AIDS Soc [Internet]. 2017 [cited 2020 June 15];20(1):21422. Available from: https://doi.org/10.7448/IAS.20.01/21422 https://doi.org/10.7448/IAS.20.01/21422...	2017	Quantitative - Cross-sectional, descriptive	V
Budhwani H et al.1313. Budhwani H, Hearld KR, Hasbun J, Charow R, Rosario S, Tillotson L, et al. Transgender female sex workers’ HIV knowledge, experienced stigma, and condom use in the Dominican Republic. PloS One [Internet]. 2017 [cited 2020 June 17];12(11):e0186457. Available from: https://doi.org/10.1371/journal.pone.0186457 https://doi.org/10.1371/journal.pone.018...	2017	Quantitative - Cross-sectional, descriptive	V
Nuttbrock LA et al.3737. Nuttbrock LA, Hwahng SJ. Ethnicity, sex work, and incident HIV/STI among transgender women in New York City: a three year prospective study. AIDS Behav [Internet]. 2017 [cited em 19 Jun 2020];21(12):3328-35. Available from: https://doi.org/10.1007/s10461-016-1509-4 https://doi.org/10.1007/s10461-016-1509-...	2017	Quantitative - Longitudinal, prospective	V
Lyons T et al.3838. Lyons T, Krüsi A, Pierre L, Kerr T, Pequeno W, Shannon K. Negotiating violence in the context of transphobia and criminalization: the experiences of trans sex workers in Vancouver, Canada. Qual Health Res [internet]. 2017 [cited 2020 June 20];27(2):182-90. Available from: https://doi.org/10.1177/1049732315613311 https://doi.org/10.1177/1049732315613311...	2017	Qualitative	VI
Lyons T et al.3939. Lyons T, Krüsi A, Pierre L, Small W, Shannon KE. The impact of construction and gentrification on an outdoor trans sex work environment: Violence, displacement and policing. Sexualities [Internet]. 2017 [cited 2020 June 20];20(8):881-903. Available from: https://doi.org/10.1177/1363460716676990 https://doi.org/10.1177/1363460716676990...	2017	Qualitative	VI
Samudzi Z et al.4040. Samudzi Z, Mannell J. Cisgender male and transgender female sex workers in South Africa: gender variant identities and narratives of exclusion. Cult Health Sex [Internet]. 2016 [cited 2020 June 20];18(1):1-14. Available from: https://doi.org/10.1080/13691058.2015.1062558 https://doi.org/10.1080/13691058.2015.10...	2017	Qualitative	VI
Ganju S et al.4141. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex [Internet]. 2017 [cited 2020 June 22];19(8):903-17. Available from: https://doi.org/10.1080/13691058.2016.1271141 https://doi.org/10.1080/13691058.2016.12...	2017	Qualitative	VI
Budhwani H et al.4242. Budhwani H, Hearld KR, Hasbun J, Charow R, Rosario S, et al. Transgender women’s drug use in the Dominican Republic. Transgender Health [Internet]. 2017 [cited 2020 June 23];2(1):188-94. Available from: https://doi.org/10.1089/trgh.2017.0032 https://doi.org/10.1089/trgh.2017.0032...	2017	Quantitative - Cross-sectional, descriptive	V
Wickersham JA et al.4343. Wickersham JA, Gibson BA, Bazazi AR, Pillai V, Pedersen CJ, Meyer JP, et al. Prevalence of human immunodeficiency virus and sexually transmitted infections among cisgender and transgender women sex workers in greater Kuala Lumpur, Malaysia: Results from a respondent-driven sampling study. Sex Transm Dis [Internet]. 2017 [cited 2020 June 18];44(11):663-70. Available from: https://doi.org/10.1097/OLQ.0000000000000662 https://doi.org/10.1097/OLQ.000000000000...	2018	Quantitative - Epidemiological, descriptive	VI
Matthen P et al.4444. Matthen P, Lyons T, Taylor M, Jennex J, Anderson S, Jollimore J, et al. “I walked into the industry for survival and came out of a closet”: how gender and sexual identities shape sex work experiences among men, two spirit, and trans people in Vancouver. Men Masc [Internet]. 2018 [cited 2020 June 23];21(4):479-500. Available from: https://doi.org/10.1177/1097184X16664951 https://doi.org/10.1177/1097184X16664951...	2018	Mixed	V, VI
Degtyar A, et al.4545. Degtyar A, George P, Mallma P, Díaz D, Cárcamo C, García P, et al. Sexual risk, behavior, and HIV testing and status among male and transgender women sex workers and their clients in Lima, Peru. Int J Sex Health [Internet]. 2018 [cited 2020 June 23];30(1):81-91. Available from: https://doi.org/10.1080/19317611.2018.1429514 https://doi.org/10.1080/19317611.2018.14...	2018	Qualitative	VI
