 FIELD ACTION REPORT 
Promoting Health for Transgender Women: Transgender
Resources and Neighborhood Space (TRANS) Program
in San Francisco
| Tooru Nemoto, PhD, Don Operario, PhD, JoAnne Keatley, MSW, Hongmai Nguyen, BS, and Eiko Sugano, MPH
Transgender women are at high risk for HIV, substance abuse, service providers are not trained street outreach and referrals
and mental health problems. We describe a health promotion in transgender care issues and from collaborating organizations,
intervention program tailored to transgender women in San might be insensitive to the psy- transgender women who reside
Francisco. chosocial needs of transgender or work in San Francisco and are
The program creates a safe space for providing transgender- clients. Transgender women have aged 18 years or older are in-
sensitive education about HIV risk reduction, substance abuse reported discrimination in health vited to the TRANS site, use re-
prevention, and general health promotion. Transgender health services, and often they are un- sources, and participate in health
educators conduct workshops and make referrals to appropri-
comfortable disclosing their gen- education workshops.
ate substance abuse treatment programs and other services in
der history to providers. This TRANS offers 18 group work-
the community.
report describes a program for shops organized around 3 do-
Evaluation findings indicate that this community-tailored
intervention may be an effective way to reach transgender women transgender women in San Fran- mains: (1) sex, relationships, and
and reduce sexual risk behaviors, depression, and perceived cisco, the Transgender Resources health (offered every Tuesday);
barriers to substance abuse treatment. (Am J Public Health. and Neighborhood Space (TRANS) (2) reducing drug use and im-
2005;95:382–384. doi:10.2105/AJPH.2004.040501) program, designed to reduce proving coping skills (every
HIV risk and substance use. Thursday); (3) general life needs
(every Friday; Table 1). These
THE TERM TRANSGENDER PROGRAM DESCRIPTION 1-hour workshops, which are
refers to individuals whose gen- held throughout the year, are
der identity and gender expres- TRANS is a collaborative proj- conducted by transgender health
sion contrast with their biological ect joining researchers, coordina- educators in both English and
sex.1 In San Francisco, the male- tors from local community-based Spanish. Health educators use
to-female transgender commu- organizations, health and social multiple group facilitation tech-
nity (individual members are service providers, and commu- niques, including interactive dis-
referred to here as transgender nity advocates in San Francisco. cussions, personal expression
women) shows some of the The program provides a welcom- exercises, videos and media, and
highest rates of HIV incidence, ing, safe venue in which to offer guest lectures.
substance use, and mental health culturally and gender-sensitive Upon their first visit to the
problems among all groups at health education to transgender TRANS space, participants volun-
risk.2–4 Qualitative research indi- women. It operates in a space lo- tarily complete a behavioral risk
cates that ecological and psy- cated adjacent to San Francisco’s intake assessment, which mea-
chosocial factors associated with Tenderloin district, where many sures sexual behaviors, substance
transgender identity—such as dis- transgender women live or so- use, attitudes toward substance
crimination, stigma, health ser- cialize. This space houses private abuse treatment, HIV knowl-
vice barriers, and poor social sup- offices for health educators (all of edge, depression, self-esteem,
port—contribute to HIV risk and whom are transgender women), and transgender community
co-occurring health problems.5,6 living room area, large confer- involvement. They are then
Researchers have urged the ence rooms, shower facility, and informed of the health education
public health community to a resource closet (donated cloth- workshops and asked to attend
address health disparities facing ing and accessories free to those at least 10 of the 18 workshops
transgender individuals.7–11 Many in need). Contacted through to be considered program gradu-
382 | Field Action Report | Peer Reviewed | Nemoto et al. American Journal of Public Health | March 2005, Vol 95, No. 3

 FIELD ACTION REPORT 
TABLE 1—Curriculum for Transgender Resources and
Findings might be biased be- KEY FINDINGS
Neighborhood Space (TRANS) Project
cause of the low completion rate
Domain Specific Topics Addressed (30% of those who completed • Transgender women have dis-
proportionate risk for HIV and
the pretest risk assessment inter-
Sex, relationships, and health AIDS knowledge and AIDS-related health services view finished 10 workshops),
related health problems, and
although it is important to note tend to distrust and underuse
Relationships with private partners
Commercial sex that participants were not re- general health and social
Drug use and sex quired to complete the workshop services.
Protection from violence
Culture, gender identity, and sex
series. Furthermore, participants
who completed 10 workshops
• Our community-tailored health
intervention program creates a
reported significantly less illicit
Reducing drug use and Drug abuse assessment
safe space where transgender
drug use at baseline than those
improving coping skills Information about drug treatment programs women feel comfortable dis-
who did not.
Positive forms of self-expression cussing issues related to gen-
Self-presentation skills
NEXT STEPS AND der history, sexual risk, depres-
Enhancing self-esteem sion, and substance use.
