Rencontre du CRIPS / Act Up-Paris "Personnes trans : quels enjeux de santé ?" - Dossier documentaire

67ème rencontre du Crips Ile-de- France en partenariat avec Act Up-Paris « Personnes Trans’ : quels enjeux de santé ? » Dossier documentaire 28 juin 2007

Sommaire Introduction Programme de la journée Trans’, transsexuel-le-s, transgenres, transphobie Trans’ et VIH/sida/IST Usages de produits psychoactifs, santé mentale Inégalités, discriminations dans l’accès aux soins et au système social Expériences étrangères • Documents à destination des personnes concernées • Documents à destination de l’entourage (partenaire-s et famille) • Documents à destination des professionnel-le-s des champs sanitaires et sociaux Sites internet associatifs

Introduction Ce dossier documentaire a été édité à l’occasion de la 67ème rencontre du Crips-Cirdd Ile-de-France, en partenariat avec Act Up-Paris, sur le thème « Personnes trans’, quels enjeux de santé ? » (28 juin 200). Il est composé : - de références bibliographiques de documents accessibles en consultation au centre de documentation du Crips Ile-de-France (4ème étage de la Tour Montparnasse, Paris 15ème, tel : 01 56 80 33 10) ; -de liens externes vers des sites internet associatifs ou vers des documents disponibles en texte intégral sur internet ; -d’informations en texte intégral. Il vise à vous fournir des informations relatives aux différents thèmes abordés tout au long de la journée, à approfondir la réflexion et les échanges entamés mais n’est bien sûr pas exhaustif.

67e rencontre du Crips Île-de-France en partenariat avec Act Up-Paris « Personnes trans : quels enjeux de santé ? » Conseil Régional d’Île-de-France Salle Paul Delouvrier 35, boulevard des Invalides - 75007 Paris Jeudi 28 juin 2007 9H00 - 17H30 Animation : Danielle Messager, journaliste à France Inter 9h00 – Accueil des participants 9h15 - 12h30 Introduction Anne Hidalgo, présidente du Crips-Cirdd Île-de-France Emmanuel Château, coprésident d’Act Up-Paris Du pouvoir des mots sur l’identité : historique de la sémantique transgenre Armand Hotimsky, sexologue Trans et genre. Des catégories construites historiquement Eric Fassin, sociologue Les psychanalystes face aux trans Marie-Laure Peretti, psychanalyste Questions de la salle 10h30 – 10h45 : pause La communauté transgenre portugaise : une réalité voilée Jo Bernardo, membre du ICRSE (International Committee on the Rights of Sex Workers in Europe) Evolution de la situation des personnes trans’ aux niveaux légal, psychomédical et associatif en Communauté française de Belgique Rosine Horincq, psychologue et formatrice, Magenta Equipe de professionnel-le-s spécialisée en Santé arc-en-ciel et questions de genre Personnes trans et modes de vie en France Kayigan d’Almeida, interne en santé publique, Crips Île-de-France Questions de la salle 12h30 – 14h00 : Déjeuner libre

14h00 – 17h30 Les facteurs de vulnérabilités sanitaires : Le parcours de transition Hormonothérapies croisées et interférences avec les ARV. Nouvelle classification des troubles de l’identité de genre Nicolas Hacher, endocrinologue Prise en charge de la réassignation chirurgicale Axel Léotard, militant, Act Up-Paris Vivre, travailler se traiter tout en étant bien dans sa peau Diane Gobeil, animatrice de prévention, Cabiria Le suivi des patients trans Anaenza Freiré Maresca, infectiologue, hôpital Ambroise Paré Facteurs de vulnérabilité et déterminants de santé au sujet des IST dont le VIH, vers la promotion de la santé globale Rosine Horincq, psychologue et formatrice, Magenta (Belgique) Questions de la salle 15h30 – 15h45 : pause café Les facteurs de vulnérabilités sociales : Mauvaise estime de soi et prises de risques Serge Héfez, directeur, Espas Refus de l'identité, retard de la prévention Hélène Hazera, activiste Act Up-Paris Difficultés de réinsertion Kristina Dariosecq Santé et insertion Camille Cabral, directrice, Le Pastt Quelle prévention ? Camille Cabral, directrice, Le Pastt Viviane Namaste, directrice, Institut Simone de Beauvoir, Québec Questions de la salle Conclusion

Trans’, transsexuel-le-s, transgenres, transphobie Définitions de transgenres et transsexualisme, extraites de ERIBON D., dir. Dictionnaire des cultures gays et lesbiennes, Dictionnaire ; Français ; Paris : Larousse ; 2003 ; ISN : 2 03 505614 9 ; 548 p. ; photographie Thème principal : HOMOSEXUALITE HOMOSEXUALITE ; HOMOSEXUEL ; LESBIENNE ; MILIEU HOMOSEXUEL ; HISTORIQUE ; LITTERATURE ; ARTISTE ; BEAUX-ARTS ; MUSIQUE ; FILM ; ASSOCIATION ; SOCIOLOGIE ; DROIT ; HOMOPHOBIE ; FRANCE ; INTERNATIONAL Résumé : De Abba à Zweig en passant par clubbing et pacs, ce dictionnaire, riche de plus de deux cents illustrations) propose un panorama complet des cultures gays et lesbiennes depuis la fin du XIXème siècle. En près de six cents articles, dont une cinquantaine de dossiers thématiques (anthropologie, associations, chansons, danse, Maghreb, mode, sida...), il aborde non seulement les cultures littéraires, artistiques, intellectuelles, populaires, mais aussi la sexualité ainsi que les enjeux sociaux et juridiques. Bien que mettant l'accent sur la France, cet ouvrage fait une large place aux personnalités et aux phénomènes étrangers, dès lors qu'ils ont eu un écho dans notre pays. Il propose également un certain nombre d'articles consacrés à des pays et à des villes étrangers. (Résumé d'auteur) Cote IDF : Usuel 281 Définition de la transphobie extraite de TIN L-G, dir. Dictionnaire de l'homophobie, Dictionnaire ; Français ; Paris : Presses Universitaires de France ; 2003 ; ISN : 2 13 053282 8 ; 451 p. Thème principal : HOMOPHOBIE HOMOPHOBIE ; HOMOSEXUALITE ; RELIGION ; HISTORIQUE ; LITTERATURE ; HOMOSEXUEL ; ARMEE ; DROIT ; JUSTICE ; DISCRIMINATION ; DISCOURS ; FRANCE ; INTERNATIONAL Résumé : Rédigé par soixante-quinze spécialistes de diverses disciplines (anthropologie, sociologie, histoire, droit, philosophie, littérature, théologie, psychologie, histoire de l'art...), ce dictionnaire offre cent soixante-cinq entrées portant sur : les discours et pratiques homophobes, les théories et justifications avancées, les apôtres de l'homophobie et ses victimes célèbres, les institutions et les espaces sociaux et géographiques de crispations homophobes. (d'après le résumé d'auteur) Cote IDF : 0606, A/0161 SADLER G. What does it mean to be transgendered ?, Saskatoon : The Avenue Community Centre, 2p.

The Avenue Community Centre, Saskatoon Words and labels, 2005, 2 p. NAMASTE V Invisible Lives: The Erasure of Transsexual and Transgendered People, Chicago : The University of Chicago Press, 2000, 320 p. http://www.press.uchicago.edu/cgi-bin/hfs.cgi/00/14037.ctl FOERSTER M Histoire des transsexuels en France Livre ; Français ; Béziers : H&O éditions ; 2006 ; ISN : 2 84547 138 6 ; 186 p. TRANSEXUEL ; HISTORIQUE ; CONCEPT ; TEMOIGNAGE ; ARTISTE ; IMAGE DE SOI ; DISCRIMINATION ; VIOLENCE INSTITUTIONNELLE ; TRANSSEXUALISME ; FRANCE ; ALLEMAGNE Résumé : Ettayé par de nombreux témoignages, ce livre retrace l'histoire du transsexualisme en France. Ce concept naît au début du vingtième siècle en Allemagne à l'Institut de Sexologie de Berlin. Après l'arrivée des nazis au pouvoir, son créateur se réfugie en France qui prend le relai du mouvement en Europe. Après la seconde guerre mondiale, Michel-Marie Poulain et Maris André Schwidenhammer posent les jalons d'une visibilité sociale des transsexuels qui atteint son apogée avec la culture cabaret transgenre. Mais les pouvoirs judiciaires, policiers et psychiatriques mettent en place une répression qui empêche les transsexuels de changer d'état civil et de faire leur transition dans de bonnes conditions. Les années quatre-vingt puis quatre-vingt-dix sont marquées par la politisation de la question et la création d'un tissu associatif rassemblant transgenres et transsexuels dans la lutte pour la reconnaissance de leur dignité. Cote IDF : 0608, A/0312 AUGST-MERELLE A ; NICOT S Changer de sexe : identités transsexuelles Livre ; Français ; Paris : Le Cavalier bleu ; 2006 ; ISN : 2 84670 142 3 ; 187 p. ; glossaire Thème principal : TRANSEXUEL TRANSEXUEL ; IDENTITE SEXUELLE ; REPRESENTATION ; ROLE SEXUEL ; SOCIOLOGIE ; PSYCHOLOGIE ; HISTORIQUE ; CHIRURGIE ; COMMUNAUTE ; FRANCE Résumé : Ecrit par deux transgenres qui ont fondé en 2004 l'association Trans Aide, ce livre fait le tour des représentations, des préjugés et des idées reçues véhiculés par les professionnels de santé, les médias et la société dans son ensemble. Il brosse le portrait d'une communauté en pleine affirmation de soi et aborde la question de la transition. Cote IDF : 0702, A/1100

CROSS K The trans biography project : stories from the lives of eleven trans people in British Columbia, Vancouver : Trans Alliance Society, 2001/09, 52 p.

Transgendered (TG) is Intersexism is a physical condition in which Sometimes the terms pre-operative (pre-op), the sex organs and/or other reproductive post-operative (post-op) and non-operative about Gender, not Sexuality structures and associated hormone producing (non-op) are used to indicate the genital glands are confused (i.e. not clearly male or circumstances of a transman or a transwoman. It is important to understand the term gender female). The variants of this condition are A non-op is someone who is content to present identity and the difference between this and almost infinite. in their birth gender and not undergo corrective gender, gender role, and sexual orientation. genital surgery. Other medical complications Transsexuals, or more correctly, transsexes, sometimes make surgery risky. Generally speaking, gender identity is an (TS’s) are people whose genitals are innate feeling of being male or female. incongruent with their gendered self, or birth In medical jurisdictions where corrective Psychologically speaking, it is our gendered gender. Since the medical profession insists on surgery is not provided by a medical plan, self (birth gender) and resides in our brain. It assigning gender based on the physical many TS’s, particulately M2F’s that are is now known to be hard wired during fetal appearance of the genitals at birth, in this heterosexual women, languish for life in the development and cannot be altered except culture transsexed children are usually raised in ‘wrong body’. If they are unable to raise the within very narrow limits. That topic is beyond the wrong gender. This causes a variety of money to purchase corrective hormones, to the scope of this pamphlet. dysfunctions, some very serious, and the eliminate their facial hair, and to access condition is rarely recognized until the person corrective surgery, even those who are Sexual orientation is about sexual attraction. self-diagnoses. Transsexes usually seek successful in presenting female are seriously We may be sexually attracted to the same sex, surgical correction, or sex change surgery. compromised as far as their natural desire for (homosexuality) the opposite sex (hetero- Transsexism is just as much a physical birth intimacy with a man is concerned, and if they sexuality) or both sexes (bisexuality). deformity as intersexism. do attempt this, they expose themselves to horrible humiliation and frequently, homicide. Like everyone else, a transgendered person Transsexism can occur spontaneously and there Many, particularly M2F’s, become so may have any of the above sexual orientations. is an abundance of evidence of its spontaneous distraught they simply end their own lives. occurrence through time and in all cultures and Gender role has two components – biological races. It can also be induced. Surgical alteration Once the deformity is corrected, to refer to (impregnation, pregnancy, nursing etc.) and of intersexed infants is one way it can be these men and women as post-operative, makes cultural. Only a few decades ago in our culture, induced. Since surgeons have no way of as much sense as identifying someone as a gender roles for women did not include being a knowing what the gender identity of the infant post-operative congenital heart defect.. police officer or a fire fighter. Today it does. So will be, when they make the mistake of creating culturally dictated gender roles can change with one genital configuration and the infants birth Transvestite. This term is often used time and can vary from one culture to another. gender is the opposite, they artificially create a interchangeably with cross-dresser. Unlike transsex, and when this occurs, such operations cross-dresser though, it is a medically Gender (gender expression) is how we present are clearly, genital mutilation. recognized term and when coined, defined a ourselves and how we are perceived. In our subset of cross-dressing males that experience everyday lives, most of us present as male or Transsexism can be induced in other ways as an erotic pleasure in wearing women’s female. Clothing is only part of this, but effects well. For instance, there is evidence that clothing. The term has questionable value, and the first impression others have of who we are. pregnant women who took the estrogen-mimic, in the transgendered community, is falling out diethyl-stilbestrol to alleviate morning sickness of favour and into disuse. Crossgendered is another term sometimes produced an elevated incidence of girls in boys used in place of transgendered. bodies. Tomboys are the opposite sexed counterpart of cross-dressing men. Except for being the Other related terms are defined as they become Transsexes are usually referred to as Male to other sex, the only difference between cross- relevant to the discussion. Female (M2F or transwomen) and Female to dressing males and tomboys is in societal Male (F2M or transmen). attitudes. At one time, a woman in pants would have been viewed with the same disdain and

even hatred (transphobia), as a man in a dress of being male or female is usually consistent Prepared by Genevieve C. A. Sadler is often viewed today. If cross-dressing males with genitalia and chromosomes. But not are included under the transgender umbrella, always. The variations are immense, but largely tomboys clearly belong here too. erased in Euro-centric cultures. If transgenders come in all three sexual Transgenders are some of these variants. orientations, it follows that gays and lesbians can be transgendered. Many drag queens are Erasure is effected through lack of advocacy simply cross-dressing males that are gay. and dissemination of information by the Similarly, many lesbians are cross-dressing medical community, even though the females that prefer male clothing. knowledge is there. But the connection does not stop here. Some Are you transgendered? drag queens are transwomen (M2F) that feel they have no choice but to identify as gay. It is now known that the only way ones gender Similarly, more than a few lesbians are identity can be determined is to ask the person. Transgender is an umbrella transmen (F2M) that feel they have no choice Neither chromosomes, genitals, hormones nor term. It has no formal but to identify as lesbian. sperm or egg production, indicate gender. Gender is the central core of the “self”, resides definition. It is usually Normal or Queer? in the brain, and is hard wired before birth. used to include cross- dressing men, and It is important to understand that in biology If you feel conflicted about the gender you transsexuals, but (and humans are biological beings) were assigned at birth, it is essential that you know that you are normal, that it is not your that is clearly variation is the norm and not the exception. inadequate. fault, and that you need feel no shame or guilt over being YOU. It is a gift, and some cultures This means that variants in sexual revere(d) those born transgendered. Such orientation, gender identity and gender conflict is called Gender Identity genital configuration, are NORMAL Disorder or gender dysphoria. This pamphlet is Man or Woman? In this culture it is important to seek a safe intended to help clarify environment to disclose who you are and “gender” and gender variance. For centuries the Hindu culture has considered explore the beauty of your creation. But no person to be completely male or completely transphobia is widespread in this culture and female. Modern science bears this out. For even more dangerous than homophobia. instance all men produce small amounts of female hormones and all females produce small Gender counseling might also be indicated if the DRAG QUEENS, KINGS? conflict is so extreme that you only feel right amounts of male hormones. Since variance is presenting in the gender opposite to what it says on TRANSVESTITES? the norm in Biology, it follows that such your birth certificate. However it is important to find TOMBOYS? hormone levels are going to vary from person knowledgeable and understanding gender specialists. INTERSEXES? to person, beginning during fetal development, The Avenue Community Centre is a safe place for and it has been shown that such variation can you, and we will try to help. cause intersexism and variance in gender identity, and most assuredly, sexual orientation. The Avenue Community Centre Saskatoon: 1-306-665-1224 So maleness and femaleness are on a Outside Saskatoon: 1-800-358-1833 continuum. Most are strongly inclined to one Prince Albert: 306-922-2228 end of this spectrum or the other and the feeling

L E Words = S B I A & Labels N G The Avenue Community Centre A for Gender and Sexual Diversity Y Saskatoon = M E N Office: Phone: 203 -- 220 -- 3rd Avenue South Saskatoon, Saskatchewan S7K 1M1 306.665.1224 306.665.1280 (in Saskatoon) (Saskatoon Fax) 800.358.1833 (outside Saskatoon) Website: www.avenuecommunitycentre.ca Email: info@avenuecommunitycentre.ca Prince Albert Office: 252 - 26th Street West Q P Prince Albert, Saskatchewan S6V 4R2 = U R E I E D R E Phone: 306.922.2228 (in Prince Albert) © The Avenue Community Centre 2005

Homophobia / Homophobe: The Words & Labels. word Homophobia used to mean a fear of As children we very quickly learn the homosexuals. Today it also refers to hate, power of words. They can make us feel afraid, discrimination and intolerance towards the gay happy, hurt or loved. Even as adults we community. A homophobe is a person who understand this. Yet, words by themselves do hates, fears, discriminates against and attacks © Haring ‘88 not have power, we give them power. Any word gay men, lesbians, bisexuals, and those seen as that can be used to hurt or insult can just as Transgender/Transsexual, Cross- gay. easily show love and respect. It is how we say the Dressers, Intersex & Drag word and how we take it in that gives it power. Heterosexism: Is the belief that being Queens/Kings: Are often thought to be straight is to be better and morally superior to Sexual Orientation: Is the drive to the same but are different. Transgender/ gay people. It also means the assumption that establish intimate emotional and sexual Transsexuals are people who are mentally and everyone is straight and to treat them as relationships with other people. It has three emotionally one gender while their body is the straight. forms: Heterosexual-- attracted to opposite sex; other. Cross-Dressers are people who enjoy Homosexual--attracted to same sex; and wearing clothes associated with the other sex; Bisexual--attracted to both sexes. they may be straight, gay or bi. Intersex are Fag, Queer, Dyke, Lesbo, Gay and people who have the sex organs of both Homo: Are all terms that were/are used to Sexual Preference: Is often used as a genders. Drag Queens are gay men who dress as attack gay men, lesbians, bisexuals and those substitute term for sexual orientation. Sexual women; Drag Kings are lesbians who dress as who appear gay. When used as insults and Preference really only applies to some bisexuals men; both do it to entertain & for fun. slurs they are hateful. Yet, many in the gay who prefer one sex to the other but still have Straight / Straight Not Narrow: community have reclaimed these same words relations with both genders. Straight is a term used to refer to heterosexual using them as terms of affection and pride. Gay / Lesbian / Queer : Gay and queer people. Straight Not Narrow, are straight This is not a new idea. The African- are both generic terms used for homosexual people who actively support the gay Canadian community have done the same for men and women. Gay is more often associated community. racist comments. When the African- with men than women. The term gay Canadians use these terms it is acceptable, man/men is very common, gay people is also The Closet: Being in the closet is when a when the white community uses them it’s q u i t e c o m m o n , b u t t h e t e r m g ay person hides their true sexual orientation. It insulting. woman/women is rare. Lesbian is a term can be because of denial, fear, or a desire to exclusive to gay women. Queer is becoming “protect” family and friends. Pride: Refers to the celebration of being popular in referring to both gay men and queer. It also refers to festivals that occur in lesbians and it also includes bisexuals and Out: People at some point chose to leave the cities around the world during the summer transgendered people. Gay Community & closet to be “out of the closet”. They accept and months. Pride Day, Pride Week or Pride Mardi Queer Community are used to describe all embrace their sexual orientation. There are Gras all commemorate the Stonewall Riots sexual minorities. And, since we live in the three levels: personal--out to yourself, private-- which took place in June 1969, in New York time of abbreviations, LGB or LGBT, are also out to family and friends, and public--out to City. The riots are seen as the birth of the seen. work and the world at large. Some people are modern movement for attaining equal rights “outed”, forced out of the closet by someone or for gay people. some event. To be outed can be very upsetting.

The Trans Biography Project Stories from the Lives of Eleven Trans People in BC by Kathleen Cross In collaboration with the Women/Trans Dialogue Planning Committee and Trans Alliance Society September, 2001 Vancouver

The Trans Biography Project Stories from the Lives of Eleven Trans People in BC by Kathleen Cross In collaboration with the Women/Trans Dialogue Planning Committee and Trans Alliance Society September 2001, Vancouver Photography Credits: All photos by Kathleen Cross, except page 17 courtesy of Kimberly Nixon, and baby photo on page 33 courtesy of Joshua Mira Goldberg. The author, the Women/Trans Dialogue Planning Committee, and Trans Alliance Society encourage the copying of this document for educational purposes.

Table of Contents Introduction ........................................................................................page 1 Acknowledgments ..............................................................................page 3 Dannis Bragas ................................................................................page 5 Gareth ..............................................................................................page 9 Aiyyana Maracle ..............................................................................page 13 Kimberly Nixon ................................................................................page 17 Joe ....................................................................................................page 21 Romham Padraig Gallacher............................................................page 25 Jewel ................................................................................................page 29 Joshua Mira Goldberg ....................................................................page 33 Linda ................................................................................................page 37 Dean Dubbick ..................................................................................page 41 Myriam Joire ....................................................................................page 45

Introduction This is a collection of biographies featuring trans people who reside in British Columbia. The purpose of this collection is to educate the broader community about the experiences, needs and situations of trans people. It features a brief biography of each person, using their words as much as possible to tell their stories, share their experiences, and articulate the issues that are relevant to them as a trans, transgendered or transsexual person (a note about language usage is below). These stories are an attempt to put a “human face” on the issues of trans people and to break down stereotypes. It is our hope that this collection may, in some small way, assist in making the voices of trans people better heard and, perhaps, more understood. Throughout this booklet different participants have used a number of terms to describe themselves and others. Some of these terms are: transsexual, transgendered, trans, tranny, trans-woman, trans-man, FtM (female-to-male), MtF (male-to-female), transformed, and gender-variant. We recognize that the language associated with these issues is fluid and the choices of descriptive terms have certain meanings to various participants. As much as possible we have tried to ensure that participants defined what they meant by the terms they were using, and in each case asked participants to describe how they would like to be identified. While we recognize that the language is constantly evolving, for the purposes of this project we have used the term “trans” as a broad category meaning anyone who defines themselves as gender fluid, whether they be pre-operative, post-operative or non-operative. The one-on-one interviews used to write these biographies were conducted in May, June and July of 2001. All but one of the people featured in this booklet were living in the Lower Mainland during this period. Four participants have chosen to remain anonymous and are indicated by a chosen first name only, while the others felt comfortable with their names and photos being represented here. The biographies are either written in the first voice, using exclusive quotes from the interviews, or using a combination of quotes and narrative. In all cases the participants had final say over the content of their biography. It is important to note that a few months prior to these interviews taking place, the BC Human Rights Tribunal had begun its deliberations on the Nixon/Rape Relief case. Kimberly Nixon, a transsexual women included in this booklet, had claimed discrimination by Vancouver Rape Relief and Women’s Shelter in 1995 because she was a transsexual. Many of the participants in this booklet attended the hearings and some of them refer to this case in their biographies. At the time of this writing the Tribunal’s decision is still pending. Similarly, many of the interviewees mention the Gender Clinic. The Gender Clinic was founded in 1985, and located in the psychiatric out-patients department at Vancouver General Hospital. In 1995 the Gender Clinic was relocated and combined with Sexual Medicine and Reproductive Health. Today it is a multi-disciplinary service that, in many ways, acts as a gate-keeper for BC’s transsexual community. If medical procedures are desired (such as 1

prescriptions for hormones, or sex reassignment surgeries) then most trans people must approach the Clinic for diagnoses as gender dysphoric and for approvals for treatments. The Clinic also offers counselling and other services to transgendered clients. Having said that, it is important to note that this booklet is not an explanation of the medical procedures or diagnoses associated with the treatment of gender identity disorders. For that, the reader will need to refer to the wealth of information written and researched by counsellors, psychologists, psychiatrists and doctors who specialize in such interventions. While many of the participants have undergone some medical procedures and talk about these in their stories, we are not intending to give detailed information of these procedures except to the point where they are part of a person’s story. And finally, this booklet was produced as a limited run of 250 copies. The intent is to make it available to groups and organizations throughout the province, especially those wishing to use it as a companion piece while doing workshops on trans issues. Should the demand exceed our initial printing, every effort will be made to secure new funding in order to print more. To view this booklet, and download it off the Internet, please visit the following sites: Trans Alliance Society: www. transalliancesociety.org BC Human Rights Commission: www.bchumanrights.org To inquire about ordering copies, please email: communications@transalliancesociety.org or write to: Trans Alliance Society c/o 1170 Bute Street Vancouver, BC V5Z 4R3 2

Acknowledgments I would like to thank the people in this booklet, each of whom welcomed me into their homes and spoke with honesty and clarity about some very difficult issues. Listening to the stories, I was struck by the immense courage it has taken for each person to travel the path they are on. It has been a privilege to meet and work with every one of you. Thank you for sharing your stories with me — and with all of us. Kathleen Cross, author On behalf of the Women/Trans Dialogue Planning Committee, the Project Advisory Team of WG Burnham, Joan Meister, and Marion Pollack would like to thank the author, Kathleen Cross, and all of the individuals who volunteered to take part in the Trans Biography Project. When the Women/Trans Dialogue Planning Committee began meeting in May 2000 in Vancouver, our intention was to increase dialogue between the trans and women’s communities. As participants introduced themselves it became apparent that the telling of people’s stories contained a powerful educational component that would help people better understand the diversity and experiences in the trans community. We realized that the experiences of trans people cannot be explained or defined without a more intimate sense of who trans people are and how they define themselves as individuals. Thus, this project was born. We would like to take this opportunity to thank the BC Human Rights Commission, and in particular former Chief Commissioner Mary-Woo Sims, for providing overall support for the Women/Trans Dialogue Planning Committee. WG Burnham, Joan Meister & Marion Pollack Project Advisory Team 3

Dannis Bragas Dannis Bragas is 20 years old. She moved to Canada from the Philippines with her parents approximately 10 years ago. She defines herself as a male-to-female transsexual and has been taking hormone therapy. She looks forward to eventually becoming a “full-time” woman which may or may not involve sex reassignment surgery. Dannis remembers first realizing that she would feel better being female than male when she was about 3 years old. I remember thinking that being female would be easier. At that time, it had to do more with material things like toys and hair and dolls. Most of my friends were girls and I liked “girl toys”. My aunt was very open and she would buy me the kinds of toys I wanted. When I grew older and bought my own toys, I would buy boy type toys, but if the toys were plastic characters in a series, I would always buy the girl of the set. I realized I was transsexual when I was 13. I had a friend who was quite feminine who turned out to be gay and we’d hang out in the library which is where we discovered books with stories about transsexuals. Everyone thought Dannis was gay but she knew that she was transsexual. After high school, Dannis started a fashion design program. At that time she continued to do research on transsexuals and joined a group for gays and transgendered people at the (gay, lesbian, transgendered) Centre in Vancouver. She met gay people and enjoyed the group but felt something was missing. She then started to go to another group in a community clinic where a doctor questioned her about transsexualism and referred her to the Gender Clinic (at Vancouver General Hospital). She began taking a hormone suppressant Spiro, then estrogen and permarine, and began electrolysis. At first, with the Spiro, I became skinny. But then with the estrogen, I became softer and more curvy. I got less hair and my nipples grew. I also felt relaxed with the estrogen. I felt naive and more concerned with relationships. Estrogen made me nicer. Without it, I was more like a gay man or someone with a lot of testosterone. Dannis decided that she wanted the option to have a baby with her own genetic make-up in the future and in order to save her own sperm for future use, she had to stop taking hormones so that it did not interfere with the sperm count. I don’t want to regret not trying to have my “own” baby later. I’d be willing to adopt or to have someone else’s but I like my genes, and it would be nice to have a baby like myself. I found a place to store the sperm and I’m now back on hormones. I suggest that all T’s consider doing this before they change their biology. 5

According to Dannis, living as a transsexual can be both positive and negative. “Passing” can be an issue. Dannis has found this particularly difficult when deciding which washroom to use when out in public. I’m confused because I’ve heard it’s against the law for me to go into the female washroom but I don’t feel entirely comfortable going into the men’s. When I’ve used the men’s washroom, I’ve been confronted over twenty times because other men thought I was a woman. I’m sick of it. I sometimes use the women’s washroom and sometimes I don’t. When I’m with my friends, I ask them what to do. I’ve never been challenged in a women’s washroom though I do get out really fast. Once I was at a club and dressed up (as a woman) so I had to use the women’s washroom. It was strange being surrounded by other girls because I was afraid of being “found out”. Like any other 20 year old, Dannis is interested in meeting people and dating. But relationships have difficulties. All her friends are gay and she has known only one other transsexual, who eventually moved away. Dannis would like to have a boyfriend who is interested in her as a person, not just as a sexual partner. The men who are interested in transsexuals are bi-curious or straight, at least, they consider themselves to be. They want something “extra” they say. Married men, rich men, poor men, young men, and old men want to be with me and they know I’m trans. I’d like something more than sex but their whole interest in me is sex. If they want a relationship, I can’t help but think that they chose me just because I’m transexual. I accept this fact now. Dannis feels like she doesn’t have enough support from people. Her friends are learning more but still frustrate Dannis and hurt her with their comments. She feels they sometimes discriminate against her either because they don’t like women or they don’t like transsexuals. They treat me like I’m dirty or crazy or like I’m making it up. Gay people consider themselves above trannies. They sometimes make me feel like a joke. A lot of it is just ignorance. At work, Dannis believes that her co-workers think she is gay. She began work at a clothing store as a male, and has started buying female clothing. She hasn’t told her co-workers that she is transsexual and has implied to them that she is a drag queen. She gets mistaken for a woman by customers frequently. They come in and call me “she” and my co-workers correct them but I don’t mind. I want to go back to school or get a better job but I want to start a new job as a female. I’d love to work in fashion and with drag queens someday. When I was in school, I was a dresser for a fashion show and there were some drag queens who had some designs in the show. It was wonderful to work with them. 6

