The risk of contracting an STI for transgender people, as well as for cisgender people, depends on sexual habits and on the knowledge of the existence of these diseases. An IST is contracted more easily through sexual intercourses without the use of condoms.

Other situations which determine a higher risk of contracting an STI are:

• anal intercourse, that can cause small lesions that facilitate the penetration of pathogens responsible for STIs
• oral intercourse, that in presence of small lesions in the oral cave facilitates the penetration of microbes inside the sperm, vaginal secretions and saliva
• to have intercourses with more people simultaneously and/or have had intercourses with more partners
• to have HIV (human immunodeficiency virus) infection which favors the entrance of microbes responsible of other STIs
• to have one or more STI, which favor transmission of infection from HIV
• to have sexual intercourse under the effect of drugs or alcohol.

There are several exams to identify various STIs, which are prescribes based on sexual habits and symptoms eventually described. The frequency on which executing these exams is influenced by some factors that increase the risk of contracting these infections: multiple partners, sex without condoms, paid sex, sex under the effect of alcohol or drugs. 

When visiting a physician to undergo a check for STIs, it is necessary to specify:

• date of last sexual intercourse
• intercourse type (oral, vaginal, anal), received or practiced
• number of people with whom one is having sexual intercourse
• gender of person or people with whom one is having sexual intercourse
• use of condom and/or other prevention tools
• frequency (how often) of use of these protections against STIs
• eventual STIs had in the past
• last exam for STIs done and related result
• eventual STI observed in the person or people with whom one is having sexual intercourse
• use of alcohol or drugs before/during sex (chemsex)
• eventual current or undergone paid sex practice.

Some sexually transmitted inflections (HIV, hepatitis B, hepatitis C, syphilis) are diagnosed through a blood test. Other STIs (chlamydia, gonorrhea and infection from Papilloma Virus) are instead diagnosed with a swab and/or urine analysis. Swab consists in a small stick with cotton on its end; it must be rubbed on the interested zone (skin or mucosa) and later put back in a phial with a liquid, that helps maintain in life the researched germs until the lab receives the sample to be examined. There are pharyngeal, rectal, vaginal and urethral swabs.

For further information related to specific STI mentioned above it’s possible to visit the website ISSalute.it at the following sections:

• HIV
• Hepatitis B
• Hepatitis C
• Syphilis
• Chlamydia
• Gonorrhea
• Papilloma virus

STIs Diagnostic process is almost always the same, for transgender people as well as cisgender ones.

People who underwent  scrotum-vaginoplasty or colon-vaginoplasty (using parts of urethra which is the channel through which urine flows), can be subject to bacterial infections from Chlamydia and Neisseria gonorrhea: in this population, if there is high risk of contracting an STI, research of these two bacteria can be useful (it’s unknown if research of these bacteria on vaginal swab of neovagina is valid). For further information on Chlamydia and Gonorrhea it’s possible to visit ISSalute.it under sections “Chlamydia” and “Gonorrhea”.
Neovagina can be easily affected by syphilis, Herpes simplex or Venereal ulcer or chancroid  bacteria. For further information on Syphilis and Herpes Symplex it’s possible to visit ISSalute.it under sections “Syphilis” and “Herpes”. For Venereal ulcer or chancroid it’s possible to visit website of Società Italiana di Andrologia e Medicina della Sessualità (SIAMS) al link: http://www.siams.info/ulcera-molle/.
Transgender people who underwent scrotum-vaginoplasty or colon-vaginoplasty don’t have uterine cervix (the lower and narrower uterus part), therefore vaginal screening (Pap-test) is not appropriate; instead virus research like Papilloma at anal level is useful. For further information about Pap Test and Papilloma virus it’s possible to visit ISSalute.it website under sections “Pap Test” and “HPV – Human Papilloma Virus”. Due to the shape of the neovagina created with surgery, a detailed exam can be performed with an anoscope (tubular tool inserted in anus to maintain it open and observe clearly the wall, visualize wounds and eventually carry out small interventions or sample collection) or a vaginal speculum (similar tool concerning scopes, with a slightly different shape, that is inserted in the vagina). Transgender people who have been undergone to scrotum-vaginoplasty or colon-vaginoplasty maintain prostate (the body part which produces part of seminal liquid, situated between the bladder and the latter part of the intestine), therefore it’s to be noted they can suffer, as cisgender men, from bladder infections.     

