Transgender and HIV: Risks, Prevention, and Care

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Transgender Health and Social Service needs in the Context of HIV Risk
by Nina Kammerer, Theresa Mason, and Margaret Connors

Citation: Kammerer N., Mason T., Connors M. (1999) Transgender Health and Social
Service needs in the Context of
HIV Risk. IJT 3,1+2, http://www.symposion.com/ijt/hiv_risk/kammerer.htm

Abstract
Introduction
Research methods
Health and Social Service Needs
Problems in Obtaining Appropriate Services
Implications and Recommendations for HIV Prevention
References
Abstract
This article describes difficulties transgenders encounter in obtaining health
and social services, including targeted HIV
prevention. Based on an anthropological HIV/AIDS needs assessment for the
transgender community of Boston,
Massachusetts, we identify misperceptions that interfere with the provision of
caring and appropriate services, including
for the most economically vulnerable male-to-female transgenders who were the
focus of the study. Drawing on the work
of a Boston-based transgendered activist, Rebecca Durkee, we recommend specific
steps for HIV/AIDS prevention that
can contribute to reducing transgenders' risks of HIV infection. These steps can
also contribute to community building
and pride and thereby to diminishing the social stigma and discrimination that
shape both transgenders' HIV risk and their
difficulties in obtaining health and social services.

Introduction
The qualitative anthropological research on which this article is based was
commissioned by Rebecca Durkee, founder
of Gender Identity Support Services for Transgenders (GISST), an advocacy and
service program located in Boston. In
1995, Ms. Durkee obtained funding for an HIV/AIDS needs assessment for the
transgender community of Boston from
the Massachusetts Department of Public Health, AIDS Bureau. The authors, all
medical anthropologists who have done
HIV/AIDS research in the United States or abroad, were hired by Ms. Durkee to
conduct the study. Our research and
the resultant report focused on the segment of the transgender community served
by Ms. Durkee, namely, economically
and psychologically vulnerable male-to-female transsexual and transgendered
individuals, many of whom end up in the
street at some point in their lives, engaging in commercial and survival sex
(Mason et al. 1995).

Central to our research was unraveling the structuring of risk for HIV infection
among transgenders. Transgenders' sexual
and injection risks for HIV arise from three main sources: (1) social stigma and
related negative self-image, (2) economic
vulnerability and related prostitution and substance abuse, and (3) the quest
for a feminine body and the need for identity
affirmation. We found that for many economically vulnerable male-to-female
transgenders substance abuse was
precipitated by participation in prostitution rather than the other way around.
Transgenders' needle risk for HIV stem not
only from the injection of illicit drugs, but also injection of hormones for
bodily transformation or silicone for breast
augmentation as part of the quest for a feminine body. The need for identity
affirmation through sexual expression can
lead to unsafe sex.

Elsewhere we have discussed transgenders' HIV risks (Mason et al. 1995; Kammerer
et al. in preparation). The focus
here is on the kinds of health and social services transgenders require,
problems specific to the transgender community
in getting such services, and, finally, insights that providers and transgenders
themselves have into how services can be
improved, especially in AIDS prevention and risk reduction.

In this article, the noun transgender and the adjective transgendered are used
in a broad way, encompassing individuals
who self-identify as transsexual, whether pre-operative, post-operative, or
non-operative, that is, not desirous of having
sex reassignment surgery, and individuals who self-identify as transgender. Our
research focused not on transvestites
who cross-dress but on transgenders who cross-live (Woodhouse 1989). Since the
1980s, a grassroots political
movement, sometimes labeled transgenderism (Rothblatt 1995, p. 16), has grown up
seeking transgender rights and
affirming transgender pride (Bolin 1994; Feinberg 1996). For many in the
transgender - or "trans" - movement, the label
transgender encompasses not only transsexuals and transgenders, as it does here,
but also cross-dressers or
transvestites, drag queens, intersexed individuals, and anyone
non-conventionally gendered (Feinberg 1996). For some,
trans unity is within the "queer" nation, with the term queer being expanded
from meaning homosexual only to meaning
non-conventional sexual orientation and/or gender identity (Valentine
forthcoming).

After describing our anthropological research methods, we consider health and
social service needs. Our contention is
that the difficulties transgenders have in gaining access to shelters, securing
safety in prisons, obtaining appropriate
mental health counseling, as well as other health and social services, are
related to their risks of HIV infection. This is a
continuation of our argument, outlined above, that discrimination and social
stigma shape transgenders' HIV risk
behaviors. Next we identify and correct some misinterpretations held by health
and social service providers that
contribute to transgenders' difficulties in obtaining caring and appropriate
services. We conclude with specific
recommendations for HIV prevention and risk reduction, particularly for the most
economically vulnerable male-to-female
transgenders who often end up in the streets and/or in prostitution. HIV
prevention by and for transgenders can help
reduce the incidence of AIDS at the same time that it provides positive role
models and contributes to community
building.