Handling daily life skills
LESSONS LEARNED
The findings suggest that this
• Findings show significant
General life needs Relaxation and meditation reductions in sexual risk, alco-
Acculturation community-tailored intervention hol use, perceived barriers to
Hormones, gender-related medical procedures is associated with reductions in substance use services, and
Community networking and empowerment sexual risk, alcohol use, perceived
depression among program
Job searching, going to work barriers to substance use services,
Basic legal issues related to gender identity graduates.
and depression. In response to
community demand, the next • Collaborations among re-
ates. Our project goals are to workshops did so in 6 weeks, wave of the health education searchers, members of the
facilitate transgender women in on average. program will include transgender transgender community, com-
socializing at the TRANS site and We examined data from men and gender variant individ- munity-based organizations,
participating in workshops ac- participants who completed 10 uals—people who do not adhere and health providers are
cording to their own schedule, al- workshops. Preliminary pre- and to traditional gender categories. essential to working with the
though health educators encour- posttest findings showed signifi- Curricula will be refined through transgender population.
age them to finish 10 workshops. cant reductions in levels of sex- community feedback to reflect
Program graduates voluntarily ual risk during the past 30 days, the needs of the larger transgen- • Health interventions for trans-
take a posttest assessment within perceived barriers to substance der community, and rigorous gender women should be
2 weeks of their final workshop. abuse treatment programs, and program evaluation will be delivered by transgender peers.
At yearly graduation ceremonies, depression (Table 2). Marginal conducted.
participants who attended 10 reductions in unprotected recep- Although we acknowledge
workshops are acknowledged for tive anal sex and alcohol use dur- that the progressive climate of securing community members’
their contribution to the TRANS ing the past 30 days were also San Francisco differs from that trust and overcoming insensitiv-
project and awarded a certificate found. However, no changes in of other areas, variations of our ity and lack of knowledge about
of completion. illicit drug use, HIV knowledge, TRANS project can be replicated transgender health issues among
self-esteem, and transgender elsewhere. For example, the con- service providers. In addition,
EVALUATION AND community involvement were tents of our TRANS curriculum this is a very fluid community—in
DISCUSSION found. can be used for developing terms of both geographical move-
A major limitation to the re- transgender-sensitivity training ment and community identifica-
Between October 2001 through sults is the absence of a control programs for health service tion. Many transgender individu-
September 2003, a total of 359 group. Marginally significant re- providers. als, especially younger ones,
eligible participants completed sults should be interpreted with Work with this community move frequently, and there is a
the pretest risk assessment inter- caution; however, a longer time was facilitated through alliances tendency for some transgender
view, 206 enrolled in the health lag for administering follow-up with transgender opinion leaders women to disengage from the
education workshop program, surveys might have allowed for and community organizations to transgender community as a way
and 109 completed 10 work- more noteworthy behavioral assess needs, define priorities, to minimize stigma.
shops and provided posttest data. changes, particularly with regard and develop locally tailored We have learned that it is cru-
Participants who completed 10 to changes in illicit drug use. programs. A major difficulty was cial to hire transgender women as
March 2005, Vol 95, No. 3 | American Journal of Public Health Nemoto et al. | Peer Reviewed | Field Action Report | 383

 FIELD ACTION REPORT 
TABLE 2—Comparison of Baseline and Follow-Up Data for 109 Transgender Resources and Neighborhood
Care: Recommended Guidelines, Practical In-
Space (TRANS) Participants formation, and Personal Accounts. Philadel-
phia, Pa: Temple University Press; 1997.
Baseline Postintervention Follow-Up
2. Clements-Nolle K, Marx R, Guz-
Mean (SD) n (%) Mean (SD) n (%) Test P man R, Katz M. HIV prevalence, risk
behaviors, health care use, and mental
HIV risk behaviors health status of transgender persons:
URAS in past 30 days, with any partner a 26 (24.1) 18 (16.7) McNemar b .08 implications for public health interven-
tion. Am J Public Health. 2001;91:
Level of risk in past 30 days, with
915–921.
all partnersc
3. Kellogg TA, Clements-Nolle K, Dil-
No risk 51 (47.2) 59 (54.6)
ley J, Katz MH, McFarland W. Incidence
Low risk 31 (28.7) 31 (28.7) of human immunodeficiency virus
High risk 26 (24.1) 18 (16.7) among male-to-female transgendered
Mean score 1.8 (0.8) 1.6 (0.8) Wilcoxond .03 persons in San Francisco. J Acquir Im-
Substance use in past 30 days mune Defic Syndr. 2001;28:380–384.
Any illicit drug (not alcohol) 50 (46.3) 50 (46.3) McNemar 4. Nemoto T, Operario D, Keatley J,
Any alcohol 59 (57.3) 49 (47.6) McNemar .06 Han L, Soma T. HIV risk behaviors
among male-to-female transgender per-
Perceived barriers to substance abuse sons of color in San Francisco. Am J
treatment programse Public Health. 2004;94:1193–1199.
