ABSTRACT

OBJECTIVE

Review the reasons for condom use and non-use among transgender women in Colombia based on the information, motivation and behavioral skills (IMB) model.

METHOD

Qualitative study in which an iterative process analysis was carried out. A focal group participated in person, and in-depth interviews were conducted virtually.

RESULTS

First study carried out in Colombia on condom use among transgender women under the IMB model. The information component finds that traditional sexual education does not have a positive impact. Regarding motivational aspects, the importance of family support and follow-up and community-based organizations to motivate sexual health care and condom use is highlighted. Regarding behavioral skills, it was found that distrust towards sexual partners and the acquisition of condoms promote their use.

CONCLUSIONS

It is important to create spaces for sexual education delivered by and for the LGBTIQ population, followed by the medical knowledge of health centers, to have positive impacts on the sexual health of transgender women; studies with sexual partners of transgender women are encouraged in order to know the reasons why they request the non-use of condoms.

Women; Transgender Persons; Unsafe Sex; Sexual and Gender Minorities, psychology; Qualitative Research

INTRODUCTION

In recent years, studies on trans women (TW) have been increasing. The term trans in Colombia, and specifically for this study, refers to an umbrella concept that includes different gender expressions and identities, such as transsexual, transgender, transvestite, gender-neutral/fluid/gender queer people, etc. This category frames a vindictive political positioning, and includes gender identities that do not fit the binary model¹1. Platero Méndez RL. Trans*exualidades: acompañamientos, factores de salud y recursos educativos. Barcelona (ES): Edicions Bellaterra; 2015.. Literature shows that the most frequently researched topic with respect to this population has to do with the prevalence of the human immunodeficiency virus (HIV)²2. Rocha ABM, Barros C, Generoso IP, Bastos FI, Veras MA. HIV continuum of care among trans women and travestis living in São Paulo, Brazil. Rev Saude Publica. 2020;54:118. https://doi.org/10.11606/s1518-8787.2020054002374
https://doi.org/10.11606/s1518-8787.2020... . There are some quantitative studies with trans women, HIV and the information, motivation and behavioral skills (IMB) model⁶6. Sheinfil AZ, Giguere R, Dolezal C, Lopes-Rios J, Iribarren S, Brown W III, et al. Information and motivation predict HIV-serostatus among a population of high-risk men and transgender women who have sex with men. AIDS Behav. 2020;24:2863-71. https://doi.org/10.1007/s10461-020-02835-z
https://doi.org/10.1007/s10461-020-02835... ,⁷7. Wang H, Chang R, Shen Q, Tsamlag L, Zhang X, Shi Y, et al. Information-Motivation-Behavioral Skills model of consistent condom use among transgender women in Shenyang, China. BMC Public Health. 2020;20:394. https://doi.org/10.1186/s12889-020-08494-y
https://doi.org/10.1186/s12889-020-08494... . It relates to practices that may predispose to the infection from sexually transmitted infections (STIs). In relation to this discussion, the research team takes an ontological stance in which it distances itself from the relationship between TW and HIV declared under the concept of key population; in line with it, empirical data⁸8. Cuenta de Alto Costo. VIH Sida en Colombia, retos y apuestas en salud. Bogotá (CO): CAC; 2020 [cited 2021 May 29]. Available from: https://cuentadealtocosto.org/site/vih/vih-sida-en-colombia-retos-y-apuestas-en-salud/
https://cuentadealtocosto.org/site/vih/v... support the fact that, in Colombia, people living with the disease are not necessarily identified in any key population. Therefore, at the national level, the challenge is to focus health promotion and disease prevention strategies on the Colombian population in general.