Everyone in Dannis’ immediate family knows she is transsexual except for her father. She told her mother a year ago and her mother told Dannis’ sister. Dannis’ brother found out “naturally”. When I told my mom, we were in the car waiting for my sister. Before I came out, I’d sometimes cry and she would find me. She thought I had something on my mind. She said to me, “so you want to be a girl instead of a guy” and I told her that she was right. My mom told me that it was a choice but I told her that I’d always felt this way. My mom accepts me but she hasn’t read anything about transsexuals. I’d like her to try to understand what I’m going through but she doesn’t. She judges me and always expects the worst. But the more I become female, the more she is willing to put me in a female context. Dannis and her mother decided not to tell her father about her transsexualism. My dad’s not easy to live with and I didn’t want to make it worse. He probably thinks I’m queer and probably knows I dress as a female because he might have found clothes in my bedroom but he doesn’t know I’m transsexual. Now that I’m out of the house I plan to write my dad a letter telling him what I am. Having recently left home, Dannis looks forward to being a “full time” woman. She feels strange being only “part time” now. Part-time means that I go out in public shaved really close, and with nothing else. People see me as a female and the ones that knew me before see me as a “tranny”. I’m in the middle and I’d like to have no facial hair, have obvious breasts so that I can be a normal looking person — a typical “girlie” girl. When I first started, I wanted to go straight to the sex change but now I wonder. If I have a sex change, I can be a normal woman but the risk is that once I have a change, no one will want me. No “normal” man will want me because I used to be a man and no man who wants a transsexual will want me because I don’t have “it” anymore. And I worry about being able to function after SRS [sex reassignment surgery]. If I don’t have a sex change I worry that people will be interested in me not because of who I am but because I’m a sex toy —because I’m both. But I could also still have lovers and people who like me. It’s all about relationships. I want to be open. I was born a girlie boy and then I became a woman. Dannis is still struggling to decide which direction is best. She says: I feel like a blank canvas where images are taking a long time to appear. For instance, a perfect canvas would be a transsexual on Spiro who could be male or female —- totally androgynous. My body (the canvas) is just waiting for the paint — the estrogen — to fill me up. 7

Gareth Gareth is a 53 year old transsexual man. He began his transition in 1995 and is now legally male. Transitioning for Gareth has involved both internal and external transitions. For me the transition process has been in three parts: internal, external and integrated. I’m almost through the external transitions — or what I call the “technology of trans”. But that is only one part of a person’s identity. If you think of a person as mind, body, heart and soul, identity is in the mind, heart and soul. But the technologies are all centered around the body. So that even though gender identify is primarily internal, transitioning ends up with a focus on the external markers, what we need to do to our bodies — the medical and legal changes. That becomes so all-encompassing that the body becomes the identity. But that’s only one part of it. The process started internally. For me that took several decades. Gareth had a sense of continuity between himself/his body and his external world until he was about four. At that point he hadn’t played with other kids and so had no one to compare himself to. I had no playmates at all before that because my mother believed none of the other kids in the neighbourhood were good enough for me. Then we moved to a new neighbourhood and I started playing with other kids. My best friend was a boy my age, but I was pushed to play with the girls (my mother was into pink and ringlets) and things didn’t fit so comfortably. But because our family was not doing so well at the time either, and kids take things on, I didn’t realized it was a gender issue. I internalized it as “I’m not adequate, I’m not appropriate”. So I responded by putting on layers of learned expectations of female behaviour: being good, being nice. Chronic depression caught up with me when I was about eleven. I never sought help. I just coped with it until my early forties. During puberty my sense of gender was not clearly masculine — I just thought it was my fault I was failing as a girl. I wanted to hurry up and develop breasts so that I could fit the physical concept of being female since the rest just wasn’t natural for me. There was an incident when I was about twelve. I had put on a combination of clothes that gave me a very masculine look. When I looked at myself in the mirror I felt as though I was seeing myself as real for the first time. My mother made such as fuss, however, I knew I was really failing at getting it right at being a girl. Being female was something I thought you had to learn and I just hadn’t learned it yet. So I started to deliberately watch how women behaved. I studied women’s movements, gestures, dress, use of language, intonation. From that time until I started to transition I 9

carried a conversation in my head: “I’m being seen as a girl/woman — What is the most appropriate female response I can give in these circumstances?” I didn’t even know that filter was there until it stopped. Once I’d taken on the external role as best I could, I sidestepped the whole body/identity thing by retreating into my head. I went through high school as a nerd. By my twenties I was interested in ideas like the nature of illusion and reality. I also took on separatist feminist ideals. If I couldn’t make it as a woman being good & nice, maybe I could make it being radical. Besides, it felt good knowing I belonged to the better half of the human race. I never actually joined the women’s community. In fact, my closest co-workers for a while were men. And I numbed my self-awareness by keeping busy doing lots of volunteer work through my church and other organizations. Also, I had season tickets to absolutely everything in Vancouver. I’m sure I helped a flourishing of the arts in Vancouver during those years! I knew a lot of people, but never got close to anybody. I had dated a tiny bit and then in my late twenties, a man came along and I had the sense that this was my last chance to get it right — to learn how to be a woman in a relationship with a man. I was involved in a fairly rigid church structure in terms of male/female roles, (man as head of the woman sort of thing) so feminist ideals got shoved aside as I gave this relationship my very best shot at trying to be a woman. It didn’t last. In my mid-thirties I suddenly became ill with what was eventually diagnosed as a type of arthritis. I stopped trying to date, but I didn’t stop my crazy work/volunteer/ social life. I just added pain and fatigue to the list. I still felt I wasn’t doing enough to be adequate or acceptable. So I kept trying harder to be good and nice. I had been woman-attracted since my early adolescence but I buried that. I didn’t do anything about it until I was about forty. But I didn’t know what to do. I had never connected with the lesbian community. When I read lesbian literature that talked about a sense of “coming home” I knew I didn’t have that sense. And I didn’t feel comfortable at lesbian events. Instead, I joined the Anglican gay group Integrity. They were all men and they kept wondering why I stayed. But I liked being with them. Some of my depression started to lift in these years. Well! A person can only live so long working full time, so busy they never eat properly, get only 3 - 4 hours sleep a night, using energy to live with a chronic illness, before something gives way. I’d done this for year and years. In 1995 my health collapsed and I was forced to drop everything except work. Suddenly the carefully constructed world of external definers disappeared out of my life. I was left too weak to run away anymore. During my recovery I bought a man’s suit jacket. (I’d been wearing only skirts and dresses for about twenty years by then.) When I looked in the mirror I met that masculine kid I’d seen briefly when I was twelve. I was working with a wonderful therapist at the time and he’d been patiently encouraging me to examine and discard all 10

the layers of pretense that I’d built up over the years trying to be good. By the time I put on that jacket the crust was thin enough that the gender energy could break through. It not only broke through, it took over my life. I started buying and wearing men’s clothes at home and then it quickly moved to cross- dressing in public. At first I said “Oh, I’m just wearing men’s clothes”, but then I started to acknowledge how right it felt and then I had to admit I couldn’t not wear men’s clothes. And finally I had to ask myself “what’s this all about?”. I had been constructing myself externally from the outside-in for so long that it took a lot of courage to accept this was coming from the inside and I could trust it. First I asked “Am I a man or a woman?”. Then when I had to accept that I was a man, I faced the worst part of the transition. I felt that I had totally failed. I’d failed my mother, I’d failed my feminist ideals (besides, I didn’t want to leave the winning side), heck, I’d failed my reincarnation. But I couldn’t stop, because it felt more and more right, comfortable, real, me. Then I asked, “But if this is me, then who am I as a man?”. Finally I realized I had absorbed role models as a kid and that energy was already a part of me. The men I felt close to were kindly, gentle, generous people. That spoke to the core of who I am. So I took a male name that means “gentle”. That was the turning point. I’d wanted a name that was macho, but nothing seemed to stick. When I was able to accept that there is strength in gentleness, then I was ready to do the external transition. I joined an FtM support group and met some neat guys and I went to the Gender Clinic at VGH where I had good support and lots of encouragement. We are so fortunate in BC to have a clinic here. Now I’m at the third part of my transition: taking the congruence of who I am and how I look as a 50 year old male, with only a few years life experience living as a man, and integrating myself into the world. So far it has gone well. I finally feel as though I fit. When I started the transition I started questioning the rigidity of the binary — the concept that there are only two genders and we fit into either one or the other. I used to talk a lot about “queering the binary” and suggested we are all in the middle, that everybody has a bit of both genders (and a bit of both sexual orientations). I think that’s a necessary dialogue, but right now I’m happy with the binary for myself. “Transsexual” implies a rigidity, moving from one side of the binary to the other. For that person the middle ground is not comfortable. And that’s me. I don’t really want to keep coming out as a “trans”. I just want to live as a man now. And the gains have been overwhelming. I work with the public and have had dozens of encouraging comments from them and from co-workers. Most friends and acquaintances have been so affirming. My partner, whom I met in 1996, has been a daily companion and champion. And finally, I feel good about myself, comfortable about myself. No need to pretend anymore. Depression’s gone. My life is much more balanced. I feel ordinary and content. Now I’m simply one more little guy in the world doing his bit to make the world a better place. 11

What being Trans isn’t, for me. by Gareth (All of these points have at one time or another been suggested to me by people, by popular opinion, or in professional, feminist or queer writing.) 1. Being so butch, that I fell off the end of the spectrum and became a man. I am not a macho man. (This seems to be a growing political stance re: butches.) 2. Homophobia about being woman-attracted. 3. Identification with male power. 4. Desire for male privilege. 5. Anti-feminist sentiment. 6. A game, a choice of being a certain way, of playing with a/several persona/e, or a passing whim. 7. A lifestyle choice. 8. Being “still a woman” with merely cosmetic changes. 9. Attempting to shock, or “gender-fuck”. 10. Attempting to get attention, be special. 11. Attempting to grab an identity, to fill up inner emptiness/ lack of strong sense of self. 12. A delusion, mental illness, instability. 13. An inability to deal with having arthritis. i.e. living with weakness and vulnerability, desiring testosterone as a way of achieving strength. (In fact, I am more vulnerable as a small man with little physical defense than I was as a tallish woman.) 12

Aiyyana Maracle Aiyyana was born in 1950 on Six Nations Reserve in southern Ontario and grew up in Buffalo and Rochester, New York. She has five children and eight grandchildren and began transitioning ten years ago and then living full time as woman in 1993. She defines herself as “a transformed woman who loves women”. Aiyanna’s story is a story about gender and race and the ongoing intersections of the two throughout her life. She knew she was different even before she went to school, growing up the middle of seven children, and surrounded by the world of her mother, grandmothers. aunts and sisters. She felt she was a girl within a world of girls. It wasn’t until the first day of school when a neighbourhood girlfriend told her she could not walk with her because she was a “little boy” that she realized that something was really wrong. It was in this same time that issues of race became brutally apparent as well. I realized that race was very important that first year. I suddenly went from being this cute little child to being this “ugly little Indian boy”. It turned my world upside down. I had a double anxiety in the segregation of being a boy separated from girls, and being Indian. But racism was paramount, with daily reminders. And in my little mind I knew deep down it was not safe for me to seriously engage in the discussion of gender. When I was a teenager and my parents committed my older sister for her indiscretions, I realized just how unsafe it was. And that scared me into silence for a long, long time. In the 1950s you hear the whispers of queers and fags and you just know that as horrible as being Indian was, being queer was even worse. The 1950s and 60s was, according to Aiyyana, a very odd time to be an urban Indian [she prefers to this term to “First Nations”]. Her family was pushed off the reserve the year after she was born when the Canadian government first started to enforce the distinctions between status and non-status Indian. Because both of her parents had been in the armed forces throughout the war, the seeds of assimilation and integration were well rooted. And in hindsight, says Aiyyana, assimilation and integration in those days made some sense. “For them, it was survival.” As a child she felt herself “one of the outcasts. Much of my childhood was spent with an unabridged dictionary and a stack of National Geographics as my companions”. In her later teens and early twenties she put the questions of gender into the background and consciously chose to partner with another native person so as to not make life even more difficult for her children. “Because of racism, it was hard enough being native. Being half bred was somewhere I didn’t want my kids to be.” 13

Aiyyana says that “to be an Indian in the 20th century in North America is inherently political”. Through her parents she became involved in the civil rights politics of the 1960s, and then the conservative side of Native politics in the 70s where she was considered too radical. But she also wasn’t terribly trusted by the more militant sections of the red power movement because of those familial ties. Prior to the 1970s, there were no class distinctions or economic distinctions in the native community in North America. It wasn’t until the funneling of government money into native communities to help solve some of the social programs began, that educational/ financial/class distinctions occurred. Young native people today think of these political structures as the norm. Just part of the way things are and have been. This situation is recent - and neither normal nor natural. By the time Aiyyana began to deal with the question of gender at 40 years old she had a history of over 20 years of social activism based on race/cultural politics. I certainly had a pretty good idea of what to expect [in transgressing gender]. For years, my politics had kept me on the periphery of a number of communities - white, left, Green, lesbian, and various factions of the Native community. Through my love of language, appreciation of writing and art, and my interest in the world, I recognized myself as a humanist very early in life. Although I was caught up in the particularities of Indian politics as a matter of survival, I believe mine to be a much more humanistic global perspective as opposed to the predominant nationalistic tendencies of Indian politics in North American. So I knew what being an outcast was. As she approached 40, Aiyyana’s family started to fall apart. Her partner of 12 years left after their relationship deteriorated, the four children (three from her partner and one that she brought to the marriage) were leaving home. And Aiyyana’s mother in law, who she describes as “more mother than my own” was very ill with cancer. During the last few months of her mother-in-law’s life Aiyyana was her constant care-giver. The day she died I took her to the hospital and they were going to take her upstairs and she sent me home to get something for her. I was only gone about ten minutes and the phone rang. It was the hospital telling me she was gone. She had sent me away while she died. A few hours later that afternoon physical things started to happen. All this energy was coming up out the ground, down from the sky, passing through me. It was as if she cleaned away the rage, bitterness and confusion, taking it with her. I cut off my hair that day, in the traditional way of honouring her. After the funeral Aiyanna shaved off her (somewhat sparse) facial hair to “see who has been hiding behind this mask all these years” and while rinsing her face she looked into the mirror and heard a giggling girl’s voice say “now you can wear make-up”. “And that”, Aiyyana says, “was the beginning”. After this epiphany-like experience, the next three years were a tumble of gender shifts from internal thoughts, to a state of male androgyny, to androgyny, to female 14

androgyny, and then living full time as a woman. “By 1993 I cleared out my closet and said okay, this is where we are going” and she has followed that path since. Aiyyana decided to approach the Gender Clinic “because few of us who aspire to surgery can afford to do it on our own, and the Clinic is where we have to go to get approved”. She knew from the start that while she fit the European definition of what a transsexual was, she feels it too limiting. Not unlike colonialism in general, there has been a colonization of gender. In my research and my travels around the world and talking to Indigenous people I have come to term Indigenous perceptions of gender as gender beyond male and female. Generally speaking, the majority of Indigenous societies in the world hold these perceptions of gender in a larger context, and see many more possibilities of gender past male and female. And for me, this perspective has very much been at the heart of my transformation. During my transformation, I’ve had to reclaim and recreate a language to describe this. I refer to myself as a “transformed woman who loves women”. I am not a transsexual. And I am not a dyke — many brown/black women who love women find that the European notion of what lesbianism is doesn’t fit. We are women-loving-women. In her choice of language, Aiyyana also steers clear of the term “two-spirited”, feeling that in its popular usage, it doesn’t adequately capture the much broader concepts which it originally encompassed. With the formation of Gay American Indians in the US at the end of the ‘70s, they began to make space to insert themselves into the larger struggle for gay and lesbian rights throughout the ‘80s. From the beginning, it was only concerned about being gay or lesbian, and Native. As in the larger society, trans folks were not considered part of the equation. The term ‘two-spirited’ was coined in the US in the late ‘80s, and coming into popular usage by the early ‘90s was synonymous with gay and lesbian Natives, with no further connotation. The whole other rich social and spiritual context associated with these positions in Indigenous societies were dropped by the wayside. And trans people had yet to be included. There is a small handful who are beginning to change that. I believe in the traditional concept, these people whose gender was beyond that of male or female were among the keepers of the culture. We were seers, visionaries, medicine people, storytellers, shamen, and artists. In the reclamation of our culture, I certainly have a vested interest in determining who we special people are seen as today. Aiyyana hopes that these broader perspectives of gender may eventually find their way into European perceptions. To that end she recently published an article in an academic journal of lesbian and gay studies in an attempt to ensure that discussions about gender variance included an Indigenous sensibility of gender and voices of those who have transformed. As Mao said, to know the pear is to eat the pear. Outside detached information will not 15

tell you what that thing is. Throughout much of the 70s and 80s, Canadians wanted to know who Indian people were. And the pattern is: first the outsiders wrote about us, then, after a few years of struggle, Native writers were able to publish our own words. This is the same. You need to hear from us, not about us, to really understand who we are. Coming out of that history I know that academia and mainstream society need to hear from us. So that was why I chose to write this paper.” [The paper was published in “torquere: Journal of Canadian Gay & Lesbian Studies Association” in May 2001]. Aiyyana is a multi-media artist, a writer, a director, and a film-maker. She has been a professional artist since her late 30s. She has written about and performed her gender story over the last ten years. Throughout her career, she has received a number of Arts Council and Canada Council awards to pursue her work, including the prestigious John Hirsch Prize for emerging theatre directors in 1997. 16

Kimberly Nixon Kimberly Nixon is a 43 year old transsexual and identifies as a heterosexual female. She underwent sex reassignment surgery 12 years ago and has lived as a woman for nineteen years. Kimberly is currently involved as the complainant in a human rights case against Vancouver Rape Relief as a result of her rejection from the organization’s volunteer training session because of her status as a transsexual. Kimberly has always identified as female. As a child of about four years, she remembers having a sense that her body didn’t match her mind. When I looked into the mirror, I didn’t see what I expected to see and it created a lot of turmoil in my early life; I grew up as a girl in a boy’s body. I couldn’t be myself so there was a dichotomy. Most people whose gender matches their body don’t spend every waking moment thinking about gender but when it doesn’t match, then it’s different. As Kimberly grew up, she continued feeling that she was a female in the wrong body. From the time she was eight years old, she prayed when she went to sleep that things would be right when she woke up the next morning. When that didn’t work, she thought she would one day live the way she wanted anyway. When I was about 11, I remember seeing Dr. Renee Richards on TV and she had had the surgery. It was then that I learned I wasn’t alone and that gave me hope because I identified with her. I figured if she could live her life that way, then it was possible for me. At 18, I moved out of my family’s house, still hoping. Several years after moving from her family home, Kimberly made the decision to go ahead and pursue the surgery. For me, it was a painful decision but I knew to be myself, I had to do something even though it might mean sacrificing my relationship with my friends, my family, and my career. Telling my dad was the hardest thing I ever had to do in my life. Many people might feel it’s wrong and have guilt about it but luckily for me, I had such a strong sense of self that I didn’t feel guilt or shame. It’s just a variation of nature. It’s not about politics and it’s not about sex. It’s about gender identity and that is the most basic thing. Kimberly worked in a number of different careers both when she “had to appear male” and when she became a woman. She often experienced discrimination when people became 17

aware that she was transsexual. Kimberly became interested in working with women who have been physically, emotionally and/or sexually abused as a result of her own experience in an abusive relationship and the help she received from Battered Women’s Support Services (BWSS). Because I was transsexual and had experienced so much discrimination, when I finally met someone, it was like the pot of gold at the end of the rainbow. I thought it was all that I had wanted because I could be myself in this relationship. Unfortunately, I wasn’t treated well and that was really hard for me because I hadn’t expected to be treated that way by someone who said he loved me. Kimberly describes the relationship as primarily emotionally abusive but when it escalated to physical abuse, she tried to get the courage to leave. I had left before for 6 months but went back because I thought he loved me and I was trying to make the best of a bad situation, as many do. I also loved this person and kept thinking that I could do something to make it better but I couldn’t. One day I was having lunch with a girlfriend from work and was telling her about the assaults. As we got up to leave, another woman approached us and told us she had overheard our conversation and handed me a note saying that there was support out there for what I was going through and it had the BWSS number on it. I was embarrassed and didn’t do anything about it for a month but then when the abuse in my relationship began to escalate again, I called Battered Women’s Support Services. When I talked to the woman on the phone, I explained my situation and told her that I was transsexual and thought I would get hung up on because of it. But she treated me like any other woman she would have talked to that night. I had been afraid I’d not be believed but I was. And it was critical at the time because I wanted the hurt to stop and I found the courage to reach out. It may have saved a life. Kimberly began to see a counsellor at Battered Women’s Support Services and eventually got the courage to attend a support group. Someone in crisis like I was is very afraid of getting hurt again. I worried that I might affect some of the women by my presence. I need not have worried. People don’t often give women enough credit for their own strength, courage and survival, because in the two and a half years I attended the support groups with between 14 and 24 women in the group each week, there was never an issue. Some people might say that they were being silenced by my presence but I know from my experience that women in that situation are often so focused on their own lives and how they’re going to manage to get through the next day and how to deal with things like custody, and access, often threats of violence, that they didn’t even think about me. 18

Kimberly’s experience at Battered Women’s Support Services was so positive that, like many women, she wanted to do support work for others in similar situations. It meant so much that those women were there for me that I wanted to give back and I learned so much during that time. I realized how necessary these organizations are. Often the support you receive allows you to take charge of your own life, thanks to information, referrals and support which allow women to empower themselves. In 1995, Kimberly saw that Vancouver Rape Relief (RR) was advertising for volunteers. Kimberly had a telephone interview and then a personal interview with 8 other women and finally was invited to join the training group. Part way through the first training session, one of the trainers took Kimberly aside and questioned her gender. She then told Kimberly she wasn’t welcome and asked her to leave. A Human Rights case arose out of that incident, which is still pending. Since that time, Kimberly has trained as a volunteer at Battered Women’s Support Services, Peggy’s Place and the Kettle Friendship Society. Kimberly believes that the rejection from Rape Relief is based on fear and stereotyping. Violence is most often committed by men against women and is systemic, which is why there’s Rape Relief, Battered Women’s Support Services, Women Against Violence Against Women, and 1,100 calls a month on the crisis line at BWSS. Women need a safe place to heal from violence and women are their own best experts on their experience. Women deserve to have their history respected and because of the perception that I might once have been male (it hurts to say that because I never identified as one), some groups think that gives them reason to exclude trans women because we might once have had privilege. But if that were the case, I would have given that up in a heartbeat because I never identified with being a male. They create a double standard when they say you must be a woman born woman. But I don’t believe that’s fair or true to our experience. Growing up as a girl in a boy’s body, is very different from growing up as a boy. I do have extensive history as a woman but it’s minimized [in court by RR] and I’m given absolutely no credit whatsoever. It wouldn’t have mattered if it was 19 years (which it has been) or 28 years or 36 years or if I had just decided to change today. I filed the complaint after thinking back to the time I was in crisis and had phoned BWSS. I knew then that I couldn’t bear the hurt any longer but I couldn’t end my life despite how I felt. I just needed some kindness and support and acceptance. I know that it takes so much strength and courage to make that call and reach out. I had a friend who had a 19

history of difficult relationships and was fed up with how she had been treated in those relationships. She wasn’t able to reach out and she jumped off the Granville Bridge in November, 2000. She was transgendered and I think it’s really crucial that if a transgendered woman gets the courage to call an organization like Rape Relief, she gets the support as any other woman would if appropriate for the services. I’m not doing this for myself. I’m doing it for other trans women. I’ve heard some organizations say they won’t support transgendered women but they’ll treat them like any man who might call— they’ll talk to them on the phone but they won’t provide services. But I think a transgendered woman’s life is as valuable as any other woman’s life. They should be offered services as any other woman is. They should be screened as any other woman. Some people want to politicize something that is innocent and is nothing more than basic survival. They do not have the right to decide who is a woman and who is not. Women in abusive relationships often have their sense of self eroded away by the abusive partner. The effects of denying someone’s gender identity feels the same. 20

Joe Joe is 42. He has been transitioning for 3 years and identifies as a heterosexual man born in the wrong body. He is African Canadian and grew up in Montreal. From as early as Joe can remember he always knew he was male. I always figured I was a man, ever since I was a little kid. I always socialized with my brother and his friends. I played all the rough and tumble guy games, like baseball, sports and playing with toy guns. When I was 12 years old, my family was in England and I saw a two-page newspaper article about an FtM [female-to-male transsexual]. They had pictures of him before as a woman and now as a man, and he looked so much happier after! And I thought, that’s me! But in 1971 who are you going to talk to about feeling like a man in a woman’s body? Puberty was a very difficult time because of the pressure to act and dress like a girl. When I was 13, my brother said I couldn’t hang around with him and his friends anymore and that really depressed me because I didn’t understand why. And my mother wanted me to dress up and put on make up. She wanted me to marry and have children. And she wanted me to go into nursing like she did, which in the 70s that was predominantly a female profession and I didn’t want anything to do with female jobs. When I got my first period I was devastated and when the breasts came in it was even harder. I hated it. People would say “this means you are going to have a baby” and I thought “no way!”. When I was twenty I wanted to have a hysterectomy but the doctor wouldn’t do it because he was afraid I’d sue him later. I got a prescription for really bad cramps, but I was a walking zombie every time my period came around from the age of 13 until I had my first testosterone shot. When I stopped having my period it was a godsend — like the first time I could actually live. Joe kept to himself in high school and didn’t tell anyone about his desire to be a man until he was twenty years old and in university. At that point, he confided in a lesbian friend but she strongly discouraged him from doing anything about it. She said “how are you going to get a woman if you become a man? Straight women won’t like you and lesbians certainly won’t want to go out with you. You’d just wind up a gay man.” So I stayed silent about it and she introduced me to the lesbian community. But I just didn’t relate to lesbians — I never felt I belonged there. I hung around with them because at least I could explore that aspect of myself. After university, Joe pursued a successful career in the military as an airplane technician. 21

From the time I was six, I wanted to go into the military. I was in the militia first for three years, which paid my way through university. Then I joined full-time and was there for about five years. I was fascinated with planes and wanted to be a pilot from the time I was eighteen. Unfortunately they weren’t letting women be pilots then, which really upset me. Instead I became an airplane technician. The last place I was stationed was Cold Lake Alberta working with CF 18s. I met lesbians in the military. But at that time there were these big witch-hunts and purges to get lesbians out of the service, which was awful. You’d hear about them having a big purge at the Halifax base, or up in Alberta. When I was moved to Kingston, someone told me it was a good thing I hadn’t come the year before because they had a big purge. After a while I just got tired of keeping these secrets. And I got tired of the limits to what women could do. So I left the military in 1988. During his time in the military Joe saw a personal ad from an FtM who was trying to meet women and Joe contacted him and talked to him about being an FtM. He learned about the process of taking hormones and what surgeries were available but at that time he decided his military career was more important. After leaving the military he moved to Vancouver. I came to Vancouver to change my life completely. I had no idea how to find people who had changed their gender. I had no idea about the Gender Clinic. My first issues were survival because I had no friends or family or job. So I started looking for a job and trying to get myself together. I decided I didn’t want to pursue a career as an airplane technician because to me, working on the CF18 was the best plane in the military and working at the airport on transport planes would be like going from working on a Lamborghini to working on a Pinto. Instead I wanted to do community work. So I volunteered at the Canadian Mental Health Association and at Rape Relief’s transition home (which is ironic to me now considering the Human Rights complaint against Rape Relief). This was in 1989. I found all the women there fascinating and they helped me tremendously when I was going through a life-skills training course. I don’t know how to explain it but it was a great experience for me and I feel as if I owe them a lot when it comes to my independence and seeing the world differently. So I was quite shocked when I heard that they would not allow Kimberly Nixon to take the training course and volunteer. I had never talked to any of them about my gender issues at that time and I realize that if I had it might have been a different story. But it was devastating to go to the tribunal hearing and listen to some of the people on the witness stand. I was just horrified that they had these opinions about trans people that I never knew about. It shocked me to hear these opinions about trans people coming from an organization that is supposed to be very leftist and radical. And one that had really helped me. I know I need some closure on this. Joe did not find that his relationships offered much support for his feelings about being a man. 22