Not knowledgeable about transgender issues 2.4 (1.0) 2.0 (0.8) Wilcoxon .001 5. Bockting WO, Robinson BE, Rosser
Insensitive to transgender issues 2.4 (1.0) 2.1 (0.9) Wilcoxon .003 BR. Transgender HIV prevention: a quali-
Have had degrading experiences related 2.3 (0.9) 2.0 (0.9) Wilcoxon .04 tative needs assessment. AIDS Care.
to being transgender 1998;10:505–525.
Psychosocial measures 6. Nemoto T, Operario D, Keatley J,
HIV knowledgef 7.8 (1.2) 7.8 (1.1) Paired t .83 Villegas D. Social context of HIV risk
behaviors among male-to-female trans-
Depressiong 18.5 (14.6) 15.1 (12.6) Paired t .003
genders of color. AIDS Care. 2004;16:
Self-esteemh 3.9 (0.7) 3.9 (0.7) Paired t .46 724–735.
Transgender community involvementi 4.0 (0.5) 4.0 (0.5) Paired t .43
7. Lombardi E. Enhancing transgen-
der health care. Am J Public Health.
Note. URAS = unprotected receptive anal sex. 2001;91:869–872.
a
Engaged in URAS at least once in the past 30 days, as a 2-category (yes/no) variable. 8. Feinberg L. Trans health crisis: for
b
The 2-tailed exact significance is reported for McNemar test. us it’s life or death. Am J Public Health.
c
Risk levels were assigned values of 1 to 3 in order of increasing risk. No risk (coded as 1) refers to individuals who either had no sexual partner 2001;91:897–900.
or never engaged in receptive anal sex. Low risk (coded as 2) refers to individuals who engaged in receptive anal sex, but used a condom each
time. High risk (coded as 3) refers to individuals who engaged in unprotected receptive anal sex at least once. 9. Lombardi E, van Servellen G.
d
The Wilcoxon signed rank test was used. Building culturally sensitive substance
e
Scores were on a scale of 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating higher levels of barriers to seeking substance abuse programs for transgendered pop-
abuse treatment programs. ulations. J Subst Abuse Treat. 2000;19:
f
HIV knowledge was measured as the total number of 9 statements (e.g.,“A positive blood test for HIV means the person has AIDS”) answered correctly. 291–296.
g
Measured by the Center for Epidemiological Studies-Depression measure.12 10. Nemoto T, Operario D, Keatley J.
h
Measured by the Rosenberg Self-Esteem Measure.13 Health and social services for male-to-
i
Measured by a scale modified from Luhtanen and Crocker.14 female transgenders of color in San
Francisco. Int J Transgenderism. In press.
professional health educators who San Francisco, 74 New Montgomery St, We thank collaborating community- 11. Bockting WO, Rosser BR, Schel-
can increase accessibility to this Suite 600, San Francisco, CA 94105 based organizations and substance tema K. Transgender HIV prevention:
(email: tnemoto@psg.ucsf.edu). abuse treatment agencies for their assis-
stigmatized population and serve implementation and evaluation of a
This report was accepted June 26, 2004. tance and all project participants who workshop. Health Educ Res. 1999;14:
as role models. Creating a safe volunteered their time and personal in- 177–183.
physical space where transgender formation to this study.
Contributors Note. The contents of this article do 12. Radloff LS. The CES-D scale: a
women feel comfortable discussing T. Nemoto conceived the study and su-
not necessarily represent the views of self-report depression scale for research
pervised all aspects of its implementation in the general population. Appl Psychol
their health issues can also increase the Substance Abuse and Mental Health
and analysis. D. Operario was involved Meas. 1977;1:385–401.
the success of intervention pro- Services Administration, Center for Sub-
in analysis, interpretation, and manu-
stance Abuse Treatment. 13. Rosenberg M. Society and the Ado-
grams for this community. script preparation. J. Keatley coordinated
the study implementation. H. Nguyen lescent Self-Image. Princeton, NJ: Prince-
and E. Sugano assisted with data analy- ton University Press; 1965.
Human Participant Protection
sis and manuscript preparation. This study was approved by the 14. Luhtanen R, Crocker J. A collective
About the Authors self-esteem scale: self-evaluation of
The authors are with the Center for AIDS Committee on Human Research at the
University of California, San Francisco. one’s social identity. Pers Soc Psychol
Prevention Studies, University of Califor- Acknowledgments Bull. 1992;18:302–318.
nia, San Francisco. This research was supported by the
Requests for reprints should be sent to Substance Abuse and Mental Health
Tooru Nemoto, PhD, Center for AIDS Pre- Services Administration (grant H79TI12
References
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384 | Field Action Report | Peer Reviewed | Nemoto et al. American Journal of Public Health | March 2005, Vol 95, No. 3