Research methods
Adhering to an ethnographic research approach, we attempted to understand HIV
risks and health and social service
needs from transgenders' and service providers' perspectives. Between April and
August, 1995, the researchers did
focus groups and open-ended interviews with transgenders and interviews with
health and social service providers. In
addition, we visited three transgender bar scenes in person to observe
first-hand. One of us also attended two of a series
of trainings for service providers led by Ms. Durkee on transgender health
issues; these were funded by the
Massachusetts Department of Public Health and held throughout the state.

Transgendered interviewees and focus group participants ranged in age from
mid-twenties to forty and included African
Americans and Anglo Americans, as well as a person living with AIDS and an
eighteen year-old recently arrived in Boston
and currently a street sex worker. Individual key informant interviews were held
with four transgendered individuals,
including an Anglo former escort service sex worker and a Latina living with
AIDS. The service providers interviewed all
worked in the field of HIV prevention and/or services for street youth.
Additional interviews were done with Ms. Durkee
and four other local transgender activists, including one female-to-male, in
part to clarify the varieties of transgenderism.

While the data focus on the economically most vulnerable transgenders, some of
the findings, especially concerning the
barrier that stigma and discrimination pose to appropriate care (Green et al.
1994), are likely to be valid even for more
economically advantaged transgenders. Similarly, while the findings cannot be
assumed to be applicable to female-to-
male transgenders, other sources suggest that discrimination diminishes the
quantity and quality of care they receive.


Health and Social Service Needs
Transgenders, whom one activist called "the orphans of the orphans," have great
difficulty with access to health and
social services. Even when transgenders do gain access, their difficulties
continue, since providers frequently do not
understand them and their needs. Aside from GISST, Enterprise (for
female-to-male transsexuals), and Boston Alliance for
Gay and Lesbian Youth (BAGLY), only one Boston service provider, the Fenway
Community Health Center's Color Me
Healthy program, explicitly targeted transgenders at the time of our research.
The economically vulnerable male-to-female transgenders who were the focus of
our needs assessment reported that
they rarely seek medical care except as it relates to their quest for a feminine
body. There are numerous reasons for this,
with lack of insurance and lack of acceptance prominent among them.
Transgenders' fears of rejection by medical
practitioners and facilities are founded either on personal experience or on
gossip about the degrading and even
dangerous encounters that others like themselves have had with doctors and
hospitals. One self-identified pre-operative
transsexual told a horrifying story of being sent away from a well-known Boston
emergency room after a car accident
even though she was suffering from serious injuries, including fractured
vertebrae and a concussion. When her male
genitalia were discovered under her female clothing, she was discharged without
treatment!

Transgenders know well from experience or from their peers that "homeless
shelters won't let a queen in. They say 'dress
like a man or get the hell out!' So you're forced back into the element," that
is, back onto the street. Staff at shelters will
not accept male-to-female transgenders in women's shelters, and most will not
permit them in men's shelters unless they
wear men's clothes. If transgenders are allowed to wear their own clothes in
men's shelters, they are subject to derision
and possible violence by fellow clients and sometimes by staff. Even if they
disguise their core personal identity by
dressing in men's clothes, they still run these risks. Service providers
interviewed attested that it was nearly impossible to
refer transgenders to shelters; one even used the adjective "ludicrous." This
same provider reported that when he
worked in Worcester, the state's and region's second largest city, he could not
find shelters willing to take transgenders
but could sometimes find sympathetic service providers willing to put them up in
their own homes for a night. Ms. Durkee
has successfully placed a male-to-female transgender at Rosie's Place, a shelter
for women in Boston.

In Boston, there are no alcohol or drug treatment groups or facilities
specifically for transgenders. Some find support in
12-step programs run for and by the gay community; yet historical friction
between transgenders and the gay community
means that this is not always a workable fit. 4 Residential detoxification
programs present the same problems as
homeless shelters: transgenders are rarely placed in women's programs, and in
men's programs they are either forced to
hide their core personal identity or risk scorn and possible physical abuse. The
only case we learned about of a male-to-
female transgender being placed in a women's program was for Worcester rather
than Boston. As one interviewee said:
"[We] can't get into detox without going completely against our nature. How
would you like to be called 'sir' all day
long?"

Obviously, the problems for transgenders in prison are similar and likely to be
more serious. Only those few who have not
only completed sex reassignment surgery but also legally changed their sex from
male to female on their birth certificate,
which is, in fact, only possible in some states, would be put in a women's
prison (Stuart 1991, pp. 67 and 71). In a men's
correctional institution, male-to-female transgenders are vulnerable to various
forms of abuse, including forced sex with
inmates or guards. One of the respondents in a focus group who had recently
gotten out of prison told such stories,
observing that when she complained to a guard she was told to "deal," since the
guard felt that she was the one who
wanted to be a woman. The risk of physical abuse, including sexual abuse, is
very real not only inside correctional
institutions but outside in society. Some interviewees told of being forced to
have sex with prison guards or others whose
duty was supposed to be to protect them, while others told of being physically
assaulted on the street. Lacking financial
resources and knowing society's disdain for them, these individuals do not seek
redress through the legal system.