I met someone in 1989 and we were together over eight years. I talked to her about my feelings about being a man but she wasn’t thrilled about it, so once again I put it on the back burner. Every woman I was with, even in the military, didn’t want to hear about my being a man, or said they would leave me if I did anything about it. So I kept it to myself. When that last relationship ended in 1998, Joe decided it was an opportunity to explore his masculinity. A psychologist told him about the Gender Clinic, which was a moment of profound realization for Joe. He’s been at the Clinic since early 1999, started hormones, and is scheduled for a surgical consultation in a few months. I had been warned about changes from being on testosterone. But it really shocked me that it made me see the whole world differently. Now I understand men’s fascination with sports and speed and why they are so readily angry, and how they look at women. At the Clinic they told me I’d be like an adolescent guy trying to go after girls in high school, and I do appreciate women in a different way. But I’m sure it will eventually calm down. Joe tried a number of different jobs before settling on the job he has now. I had been living in Victoria for two years. In that time I took a four month legal course and worked in a law firm for about 9 and a half months where I learned a lot about legal research and commercial and corporate law. Then I worked on a temporary basis with different government agencies like legal services branch. When I moved back to Vancouver I had a number of jobs before I found one in the service industry. I have been working with the same company since 1993. Joe started living full time as a man in 1999. First, I gradually changed my appearance at work and did it in such a way that people didn’t really comment on it. Then I got on the hormones. One year later I was diagnosed with type-1 diabetes and my whole world changed because of that. In order to minimize my stress, I decided to tell my company I was transitioning so I went to the union and they phoned head office and sent them documentation from the Clinic and I gave them a pamphlet made by one corporation to prepare other corporations where people were transitioning on the job. But head office said they weren’t going to treat me as a guy until I had surgery. And then last week I had a performance review and the general manager asked me how I would like to be addressed. I said that since I was transitioning I would like to be addressed as sir, and he said okay, and he let everyone know. And he said if there was any harassment going on please let him know. It was great. I just kept my mouth shut about head office. I guess they don’t communicate with their managers! Joe has been estranged from his family but last year he told his aunt about being FtM, and he told his mother before she died. Both appeared to understand. He hasn’t told his father yet because it has “never seemed like the right time”. Almost all of his friends have understood and have offered some support. But most of his support has come from other trans people, and 23

from his internal spiritual beliefs. I went to a couple of FtM support groups and I met people there and I knew I could get support. I learned a lot about the politics of the trans community — which was an eye opener. I learned about the Trans Alliance Society and the different organizations for both FtMs [female-to-male] and MtFs [male-to-female transsexuals] and I got on the computer and found a huge community there. I also get a lot of support from inside. I grew up in a very spiritual family so even when I came to Vancouver by myself I never felt alone. This is my journey and it’s temporary, and I have friends and family on the other side who — like spirit guides — give me support. I think that has really helped me especially with people who are uncomfortable with trans people. I just wish people could see us as ordinary people. We work. Most of us are taxpayers. Some of us are married. We’re living in this community and contributing to it. There’s nothing to be scared of. In many ways, there is nothing unique about us — we just want to live our lives. For me, it turned out my mind is that of a man and I was somehow born into the wrong body. Now I’m getting a chance to correct it. 24

Romham Padraig Gallacher Romham is a 29 year old queer trans-guy who has been transitioning for almost four years. He describes himself as a “queer fat tranny gimp”. He has a disability derived from complications from two car accidents, and lives with Attention Deficit Disorder, chronic pain and arthritis, and walks with forearm crutches. Here is his story. My identity has been moving around a lot over the last few years, but generally I define myself as a queer trans-guy. Sometimes I use FtM (female-to-male) and sometimes transgender. Mostly I use the term “queer”. It’s a broader term than FtM. It becomes the catch-all term (for me) for gender identity and sexual orientation. I never really fit in when I identified as a dyke, never called myself a lesbian, and now I wouldn’t call myself a gay man. My sexual, social stuff just doesn’t fit politically or socially. I came out as queer when I was 22 and as trans when I was 25. I read Transgender Warriors by Leslie Feinberg and it had a lot of resonance for me. I feel like a guy, but the term transsexual is a medical/psychiatric term because it defines someone who is, wants to, or should undergo surgery, and I’m not certain where I fit in there. Romham began hormones in December of 1998. I had to get myself on hormones basically by sneaking around. I’d been going to the Gender Clinic for a year, and seeing my “worker” there twice a month. They didn’t seem to understand my case, which is why I was there so much. Some of it was my disability, some of it was because I am fat and they wanted me to lose weight for all sorts of reasons. They wanted me to bind my breasts, which is very difficult for me with my disability, but they read that as not being “willing to bind”, so I didn’t present a good enough case for “passability” or willingness to try and pass. Which meant they were reluctant to approve hormones — although they had already diagnosed me as a “level 4 transsexual”. I grew increasingly frustrated with the whole process, but I knew that what I wanted — what would keep me alive at that point — was testosterone. So I went to this doctor, made up a bit of a story and managed to get some testosterone. A few months later she found out I wasn’t really approved for it by the Clinic and she was persuaded by them to take me off. Which was really awful. I had been getting shots every two weeks, had been feeling great and was seeing some of the effects. Immediately I was back in a pretty horrible place emotionally and physically. With support from a friend, I went to a 25

walk-in clinic and, since I had the vial already, they gave me the injections. I’ve seen a doctor every two weeks since, and I’m very happy with the testosterone, which I knew I would be. Romham notes that the issue of surgery can be a difficult one for FtMs since a full sex- reassignment is presently not funded by MSP (the Medical Services Plan) for female-to-male transsexuals, while it is for male-to-female. For example, the approved surgeries include a hysterectomy and a mastectomy, which are funded. But phalloplasty (the construction of a phallus) isn’t covered at all and has mixed results, and metoidioplasty (constructing a phallus out of the clitoris) also isn’t covered, although it is generally successful. I recently got approval for the mastectomy, hysterectomy and removing the ovaries, which took a long long time. Now I’m trying to figure out what to do. I don’t want a mastectomy because it won’t leave me with the body that fits me. I’m a fat boy, and getting fatter, and fat boys have boobs. But when I went in for my first consultation with the surgeon I was sitting there in a big fluffy terry robe, with my boobs exposed and she said “oh, we’ll just get rid of those”. I had all these questions written down to ask her and they all just disappeared because I was so stunned. I wanted to say “No you won’t. You’ll get rid of some of it, but not all of it!”. But for that surgeon a breast reduction wasn’t an option because all of the guys she had seen up until then — that’s what they wanted. They all wanted flat chests through mastectomies. And at that moment I realized that I wanted a reduction, not a mastectomy. I felt really destroyed inside and I had to remind myself that I could do this and just had to find someone who would respect that and do it. And as soon as I reminded myself of that I was back feeling really good about it, and set out to do something about it. And as it turned out, that surgeon could do it, just no trans guy had asked her before. Romham feels that he would be a lot happier with a reduction because it would allow him to have some choices. Binding is painful, exacerbates his disability, and since he has large breasts it often doesn’t work. He received no assistance from the Gender Clinic on how to bind safely, but had a lot of pressure from them to bind. Getting a reduction means not having to bind or be confined physically or emotionally. But I’m just sad I have to do that in order to walk down the street and be safe. It feels like a real invasion. It’s not about being taken as a guy, ‘cause I am a guy and don’t feel like I have to pass ‘cause I’m a guy whether people respect that or see it. I’m just tired of fighting so bad. Romham had no early signs that he was trans. When he was in San Francisco, he met someone who was transitioning, and had a body like his. Then while reading Transgendered Warriors he started to remember things from growing up and how he had denied feelings when he was young. 26

I felt like I was a boy until I started bleeding. Up until then I was allowed to act like a boy, although that’s not what it was called, and feel really lucky that I was able to do that. (If I had been born a boy it wouldn’t have been as easy to have explored girl stuff). I was allowed to, and in fact expected to, be tough, to fight with the boys and all of that. When I came out as queer I remember thinking I’d been queer my entire life. I remember as young as eight having crushes on my mom’s friends. I was called lesbo in school. Before coming out as queer I never had a sense that I could be happy. No one ever said that it would be okay, that maybe I could be happy, and there would be people in my life, that it wouldn’t always be crap. I lost friends but got immersed in the queer community, was active, in addition to other political work, and it was a great time in many ways. When I started coming out as trans the reaction was mixed. Some friends have stuck around, but some haven’t and don’t accept it. It’s probably the scariest thing I’ve ever done, to come out as trans and open myself up to the strong feelings of some in the community. It’s been very painful. But when I read Transgendered Warriors, I thought that maybe in fact I did exist. Before that there was no future, there was something really wrong: there was nothing. Romham has noticed that his sexual orientation has shifted during his transition. Since I began “transitioning” I now find myself attracted to men as well. I’m a queer boy, but still trying to reconcile a lot of hurt. Romham has been involved with the Women/Trans Dialogue since it began in 2000. He doesn’t believe that the lack of support for trans people (for example by some feminist groups not providing services or access to trans people) is just about a lack of information. It’s condescending to say that if people just had enough information they’d “understand”. I’d find that condescending. I’d have been irritated if someone told me it was just that I didn’t have enough information. Because I went out of my way to get as much info as I could. Also, it implies that with this magical information, folks will just “get it” somehow. And I don’t think it’s that simple. If it was that easy, we wouldn’t still be bitching about it. And really, some of the people who have access to tons of info on trans stuff are among the most anti-trans folks I’ve ever met. I mean, there’s always room for more info — it’s better than none — and some folks are missing some pretty basic stuff; but it just gets to where trans folks have to constantly justify our existence & I think that’s bullshit. We shouldn’t have to prove we’ve “always existed” historically or that we’ve “always felt this way” (whatever way that is!) in order to take part in stuff. We all know who gets left out when we use these kinds of crap tests for admittance or acceptance or legitimacy; and it tends to be those of us who don’t fit “neatly” that could really use the stuff we’re denied. I lived as a woman for the first twenty-five years of my life. It’s been a struggle, but 27

twenty years from now it’ll still be a source of pride to me that I survived long enough to see the day I’d start getting my shit together. This stuff isn’t easy for any of us. But I know I’m gonna walk into the local woman’s health center for a pelvic exam, or a women’s shelter in crisis, and these places need to be prepared for that because my boy identity doesn’t take away from the fact of my woman’s body, and this body doesn’t erase or negate my identity. These groups or services or whatever, need to know that just cause they’re a volunteer group or have certain folks they’re dealing with doesn’t mean they can continue to deny the reality that people identify in lots of ways, and more and more those identities can’t be neatly contained in specific bodies to scrutinize or boxes to check. It’s similar to the mentality that says “because the majority of our clients don’t need wheelchair access, we don’t need to change or update our information or thinking and put it into action: make your own space!” This stuff is disguised in “we don’t have the funds/energy/time/etc.”, but you find a way to at least open honest dialogue if there’s a willingness to try. That doesn’t cost anything. But the cost of not doing anything or of actively fighting it, brings way more sadness and hurt than there needs to be. 28

Jewel Jewel is 51 years old and identifies as a lesbian. She has been “a gender-variant activist” for the past 10 years. Jewel’s earliest memories of wanting to be a girl are from when she was four years old. I knew I was different, but of course I didn’t have a word for it. Although people referred to me as a young boy, and I certainly saw myself in the world as a young boy, I also had this conflicting feeling and identity of being a girl. Jewel’s clearest cross-gendered incident, as a child, is when she asked permission from her grandmother to play dress up in her grandmother’s closet. Though being allowed to play, she knew better than to tell her parents or let on about her girl-feelings. I had my first major gender-identity crisis on my 16th birthday. I’ll never forget how I couldn’t stop crying. I knew I had to make a decision, right there and then, to either tell someone about my desire to be a woman or promise myself that I would go on to be the best man I could - a superman. I chose the latter thinking it was the right thing to do — the most achievable. And, I wanted to make my parents proud. Jewel has had three common law relationships prior to transitioning at age 41. What is interesting for me is that sexually I have always been attracted to women. I’ve never been attracted to men. The thought of being attracted to a man is inconceivable, almost homophobic. Throughout her heterosexual relationships Jewel could not successfully purge a secret obsession with cross-dressing, which created a sense of self-loathing, though she tried endless times to gain control of her behaviour. Between the ages 19 - 38 I grew a beard to not only to project an image of maleness but to protect myself from myself. However, in 1982, I shaved off my beard and dressed as a woman for a Halloween Party. That was really significant for me because removing my beard made me feel very vulnerable and risked having “my truth” found out. In private, my beard did not interfere with my cross-dressing or feelings of feminine identity because I looked right past it; I could look in the mirror and not even see the beard. Her two children, both adults today, come from Jewel’s first common-law relationship. Though her cross-gender identity did not directly have an impact on this relationship, her spouse and children left after seven years. It was during Jewel’s second marital relationship that she made her greatest effort to purge her cross-dressing. Regrettably, her behavour re-surfaced and she eventually told her spouse, which resulted in the relationship ending. During her third common- 29

law relationship she decided to be up front about her cross-dressing from the beginning. I was cross-dressing a lot by now, almost nightly. And my spouse and I were watching TV one day and saw some transsexuals on Geraldo. Suddenly, I came to understand that maybe I was a transsexual, not a cross-dresser. Prior to that program, I had been in such deep denial that I had never heard of the term transsexual. A few months later Jewel shaved her legs for the first time and simultaneously began to develope asthma. I went from having mild to severe asthma quickly and I was hospitalized for a week and on oxygen. A few months later I was back in the hospital. It was during this second hospital stay that I verbalized for the very first time, telling my spouse that I needed to do something about my desire to be a woman. And then, like a miracle, I put aside my pills and my inhaler and walked out of the hospital the next day — the asthma was gone. It has never returned. It would take another seven months, but in March of 1991, Jewel was diagnosed at the Gender Clinic as transsexual. On Sept. 3, 1991, I began my transition living as a woman, leaving behind everything: my children, my spouse, my business, my home — everything. Though my spouse and I had originally talked about us living together as lesbians, she eventually came to telling me: “I can’t do it. I’m not a lesbian. I need man in my life.” Though we still remain good friends, we have each moved on with our separate lives. Telling her daughters was the biggest and most painful hurdle for Jewel. After first telling the mother of her children, Jewel and her partner decided to tell the girls while on vacation, two weeks before she moved. They were aged 14 and 11 at the time. I told them I was going to move away to Vancouver and I was going to live my life as a woman. It was horrible. My eldest daughter became angry immediately and ran off in tears into the woods. Had my spouse not gone after her she may have never come back. She has remained angry for 10 years now and we are estranged. My youngest daughter, at the time of me telling her, appeared undisturbed by the news. This is not to say she hasn’t been affected because as hard as she has tried to be strong, to be understanding and accepting, she has suffered. Though we have remained connected for all these years, it has not been easy for her to overcome the pressures of “family issues”. Jewel’s parents and siblings have remained supportive from the moment she told them. When she told her parents that she had something really important to tell them, they were relieved to learn that she wasn’t dying of cancer or AIDS. Jewel remembers going shopping at Eaton’s with her parents a few months after telling them. 30

My mom and I were popping in and out of the changing room trying on different outfits and my dad was sitting there in the chair saying what he liked and didn’t like. It was my first rite of passage — shopping for women’s clothes with my mom and dad. And that was followed by my mom and I having to pee, we sat in cubicles next to each other — that was my second rite of passage. But the first year of transition was more challenging than Jewel had imagined. I was so naive. That which had seemed so do-able became the unimaginable. I had lost almost everything that was dear to me, plus I couldn’t find a job. I had assumed my work history and skill set would serve me well, but I failed time after time to secure a job. I couldn’t even get a job pumping gas. I either was rejected without an explanation or I was told I was over qualified. Within seven months I had exhausted all my savings and ended up on welfare. But I was resigned to being employed. By combining my enterprising spirit and knowledge of how “the system” works, I managed to re-establish my career by designing and implementing a public interest research project addressing trans employability issues. After three years of on-again off-again short-term government contracts, I started a fee-for-service business that has continued to evolve and prosper for these past six years. Jewel regrets how difficult her transition has been on her daughters. My children were so negatively impacted, both emotionally and financially. I had taken what I had thought to be sound steps in the process of providing for my children, but everything seemed to fail. It was as if we were separated by a wall of social hate and mistrust, and powerlessness. Had we lived closer, we may have found a more supportive network. Just think if we lived in a world where it would have been “Wow - your dad’s one of those? Amazing!”. But instead they felt so ashamed and fearful. They had their fears re-enforced with people saying I was crazy and irresponsible, etc. My kids had to cope as best they could in a very homophobic, transphobic world. With the knowledge and experience I have today as a social activist, I wouldn’t ever let that happen to them again. Jewel’s present relationship began nine months after sex reassignment surgery. Her partner (female) identifies as bisexual. It was the classic bells and whistles, love/intrigue at first sight. Within a few months we risked being intimate, which led to having sex. But before we had sex, I told her I was “gender dysphoric”, to which she replied, “Oh, you’re in transition”. It wouldn’t be for another month or so — of hot passionate sex — that I found myself using the term transsexual to describe myself. This surprised her. “You’re transsexual?”. She had no 31

idea! She had assumed that being gender dysphoric and “in transition” was about changing from heterosexual to lesbian. She had no idea I used to be a man. Here I thought I was being open and yet it was if we were talking different languages! Recently, Jewel’s gender identity shifted, again. I no longer focus on being transsexual. I consider myself gender-variant. It’s a relatively new concept for me to use. I am moving away from the trans, transsexual, transgendered, gender binary mindset. The term transsexual is tied to sex reassignment surgery, which is tied to organizing the world by our genitals. I am consciously distancing myself from the stereotypical gender preconceptions I came to rely on and instead I have come to see my diversity and fluidity as being more important. At the beginning of my transition I labeled myself a “lipstick lesbian”, but today I have taken on more of a “butch dyke” persona. It feels good. Though there are those trans people who need the stability offered by the rigid gender binary, I’ve moved on. For Jewel the future lies in a culture that will be more open-ended about gender identity. I want to contribute to a social reconstructing of gender, where four year olds are able to talk freely about their gender feelings, a world where all forms of cross-dressing is accepted, and encouraged if need be. I want to see a society where pressures to conform are minimized, such as the assumption that sex reassignment surgery is necessary. I envision a change in attitudes and expectations that will view individualism and gender-variance as synonymous. Whether it be 20 or 200 years, I trust that one day we will de-genderize people. And, I see feminism and trans issues as being connected. The trans movement is an extension of the feminist movement — it’s the next step in feminism in the sense that it is further breaking down gender barriers. It is about gender equity and making things more balanced, mixing it all up so that “the different” blends into “the other”. I understand the anxiety some people feel around this issue. I understood how reconstructing gender may be foreign or scary to those who only know it as a stable force in our society. However, I have also come to appreciate that there are many other changes taking place to a whole range of social institutions and values once deemed sacred. And, as we are slowly beginning to see an attitudinal shift taking place around issues of racism, ableism, sexism, I believe we will also instinctively come to embrace gender diversity and fluidity as being something that is powerful and humanly good. 32

Joshua Mira Goldberg Joshua is 30 years old, Jewish, and identifies as a gay transman. He started transitioning about four and a half years ago. Since that time he has co-founded three trans organizations and assisted in numerous others. This whole gender identification stuff drives me crazy. I usually say I’m a transman because that’s the closest word that people understand, but transgendered seems to encompass the most truth both about my historical experience and how I present in the world now. I was born female. I went through various processes to change my body, and as a result of both hormones and surgery I am (for the most part) perceived as a man. I have some perspectives of having lived as a woman for the first 25 years of my life, and being a very active feminist; in the last couple of years I have the additional perspective of being perceived as a man and participating to some degree in men’s communities. I still cross-dress and wear “women’s clothing”. I don’t wear it to work because there is only so much harassment one wants to deal with. But if I had my druthers I would wear women’s clothing. I think it’s more comfortable and there are better colors. And for me as a gay man, there are aspects of gender transgression in my sexuality that aren’t necessarily about the neatly separated categories of gender and sexuality. I had no idea even five years ago that I would go through this. It was very sudden for me. I was a very feminine looking female. I had long hair, wore skirts, was never even remotely masculine. I had recurring gynecological problems that led me to have cysts removed from my ovaries. I woke up from that surgery feeling something had changed beyond the physical level. Then I cut off all my hair and I started wearing pants and big shirts that concealed my breasts. I don’t know if it was a massive hormone change or what, but it seems that overnight I became transgendered. So for about a year I tried to be more butch in appearance, but I was too much of a sissy to be butch. And I wasn’t comfortable being a masculine woman. And I wasn’t a lesbian — I was gay. I knew I was queer, but having sex with men while I was female would make me heterosexual. That wasn’t right. So I kept trying to be with women, because that was “queer”, but it didn’t work out and I couldn’t understand why. Reading the book Stone Butch Blues was really important in so many ways. I decided 33

fairly impulsively this was what I needed to do. Before that I was quite transphobic. I had a friend who was born male who was a cross-dresser and was thinking about sex- reassignment, and I was really lousy around that. I put it all in feminist political terms: that he was denying he was a man, etc. I didn’t have any sense that I would go through this process of becoming a man. I found the intersection of being Jewish and trans really interesting. When I was thinking about how to be masculine I looked at the men I respected in my life who are not masculine by WASP standards. Masculinity was more about the brain and intellectual prowess than muscular power. Then I read an article that talked about Jewish masculinity and I thought, oh my god, that’s it!. I’m just Jewish. I do masculinity in a Jewish way! Before I transitioned, I had a particular understanding of gender that was based on growing up in a very strongly feminist household, my own life experience, and from women’s studies at university. I had both a community and an academic perspective of how gender works — that there are two genders, and one oppresses the other. Now I realize that analysis is about 20 years out of date. What I have learned through being transgendered is that gender works in many ways. Sexism is one way that it works — true. But there are also all these other layers of how it works. I used to believe really strongly in transition houses. I believed there was a need for women to have access to a space where there were no men. But transition houses aren’t actually for all women. They are not for anyone who is ill, or for seniors or people with disabilities who can’t get up the stairs. They are certainly not culturally diverse. And although they may say they are open to lesbians, the way they look at violence is in a heterosexual way. So, they are for a particular kind of women. And realizing that got me thinking. If they really are for only a particular kind of woman, then what am I defending about women-only space? I think women-only space meets the needs of some women, no question. And I would still fight for those women to have access to what they need. But I think many women don’t want women-only space, or at least not the women-only space that currently exists. Some women might not feel safe in a women-only space because they have been abused by women, or might feel safer being around men from their cultural community than around women who don’t understand or respect their cultural practices. Or they might want their male children with them past the age where that is deemed okay. There’re lots of different kinds of needs and all of those needs are important and not one of them should be at the expense of others. There is this whole focus around trans women and access to women’s services that I find unnerving. I find it sad that non-trans women are so upset about it. I never believe that principles should come before people. And I really think the issues are a lot broader than that for us trans people. I’d like to see the debate be about what are the services that trans people need (“trans” encompassing a broad diversity) and what are some of the ways those services could be provided? I think the important thing is to provide services based on need. 34

Some trans women want to go into women-only space because they want to be with other women. Many trans women are lesbians; many of them want to learn about feminism and want to be a woman who cares about and does something for other women. So why not make their access be about behaviour instead of their bodies? I worked at street outreach services for a number of years, and you got to be in the space if you weren’t causing problems for other people. That’s pretty simple. But it doesn’t seem to be clear in many cases. I’ve seen some instances where MtFs who are following the rules of a shelter get kicked out just because they are trans. It’s not open discrimination, it’s supposedly about their behaviour, but there’s a double standard for trans and non-trans women. In one case an MtF was asking some very personal questions that staff didn’t want to answer. Rather than setting limits about what they were willing to talk about, they said she was making them uncomfortable and told her to leave. The issues are pretty clear: do you have policies around behaviour, and do you apply them equally or not? If you don’t, then it’s about transphobia. I often hear women’s groups who don’t want to be inclusive say, “Well, we support you going off and creating your own organizations”, and I keep thinking, half the population is women and you have trouble organizing. How on earth is 1% of the population supposed to organize? It’s not going to happen. Women’s organizations should know how hard that is. Getting back to what the needs are, there are a number of really important health issues for trans people. For example, there is a high incidence of gynecological disease in FtMs (it’s not understood why) and there’s nowhere for us to go. Finding a doctor who will even examine us is really hard. Who will do a breast exam for an FtM or teach them how? Who will do a prostrate exam for an MtF? So many of us have body parts that need attention but it’s hard when you have strong emotional feelings about those body parts. It’s even harder when doctors just refuse to deal with them. One doctor refused to examine me in the emergency room, saying that I needed to see my own doctor. Another didn’t want to touch me, and then started asking me if I had had genital surgery, even though what I was in for had nothing to do with my genitals. I have many of these stories. For FtMs it’s also difficult in women’s communities. Some FtMs who transitioned wanted to stay in those communities but got unceremoniously booted out. Some are experiencing being isolated from the women’s communities they worked hard to create. And others are quite comfortable with separating themselves. Some stay in it as butches (not doing any physical changes). I’m not sure where I stand on FtMs in women’s spaces. For trans women, I feel it’s straightforward: they are women, they have a right to access women’s stuff. Whether FtMs do or not, I’m not so sure... If we are at a stage of transition where we are clearly wanting to be perceived as male, I don’t think you can have it both ways. But I still have 35

questions to women who want to keep FtMs out. Why do they want us to leave? If we’ve fought with them for 20 years and they like the work we do, who cares how we look? I have to admit that there seems to be some attraction at the moment to trying out being transgendered, that gender transgression is hip. Its sort of like gay and lesbian chic was. I’m a little too cynical to believe that Hollywood movies are about representing trans people – it’s more like a freak show where our whole experience gets made into a commodity — but I wonder if that’s part of what makes it attractive. It will be kind of interesting to see how many people who are transitioning now will have regrets a couple of years down the road. I do have some regrets. I regret having chest surgery. The issue for me was never about how comfortable I was with my breasts. I felt fine with my breasts. I actually kind of liked them. But there’s a big difference between how you feel about your own body and how you feel about the way other people perceive you. I think it’s a valid reason to have chest surgery so you don’t get killed. For me, that was an ongoing issue. I used to get the worst kind of fear walking around at night because people would yell and throw things at me. So, did I have chest surgery for me? No. Did I have it for them? Maybe. I don’t know. There’s no place to explore what are the reasons I want this, what are my doubts? If I have doubts does that mean I shouldn’t transition? Not necessarily. Maybe you just always have doubt. Is it bad to have regret? Not necessarily. Maybe all kind of loss has regret. You know, many trans people are really on the edge, have basic needs for housing, food and some support. Many trans people lose all their support from a very early age, and so many deal with such shame. I see trans people really struggling with relationships and it’s often really hard for trans people to trust that they will be loved, and love themselves and really value who they are. I think trans people need some of the really basic things I remember learning from feminism. Like having self respect or dealing with abuse issues. We all have a unique and precious story to tell, but we are like everyone else. People need to see us as part of the human family. 36

Linda Linda is a 53 year old cross dresser who identifies as a heterosexual man when she is not dressing as Linda. She is separated, has two children, and is a member of the Cornbury Society, a support group and social club for heterosexual male cross-dressers. Linda has been exploring her cross-dressing in a focused way for three years, after the deterioration of her marriage. It has been a very interesting journey for me. Linda didn’t emerge until I was 50 although she was in my mind for a long time. But for the last three years I’ve been able to really express myself and see where this will take me. Perhaps the worst thing that has happened to me was that maybe my confusion over gender or my lack of real “maleness” was responsible for the end of my marriage, which is a shame. But I guess it had to happen. Linda had a normal and relatively happy childhood. As a youngster, I was a mild person who didn’t play competitive games and didn’t like rough sports. I got along well with my family. I liked to talk to my sisters and my mother. My parents were pretty normal. My dad was a very nice person and a good father although a bit distant, as I think all fathers were in those days. But I have very fond memories of being given a lot of freedom and my parents were very easy-going with me. Linda remembers being intrigued by women’s clothing early in life, but didn’t really think her feelings were very unusual. As a child I didn’t really cross dress, although I remember being fascinated by the dressier things that women had, like my grandmother’s gloves. I experimented a bit with my mother’s things but not very much and I thought it was just normal curiosity. I was furtive about it and I don’t think I was ever discovered. In my teens it probably became a little more of a fetish. But unlike other boys, I never felt much of a sexual drive in my adolescence. They could objectify women and I couldn’t. I think my testosterone levels have never been high. I was a bit of a loner and I had acne and very bad eczema. Linda met her wife when she was 34. They fell in love and were married seven months later. They were married for seventeen years, fifteen happily. It was three years into our marriage, when our first child was still a baby, that I started to realize there was this other side of me. At that time, I had tried on the odd thing that she had thrown out, thinking it was just curiosity I had never completely dressed as a woman yet. But then one day, after she had left for work, and I was still at home I tried on this very attractive suede blouse that someone had given her that was too big for her. I 37

looked in the mirror and it was a perfect fit and I thought it looked lovely on me. And I immediately phoned her at work, without any warning, and I told her what I had done and that I enjoyed wearing it and could it (cross-dressing) be part of our marriage? There was a silence and then she said, “I’ll talk to you later.” When she came home she told me “I am not going to leave you over this — yet”. But she didn’t want to have anything to do with it. There was no dialogue. She thought I must be gay. I told her I wasn’t gay. She asked if it was sexual, and to some extent it probably was. She couldn’t figure it out. She was upset and it took her a long time to get over it. She made me promise not to touch anything of hers. And I kept that promise. And the whole thing subsided. But Linda’s interest in cross-dressing didn’t. Eight years into the marriage her wife took the two kids to Disneyland and Linda saw the empty house as an opportunity to fully experiment. I shaved my legs, I painted my nails, I tried on makeup. At that point I knew I was a cross-dresser. I knew I didn’t want to become a woman, and I knew I wasn’t gay. I enjoyed dressing as a form of expression. And I spent hours like that. There was some sexual component to it, but it was also something other than sexual. I felt some comfort and relief that I had actually found a way of expressing something I had been holding in for a long time. When my wife came home from the holiday, I had an honest talk about it. But again she couldn’t handle it. Which was a shame. So I hid it from her. And I started collecting small amounts of clothing of my own. But one day, she found a piece of my clothing and she blew up. We stopped sleeping together and shortly after, she asked me to leave. That was two years ago. My kids were 8 and 15 and they had no idea what was happening. For Linda, it was like walking through a door into another room. She used the time living alone to read about cross-dressing and experiment more. During that time, she found the Cornbury Society, a Vancouver support group for heterosexual, male cross-dressers. It was named after a governor of New York in the early 1700s who is reputed to have engaged in cross-dressing behavior. The intention of the group is to reduce stress and guilt, and assist in gaining understanding for associates and loved ones. Many of the members are married. I found the men there very nice, very understanding, thoughtful and intelligent. I enjoyed their company and I appreciated the sessions on guilt and talking about my feelings. Some of the people come there on their way to realizing they are transsexuals. After all, every person who transitions starts as a cross-dresser. But we also have members who just stay as cross-dressers and don’t transition. It’s very individual. And some members live full time as women and identify as transsexual, but have chosen to be non-operative in the sense that they are choosing that lifestyle and that way of looking but not interested in sex reassignment surgery. Or sometimes the Gender Clinic has judged them not suitable for surgery in which case it’s very hard to get it done if you are not recommended. 38