Khalid M et al.4646. Khalid H, Martin EG. Relationship between network operators and risky sex behaviors among female versus transgender commercial sex workers in Pakistan. AIDS Care [Internet]. 2019 [cited 2020 June 22];31(6):767-76. Available from: https://doi.org/10.1080/09540121.2018.1557317 https://doi.org/10.1080/09540121.2018.15...	2019	Quantitative - Cross-sectional, descriptive	V
Sherman SG et al.4747. Sherman SG, Park JN, Galai N, Allen ST, Huettner SS, Silberzahn BE. Drivers of HIV infection among cisgender and transgender female sex worker populations in Baltimore City: Results from the SAPPHIRE Study. J Acquir Immune Defic Syndr [internet]. 2019 [cited 2020 June 22];80(5):513-21. Available from: https://doi.org/10.1097/QAI.0000000000001959 https://doi.org/10.1097/QAI.000000000000...	2019	Quantitative - Cohort	IV
Jarrett D et al.4848. Jarrett D, Miles G, Quinley JH. “Same same, but different”: A baseline study on the vulnerabilities of transgender sex workers in the sex industry in Bangkok, Thailand. Int J Sociol Soc Policy [Internet]. 2019 [cited 2020 June 23];39(7/8):550-73. Available from: https://doi.org/10.1108/IJSSP-01-2019-0022 https://doi.org/10.1108/IJSSP-01-2019-00...	2019	Qualitative	VI
Guler E et al.4949. Guler E. A divided sisterhood: support networks of trans sex workers in urban Turkey. AAPSS [internet]. 2020 [cited 2020 June 22];689(1):149-67. Available from: https://doi.org/10.1177/0002716220919745 https://doi.org/10.1177/0002716220919745...	2020	Qualitative	VI
Wang Q et al.5050. Wang Q, Chang R, Wang Y, Jiang X, Chang S, Shen Q, et al. Correlates of alcohol and illicit drug use before commercial sex among transgender women with a history of sex work in China. Sexual Health [Internet]. 2019 [cited 2020 June 22];17(1):45-52. Available from: https://doi.org/10.1071/sh18194 https://doi.org/10.1071/sh18194...	2020	Quantitative - Cross-sectional, descriptive	V
Drückler S et al.5151. Drückler S, Van Rooijen MS, Vries HJC. Substance use and sexual risk behavior among male and transgender women sex workers at the prostitution outreach center in Amsterdam, the Netherlands. Sex Transm Dis [Internet]. 2020 [cited 2020 June 22];47(2):114-21. Available from: https://doi.org/10.1097/OLQ.0000000000001096 https://doi.org/10.1097/OLQ.000000000000...	2020	Quantitative - Cross-sectional, descriptive	V
Miller WM et al.5252. Miller WM, Miller WC, Barrington C, Weir SS, Chen SY, Emch ME, et al. Sex work, discrimination, drug use and violence: a pattern for HIV risk among transgender sex workers compared to MSM sex workers and other MSM in Guatemala. Glob Public Health [Internet]. 2020 [cited 2020 June 22];15(2):262-74. Available from: https://doi.org/10.1080/17441692.2019.1671984 https://doi.org/10.1080/17441692.2019.16...	2020	Quantitative - Cross-sectional, descriptive	V
Poteat T et al.5353. Poteat T, White RH, Footer KHA, Park NJ, Galai N, Huettner S. Characterising HIV and STIs among transgender female sex workers: A longitudinal analysis. Sex Transm Infect [Internet]. 2021 [cited 2020 June 23];97:226-31. Available from: https://doi.org/10.1136/sextrans-2019-054414 https://doi.org/10.1136/sextrans-2019-05...	2020	Quantitative - Cohort	IV
Capous-Desyllas M et al.5454. Capous-Desyllas M, Loy V. Navigating intersecting identities, self-representation, and relationships: a qualitative study with trans sex workers living and working in Los Angeles. Sociological Inquiry [Internet]. 2020 [cited 2020 June 23];90(2):339-70. Available from: https://doi.org/10.1111/soin.12350 https://doi.org/10.1111/soin.12350...	2020	Qualitative	VI

Thematic Categorization	Synthesis of the health vulnerabilities of transgender sex workers