Conversely, transgender people that maintain uterus and ovaries and have vaginal intercourses can suffer from pelvis inflammatory disease (serious disorder that can be consequence of Chlamydia and Gonorrhea). Furthermore, it’s important to note that testosterone treatment can cause dryness, volume loss and vagina shape change. Hence it is suggested use of lubricants during intercourses and small vaginal speculums during visits. Transgender men who have undergone a gender affirming surgery can maintain part of the vagina, hence they should undertake the same checks suggested to cisgender women. 

The main prevention for all STIs is the correct use of condoms. To prevent HIV infections also pharmacological prophylaxis called PreP and nPEP, further information is available under section “HIV infections”.

For some STIs there is a vaccination that guarantees protection. The following ones:

• HBV, Hepatitis B virus
• HPV, Papilloma virus
• HAV, Hepatitis A virus

In Italy it’s possible to make these vaccinations to people with high risk of STIs, for free or at a facilitated price, according to specific indications decided in different regions. It is therefore important to be aware of each own health status making screening checks, on blood or via swabs, in specialized centers: in STIs control centers available in various cities, in Infective Disease Clinics of some Hospitals and in Check Points (Territorial centers extra hospital for sexual health, managed by non-sanitary operators and medical operators, currently active in Milan and Bologna). Undergoing test to search for STIs can mean prevention and in case of positivity, adopt the most timely and appropriate treatments under medical supervision.

HIV is the virus which causes AIDS (Acquired Immune Deficiency Syndrome), a group of infective diseases, cancers and other diseases peculiar to this condition in which our defense cells against germs and tumors are destroyed and made ineffective. For further information regarding HIV infection it’s possible to visit ISSalute.it under section “HIV-AIDS”.

Test to detect HIV, that has to be performed and eventually repeated based on the risk of contracting the infection, is suggested to all people sexually active both transgender and cisgender. The risk depends on sexual habits and the kind of intercourses (vaginal, anal, oral; receptive or insertive, with or without ejaculation), from exchange of used syringes to inject drugs in blood vessels or filling substance under skin. It’s unknown in percentage terms the risk of HIV infection through receptive vaginal sex in a transgender woman who has undergone scrotum-vaginoplasty or colon-vaginoplasty, as well as the risk of contracting HIV for transgender men who have undergone masculine genital reconstructions as phalloplasty.

HIV INFECTION PREVENTION
Condoms continue to be a milstone of HIV infection prevention. Anyway, use of condom can be difficult for transgender women who take de-masculinizing hormones due to tumescence reduction (incomplete erection). The role of condoms in transgender men who underwent phalloplasty is unknown and probably it depends from specific anatomy and surgical approach adopted. Feminine condoms can be an option for transgender women that have receptive vaginal sex. Other than these barrier methods currently there are two other pharmacological solutions complementary to condom for prevention of HIV infections, effective both in transgender and cisgender people. These solutions use medicines already utilized for a long time in clinical practice for treatment of HIV infections but that demonstrated efficacy also in prevention of this infection for HIV-negative people:

1. prophylaxis pre-exposition, or PrEP (dedicated to people who regularly or occasionally have sexual intercourse at risk
2. non professional prophylaxis post-exposition, or nPEP (dedicated to people who have had a sexual intercourse at risk)

For undertaking PrEP it’s necessary to refer to specialist infectiology physician. For post-exposition prophylaxis following an intercourse at risk it is instead necessary to go as soon as possible, and anyway within 48 hours from it, to First Aid clinic of an Hospital which carries an Infective Disease service.

HIV INFECTION TREATMENT
In case of infection from HIV (if test gets positive result) a treatment made of medicines active against the virus is started. Recommendations for infection treatment do not differ between transgender and cisgender people. When HIV infection diagnosis and its treatment are timely, survival and quality of life remain very similar to the ones of the general population. Potential pharmacological interaction between oestrogens (feminizing hormones taken by some transgender people) and some medicines used in therapy against HIV. There are studies which demonstrate that transgender women affected by HIV privilege hormonal therapy instead of therapy against HIV (they tend in other words to not adhere to the HIV-therapy given by the physician, risking seriously their health). Anyway, based on available data, most of therapies against HIV can be used safely in people who take oestrogens: it is important to warn the own physician on assumption of hormonal therapy in order for the physician to choose antiviral medicines that on one side don’t reduce desired efficacy of therapy with oestrogens, on the other side don’t reduce therapy efficacy against the virus.
Limited data exist on interaction between therapy against HIV and masculinizing hormones or other medicines used as anti-androgens for feminization.