After a while I went to the Gender Clinic and asked to be castrated. I just didn’t want any more testosterone in my body. It was fairly vain, really. I didn’t want to lose my hair. I didn’t want to age in a typical male way. But they wouldn’t do it. Instead they gave me spironolactone or Spiro which is a testosterone uptake inhibitor. This allows your body to be sensitive to your own estrogen. It had the effect I wanted and it also had the added bonus of improving my skin — the eczema and the acne just disappeared. I have to admit it’s unusual for a cross-dresser to take Spiro, usually only transsexuals do because it has some very serious side effects, like impotence, which most wouldn’t want because there is often a sexual stimuli component to cross-dressing. But that’s not the case with me. In some ways I’m more gender variant than most cross-dressers, although I’m not a transsexual. I do Spiro and hair removal. But I don’t want to live as a woman all the time. For Linda, cross-dressing is an expression of a femininity in her personality that is always present. I don’t want to have SRS (sex reassignment surgery) because I don’t think I can live as a woman. I don’t feel the urge to do that 24 hours a day. And frankly I feel an obligation to be a father to my children. If I transitioned I don’t know how much of my family I would lose. It seems pretty common that you lose some of your family. I hope I wouldn’t lose my sisters, because we are very close and I’d still be the same person inside. But I haven’t told anyone about my cross-dressing. I’m planning to tell my kids when they are older, but I’m chicken about telling my sisters. I have this real fear of being treated differently even though I’m not a different person. That would just kill me, to think that someone would avoid me all of the sudden because I’m not perceived to be as wholesome as I was before. So I question whether it’s wise to transition. Maybe at some point, but right now it’s not what I want. Now I go out as a woman sometimes but I work as a man. I have a pony tail and I’ve had electrolysis so I don’t have much of a beard, and Spiro has made my features a little more feminine. And I’m happy with that. My masculinity never struck me as having any particular power. It never did me that much good. I know that sounds strange coming from someone who had a good marriage for 15 years, to say that my masculinity was a failure. But I feel as if I was just never male enough to really hold it together. Linda feels more confident now than ever before in her life. She says that the last few years have been a time of exploration and a wonderful realization of who she is. She’s not sure where this will all lead at this time, but she is enjoying finding out more about her experiences of gender variance. You know, people don’t come with instruction manuals. There’s nothing that tells you to beware of feelings about your wife’s clothes. I had to figure it all out myself and there was nobody who could tell me what was happening. So I finally have had a chance to let Linda emerge, and it feels great. 39

Dean Dubbick Dean is a 45 year old First Nations trans-guy. He began transitioning five years ago, and has recently begun hormone treatments. For Dean, wanting to be a boy was innate and present throughout his whole childhood. I was three when I first figured out I was trans. Well, I didn’t know the word for it, but I knew that I was going to grow up and be a boy. And I was going to marry my mom and look after my mom. My mom was Cree — First Nations. And she was raised in a residential school and suffered the typical abuse from residential school. And she went to the bars looking for someone to love her. And she would keep bringing home these guys who would abuse her and get her pregnant and then leave. So she had 13 kids with 12 different guys and had a really hard life. She died when she was 33 — she had TB and was an alcoholic. Just after three years old I was put in foster care in Edmonton and raised by a number of different people. But I never lost track of wanting to be a guy. The home I spent the most time in was very straight, French Roman Catholic, and they were not impressed with this boy theory and they did everything possible to make me a little girl. They permed my hair and dressed me in little dresses but I would not give it up. They told me I was a tom-boy, that it was a stage and I’d grow out it. But I never did grow out of it. The process of transitioning began when Dean was 41. At that time he had been very active in the lesbian and feminist communities and it was difficult to begin to acknowledge his gender identity. It’s been a difficult process. When I started identifying four years ago as trans, I was shut out. My whole life was centred around the women’s community so I had to turn my back on my whole life. My partner at the time was telling me not to go on hormones. All my friends and support system were saying, “No don’t do it, don’t become a guy.” Women in that community would say to me “I don’t have guys in my life. I don’t like guys. I don’t want to be around guys. Yes we’ve been friends for the last 20 years, we got clean together, but if you’re gong to be a guy, you’re out the door.” I was involved in working in a woman-only space. Going to an AA meeting that was a women-only meeting. The clubs I went to were women-only. So I had to change my own world. But I am a guy. Not only am I a guy now, I always was a guy. When I marched in rallies carrying banners, and worked in women-only spaces, I’ve always been a guy. It seems as if they are telling me to just pretend I’m not a guy. How screwed up is that? 41

It’s still tender and still hard. I just feel like ... I’m being rejected for being honest. And for speaking out about what people already knew anyway. This is the way I’ve always looked. I’ve never looked feminine. I’ve always traumatized women in women’s washrooms because they thought I was a guy. To be rejected because I speak out about who I am inside doesn’t feel right. If I’d stayed silent I wouldn’t have been rejected. But because I choose to talk about it they now think I’m the enemy. And if now I’m the enemy, then I always was. The medical aspects of transitioning were also very difficult. Dean had difficulty being approved and getting onto hormone therapy. I signed up at the Gender Clinic (at VGH) and there was a year long waiting list. I’m not very patient so I found out that there was a doctor who was giving hormones to people. I decided I needed to do this for myself, even if it meant walking away from my life. I went to see him and he did all the blood work and told me my liver wasn’t healthy enough to take hormones. I’ve been clean and sober for eleven years, but for some reason my liver wasn’t healthy. And I was so frustrated. I was thinking, “I’m a trans guy and I can’t transition? I can’t go on hormones?? How the hell am I going to live my life? As what?” So I tried to find some middle ground in between “trans” and “dyke”. I tried to find some place that was more comfortable so that in some parts of my life I was a guy and other parts I was a dyke. But there isn’t any middle ground. It was crazy. After a few years, I was having a really hard time around this stuff and I met this woman who encouraged me to go to the Clinic. And I was stressed all over again. Can I turn my whole life upside down again? Go through all of that again just to be told I couldn’t transition? Should I let myself get my hopes up? But I decided I needed to know that I’d really tried my very best to resolve this. And if they rejected me I had two options. One was to try to find some testosterone on the black market, and the other one was suicide — because I knew I couldn’t live like this anymore, in this in-between place. And it’s really hard to admit that, because I’m a really spiritual person, and I carry a pipe and I run a sweat lodge and I do all this other stuff. But it was that intense. Luckily for me, when I saw the specialist they said there was no problem with my liver — that it was fine. And now I wonder if earlier I had just not been ready. I had quit smoking. I had a new partner who was supportive of the transition because she’s not a lesbian. (She identifies as bisexual and sees and loves the male side of me). The friends in my life now have accepted it and I’ve learned more about trans issues and I have more supports. So now I’m more ready. The only problem was my job. I was working at a women-only drug and alcohol place on the Downtown Eastside and they were getting uncomfortable with me. I had to quit my job. I’m just really lucky that we are financially in the place were we can afford for me not to work while I do this. Dean began injecting testosterone 3 weeks prior to this interview. Having waited for four years 42

to be approved he was very excited. A nurse friend showed him how to do the injections himself, which has been difficult to get used to. The first shot felt like this big rush. I was so excited that after 45 years I was finally going to be a guy! Within two days I noticed the physical effects. My energy level was up. Then I noticed my sex drive hit the ceiling - and I have a really high sex drive to begin with! I noticed that my muscles are changing. And my attitudes are changing a bit. I got a little more sexist about women, which is funny because for years I was active to empower women. I decided to write a book and I started to journal about what it was like to do this transition and to record all the changes. And the last shot I did I took a picture of me injecting myself. Dean has noticed a lot more interest in transitioning in the butch-dyke community. Sometimes I think the line between butch-dyke and trans-guy is really thin. I used to go this bar on Main Street back in the days when there were butches with the rolled up sleeves and slicked back hair. They were really tough looking. I mean, they scared me. There were butch dykes and ultra fem, and you were one or the other. So for me, it was really clear. I’m a guy so I just blended in with the butches. And I think about it now and wonder just how many of those diesel dykes would be trans-guys today if they had had the chance. I bet the percentage would be really high. While Dean has been active in the women’s community, he never really felt as if he fit in. I started in the women’s community years ago. I was involved in the lesbian mothers defense fund back 20 some-odd years ago and I was involved in a bunch of different lesbian groups. I spoke at Take Back the Night Marches and spoke up for the women of the Downtown Eastside. But I never fit in. I was always in trouble because I was too masculine. I was told by this one heavy duty feminist, “you are totally disgusting. You are a sexist pig, and I’d love to keep you locked in my bedroom closet”. Now there’s a mixed message. And being a First Nations person, I find feminism in Vancouver is very elite. It’s for the white, educated, middle class women. It’s not for First Nations women or women of colour, or poor women in the Downtown Eastside. Dean believes that women’s services and organizations should be inclusive, both to MtFs and FtMs. Right now there is no access for us in women-only spaces. I could go out and get raped tomorrow but I’d have nowhere to go. I see this as totally wrong. I should be able to go to women’s spaces and women’s clubs. I have been socialized my whole life long as a female and I should have the choice of when I’m going to leave and not be told or pushed out or tossed out when somebody else decides. If the women’s community ostracizes 43

FtMs, the community is going to get smaller. I’ve experienced women’s oppression. I’ve been abused & raped and been out there on the streets demonstrating. I still have that shared experience. For the last 25 years, I’ve been working for women’s rights, to stop oppression, to stop violence against women, to make the world safer for women. I don’t plan on changing that. I don’t plan on becoming some male chauvinist who is going to beat up his wife every Friday night. I plan on still being a feminist — still fighting to make this world a safer place for women. And as someone who was born female, I would also like to make this place safer for me, as a trans guy. And I think that’s the hard part. I feel that by refusing access to me the last 25 years are getting thrown away by others. It’s a huge cost. Bigger than I thought it was going to be. And part of me doesn’t want to let go of my community. I was thinking that I’m not the only one transitioning. Look at how many people are affected by this. My partner, my parents, my family, my family of friends. They are all transitioning as well. And then beyond that, there’s the neighbors who I talk to over the fences about the garden, and the old guy next door whose lawn I cut. And the woman at the supermarket who is not aware of my transitioning, but she’s going to see my changes and transition with me. The women where I buy coffee at work will watch it too. Look at how many people will be affected by one life transitioning. And I think the women’s community is transitioning too. It has to. Because in the end, we have to go with our hearts. We have to look at people and see them for what is in their hearts. And I trust the women’s community and my former lesbian community, will come to see this, and see us for who we are. Just people, with good hearts. 44

Myriam Joire Myriam Joire is 32 years old and identifies as a queer trans woman. She believes she has always felt and always will feel androgynous. Myriam grew up in what she calls a “good, secure, stable and happy family in a good, secure, stable neighbourhood”. Although she felt happy as a child, she now thinks that she denied a vital part of herself while trying to please her parents, and in particular, her father. Born in Cannes, France, Myriam came to Canada (London, Ontario) in 1986 as an exchange student when she was 17 years old, and chose to stay. She went to university, started a career, got married and in 1996, moved to Vancouver. It was shortly after that move that Myriam began to examine her gender identity and sexual orientation. She started transitioning in 1999. Myriam remembers that as a child, she felt androgynous. She felt comfortable with knowing she was male but had difficulty during puberty when she could no longer be truly androgynous. Facial hair was the hardest thing for Myriam to deal with I hoped that if I didn’t touch it, it wouldn’t grow so much. I actually wore a little goatee before it was in style. I looked silly and people laughed at me and eventually, I had to bite the bullet and shave, which I realize, now, was very traumatic for me. I did what other people wanted me to do rather than listen to myself and what I wanted to do for me. As a teenager, Myriam was sexually involved with both boys and girls. She believed her involvement was purely experimental and consequently didn’t recognize her own bisexuality. She perceived herself to be heterosexual. This self-perception continued until after Myriam had moved to Canada and married. When I moved to Canada, it was such a big change with so much to learn in terms of language and culture and eventually, my career, that I paid even less attention to my own sexuality than when I had lived in France. In 1996, one year after having married, Myriam moved to Vancouver and for the first time, began to recognize that she was trans [She prefers the word “trans” to the words transgender and transsexual because it is a more generic term, representing transgressions of all aspects of sex and gender.]. When I got to Vancouver, my eyes were opened thanks to queer culture being all around 45

me, and I realized that I’d always been queer. I remember suddenly thinking, “Oh my God! This is who I am!” At the time, my definition of queer was bisexual. I had been toying with it in my head for a long time but I didn’t admit it till I came to Vancouver. Although it had been a part of me, I wasn’t really in touch with it. I think this awareness was not only a consequence of the change of moving, but also as a result of my father’s passing away two years before in 1994. That was a milestone for me. I realized that I was letting go of some of the control he had over me. It started out with my feeling I could control my career but then it expanded to everything. Myriam separated from her wife in 1997 at which point she started to explore her sexuality and her gender. She looked for friends in the queer community and defined herself as bisexual. I started cross-dressing for fun and my friends thought that was neat. I did more and more of it. So then I began to define myself as a “bi-boy cross dresser”. Eventually, no matter how much I cross-dressed and expressed my queerness, I just wasn’t happy. I did a lot of thinking, a lot of talking to people, and a lot of reading on the internet and in books about why I wasn’t happy. I was cross-dressing a lot and I wasn’t upset about my sexuality but I was really depressed. Some of my friends suggested I might be trans and suggested hormones so I decided to research that. I decided to play “what if” and imagined what would happen and what the impact would be on my life if I did transition. I thought about it and thought about it and eventually, I came to a place where the list of “no’s” was much shorter than the list of “yes’”. One night, I went to a party where I felt a queer and trans energy I’d never felt before and I knew that that was what I needed to do to be happy and to fit in. Myriam found a physician in whom she could confide in and was referred to the Gender Clinic at Vancouver General Hospital. She started electrolysis there and shortly after, was approved for hormones. She “came out” to friends, family, and to people at work, and changed her name. She then made the decision to have surgery and is currently waiting for approval. It’s kind of interesting what happened to me in terms of my feelings about my physical body. As a boy, when I looked at myself, I never disliked what I saw. I saw a happy, good looking boy and that was fine but I didn’t feel completely comfortable. When I started taking hormones, and I looked at myself, I really liked what I saw and I felt really comfortable. But after doing hormones for a while, I began to feel uncomfortable with my genitals and I’d never felt that before. We’re raised with such stereotypical ideas of what male and female bodies should be that I think for me, I need to have my whole body match. Now I’m part way there I want the rest, even though in my ideals it shouldn’t really matter. People should be able to be the way they want. I really identify as trans. I was born a genetic male and I can’t just give up or deny my past. To me, that’s denying part of myself—who I am. And to me, being able to transition and coming to terms with my gender identity and my body is all about being myself and not denying that. In a way, 46

changing gender is just another form of body modification. I have tattoos and piercings and I see transitioning as a kind of extreme form of that. I feel that my gender identity is in the middle. I see myself more as a butch, assertive woman who is in touch with feelings. I believe I use it for the betterment of women’s rights and the community. I’m a trans-feminist. As far as my sexual orientation goes, that’s shifted. I was bisexual and did socialize to an extent with bisexual men. They’re fine with my transitioning. I had thought that it was a possibility that my sexuality might shift and it has. I now identify as a dyke. I sometimes wonder why it is that I’m so accepted as a dyke in my community and I think it’s that I’m being myself rather than trying to be a stereotypical woman. I don’t think it’s healthy for trans people to try to “pass” because in doing that, they’re trying to be acknowledged by a system of oppression that defines who they are rather than defining that for themselves. I don’t want to do that. I’ve always liked to be different and now I’ve exteriorized that in my appearance. I want to make people feel uncomfortable so that they have to think and learn and educate themselves. I want to remind them that there is an “other”. 47

Trans’ et VIH/sida/IST Ministère de la santé et des solidarités, France Programme national de lutte contre le VIH/sida et les IST 2005- 2008 Rapport ; Français ; 2005/06 ; 83 p. ; tableau Thème principal : PLAN DE LUTTE CONTRE LE SIDA DEPISTAGE ; DETENU ; DISCRIMINATION ; EPIDEMIOLOGIE DESCRIPTIVE ; HOMOSEXUEL ; MIGRANT ; PERIODE 2005-2009 ; PERSONNE SEROPOSITIVE ; PLAN DE LUTTE CONTRE LE SIDA ; PLAN DE LUTTE CONTRE LES MALADIES TRANSMISSIBLES ; PREVENTION ; PRISE EN CHARGE PLURIDISCIPLINAIRE ; PROSTITUE ; QUALITE DE VIE ; TRANSEXUEL ; USAGER DE DROGUE ; FRANCE Résumé : En s'appuyant sur les évolutions épidémiologiques et scientifiques et sur le bilan de l'action publique menée entre 2001 et 2004, le champ du programme national de lutte contre le VIH/sida pour la période 2005-2008 est élargi aux IST dans un objectif de cohérence. Ce rapport livre un état des lieux épidémiologique du VIH/sida et des IST, présente le programme 2005-2008, puis aborde les cinq axes du programme : la prévention, le dépistage, le suivi et la prise charge thérapeutique, le soutien, l'accompagnement des personnes atteintes, la lutte contre les discriminations et enfin, la mise en oeuvre et le pilotage des programmes d'action développés au niveau national et régional. Cote IDF : 0107, A/0564 Extrait : I.3.1.3.5 Adapter la prévention de la transmission sexuelle pour d’autres groupes de populations dans des situations de vulnérabilité spécifique Les personnes transsexuelles a- Constats Aucune donnée statistique ne fait état de la prévalence de troubles d’identité sexuelle au sein de la population vivant en France. Les personnes transgenres sont très gravement atteintes par le VIH/sida et les IST d’après des études menées à l’étranger et selon l’expérience des associations de terrain. Diverses estimations font état du chiffre de 70% de séropositifs parmi les transgenres se prostituant. b- Axes stratégiques - Développer des actions spécifiques en s’appuyant sur les relais communautaires en direction des transgenres et notamment des prostitués.

- Recommander des bonnes pratiques de prise en charge adaptées aux différents sous groupes transidentitaires. - Développer la recherche sur la santé de cette population. c- Actions - Réaliser une étude sur le VIH et les IST dans la population des transgenres. - Mobiliser les associations communautaires pour être le relais des actions de prévention du VIH et des IST. - Communiquer sur la prévention du VIH et des IST spécifique aux pratiques et situation de cette population. d- Indicateurs de suivi des actions - Nombre d’actions financées en direction de cette population. BERDOUGO F Trans' : les oublié-e-s in : Passons aux actes : compte rendu, XVIe Conférence internationale sur le sida, Toronto, 13-18 août 2006 Article ; Français ; Revue : TranscriptaseS ; 2006/10 ; n° 129 ; ISN : 1166 5300 ; pp. 78-80 Congrès : XVIe Conférence internationale sur le sida : passons aux actes, Toronto, 2006/08/13-18 Thème principal : TRANSEXUEL TRANSEXUEL ; PREVALENCE VIH ; ACCES AUX SOINS ; PARTICIPATION COMMUNAUTAIRE ; DROIT DES PERSONNES ; ASIE ; AMERIQUE DU NORD Description : Ce numéro spécial co-édité par l'ANRS et l'association Pistes possède une double numérotation : ANRS Information n° 43 et TranscriptaseS n° 129 Résumé : L'auteur résume les communications de la 16ème Conférence sur le sida (Toronto, 13-18 août 2006) consacrées à la question transexuels et VIH : prévalence VIH dans cette population, problème d'accès aux soins, stratégies de prévention, implication des communautés, question du droit des personnes. Cote IDF : TranscriptaseS, n° 129 HAZERA H ; LEOTARD A ; HACHER N ; CASALINO E Act Up-Paris Trans et VIH : après le silence... Acte de colloque ; Français ; 2007 ; 26 p. Congrès : 59ème RéPI : Trans et VIH, après le silence..., Paris, 2006/06/28 Thème principal : TRANSEXUEL

TRANSEXUEL ; PERSONNE SEROPOSITIVE ; HORMONE ; INTERACTION MEDICAMENTEUSE ; TRAITEMENT ANTIRETROVIRAL ; PSYCHIATRIE ; RELATION SOIGNANT-SOIGNE ; PRISE EN CHARGE PLURIDISCIPLINAIRE ; FRANCE Résumé : Ce document rend compte des communications et des débats de la 59ème RéPI (Réunion Publique d'Information) d'Act Up-Paris, consacrée aux transexuels et au VIH. Dans une première partie, une personne transexuelle témoigne de son vécu et un membre de la Commission Trans d'Act Up-Paris effectuie un point sur les données existantes (épidémiologie, prévalence VIH...). Dans un deuxième temps, le Dr Hacher, endocrinologue, évoque le transexualisme masculin vers féminin puis l'inverse et sur l'utilisation des hormones dans ce contexte. Il aborde ensuite les interactions entre les antirétroviraux et les hormones. La question de l'intervention psychiatrique dans la prise en charge des trans est longuement débattue. Dans la dernière partie, le Dr Casalino, infectiologue, parle de la prise en charge de patients transexuels atteints par le VIH et en pointe les insuffisances. Cote IDF : 0702, A/1110 http://www.actupparis.org/article2429.html#3763 Act Up-Paris Trans et VIH, après le silence Article ; Français ; Revue : Action ; Paris : Act Up-Paris ; 2006/06 ; n° 103 ; ISN : 1158-2197 ; pp. 31 Thème principal : TRANSEXUEL TRANSEXUEL ; PRISE EN CHARGE Résumé : La situation de la communauté transexuelle par rapport au VIH/sida. Cote IDF : Action, n° 103 http://www.actupparis.org/article2454.html BONNIN O Le sida chez les transsexuels : les trans, invisibles jusque dans la lutte contre le sida Article ; Français ; Revue : Journal du Sida (Le) ; 2006/01 ; n° 182 ; ISN : 1153 0863 ; pp. 25-26 Thème principal : TRANSEXUEL TRANSEXUEL ; ASSOCIATION ; PREVENTION ; FACTEUR DE RISQUE ; VULNERABILITE ; PASST ; FRANCE Résumé : Les transgenres et les transsexuels, très vulnérables face aux VIH, sont pourtant invisibles dans la lutte contre le sida, avec une seule association, le Passt, qui lutte contre le sida auprès des trans prostituées de la région parisienne. L'article présente les facteurs de vulnérabilité et les prises de risques spécifiques à ce public, et met en lumière le manque d'information, d'actions de prévention et de données épidémiologiques le concernant. Cote IDF : Journal du sida, n° 182 http://www.arcat-sante.org/56/JDs_182&numero_jds=182

LAURINDO DA SILVA L ; EVANGELISTA L L'usage du préservatif in : La consommation de drogues dans le milieu de la prostitution masculine Extrait ; Rapport ; Français ; Saint-Denis : Observatoire français des drogues et des toxicomanies ; 2004/10 ; ISN : 2 11 094936 8 ; pp. 121- 128 ; tableau Thème principal : USAGE DU PRESERVATIF USAGE DU PRESERVATIF ; PROSTITUE DE RUE ; HOMME AYANT DES RAPPORTS SEXUELS AVEC DES HOMMES ; TRANSEXUEL ; PRATIQUE SEXUELLE ; ENQUETE ; 2003 ; BOUCHES DU RHONE ; PARIS Résumé : Les auteurs présentent et analysent les déclarations d'usage du préservatif, selon le produit consommé et selon la pratique sexuelle en cause, dans une enquête réalisée en 2003 par questionnaire et entretien semi-directif auprès de 252 prostitués masculins de rue, dont 124 transgenres. Cote IDF : 09, A/0036 http://www.ofdt.fr/ofdtdev/live/publi/rapports/rap04/epfxdlka_fr.html WHITMAN-WALKER CLINIChitman-Walker, HIV/AIDS and Transgender People, 2006/02, 2 p. KAMMERER N, MASON T, CONNORS M Transgender Health and Social Service needs in the Context of HIV Risk International journal of transgenderism, n°1-2, 1999/01 http://www.symposion.com/ijt/hiv_risk/kammerer.htm CLEMENTS K, WILKINSON W, KITANO K, MARX R HIV Prevention and Health Service Needs of the Transgender Community in San Francisco International journal of transgenderism, n°1-2, 1999/01 http://www.symposion.com/ijt/hiv_risk/clements.htm NAMASTE V HIV/AIDS and Female to Male Transsexuals and Transvestites: Results from a Needs Assessment in Quebec International journal of transgenderism, n°1-2, 1999/01 http://www.symposion.com/ijt/hiv_risk/namaste.htm HEIN D, KIRK M Education and Soul-Searching: The Enterprise HIV Prevention Group International journal of transgenderism, n°1-2, 1999/01 http://www.symposion.com/ijt/hiv_risk/hein.htm

BOCKTING W, ROSSER S, COLEMAN E Transgender HIV prevention: Community involvement and empowerment International journal of transgenderism, n°1-2, 1999/01 http://www.symposion.com/ijt/hiv_risk/bockting.htm WARREN B Sex, Truth and Videotape HIV: Prevention at the Gender Identity Project in New York City International journal of transgenderism, n°1-2, 1999/01 http://www.symposion.com/ijt/hiv_risk/warren.htm HACHER N ARV et hormones chez les trans' Article ; Français ; Revue : TranscriptaseS ; 2006/12 ; n° 130 ; ISN : 1166 5300 ; pp. 9-12 Thème principal : HORMONE HORMONE ; INTERACTION MEDICAMENTEUSE ; TRAITEMENT ANTIRETROVIRAL ; TRANSEXUEL ; TROUBLE DU METABOLISME ; ATTEINTE CARDIOVASCULAIRE ; CYTOCHROME P450 Résumé : L'auteur commence par préciser les traitements hormonaux utilisés dans le cadre des transsexualismes homme>femme et femme>homme. Il passe ensuite en revue les interactions entre l'hormonothérapie et les antirétroviraux : induction-inhibition du cytochrome P450, anomalies glucidiques et lipidiques, accidents thromboemboliques. Cote IDF : TranscriptaseS, n° 130