In this context, condoms continue to be the best prevention tool⁹9. Del Romero J, García-Pérez JN, Espasa-Soley M. Prevention and treatment of sexually transmitted infections in high-risk individuals, including patients with HIV infection. Enferm Infecc Microbiol Clin (Engl Ed). 2019;37(2):117-26. https://doi.org/10.1016/j.eimc.2018.11.008
https://doi.org/10.1016/j.eimc.2018.11.0... ,¹⁰10. Operario D, Gamarel KE, Iwamoto M, Susuki S, Suico S, Darbes L, et al. Couples-focused prevention program to reduce HIV risk among transgender women and their primary male partners: feasibility and promise of the couples HIV intervention program. AIDS Behav. 2017;21:2452-63. https://doi.org/10.1007/s10461-016-1462-2
https://doi.org/10.1007/s10461-016-1462-... . However, their use by TW is not as consistent as expected¹¹11. Yi S, Plant A, Tuot S, Mun P, Chhim S, Chann N, et al. Factors associated with condom use with non-commercial partners among sexually-active transgender women in Cambodia: findings from a national survey using respondent-driven sampling. BMC Public Health. 2019;19:326. https://doi.org/10.1186/s12889-019-6656-x
https://doi.org/10.1186/s12889-019-6656-... ,¹²12. Ayer A, Perez-Brumer A, Segura ER, Chavez-Gomez S, Fernandez R, Arroyo C, et al. Let’s talk about sex: the impact of partnership contexts on communication about hiv serostatus and condom use among men who have sex with men (MSM) and transgender women (TW) in Lima, Peru. AIDS Behav. 2021;25:2139-53. https://doi.org/10.1007/s10461-020-03144-1
https://doi.org/10.1007/s10461-020-03144... . This is due to several factors, both objective and subjective ones. The former has to do with material conditions, such as lack of money for access to condoms, and with external conditions, such as the reluctance of the partner to use them during sexual intercourse¹³13. Satcher MF, Segura ER, Silva-Santisteban A, Sanchez J, Lama JR, Clark JL. Partner-level factors associated with insertive and receptive condomless anal intercourse among transgender women in Lima, Peru. AIDS Behav. 2017;21:2439-51. https://doi.org/10.1007/s10461-016-1503-x
https://doi.org/10.1007/s10461-016-1503-... . Subjective factors are associated with the so-called sexual education¹⁴14. Parsons JT, Antebi-Gruszka N, Millar BM, Cain D, Gurung S. Syndemic conditions, HIV transmission risk behavior, and transactional sex among transgender women. AIDS Behav. 2018;22(7):2056-67. https://doi.org/10.1007/s10461-018-2100-y
https://doi.org/10.1007/s10461-018-2100-... ,¹⁵15. Moayedi-Nia S, Taheri L, Hosseini Rouzbahani N, Rasoolinejad M, Nikzad R, Ardebili ME, et al HIV prevalence and sexual behaviors among transgender women in Tehran, Iran. AIDS Behav. 2019;23:1590-3. https://doi.org/10.1007/s10461-018-02380-w
https://doi.org/10.1007/s10461-018-02380... , the history that is embodied and reproduced with respect to knowledge, beliefs, emotional state and the use of psychoactive substances, among others. Therefore, it is not possible to reduce the aforementioned practice to a rational choice tied to what is called the “logical acting”.

Given the importance and need for qualitative studies on condom use among TW and the relevance gained by the IMB model in studies to understand risk behaviors associated with STIs, especially HIV, and to inform the development of preventive interventions in different population groups with limited resources¹⁶16. Rongkavilit C, Naar-King S, Kaljee LM, Panthong A, Koken JA, Bunupuradah T, et al. Applying the information-motivation-behavioral skills model in medication adherence among Thai youth living with HIV: a qualitative study. AIDS Patient Care STDS. 2010;24(12):787-94. https://doi.org/10.1089/apc.2010.0069
https://doi.org/10.1089/apc.2010.0069... , the present study aims to analyze the reasons for condom use and non-use among TW based on the IMB model.