Knowledge, prevention and exposure to STIs in sex work	The following was revealed: lack of knowledge about the transmission of the HIV virus and the fragile knowledge about the identification of signs and symptoms of some STIs, such as HPV warts. “Sexual agreements” favor low adherence to condom use. The performance of anal sexual practice (insertive and receptive) and ejaculation in the mouth without a condom and how the feminization of transsexual women can influence the use or not of the condom were identified. It was also possible to evidence high prevalence values of HIV, Hepatitis B and syphilis, in addition to the high-risk genotypes of HPV99. Cai Y, Wang Z, Lau JT, Li J, Ma T, Liu J. Prevalence and associated factors of condom less receptive anal intercourse with male clients among transgender women sex workers in Shenyang, China. J Int AIDS Soc [Internet]. 2016 [cited 2020 June 18];19(3 Suppl 2):20800. Available from: https://doi.org/10.7448/IAS.19.3.20800 https://doi.org/10.7448/IAS.19.3.20800... ^,1313. Budhwani H, Hearld KR, Hasbun J, Charow R, Rosario S, Tillotson L, et al. Transgender female sex workers’ HIV knowledge, experienced stigma, and condom use in the Dominican Republic. PloS One [Internet]. 2017 [cited 2020 June 17];12(11):e0186457. Available from: https://doi.org/10.1371/journal.pone.0186457 https://doi.org/10.1371/journal.pone.018... ^,2626. Reisner SL, Mimiaga MJ, Bland S, Mayer KH, Perkovich B, Safren SA. HIV risk and social networks among male-to-female transgender sex workers in Boston, Massachusetts. J Assoc Nurses AIDS Care [Internet]. 2009 [cited 2020 June 18];20(5):373-86. Available from: https://doi.org/10.1016/j.jana.2009.06.003 https://doi.org/10.1016/j.jana.2009.06.0... ^,2929. Farías MS dos R, García MN, Reynaga E, Romero M, Vaulet MLG, Fermepín MR, et al. First report on sexually transmitted infections among trans (male to female transvestites, transsexuals, or transgender) and male sex workers in Argentina: high HIV, HPV, HBV, and syphilis prevalence. Int J Infect Dis [Internet]. 2011 [cited 2020 June 18];15(9)e635-640. Available from: https://doi.org/10.1016/j.ijid.2011.05.007 https://doi.org/10.1016/j.ijid.2011.05.0... ^-3030. Farías MS dos R, Picconi MA, García MN, González JV, Basiletti J, Pando ML, et al. Human Papilloma virus genotype diversity of anal infection among trans (male to female transvestites, transsexuals or transgender) sex workers in Argentina. J Clin Virol [Internet]. 2011 [cited 2020 June 18];51(2):96-9. Available from: https://doi.org/10.1016/j.jcv.2011.03.008 https://doi.org/10.1016/j.jcv.2011.03.00... ^,3333. Altaf A, Zahidie A, Agha A. Comparing risk factors of HIV among hijra sex workers in Larkana and other cities of Pakistan: an analytical cross sectional study. BMC Public Health [Internet]. 2012 [cited 2020 June 23];12:279. Available from: https://doi.org/10.1186/1471-2458-12-279 https://doi.org/10.1186/1471-2458-12-279... ^-3737. Nuttbrock LA, Hwahng SJ. Ethnicity, sex work, and incident HIV/STI among transgender women in New York City: a three year prospective study. AIDS Behav [Internet]. 2017 [cited em 19 Jun 2020];21(12):3328-35. Available from: https://doi.org/10.1007/s10461-016-1509-4 https://doi.org/10.1007/s10461-016-1509-... ^,4141. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex [Internet]. 2017 [cited 2020 June 22];19(8):903-17. Available from: https://doi.org/10.1080/13691058.2016.1271141 https://doi.org/10.1080/13691058.2016.12... ^,4343. Wickersham JA, Gibson BA, Bazazi AR, Pillai V, Pedersen CJ, Meyer JP, et al. Prevalence of human immunodeficiency virus and sexually transmitted infections among cisgender and transgender women sex workers in greater Kuala Lumpur, Malaysia: Results from a respondent-driven sampling study. Sex Transm Dis [Internet]. 2017 [cited 2020 June 18];44(11):663-70. Available from: https://doi.org/10.1097/OLQ.0000000000000662 https://doi.org/10.1097/OLQ.000000000000... ^,4545. Degtyar A, George P, Mallma P, Díaz D, Cárcamo C, García P, et al. Sexual risk, behavior, and HIV testing and status among male and transgender women sex workers and their clients in Lima, Peru. Int J Sex Health [Internet]. 2018 [cited 2020 June 23];30(1):81-91. Available from: https://doi.org/10.1080/19317611.2018.1429514 https://doi.org/10.1080/19317611.2018.14... ^-4747. Sherman SG, Park JN, Galai N, Allen ST, Huettner SS, Silberzahn BE. Drivers of HIV infection among cisgender and transgender female sex worker populations in Baltimore City: Results from the SAPPHIRE Study. J Acquir Immune Defic Syndr [internet]. 