TRANS’ : LES OUBLIÉ-E-S François Berdougo Act up-Paris A Toronto, 24 abstracts étaient dédiés aux trans’ : une population dont la vulnérabilité au VIH mal des compétences 4 et une réunion satel- concernées dans la lutte contre l’épidé- connue et mal prise en charge com- lite au sein du Village global 5 permet- mie 6. mence tout juste à être reconnue. taient de participer à l’élaboration d’une Alors qu’émerge depuis peu, au stratégie de prévention en direction des DES DROITS sein des communautés trans’ et sida trans’. Quant aux abstracts, 24 (sur plus La question des droits des personnes françaises, un discours public sur l’im- de 10 000 soumis) traitaient spécifi- trans’ parcourt tous les travaux présentés pact de l’épidémie parmi les personnes quement des enjeux des trans’ et pré- à Toronto et est au cœur des préoccupa- trans’ 1 et que nous manquons de don- sentaient les résultats de recherches, de tions de la communauté. Elle a en par- nées sur la situation française, la recherches-actions ou d’actions de ter- ticulier été l’objet principal de l’atelier Conférence de Toronto pouvait être l’oc- rain, menées par des professionnels de communautaire, faisant passer son sujet casion de nourrir notre expertise. Avant l’action sanitaire et/ou sociale, par les annoncé (l’élaboration d’une stratégie de poursuivre, clarifions la terminologie. membres des communautés ou par ces de prévention auprès des trans’) à l’ar- Les données dont il sera question ici trois types d’acteurs. Ils se répartissent rière-plan. Les quatre oratrices, toutes concernent, en anglais, les « transgen- assez également entre les domaines trans’, ont décrit à quel point la discri- ders », traduit en français par « trans- « Epidémiologie, prévention et recherche mination et l’absence de reconnaissance genres ». Ce terme s’est récemment sub- en prévention » (11) et « Sciences juridique et sociale, ainsi que les vio- stitué à celui, médical, de « transsexuel », sociales, comportemen- lences exercées qui réduisait le parcours de vie des tales et économiques » LA QUESTION DES DROITS contre les trans’ (y personnes à l’intervention chirurgicale (12, dont 8 pour le sous- DES PERSONNES TRANS’ compris par les qu’elles pouvaient avoir vécu. En domaine « Transgenres & PARCOURT TOUS forces de l’ordre) revanche, « transgenre » n’implique plus Intersexuels »), le dernier LES TRAVAUX PRÉSENTÉS faisaient obstacle la problématique de l’opération et a une abstract étant classé dans À TORONTO à la mise en place définition plus large que « transsexuel », le domaine « Recherche d’actions efficaces puisqu’il désigne toute personne qui vit clinique, traitement et soins ». L’Asie auprès des communautés. En France dans une identité autre que son identité (Inde et Thaïlande surtout) et l’Amérique d’ailleurs, les trans’ réclament en vain, de naissance et biologique 2. En France, du Nord (Etats-Unis et Canada) sont très pour les personnes non opérées, un chan- le terme le plus employé dans la com- majoritaires, avec respectivement 10 et gement du numéro de sécurité sociale à munauté est celui de « trans’ » qui 9 abstracts. Les rédacteurs de ces travaux leur demande, ce qui faciliterait les rap- désigne des hommes et des femmes sont issus d’associations ou d’ONG (11), ports avec l’administration et, éventuel- transgenres 3 – sachant que l’on parle d’institutions universitaires (8) ou des lement, la relation thérapeutique 7. des trans’ dans leur sexe d’arrivée et pas deux à la fois (5). Les données présentées dans celui de départ – opérés ou non. portent sur la prévalence du VIH au sein DÉNOMBRER ET CONNAÎTRE C’est celui que nous emploierons ici. des communautés trans’, les détermi- Le premier défi à relever si l’on souhaite nants des prises de risque, l’épidémio- réfléchir aux enjeux de l’épidémie parmi QUESTIONS logie des comportements de prévention, les trans’ est la connaissance de l’épi- On ne trouvait pas, dans le programme, les enjeux de l’accès aux soins et à une démie au sein de cette communauté et, de session spécifique aux enjeux des prise en charge médicale de qualité, en particulier, celle de la prévalence. trans’. Seuls un atelier de renforcement enfin sur l’implication des personnes Remarquons qu’en France, il n’existe 78 Toronto • numéro spécial ANRS information – Transcriptases • automne 2006

pas de données à ce sujet. A Toronto, les trans’, dans la mesure où elles portent sur nautés trans’ de huit sites au sein des- résumés présentés permettent diverse- de petits échantillons de population, et quels ont été recrutées des trans’ choi- ment de s’en faire une idée, soit qu’ils majoritairement sur des travailleurs du sies pour leur potentiel de formateurs, et présentent des données supposées sexe et peu ou pas sur des trans’ qui ne de concevoir un modèle de formation connues sans en présenter les sources, se prostituent pas. Remarquons au pas- inédit. De même, un centre de formation soit qu’ils extrapolent à partir de la pré- sage que le principal stéréotype discri- à la prévention du VIH et des IST de valence au sein d’autres groupes de minatoire subi par les femmes trans’ est Californie 9 offre, depuis 2004, une for- population « proches » 8, soit qu’ils rap- celui qui laisse entendre que le seul mation destinée à accroître la capacité portent des données d’une enquête, soit métier souhaité et possible est celui de des agents de santé à travailler auprès enfin que les travaux présentés aient prostituée ; or l’on sait que des femmes des trans’. 159 d’entre eux (animateurs eux-mêmes eu pour objet de produire trans’ n’exercent pas cette activité. Il de santé, counselors, infirmiers et méde- des connaissances en la matière. est donc nécessaire de mener des études cins) ont ainsi été formés, notamment sur Ainsi, pour la première catégorie, on lit épidémiologiques de plus grande ampleur les pratiques à risque des travailleurs du que la prévalence du VIH parmi les qui permettraient de déterminer le sexe en matière de VIH et d’IST ou les femmes trans’ se situe entre 26 et 63 %, nombre de personnes trans’ 17, leur pro- comportements de leurs clients. Les qu’elle est, à ce titre, « un défi interna- fil sociodémographique et de connaître la résultats, évalués en termes de percep- tional » 9, et qu’on estime qu’elle se situe prévalence du VIH parmi elles. tion par les participants des compétences dans une fourchette de 11 à 78 % 10 acquises, montrent un accroissement parmi les femmes trans’ vivant aux Etats- ACCÈS AUX SOINS important (28 % en moyenne sur 14 des Unis. Puis, à Bangkok, qu’elle est pré- L’un des enjeux majeurs de la prise en critères d’évaluation) de leurs capacités sumée supérieure à celle des hommes charge médicale des personnes trans’ et de leur confiance à intervenir auprès ayant des relations sexuelles avec touchées par le VIH est leur accès au des trans’ 19. La présence de trans’ parmi d’autres hommes (28 %) 11. On apprend système de soins et aux services de santé. les formateurs est apparue aux partici- encore qu’un article de la US Leadership Les obstacles au développement d’ac- pants comme l’un des déterminants de Campaign on AIDS l’estime entre 14 et tions de prévention et de réduction des cette réussite. 69 %, sur la base de l’expression, par les risques ou à un accès aux soins de qua- trans’, de leurs besoins en matière de lité que les travaux présentés identifient SANTÉ COMMUNAUTAIRE VIH/sida et des études sur leurs com- sont, très fréquemment, la méconnais- L’implication des communautés trans’ portements sexuels à risque 12. sance, par les professionnels de santé, dans les programmes qui leur sont desti- Plus intéressantes sont les études de des enjeux et problématiques spécifiques nés est l’un des éléments clefs de la prévalence présentées. En Thaïlande des trans’ ainsi qu’un très fort senti- réussite des expériences présentées. Celle (Bangkok, Chiang-Maï et Phuket), en ment, chez les personnes concernées, menée à Phnom Penh (Cambodge) 20 2005, la prévalence découverte parmi d’isolement et de stigmatisation de la pour accroître l’usage du préservatif les 474 personnes incluses dans l’étude part des soignants, allant parfois jus- parmi les trans’ travailleuses du sexe et était de 13,5 % 13. A San Francisco, la qu’au refus de soins. Les quelques pro- lutter contre les discriminations subies de prévalence du VIH que déclarent les 540 grammes présentés la part des équipes femmes et 231 hommes trans’ inclus tentent de lever ces ON DOIT DÉPLORER médicales a montré l’ef- dans le projet TRANS depuis 2003 freins dans la fourni- L’ABSENCE, AU SEIN ficacité de la formation s’élève respectivement à 25 et 2 % 14. ture de prestations DE LA CONFÉRENCE, par les pairs en termes Aux Pays-Bas, la prévalence du VIH parmi de santé adaptées. DE TRAVAUX DE RECHERCHE de diffusion d’informa- 45 trans’ travailleuses du sexe était, en Ils portent essentiel- MÉDICALE SPÉCIFIQUES tion. Les groupes d’au- 2002, de 18,2 %, contre 5,3 % parmi les lement sur la forma- AUX TRANS’ tosupport ont en effet femmes travailleuses du sexe 15. Enfin, tion et l’acculturation fortement contribué à à Mumbai (Inde), la prévalence du VIH des agents de santé, qu’ils soient pro- promouvoir les pratiques de safe sex, à parmi 205 femmes trans’ qui accèdent fessionnels médicaux ou non-médicaux. inciter à la réalisation de dépistages régu- au dispositif de dépistage est de 40 % ; A San Francisco et dans le Vermont 18, un liers des IST, à diffuser des connais- celle de la syphilis est de 25 % 16. Soit, centre de formation sur le sida a mis en sances sur la prise en charge du VIH et pour cette dernière catégorie d’abstracts, place une formation de formateurs, des- à sensibiliser à la solidarité avec les per- un taux de prévalence très élevé puisque tinée à apporter aux cliniciens VIH une sonnes atteintes. Les chantiers à venir se situant entre 13 et 40 %. connaissance des problématiques des sont : l’implication d’un nombre plus Les études présentées ne permettent tou- trans’ séropositives. Elle a permis, après important de pairs, le renforcement du tefois pas de conclure à une forte préva- deux ans, d’élaborer un partenariat entre partenariat entre les communautés trans’ lence généralisée dans les communautés le centre de formation et les commu- et les institutions publiques afin, notam- 79 Toronto • numéro spécial ANRS information – Transcriptases • automne 2006

ment, de permettre un meilleur accès déficit de reconnaissance sociale et juri- 9 - Sausa L. et al., « Impact of an innovative des personnes aux services de santé et de dique. Il ne faudrait cependant pas que HIV/STD prevention training program in improving skills of health providers working with transgender demander leur inclusion dans le dispositif le combat pour la reconnaissance des clients », MOPE0617 de surveillance de l’épidémie. Au Nigeria droits des trans’ – qui doit se livrer dans ou au Ghana 21, un groupe d’autosup- l’arène médiatique, politique et sociale – 10 - Craig S. et al., « Lessons learned from a rapid testing project among male to female port a été créé au sein d’un réseau de cli- fasse écran à la mise en place d’une stra- (MtF) transgender Latinas », CDD0192 niques de soins primaires afin d’amélio- tégie concrète de lutte contre l’épidé- rer l’inscription des trans’ séropositives mie. On doit à ce propos déplorer l’ab- 11 - Apichaisiri T. et al., « Promoting consistent condom and water-based lubricant (WBL) use dans la démarche de soins, leur adhé- sence, au sein de la Conférence, de among transgenders : findings from Pattaya, rence aux traitements et de lutter contre travaux de recherche médicale spéci- Thailand », WEPE0853 leur sentiment d’isolement et de stig- fiques aux trans’. Pourtant, certains matisation. 12 personnes, dont des tra- enjeux, comme les interactions médica- 12 - Bushnell S. et al., « Addressing and promoting transgender-specific HIV/AIDS issues through vailleuses du sexe, ont participé, durant menteuses entre les antirétroviraux et les community based interventions », CDD0196 deux ans, à des sessions régulières au traitements hormonaux, ont été identi- cours desquelles ont été abordés l’édu- fiés par la communauté scientifique fran- 13 - Wimonsate W. et al., « Risk behavior, hormone use, surgical history and HIV infection cation mutuelle sur le safe sex , les çaise comme suffisamment importants, among transgendered persons (TG) in Thailand, aspects médicaux du VIH, la lutte contre car potentiellement dangereux pour les 2005 », MOPE0349 la discrimination, les enjeux de l’usage personnes, pour être abordés dans la der- 14 - Nemoto T. et al., « Transgender resources du préservatif et les risques de la violence nière édition du rapport d’experts sur la and neighborhood space (TRANS) project physique des clients. Le maintien de prise en charge médicale 22. Aujourd’hui, in San Francisco, USA », CDC0662 l’apparence physique des femmes trans’ les institutions sanitaires, les chercheurs, malgré le VIH et les traitements est les soignants et les acteurs de la préven- 15 - Van Veen M. et al., « Substantial risk behaviour among transgender sex workers apparu comme une préoccupation tion ont un rôle essentiel à jouer dans une in the Netherlands », MOPE0478 majeure. Au terme du processus, les par- meilleure prise en compte des besoins ticipantes ont fait part d’un accroisse- spécifiques des trans’ en matière de 16 - Kumta S. et al., « Sexual risk behavior and HIV prevalence among male-to-female transgendered ment spectaculaire de leur confiance VIH/sida, en particulier en termes d’accès people seeking voluntary counseling and testing dans le personnel soignant, et le nombre au système de santé ou de prise en charge services in Mumbai, India », MOAD0303 de rendez-vous médicaux manqués par médicale adaptée. 17 - Les associations trans’ françaises s’accordent les membres du groupe a chuté de 64 % sur le chiffre de 50 000 à 60 000 personnes en 2003 à 12 % en 2004. Ce groupe a vivant dans un genre opposé à leur sexe biologique, constitué une communauté de soutien 1 - Pour la première fois en 2005, le mot d’ordre voir Act up, loc.cit. qui a permis à ses membres, en déve- de la marche « Existrans » portait sur le sida ; voir aussi la 59e RéPI d’Act up-Paris, 28/06/06 ; 18 - Bernstein M. et al., « Building HIV provider loppant une appréhension globale de www.actupparis.org/article2454.html capacity for serving infected transgender leurs problématiques, d’accroître leur populations : a train-the-trainer model », adhérence aux soins et de renforcer leur 2 - H.Hazera, commission Trans’ d’Act up-Paris MOPE0612 estime de soi. 3 - voir les travaux de T.Reucher 19 - Parmi ces critères : capacité de mieux communiquer avec des trans’, être plus à l’aise MEILLEURE PRISE EN COMPTE 4 - « Transgender and network care of trangender lors des interventions, identifier les leviers patients with HIV », TUSB06 d’action efficaces Avec les trans’, l’épidémie de VIH/sida nous pose, une fois de plus, la question 5 - « Building a global transgendered HIV/AIDS 20 - Chanthan M., « The plight of transgender des droits des personnes – comme elle le prevention strategy », Village global, WEPA43 in Phnom Penh », THPE0293 fit notamment pour les homosexuels. En 6 - on ne pourra privilégier ici les travaux portant 21 - Nwando O., « HIV/AIDS transgender support effet, l’absence des trans’ des systèmes sur les déterminants des prises de risque et group : improving care delivery and creating de surveillance épidémiologique et des l’épidémiologie des comportements de prévention a community », CDB1130 programmes de santé publique, la quasi- 7 - Act up-Paris, La communauté du silence, 22 - Yéni P. (dir), Prise en charge médicale des inexistence de stratégies de prévention et 2005 personnes infectées par le VIH. Recommandations de réduction des risques en direction des du groupe d’experts, 2006, 73-74 trans’ – en dehors du prisme du travail du 8 - WEPE0853 ; les auteurs extrapolent la prévalence connue parmi les HSH de Bangkok pour sexe –, l’absence de prise en compte de présumer que celle des trans’ lui est supérieure leurs spécificités en matière de prise en charge médicale et, bien sûr, les pro- blèmes d’estime de soi, de discrimination et de stigmatisation révèlent un criant 80 Toronto • numéro spécial ANRS information – Transcriptases • automne 2006

HIV/AIDS and Transgender People In the District of Columbia, male-to-female (MTF) transgender people are the single highest at-risk group for HIV Infection* o One-quarter of transgender people surveyed in the 2000 Transgender Needs Assessment Survey reported they were HIV-positive. ** o Eighty-one percent of those who were HIV-positive were African-American. Two-thirds of those who were HIV-positive believe they became infected through unprotected sex with men. o At least 56 percent of MTFs had engaged in unprotected anal intercourse at least once. o In participants age 15-24, the 9 percent said they were HIV-positive. Another 29 percent did not know their status, including 24 percent who had never been tested. o Data from other quantitative needs assessments, sexual risk and substance abuse studies of urban transgender populations in the United States have found HIV seroprevalence rates ranging from 14 percent to 70 percent. o The Centers for Disease Control does not separate transgender people from its men who have sex with men category – thus obscuring these alarmingly high rates Transgender people of color are at high risk not only for HIV/AIDS and other STDs but also violence, substance abuse and suicide o 43 percent report being victims of violence or crime o 36 percent report drug problems and 34 percent report alcohol problems o 35 percent report they have considered suicide, and 16 percent have made suicide attempts. G:CommunicationsEPIDEMIOLOGICAL PROFILEfacts-hiv-transgender-feb06.doc February 2006

* In comparison with black injection drug users attending a sexually transmitted disease clinic (27%) and men who have sex with men attending an STD clinic (15%) – see District of Columbia HIV Prevention Three-Year Plan, 1999-2002, p. 5.2. ** In the 2000 Washington, D.C. Transgender Needs Assessment Survey (n=252; 69 percent African-American; 22 percent Latino/a) the self-reported HIV seroprevalence rate was 25 percent overall – 32 percent in MTFs. Sources: Xavier, J.M. (2000). Final report of the Washington Transgender Needs Assessment Survey, Washington, DC: Administration for HIV and AIDS, District of Columbia Department of Health. Administration for HIV/AIDS, District of Columbia Department of Health, and the HIV Prevention Community Planning Committee (1999) District of Columbia HIV Prevention Three Year Plan, 1999-2002. Washington, D.C.: Administration for HIV/AIDS, District of Columbia Department of Health. G:CommunicationsEPIDEMIOLOGICAL PROFILEfacts-hiv-transgender-feb06.doc February 2006

décembre 2006 no 130 T R A N S C R IPTASES VIH et virus des hépatites VIH – HORMONES THERAPEUTIQUE, CLINIQUE ARV et hormones chez les trans’ 9 Nicolas Hacher Service d’endocrinologie Clinique Internationale du parc Monceau (Paris) Elbers JM et al. « Effects of sex steroids on components of the Alors que, comme rapporté insulin resistance syndrome in dans notre numéro spécial transsexual subjects » Clinical consacré à la Conférence androgènes et les androgènes. Pourtant, la Endocrinology, 2003, internationale de Toronto, question mérite d’être posée, dans la mesure 58, 562-571 la reconnaissance des où cette population présente souvent une poly- Polderman KH et al. « Induction of insulin problèmes posés par le VIH pathologie avec interférences médicamen- resistance by androgens and chez les transsexuels teuses multidirectionnelles. Il faut ajouter au estrogens » commence à progresser, risque de modification des taux hormonaux et Journal of Clinical Endocrinology and la question des interactions à leurs conséquences cliniques, les perturba- metabolism, 1994, revue 79(1) entre traitements hormonaux tions métaboliques glucidolipidiques qui s’ad- Winston A et al. et antirétroviraux demeure ditionnent à ceux des antiviraux, le risque « The management encore trop mal connue. thromboembolique, et la toxicité hépatique. of HIV-1 protease inhibitor Le transsexualisme se caractérise Sans compter que tous ces risques sont majo- pharmacokinetic interactions » par le sentiment prégnant et irréversible d’ap- rés par une automédication fréquente, faisant Jounal of antimicrobial chemotherapy, 2005, partenance au sexe opposé, avec souffrance appel à des produits et doses inadaptés. 56, 1-5 et demande de soins, pouvant aller jusqu’à la Levy A et al. réassignation chirurgicale. Il n’existe pas de Traitements hormonaux « Endocrine intervention for consensus absolu dans la prise en charge, mais Avant l’intervention de réassignation chirurgi- transsexuals » Clinical on dispose de recommandations, notamment cale, l’objectif des traitements hormonaux est endocrinology, 2003, les « Standards Of Care For Gender Identuty d’entamer la transformation par la mise en 59, 409-418 Disorders » de la Harry Benjamin International conformité de l’habitus avec le sexe psycho- Moore E et al. « Endocrine Treatment Gender Dysphoria Association (version 6, logique. Après une possible intervention, outre of transsexual people : a review of février 2001). la poursuite de cette transformation, ces hor- treatment regimens, Les interactions entre les ARV et les pilules mones sont nécessaires à la préservation du outcomes, and adverse effects » œstro-progestatives, qui sont des substrats du capital osseux et à la prévention cardiovas- Journal of clinical endocrinology and cytochrome P450 CYP3A4, sont actuellement culaire. metabolism, 2003, 88(8), 3467-3473 bien connues, avec les risques de sur-dosage ou de sous-dosage des taux hormonaux, selon Transsexualisme homme>femme Chu JH et al. « Hormonal les inhibitions ou les inductions enzymatiques. Les anti-androgènes prescrits dans le cadre contraceptive use and the effectiveness En revanche, il y a peu de données sur ces inter- d’un transsexualisme homme>femme sont de of highly active antiretroviral therapy » actions avec les divers traitements hormonaux 4 types : non-stéroïdiens, stéorïdiens, inhibi- American Journal prescrits aux patients transsexuels et séropo- teurs de la 5 alpha réductase, et agonistes of Epidemiology, 2005, 161(9) sitifs, que ce soit les œstrogènes, les anti- GnRH (castration chimique).

décembre 2006 no 130 TRANSCRIPTASES VIH et virus des hépatites Le produit le plus utilisé en France est l’acétate Interaction avec les anti- THERAPEUTIQUE, CLINIQUE de cyprotérone (CPA), à la dose de 50 mg/j. Il rétroviraux : induction-inhibition a trois propriétés : anti-androgène, anti-gona- du cytochrome P450 dotrope, et progestatif de synthèse. Il entraîne Les effets, précédemment décrits pour les une inhibition de la liaison de la 5 alpha DHT à modifications des taux d’EE de la pilule contra- son récepteur cytosolique dans les cellules ceptive, ne sont pas extrapolables comme tels cibles. C’est un dérivé de la 17 hydroxypro- pour les produits utilisés pour les transsexuels, gestérone. pour lesquels il y a peu de données concernant Alternative à la cyprotérone, la spironolactone l’interaction entre hormones et ARV (œstro- 100 à 200 mg/j est un anti-minéralo corticoïdes gènes naturels, cyprotérone, testostérone). En ayant des effets anti-androgènes. Seules la tout état de cause, ces traitements peuvent cyprotérone et la spironolactone sont utilisées subir les mêmes fluctuations hormonales que 10 en France dans le traitement du transsexua- l’ EE . L’initiation du traitement doit être pru- lisme homme>femme, en pré-opératoire. On dente, surtout s’il s’agit d’ ARV inhibiteurs du notera en outre que, parmi les non stéroïdiens, cytochrome P450, en faisant appel à des doses l’anandron, le flutamide et le casodex sont uti- faibles d’œstrogènes naturels par voie percu- lisés, dans certaines conditions, dans le can- tanée et de CPA pour les transsexuels homme> cer de la prostate, que le finastéride est pres- femme, et de testostérone pour les trans- crit dans l’hypertrophie prostatique, et enfin sexuels femme>homme. En pratique, il est que les agonistes LHRH ou GnRH sont indiqués indispensable de faire un monitoring par des dans certaines pubertés précoces, le cancer de dosages de l’œstradiol plasmatique, en ayant la prostate ainsi que les protocoles de PMA . pour objectif un taux égal ou supérieur à , Parmi les œstrogènes, l’ethinyl-estradiol (EE) 60 pg/m L (taux minimum pour limiter la perte est surtout utilisé dans de nombreux pays osseuse et assurer la protection cardiovascu- étrangers à des doses allant de 50 à 100 mcg/j laire), tout en permettant une féminisation adé- par voie orale. La tendance actuelle est à la quate. Le CPA à 50 mg/j ne pose pas de pro- prescription de l’œstradiol 17 beta, que ce soit blème à ce dosage, pas plus que la testo- par voie orale 1 à 2 mg/j, par patch hebdoma- stérone aux doses habituelles, quel qu’en soit daire ou bi-hebdomadaire, et par gel délivrant le mode d’administration. 0,5 à 0,75 mg/pression, 1 à 3 pressions par jour. , La complexité de ce type d’interactions est , Après réassignation chirurgicale, les œstro- proportionnelle au nombre des molécules en gènes sont maintenus, et la cyprotérone peut cause, notamment celles ayant ces effets d’in- être remplacée par la progestérone naturelle, duction ou inhibition du cytochrome P450 : IPP, réalisant ainsi l’équivalent du THS. rifampicine et rifabutine, ketoconazole, antico- mitiaux, méthadone, griseofuline, glitazone, Transsexualisme femme>homme hypericum perforatum, statines. Pour celles-ci, Dans le cadre d’un transsexualisme femme> des précautions particulières doivent être homme, les produits utilisés sont : Androtardyl ® prises, notamment la lovastatine et la simvas- (ampoule IM à 250 mg toutes les 2 ou 3 ou 4 tatine, qu’il ne faut pas associer aux inhibiteurs semaines) ; Nebido (undecanoate de testo- ® de protéase, en particulier le ritonavir, sous stérone 1 000 mg/4 mL, ampoule IM tous les 3 peine d’une augmentation de 3 000 % de leurs mois) ; Androgel (50 mg sachet gel, une dose ® taux circulants, et de 343 % pour l’atorvasta- percutanée par jour) ; Andractim® (dihydrotes- tine, avec risque de rhabdomyolyse. Notons le tostérone, une mesure percutanée par jour) ; cas particulier d’un aspect positif de l’effet inhi- Pantestone® (capsule à 40 mg de testostérone biteur enzymatique du ritonavir qui sert de undécanoate, 2 à 4 capsules/jour). potentialisateur (boosting) de l’inhibiteur de Dans certains cas, en pré-opératoire, un pro- protéase qui lui est associé, pour lutter contre gestatif de synthèse y est ajouté pour l’amé- la résistance virale. norrhée. Seule la testostérone est poursuivie en post-opératoire.

décembre 2006 no 130 T R A N S C R IPTASES VIH et virus des hépatites Anomalies glucidiques 17 béta a des effets inverses, aux doses phy- THERAPEUTIQUE, CLINIQUE La prise en compte des effets métaboliques est siologiques : diminution de la glycémie à jeun, importante à court et long terme : pancréatites réduction de l’HbA1C, et réduction de surve- aiguës, accidents thromboemboliques et coro- nue du diabète, quelque soit le mode d’admi- naropathies. Parmi ces troubles, on évoquera nistration, per os ou percutané. Le CPA par en premier lieu les anomalies glucidiques. contre, dérivé de la 17 hydroxyprogestérone, Prés de 50 % des patients traités avec une anti- est un facteur d’insulino-résistance, mais celle- protéase (IP) présentent un spectre de troubles ci peut être compensée par les œstrogènes glucidiques allant de l’hyperinsulinisme – insu- naturels qui lui sont associés. linorésistance, au diabète insulinorequérant, ,Ces troubles du métabolisme glucidique doi- avec ou sans syndrome métabolique. On sait vent être pris en charge selon les recomman- que les IP , en particulier l’indinavir, ont une dations actuelles de la diabétologie, avec 11 action directe inhibitrice sur les transporteurs objectif d’HbA1C < à 6,5 %, et traitement des du glucose GLUT4, associée à un effet sur le autres facteurs de risques cardiovasculaires. 1 - Kees H et al. tissu adipeux. Gooren et al. 1 ont étudié les Ils impliquent une escalade thérapeutique com- « Induction of insulin resistance effets de l’EE chez l’homme et de la testosté- portant toujours des conseils hygiéno-diété- by androgens and estrogens » rone chez la femme, par le test du clamp hyper- tiques, associés si besoin aux antidiabétiques Journal of Clinical insulinique – euglycémique, avant et 4 mois oraux, et à l’insulinothérapie. Parmi les antidia- Endocrinology and metabolism, 1994, après hormonothérapie. L’étude a porté sur 13 bétiques oraux et leur éventuelle association, il 79(1), 265-71 transsexuels femme>homme traités par esters convient de souligner l’intérêt supplémentaire 2 - Jolanda MH et al. « Effects of sex de testostérone (250 mg/2 semaines), et sur 18 des glitazones (rosiglitazone, et pioglitazone) steroids on transsexuels homme>femme traités soit par EE dans les lipoatrophies liées au VIH, par le biais components of the insulin resistance seul (0,1 mg/j per os) soit par association avec d’une augmentation de la lipogenèse sous syndrome in transsexual subjects » CPA (100 mg/j, per os). Il en ressortait une insu- cutanée aux détriments de la graisse viscérale. Clinical Endocrinology, 2003, 58(5), 562-71 lino-résistance induite par ces traitements. Celle-ci va se surajouter aux effets des IP. Dans Anomalies lipidiques revue cette étude les hommes biologiques traités par Elles sont dominées par les hypertriglycéridé- EE avaient une diminution de l’insulino-sensibi- mies (35 % des cas) et les hypercholestérolé- lité malgré la réduction du taux de testostérone. mies (25 % des cas). C’est surtout le ritonavir Dans la mesure où les injections de testosté- qui possède les effets les plus marqués (aug- rone entraînaient une insulino-résistance chez mentation de la production hépatiques des les femmes, on aurait pu s’attendre à une aug- VLDL et diminutions de leur clearance par la mentation de l’insulino-sensibilité lorsque les LPL) sur les triglycérides. Là aussi, il y a cumul taux de testostérone étaient nettement dimi- éventuel avec les traitements hormonaux « croi- nués. On peut émettre deux hypothèses pour sés » des transsexuels. Aux hyperlipidémies expliquer ce paradoxe apparent : on peut mixtes des ARV, avec hypertriglycéridémies pré- d’abord invoquer le fait que les effets de réduc- dominantes, se surajoutent les effets éventuels tion des taux de testostérone sur l’insulino-sen- des hormonothérapies « croisées » spécifiques sibilité étaient moindres que les effets des taux des transsexuels, dont les effets sont d’autant élevés des œstrogènes. Ou bien, deuxième plus marqués qu’il s’agit d’EE per os, à la dose hypothèse, on peut supposer qu’il existe une de 50 à 100 mcg/j comme en témoigne l’étude différence des effets de la testostérone suivant de Gooren et al. de 2003 2. Ce travail a porté le sexe, et que celle-ci induit une insulino-résis- sur 20 transsexuels homme>femme et 17 trans- tance uniquement chez les femmes. Tout cela sexuels femme>homme traités respectivement montre à quel point il est difficile d’extrapoler par CPA 100 mg + EE 100 mcg pour les pre- à la population transsexuelle les connaissances miers, et testostérone 250 mg IM/2 semaines pharmacologiques des traitements hormonaux pour les seconds. L’association CPA 100 mg iso-sexuels. Il y a bien là une singularité dans + EE 100 mcg, si elle a permis une augmenta- les traitements « croisés ». Il n’en reste pas tion de l’HDL et une diminution du LDL, ce qui moins que, contrairement à l’EE , l’œstradiol est bénéfique, a néanmoins augmenté les tri-

décembre 2006 no 130 TRANSCRIPTASES VIH et virus des hépatites glycérides, la pression artérielle, la graisse vis- de l’estradiol 17 béta oral est la preuve qu’il THERAPEUTIQUE, CLINIQUE cérale et sous-cutanée, et diminué la taille des s’agit d’une différence moléculaire plutôt que particules LDL, ainsi que l’insulino-sensibilité : la conséquence d’un premier passage hépa- tout cela étant défavorable sur le plan cardio- tique. Cela explique pourquoi les transsexuels vasculaire. La testostérone, quant à elle, a dimi- homme>femme traités par EE oral sont à plus nué le HDL en même temps que la taille des par- haut risque d’accidents thromboemboliques ticules LDL , et augmenté les triglycérides et que ceux traités par estradiol percutané. l’activité de la lipase hépatique. Il y a eu par La testostérone prescrite aux transsexuels ailleurs une répartition androïde de la graisse femme>homme montre au contraire un effet au bénéfice du tissu adipeux viscéral. La TA, le anti-thrombotique. cholestérol total et le LDL, l’activité lipoprotéine lipase ainsi que l’insulino-sensibilité étaient pra- Conclusion 12 tiquement non modifiés. Ces résultats doivent La prise en charge des divers troubles méta- inciter à faire appel, chaque fois que c’est pos- boliques en rapport avec les traitements anti- sible, aux œstrogènes naturels, par voie per- rétroviraux et l’infection à VIH a été largement cutanée, aux mêmes doses que celles utilisées développée dans des publications antérieures dans le traitement hormonal substitutif de la et ne sera pas détaillée ici. ménopause, surtout chez les patients sous IP. La spécificité de la prise en charge de ces Ainsi qu’il a été indiqué plus haut, le dosage le patients traités par ARV, réside dans l’hormo- l’œstradiol plasmatique est nécessaire avec nothérapie « croisée » qui les caractérise, qui pour objectif un taux allant de 60 à 70 pg/mL. peut faire l’objet d’interactions multidirection- Les œstrogènes naturels entraînent une dimi- nelles et d’effets secondaires. La prudence nution du CT, du LDL et de la Lp(a), ainsi que s’impose avec les IP inhibiteurs du cytochrome l’augmentation du HDL. Par contre, cette aug- 450 (efavirenz-indinavir) avec les risques d’augmentation du HDL est plus importante par la mentation des taux hormonaux. Il est clair que voie orale que par la voie percutanée. Enfin, il la préférence doit aller à l’estradiol 17béta par existe une légère augmentation des triglycé- voie percutanée, et que l’EE ne doit plus être rides lors de la voie orale, mais pas par la voie employé pour cette population à risque car- percutanée. diovasculaire. Pour les diabétiques, les glitazones méritent des études évaluant leur intérêt Thromboses veineuses et éventuel dans les lipoatrophies. Les hypertri- accidents thromboemboliques glycéridémies insuffisamment contrôlées par Les accidents thromboemboliques mettent en les fibrates pourraient bénéficier de l’adjonc- jeu le pronostic vital, et leur prévention est d’im- tion de l’acide nicotinique (Niaspan®) actif à la portance capitale. Leur incidence chez les fois pour réduire les VLDL et le LDL , et aug- transsexuels homme>femme traités par EE oral menter le HDL. Par ailleurs, de nombreux pro- est significativement plus importante qu’avec tocoles avec remplacements des IP par des l’estradiol 17 béta percutané, associé ou non inhibiteurs de la transcriptase inverse, nucléo- au CPA . L’étude de Gooren et al. (2003) 3 a sidiques (INTI) ou non (INNTI), semblent pro- 3 - Toorians AF, et al « Venous thrombosis montré que cette différence était due à l’effet metteurs. L’objectif pour ces patients, outre la and changes of hemostatic variables spécifique de l’EE sur les facteurs d’hémostase. féminisation ou la masculinisation, est le main- during cross-sex Le CPA seul, l’association estradiol percutané tien de l’efficacité antivirale, ainsi que la pré- hormone treatment in transsexual + CPA , ou estradiol oral + CPA , avaient peu vention à court terme des accidents throm- people » Journal of Clinical d’effet sur les facteurs de l’hémostase, alors boemboliques, et, à long terme, des risques Endocrinology and metabolism, 2003, que l’EE entraînait une importante augmenta- cardiovasculaires. - Nicolas Hacher 88(12), 5723-9 tion de la résistance à la protéine C activée (p < 0,001), une légère augmentation de la pro- téine C (p = 0,012) et une diminution significa- tive de la protéine S libre et totale de 30 %. Cette différence entre les effets de l’EE oral et