The IMB model proposes that to the extent that people are informed and motivated, they engage in appropriate health care behaviors¹⁹19. Fisher JD, Fisher WA, Shuper PA. The information-motivation-behavioral skills model of HIV preventive behavior. In: DiClemente RJ, Crosby RA, Kelger MC, editors. Emerging theories in health promotion practice and research. San Francisco, CA: Jossey Bass/Wiley; 2009. p. 21-64.,²⁰20. Gerend MA, Madkins K, Crosby S, Korpak AK, Phillips GL 2^nd, Bass M, et al. A qualitative analysis of young sexual minority men’s perspectives on human papillomavirus vaccination. LGBT Health. 2019;6(7):350-6. https://doi.org/10.1089/lgbt.2019.0086
https://doi.org/10.1089/lgbt.2019.0086... . In this sense, this model includes three main constructs that influence behavioral changes: information, motivation and behavioral skills to perform the behavior²⁰20. Gerend MA, Madkins K, Crosby S, Korpak AK, Phillips GL 2^nd, Bass M, et al. A qualitative analysis of young sexual minority men’s perspectives on human papillomavirus vaccination. LGBT Health. 2019;6(7):350-6. https://doi.org/10.1089/lgbt.2019.0086
https://doi.org/10.1089/lgbt.2019.0086... ,²¹21. Fisher JD, Fisher WA, Misovich SJ, Kimble DL, Malloy TE. Changing AIDS risk behavior: effects of an intervention emphasizing AIDS risk reduction information, motivation, and behavioral skills in a college student population. Health Psychol. 1996;15(2):114-23. https://doi.org/10.1037//0278-6133.15.2.114
https://doi.org/10.1037//0278-6133.15.2.... . Information refers to relevant knowledge about condoms, such as their role in preventing pregnancy and STIs. Motivation includes personal and social motivations; the former encompasses positive attitudes or benefits and negative attitudes toward condom use, while social motivation includes the individual’s perceptions of the social support provided by supportive networks available to promote condom use. Behavioral skills refer to the objective ability of individuals to have sex (oral, anal and/or vaginal) with a condom, and to the identification of factors that affect protected sexual practice by means of this method of protection²²22. Fisher JD, Fisher WA, Amico KR, Harman JJ. An information-motivation-behavioral skills model of adherence to antiretroviral therapy. Health Psychol. 2006;25(4):462-73. https://doi.org/10.1037/0278-6133.25.4.462
https://doi.org/10.1037/0278-6133.25.4.4... .

METHOD

Design

This is a qualitative study in which iterative process analysis was carried out²⁰20. Gerend MA, Madkins K, Crosby S, Korpak AK, Phillips GL 2^nd, Bass M, et al. A qualitative analysis of young sexual minority men’s perspectives on human papillomavirus vaccination. LGBT Health. 2019;6(7):350-6. https://doi.org/10.1089/lgbt.2019.0086
https://doi.org/10.1089/lgbt.2019.0086... ,²³23. DeCuir-Gunby JT, Marshall PL, McCulloch AW. Developing and using a codebook for the analysis of interview data: an example from a professional development research project. Field Methods. 2011;23:136-55. https://doi.org/10.1177/1525822X10388468
https://doi.org/10.1177/1525822X10388468... ,²⁴24. Yan GW, Bernard HR. Techniques to identify themes. Field Methods. 2003;15(1):85-109. https://doi.org/10.1177/1525822X02239569
https://doi.org/10.1177/1525822X02239569... . In-depth focal group interviews were conducted, and discussed components of information, motivation and behavioral skills.

Participants

The foundation that works with trans women called the participants chosen for the focal group (n = 11); the research group called them for the in-depth interviews (n = 22) by phone to confirm their participation, and if they met the conditions for making the interview and scheduling the meeting. It was ensured that participants had the necessary tools to carry out the focal group and interviews. Transportation allowance was offered (for the focal group) and internet connectivity was ensured, specifically to Google Meet for the interviews. The focal group lasted 180 minutes, and was conducted in January 2020. The in-depth interviews lasted 90–120 minutes, and were conducted from November 2020 to January 2021.

Participants (n = 33) were selected using the snowball strategy. Following were the eligibility criteria: trans women (transgender, transsexual, travesty, drag queen) of legal age (18 years old or more), residing in two of the main cities of the country (Cali and Medellín), and who voluntarily decided to participate in the study. For the eligibility of trans women, the two-question method was used, which was included in the sociodemographic data collected prior to the interviews and focal groups. All of them provided written and audio-recorded informed consent. Participants were paid $12 as transportation allowance and to ensure internet connectivity. The research team transcribed the interviews verbatim, and two team members reviewed these prior to data analysis.

Focal Group and In-Depth Interviews

During January and December 2020, an in-person focal group and in-depth interviews were conducted virtually, due to the covid-19 health contingency.

The research team assembled both the focal group and the in-depth interview, which were reviewed by the foundation to ensure the greatest possible clarity in the use of language for the participants. This allowed for more in-depth information to enhance the analysis. The focal group had guidelines that encouraged participants to talk about information, motivation and behavioral skills on condom use through the dramatization of everyday scenes involving sexual health care, e.g., the relationship with the stable partner and with the client, contact with health centers and community-based organizations or foundations.

The in-depth interview guideline addressed the constructs of the IMB model. Information on condom use, on the motivations they have for taking care of their sexual health and, finally, on their sexual practices were asked regarding behavioral skills. At the end of each field (focal group and in-depth interviews), participants filled out a sociodemographic questionnaire that allowed the identification of contextual characteristics (Table 1).