2019 [cited 2020 June 22];80(5):513-21. Available from: https://doi.org/10.1097/QAI.0000000000001959 https://doi.org/10.1097/QAI.000000000000... ^,5353. Poteat T, White RH, Footer KHA, Park NJ, Galai N, Huettner S. Characterising HIV and STIs among transgender female sex workers: A longitudinal analysis. Sex Transm Infect [Internet]. 2021 [cited 2020 June 23];97:226-31. Available from: https://doi.org/10.1136/sextrans-2019-054414 https://doi.org/10.1136/sextrans-2019-05... .
Use (and abuse) of illegal substances and/or alcohol	The use of drugs such as cocaine was identified, in addition to injectable and inhalation drugs during sex work. There are reports of excessive alcohol use, professional practice under the influence of alcohol and combined use of alcohol and drugs during and/or before the sexual practice, describing that “physical work is easier”1010. Logie CH, Wang Y, Lacombe-Duncan A, Jones N, Ahmed U, Levermore K, et al. Factors associated with sex work involvement among transgender women in Jamaica: a cross-section study. J Int AIDS Soc [Internet]. 2017 [cited 2020 June 15];20(1):21422. Available from: https://doi.org/10.7448/IAS.20.01/21422 https://doi.org/10.7448/IAS.20.01/21422... ^,2424. Russi JC, Serra M, Vinõles J, Pérez MT, Ruchansky D, Alonso G, et al. Sexual transmission of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus type 1 infections among male transvestite commercial sex workers in Montevideo, Uruguay. Am J Trop Med Hyg [Internet]. 2003 [cited 2020 June 18];68(6):716-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12887033 https://www.ncbi.nlm.nih.gov/pubmed/1288... ^,3535. Nemoto T, Iwamoto M, Perngparn U, Areesantichai C, Kamitani E, Sakata M. HIV-related risk behaviors among kathoey (male-to-female transgender) sex workers in Bangkok, Thailand. AIDS Care [Internet]. 2012 [cited 2020 June 18];24(2):210-9. Available from: https://doi.org/10.1080/09540121.2011.597709 https://doi.org/10.1080/09540121.2011.59... ^,4242. Budhwani H, Hearld KR, Hasbun J, Charow R, Rosario S, et al. Transgender women’s drug use in the Dominican Republic. Transgender Health [Internet]. 2017 [cited 2020 June 23];2(1):188-94. Available from: https://doi.org/10.1089/trgh.2017.0032 https://doi.org/10.1089/trgh.2017.0032... ^-4343. Wickersham JA, Gibson BA, Bazazi AR, Pillai V, Pedersen CJ, Meyer JP, et al. Prevalence of human immunodeficiency virus and sexually transmitted infections among cisgender and transgender women sex workers in greater Kuala Lumpur, Malaysia: Results from a respondent-driven sampling study. Sex Transm Dis [Internet]. 2017 [cited 2020 June 18];44(11):663-70. Available from: https://doi.org/10.1097/OLQ.0000000000000662 https://doi.org/10.1097/OLQ.000000000000... ^,4747. Sherman SG, Park JN, Galai N, Allen ST, Huettner SS, Silberzahn BE. Drivers of HIV infection among cisgender and transgender female sex worker populations in Baltimore City: Results from the SAPPHIRE Study. J Acquir Immune Defic Syndr [internet]. 2019 [cited 2020 June 22];80(5):513-21. Available from: https://doi.org/10.1097/QAI.0000000000001959 https://doi.org/10.1097/QAI.000000000000... ^,5050. Wang Q, Chang R, Wang Y, Jiang X, Chang S, Shen Q, et al. Correlates of alcohol and illicit drug use before commercial sex among transgender women with a history of sex work in China. Sexual Health [Internet]. 2019 [cited 2020 June 22];17(1):45-52. Available from: https://doi.org/10.1071/sh18194 https://doi.org/10.1071/sh18194... ^-5252. Miller WM, Miller WC, Barrington C, Weir SS, Chen SY, Emch ME, et al. Sex work, discrimination, drug use and violence: a pattern for HIV risk among transgender sex workers compared to MSM sex workers and other MSM in Guatemala. Glob Public Health [Internet]. 2020 [cited 2020 June 22];15(2):262-74. Available from: https://doi.org/10.1080/17441692.2019.1671984 https://doi.org/10.1080/17441692.2019.16... .