Usages de produits psychoactifs The safe guards project and the LGBT Health resource centre, Philadelphia. Trans issues : smoking, 2004/04 http://www.safeguards.org/?cat=9 OGGINS J Engaging Transgender Substance Users in Substance Use Treatment International journal of transgenderism, n°1-2, 1999/01 http://www.symposion.com/ijt/ijtvo06no02_03.htm Santé mentale BOCKTING W, KNUDSON G, GOLDBERG JM Counselling and Mental Health Care of Transgender Adults and Loved Ones, 2006/01, 71 p. http://www.vch.ca/transhealth/resources/library/tcpdocs/guidelines- mentalhealth.pdf

Inégalités, discriminations dans l’accès aux soins et au système social MIGNOT S Discrimination de genre Article ; Français ; Revue : Transversal : journal des acteurs de la lutte contre le sida ; 2003/01 ; n° 12 ; ISN : 1627 0428 ; pp. 9-13 ; liste d'adresses Thème principal : TRANSEXUEL TRANSEXUEL ; DROIT ; DISCRIMINATION ; VIE SOCIALE ; MILIEU PROFESSIONNEL ; LOGEMENT ; ASSOCIATION ; PREVENTION PRIMAIRE ; PASTT Résumé : Cet article présente le travail que font les associations telle que le PASTT (Prévention, action, santé, travail pour les transgenres) Il attire l'attention sur les discriminations que subissent les transexuels lorsqu'ils doivent présenter leurs papiers d'identité, chercher un logement ou du travail, et également en ce qui concerne la santé et plus particulièrement l'infection à VIH/SIDA. Cote IDF : Transversal, n° 12 CABRAL C ; GUILHEM J-L Transgenres : combat contre la discrimination Article ; Interview ; Français ; Revue : Combat face au Sida ; 2002/06 ; n° 28 ; ISN : 1267 7841 ; pp. 38-40 Thème principal : TRANSEXUEL TRANSEXUEL ; PROSTITUTION ; DISCRIMINATION ; DROIT DES PERSONNES ; PASTT ; FRANCE Cote IDF : Combat face au sida, n° 28 XAVIER J, BRADFORD J, Transgender health access in Virginia : focus group report, Virginia Department of health, 2005/12, 56 p. WHITTLE S, TURNER L, AL-ALAMI M Engendered penalties : transgender and transsexual people’s experiences of inequality and discrimination, in the Equalities Review, 2007/02, 120 p. XAVIER J, HONNOLD J, BRADFORD J, The health, health-related needs and lifecourse experiences of transgendered Virginians, Virginia Department of health, 2007/01, 76 p.

social Discrimination de genre La communauté transgenre est multiple Au Pastt, une enquête a été réalisée pour ment les demandeurs trans. L’Ardhis en et difficile à cerner. En passe de consti- mieux connaître les besoins du public suit ainsi une dizaine. Car ils sont nom- tuer un mouvement global, des asso- visé par l’association, essentiellement breux à venir en France, poussés par les ciations attirent l’attention sur les dis- des travailleurs sexuels. Les résultats don- persécutions subies dans leur pays d’ori- criminations qu’elle subit. nent la priorité aux papiers, suit l’hé- gine ou par le mirage de l’eldorado éco- bergement et enfin, seulement, la santé. nomique et social français. « A trois re- C haque premier samedi d’octobre, Il est vrai que pour les trans, la plupart prises, nous avons pu obtenir des titres depuis six ans, l’ExisTrans défile des démarches administratives se trans- de séjour, reconnaît Guillermo Rodri- dans les rues de Paris afin de sen- forment régulièrement en séances d’hu- guez, mais il a fallu recourir à l’argu- sibiliser le public et les médias au com- miliation publique. Guillermo Rodriguez, ment du VIH, que je n’aime pas utiliser. » bat quotidien mené par les trans pour la président de l’Ardhis 1/, confirme : « A la reconnaissance de leurs droits. « Nous préfecture, l’accueil est assez dur. Les papiers. Pour les autres, ceux qui devons obtenir des papiers conformes Quand les agents nous reçoivent, ils line sont pas clandestins, qui ont un em- à notre genre et non à notre sexe », resent le dossier, regardent le demandeur ploi et une vie sociale normale, présen- vendique Camille Cabral du Pastt, as- et protestent : mais c’est pas vous, là… Il ter ses papiers à un contrôle de police, sociation fondée et gérée par des per- est où le monsieur ? En plus il n’y a pas à un bureau de vote ou au guichet d’une sonnes transgenres. D’autres voudraient un rapporteur attitré par dossier. A banque, peut également devenir une vé- plutôt voir inscrits dans la loi les droits chaque visite, on tombe sur un nouvel ritable épreuve. En France, l’identité des transsexuels et un changement d’état agent et il faut réexpliquer la situation…» sexuelle est inscrite désormais sur la plu- civil facilité, comme Natacha Taurisson, C’est pourquoi les responsables de l’as- part des papiers identitaires (carte présidente de l’Association du syndrome sociation accompagnent systématique- d’identité, passeport, permis de conduire de Benjamin (ASB). Enfin, d’autres en- 1 et tous documents comportant un numéro /Ardhis : Association pour la reconnaissance core estiment que la solution aux discri- des droits des personnes homosexuelles et trans- de Sécurité sociale). Natacha Taurisson minations passe avant tout par l’éduca- sexuelles à l’immigration et au séjour (ex-collec- se souvient de sa première participation tion et la sensibilisation. tif des homos sans papiers). à un scrutin en tant que femme. Sa carte Transversal janvier-février 2003 9

social d’identité était encore estampillée du fonde. Selon Armand Hotimsky du Ca- « Trouver des aménagements de poste « M. » incongru : « On m’a demandé la ritig 2/, le RMI a permis d’en limiter le peut être utile lorsqu’on entame un trai- procuration de mon mari. Il a fallu que recours. Mais elle demeure l’unique tement (en raison de la fatigue physique j’explique, que je me dévoile. Ça ne source de revenus pour bon nombre de et des modifications corporelles difficiles s’est pas trop mal passé. Tout dépend trans étrangers, souvent sans papiers. à assumer) ou que l’on doit subir une de la personne qui est en face de toi. » En outre, une grande proportion de la ou plusieurs interventions chirurgicales, Parfois cela peut aussi se terminer au population transgenre présente un faible nuance-t-elle. Mais les gens doivent sa- poste de police… niveau de formation. « Ils ont souvent voir qu’ils peuvent garder leur emploi. » mal vécu leur adolescence et donc leur Dans les pays anglo-saxons, on embau- L’hébergement. Quant à trouver un scolarité », poursuit Armand. Dans ces cherait même spécifiquement des trans, logement dans le système de droit com- conditions, les emplois proposés sont estimant que ce qu’ils ont enduré les mun, avant le changement de sexe offi- souvent des activités de ménage, fort rend particulièrement combatifs et avides ciel (qui ne peut aboutir qu’après inter- peu valorisantes pour l’estime person- de faire leurs preuves. Probablement le vention chirurgicale), point de salut : nelle d’un individu au psychisme déjà résultat d’un lobbying intensif. Claude Anjos Cruz, médiateur en santé malmené. Dans l’Hexagone, la condition des per- publique au Pastt, cherche un apparte- Globalement, l’accès à l’emploi est loin sonnes transgenres est aussi en train ment depuis sept mois. « Quand on me d’être un parcours fléché. « On répond à d’évoluer. Natacha Taurisson s’est reçoit ou que je laisse un dossier dans l’entretien, on correspond au profil, mais beaucoup investie afin de sensibiliser une agence, je ne suis jamais rappelé », au moment de présenter ses papiers, son le milieu associatif et politique à la résume-t-il. Il met cela sur le compte de numéro de Sécu, les réticences appa- cause qu’elle défend, notamment son physique, ni tout à fait homme ni raissent, on nous demande de revenir, en s’adressant d’abord aux associa- tout à fait femme. Les HLM ne sont ac- résume Natacha Tau- tions homosexuelles, cessibles qu’après plusieurs années d’at- risson. Finalement le milieu longtemps hos- tente. Alors, pour les plus démunis, il reste les solutions d’urgence. Le Pastt contrat n’est jamais si- gné.» Les circonstances «L’importance tile aux personnes transgenres. « Les trans travaille ainsi avec des hôtels. Pour les personnes séropositives, l’association a seront plus favorables à celles et ceux qui ont du ont longtemps été reje- tés, car ils étaient également mis sur pied son propre programme d’appartements-relais (lire obtenu un changement d’état civil, quand ils changement associés exclusivement au travail sexuel, à la p. 12). « Auparavant, quand les filles demandaient des appartements aux ont opté pour une chirurgie et un traitement d’état civil» débauche, note-t- elle. Cela change : on autres associations, il n’y avait jamais hormonal. constate que nous vi- de place », se souvient Marina Braga Dans ces conditions, pour ceux qui vons les mêmes discriminations. » Ainsi du Pastt. Avant l’émergence des multi- avaient un emploi avant leur transition, la Gay Pride est devenue la Marche des thérapies et l’amélioration de l’espé- il est préférable qu’ils le conservent, fiertés lesbiennes, gay, bi et trans. De rance et de la qualité de vie des séro- même si la chose n’est pas facile. Parfois même, les Etats généraux de l’homo- positifs, il ne fallait pas non plus espérer la personne elle-même s’autocensure : sexualité ont inclus la question de l’iden- trouver une chambre dans un apparte- en quittant son poste, elle n’aura plus à tité sexuelle à leur programme, en mai ment de coordination thérapeutique affronter le regard des collègues, des dernier. Lors des Universités d’été euro- (ACT) pour un transsexuel. Mais les men- patrons, des clients. Quant à l’em- méditerranéennes des homosexualités talités évoluent. « Et maintenant on arrive ployeur, il fera pression pour changer à Marseille, des associations homos ont parfois à obtenir un ACT auprès de Cor- le salarié de poste s’il juge celui-ci in- même trouvé dans leurs rangs des trans, dia, Arcat Sida ou SOS habitat et soins, adéquat avec le nouveau sexe de l’em- jusque-là ignorés. note Marina, via la plate-forme interas- ployé. Et, selon Vincent Guillot, chargé sociative pour le logement/sida (Pils). » d’insertion professionnelle à l’Agefiph La santé. Dans les associations de D’autres associations cherchent à se- et membre du Caritig : « La transition est lutte contre le sida, peu de programmes courir ainsi les trans prostitués, à la un moment de fragilité, dans lequel l’em- sont destinés spécifiquement aux trans. condition qu’ils consentent à cesser le ployeur peut voir l’occasion de se dé- On retrouve la problématique dans les travail sexuel. barrasser d’un salarié gênant. » projets liés à la prostitution. Olivier Ma- Pourtant, en France, selon Natacha Tau- guet, de l’association Aides, explique : L’emploi. Car longtemps la prostitu- risson, de plus en plus de transsexuels « Nous recevons des trans depuis tou- tion a été la seule activité possible pour gardent leur emploi ou y accèdent. jours. Nous les soutenons, les écoutons des personnes marginalisées, discrédi- 2 /Caritig : Centre d’aide, de recherche et d’in- et répondons à leurs questions. Mais tées par un physique en contradiction formation sur la transsexualité et l’identité de sur le terrain, il n’y a pas de demande avec leurs papiers ou leur conviction pro- genre. pour un programme distinct comme 10 janvier-février 2003 Transversal

c’est beaucoup plus facile pour un trans de “trouver un coup”, que de rencon- trer un compagnon. » Parallèlement, le VIH reste un sujet tabou. « Pour les transsexuels, il semble qu’il y ait une période, peu avant la transition, où la sexualité est mise en veilleuse », sug- gère Armand Hotimsky. Une commission spécifique vient pourtant d’être créée à Act Up-Paris, sous la houlette d’Hélène Hazera : « Nous allons nous atteler à un problème urgent : les contre- indications entre hormones et trithéra- pies qui obligent parfois certains trans séropositifs à interrompre leur transformation. » Avec toutes les conséquences que cela comporte sur la féminisation ou la masculinisation en cours. Hélène Hazera compte également utiliser les méthodes militantes de l’association afin de faire évoluer la prise en charge médicale de la transformation des personnes transgenres. « Aujourd’hui, on ne peut pas choisir son chirurgien, s’in- surge-t-elle. L’intervention est très longue à obtenir, et il faut d’abord intégrer un protocole en répondant à un questionnaire caricatural : en résumé, il faut dire qu’on aime le rose, les dentelles et nous en avons mis en place pour les la prostitution mais aussi via le multi- Marie Laurencin, ne pas être marié et gays, les sourds, les prostitué(e)s, etc. » partenariat. « On a besoin de prouver surtout ne jamais avoir eu d’enfant. Pourtant la population transgenre est par- qu’on est capable de séduire, explique Moyennant quoi les gens mentent pour ticulièrement exposée au VIH, à travers Hélène Hazera, d’Act Up-Paris. Et puis obtenir l’opération qu’ils souhaitent. » En outre, la plupart des équipes refu- sent l’intervention aux personnes séro- positives… Seul bon point attribué à l’univers mé- Une communauté hétéroclite dical, le suivi réservé aux séropositifs dans les Cisih et l’accueil en CDAG. ● Transgenre est une expression large qui recouvre diverses réalités. Selon la dé- finition du Caritig, le terme englobe les travestis conventionnel masculin ou féminin. Les défi- nitions sont en perpétuelle évolution, signe d’une culture en phase d’élaboration. Ainsi à Comme à l’hôpital Bichat où il existe un service habitué de longue date à re- cevoir des prostitué(e)s trans qui habi- (qui désirent porter les vêtements associés à l’ASB, on considère que les personnes opé- tent ou travaillent dans le nord de Paris, l’autre sexe), les transsexuel(le)s (qui désirent rées ne sont plus des transsexuels, mais bien et où ont été formés les adultes-relais subir une thérapie hormonale et/ou chirurgi- des hommes et des femmes comme les autres. du Pastt. L’association salue aussi l’ex- cale de changement de sexe), les transgen- On peut retrouver des personnes transgenres cellent accueil des bureaux de l’aide déristes (qui vivent dans le rôle de genre as- à tous les niveaux de la société, avec des médicale d’Etat, ainsi que le service socié à l’autre sexe sans désirer d’opération), conditions de vie très variées, même si toutes d’urgence de l’hôpital Ambroise-Paré, à les personnes bigenres (qui s’identifient à la sont exposées à la discrimination. On estime la proximité du bois de Boulogne, trop fois comme homme et femme), les drag population des transsexuels à environ 6 000 souvent sollicité pour des agressions… queens et drag kings (gays et lesbiennes qui personnes. Mais la communauté transgenre sur les prostitué(e)s transgenres. draguent et s’habillent respectivement en est probablement beaucoup plus importante, Le chemin est encore long pour parve- femmes et en hommes), les personnificateurs surtout si l’on prend en compte celles et ceux nir à l’insertion sociale des trans dans (des hommes qui incarnent des femmes et vice qui n’osent pas s’affirmer. la société française. versa) et quiconque n’ayant pas un genre S. M. Sandra Mignot Transversal janvier-février 2003 11

social Le Pastt : la structure des trans Le Pastt a mis en place un programme d’appartements-relais pour les prosti- tuées transsexuelles ou travesties sé- ropositives. «A la fin des années 80, quand les filles étaient vraiment malades, on ne trouvait jamais de place pour elles dans les appartements thérapeutiques », se souvient Marina Braga, médiatrice au Pastt. Pourtant la recherche de logement fait partie des priorités des usagers de l’association. « Ce sont souvent des mi- grants, en situation précaire », résume Marina. Alors dès 1996, peu après sa création, le Pastt a cherché une solution. Le programme gère cinq appartements, disséminés dans Paris. Ils sont financés par la Ddass et sous-loués à l’association lLe Pastt, le 1er décembre 2002 au Centre Pompidoul Habitat et Soins. Le Pastt règle les fac- tures (téléphone, électricité…). Des tic- vers le dispositif de droit commun. De- nos usagers ont obtenu un logement au- kets-services sont également attribués puis février 2001, le Pastt est intégré à près de SOS habitat et soins, Cordia, aux locataires pour leurs dépenses heb- la plate-forme interassociative pour le Arcat », précise Marina. Quand les per- domadaires. L’un des logements est ré- logement/sida. Dans ce cadre, des ré- sonnes sont orientées par le Pastt et servé aux situations d’urgence (notam- unions mensuelles sont organisées en qu’elles ont régularisé leurs conditions ment en cas d’agression). Les personnes présence des bailleurs (Opac, mairie de séjour sur le territoire, elles bénéfi- bénéficiaires doivent répondre à deux de Paris, préfecture…) afin de suivre les cient d’une meilleure écoute. critères : séropositivité et précarité. Les dossiers des locataires et de les rendre Le programme d’hébergement-relais du contrats de location sont concédés pour prioritaires. « Ainsi, nous avons déjà re- Pastt gagnerait probablement à être dé- une durée de six mois. « Mais on ne met logé trois personnes », veloppé. Mais pour pas les gens dehors à l’issue du contrat, explique Marina. l’heure, l’association explique Marina. Leur séjour est souvent La difficulté réside cherche d’abord à se prolongé en attendant que la situation dans la justification de «Critères s t a b i l i s e r. « N o u s s’arrange. » Un hébergement en hôtel revenus réguliers. « Ce sommes une associa- peut également prendre le relais. sont des travailleuses retenus: tion très vulnérable, ex- Le Pastt prend également en charge l’ac- du sexe, et nous ne plique Camille Cabral. compagnement social des personnes. leur imposons pas de séropositivité La seule structure Chaque semaine, Marina visite ses pro- cesser leur activité, il connaissant aussi bien tégées. Elle engage le dialogue, tend n’est donc pas évident et précarité» la communauté trans et l’oreille aux personnes qui ont besoin d’apporter la preuve ses problématiques. d’une écoute, oriente celles qui cher- de leurs ressources. Le problème ici est Nous devons d’abord travailler à pé- chent conseil pour des démarches offi- la profession, pas le transgenre. » Ac- renniser nos financements. » L’associa- cielles. Elle les accompagne à la pré- céder à un logement social est plus fa- tion, soutenue par le ministère de la fecture pour des demandes de cile pour celles qui perçoivent l’alloca- Santé, la Ddass et Ensemble contre le régularisation, à l’hôpital. « Parfois, je tion adulte handicapé. sida, propose également un programme leur trouve même une aide à domicile, Depuis la création de la plate-forme, de prévention VIH et MST, un accom- si cela s’avère nécessaire. » En cas de les contacts avec les associations qui pagnement médico-social et un relais besoin, des consultations psy sont éga- gèrent le parc des appartements-relais vers l’insertion professionnelle via 14e lement accessibles via l’association. sont facilités. « Des demandes indivi- Emploi Développement. Ces appartements sont surtout un sas duelles aboutissent parfois. Certains de S. M. 12 janvier-février 2003 Transversal

« Retrouver une dynamique » 14e Emploi Développement est une as- un contrat de travail et les fiches de La personne doit parvenir à distinguer sociation parisienne intermédiaire de paye, puis un contrat tripartite est signé ses priorités. réinsertion. Elle propose des missions avec l’employé et le client. Ils ne font de travail de courte durée pour des per- pas forcément attention à l’identité com- Quels sont les avantages et les sonnes en insertion. Depuis 1998, elle plète de la personne, surtout quand les contraintes de ce dispositif ? emploie également une petite dizaine prénoms sont mixtes ou proches de celui Les personnes sont employées sous la de personnes transgenres, issues du mi- d’origine. On a beaucoup de gens forme d’un contrat de mise à disposition lieu de la prostitution. Elle se veut une d’Amérique latine… Une lettre suffit par- (maximum un mois, renouvelable à l’in- base de lancement afin que chacun fois à le féminiser. fini), rémunérées au smic, à temps par- puisse retrouver ses marques et accé- tiel. Si elles ont suffisamment cotisé, elles der à un travail « classique ». Le retour à un emploi « classique » peuvent bénéficier des Assedic. C’est un soulève quels types d’obstacles ? statut précaire, mais qui n’empêche pas epuis quand recevez-vous Il faut d’abord se réadapter aux règles de travailler en parallèle. Ou d’utiliser le D des personnes transgenres? Cela date de 1998. Au départ, des personnes se sont présentées de leur propre initiative en session de re- de base du travail (ponctualité et fiabi- lité). Certains viennent à l’entretien de re- crutement avec l’envie de travailler, mais ils ne sont pas prêts. D’autres problèmes reste du temps pour les démarches administratives ou médico-sociales qu’elles ont à mener. Elles peuvent s’arrêter dès qu’elles trouvent quelque chose d’autre. crutement. On a essayé de savoir com- doivent parfois être réglés avant de re- Il est rare que ça débouche sur un emploi ment elles étaient parvenues jusqu’à nous. prendre un emploi, comme ceux liés à la permanent. Il ne faut pas se faire d’illu- Probablement via le bouche à oreille, car santé ou à la transition. Il faut aussi ap- sions. Le but est vraiment de retrouver nous travaillons aussi avec des associa- prendre à affronter le regard des autres, une dynamique et un travail à l’extérieur. tions de soutien aux prostitué(e)s. sortir d’un milieu et changer de repères. Propos recueillis par S. M. Quels types de mission proposez- vous ? Nos clients sont des associations, des collectivités, des cabinets médicaux, des Contacts : syndics d’immeubles, des restaurants hospitaliers… En majorité, les trans sont Pastt Caritig embauchés par des associations pour Mme Camille Cabral Boîte postale 756 faire le ménage. Une grande partie ont 94, rue Lafayette 75010 Paris 75827 Paris Cedex 17 un niveau de français très faible et vien- Tél. : 01 53 24 15 39 Tél. : 01 53 17 05 27 nent de la prostitution. Reprendre un em- Mail : pastt@noss.fr Fax : 01 53 17 05 27 ploi régulier nécessite un temps d’adap- Mail : caritig@caritig.org tation. Alors on commence par leur Ardhis Site : www.caritig.org donner quelques heures de travail par se- M. Guillermo Rodriguez maine, puis on augmente progressive- C/O Centre gay et lesbien 14e Emploi Développement ment la durée en fonction de leur de- 3, rue Keller 75011 Paris 70, rue du Moulin-Vert mande. Nous évitons de les placer en Tél. : 01 43 57 19 69 75014 Paris restauration, car c’est un milieu très dur Mail : ardhis@writeme.com Tél. : 01 40 52 08 80 physiquement, avec beaucoup Site : http ://ardhis.free.fr/ d’hommes, et les relations avec les col- Act Up-Paris lègues peuvent être difficiles. Association du syndrome Mme Hélène Hazera de Benjamin BP 287 Le client connaît-il les difficultés Mme Natacha Taurisson 75525 Paris Cedex 11 d’inser tion vécues par le tra- C/O Relais 59 Tél. : 01 48 06 13 89 vailleur transsexuel ? 1, rue Hector-Malot 75012 Paris Fax : 01 48 06 16 74 On part du principe que le client sait Tel. : 01 43 57 21 25 Site : www.actupp.org que nous sommes une association inter- Mail : asb@asbfrance.org médiaire et que nous travaillons avec Site : www.asbfrance. org/ des publics d’insertion, mais ça s’arrête là. Nous sommes l’employeur. On établit Transversal janvier-février 2003 13

Transgender Health Access in Virginia: Focus Group Report Virginia Transgender Health Initiative Study Phase 1 Members of the Study Team: Judith Bradford, Ph.D. Principal Investigator and Project Director Jessica Xavier, M.P.H. Co-Investigator and Focus Group Facilitator Michael Hendricks, Ph.D. Co-Investigator and Chair, VHCPC Research Subcommittee, 1994-2005 Lauretta Safford, M.S.W. Project Manager and Focus Group Co-Facilitator Madge H. Young, M.A. Focus Group Co-Facilitator Ryan McKee, M.S. Research Analyst and Focus Group Co-Facilitator Milagritos Flinn, B.S. Focus Group Co-Facilitator Scout, Ph.D. Focus Group Facilitator Alejandro Marcel, M.A. Focus Group Facilitator Earline Budd Focus Group Facilitator Ruby Corado Focus Group Facilitator Julie A. Honnold, Ph.D. Statistical Analyst With assistance from members of the Virginia Transgender Task Force (VTTF) and members of the Virginia HIV Community Planning Committee (VHCPC): Bill Briggs VHCPC Rosalyn Cousar VHCPC, Chair, Research Subcommittee, 2005- Catherine Hulbert VTTF Zakia Jemayece VTTF Martha Lees VHCPC and VTTF Elaine Martin VHCPC and VTTF Nick Mattsson VHCPC Joseph Riddick VHCPC Prepared under the auspices of the Virginia Department of Health, Division of HIV, STD, and Pharmacy Services through the Centers for Disease Control and Prevention, Cooperative Agreement #: U62/CCU-323468; PA Announcement 04012. 1

Table of Contents Executive Summary 2 Introduction 5 Literature Review 5 The Virginia Transgender Health Initiative Study 6 Study Design and Methodology 7 Study Results 8 Study participants 8 Access to regular medical services 10 Access to transgender care services 12 Access to mental health services 16 Employment discrimination 18 Housing discrimination 20 Violence 21 Substance abuse 23 Self-esteem 25 HIV knowledge & perception of risk 28 HIV testing 33 Improving access to HIV/AIDS treatment services 35 Summary of Key Findings 38 Recommendations to VDH and the VHCPC 40 References 43 Appendices: Appendix I: Glossary of Transgender Terminology 45 Appendix 11: HIV Community Planning in Virginia 47 Appendix 111: Focus Group Protocol 50 Tables and Figures Table 1: THIS Focus Group Participants – Observed Demography 9 Table 2: THIS Focus Group Participants – Demographic Questionnaire Results 9 2