Information Analysis

Sociodemographic data were calculated by means of descriptive statistics (Table 1). Transcripts were entered into Nvivo software and coded by three members of the research group using the components of the IMB model. For the analysis, the iterative process²⁰20. Gerend MA, Madkins K, Crosby S, Korpak AK, Phillips GL 2^nd, Bass M, et al. A qualitative analysis of young sexual minority men’s perspectives on human papillomavirus vaccination. LGBT Health. 2019;6(7):350-6. https://doi.org/10.1089/lgbt.2019.0086
https://doi.org/10.1089/lgbt.2019.0086... ,²³23. DeCuir-Gunby JT, Marshall PL, McCulloch AW. Developing and using a codebook for the analysis of interview data: an example from a professional development research project. Field Methods. 2011;23:136-55. https://doi.org/10.1177/1525822X10388468
https://doi.org/10.1177/1525822X10388468... ,²⁴24. Yan GW, Bernard HR. Techniques to identify themes. Field Methods. 2003;15(1):85-109. https://doi.org/10.1177/1525822X02239569
https://doi.org/10.1177/1525822X02239569... was used to create a codebook based on the theoretical component of the IMB model. Subsequently, each researcher reviewed the coding to rectify and establish them under agreement of the whole team. The information from all the transcripts was organized in a matrix where a primary code and a secondary code were assigned to each component, to each of which an exemplary quote from the transcripts was assigned (Table 2). Coding inconsistencies were reviewed with the team until consensus was achieved.

Ethical Considerations

The research project was approved by the Research Ethics Committee of the Universidad Antonio Nariño. Each participant in the project expressed their informed consent prior to the focal group and in-depth interviews.

RESULTS

Characteristics of the Sample

The average age of participants was 41 years old. Of the total number of participants (n = 33), 51.5% (n = 17) have engaged in sex work at some point in their lives (6 virtually through webcam work, and 11 through street sex work); of these, 14 are currently engaged in sex work; the most frequent current occupations are styling (21.2%, n = 7) and human rights advocacy (21.2%, n = 7). Regarding the highest level of education attained, 21.2% (n = 7) did not complete basic education, 27.2% (n = 9) completed high school, 21.2% (n = 7) completed a technical or technological level, 15.1% (n = 5) have incomplete undergraduate degree, and 15.1% (n = 5) completed undergraduate degree. In terms of socioeconomic level, 93.4% (n = 31) are in strata 1, 2 and 3; in a disaggregated manner this corresponds to 24.2% (n = 8) in stratum 1, this same value for stratum 2, 45.4% (n = 15) in stratum 3, while only 6% (n = 2) are located in stratum 5 (see table of sociodemographic data). The sample characteristics are provided in Table 1.

Recurrent Theme of the IMB Model: information.

Knowledge about condoms: All participants, at the time of the interviews, had information about condom. They knew that condoms are used to prevent pregnancy and sexually transmitted infections. The first information they received about condoms was at school and at their homes (families), and they referred to condoms as a pregnancy prevention method. Therefore, they associated condom use for cisgender women. Some participants associated condoms with HIV, gonorrhea, syphilis and papillomavirus. Most of the participants had information about where condoms are available, namely pharmacies, community-based organizations, and health centers. However, some of them did not buy condoms from these places because of embarrassment. All participants mentioned that as they experienced sexual life, they learned about STIs from their friends or sexual partners, which led them to learn more about condoms, and made condom use more important. The participants mentioned that the information on the use of condoms (how to store, open and use them) was acquired through their friends and some through community-based organizations that work to defend transgender people’s rights.

Misinformation about condoms: Most mentioned that at the time they started their first sexual relations they did not have information about condoms as a method of protection against STIs; for this reason, they had the erroneous idea that this method was only to prevent pregnancy, and should be used only by biological women. In addition, when they started having sex, they did not know the importance of using a condom for each penetration, and of opening the package carefully so as not to damage it. A quarter of the participants reported misunderstanding the use, thinking that by using two condoms at a single penetration they would be safer. Most respondents reported that at some point in their lives they were not clear about the use of condoms in oral sex, thinking it was not necessary to use them in this sexual practice. Participants were not sure about the different materials of condoms or the need for lubricants for their use in anal penetration.

Recurrent Theme of the IMB Model: motivation.

