HIV Risk Behaviors of Male-to-Female Transgenders in a Community-based Harm
Reduction Program

by Cathy J. Reback, Ph.D. and Emilia L. Lombardi

Citation: Reback C.J., Ph.D. and E.L. Lombardi (1999) HIV Risk Behaviors of
Male-to-Female Transgenders in a
Community-based Harm Reduction Program. IJT 3,1+2,
http://www.symposion.com/ijt/hiv_risk/reback.htm

Director
Prevention Division
Van Ness Recovery House
1136 N. La Brea Avenue
West Hollywood, CA 90038
323-463-2295 (phone)
323-463-0126 (fax)
Rebackcj@... Emilia L. Lombardi, Ph.D.
Post-Doctoral Fellow
Drug Abuse Research Center
University of California, Los Angeles
1640 S. Sepulveda Blvd, Suite 200
Los Angeles, CA 90025
310-445-0874, x291(phone)
310-478-7884 (fax)
Elomb@...

Abstract
Overview of the Community-based Program
Method
Conclusion and Discussion
References
Acknowledgements

Abstract
This paper analyzes data collected from a transgender HIV Harm Reduction Program
located in Hollywood, CA. Over an
eighteen-month period, from January 1996 to June 1997, 209 male-to-female
transgenders participated in the program.
Demographic data and baseline HIV risks were collected at first contact and
first intervention session, respectively.
Within this sample, HIV infection risk seems to be related to whether
participants engaged in sex work. The sex workers
were more likely to have used alcohol and other drugs, including injection
drugs, within the previous 30 days than the
non-sex workers.

Running Head: HIV Risk Behaviors of Male-to-Female Transgenders


Overview of the Community-based Program

The Van Ness Recovery House and Van Ness Prevention Division
The Van Ness Recovery House is a non-profit corporation dedicated to serving the
needs of gay, lesbian, bisexual, and
transgender/transsexual substance users. The recovery house, which was founded
in 1973, is a 90-day, 20 bed
residential drug and alcohol treatment facility. The Van Ness Recovery House
served its first transgendered resident in
1984. Between 1984 and 1988, the Van Ness Recovery House served one to two
transgendered residents per year.
Since 1988 to present, the Van Ness Recovery House has consistently served from
10 to 20 transgendered residents
per year. Additionally, since 1988 we have had a minimum of one transgendered
person of staff.

In December 1994, the Van Ness Recovery House began its Prevention Division
which offers HIV and substance abuse
prevention interventions to gay, lesbian, bisexual and transgender/transsexual
drug users in the Hollywood and West
Hollywood areas of California. The Van Ness Prevention Division (VNPD) is based
on the philosophy of harm reduction.
The overall objective of the prevention programs is to reduce the harm that can
result from drug use by preventing HIV
infection and managing the physical, psychological and psychosocial
manifestations of drug use without the requirement
of abstinence or recovery. Success is evaluated by any change in behavior that
reduces physical, psychological or
psychosocial harm to our participants, their loved ones, and/or their community.

The staff of the VNPD conduct face-to-face street outreach, counseling
interventions, immediate linkage to services,
pre- and post-test counseling, education/prevention groups, community workshops,
art exploration groups and support
groups. These services are provided on the streets in identified high-risk areas
of Hollywood, in natural settings where
participants congregate including street corners, bars, fast food stands, parks,
bathhouses, and sex clubs, and at the
Prevention Division site located at the intersection of the Hollywood/West
Hollywood stroll district.

The Transgender Harm Reduction Program
The VNPD Transgender Harm Reduction Program was initiated in October 1995 and is
designed to reach a variety of
male-to-female (MtF) transgendered individuals including persons living on the
streets or in low-rent hotels, sex workers,
bar queens, as well as those integrated and living in the suburbs. The specific
prevention interventions offered are based
on a needs assessment done prior to program implementation that included
in-depth interviews and a focus group with
members of the target population.

Staff conduct face-to-face outreach with transgendered persons on the streets in
identified high-risk areas and in specific
venues such as hotels and "queen bars" where transgendered persons are known to
congregate. Efforts are made to
have repeated contacts with clients to enhance trust and encourage participation
in the community workshops and
mentoring support group.

