Photo by LuAnn Hunt on Unsplash

According to their website, the American Red Cross now uses a donor’s self-reported gender identity, not their birth sex, in determining eligibility for blood donation.

The new blood product safety guidelines issued by the Food and Drug Administration (FDA) in 2015 state, “In the context of the donor history questionnaire, FDA recommends that male or female gender be taken to be self-identified and self-reported.”

This is significant considering men who have sex with men (MSM) are still considered to be a high-risk donor group. Two-thirds of all new cases of Human Immunodeficiency Virus (HIV) in the US are found within this group, despite the fact that they only comprise 2% of the population overall.

While modern screening methods have dramatically reduced the risk of transmitting blood-borne diseases via blood products, there is, critically, a period of time between when a person is exposed to HIV and when it can be detected in their blood. During that “window period,” which can last as long as nine days, it’s possible for the virus to be transmitted to another person even though it can’t yet be detected in the blood of the donor.

It’s for that reason that MSM are deferred from donation until one year after their last sexual contact with another man.

Other high-risk donor groups requiring a deferral period include commercial sex workers, intravenous drug users, and people who’ve recently had a new tattoo or piercing. This waiting period allows time for any virus present in a donor’s blood to become detectable by nucleic acid testing, the highly sensitive test recommended by the FDA’s blood product testing guidelines.

While trans women identify socially and sometimes legally as female, they are biologically male. Over 90% of trans women undergo no gender affirming surgeries. According to the Center for Disease Control (CDC), 14% of trans women are infected with HIV. This figure, while lower than the estimated 19% infection rate for gay and bisexual men, is dramatically higher than the 0.2% infection rate for non-trans women.

Additionally, the 14% infection rate reported by the CDC doesn’t differentiate between trans women who have sex with men and those who have sex with women.

Because the FDA has directed the American Red Cross to use gender identity rather than birth sex in determining donor eligibility, a gay man in a monogamous relationship is ineligible to donate while a trans women is eligible with no waiting period after male sexual contact.

From the American Red Cross’s Blood Donation FAQ

It’s difficult to begin to guess at the the FDA’s justification for basing something as objective as blood donor risk criteria on something as subjective as gender identity, particularly when epidemiological statistics indicate that disease risk follows biological sex, not gender identity.

In addition to trans women being eligible to donate with no waiting period after sexual contact with men, trans men, who are biologically female, are not eligible to donate if they’ve had sex in the last year with someone who identifies as a man. This is likely to result in low-risk donors (for example, trans men in relationships with trans men) being turned away.

From the American Red Cross’s Blood Donation FAQ

Before the updated donor guidelines were issued by the FDA in 2015, there was discussion by the administration of removing the one-year MSM deferral period altogether, which would have allowed gay and bisexual men to donate blood regardless of their recent sexual activity. However, it was determined that doing so would present an unacceptable increase in risk to blood product recipients.

From the report:

“[I]n the setting of the approximately 50,000 new HIV infections per year in the United States, conservative calculations performed by FDA estimate that this approach could potentially be associated with an approximately four-fold increase in HIV transmissions resulting from blood transfusions each year. Such a policy, increasing the potential for the transmission of HIV infection, is not aligned with maintaining or improving the safety of the blood supply in the U.S.”

Aside from a single sentence directing agencies to use self-reported gender in determining donor eligibility, there is no discussion on the rationale used for classifying people this way for the purpose of blood donation. Nor is there any mention of the 14% HIV infection rate among transgender women.

In fact, the word “transgender” doesn’t appear in the guidance document at all.

In addition to the safety and supply concerns raised by this policy, there are patient care issues as well. A 2017 study found that men who had received blood from a woman who had previously been pregnant had a statistically significant increased short-term risk of dying when compared to men who received blood products from men.

These findings indicate there may be a strong case for matching blood products to sex. Current labeling practices, however, follow the FDA donor guidelines and indicate the gender identity of the donor rather than their biological sex.

Even if a provider wanted to give a patient sex-matched donor blood, they would have no way to do so with certainty.