Motivational experiences: These experiences were probed at the personal and social levels. At the personal level, awareness of self-care becomes the main motivation for using condoms, to avoid the consequences of an STI in one’s body. With regard to social motivation, the following experiences are found: acceptance, support and interest in health care by the family or supportive networks that motivate them to take care of their sexual health. Participants are motivated to care for themselves to avoid the physical consequences and the social stigma generated by STIs. All participants who have practiced sex work reported that clients motivate them not to use condoms in exchange for money. Trust in the relationship is a motivation for not using condoms with their regular sexual partners, according to a large number of participants.

Recurrent Theme of the IMB Model: behavioral skills.

Condom use: Participants use condoms when they are suspicious of their sexual partner, i.e., when they suspect they may become infected with a disease. Some participants demand and use condoms in sex work, and this involves not receiving additional money. Most participants use condoms if they have them available at the time of sexual intercourse; they purchase them at health centers and, to a greater extent, at foundations or community-based organizations.

Non-use of condoms: The factors expressed by participants as affecting sexual practices with condoms are more abundant than those they refer with respect to use. Participants who had engaged in sex work reported not using condoms at some point in their work due to client’s request or demand. Most of the participants mentioned that it is common not to use condoms with their regular sexual partners. Participants in strata 1, 2 and 3 mentioned that sometimes they do not use condoms because of difficulties in purchasing them, either for economic reasons or because they are embarrassed to ask for them at a drugstore or health center. In addition to the above, all of the participants reported that they had not protected themselves during sexual intercourse at some point in their lives because they had had sex while consuming psychoactive substances and alcohol, as well as because of the excitement of the moment and the attraction they felt toward a casual sexual partner. A quarter of the participants reported not using condoms because of the characteristics of the condom, namely the size and material. Finally, all the participants mentioned that the sexual practice in which they were most likely not to use a condom was oral sex; they attributed this to the discomfort they and their sexual partners felt when using a condom.

DISCUSSION

This study identified the reasons that TW have for condom use based on the IBM model. We identified external or contextual and internal elements, both relevant to the decision to use or not to use condoms. Despite the limited qualitative literature²³23. DeCuir-Gunby JT, Marshall PL, McCulloch AW. Developing and using a codebook for the analysis of interview data: an example from a professional development research project. Field Methods. 2011;23:136-55. https://doi.org/10.1177/1525822X10388468
https://doi.org/10.1177/1525822X10388468... on this research topic, we found consistency with studies conducted in other contexts²⁵25. Andrzejewski J, Pampati S, Johns MM, Sheremenko G, Lesesne C, Rasberry CN. Sexual behaviors, referral to sexual health services, and use of sexual health services among transgender high school students. J Sch Health. 2020;90(5):349-57. https://doi.org/10.1111/josh.12880
https://doi.org/10.1111/josh.12880... ,²⁶26. Poteat T, Malik M, Scheim A, Elliott A. HIV prevention among transgender populations: knowledge gaps and evidence for action. Curr HIV/AIDS Rep. 2017;14:141-52. https://doi.org/10.1007/s11904-017-0360-1
https://doi.org/10.1007/s11904-017-0360-... regarding the reasons for not using condoms. Results suggest challenges faced by TW in relation to contextual conditions of inequality that promote risky sexual practices.