The workshop topics include grooming and hygiene, legalization and
documentation, health care, and hormone therapy.
These areas were chosen based on the results of the needs assessment. The
program consists of an outreach
component and a series of four community workshops designed to promote
skills-building and behavior change to
reduce HIV risk, a weekly mentoring support group, and job training. Implicit in
each workshop topic is the importance of
increasing self-esteem as an important precursor for adopting safer behavior.
Each workshop also includes an explicit
HIV/AIDS risk reduction component. Concurrent with the community workshops is
the weekly mentoring support group.
The format of the support group is open thereby providing an opportunity for
participants to choose the topic for
discussion. The program participants who complete the four community workshops
and maintain ongoing participation in
the support group are encouraged to serve as mentors to the newer participants.
Job training is available to each
participant after they complete the four community workshops. Participants are
also referred for HIV counseling and
testing and other services as needed.



Method
During the first 18 months of the program, January 1996 through June 1997, 861
MtF transgender/transsexual persons
were contacted through street outreach. Of those, 209 participated in the
Transgender Harm Reduction Program.
Demographic data was collected during the first outreach contact and a more
in-depth HIV risk assessment, including
drug and sex behaviors, was conducted at a baseline intervention session.
Follow-up risk assessments were conducted
at each subsequent intervention session.

Analysis
Data from the 209 intervention participants was analyzed by comparing
individuals who reported exchanging sex for
money and/or drugs sometime in the previous 30 days with those who did not.
Analysis of variance was conducted upon
demographic factors such as age, ethnicity, marginal living situation (living in
a low-rent hotel, rooming house, shelter, or
the streets), and whether they were monolingual Spanish speakers. The difference
in substance use was assessed by
identifying which substances were used by the intervention participants.
Finally, differences in sexual activity were
analyzed by identifying the number of exchange and non-exchange male sexual
partners the participants reported within
the previous 30 days and the percentage of reported condom used during these
sexual encounters.

Demographics
Of the 209 participants in the Transgender Harm Reduction Program, 40% are
Latin/Hispanic, 28% Caucasian/white,
22% African American/black, 6% Asian/Pacific Islander, and 3% Native American.
Their ages ranged from sixteen to 55
years and the mean age was 31 years. Twenty-six percent of the participants
reported a marginal or transitional living
situation at baseline intervention such as a low-rent hotel (13%); on the
streets (5%), for example "squatting" in an
abandoned building, finding shelter in a vacant lot or abandoned car, sleeping
in a park; or living in a shelter or other
service facility (2%). Seventy-nine percent of the participants identified as
heterosexual, 10% as bisexual, 8% gay, and 2%
lesbian. Sexual identity takes on varied meaning within transgender communities
and must be considered when creating
transgender-specific programs. For example, an HIV intervention participant
could be a MtF transgender who identifies as
lesbian and has a penis.

Table 1. Demographic Characteristics of Program Participants (N=209)
Variable Age:
<20 7.2
21-29 45.9
30-39 28.2
>39 18.7
Mean Age 30.7
Race/Ethnicity:
Latin/Hispanic 40.2
Caucasian/white 28.2
African American/black 21.5
Asian/Pacific Islander 6.2
Native American 2.9
Monolingual Spanish Speakers 10.8
Homeless or Marginal Living Situation 25.5
Sexual Identity:
Heterosexual 79.0
Bisexual 10.2
Gay 8.3
Lesbian 2.4

Alcohol and Drug Use
Table two summarizes the extent of drug and alcohol used by participants in the
previous 30 days. At baseline
intervention almost half (45%) of the participants reported some alcohol and/or
drug use in the previous 30 days. Alcohol
was the most frequently used substance by the program participants, with 37%
reported use. Thirteen percent reported
using marijuana at least once in the previous 30 days. The third most frequently
used drugs were crack and crystal
methamphetamine with 11% of the participants using each in the previous 30 days.
Seven percent of the participants
reported cocaine use and 2% reported heroin use within the time period measured.
(See Table 2.)

Table 2. Drug Use of Program Participants, % (N=209)
Drug Use in Previous 30 Days %
Alcohol 37.0%
Marijuana 12.5%
Crack 11.1%
Crystal 11.1%
Cocaine 7.2%
Heroin 1.9%

Approximately 5% of the participants reported injection drug use in the previous
30 days, as seen in Table 3. The most
frequently injected drug was methamphetamine "crystal" (4%) and only a few
individuals reported injecting either cocaine
or heroin. Only a small proportion of those within the intervention were at risk
of HIV infection due to injection drug use.
Of those reporting any injection use in the previous 30 days only one third
reported using a needle exchange program or
bleach to clean their needles and 20% reported never sharing needles.