Executive Summary In 2002, the Virginia HIV Community Planning Committee (VHCPC) chose transgender people as its next priority subpopulation for HIV prevention research. At that time, transgender people were one of four subpopulations with virtually no data to inform the VHCPC’s process. The Virginia Transgender Health Initiative Study (THIS) was implemented by the Virginia Department of Health (VDH) to address this knowledge gap. In this report, we provide results from Phase One of THIS: seven focus groups composed of diverse transgender subgroups conducted in March and April, 2004. The study was designed and conducted by the VHCPC’s research partner, the Survey and Evaluation Research Laboratory (SERL) at Virginia Commonwealth University. The purposes of the study were to assess the risk factors driving HIV infection among transgender people in Virginia, and their experiences in accessing medical care. Analysis of the data will assist VDH and the VHCPC with program development and resource allocation decisions. Although the participants demonstrated a high level of knowledge about HIV, many of the participants had engaged in unprotected sex. Transgender women had unprotected sex with non- transgender men, and FTMs had unprotected sex with non-transgender men, non-transgender women 1 and other FTMs. Other risk factors included substance abuse and unprotected sex in prostitution due to extreme financial need. Sex worker participants were mostly transgender women, but there were also some FTMs. Economic vulnerability was the primary reason for doing sex work. Perception of HIV risk greatly varied and was highest among African-American transgender women, who also had the highest frequency of condom use. Latina transgender women used condoms less frequently than other participants. Reasons for not using condoms or other barriers included monogamy, denial of risk, substance abuse, and cultural and societal factors. IDU needle sharing occurred among transgender women who were sex workers. Barriers to getting tested for HIV included not knowing where to get tested, fear of hostile or insensitive HIV Counseling, Testing and Referral (CTR) personnel, and fear of testing positive and its consequences. The most common barrier to getting tested was a lack of trust in HIV testing sites to keep test results confidential, especially for participants in rural areas. High levels of substance abuse were reported by participants, with alcohol and marijuana use most common. Most participants cited their need to cope with many interrelated life stressors 1 Many of the FTM (Female-To-Male) participants were ambivalent about or resented being perceived as non- transgender men, probably due to sexism. Accordingly, FTMs will be used in this report, except where participants used transgender man to identify themselves. Transgender women refers to Male-To-Female transgender persons. Where it is used, Transsexual usually implies having obtained or desiring surgical sex reassignment. See the Glossary for a complete explanation of all transgender terminology used in this report. 3

produced by their extreme social marginalization. Other reasons included coping with depression, coping with internalized transphobia (often as a substitute for psychotherapy) and coping with the pressures of sex work. Some participants reported how transitioning to their chosen genders eased their depression and reduced their substance abuse. The most significant means of improving self-esteem was passing in their chosen genders, especially for the transgender women. Passing allowed them to avoid social stigma, affording them social acceptance. Passing was also important for the self-esteem of the FTMs, although some were ambivalent about being perceived as men. Gender identity affirmation through sex with non-transgender persons was another means of improving self-esteem, especially for African- American and Latina transgender women. Access to transgender care services – principally hormone therapy – was a priority need for most of the participants, since it allowed them to pass in their chosen genders. However, many participants experienced barriers to access, including lack of insurance (related to lack of employment or doing sex work as an alternative to regular employment); failure of insurance to cover their transgender care; identity documentation issues; and the lack of willing providers. Due to these barriers, many participants engaged in self-medication of hormones and injection silicone use, which involve their own health risks. Sharing of needles to inject hormones and silicone was not mentioned by the participants, although it may have occurred. Many participants experienced barriers to access to regular medical care due to hostility and insensitivity of medical providers. Negative experiences with care providers (especially with female-to- male participants accessing gynecological care) resulted in nondisclosure of transgender status or avoidance of necessary medical care. Lack of insurance and identity documentation problems were also barriers to access. Some participants also experienced poor care relationships with mental health care providers who lacked clinical experience with transgender people or believed that transgenderism is a mental illness. Participants who did not access mental health care had negative attitudes towards it due to traditional mental illness stigma and feelings that being transgender was not a mental illness. Those seeking psychotherapy had great difficulties finding mental health providers who were compassionate, experienced, and competent. Many participants had experienced employment discrimination and difficulties in employment, including job loss and failures to be hired. An inability to pass in one’s chosen gender was often linked to job discrimination and difficulties with co-workers. Hostile work environments, with harassment and occasional physical abuse, were also reported. Generally, white collar workers, with employment longevity experienced the least discrimination. Housing discrimination was experienced by fewer participants than employment discrimination. Common housing barriers included unemployment, low 4

wages and the stigma associated with being transgender. Some African-American and Latina transgender women mentioned discrimination in public housing and shelters. Many participants were survivors of violence, especially African-American transgender women, with murders of peers often reported. Many participants experienced harassment and intimidation in their own neighborhoods. Some complained about secondary victimization by the police when they reported the violence. Unmet prevention needs reported by participants included HIV educational workshops, condom distribution, HIV counseling and testing, and individual and group level interventions. Groups with the most unmet needs for prevention were Latina transgender women, FTMs and transgender youth. Participants also mentioned cultural competency training for doctors, social workers, and other HIV workers, as well as additional training for medical providers in delivering transgender care. Other needs included financial assistance to pay for HIV treatment and job training. Study results support the following recommendations for consideration by VDH and the VHCPC. • Cultural competency training for medical, social service, shelter and transitional housing staffs. • Medical service delivery training for medical providers in transgender care services and mental health service delivery training for mental health providers. • Local clinical transgender care programs operating on a harm reduction model. • A vocational rehabilitation program for transgender sex workers. • Expansion of outreach and condom distribution to transgender subpopulations, especially Latina, transgender youth, and FTM groups. • Development of transgender-specific HIV/AIDS prevention materials and implementation of transgender-specific prevention workshops. • Improvement of HIV testing for transgender people. • Educational programs for transgender people about transgender care. 5

Introduction Subsequent to its studies of other at-risk subpopulations, the Virginia HIV Community Planning Committee (VHCPC) chose transgender people as its next priority subpopulation for research in 2002. At that time, virtually no data were available on transgender health concerns that could adequately inform the VHCPC’s process. Transgender people are those who cannot or choose not to conform to societal gender norms based upon their physical or birth sex. Transgender women are natal males with female identification or expression (male-to-females, or MTFs) and transgender men are natal females with male identification or expression (female-to-males, or FTMs). Transgender includes a variety of subpopulations, with many individual identity self-descriptors that can be hard to define. Transsexual people are generally transgender people who seek or who have undergone surgical sex reassignment. The Centers for Disease Control and Prevention currently classifies transgender people as a “Special Population” within the Men who have Sex with Men category, without regard to their gender vector. As of this date, the CDC has not yet conducted separate surveillance assessing the prevalence or incidence of HIV among transgender persons. However, there is sufficient data from studies conducted by other public health organizations suggesting that transgender people are at high risk for HIV infection. Literature Review HIV prevalence among transgender women has been found to be extraordinarily high, ranging from 14% in San Juan, PR (Rodríquez-Madera, & Toro-Alfonso, 2000); 19% in Philadelphia, PA (Kenagy, 2002); 21% in Chicago, IL (Kenagy & Bostwick, 2001); 22% in Los Angeles, CA (Simon, Reback, & Bemis, 2000); 22% in New York, NY (McGowan, 1999); 32% in Washington, DC (Xavier, Bobbin, Singer & Budd, in press, 2005) and 35% in San Francisco, CA (Clements-Nolle, Marx, Guzman, & Katz, 2001). Transgender women sex workers are at particularly high risk, since they are often financially induced to engage in barrier-free sex (Boles & Elifson, 1994; McGowan, 1999; Nemoto, Operario, Keatley, Han, & Soma, 2004). A 1993 study of transgender women sex workers in Atlanta, GA found HIV prevalence to be 68% (Elifson, Boles, Posey, Sweat, Darrow & Elsea, 1993). High rates of substance abuse have been found by all of the studies cited above, including injection drug use involving needle sharing among transgender women and transgender men (Clements, Katz, & Marx, 1999). Other overlooked means of viral transmission are sharing of needles for the injection of hormones and the injection of silicone or other heavy liquids by transgender women or illicit providers to alter their body shapes. Among transgender women, injection silicone use has been found to range from 25% to 33% (Xavier et al, 2005; McGowan, 1999; Kenagy & Bostwick, 2001; Kenagy, 2002; and Reback, Simon, Bemis, & Gatson, 2001). Although significantly under-examined, HIV 6

prevalence among FTMs was found to be 3% in Washington, DC (Xavier et al, 2005) and 2% in San Francisco, CA (Clements-Nolle et al, 2001). In addition to quantitative research, a number of qualitative studies have examined the health care and social service needs of transgender people, in addition to their HIV, other STD and substance abuse risks (Boles & Elifson, 1994; Bockting, Robinson, & Rosser, 1998; Kammerer, Mason, Connors, and Durkee, 1999; Clements, Wilkinson, Kitano, Marx, 1999; JSI Research and Training Institute and GLBT Health Access Project, 2000; and Nemoto, Operario, Keatley, & Villegas, 2004). Taken together, these quantitative and qualitative studies suggest that due to pervasive stigmatization, transgender people are extremely socially marginalized and deal with discrimination, violence, and multiple barriers to access to health care and social services. In addition, they are underserved not only with regards to HIV prevention and treatment services, but also with access to regular medical care and to transgender- related health care. The Virginia Transgender Health Initiative Study The Virginia Transgender Health Initiative Study (THIS) is a multi-phase, multi-year project implemented by the Survey and Evaluation Research Laboratory, under the direction of the VHCPC and the Virginia Department of Health. Using both qualitative and quantitative research methods, THIS seeks to improve health care access and identify possible means to reduce risk behaviors in its target population. The principal components of THIS include provider education; a qualitative study phase (focus groups); a quantitative study phase (survey instrument); the development of a resource manual for use by transgender people and their providers; and ongoing capacity building for public health organizations and their staffs. To assist SERL and VDH in the implementation of THIS, the Transgender Taskforce (TTF) was formed to enlist community involvement in its process. The TTF began meeting in the fall of 2003 and became instrumental in a community mobilization process, informing the transgender communities of Virginia about the purposes of THIS and the opportunities to participate in the study. A newsletter was produced for circulation among providers and transgender residents of Virginia, to illustrate the work of THIS and the TTF. The first phase of THIS reported herein examines the qualitative data collected from participants in the focus groups and builds on a presentation made at the Annual Meeting of the American Psychological Association in 2004 (Hendricks M, Bradford J, Xavier J, 2004) . 7

Study Design and Methodology The principal research questions were: (1) what are the risk factors driving HIV infection, and (2) what are the social determinants (race, class, education, employment, etc.) of health status among transgender people in Virginia? Secondary questions included how transgender people currently access routine medical, transgender-related, HIV-related and mental health services in Virginia: what experiences have they had with their providers, what barriers to access have they encountered, and what are their service needs. This first qualitative stage employed a rigorous topic-based approach, using focus groups to explore not only the psychological and behavioral contributors to increased risk, but also the impact of barriers routinely encountered by transgender individuals in attempting to access healthcare services. An exhaustive search of the available literature was conducted to examine both the methodologies employed by other qualitative studies and their findings with regard to the research questions. From this analysis, a four level conceptual model evolved to address the principal research questions. Social stigma was hypothesized to be a root cause, producing societal factors such as discrimination; low self-esteem; health care provider ignorance of transgender health; and the prioritization of access to transgender- related medical services by transgender people. These societal factors produce mediating factors such as poverty, sex work, substance abuse, gender identity validation through sex, and provider hostility/insensitivity. The final products of these mediators are direct HIV risk factors including unprotected sex, lack of negotiation for safer sex, low perception of risk, IDU and viral transmission risks, lack of insurance and barriers to access to care. From this conceptual model, nine question areas were developed into the focus group protocol, including: • Access to regular medical services • Access to transgender care services • Employment discrimination • Housing discrimination • Violence • Substance abuse & self-esteem • HIV knowledge & perception of risk • HIV testing • Access to HIV/AIDS treatment services Eleven drafts of the focus group questions were developed and revised, including input from an experienced group of transgender health advocates and researchers. The final focus group protocol (see 8

Appendix Two) was submitted to the VCU Institutional Review Board in December, 2003. A combined pilot testing and focus group facilitator training session was conducted on January 14, 2004. Transgender women and men of different ethnicities were trained as focus group facilitators, and they were assisted by SERL staff members who acted as co-facilitators. The co-facilitators were responsible for focus group session logistics, including tape recording and note taking. The focus group protocol included a verbal reading of the informed consent by each focus group facilitator, assuring that participation was completely voluntary. All participants were informed that no identifying information would be used in reporting the data. A financial incentive of $10 was paid to each participant, and lunch was served before each focus group session. Eligibility for participation in this qualitative study was restricted to transgender self- identification, Virginia residency, and age 18 or older. Study recruitment was conducted by regional coordinators who worked with the Transgender Task Force to promote the survey and alert potential participants to the locations, dates and times of the focus groups. The focus groups were conducted from late March to late April, 2004. In order to assure diverse demographic and geographic participation, 10 focus groups were originally planned. However, two groups were cancelled due to lack of participation, and one group drew only one participant. The qualitative phase was completed by the end of April 2004, with a total of 7 focus groups and one solo interview, for a total of 48 participants. The transcripts were then encoded for analysis using a special software tool for qualitative data, NVIVO Revision 2.0.163 (QSR, Incorporated). The results from the demographic questionnaire were entered into SPSS Version 12 for Windows. Study Results Study Participants The seven focus groups conducted included three for Male-to-Females (one white, one Latina and one mostly African-American); three for Female-to-Males (all mixed ethnicity); and one rural group of mixed gender vector and ethnicity. There also was one solo interview with a white MTF. The observed demography of all participants (n=48) is shown in Table 1. The demographic figures for Table 2 represent those participants who responded to the questions of the Demographic Questionnaire (n=27). Only valid percentages are shown. 9

Table 1: Observed Demographics of Participants (n=48) Frequency Valid Percent Race African-American 25 52% White 18 38% Hispanic or Latino/a 4 8% Other 1 2% Assigned Sex at Birth Male 30 62% Female 14 30% Intersex – assigned male 2 4% Intersex – assigned female 1 2% Missing 1 2% Table 2: Responses to the Demographic Questionnaire (n=27) Frequency Valid Percent Age 19-29 14 54% 30-39 6 23% 40+ 6 23% Present Gender Identity Transgender 16 59% Woman 5 18% Man 5 18% Other 1 3% Sexual Orientation Queer 9 33% Gay 8 30% Heterosexual 5 18% Bisexual 3 11% Questioning/Asexual 2 7% Education High School Degree or GED 5 18% Some college (no degree) 6 22% College graduate 8 30% Some graduate school 1 4% Graduate/Professional Deg. 5 18% Technical school 2 7% Income Less than $10,000 5 19% $10,000 to $16,999 6 23% $17,000 to $24,999 4 15% $25,000 to $35,999 3 11% $36,000 and above 7 27% Employment Full-time 18 69% Part-time 4 15% Unemployed 4 15% 10

Of those responding to the Demographic Questionnaire, 90% spoke English or were bilingual and two spoke only Spanish. Nearly 90% were U.S. Citizens and only four had immigrated to the U.S. While living in Virginia, forty-eight percent had lived in an urban area, 22% in a suburban area, 18% equally in urban and rural areas, and 11% in a rural area. Forty-one percent were in a monogamous relationship, 22% in non-monogamous relationships, 26% were looking to be in a relationship, and 7% were not looking for a relationship. Access to Regular Medical Services Although this section asked about regular medical care, the participants mostly discussed their access to transgender care services, reflecting its importance to them. Lack of health insurance was a commonly reported barrier to access to health care by many participants, especially transgender women of color. It was often linked to lack of employment, which was often a product of discrimination. “In order for you to get insurance, you have to get a job first, and for a transgender it's really hard for you to just walk in to apply for a job and the person that’s interviewing you actually wants to know if you’re going to get along with the people that already work in the job, instead of saying maybe she’s qualified for the position.” “You have so many girls that cannot receive any type of insurance … that work the streets. … They can’t receive insurance because they don’t have jobs … they’re afraid to try and get jobs because they want to live as women… so it causes them to go without a lot of things [healthcare].” Lacking insurance, some participants did not have regular doctors. “I haven’t seen a doctor since I moved here eight months ago, and I’ve needed care for stuff that could’ve been taken really easily with a primary care, but I didn’t have (a doctor), so I ended up in the ER a bunch of times, and paying out of pocket for some of that, paying out of pocket for hormones, but mostly it’s the not having been checked out in a really, really long time that’s scaring me.” Generally, white participants fared better than participants of color with regard to having health insurance that covered their health care. However, even those who had insurance experienced difficulties when it failed to cover their transgender care services. “Everything beyond my prescriptions is not covered by insurance, and I fight with my insurance company over the rate at which they compensate me for seeing my endocrinologist because he is outside their particular system… they do not have a referred endocrinologist for transgender issues.” “I’ve pretty much given up on getting insurance companies to cover like hormones or anything.” Due to insurance problems, some participants could not find doctors to treat them with hormones. 11

“Because of the conflicts in insurance, I called (many doctors’) offices… and said do you have trans patients? Can you tell me a little bit about how you work with trans, and they were like either hostile or clueless, and so I just stopped.” One participant noted that everything changes with HIV infection. “My opinion is a lot of the girls, they don’t have the means to find employment to receive (health insurance) benefits. Unless down the road they find out that they're positive, and they are able to receive a check at that point.” Some participants had identity documentation difficulties that prevented them from getting the care they needed. “If your job thinks you’re a man, but you need gynecological care, and you’re signed up under your insurance as male, so you don’t get your gynecological care covered.” “Having your name legally changed makes a difference. Because a lot of times, insurance, they don’t know you personally, but just having a female name, they’re going to associate that with being female.quot; One participant had the same difficulties even after a name change. “Although I changed my name, I was still with the same insurance company, so they were still dealing with (my male name) versus (my female name). So having the name change really did not matter, they were still giving me what they would have offered (me) as being a male.” For some participants, obtaining insurance became an issue since it involved disclosure of their transgender status, which put them at risk for job loss. “Do you come out at work, (and) come out on your insurance company, do you call them up and say there’s been a mistake, or do you just pay for your gyn stuff out of pocket and hope nothing’s ever wrong. I know that was always a big issue. Last year I changed jobs twice, and I had to make that decision twice. And both times I chose what I knew work was looking at me as.” One FTM participant expressed fears of losing his health insurance if his transgender status became known to his insurer through his doctors. “If they prescribe me hormones, they don’t have to put me down as (having Gender Identity Disorder), or as any way that would disclose me and I would get kicked off the plan. So all of my gyn stuff is covered, but all of my trans stuff isn’t, including hormones (and) blood tests.” The participants' care experiences with their doctors were mixed. Fear of a hostile or insensitive reaction led some participants to not disclose their transgender status to doctors they did not know well. Those who were out to their doctors were comfortable with them, and they tended to stay with the same doctor who knew their transgender status. However, some participants mentioned hostility and lack of respect for them as transgender people as a barrier to access to care. Their experiences reflected their providers’ ignorance of transgender people and sometimes frank discrimination. 12

“The doctors don’t understand the transgender community… They want to be seen as women, and they want to be able to come to [doctor’s offices] and be accepted, and lots of times they aren’t because of their physical appearance.” “(The) last time I went to the doctor, this woman closes the door and then starts just like chewing me out because of my appearance, (she) just totally reamed me, and I (said) I just wanted you to look at my back so that I could work. And she didn’t even address that, she was just like oh, you’re fine… I hate going to the doctor.” Some participants had such bad experiences due to the insensitivity of doctors; they avoided being seen for treatment. “Some girls do have insurance and some don’t, but when they go to care, the physicians feel like they have to call them by their legal name. And if they’re dressed as Betty Jo, but their legal name is John Doe, they’re not going to get up, they’re going to wait for things to die down, and then they’re going to walk out. And a lot of them are lost to care because of that.” Many female-to-male participants had some particularly difficult experiences when trying to access gynecological care. “So I’m sitting there in my boxers, and the woman (doctor) comes in and says to me, ‘Are you in the middle of a sex change?’ like just flat out… I said yeah... and then she said, ‘Well, I don’t know how this works, do women have penises sewn on?’ And that was the first thing she said to me, and I was sitting there with no clothes on… Oh my God, you know it was really horrible. I was stuck here at her mercy, and I need this care, but I’ve got this crazy woman in the way.” “I don’t know many (who go) to a gynecologist, but that’s already a pretty miserable experience in my mind. When I’m there, I’m not necessarily in my best state of mind to be asking whatever questions I might have or reaching out for help or assistance. I don’t necessarily want to talk about how I have sex, because this person might be thinking it's weird that I have the genitals that I have. I don’t want to be paying any more attention to it than I already am, by having them do their thing in there.quot; Some doctors even incorrectly identified the participants’ transgender status as the cause of their medical problems. “Once they find out that you’re transgender, any other illnesses that you may have, they don’t tend to address them as strongly as they might if you weren’t transgender because they (believe) that that is your main problem, and that’s something’s wrong psychologically with you.” “Well they didn’t know that I was F to M, even though the forms I filled out said I am legally female… They had me take my shirt off, which was not comfortable for me at all, and when they realized at that point that I am female, they assumed that that was the cause of any problems that I could have had, when it was an entirely unrelated situation. “ Access to Transgender Care Services Since transgender-related medical care (hormone therapy and surgery) is not yet viewed as medically necessary by most doctors and nearly all insurance companies, most participants experienced 13

barriers to accessing it. Yet most of the participants felt it was a high priority need for them. One participant summed up the importance of this need. “My experience has been that people not only buy hormones everywhere they can possibly get them, but they are willing to do almost anything to get them. They’re willing to sell themselves often, and sell their life to feel better about themselves.” Lack of insurance was again mentioned by some as a barrier to getting transgender-related care. While some insured participants were fortunate to get their hormone therapy covered by their health insurance, many mentioned the failure of their plans to cover it and also cosmetic procedures viewed as elective by their insurers. “Some things are covered, some things aren’t.” “Even the girls that are lucky enough to obtain insurance through employment benefits, a lot of times they’re not able to use that insurance where transgenderism is concerned, because we know that a lot of the processes we go through to transition entail cosmetic surgery, and most insurances don’t cover that.” The lack of insurance, having insurance that did not cover transgender-related care, and the expense of paying for it out of pocket were common barriers to access. “I think the biggest problem most people have is paying for it when it isn’t covered. It’s generally been not too difficult for me since I’ve had good paying jobs, (but) there’s months here and there where all your bills get a little bit higher and sometimes it’s difficult.quot; “I do know of people out there who can’t get the care because they just don’t have the money, period.” The lack of willing local providers frustrated many participants. “We need to pull together to find these doctors that are caring, that are willing on sliding scales.” “I hear you. It’s just no resources. There’s nobody in town.” Some participants went out of state to get their hormones. “We used to go to a place in D.C. and get shots. Drive all the way to D.C. and get shots.” Most participants knew about self-medication with transgender hormones. They either did it themselves or knew of friends who got their hormones on the streets, from friends or through the internet. When asked if they knew anyone who has received hormones from someone other than a doctor or licensed healthcare provider, one participant simply answered “everyone”. “I’m out on the streets. And on the streets you pay for your hormones and you do street treatment.” 14

“I’ve known people (that) it wasn’t so much a money issue as they were simply afraid to talk to a doctor, so they simply read on the internet what the drugs, kind of back door, and self- medicated, you know, just choose a dosage and self-medicate.” Some MTF participants rationalized self medication due to their lack of insurance coverage and the 2 constraints of the Standards of Care of the Harry Benjamin International Gender Dysphoria Association (HBIGDA). The Benjamin Standards largely govern access to transgender-related medical care by middle class transgender people and are often viewed negatively as a gatekeeper system by many of them. “The insurance will not cover it, and there’s a lot of requirements before you can start the process with a legal doctor. So you have to go with the second option, which is getting illegal hormones from other people or from other people who have already had the treatment. So as a transgender, I have (done) that, and I wouldn’t like for the people who are starting to have to go through that, that’s why we’re asking to have some more support from the state on this issue.” “(Since) the insurances will not cover that treatment, it becomes very expensive, so transgender people will always have to look for second options, which will be cheaper and faster for them, and will not have to go through all that headache and trouble of getting hormones (through a doctor).” Some FTM participants mentioned sharing their testosterone in the context of friendship. Although testosterone is administered primarily by injection, needle sharing by FTM participants was not specifically mentioned, although it may have occurred. “If a friend of mine who ran out of insurance is like on T (testosterone), needs the T, asks me for it, okay fine. You know, okay, I can do that for you.” “I haven’t done it myself, but I do know people who have done it, and I mean, I don’t know what you’d call street T (testosterone), but you know, if I have a prescription and my friends (ask) ‘can I just have a shot’, you know, that kind of stuff happens a lot.” However, many participants were aware of the dangers of self-medication. “One friend of mine was taking an enormous dosage, and when I found out what she was taking, I told her you really need to see a doctor, and she credits me with saving her life, because … her blood pressure had gone way up.” “If (there) was a way for… hormone or silicone treatments to be offered through a doctor, through a physician, at affordable rates, that would eliminate a lot of transmitted diseases or anything like that, because that’s very unsafe and unclean.” Injection silicone use was popular among most African-American and Latina transgender women participants, as an adjunct to or replacement for hormone use. Unencapsulated silicone injections were 2 The Sixth Version of the Harry Benjamin International Gender Dysphoria Association's Standards of Care for Gender Identity Disorders is available online at http://www.hbigda.org/soc.htm 15

3 banned by the U.S. Food and Drug Administration in the 1960s as a serious health risk. The most common reason given by participants for their injection silicone use was the speed of physical transformation, which seemed to be linked with immediate improvement of self-esteem. “(I) personally have gotten silicone injections, and the reason that I got them is because the hormone process took too long. And I wanted what I wanted then, and I wanted my results immediately.” “The process of taking hormones can be so long depending on your body taking on that medication, and some girls, they want instant breasts, they want instant hips, they want instant facial work, so they’re not going to take the time that the hormones can take. They want that instant gratification, so they go with the silicone.” One participant mentioned that some do silicone injections exclusively. “I would say within our city… we have many girls who only do silicone injections. We’ve had girls who have come here from different cities to get the silicone, and I think the purpose of a lot of the girls receiving it is because its instant, it's giving them the gratification that they’re looking for instantly, so they don’t want to sit back and go through all that it would take to go through legal aspects. Because they want it now. It's about getting it now, it's about being able to show it off now, so that’s what the girls want that would cause them to consider taking illegal hormones or doing illegal silicone injections.” Another participant mentioned peer pressure. “A lot of them are young, and they’re being peer pressured… more of the younger children are doing it because they’re telling them ‘oh you look so flawless, and if you get this done, you’re really going to look (even better).” One participant mentioned the lack of insurance as a factor. “And we go back again to the insurance issue. The way you can go legal is implants. But when you cannot afford implants, what is your second option? Silicone injections. So, that’s why most of the girls choose to do that. Again, because we don’t have the support of any state or health insurance that would help you afford the more healthy, legal methods” Silicone use also improved the desirability of transgender women who do sex work in a competitive environment, but it may result in their inability to obtain other employment. “Like she was saying about a girl with a flat chest, and the girls who are more round, it does become competitive. And that’s another reason why a lot of girls don’t have jobs… They get all this stuff for the men on the street who mean nothing to them and think nothing of them, and then… they look too abnormal to work in the daytime. Some of it is good at night, but then you can get outrageous with it, and if you look a mess in the daytime, don’t nobody want to hire you because you’re such a spectacle.” “A lot of the girls are involved in street walking and prostitution, (and) it's become very competitive on the streets. The hormones and silicone are just a way of improving yourself and 3 Gender Education & Advocacy (2003) Silicone Use: Illicit, Disfiguring, Dangerous. Medical Advisory Bulletin, August 22, 2003. Available online at : http://www.gender.org/advisories/silicone.html 16

marketing yourself toward that industry, because the girls that have had more work and visually look more feminine and rounded are the ones that the johns are approaching more. So they’re more marketable, and they look the part, and the men want them more.” Injection silicone use was not restricted to transgender women participants, according to one female-to-male participant, who spoke of its dangers. “I know a lot of transgender people, female to male, male to female, it is hard, and they’re left to (getting) it on the black market. So and so here has silicone, so I’m going to go here and get my face pumped or get my pecs pumped, and that oftentimes frightens me, because anything could happen. Just like you can catch a disease getting a tattoo in somebody’s basement, or piercing your ears, getting silicone from whomever on the street is just as dangerous, but it's something they feel that they need to do, that helps them to feel comfortable with who they are.” Although there was no direct mention of participants’ sharing needles for silicone injections, it may have occurred. Access to Mental Health Services The participants expressed both positive and ambivalent attitudes about mental health care. Those who had psychotherapists were generally happy with them, and they accepted the requirement for psychological evaluation prior to referral for hormone therapy. However, some had had negative experiences with their psychotherapists, who had treated them very poorly, due to inexperience and/or bias. “You can’t report the depression or the anxiety that you’re feeling, because if you do, no one is going to see you as far as seeing a transgender person, because they’re going to think you’re suicidal.” “Worse yet, we get treated with derision by professionals… this might not be something in their everyday experience, or something that they’ve done any reading on since graduate school, but (they) still end up treating transgender patients with a certain contempt that is really unacceptable.” Some psychotherapists still viewed transgenderism as a mental illness. “My own experience (with mental health care practitioners has) been completely negative. I would say over the years, I’m 55 now, I’ve probably spent most of my adult life in some kind of therapy or another. And I’d say in every instance except maybe one or maybe two, I was told that I was either very sick or something comparable to that. It was always a problem. It was never like this is something you obviously need to do. It was always the opposite, like this is something that you shouldn’t be doing and you’ve got to stop.” One transsexual participant was devastated when his psychotherapist failed to refer him for sex reassignment surgery. The therapist’s actions seemed to indicate a lack of experience and/or lack of competency in working with transsexual clients. 17

“It's like he didn’t do his homework, it's like he didn’t realize what he was agreeing to write (for) me, like he didn’t look it up in the dictionary. And when I got there, I was like okay, session’s over, where’s my letter? (He said) ‘um, yeah, about that, I found out what that means, and I don’t think I’m really ready to write you that letter. I feel that I can lose my licensing over that, and I’m sorry, you’re going to have to find a different therapist because I’m not your man.’ And then he proceeded to like break me down mentally and emotionally, and I just cried for like hours, and I was totally destroyed.” Those participants who had not seen a psychotherapist had negative attitudes towards mental health care, which seemed to originate from the stereotypical social stigma attached to seeking mental health care. There were also some who felt that being transgender was not a mental illness, and expressed resentment. “I just have issues with them treating who we are as a mental health issue…I’m not crazy. This is just who I am…I didn’t go to a mental health (provider) because I didn’t have a problem with my mind. I feel that us complying and going to mental health (providers) only contributes to what (the State of) Virginia says, (that) we’re crazy. I’m not crazy. I don’t feel like I need a (psychological exam) because I’m a man who wants to be a woman. I’m a man who wants to be a woman who wants to work every day.” An African-American participant noted a racial difference in mental health access. “I think the services, they’re being used, they’re just not being used in the transgender of color community… the white transgenders are using them to the fullest. We’re just not getting out there and using them.” Another participant explained the African-American cultural taboo of seeking mental health care. “I don’t think they even considered getting any kind of mental health because of the stigma of mental health… It's negative, any kind of therapy is looked down upon, I guess because it's learned behavior, that you have to be crazy to have any kind of mental health (care). And I believe that happens a lot in the African Americans, you know, from way back… I think it goes back to the African American family. In a lot of families, you don’t tell anything that happens in your household. So why would we go tell somebody and pay them? So mental health is not an option.” For many who sought psychotherapy, finding mental health providers who were compassionate, experienced and competent was very problematic for them. “I’ve heard absolute horror stories of people just trying to find a local therapist through the phone-book or whatever, and getting all sorts of horrible advice.” “If you live out in the country…there’s just nobody out there that’s available that understands the issue.” Some participants mentioned their support groups as an information resource where they could get a list of experienced psychotherapists, while others mentioned the benefit they received from their peer support groups. 18