Findings were consistent with quantitative studies on non-use of condoms among TW in different contexts²⁷27. Minor Peters M. ‘They wrote “gay” on her file’: transgender Ugandans in HIV prevention and treatment. Cult Health Sex. 2016;18(1):84-98. https://doi.org/10.1080/13691058.2015.1060359
https://doi.org/10.1080/13691058.2015.10... . It is common to find that trans women do not use condoms due to client demand in cases of sex work²⁹29. Ferreira Jr S, Francisco PMSB, Nogueira PA. [Profile of transvestites and transgender women: tuberculosis and HIV/AIDS in the city of São Paulo]. Rev Panam Salud Publica. 2016;40(6):410-7. Portuguese.,³²32. Maliya S, Zul AR, Irwan MS, Samsul D, Zakiah MS, Rafidah HM. Mak Nyahs in Malaysia: does HIV/AIDS knowledge really reduce HIV-related risk behaviours? IMJM Int Med J Malaysia. 2018;17(3). https://doi.org/10.31436/imjm.v17i3.241
https://doi.org/10.31436/imjm.v17i3.241... , which exposes this risk. In the Colombian context³⁶36. Urrea Giraldo F, La Furcia A. Pigmentocracia dei deseo en el mercado sexual Trans de Cali, Colombia. Sex Salud Soc (Rio J). 2014(16):121-52. https://doi.org/10.1590/S1984-64872014000100007
https://doi.org/10.1590/S1984-6487201400... ,³⁷37. Lucero Posso J, La Furcia A. El fantasma de la puta-peluquera: género, trabajo y estilistas trans en Cali y San Andrés Isla, Colombia. Sex Salud Soc. 2016;(24):172-214. https://doi.org/10.1590/1984-6487.sess.2016.24.08.a
https://doi.org/10.1590/1984-6487.sess.2... , as well as in other countries³⁸38. Fontanari AMV, Rovaris DL, Costa AB, Pasley A, Cupertino RB, Soll BMB, et al. Childhood maltreatment linked with a deterioration of psychosocial outcomes in adult life for. Southern Brazilian transgender women. J Inmigr Minor Health. 2018;20:33-43. https://doi.org/10.1007/s10903-016-0528-6
https://doi.org/10.1007/s10903-016-0528-... ,³⁹39. Jesus JG, Belden CM, Huynh HV, Malta M, LeGrand S, Kaza VGK, et al. Mental health and challenges of transgender women: a qualitative study in Brazil and India. Int J Transgend Health. 2020;21(4):418-30. https://doi.org/10.1080/26895269.2020.1761923
https://doi.org/10.1080/26895269.2020.17... , it is common for TW to have to engage in sex work due to the structural barriers they face when accessing formal employment. The results of this study also coincide with research conducted with people with heterosexual and trans gender identity in stating that condoms are not usually used with stable sexual partners⁴⁰40. Saura S, Jorquera V, Rodríguez D, Mascort C, Castellà I, García J. Percepción del riesgo de infecciones de transmisión sexual/VIH en jóvenes desde una perspectiva de género. Aten Primaria. 2019;52(3):218-9. https://doi.org/10.1016/j.aprim.2019.07.003
https://doi.org/10.1016/j.aprim.2019.07.... .

Other consistent findings are the recognition of the non-use of condoms due to disinhibition as a result of excitement⁴¹41. Van Schuylenbergh J, Motmans J, Defreyne J, Somers A, T’Sjoen G. Sexual health, transition-related risk behavior and need for health care among transgender sex workers. Int J Transgend. 2019;20(4):388-402. https://doi.org/10.1080/15532739.2019.1617217
https://doi.org/10.1080/15532739.2019.16... and the consumption of psychoactive substances and liquor⁴²42. Beckwith CG, Kuo I, Fredericksen RJ, Brinkley-Rubinstein L, Cunningham WE, Springer SA, et al. Risk behaviors and HIV care continuum outcomes among criminal justice-involved HIV-infected transgender women and cisgender men: data from the Seek, Test, Treat, and Retain Harmonization Initiative. PloS One. 2018;13(5):e0197730. https://doi.org/10.1371/journal.pone.0197730
https://doi.org/10.1371/journal.pone.019... . The practice of oral sex was a recurrent expression in this and previous studies⁴³43. Druckler S, 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. 2020;47(2):114-21. https://doi.org/10.1097/OLQ.0000000000001096
https://doi.org/10.1097/OLQ.000000000000... . It is common to find in literature that the first knowledge about condoms is related to its function of preventing pregnancy; studies suggest that this is because this method of protection is designed more for heterosexual couples⁴⁴44. Haley SG, Tordoff DM, Kantor AZ, Crouch JM, Ahrens KR. Sex education for transgender and non-binary youth: previous experiences and recommended content. J Sex Med. 2019;16(11):1834-48. https://doi.org/10.1016/j.jsxm.2019.08.009
https://doi.org/10.1016/j.jsxm.2019.08.0... .

New findings were also observed in this study. The motivational experiences of acceptance and support to gender identity received from their blood and social families were related to motivation for self-care in general⁴⁵45. Brown C, Eisenberg ME, McMorris BJ, Sieving RE. Parents matter: associations between parent connectedness and sexual health indicators among transgender and gender-diverse adolescents. Perspect Sex Reprod Health. 2020;52(4):265-73. https://doi.org/10.1363/psrh.12168
https://doi.org/10.1363/psrh.12168... ; this was also related to the use of condoms as a protected sexual practice. We noticed that the information, which turned out to be significant for participants, on the use of condoms did not come directly from their blood families, but from their social families (trans friends who become a support network at an emotional, psychological and legal level). This study confirms the importance of the actions by community-based organizations, foundations and NGOs, in health care²⁸28. Khalid H, Martin, EG. Relationship between network operators and risky sex behaviors among female versus transgender commercial sex workers in Pakistan. AIDS Care. 2019;31(6):767-76. https://doi.org/10.1080/09540121.2018.1557317
https://doi.org/10.1080/09540121.2018.15... . Similarly, these organizations promote the distribution of condoms, a factor that was mentioned in the behavioral skill to use condoms.