According to service providers, transgenders are disproportionately represented
among street youth, as are gays and
lesbians. Given that problems in school and at home often contribute to a young
person being on the street, this
disproportionate representation is not surprising. Unfortunately, however, we
found only one self-identified transgender
service provider working directly with youth in the Boston metropolitan area.
Fortunately, however, Boston's providers of
services to street youth recognize the need for transgendered workers, although
they have had difficulty finding and
retaining such workers.

To get off the streets, transgenders, whether youth or adults, need jobs to
provide the financial resources to pay for
housing, food, and other necessities. But society makes it extremely difficult
for transgenders to hold down jobs,
especially those who do not pass well. Job training and placement are thus
useless unless accompanied by efforts to
ensure that transgenders will be retained on the job even with a five-o'clock
shadow. Such efforts would need to include
education to alter social attitudes towards transgenders and legal changes to
prevent and punish discrimination against
them. Currently such discrimination is not illegal. Transgenders often have
trouble getting on welfare because, as one
provider explained, "from the minute you write in your name, welfare will say,
'No, what's your real name?' And right there
it's downhill."

The social stigma that transgenders face from early in life is translated via
internalization and fear into psychological
problems, notably, low self-esteem and even loathing, often to the point of
suicidal tendencies. Transgenders are thus
frequently in need of sensitive and knowledgeable counseling. Unfortunately,
their issues and problems are often little
understood by providers of psychological services. One service provider, who had
himself sought such services in his
youth, noted that in practice,

Service providers who serve adolescents really don't encourage people to
experiment far from the norm. . . . I think they
say, "Well, this is nice and everything, but your goal is to act as conventional
as possible by the time you're out of our
hands." So, you know what I mean? So it's like "that sounds great and everything
but ditch the eye make-up," you
know?

While this comment was made with respect to providers of services to
adolescents, similar failures to acknowledge and
respect the seriousness of transgender issues can also be found among counselors
serving adult transgenders.

Various forms of outreach that might be thought to serve transgenders do not do
so effectively. For example, given the
existence of friction between the gay and transgender communities and the fact
that most transgenders do not self-
identify as gay, gay organizations can have trouble reaching them. It is also
important to point out, as one gay service
provider did, that gays are not necessarily any more knowledgeable about
transgenders and their issues than anyone
else. After listening to a colleague give a nuanced and thorough overview of
transsexual, transgender, and related
categories, he commented, "I can tell you that the average gay man living in the
South End [a gay neighborhood in
Boston] would not have said anything other than people who have a sex change
operation." His colleague, himself a
drag performer, pointed out that gay men also mistake transgenders for drag
queens, that is, for homosexual men who
wear women's clothes for performance (see Newton 1972).

Organizations that target prostitutes are often run by women for women, and
transgenders are left out. As Janice
Raymond's attack on transsexuals in her book The Transsexual Empire testifies,
some women, more particularly, some
feminists and lesbian feminists, are antagonistic towards transsexuals --
"artificial women" in Raymond's (1994[1979], p.
69) terms -- because they are seen as representing a retrogressive vision of
womanhood.

Cruising zones for female, gay, and transgendered commercial sex workers are
geographically separate. One particular
Boston neighborhood is known as the transgender zone; indeed, one transgendered
interviewee said that she assumes
that any man who does a pick-up there knows that the prostitute is
transgendered. This geographical specialization
means that outreach workers in a zone traditionally used by women sex workers or
by gay street hustlers are not likely to
run into transgendered sex workers. The same is true for drug outreach. While
many transgenders have drug problems,
they are not reached by services targeted to the drug-using population because,
as one transgender observed, "They
are in different areas, keep different hours."

Another reason that transgenders may not be reached effectively by drug outreach
is that, in the words of one service
provider, it is for "people who are about needles" and transgenders are not
primarily about needles. Thus, transgenders
often "don't identify as drug users . . . even though they're using a pretty
high amount of recreational drugs." For them,
their primary issue is a "gender issue" rather than drug use. People who are
about needles are likely to go to substance
abuse outreach workers who "talk that talk." What transgenders need is outreach
workers who talk gender issue talk.

