This study was conducted to evaluate the sexual behaviors of transgender women and their vulnerability to STIs including HIV.
Results of the study on sexual behaviors of 127 transgender women showed that although 92% of them were single at the time of the study, about 93% had sex experience in their life. Although the majority of participants had sex with a single partner for the past 2 years, it is important to pay attention to the rest 40.7% who had more than 2 partners in the last 2 years. Considering the fact that in Iran, sex is legal only in marriage, these people are exposed to high-risk behaviors, and STIs including AIDS. This conclusion seems plausible by looking at demographic characteristics such as 62.2% unemployed and inappropriate financial situation in 56.7% of participants. In a study by Clements-Nolle, 80% of transgender women had sex in the last 6 months and 37% had sex with more than 10 people . In the study by Herbst, 31.7% of transgender women had multiple sex partners .
In the present study, sexual interests of transgender women were similar to those of Cisgender women in many ways. Romantic touching and caressing (53.1%) and then kissing (48.7%) were the first and second sexual behaviors and preferences in transgender women. Naturally, due to the absence of vagina in 74% of the participants in this study, vaginal sex, despite their strong desire, was less prevalent in their sexual relations and oral and anal sex were inevitably the third sexual behavior with a frequency of 22.1% and 19.5%. The frequency of oral and anal sex in Iranian transgender women seems lower relative to other transgender women, which is consistent with the unpleasantness of these behaviors among most Iranian cisgender women . By contrast, in the study by Sinha in India, all transgender participants had receptive anal sex and 73.3% had receptive oral sex . In his study, 70% of participants had sex for money and therefore, they were willing to perform any type of sex even against their will. Other patterns of sexual behavior, such as very low preference for fantasy or masturbation, were consistent with patterns of sexual behavior among Iranian women .
Although transgender women had similar interests to Cisgender women, there were significant differences in their sexual function. In this study, about 67.2% of transgender women reached orgasm in at least 50% of sexual intercourse and only 8% of them did not experience orgasm, which is quite significant compared to the prevalence of orgasmic disorders (37%)  and anorgasmia (26%) in Iranian women  Experiencing a more pleasurable orgasm in transgender women compared to cisgender women may be due to the previous experience of orgasm owing to having a penis. In addition, the high ability to reach orgasm without vaginal penetration reaffirms that orgasm in women is less dependent on vaginal intercourse.
It should be noted that despite reaching proper orgasm, transgender women did not report high sexual satisfaction and 41.6% of them reported low and very low satisfaction with their sex life. This finding is important from several perspectives. First, consistent with other studies, this finding shows that reaching orgasm does not necessarily imply high sexual satisfaction, and sexual satisfaction in women is largely influenced by other factors such as satisfaction with husband [30, 31] and body satisfaction [32, 33] In this study, about 60% of people were moderately satisfied or dissatisfied with their appearance and believed that appearance has a great impact on their sexual satisfaction. Therefore, efforts should be made to nurture a positive body image in them.
Another reason for low sexual satisfaction in transgender women is the significant prevalence of dyspareunia in them. The frequency of dyspareunia in transgender women was 42.5% which is significant compared to the prevalence of severe (10.5%) and moderate dyspareunia (25.8%) in Iranian women . At the same time, due to the absence of vaginoplasty in 74% of participants, they had to have anal sex which was described as painful and unpleasant. This shows that in order to improve the sexual health of transgender women, more useful and less complicated surgical methods are required, and special attention should be paid to sexual counseling, especially with their sex partner.
In addition, low sexual satisfaction in transgender women despite proper orgasm can be attributed to common sexual scripts in the society that generally consider sex to be penetration-based, and if absent, sexual satisfaction is overshadowed by dyspareunia or absence of vagina. With proper culture development and sexual counseling, however, their high potential for orgasm can be used to improve their sexual satisfaction.
This study showed that a significant portion of transgender women were not familiar with any STIs signs and symptoms and unfortunately 88.2% did not even consider themselves at risk for HIV infection. This finding is mostly related to cultural factors and lack of awareness on STIs in traditional societies. In India for instance, 88% of transgender people were not familiar with STIs(8) but in Canada 95% of transgender people were familiar with at least three main ways of HIV transmission .
STIs and HIV screening was never performed in 87.4% and 72.4% of participants respetively. However, among the few transgender women who underwent these tests, 1.6% were HIV positive and 18% had STIs. However, a study on general population of Iranian women indicated that the prevalence of gonorrhea is 0-2.4%, chlamydia 6.4- 10.3%, syphilis less than 1%, HPV 7% and the prevalence of HIV infection is 0.14% . The high prevalence of STIs and HIV in transgender women compared to the general population indicates their high vulnerability to high-risk sexual behaviors such as unprotected sex and sometimes having multiple sex partners. Similarly, in the studies conducted on transgender women, the prevalence of STIs was between 13 and 21% [24, 26, 37]. In contrast to the present study, in most studies, the average prevalence of HIV infection in transgender women based on a positive laboratory test was between 14 and 41% [23, 24, 37, 38], which is significant, because more than 72% of participants in this study had never undergone HIV test. Also, these people have been deprived of of other health services due to social stigma and discrimination .
In this study, about one-third of participants never used condoms during sex, and half of them used it occasionally. In addition, they mentioned that the most common reason for not using a condom was not having one, and given that the majority of participants in the study were in poor financial conditions, it seems necessary to provide them with free condoms and give them necessary training for safe sex. Results of other studies showed that the average condom nonuse in transgender people was low and between 34% and 48% [24, 37, 39].
To interpret the results of this study, it is necessary to consider its limitations such as data being self-reported and the lack of a cisgender group for comparison. However, this is the first study in Iran that examines sexual behaviors and vulnerability to sexually transmitted diseases in transgender women in a significant sample size.