Although previous studies have found discrepancies between the relationship condom knowledge and practice, i.e., its use, some suggest that the relationship is effective⁴⁶46. Balán IC, Lopez-Rios J, Dolezal C, Rael CT, Lentz C. Low sexually transmissible infection knowledge, risk perception and concern about infection among men who have sex with men and transgender women at high risk of infection. Sex Health. 2019;16(6):580-6. https://doi.org/10.1071/SH18238
https://doi.org/10.1071/SH18238... and others suggest the opposite due to the lack of management and engagement of those who delivered the workshops on the topics⁴⁷47. Rasberry CN, Morris E, Lesesne, CA, Kroupa E, Topete P, Carver, et al. Communicating with school nurses about sexual orientation and sexual health: perspectives of teen young men who have sex with men. J Sch Nurs. 2015;31(5):334-44. https://doi.org/10.1177/1059840514557160
https://doi.org/10.1177/1059840514557160... . This study proposes as challenge that pedagogical programs (which provide information) on condom use could have greater effect to the extent that they are delivered by the trans population that recognizes the experiences and life contexts of the TW. Additionally, participants were more open to the information delivered by community-based organizations, foundations, NGOs and social families, since these are spaces where they felt welcomed, cared for and defended through psychosocial accompaniment, in addition to being spaces of empowerment⁴⁸48. Baams L, Dubas JS, Aken MAG. Comprehensive sexuality education as a longitudinal predictor of LGBTQ name-calling and perceived willingness to intervene in school. J Youth Adolesc. 2017;46(5):931-42. https://doi.org/10.1007/s10964-017-0638-z
https://doi.org/10.1007/s10964-017-0638-... . In this sense, information from these institutions is highly effective in the use of condoms.

Studies place TW as one of the main populations carrying STIs, especially HIV³²32. Maliya S, Zul AR, Irwan MS, Samsul D, Zakiah MS, Rafidah HM. Mak Nyahs in Malaysia: does HIV/AIDS knowledge really reduce HIV-related risk behaviours? IMJM Int Med J Malaysia. 2018;17(3). https://doi.org/10.31436/imjm.v17i3.241
https://doi.org/10.31436/imjm.v17i3.241... . The results of this study show that one of the main reasons for non-use of condoms is due to the client’s request and demand in exchange for money. In Colombia, it is common for TW to engage in street sex work, due to the barriers they encounter in the educational and formal work sectors because of the stigma associated with their gender identity. It means that the sources of income generation are through informal work, including street sex work, in which they are exposed to risky sexual practices. This study shows the need to carry out studies with the sexual partners of TW, since it is found that they are the ones who promote, to a large extent, unprotected sexual practices⁴⁸48. Baams L, Dubas JS, Aken MAG. Comprehensive sexuality education as a longitudinal predictor of LGBTQ name-calling and perceived willingness to intervene in school. J Youth Adolesc. 2017;46(5):931-42. https://doi.org/10.1007/s10964-017-0638-z
https://doi.org/10.1007/s10964-017-0638-... ,⁴⁹49. Moncayo Quevedo JE, Pérez-Arizabaleta MM, Reyes Sevillano W, Orejuela J. Salud sexual y subjetividad: sentidos construidos alrededor del uso y no uso del condón. In: Moncayo JE, Orejuela J, Reyes Sevillano W, Pérez Arizabaleta MDM. Salud, subjetividad y estudios cualitativos. Aproximaciones a la salud sexual, física y mental. Cali (CO): Editorial Universidad Santiago de Cali; Universidad EAFIT; Universidad Antonio Nariño; 2022. p. 67-215..