Despite the significant HIV/AIDS risks faced by transgenders, we could locate
targeted prevention programs in only a
handful of locations around the country. Besides Ms. Durkee's work locally in
Boston and statewide in Massachusetts,
these include efforts in Minneapolis, Minnesota (Bockting et al. 1993); San
Francisco, California (Green et al. 1994, p.
29; Lockett 1995, p. 213); New York City (Withers 1995; Newsline 1996. p. 38);
and Philadelphia, Pennsylvania, where
ActionAIDS (1994) has Care in Action Transgendered Program, which includes
street outreach, a telephone information
line, and support groups by transgenders for transgenders. In Boston, there are
no AIDS prevention messages posted at
the primary drag queen and transgender bar. Transgenders report that condoms
distributed free to this establishment are
kept behind the bar out of sight instead of being openly available on the
counter like in many other bars. The service
organization founded by Ms. Durkee is the only transgender organization locally,
or, indeed, in Massachusetts as a
whole, dedicated to HIV/AIDS prevention for this community.

Once transgenders are infected with HIV, they confront the problem with which
this section began, namely, lack of
access to standard medical care. One HIV-positive self-identified transsexual
interviewee, who is unusual in having the
benefit of membership in a health maintenance organization (HMO), recounted a
sad saga of trying to find a participating
physician to treat her. She called every provider listed in a lengthy booklet
sent out by her HMO. Some hung up on her;
others refused to accept her as a patient. She found only one doctor on the list
willing to take her on as a patient.
Fortunately for her, he is not only willing to treat her but also familiar with
transsexuality, having worked in the past at The
Johns Hopkins Gender Identity Clinic. What would she have done if she hadn't
found him?

Problems in Obtaining Appropriate Services
Problems in obtaining services, such as discrimination, lack of acceptance, and
absence of legal protection, are already
evident from the preceding discussion. Many of these stem from the social stigma
carried by transgenders. For example,
placement in shelters for either women or men would not be a problem if society
accepted transgenders wholeheartedly.
Here we correct some misperceptions commonly held by service providers that may
inhibit the provision of appropriate
health and social services. Before so doing, we want to stress that in our
interviews with Boston area providers we found
great concern about transgender issues, overwhelming interest in learning more
about transgenders and their needs, and
sincere desire to improve and expand services for them. In this spirit, we
identify some misperceptions that can hamper
the efforts of well-intentioned providers.

1. To be transgendered is not necessarily to be gay.

Transgenderism concerns gender identity rather than sexual orientation (Bolin
1988, p. 13; Stuart 1991, p. 5; Griggs
1998, p. 1). There are heterosexual, bisexual, and homosexual transgenders,
though sources report that the majority of
transgenders are heterosexual (Stuart 1991, p. 55). Some providers equate
transgendered gender identity with gay
sexual orientation. Yet information and approaches appropriate to gay men may
not fit the many transgenders who are
not homosexual and may be ignored or actively rejected by them.

Historically, transgenders have gravitated to gay spaces and communities, where,
as Stuart (1991, p. 41) observes, they
"find some measure of acceptance." Indeed, some transgenders not only spend time
within the gay community but also
consider themselves gay for at least a period of their lives. Stuart (1991, p.
47) reports that most of the heterosexually
identified transsexuals she interviewed "had explored the homosexual world."
Some male-to-female transgenders
consider themselves gay men only later to realize and/or acknowledge that they
are female rather than effeminate. As
the category transgender becomes more widely known, this phenomenon of a gay
phase in the life cycle of those
transgenders whose sexual orientation is not homosexual may become less common.

Given the co-existence of transgenders and gays in the same social space and the
gay phase in some transgenders'
lives, it is easy for service providers and others to mistakenly equate being
transgendered with being gay. It is also
important to point out that what appears to outsiders as a same sex encounter
may be perceived by one or more of the
partners as heterosexual. Thus, for a heterosexually self-identified
male-to-female transgender, whether possessing male
genitalia or surgically constructed female genitalia, having sexual intercourse
with a genetic male is a heterosexual act:
she is a woman having sex with a man.

2. Many, perhaps most, transgenders do not consider themselves drag queens.

Another misreading found among the gay community and elsewhere is to equate
transgenders with drag queens. Drag
queens, as one gay service provider who is himself a drag performer explained,
"do it for the show only, they don't try to
pass in real life, and the whole purpose of the show is look. . . . there's a
wink that goes on with the audience through
the whole show." Even those male-to-female transgenders for whom life's
exigencies - "grave concern over the potential
loss of jobs, family, and friends" (Griggs 1998, p. 39) -- prohibit living
full-time as women are not dressing for show but,
rather, to express their core gender identity. To read a transgender as a drag
queen is to trivialize her female self-identity,
misinterpreting it as simply dress or performance.

In sum, a drag queen, in the sense of a cross-dressing performer, may identify
as a woman while dressed as one.
However, transgenders by definition experience their gender as either distinct
from or in opposition to their biological sex
all the time. This is true even if they are unable to live out that gender
identity full-time. Some transgenders do perform in
drag shows. Since transgendered performers and gay drag queens often share the
same stage, equating the two is an
easy mistake for outsiders to make. Some transgenders self-identify as drag
queens while recognizing their difference
from their fellow drag queens who are non-transgendered. Some transgenders and
gay drag queens insist on remaining
united within the trans movement. At the Stonewall 25 march, in which drag
queens were placed in front and
transgenders further back, one transgender carried a sign saying "DRAG AND
TRANSGENDER WILL NOT BE
DIVIDED. QUEER UNITY = HUMAN RIGHTS" (Feinberg 1996, p. 99, photo and caption,
emphasis in the original).