The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies	Economic and interpersonal adversities stand out, a history of home evictions, weak support networks and difficulties in employment due to gender, in addition to the exclusion that restricts access to social spaces. Insertion in sex work is considered a “norm” for young transgender women due to prejudice and difficulties in the formal job market, making it possible to identify that the population under 36 years of age was more involved in sex work. Involvement in sex work is often due to survival needs. The context of violence and harassment against transgender sex workers emerged, as well as how this prejudice is shaped by the socio-structural context, in addition to the incarceration and criminalization scenarios. In general, vulnerability is influenced by the social context and stigma, as well as access to scarce support networks and lack of support in terms of health and social programs1010. Logie CH, Wang Y, Lacombe-Duncan A, Jones N, Ahmed U, Levermore K, et al. Factors associated with sex work involvement among transgender women in Jamaica: a cross-section study. J Int AIDS Soc [Internet]. 2017 [cited 2020 June 15];20(1):21422. Available from: https://doi.org/10.7448/IAS.20.01/21422 https://doi.org/10.7448/IAS.20.01/21422... ^,2424. Russi JC, Serra M, Vinõles J, Pérez MT, Ruchansky D, Alonso G, et al. Sexual transmission of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus type 1 infections among male transvestite commercial sex workers in Montevideo, Uruguay. Am J Trop Med Hyg [Internet]. 2003 [cited 2020 June 18];68(6):716-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12887033 https://www.ncbi.nlm.nih.gov/pubmed/1288... ^-2525. Sausa LA, Keatley JA, Operario D. Perceived risks and benefits of sex work among transgender women of color in San Francisco. Arch Sex Behav [Internet]. 2007 [cited 2020 June 20];36(6):768-77. Available from: https://doi.org/10.1007/s10508-007-9210-3 https://doi.org/10.1007/s10508-007-9210-... ^,2727. Wilson EC, Garafalo R, Harris RD, Herrick A, Martinez M, Martinez J, et al. Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS Behav [Internet]. 2009 [cited 2020 June 18];13(5):902-13. Available from: https://doi.org/10.1007/s10461-008-9508-8 https://doi.org/10.1007/s10461-008-9508-... ^-2828. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: Vulnerability of male, transvestite, transgender and transsexual sex workers. Cult Health Sex [internet]. 2009 [cited 2020 June 23];11(2):125-37. Available from: https://doi.org/10.1080/13691050802431314 https://doi.org/10.1080/1369105080243131... ^,3131. Cortez FCP, Boer DP, Baltieri DA. A psychosocial study of male-to-female transgendered and male hustler sex workers in São Paulo, Brazil. Arch Sex Behav [Internet]. 2011 [cited 2020 June 20];40(6):1223-31. Available from: https://doi.org/10.1007/s10508-011-9776-7 https://doi.org/10.1007/s10508-011-9776-... ^,3535. Nemoto T, Iwamoto M, Perngparn U, Areesantichai C, Kamitani E, Sakata M. HIV-related risk behaviors among kathoey (male-to-female transgender) sex workers in Bangkok, Thailand. AIDS Care [Internet]. 2012 [cited 2020 June 18];24(2):210-9. Available from: https://doi.org/10.1080/09540121.2011.597709 https://doi.org/10.1080/09540121.2011.59... ^,3737. Nuttbrock LA, Hwahng SJ. Ethnicity, sex work, and incident HIV/STI among transgender women in New York City: a three year prospective study. AIDS Behav [Internet]. 2017 [cited em 19 Jun 2020];21(12):3328-35. Available from: https://doi.org/10.1007/s10461-016-1509-4 https://doi.org/10.1007/s10461-016-1509-... ^-4242. Budhwani H, Hearld KR, Hasbun J, Charow R, Rosario S, et al. Transgender women’s drug use in the Dominican Republic. Transgender Health [Internet]. 