At the level of LGBTI public policy in Colombia⁵⁰50. Ministerio del Interior (CO). Decreto Nº 762 del 7 de Mayo de 2018. Por el cual se adiciona un capítulo al Título 4 a la Parte 4, del Libro 2, del Decreto 1066 de 2015, Único Reglamentario del Sector Interior, para adoptar la Política Pública para la garantía del ejercicio efectivo de los derechos de las personas que hacen parte de los sectores sociales LGBTI y de personas con orientación sexual e identidades de género diversas. Bogotá (CO); 2018 [cited 2021 Jun 19]. Available from: http://es.presidencia.gov.co/normativa/normativa/DECRETO%20762%20DEL%2007%20DE%20MAYO%20DE%202018.pdf
http://es.presidencia.gov.co/normativa/n... , there are no objectives specifically focused on the sexual health of transgender people or the living conditions that, as already mentioned, act as a risk factor for STIs. In this sense, it is recommended to include within these policies an axis that specifically addresses sexual health in which the distribution of condoms to trans women street sex workers is promoted, since the monthly income of the participants in this study does not allow them to cope with the monthly expenses with the condoms they use⁵¹51. Pérez Arizabaleta M, Acuña Lara YA, Moncayo Quevedo JE, Jiménez Ruiz MC, Reyes Sevillano WH. Por el placer y la vida. Cartilla de salud sexual, prácticas y formas de protección. Bogotá (CO): Universidad Antonio Nariño; 2021 [cited 2021 Jun 19]. Available from: http://repositorio.uan.edu.co/bitstream/123456789/4784/1/Cartilla%20Sexualidad%20Completa.pdf
http://repositorio.uan.edu.co/bitstream/... .

In addition to the above, the findings of this study suggest strategies for disease prevention and sexual health promotion, specifically to promote increased condom use, thus reducing cases of STIs. Beyond promoting pedagogical spaces, it is essential that information about condoms and STIs be accompanied by the promotion of self-care. Likewise, the information should be provided by people they trust in, and who do not judge their gender identity, sexual orientation, and sexual practices.

Limitations

This study has some limitations: the sample size does not allow generalizations, as it was based on convenience and intentionality, as well as voluntary participation and snowball strategy, something that occurs very frequently in studies with transgender population, as shown in studies³⁴34. Ávila MM, Farias MSR, Fazzi L, Romero M, Reynaga E, Marone R, et al. High frequency of illegal drug use influences condom use among female transgender sex workers in Argentina: impact on HIV and syphilis infections. AIDS Behav. 20217;21(7):2059-68. https://doi.org/10.1007/s10461-017-1766-x
https://doi.org/10.1007/s10461-017-1766-... ,⁵²52. Bao A, Colby DJ, Trang T, Le BQ, Dinh TD, Nguyen QH, et al. Correlates of HIV testing among transgender women in Ho Chi Minh, Vietnam. AIDS Behav. 2016;20 Suppl 3:S371-8. https://doi.org/10.1007/s10461-016-1574-8
https://doi.org/10.1007/s10461-016-1574-... ,⁵³53. Degtyar A, George PE, Mallma P, Diaz DA, Cárcamo C, García PJ, 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. 2018;30(1):81-91. https://doi.org/10.1080/19317611.2018.1429514
https://doi.org/10.1080/19317611.2018.14... . Therefore, the sample of this study presents a high degree of homogeneity, which in turn is related to the difficulties of access to the population studied.

The snowball technique led us to recruit subjects from strata 1, 2 and 3 with incomes below the legal minimum wage in force in Colombia (approximately 280 dollars). This has limited the possibility of analyzing the wealthier population. We also recognize that there are other socio-cultural discourses and knowledge relevant to understanding the phenomenon studied, which did not emerge in our interviews.

CONCLUSION

Although the term “key population” assigned to specific populations, including trans women, is currently being debated and analyzed in Colombia⁸8. Cuenta de Alto Costo. VIH Sida en Colombia, retos y apuestas en salud. Bogotá (CO): CAC; 2020 [cited 2021 May 29]. Available from: https://cuentadealtocosto.org/site/vih/vih-sida-en-colombia-retos-y-apuestas-en-salud/
https://cuentadealtocosto.org/site/vih/v... , studies are needed to understand the sexual practices demanded by trans women’s sexual partners (clients or steady partners), as well as social and political efforts to improve the possibilities of access to formal work for trans women in Colombia. The findings of this study provide an important basis for the development of future interventions to promote condom use among trans women. For the positive impact of these interventions, strategies that are adapted to the population become indispensable, e.g., that leadership is carried out by the trans population that recognizes the dynamics and life experiences of participants.

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