3. Male-to-female transgenders do not necessarily live full-time as women.

At least one service provider defined transsexuals as living as the opposite
gender full-time. It is important to remember
that many exigencies, financial and otherwise, can prevent a male-to-female
transgender from always dressing as a
woman even if she wants to. So it would be wrong to assume that someone
presenting at a service provider in men's
clothes could not be a male-to-female transgender.

Transgendered interviewees reported that there are providers who believe that
some or all transgendered prostitutes
wear women's clothes to attract clients and/or get more money per trick. This
view depicts female presentation of self as
something put on and thereby refuses to recognize that for transgenders wearing
women's clothes is an expression of
their core personal identity. It is possible that this view derives either from
the misinterpretation of transgenders as gay or
as drag queens or from a mistaken analogy between them and those male street
hustlers whose sexual orientation is
heterosexual but who act homosexual for money, engaging in sex with men only
when hustling.

4. Transgenders' adolescent confusion is not the same as other adolescents'
confusion.

An additional misperception is to equate transgenders' adolescent problems with
typical adolescent soul-searching and
rebelliousness. On the surface the confusion of a non-transgendered adolescent
who is experimenting with identities
and/or sexual orientations may appear similar to that of a transgendered
adolescent. Yet they spring from vastly different
sources, and transgenders can suffer from both sorts of confusion.

Adolescence is recognized as a time of searching, experimentation, and rebellion
as self-identity is defined and
independence established. An adolescent, whether transgendered or not, may be
unsure of their identity. Yet there is a
significant difference between confusion arising from not knowing who you are
and confusion arising from a disjuncture
between your personal self-knowledge and the categories and roles society
presents and accepts. Whereas the
confusion of a typical teenager falls into the first, the so-called confusion
specific to a transgendered teenager falls into
the second.

Transgenders typically know themselves to be different from an early age (Stuart
1991, pp. 38-50), as young as three
years old for one of our informants. As Griggs (1998, p. x), herself a
male-to-female transsexual, notes, most of her
transsexual informants "believe that it is something they were born with."
Transgenders may not have the categories with
which to think about and understand their difference until much later in life,
however. For such individuals, knowing that
there are others like themselves can be a lifeline which, quite literally,
prevents them from committing suicide. Vivian
Allen, formerly of the Waltham-based International Foundation for Gender
Education (IFGE), reported that "every day
someone calls up and says 'Oh, my God, I thought I was the only one'."

During a state-funded training on transgender health led by Ms. Durkee in
Worcester, Sterling Stowell of the Boston
Alliance for Gay and Lesbian Youth emphasized that there is a difference between
playing with gender identity and/or
sexual orientation as part of adolescent exploration and "seriously exploring"
sexual orientation by gay, lesbian, and
bisexual youth and gender identity by transgendered youth. What it means to
provide a safe space for playful adolescent
exploration and for serious exploration is different. Many service providers
steer clear of labels -- gay, lesbian,
heterosexual, homosexual, and the like -- so that adolescents can find
themselves rather than being pigeon-holed by
others. Yet precisely what youthful transgenders may need is categories to help
them name what they already know but
for which they have no label. For transgendered youth to discover other
transgenders can be transformative, as one
transsexual we interviewed recounted:

And then I had met a transsexual. . . . I met her and I saw a little of myself
in her. I looked at her, admired her for her
going out and doing what she wanted to do for her self-comfortability [sic], and
how she saw herself within.

Shifting identities, often including a period of gay self-identification, are
evident in the life histories of transgenders
collected by us and by other researchers (e.g., Stuart 1991:47-48). These must
be understood, at least in part, as
expressions not of fluid personal identity but of the quest for a fit between
individual self-perception and social categories.
There are no legitimized existing social categories for who transgenders are.
Transgendered adolescents confused about
where they fit into society may well need affirmation that they are not
experimenting but rather expressing their
fundamental personal identity. This affirmation may be particularly important
coming from service providers. It may help
transgenders to avoid seeking social acceptance in risky ways, including through
unprotected sexual encounters with
male paying or non-paying partners who treat them like women (Mason et al. 1995;
Kammerer et al. in preparation).

5. Male-to-female transgenders are not necessarily feminists.

Providers can go overboard in affirming the womanhood of a male-to-female
transgender. That a transgender considers
herself a woman does not mean that she is a feminist. A feminist and/or lesbian
may not be the most appropriate service
provider for "a queen" who, in the words of one interviewee, " tries to be the
perfect girl" whose idea of femininity may
be retrogressive from a feminist and/or lesbian perspective. At the Worcester
training led by Ms. Durkee, a service
provider had an epiphany in which she laughed at herself for assigning a
male-to-female transsexual to a radical lesbian
service provider.