Table 3. Injection Drug Use and Risks, % (N=209)
Injection Drug Use %
Any Injection Drug Use 4.5%
Crystal 4.0%
Heroin 2.0%
Cocaine 1.0%

Sex Work
Baseline data from the 209 program participants was analyzed by comparing those
who reported sex work (n=76) with
those who did not (n=133). Although 44% identified as a sex worker at outreach
contact, at baseline intervention session
only 36% reported exchanging sex for money and/or drugs in the previous 30 days.

The differences between sex workers and non-sex workers are summarized in Table
4. The mean age of sex workers
was younger than non-sex workers (26.9 versus 32.9). Sex workers were more
likely than non-sex workers to be
Latin/Hispanic (60.5% versus 28.6%), were significantly less likely to be
Caucasian/white (10.5% versus 38.4%), and
equally likely to be African American/black (21.8% versus 21.1%). Among the
Latin/Hispanic transgenders in the
program, those who engaged in sex work were more likely to be monolingual
Spanish speakers (18.4% versus 7.5%).
Additionally, sex workers were significantly more likely to be homeless or live
marginally than non-sex workers (42.1%
versus 14.6%).

Sex work was also associated with greater substance use.

Those who engaged in sex work were significantly more likely to report alcohol
use in the previous 30 days (51% versus
29%), marijuana use (20% versus 8%), crack use (25% versus 3%), crystal use (21%
versus 5%), and cocaine use (12%
versus 5%). Additionally, sex workers were significantly more likely to be
injectors than non-sex workers (9% versus 2%);
this also included injecting crystal (8% versus 2%). In a recent study of
methamphetamine use, the transgender
respondents reported using the drug to enhance sexual encounters during sex work
(Reback 1997).

There are also differences between sex workers and non-sex workers in their
sexual activity with non-exchange male
partners. Those engaged in sex work reported having a greater number of
non-exchange male sexual partners (21
versus 3) in the previous 30 days. However, the sex workers demonstrated greater
understanding of HIV transmission
risks as well as a greater personal perception of risk as is evidenced in their
reported condom use. Sex workers reported
a high use of condoms with their exchange partners (95%) and were more likely to
use condoms with their non-exchange
male sex partners (94% versus 56%). Consequently, among this sample, although
sex workers reported significantly more
male partners, their HIV risk through sexual behavior may be lower than non-sex
workers as a result of their higher use of
condoms.

Table 4. Comparison Between Sex Workers and Non-Sex Workers, % (N=209)
Sex Workers
(n=76) Non-sex Workers
(n=133)
Mean Age 26.9 32.9
Homeless or Marginal Living Situation 42.1% 14.6%***
Race/Ethnicity
African-American/black 21.1% 21.8%
Caucasian/white 10.5% 38.4%***
Latin/Hispanic 60.5% 28.6%***
Monolingual Spanish Speakers 18.4% 7.5%*
Alcohol Use 51.3% 28.8%***
Crack Use 25.0% 3.0%***
Crystal Use 21.1% 5.3%***
Marijuana Use 19.7% 8.3%*
Cocaine Use 11.8% 4.5%*
Injection Drug Use 9.2% 2.3%*
Injected Crystal 7.9% 1.5%*
Injected Heroin 3.9% .7%
Number of Times with Male Sex Partner 20.9 2.6***
Condoms Use During Sex with Male Partner 94.3% 55.6%***
Number of Times Performed Sex Work 28.5 -0-
Condom Use During Sex Work 95.3% -0-
*p=.05 / ***p=.001

Conclusion and Discussion
Little is known about the HIV risks of MtF transgendered persons although past
studies have found a high HIV sero-
prevalence rate among MtF transgendered women (Pang, Pugh, and Catalan 1994;
Rekart, Manzon, and Tucker 1993;
Modan, et al. 1992; Alan, Guinan, McCallum 1989). One of the primary reasons
given for their high rate of HIV infection
has been the high prevalence of sex work among the individuals within their
samples. We also found a similar pattern
within these data. Those who exchanged sex were found to use more drugs and
alcohol, including more injection drug
use, than those not engaged in sex work. In addition to their exchange sex
partners, the sex workers reported a greater
number of non-exchange male sex partners. However, the sex workers reported
greater condom use than non-sex
workers.

