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Respondent demographics

Median age of respondents was 26 years (IQR 21.532.5), and all reported current engagement in commercial sex work at the time of data collection (Table1). 85% of respondents reported living in one of the three casas trans. Five respondents (25%) were born in Lima/Callao. Among respondents born elsewhere, median time spent living in Lima was 5 years (IQR 1.6-7). 35% of respondents reported being in a partnership and 55% reported having one or more dependents.

In SNIs, respondents nominated a total of 161 alters they had interacted with in the past month (Table2). Median age of alters was 26.5 years (IQR 22-39.5). Median social network size was 7 (IQR 6-10.5, range 317). 33% of alters were cisgender men, 34% were cisgender women, and 33% were TW. All respondents nominated at least one family member as part of their network, with family comprising 52% of alters. Seven respondents reported being in a partnership at the time of the study. There was overlap noted between TW networks, where several respondents nominated the same TW alter(s) (Fig.1A-D).

There was no difference in the perceived provision of emotional support based on alter relationship type (Table3) or gender identity (Table4). Family members were less likely to provide financial support (adjusted (a)OR 0.21, CI 0.080.54) compared to non-family members. TW alters were more likely to be considered sources of financial support (aOR 3.08, CI 1.227.75) compared to alters who were not TW. Being a family member was associated with a lower likelihood of providing instrumental support compared to non-family member alters, while being a TW was associated with a higher likelihood of providing instrumental support (aOR 6.24, CI 2.8113.84) compared to non-TW alters. Family members were less likely to provide HPS than non-family alters, while TW alters were more likely to provide HPS (aOR 3.24, CI 1.188.92) compared to non-TW alters.

Respondents reported weekly communication with 77% of non-family and 45% of family alters. Respondents reported weekly communication with 83% of TW alters compared to 49% of non-TW alters (aOR 6.95, CI 2.8217.10). Family members were significantly more likely to communicate with respondents via telephone and computer and less likely to communicate in person. In comparison, alters that were TW were more likely to communicate with respondents in person and less likely to communicate via phone.

Respondents primarily viewed family members as sources of emotional support that appeared to be valued despite the distance and superficiality of many of their interactions. However, several respondents did report more involved family members, which contributed to positive feelings and support for self-efficacy and health promotion.

In SNIs, 75% of respondents reported receiving emotional support from family members (Fig.1A). In qualitative interviews, almost all respondents identified a family member, most often a cisgender woman such as a mother or sister, as one of the most trusted, influential, and closest members of their network. Families were widely considered an important source of social and emotional support, which was often simply associated with their role as family members. Several respondents echoed the sentiment that they trusted and felt closest to their mothers simply because she is my mama. Even respondents with family members who did not accept their gender identity sometimes considered them close network members.

Discussions with family members were often described to be superficial, involving general encouragement to maintain a healthy lifestyle and avoiding explicit discussions about sexual health, HIV/STI prevention and trans-specific issues such as access to gender-affirming healthcare. Family members expressions of concern and questions about wellbeing were not always well-articulated and were instead encompassed by the general advice to take care. This level of support was generally considered basic and less practical within the context of respondentslifestyles, but was still appreciated as a demonstration of care.

She [mother] is always giving me advice, telling me to take care of myself, how am I, she is always asking, if I have eaten lunch or not 23 years old, from Pucallpa.

We just chat like this how are you girl, are you doing well? My brothers, my sisters-in-law, everyone, Take care of yourself are you doing well? 36 years old, from Pucallpa.

However, when families accepted respondents identities and openly discussed issues including HIV/STI risk, gender-affirming procedures, and/or sex work, respondents often described feeling encouraged to engage in HIV preventive behaviors and empowered in the face of discrimination. One respondent even described her mother helping her pay for gender-affirming care, while others described feeling emotionally supported through their transition.

I think she [mother] felt bad when I started to get depressed because I was feeling the bullying from people, so we talked more and she understood my suffering and my desire to be a woman physically because internally I have always been one. So then she said, Im going to support you. 38 years old, from Lima.

She [sister] always tells me whatever you decide I will always support you, I have no reason to be judging you, nor telling you things. 22 years old, from Cajamarca.

Though less common, some respondents also reported receiving encouragement from family to engage in HIV/STI prevention, with one respondent describing that her mother reminded her to take PrEP and another stating that her mother buys her condoms.

When [my mother] found out I was gayshe accepted me for who I am. [She told me] to take care, that there are [sexually transmitted] diseases, that I should always use protection. 19 years old, from Pucallpa.

More often, when respondents felt comfortable discussing HIV/STI prevention with family members, respondents were the ones initiating this conversation to educate their family about these issues.

I have explained to [my mother] the risks that Im exposed to from working in the street I tell her that there are various sexually transmitted diseases like HIV, AIDS, syphilis. 27 years old, from Piura.

Some even used their experience and knowledge to advise younger family members, such as siblings, nieces, and nephews, about HIV/STI prevention.

I told [my sister], you have to use a condom so that you dont get pregnant, another reason is there are plenty of sexually transmitted infections like HIV, the condom isnt just for pregnancy, but also for other risks that you need to protect yourself from, I told her. 23 years old, from Pucallpa.