Implications and Recommendations for HIV Prevention
Both transgenders and service providers pointed to community building as the
foundation not only for HIV/AIDS
prevention but also for improved health and social services more generally for
transgenders. Pointing to the model of the
gay community, they stressed that without a strong sense of community and mutual
responsibility transgenders cannot
get the kind of support they need as individuals. In addition, they pointed out
that self-respect and pride promote
changes in social attitudes towards members of the community by outsiders which,
in turn, foster self-respect. Since
many HIV/AIDS risks among transgenders arise from social stigma and resultant
self-loathing, community building is
fundamentally related to HIV/AIDS prevention, as well as to other health and
social service needs (Mason et al. 1995;
Kammerer et al. in preparation). Transgenders and providers also identified
having transgendered leaders and role
models, transgendered outreach workers, transgender 12-step programs,
transgender support groups, and trainings in
transgender health like those conducted by Ms. Durkee as being vital to HIV/AIDS
prevention and to improving health
and social services more broadly.

The following recommendations draw directly on Ms. Rebecca Durkee's ideas,
insights, and work on HIV/AIDS
prevention.

1. Training on transgender issues.

In order to create a more socially accepting and supportive environment for
transgenders most at risk of HIV infection,
key HIV-related service providers should be trained in and sensitized to
transgender perspectives, issues, and
circumstances. Based on the state-funded trainings she conducted for service
providers, Ms. Durkee (1995) produced a
curriculum on HIV prevention for transgenders. The trainings themselves, which
were well attended and highly rated by
service providers, involved transgendered volunteers, including one woman living
with AIDS. These volunteers spoke in
public, in some cases for the first time, about the tremendous challenges they
have faced with different facets of the
health and social service systems. Such trainings clearly need to be continued
in Massachusetts and inaugurated
elsewhere. Given staff turnover at health and social service providers, they
should be offered on a regular basis.

2. Transgender-targeted HIV prevention outreach.

Outreach is needed to the streets and bars where transgenders commonly encounter
"tricks" or sexual partners. The
outreach should be conducted by transgender-identified individuals themselves in
order to establish the connections of
trust and rapport necessary for the HIV education and risk reduction process to
have an impact. This is also imperative
because of transgenders' tremendous need for role models and for developing a
sense of community. Transgenders
offering escort service advertisements in local papers, such as the Boston
Phoenix, should also be targeted. Outreach is
a crucial aspect of HIV prevention among those who have been marginalized and
who must struggle with poor self-
images. The outreach teams should be ethnically mixed to facilitate engaging the
diversity of transgenders in a variety of
neighborhoods, especially the younger and perhaps more isolated ones.
Collaborations should be pursued with local
agencies that may be intersecting with but perhaps not adequately addressing
transgenders in their areas. In the Boston
metropolitan area, for example, an agency such as Centro Hispano de Chelsea,
which is already involved with Latino
cross-dressers, might be enlisted.

3. Risk network-targeted HIV prevention.

Outreach should also work to have an impact on the customers at the bars and the
clients of transgender prostitutes as
well. It is Ms. Durkee's idea that a transgender outreach worker should visit
the transgender bars on weekend evenings
and on special event nights, which draw a larger clientele. These outreach
workers would carry around baskets of
condoms and generally strive to integrate the spirit, vocabulary, and materials
of HIV prevention into these scenes.
Another intriguing idea from Ms. Durkee and the transgendered volunteers with
whom she has been working is to
introduce educational skits containing HIV prevention messages into the shows by
transgendered and drag performers.
This would have a powerful impact on the culture of the bars. In anticipation of
the need to engage the bars in the HIV
education and risk reduction process, Ms. Durkee placed one of the
bartenders/managers on the board of the
transgender community-based service organization she formerly headed. Another
advantage of having transgendered
outreach workers in the prostitute stroll areas is the likelihood that they
would be approached by clients and could begin
the process of making them more aware of the need for prevention, providing them
with condoms and HIV educational
brochures.

4. Transgender-appropriate HIV prevention literature.

Another clear need is for the development of HIV prevention materials such as
posters, brochures, and risk reduction
packets targeted for transgenders. The tone and imagery, as well as the
information, should take into account the
serious need for transgenders to feel that they matter, that their health and
safety are important, and that they have the
power to protect themselves. Such materials should be posted and available in
bars and clubs, and in health and social
service agencies utilized by transgenders. Risk reduction packets could also be
created to be handed out to the street
sex workers and those transgenders frequenting bars.

5. Social acceptance and support.

Outreach is also needed as a means of engaging transgenders, especially
transgendered youth, in a process of self-
assessment and psychological support. Drawing individuals into an office or a
space where they can feel comfortable or
offering parties during which HIV education messages are conveyed can also
encourage the empowering experience of
feeling noticed and taken seriously. All of this can further advance the goals
of HIV prevention.