Papilloma Virus infection is the most common STI: almost all men and women during their life encounter at least one this virus. Most of the infections disappear within one or two years but in some cases it persists causing also tumoral diseases. Some HPV types can cause external and internal warts that despite the treatment can form again, others can form uterin cervix, anal and oropharynges’ cancer. It is estimated that men who have sexual intercourses with men  have five times more probabilities to get that infection than heterosexual people: recent studies would confirm that also transgender women are at high risk of HPV infection. One of the causes of Papilloma virus persistence is immunodepression, which means having low immunity defenses hence not being able to control the virus. For example who is HIV positive presents a high risk of having HPV linked tumoral diseases.  Diagnosis is made with colposcopy (exam which aims to look into uterus neck with an optical instrument, called coloscopies, which allows enlargement) or anoscopy (exam that allows to visualize ano-rectal mucosa through a tool called anoscope), and with the consequent biopsy of the wound which identifies presence and type of HPV. The treatment is surgical and consists in the removal of the wound which anyhow can reappear (surgical treatment that becomes very problematic at rectal mucosa level).
Constant and correct use of masculine condom can reduce HPV infection risk, can anyway not completely eliminate the risk because HPV can infect areas not fully covered by the condom.

HPV prevention takes place though vaccination. Three types of vaccine exist:

• nonavalent that protects from nine types of HPV (currently used vaccine)
• quadrivalent that protects from four types of HPV
• bivalent that protects from two types of HPV

Even if there is no proof that being a transgender person is a risk factor for Hepatitis C, some layers of this population can present a higher risk. Percentages of HIV infection and use of injected drugs are higher among transgender people, that can eventually inject under skin hormones or filling substances like silicon. Sharing or use of contaminated needles, syringes or vials is a risk factor for infections caused by microbes transmitted by blood, including Hepatitis C virus. It’s necessary to always use sterile needles once without sharing them and this applies to both transgender and cisgender people.

Hepatitis C is not per se a contraindication to hormonal therapy. In this case for people who use oestrogens or testosterone, the monitoring of liver function can be recommended. Some medicines used for Hepatitis C treatment can interact with oestrogens and be contraindicated. Transgender people treated with oestrogens must be carefully monitored.

Are sex toys safe?
Yes, they are safe if used responsibly and washed after every use, otherwise they can transmit sexually transmitted and other infections (for example Hepatitis A). 
 

In order to avoid STIs through use of sex toys, it is necessary to:

• mantain clean sex toys (wash after every use);
• avoid use on different body parts during the same intercourse, such as mouth, vagina and anus without having washed them before;
• apply a condom on sex toys suited for penetration, like vibrators. Use a new condom every time they are used;
• don’t share sex toys.

Risk of STI transmission through use of sex toys increases when there are cuts or sores near vagina, anus or penis.
Sex toys should be accompanied by suggestions on how to clean and preserve them. Follow carefully instructions especially if the sex toy has batteries and parts that cannot be washed.
Check regularly sex toys for eventual scratches or breaks in the surface material in which can be present and spread germs, because this can increase risk of infection. If allergic to latex, do not use sex toys made of or containing latex.

Brady M, Rodger A, Asboe D, et al. BHIVA/BASHH guidelines on the use of HIV pre-exposure prophylaxis (PrEP) 2018. HIV Med. 2019;20 Suppl 2:s2-s80.

Poteat T. Transgender people and sexually transmitted infections (STIs). Transgender Care. 2016

Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV—United States 2016. Centers for Disease Control and Prevention (CDC). 2016.

Trickey A, May MT, Vehreschild JJ, et al. Survival of HIV-positive patients starting antiretroviral therapy between 1996 and 2013: a collaborative analysis of cohort studies. Lancet HIV. 2017; 4 (8):e349–56.