Based on qualitative discussions, respondents appeared to hold the role of active support figures for the rest of their families. The support respondents reported receiving from their family was primarily social and emotional, while the support respondents provided to family was often much more tangible. While six respondents nominated a family member as a potential source of urgent financial assistance if needed (Fig.1B), almost no respondents reported receiving consistent financial support from their families. On the other hand, several respondents reported that they were responsible for providing consistent financial support to their families and notably, almost half of respondents reported having no sources of consistent financial support themselves.

My family is depending on me, theyre passing through a [difficult economic] situation. I send them 100, 150, 200 Soles weekly. 28 years old, from Pucallpa.

I support [my mother] economically I send her money weekly for her food costs, or for my nieces costs, for her school. 27 years old, from Piura.

Eleven respondents (55%) identified a current or former romantic/ primary partner as part of their network. Of note, no respondents included any other sexual partners among this list, though other partners were briefly mentioned in interviews. Almost all partnered respondents reported receiving emotional support from their primary partner (Fig.1A). In interviews, several respondents described partners who made them feel respected and confident, which contributed to feelings of empowerment and resistance against stigma and discrimination.

He makes me have a lot of confidence in myself. With the other partners I had, it was like they hid me, dont come to my work, wait for me on the corner. Him no, sit at my side while I work or come to my house, come to the room where I live. Things like that. 38 years old, from Lima.

Most respondents with long-term partners reported being financially supported by these partners in some way, such as helping with rent payments, though a few TW also described financial arrangements that involved shared expenses within these relationships.

Well we both support each other, my partner and I. The day that he doesnt have [money], well I go out [to work] like him, he is also working. 38 years old, from Lima.

Most partnered respondents described partners checking in on their health generally or even taking care of them when they were sick. However, with regard to HIV/STI prevention, respondents felt responsible to educate and provide that type of support to their partners.

He [partner] did know about HIV but didnt know some things that I, from experience, know a ton. About precautionsabout how to avoid contracting [HIV]. 38 years old, from Lima.

In this way, respondents were again found to be important sources of support within their other relationships. While the type of social support received in return was not always as tangible, when present and robust, it had the potential to contribute to emotional wellness and empowerment.

In SNIs, respondents reported receiving a significant amount of support at all levels from other TW. Importantly, this support was concrete, bidirectional, and shared within their community. 70% of respondents reported receiving emotional support from other TW and 75% reported receiving instrumental support from other TW (Fig.1A C). Respondents and other TW in their networks had a unique and important role in creating new social structures and channels of support within their community. Many respondents reported moving from other regions to come to Lima and feeling supported by TW in the area who welcomed and oriented them to the local community. In this way, the casas trans represented gateway points for integration into the local community of TW and were essentially a pre-existing support system and network that TW who were new to Lima could connect with.

Everyone [in my family] lives in Pucallpa All I have here are the trans girls that are also my friends. 28 years old, from Pucallpa.

Several respondents who did not have supportive family members cited this fact as another key reason for moving to Lima, where they found a more supportive environment. These new and alternative systems of support created by TW for other TW contrasted significantly with the more traditional family and romantic relationship structures respondents described. Support systems within the trans community were generated organically as a result of shared identities and experiences, and were crucial for defining social norms, sharing knowledge, and facilitating labor opportunities.

I decided to change physically [transition], so I made the decision to come [to Lima] and I contacted the girls here and at that time they were already working in this environment [sex work]. 28 years old, from Pucallpa.

I simply came [to Lima] because I had friendships here, and then I stayed. My friend encouraged me, dont go, get to work here, here well make money and I stayed to work. 19 years old, from Tarapoto.

Financial and instrumental support was described to be bidirectional in these relationships; TW helped each other out as needed.

When sometimes she [TW friend]doesnt have [money] and I do, and sometimes when I dont have [money] and she does, I invite her to eat like this and she does the same. We support each other. 19 years old, from Tarapoto.

When I need to eat, she [TW friend] supports me because she has a kitchen, she cooks or she lends it to me, and also she lends me clothes, or I also lend her things and its like this. 23 years old, from Pucallpa.

In general, respondents tended to have fewer sources of HPS, and TW represented a majority of those sources (Fig.1D). TW network members were reported to provide more active and concrete HPS in the form of knowledge sharing, facilitating access to services, and modeling HIV preventive behaviors, especially in the context of sex work, in contrast to the general encouragement respondents sometimes described receiving in relationships with family or partners. Often, older or more experienced TW educated younger or newly arrived TW, such as those that were new to the city and/or the profession of sex work. Several respondents reported that the friend that introduced them to sex work and this community of TW also taught them about prevention.

When I started working in this [sex work] a trans friend [told me] that I always have to use condoms, always in this routine that I have, I have to use them because it is sex work. 31 years old, from Trujillo.

Thus, although some respondents received HPS from family, TW were typically the source of HPS and education for their non-TW network members. In relationships with other TW, the provision of this type of support was often bidirectional as respondents described being in positions to both give and receive all types of support within their network of other TW.

A-D Social network graphs depicting alters nominated as potential sources of emotional support, instrumental support, financial support, and HIV prevention support

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