These five recommendations are made in recognition of the substantial HIV risks
faced by transgenders, especially male-
to-female transgenders involved in prostitution and related substance abuse. The
current near absence of HIV/AIDS
prevention for transgenders in Boston and throughout the United States can be
attributed in part to the invisibility of this
population and to its social and economic marginalization. Due to that
marginalization, it does not have the wherewithal
to protect itself without outside assistance. Interviews with activists
belonging to the economically more secure segment
of the transgender community revealed an unwillingness to confront HIV/AIDS head
on despite a recognition that male
cross-dressers -- transvestites - and economically well-off transgenders are at
risk like their less affluent transgendered
sisters. As Vivian Allen, previously of the International Foundation for Gender
Education, put it, "the problem always is
ownership." More affluent transgenders are loath to "own" HIV/AIDS because it
simply reinforces the stigma already
attached to transgenderism, a stigma which their transgenderist political
movement is trying to dispel (Bolin 1994;
Feinberg 1996). Ms. Durkee, who represents the most at-risk members of the
transgender community, has come forward
to claim ownership of HIV risk and prevention, as have a few of her
transgendered sisters in New York, Philadelphia, and
elsewhere. AIDS prevention by transgenders for transgenders is the necessary
first-step in ownership.

Nina Kammerer is a Senior Researcher at Health and Addictions Research, Inc. in
Boston and a Resident Scholar in
Brandeis University's Women's Studies Program, Waltham, MA. Theresa Mason is on
the senior research staff at Abt
Associates in Cambridge, MA. Margaret Connors is a Lecturer at Harvard Medical
School in Boston.

GISST is housed at Beacon Hill Multicultural Psychological Association in
Boston.

For example, in his keynote address to the 1997 Second New England Transgender
Health Conference, organized by
Rebecca Durkee, Leslie Feinberg, a well-known female-to-male transgender
"warrior" and author (1993, 1996),
recounted a saga of withheld and inappropriate care that almost cost his life
(Gray 1997, p. A28).

Female-to-male transgenders also face HIV risks. Social stigma and its
internalization as low self-esteem contribute to
their risks, just as they do to male-to-females' risks. Partly because their
hormonal transition is more complete, female-to-
male transgenders often pass more easily than their male-to-female sisters
(Griggs 1998, pp. 9 and 24). Whereas for male-
to-female transgenders hormone replacement therapy does not raise the voice or
eliminate the need for electrolysis, for
female-to-male transgenders it lowers the voice and encourages facial and body
hair growth. American gender ideology
may also be a factor in relative ease of passing, since short men attract less
notice than tall women. Greater ease of
passing together with the gendered wage gap between males and females in the
United States make female-to-male
transgenders somewhat less economically vulnerable overall, though individual
cases by no means always follow this
general rule. A key risk for male-to-female transgenders is participation is
prostitution, yet there is no market for female-to-
male sex workers. Contributing to female-to-male transgenders' risks, however,
is the sexual drive, sometimes both
precipitous and strong, brought on by the use of male hormones to effect bodily
transition, perhaps accentuated, as
Griggs (1998, p. 34) notes, by "cultural reinforcement of masculine [sexual]
expression."

4 Many transgenders feel that their contribution to gay liberation is either
unacknowledged or insufficiently
acknowledged. In 1969 at Stonewall in New York City's Greenwich Village, drag
queens and transgenders "fought back
against a police bar raid" (Feinberg 1996, p. 9). Transgenders and drag queens
who were thus at the forefront at the
Stonewall Rebellion, which is commonly considered the beginning of the gay
rights movement, have felt pushed aside,
even rejected, by the gay movement in its attempts to gain social and political
respectability.

For example, an article on "Providing Sensitive Health Care to Gay and Lesbian
Youth" observes that for those
adolescents who do not accept their homosexuality "[i]t is still premature to
label during this time of identity development"
(Sanford 1989, p. 35). Another article on the same topic observes that "the
12-year-old boy who has physical and
emotional attractions only to other males may question his identity as a male
until he feels more secure and healthy about
his gay sexual orientation" (Nelson 1997, p. 106). Interestingly, a sensitive
service provider could misconstrue a male-to-
female adolescent's female gender self-identity as a lack of self-acceptance of
homosexuality.

References

ActionAIDS (1994) "Don't Forget HIV/AIDS" (brochure). ActionAIDS: Philadelphia.

Bockting, Walter O., Roser, B.R. Simon, and Coleman, Eli (1993) Transgender
HIV-AIDS Prevention Program: Manual.
Program in Human Sexuality, Department of Family Practice and Community Health,
Medical School, University of
Minnesota in collaboration with City of Lakes Crossgender Community, Minnesota
Freedom of Gender Expression,
Minnesota AIDS Project, and Aliveness Aware: Minneapolis.