2017 [cited 2020 June 23];2(1):188-94. Available from: https://doi.org/10.1089/trgh.2017.0032 https://doi.org/10.1089/trgh.2017.0032... ^,4444. Matthen P, Lyons T, Taylor M, Jennex J, Anderson S, Jollimore J, et al. “I walked into the industry for survival and came out of a closet”: how gender and sexual identities shape sex work experiences among men, two spirit, and trans people in Vancouver. Men Masc [Internet]. 2018 [cited 2020 June 23];21(4):479-500. Available from: https://doi.org/10.1177/1097184X16664951 https://doi.org/10.1177/1097184X16664951... ^,4747. Sherman SG, Park JN, Galai N, Allen ST, Huettner SS, Silberzahn BE. Drivers of HIV infection among cisgender and transgender female sex worker populations in Baltimore City: Results from the SAPPHIRE Study. J Acquir Immune Defic Syndr [internet]. 2019 [cited 2020 June 22];80(5):513-21. Available from: https://doi.org/10.1097/QAI.0000000000001959 https://doi.org/10.1097/QAI.000000000000... ^-4949. Guler E. A divided sisterhood: support networks of trans sex workers in urban Turkey. AAPSS [internet]. 2020 [cited 2020 June 22];689(1):149-67. Available from: https://doi.org/10.1177/0002716220919745 https://doi.org/10.1177/0002716220919745... ^,5252. Miller WM, Miller WC, Barrington C, Weir SS, Chen SY, Emch ME, et al. Sex work, discrimination, drug use and violence: a pattern for HIV risk among transgender sex workers compared to MSM sex workers and other MSM in Guatemala. Glob Public Health [Internet]. 2020 [cited 2020 June 22];15(2):262-74. Available from: https://doi.org/10.1080/17441692.2019.1671984 https://doi.org/10.1080/17441692.2019.16... .
Psychosocial diseases, discrimination and challenges of transgender sex workers	Sex for money was associated with depression, suicidal ideation and higher levels of harms. Negative feelings in relation to dealing with stereotypes and stigmas are described. There are several challenges that involve from transphobia experiences of clients to feelings of disgust reproduced by family, clients and society, which will culminate in contexts of psychological distress1010. Logie CH, Wang Y, Lacombe-Duncan A, Jones N, Ahmed U, Levermore K, et al. Factors associated with sex work involvement among transgender women in Jamaica: a cross-section study. J Int AIDS Soc [Internet]. 2017 [cited 2020 June 15];20(1):21422. Available from: https://doi.org/10.7448/IAS.20.01/21422 https://doi.org/10.7448/IAS.20.01/21422... ^,3131. Cortez FCP, Boer DP, Baltieri DA. A psychosocial study of male-to-female transgendered and male hustler sex workers in São Paulo, Brazil. Arch Sex Behav [Internet]. 2011 [cited 2020 June 20];40(6):1223-31. Available from: https://doi.org/10.1007/s10508-011-9776-7 https://doi.org/10.1007/s10508-011-9776-... ^,3535. Nemoto T, Iwamoto M, Perngparn U, Areesantichai C, Kamitani E, Sakata M. HIV-related risk behaviors among kathoey (male-to-female transgender) sex workers in Bangkok, Thailand. AIDS Care [Internet]. 2012 [cited 2020 June 18];24(2):210-9. Available from: https://doi.org/10.1080/09540121.2011.597709 https://doi.org/10.1080/09540121.2011.59... ^,5454. Capous-Desyllas M, Loy V. Navigating intersecting identities, self-representation, and relationships: a qualitative study with trans sex workers living and working in Los Angeles. Sociological Inquiry [Internet]. 2020 [cited 2020 June 23];90(2):339-70. Available from: https://doi.org/10.1111/soin.12350 https://doi.org/10.1111/soin.12350... .

Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem Campus Universitário Trindade, 88040-970 Florianópolis - Santa Catarina - Brasil, Tel.: (55 48) 3721-4915 / (55 48) 3721-9043 - Florianópolis - SC - Brazil
E-mail: textoecontexto@contato.ufsc.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] CORRESPONDING AUTHORS
Alef Diogo da Silva Santana alefeerp@usp.br