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Glob Public Health. 2016 Aug-Sep;11(7-8):849-65. doi: 10.1080/17441692.2016.1181193. Epub 2016 May 12.

Towards 'reflexive epidemiology': Conflation of cisgender male and transgender women sex workers and implications for global understandings of HIV prevalence.

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a Department of Sociomedical Sciences , Columbia Mailman School of Public Health , New York , NY , USA.
b Department of Epidemiology , Harvard T.H. Chan School of Public Health , Boston , MA , USA.
c Division of General Pediatrics , Boston Children's Hospital/Harvard Medical School , Boston , MA , USA.
d The Fenway Institute, Fenway Community Health , Boston , MA , USA.
e Department of Medicine , David Geffen School of Medicine at UCLA , Los Angeles , CA , USA.
f ABIA (Brazilian Interdisciplinary AIDS Association) , Rio de Janeiro , Brazil.


The HIV epidemic has had a widespread impact on global scientific and cultural discourses related to gender, sexuality, and identity. 'Male sex workers' have been identified as a 'key population' in the global HIV epidemic; however, there are methodological and conceptual challenges for defining inclusion and exclusion of transgender women within this group. To assess these potential implications, this study employs self-critique and reflection to grapple with the empiric and conceptual implications of shifting understandings of sexuality and gender within the externally re-created etic category of 'MSM' and 'transgender women' in epidemiologic HIV research. We conducted a sensitivity analysis of our previously published meta-analysis which aimed to identify the scope of peer-reviewed articles assessing HIV prevalence among male sex workers globally between 2004 and 2013. The inclusion of four studies previously excluded due to non-differentiation of cisgender male from transgender women participants (studies from Spain, Thailand, India, and Brazil: 421 total participants) increased the overall estimate of global HIV prevalence among 'men' who engage in sex work from 10.5% (95% CI 9.4-11.5%) to 10.8% (95% CI 9.8-11.8%). The combination of social science critique with empiric epidemiologic analysis represents a first step in defining and operationalising 'reflexive epidemiology'. Grounded in the context of sex work and HIV prevention, this paper highlights the multiplicity of genders and sexualities across a range of social and cultural settings, limitations of existing categories (i.e. 'MSM', 'transgender'), and their global implications for epidemiologic estimates of HIV prevalence.


HIV; Men who have sex with men; epidemiological categories; sex work; transgender women

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