Bolin, Anne (1988) In Search of Eve: Transsexual Rites of Passage. Bergin &
Garvey: New York.

Bolin, Anne (1994) "Transcending and Transgendering: Male-to-Female
Transsexuals, Dichotomy, and Diversity," In
Third Sex, Third Gender: Beyond Sexual Dimorphism in Culture and History.
Gilbert Herdt, ed., pp. 447-486. Zone Books:
New York.

Durkee, Rebecca Capri (1995) The Invisible Community - Transgenders and HIV
Risks: Training Curriculum. Gender
Identity Support Services for Transgenders: Boston.

Feinberg, Leslie (1993) Stone Butch Blues. Firebrand Books: Ithaca, NY.

Feinberg, Leslie (1996) Transgender Warriors: Making History from Joan of Arc to
RuPaul. Beacon Press: Boston.

Gray, Steven (1997) "Conference Explores Health Care Bias against Transsexuals,"
Boston Globe, June 4, p. A28.

Green, Jamison, with Brinkin, Larry, and HRC Staff (1994) Investigation into
Discrimination against Transgendered
People. Human Rights Commission, City and County of San Francisco: San
Francisco.

Griggs, Claudine (1998) S/he: Changing Sex and Changing Clothes. Berg: Oxford.

Kammerer, Nina, Theresa Mason, and Margaret Connors (in preparation)
"Transgenders, Substance Abuse, and
HIV/AIDS: From Risk Group to Group Prevention," In Integrating Anthropological
and Epidemiological Approaches in
Prevention Research on HIV/AIDS and Drug Abuse. Patricia Marshall, Merrill
Singer, and Michael Clatts, eds.

Lockett, Gloria (1995) "CAL-PEP: The Struggle to Survive," In Women Resisting
AIDS: Feminist Strategies of
Empowerment. Beth E. Schneider and Nancy E. Stoller, eds., pp. 208-218. Temple
University: Philadelphia.

Mason, Theresa Hope, Connors, Margaret M., and Kammerer, Cornelia Ann (1995)
Transgenders and HIV Risks: Needs
Assessment. Gender Identity Support Services for

Transgenders, prepared for the Massachusetts Department of Public Health,
HIV/AIDS Bureau: Boston.

Nelson, John A. (1997) "Gay, Lesbian, and Bisexual Adolescents: Providing
Esteem-Enhancing Care to a Battered
Population," The Nurse Practitioner 22(2), pp. 94-109.

Newsline (1996) "AIDS in the Transgender Community," April, pp. 6-38. People
with AIDS Coalition of New York: New
York.

Newton, Esther (1972) Mother Camp: Female Impersonation in America.
Prentice-Hall: Englewood Cliffs, NJ.

Raymond, Janice G. (1994) The Transsexual Empire: The Making of the She-Male.
Teachers College Press: New York.
(Originally published 1979.)

Rothblatt, Martine (1995) The Apartheid of Sex: A Manifesto on the Freedom of
Gender. Crown Publishers: New York.

Sanford, Nancy D. (1989) "Providing Sensitive Health Care to Gay and Lesbian
Youth," The Nurse Practitioner 14(5),
pp. 30-47.

Stuart, Kim Elizabeth (1991) The Uninvited Dilemma: A Question of Gender.
Metamorphous Press: Portland, OR.

Valentine, David (forthcoming) "'We're Not about Gender': How an Emerging
Transgender Movement Challenges Gay
and Lesbian Theory to Put the 'Gender' Back into 'Sexuality'," In Anthropology
Comes Out: Lesbians, Gays, Cultures. Bill
Leap and Ellen Lewin, eds. University of Illinois Press.

Withers, Kristine (1995) "Notes from a Survivor," LAP Notes 3, p. 12. Lesbian
AIDS Project of the Gay Men's Health
Crisis: New York.

Woodhouse, Annie (1989) Fantastic Women: Sex, Gender, and Transvestism. Rutgers
University Press: New
Brunswick, NJ.

Acknowledgments: Our sincere thanks to Rebecca Durkee, founder of Gender
Identity Support Services for
Transgenders (GISST). We are grateful to Rebecca for the opportunity to do the
HIV/AIDS needs assessment on which
this article is based and for her invaluable assistance in facilitating the
research and in providing information and insight.

This article is a revision and expansion of sections of Transgenders and HIV
Risk: Needs Assessment (Mason et al.
1995). An earlier version was presented at the 1997 American Anthropological
Association Annual Meeting, Washington,
D.C., on a panel on "Transgender Identity, Community Building, and Health." Our
thanks to members of the audience, in
particular David Valentine, for their helpful comments. Finally, our
appreciation to our editors, Walter Bockting and Sheila
Kirk, for their suggestions.

Correspondence and requests for materials should be addressed to:
Nina Kammerer at nkammerer@....


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It is not the strongest of the species that survive, nor the most intelligent,
but the one most responsive to change - Charles Darwin

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