Past studies on transgender HIV risk factors have focused primarily on
individual risk factors and have not dealt with the
social context that could influence ones individual risk factors. It is
possible that the marginalization of these individuals
creates a social context that places them at risk of HIV infection. For example,
Sanjay (1996) concludes that much of the
HIV risks experienced by transsexuals in India was due to their illegal status
and, consequently, their limited access to
legal and social resources. A similar situation exists in the United States. For
MtF transgenders a legal identity that is
inconsistent with ones presenting gender may lead to employment discrimination
which serves to drive many into illegal
forms of employment. Boles and Elifson (1994) also note a relationship between
transgender discrimination and sex work.

For transgendered persons it is often difficult and costly to establish a legal
identity in ones chosen gender. The
inconsistency between ones legal gender identity and gender presentation may
force many trans-persons into the
margins of society. For many, this marginalization may force them into work that
does not require legal documentation. Of
the participants in the Transgender Harm Reduction Program, 55% of those who
were Latin/Hispanic and 58% of those
who were monolingual Spanish speakers engaged in sex work. Furthermore, the
current political climate for all
undocumented immigrants in California creates difficulty in gaining legal
documentation.

Transgendered persons currently have little protection from discrimination in
the work place. A previous study found 37%
of their sample reported some type of employment or economic discrimination such
as not being hired or losing ones job
due to their presenting gender (GenderPAC 1996). Employment discrimination may
force people into sex work due to the
limited choices given to transgendered persons.

Another employment consideration is job accessibility. For many undocumented
women, access to domestic jobs such as
child care and other housework services is usually obtained through family
support networks, and many transgendered
women are estranged from their families. The lack of access to jobs could serve
to pressure transgendered women into
sex work.

The data from this study came from a community-based HIV harm reduction program.
Given that only a limited amount of
data can be collected prior to an intervention session, both the contact and
intervention forms must be brief. Therefore,
information was collected on participants current drug use and sexual
behaviors. Further studies are needed to examine
the legal, social and economic situations of transgendered persons.

Correspondence and requests for materials can be set to:
Cathy J. Reback, Ph.D., 113


References

1. Reback, C.J. (1997) "The Social Construction of a Gay Drug: Methamphetamine
Use Among Gay and Bisexual Males
in Los Angeles." Report for the City of Los Angeles, AIDS Coordinator.

2. Pang, H., K. Pugh, and J. Catalan. (1994) "Gender Identity Disorder and HIV
Disease." International Journal of STD
and AIDS. 5:130-132.

3. Rekart, M.L., L.M. Manzon, and P. Tucker. (1993) "Transsexuals and AIDS." IX
International Conference on AIDS.
9:734.

4. Modan, et al. (1992) "Prevalence of HIV Antibodies in Transsexual and Female
Prostitutes." American Journal of
Public Health. 82:590.

5. Alan, D.L., J. Guinan, and L. McCallum. (1989) "HIV Seroprevalence and Its
Implications for a Transsexual
Population." V International Conference on AIDS. 5:748

6. Sanjay, G. (1996) "HIV/AIDS Intervention Among Transsexuals in Bangalore,
Medico - Legal Impediments for
Effective Intervention." XI International Conference on AIDS. 11:52.

7. Boles, J. and K.W. Elifson (1994) "The Social Organization of Transvestite
Prostitution and AIDS." Social Science
and Medicine. 39:85-93.

8. GenderPAC. (1997) First National Survey of Transgender Violence. New York:
GenderPAC.

All figures are percent, unless indicated

Acknowledgments

This research was funded by Contract No. H208837-2 from the U.S. Centers for
Disease Control and Prevention and the
County of Los Angeles Department of Health Services, Office of AIDS Programs and
Policy. Dr. Reback would like to
thank the field staff of the Van Ness Recovery House Prevention Division for
their ongoing commitment and hard work
and Kathleen Watt for her support of this program. Dr. Lombardi would like to
thank Talia Bettcher, Shirley Bushnell and
Jacob Hale for their support.


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but the one most responsive to change - Charles Darwin

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