“We talk in our support group on Mondays about letting the girls know if they’re not knowledgeable about what sorts of things are out there, ask someone. And it's okay if you can take the time to ask someone …how can I get these resources that are out here to get these hormones and go through the proper things I need to live as a woman.” Employment Discrimination Employment discrimination and difficulties in employment were common experiences among many participants. Four of the 27 participants answering the Demographic Questionnaire felt they had lost a job because of being transgender, with another three unsure, though they may have. “I know personally two people who were very quickly fired when they came out.” In addition to job loss, many participants experienced discrimination when they applied for jobs and did not get hired. In many cases, the discrimination was obvious. “I’ve applied for so many jobs, and unfortunately, they don’t look at my resume, they look at what they see in front of them… I feel that’s totally unfair, because if you’re qualified for the position that you’re applying for, they should look at your resume, they should not look at your appearance (or) your gender.” “I have a girlfriend (who worked) at Pizza Hut. And they have other gay people that work at Pizza Hut, but being that she’s transvestite, they (made) up a lot of excuses to get rid of her, and they finally got rid of her, and didn’t really give her a reasonable excuse why they’re getting rid of her. It’s just a lot of that goes on.” An inability to pass in one’s chosen gender was often linked to job discrimination. “I have heard of other transgender girls who have been discriminated and have not gotten the positions because of their physical appearances or because they later found out that they were transgenders.” “I have seen people experience (job discrimination) because of their physical appearance, and I think it becomes a little easier for girls that have a physical convincing appearance as a female, versus someone that does not have that physical convincing appeal as a female and causes a lot of problems… a lot of girls can never get through the door to live as women because physically they would never be convincing to the public eye.” One participant mentioned a difficult experience with job training. “When you go and try to get job training… they try to tell you first that transgender people are like very sexual, so when you go to apply for school or a job, you try to dress down, and try to look very conservative. But once it comes out that you’re a male, it's still a problem… It’s just a problem with you being transgender.” Many of the participants had difficult experiences on the job if they were known to be transgender or in the process of gender transitioning. Usually, their behaviors or their non-passing appearance would disclose their transgender status. Hostile work environments, with harassment and sometimes physical abuse by co-workers, were reported by several participants. 19

“It just becomes clear that I’m different, and they pick it up. It’s almost like you can feel it, just feel how they look at you, how they don’t include you in their talks and stuff, and you start becoming marginalized, and it makes it hard to do your job… It usually devolved into at least verbal abuse, but sometimes it would get physical, like people would throw things at me or whatever. If I wasn’t fired, I would usually start making plans to get another job, and then the cycle would start again.” Participants who worked in the blue collar trades seemed to face the most harassment. Getting transferred to a more difficult position and getting hazed into quitting a job was reported by some participants. “Sometimes what happens is you get moved to another job that’s a dirtier job sometimes because you are a female, and I guess sometimes they’re trying to see if they can break you, I believe, make you quit. And what happens sometimes is we don’t quit, and then they finally give up. “ Generally, those in white collar positions, with employment longevity and/or who were good at their jobs, were more fortunate in keeping their jobs when they came out as transgender. “I started off by telling my closest girlfriends and my assistant, and then my direct boss, all over individual lunches, then talking to human resources, then bringing out my therapist to talk about transgender issues in a presentation to the whole company, making myself available to talk to everyone, everyone made a point of coming in and talking to me… It worked out extremely well, but it was also based on a lot of communication, I put together a lending library so that people could come and read things, I gave them a lot of on-line resources.” “They’re with me all the way. They know my work because I’ve been there for 16 years and they also understand loyalty, which I wasn’t really sure would pay off. So I have had for myself just a very easy time of this.” The sex workers among the participants were mostly transgender women, but there were also a few FTMs. They had complex, often interrelated reasons for doing sex work. For some, regular employment was too hard to get because of discrimination, fears of discrimination, or fears of lack of acceptance in a routine job. “I think that’s why you have the large number of transgenders who walk the street corner or hustle or date… because they can’t find work doing legitimate stuff.“ Economic vulnerability was given as a reason for doing sex work by one participant, who also mentioned the threat of STD transmission. “Nobody wants to be out there, but if you want to eat, and you don’t have your hotel money, you’re out on the streets, you’ve got to go out there and get it. So if you’re sick, then ten more people are sick. (That’s) another reason to get the girls off the streets and into jobs and housing because they don’t have to be on the streets.” Another participant felt it was an easy, fast way to make money. 20

“With me, I don’t feel as though I was forced into working the streets. Of course it made my desire even greater knowing that money is there instantly. It’s not like waiting a week or maybe two weeks or whatever. It’s not because I felt like that was all I could do. But just the dollar bills, and being in your eyes, knowing that I could go out and get it. Just that quickly.” One participant linked sex work with being able to earn the money to transform her body. “Being a transgender is an expensive life, and most jobs that we can get is not going to do it. You’ve got to have some extra income, you’ve got to have some fast money. The regular job, you can’t pay your bills and change your body and be a woman.” Another participant spoke of having her gender affirmed, of being in control, getting sexual gratification and not having to deal with lack of acceptance in a job. “This is an easy way to have a man attracted to me… you’re out there, (with) other people like you, on your own particular terms… and it's also sexual gratification. It’s a little bit easier than going up to a 9 to 5 job, dealing with everyday ridicule…quot; Housing Discrimination Housing discrimination was not widespread among the participants, although it did happen to some. Victims of housing discrimination were mostly African-American and Latina transgender women, and some of them mentioned discrimination in public housing and shelters. “I think there’s much discrimination against transgender community (in) housing in this area in particular because there’s no housing options offered specifically to transgender people. I know… they have no shelters that will offer to accept transgenders in this state, they have no form of transitional housing to address transgender needs. If a transgender individual needs housing, they’re placed in a situation with heterosexuals who clearly won’t accept them, or will make it hard for them to live in that sort of dwelling, which eventually forces them out.” “A friend of mine right now is going through the situation now where (she’s) homeless (and) went to the men’s shelter. The men’s shelter said she couldn’t come there because she would be raped by the men. She couldn’t go to the women’s shelter because she wasn’t a woman. (So she) had to actually live in the park. ” Some participants mentioned the stigma associated with being transgender or transsexual (itself related to sex work stigma) as a barrier to obtaining housing. “Here in Richmond, we’re automatically labeled trouble or prostitutes, or we’re going to create a situation with the other tenants, so they won’t rent to us. Not knowing us as a person or what the situation might be. They don’t know our back history. It’s just that the label Richmond has with transgender people is drug addicts, prostitutes, and whores.” “When they find out you’re a transsexual (or) transgender, trying to live in certain buildings, they automatically think of a transsexual’s reputation to be a party girl or to be just not good for the neighborhood. So they will actually deny your application. “ One participant mentioned being denied housing after providing his legal identification. 21

“Before I moved in my place, I went to another place and I put on the application my name because it’s legally changed. (The rental agent) called me and told me I had the apartment. Then when I went (in), she went to print my identification card and she said ‘they made a mistake on your ID and they put male,’ and I said no, I am a male. And she changed the whole subject and (then she) told me I was approved, (and) I didn’t need a co-sign or anything. (Afterwards) she did that she called me back and she said… your credit isn’t good enough. And even when my mother was going to sign for me, she still just didn’t want to help me as a tenant.” Besides discrimination, other types of housing difficulties were reported. Many participants had landlords who did not discriminate against them, but reported their housing choices to be severely limited. Once they found housing, they tended to live there for many years, even if it was inadequate. Some participants lived together as roommates, and others lived with friends or family members. Some participants linked employment difficulties with a lack of housing opportunities. “(Working) at a minimum wage occupations… makes it harder to build the credit or be able to show some type of proof of their actual occupation or job. (So) it’s harder to be able to rent an apartment, (or) get a loan for a house…” “I have heard that many transgenders don’t apply to get a home because they don’t have employment and therefore they cannot apply.” Violence Violence was widely reported among the participants. Of the 27 participants who completed the Demographic Questionnaire, 15 reporting having been victims of violence or crime. The types of violent incidents most often reported were intimidation (9 participants); verbal or sexual harassment (9); sexual assault/rape (4); and assault without a weapon (4). As perceived by victims, the most commonly- reported motives of perpetrators were homophobia (10 participants); transphobia (7); material/ economic gain (5); and domestic violence (5). There were many personal experiences with violence, with participants who spoke about being shot, stabbed, run over by cars, beaten with fists and feet, etc. Many also had been robbed of possessions and money. Murder was commonly reported. “I have friends that have been gay-bashed or attacked because individuals later on found out their real sex. (It was) not that they were trying to hide it or anything. It was just that they were living (their) lives as females, from males to females… I have friends who have gotten killed because of being transgender.” “Yes, I do know people who have been killed, I know people who have been attacked just for the fact that they find out they’re actually a transsexual.” African-American transgender women sex workers seemed to experience the most violence. “We had two girls, both of them got shot, one got killed, we had another girl who was out working who got cut up. We had another girl maybe seven or eight years ago who was killed on a bridge. They’ve been shot. They’ve been beat up.“ 22

“I’ve had bad experiences when I worked on the streets. I’ve had guns pulled out on me. I’ve had a guy that punched me in my head before. I’ve been robbed before.” One white participant spoke about being sexually assaulted twice. “I’ve been raped a couple of times, (when) I was a prostitute and they found out…One beat me badly and raped me, (and the other) just raped me. And I have heard of transgenders getting killed if it’s been found out (that they were transgender).” Some participants talked about the issue of disclosing or not disclosing one’s transgender status to a sex work client before having sex with them. “I think what happens is sometimes transgenders have sex with people and they don’t tell them they’re transgenders. So when the person finds out, they just freak out.” “Safety is a huge factor (behind) disclosure or nondisclosure (to sex work clients)… I think even within trans communities, there’s a huge debate about disclosure, and kind of an assignment of moral judgment around it… If somebody takes you home, or if you bring someone home with yourself, and then you don’t disclose and there’s violence, that’s your fault. And that’s a judgment that law enforcement throws on you, that the trans community can throw on you, non-trans feminists… You kind of get it from all different sides.” One sex worker assumed that by working the transgender stroll, she was safer because her clients would know she was transgender. “When I first started going out, the area that I was going, I just kind of assumed the men out there knew… but I found out one night that some guys out there really don’t. And I had a gun drawn on me one night because the guy just simply didn’t know, and he felt like I had tricked him or something, and that was kind of scary for me. I guess I was kind of thinking that everybody knew.” One FTM participant spoke of the necessity to pass in order to avoid assault. “It makes you feel like you have to hide, that you actually have to keep it secret, or make yourself seem like you blend in with the straight community so that these things don’t happen… I’ve accepted who I am, and I’ve made myself this way… But if they look and they see, ‘oh you’ve got hair on your face and you’re supposed to be a woman,’ you’ll get assaulted for that.” Many participants also spoke of harassment and intimidation in their own neighborhoods. “My first couple of times coming out through the neighborhood and just dealing with the ridicule and the people throwing rocks, people throwing eggs and stuff… A lot of people will really, really push the issue and will really, really try and harm a person (who’s) transgender. A lot of times people will like wink, they feel like we’re scared and we’re not supposed to say anything back, we’re just supposed to take whatever they dish out to us…” A few participants talked about fighting back and defending themselves, since they had difficult relationships with the police. Many participants complained about secondary victimization by the police when they reported the violence. 23

“I know of many cases that have not been reported to the police because they feel that the police would not actually do anything to protect them. I have seen cases in which they have reported it and once the police arrived to the scene and finds out (they’re transsexual)…they start acting differently, and they don’t even want to deal with you.” “They fear that they (will also be) thrown in jail, (and) the person who attacked (them will be) released right away or after a short time, and then they are again at risk being a victim (because they reported it).” Some participants reported discrimination by the police, including being blamed for their own assaults. “They make fun of you. Instead of them helping the transgenders, they’re even making it worse (by) making it like it’s the transgender’s fault for getting beaten up…” “They (the police) consider (us) male to male, not male to female.” Secondary victimization also occurs in the court system. “I’ve been to the cases… and I’ve seen how they actually didn’t really punish the person like they was punished because the people on the jury or whoever might say well this was transgender, you lead this person to kill you because you fooled them. And that’s exactly what they tell you in the courts when you go for these charges, and it actually gives leniency to the person who done the crime. And it makes… other guys feel like okay, we can go kill this fag because they really don’t give out that much time for killing faggots. That’s actually the message that they send out in the courtrooms when they go to get sentenced.” Substance Abuse The participants reported high levels of substance abuse. Specific drugs mentioned by the participants included alcohol, marijuana, crack cocaine, cocaine, PCP, ecstasy, pharmaceuticals, inhalants, and heroin by injection and nasal ingestion. Tobacco use was also reported by some participants. There were many active users, with alcohol and marijuana most often mentioned by them. “I mean I definitely have a drug problem – I know it. I don’t know if it’s a problem, but I definitely have an active using lifestyle but with marijuana. It’s not an occasional thing at all.” The reasons given for using or abusing alcohol and drugs were often interrelated. Many participants mentioned the lack of societal and family acceptance, the stress it caused, and its impact on their self- esteem. Using drugs and alcohol is a means of dealing with all of these stressors. “I think the majority of transgender individuals that I’ve encountered that do a lot of drugs and alcohol because they’re not being accepted (by society). A lot of times (it’s) their family situations, and it’s (also) a lot of peer pressure. A lot of these things tend to cause them to drink or to take drugs just to feel good and have a moment to forget.” “I (used) drugs and alcohol to medicate my feelings, and feeling worthless, not being accepted by my family, the people on my job, society…” A few participants connected employment discrimination with drinking and drugging. 24

“I believe that the use of drugs and alcohol is mainly related to the job situation, because if you are discriminated against, if you have no hope, and if you have all this fear and anger inside, you try everything to drown it.“ Some participants talked about the depression they suffered when they first realized they were transgender and drinking and drugging to deal with that depression. “In the early stages of learning and coping with it, I know a lot of people who (did alcohol and drugs) in trying to cope with depression or that angst. I myself at one time wasn’t an alcoholic, but probably an abuser, and I know a lot of people who have been very depressed and easily got addicted to things to treat depression.” Other participants attributed substance abuse to internalized transphobia, manifested by a lack of self- esteem and self-acceptance. “It is a part of self-hatred, it is a part of low self-esteem… with anybody that’s transgender, (I think it has a lot to do with) self-acceptance.” “It’s a lack of loving themselves… People who use drugs or abuse their bodies all have the same thing in common. You can’t love yourself if you want to do that. “ Some mentioned drug and alcohol use as a substitute or replacement for psychotherapy. “Instead of going to a psychologist or psychiatrist to tell them their problems, they think that by using drugs or drinking alcohol, their problems will go away. (But) they don’t know that they’re making it worse by doing that. Because the state at the moment is not providing psychologists or psychiatrists for transsexuals to go to.” “Most of the times, unfortunately for transsexuals, it’s drugs and alcohol… they have access to it faster and easier than they would if they had to go to a psychologist, or if they had to go through a state or a mental health department.” Several participants mentioned a connection between sex work and drugs, and using as a means of coping with the pressures of sex work. “From the sex workers that I know, there’s a lot of marijuana and ecstasy use and abuse… Is it a coping mechanism with being a sex worker or being transgender? That’s where I don’t know (if) you can make that division necessarily. Clearly their lives aren’t all sweetness and light, and so it’s kind of an escape mechanism…” Some of the participants were no longer active users and had entered recovery. Among this group were those who were struggling to maintain their sobriety. They expressed how their twelve step groups really helped them. “Drinking has been a big struggle for me, and I think part of that has to do with coming to terms with gender stuff and all that… I’m in AA now and not drinking, and that’s definitely helped me a lot as far as like getting on dealing with the transitioning issue and stuff like that. Instead of just stewing around in it and being frustrated with it and drinking, now I’m actually clear-headed and moving on with it.” 25

Some participants also spoke about how self-acceptance, coming out and entering transition had helped them in their struggle to reach sobriety. Gender transition eased their depression and reduced their need to drink and drug. “I actually had huge drug problem, and I used to drink insanely. And as soon as I started to pass, I felt better about myself, and it just seemed like I didn’t need any of that any more.” “I had a big drinking problem that I couldn’t stop. I’ve been to rehab and stuff, and I couldn’t, and honestly, I tried and tried, and I couldn’t, and once I started coming out and dealing with trans, I just naturally drink less. I’m more interested in being sober. And I still drink a little bit, but I don’t feel I have a problem anymore. I mean I’m aware of it, but it’s like that became such a second issue… I didn’t go through rehab, I didn’t need anything, I just went through withdrawal on my own, (and) sobered up pretty much.” Self-Esteem The participants’ comments about substance abuse were often linked to their lack of self- esteem. The ultimate means of improving self-esteem was passing in their chosen genders, especially for most of the transgender women. “I think (passing) is really important for girls to (be) able to be in public. If you’re trying to be a woman, to be as convincing as possible because it builds your self-esteem, I truly believe that.” “When you don’t see yourself physically as you do mentally or psychologically, I believe that it brings your self-esteem down. Once that transformation has occurred, then I believe your self esteem goes up… because you are able to blend in with society, and be accepted or tolerated by society.” Passing was most important for those who had gender transitioned or were in the process of transitioning. “The goal of being a transgender is to be passable.” “I think the feeling of being free is gained there, especially (with) somebody who’s been waiting all their life (to be able to pass)… I think self-esteem really kicks in when I get that acceptance from other people, and I’m not looked down on as somebody who is odd or funny, you accept me just for who I am.” For many participants, passing equaled societal acceptance, a normal life and a means of avoiding effects of the social stigma, such as ridicule. “Nobody wants to be laughed at, and this is very serious, this is our life, and when you continue to be a joke or be ridiculed or whatever, it’s just ugly.” “To me, it’s a matter of dignity… and I don’t want to be having confrontations with people all the time, I just want to go about my life, so passing makes that a lot easier.” 26

Passing was also important for the self-esteem of the FTMs, yet some were ambivalent about being perceived as non-transgender men, possibly due to their experiences with sexism prior to their gender transitions. “Even though I do pass all the time, and that’s great, and I do like it, a lot of times I really hate it, because… I don’t identify as a male, and people make this assumption about me all the time because I have those secondary characteristics that are making me a happier person… But socially, I want to be recognized as trans, but it never happens. I find that happens a lot with FTMs who transition, people don’t spot it as easily, and I don’t like being invisible like that, and I don’t ever want to be just locked into the male culture.” Another FTM participant downplayed the importance of passing. “I feel like I’m mostly comfortable, (so) it’s funny to me when I go places to eat and people say sir, and inside I’m laughing, but it’s just like okay, they really see me like a man. Some people realize it and some people don’t… but I’m just like it’s fine, it doesn’t matter to me.” Since passing is subjective and creates a social hierarchy among transgender people (between those who pass and those who do not), it was a sensitive subject for many participants. One white transgender woman seemed to confuse beauty with passing. “I couldn’t give a damn about passing. If somebody comes up to me and says I’m the ugliest girl in town, I’ll say well at least you got it half right. Because I don’t really care what anybody thinks. I’ll do my best to look my best, but if I don’t actually fit in and have a nice symmetrical face like you, I am not going to worry about it.” Still other participants dismissed the importance of passing altogether. “(It’s) no use worrying if somebody knows you’re a man or a woman.” “I think you shouldn’t let your self-esteem down when someone calls you out.” Having sex was another means of improving self esteem to many participants. Besides sexual gratification, it also affirmed their gender identities when they had sex with non-transgender men and women. Most of the African-American transgender women felt this affirmation by having sex with non- transgender men. “It makes you feel more feminine and more womanly to have what you perceive as a masculine, domineering male figure approach you and accept you and go to bed with you. (If) he accepts (you), it boosts your morale, and it makes your persona feel gratified because you say I must be representing well. This big husky man chose me because I look like a woman.” “Yeah, it makes you feel real. It does. Because that’s what you’re transformed for, to get a man… when you meet a straight-acting masculine man to make you feel feminine like a woman. Regardless of what you all do under the covers.” Latina transgender and transsexual women also felt their genders affirmed by being in sexual relationships with non-transgender men. 27

“(When) heterosexual males are attracted to us… that will raise our self-esteem. (It) will also make us feel more comfortable in society and more accepted in society because we will be seen as a straight couple. Nobody needs to know what’s in between your legs other than the person that you’re going to be sexually involved with.” “Once you become involved with a heterosexual male, which is in fact what transsexual women are trying to accomplish, you will become more acceptable, you will become more of what you actually feel inside, and what you mentally are, a woman.” The wide variety of sexual orientations self-reported by the participants were not defined beyond their usual meanings, and therefore should be viewed with discretion for their implications regarding sexual risk behaviors. A transgender woman without surgery might view having sex with men as being heterosexual, while an FTM might resist the labeling of his relationship with a woman as heterosexual. One transgender man married to a transgender woman rejected other people’s attempt at labeling their relationship. “I met an MTF, so everybody looks at me and says now you’re a gay guy, and I think if I’m a gay guy, what is she? She considers herself a woman. I consider myself a man. So I consider myself a straight man married to a woman. Well, the world has a different opinion, but I think my opinion should count.” For many transgender persons, gender transition is also a time of questioning and experimenting with their sexualities. Shifts in sexual orientation were not uncommon. “Having formerly been a heterosexual male and now being a transgender person who dates men, it’s just something where I was never a gay man, or I had never been in the position of being a man and being with another man.” “I know this (transsexual) woman, she’s post op, and she recently had sex with a genetic male. And for her, it was pretty nice but it didn’t ring every bell.” The Latina transsexual and transgender women spoke about their heterosexuality in strict terms, in that they would clearly be attracted to only non-transgender men as sex partners. Other Latina transgender women having sex with each other seemed to be unheard of. “You are trying to match your mental feelings to your physical appearance. You are trying to become a woman, (so) of course you want a male as your partner. Being with another transgender person, interacting with them in the level of relationship, I don’t think that is something that the transsexual community that I know of do, (or) have done.” “We are basically trying to accomplish what any woman would. We are trying to become a woman in every sense of the word, being that we will be attracted to heterosexual males. I personally am not attracted to homosexual males or transgender individuals… What most of the male to female transsexuals are trying to accomplish (is) a heterosexual relationship with a heterosexual male.” 28

Gender identity affirmation through sex was also expressed by some of the FTM participants. One spoke about the importance of being accepted and affirmed by having a relationship with a non- transgender woman. “If you are in a relationship, especially if that woman knows that you made that transition, and she just accepts you for the man you are, and loves you regardless, that would be the true acceptance. Especially if you can meet someone and you share your life together, and regardless if anyone else knows, the acceptance is really like the pinnacle of like okay, I am, I can totally be who I am and what I am, and whatever, and not worry about it, and somebody I can share that.” However, other FTMs who were in relationships with non-transgender men expressed the psychological stressors they experienced in their changing sexualities. “I can tell I have issues, of maybe just not being able to just be a guy for a while. (I’m) going from straight to being a gay guy. There’s nothing wrong with being a gay guy, its not like I have anything wrong with it, but all of a sudden I’m with a gay guy right away. I just want to be a guy and honestly not worry about my sexuality right now.” “I was in a relationship with a girl before I transitioned and I had to go through this whole sexuality crisis again... I started transitioning and of like oh my God, now I have to come out for the third time that I’m gay… But I still deal with this issue where I’m not out, I cannot come out to my parents again. I just can’t. Like twice was enough. Like once as a lesbian, once as trans, I can’t (say) by the way, I’m a gay man, because they’re just going to be like what’s next.” Disclosing their transgender status to male sex partners was also an issue for some gay FTMs. “I date biological men and trans men, (and) I’ve had really good experiences but also some freaky times. You disclose, and they’re like, they think you must now have a totally (awesome penis)… I’ve had some people where it’s not really an issue at all, other people who are like score and they fetishize that and that’s weird, or people who totally freak out.” “With bio guys, I know (FTMs) who… go home with somebody, having thought they fully disclosed, and having the guy freak out when they took their clothes off because the guy just did not get it. They freaked out or left or went on with (it), but had that little moment, and those are the things that I’m afraid of. So I think I’d prefer to have sex with somebody who is trans than somebody who is not trans.” HIV Knowledge & Perception of Risk HIV knowledge levels were high among the participants, and most knew the means of HIV transmission and common risk factors associated with it. Substance abuse was often mentioned as a risk factor, especially among transgender women. “Substance abuse will always put a person in danger, because it always happens, if I’m under the influence, then the rules change. My behavior changes, my thinking changes. They always go hand in hand. You just can’t get away from substance abuse and HIV.” “They feel discriminated and become stressed (and) depressed. When you become depressed, you go after alcohol, drugs. When you are under the influence of drugs and alcohol, you don’t 29

care about protection, you don’t care about sharing needles, you don’t care about any of the facts that you already know of. “ Financial need leading to unprotected sex in prostitution was mentioned by several participants. “(If your) financial need is such that if there’s a client (who) just insists on going raw and for a certain price, when you’re stuck in that particular stratum of society, then eventually you end up coming up with your own price.” “(It’s) the money situation. A lot of them will pay you more to let them do it raw.” FTM participants spoke about having unprotected sex with non-transgender men. “Especially a lot of random anonymous (sex) like blow jobs and stuff like that… There are (FTMs that) I know who have sex with men without protection…” Despite the high level of HIV knowledge, perceptions of risk varied. Most transgender women thought their risk was equal to that of gay men, although some felt gay men were more at risk than they were. FTMs felt their risk was either equal to or less than that of gay men and transgender women. Only a few transgender women felt they were at higher risk than gay men. One participant noted that transgender women were are higher risk due to their sexual role. “A lot of it is just mechanics. I would suggest that male to female transgenders are more than likely to be bottoms, and as such, they are usually the ones that are engaged in a riskier sexual behavior… It’s just something where you’re the one who’s at extreme risk if you are in that sexual role.” Another participant noted that transgender women taking estrogen are less inclined to put condoms on themselves because of its effects. “A lot of MTFs don’t not want to penetrate, and they don’t ejaculate if they’re on estrogen and all that, it (affects) their prostate or whatever. “ Perception of HIV risk seemed to be the highest among African-American transgender women. “I’ve always had knowledge and education of how to and where to and with whom. I know that it was taught to me that you should always think that everyone is infected. Therefore, you should always wear protection, whether you’re giving or receiving.” However, another African-American MTF participant noted a difference in condom use between oral and anal sex. “I think there are more people that are using condoms (with anal sex). I think a lot of girls still want to have oral sex without a condom… I don’t mind saying it: I have oral sex without condoms. But anal sex, I will not do that without condoms…” The use of condoms and other protective barriers varied across subgroups. African-American transgender women seemed to express the highest frequency of condom use. “All the transgender people that I know that are having sex with men use condoms.” 30

“I think transgenders use more protection having sex than straight and gay guys and everybody (else).” One noted that transgender women sex workers used condoms because of their continuing need to work in the sex industry. “I think a lot of the girls are using more condoms because if you’re more of a street girl, you don’t want to take the chance of not only catching HIV, (or) any other type of STD… If you’re a true street walker, that’s going to break your money bag if you’re not able to go out and do what you gotta do.” Another African-American participant noticed an age difference in condom use and risk perception. “I think maybe the older transgenders (use condoms), but the young ones, they haven’t really seen people suffer like we have… from AIDS. The people they see with AIDS are still walking around doing shows, laughing and joking, so they don’t take it as serious as we do. So I think they’re more unsafe than the older transsexuals. Cause we’ve actually seen children suffer and die…” The lowest level of condom use seemed to be among Latina transgender and transsexual women. “Unfortunately, in the Latino transsexual community, not most of them use (condoms). Once again, we go back to the way that we’re raised. If their men ask them not to wear a condom because it feels better, or because that’s the way it should be with a woman, then they don’t do it.” “In the Latino transsexual community, the way you are raised, you don’t believe in condoms. You don’t believe in protection…. (In) the countries that we come from, there is a belief that if you have a boyfriend, or if you have your man, you can have unprotected sex with him because he is your man. But you can have sex with other people if you’re wearing a condom. And that’s the other risk.” The reasons given by participants who did not use condoms included monogamy, substance abuse, denial of risk, fluid bonding, and cultural and societal factors. Being in a monogamous relationship was the most common reason, yet some transgender women continued to use condoms with their monogamous partner. Some FTMs refused to use barriers and condoms because they associated it with birth control, about which they apparently no longer worried because they were now men. “I know some (FTMs) who have had sex with biological men (and) don’t use condoms because they really don’t get their period any more, and so they’re not worried about that. It’s really risky…” Other FTMs spoke of their refusal to use dental dam barriers in the context of fluid bonding, a conscious strategy to reduce risk while having sex that’s considered risky. In fluid bonding, sex partners choose to expose each other to their bodily fluids, usually after getting checked for sexually transmitted diseases. 31

“I’m going to be up front about it… that I don’t get into the (dental) dam situation, I don’t want to use one and I don’t want to have one used, so we just don’t do that. Unless it turns into a relationship and things progress, and then you can start talking about being fluid bonded and make sure, that way later on in the relationship you trust your partner to honor that. But you know, but I’m going to be up front and say it’s safe sex or no sex, period.” “I can’t deal with the (dental) dam situation, so I won’t go there with somebody unless I’m fluid bonded with them. I find that my kind of range of sexual behavior is very, very limited when it comes to casual sex because I won’t do things that would require certain things that I’m not comfortable using. So it’s like these activities are okay, and from there the risk factor goes up and I can’t go there with you. But I will go there with a partner that I’m fluid bonded with.” Some participants spoke about the denial of risk. “Even though they are male to females, there’s still that male bravado there that okay, this can’t happen to me…” “So among the transsexual community, I believe that the HIV/STD rate is increasing because the Latino community is in fact still thinking that it cannot happen to them.” Other participants linked discrimination and low self esteem with substance abuse and specific HIV risk behaviors. “The whole fact of feeling discriminated against will stretch you out, will put you in a certain mood of low self esteem, and will cause you to sometimes abuse drugs or alcohol, which leads to unprotected sex, or sharing needles, or anything of that nature.” “What contributes to a higher rate in transsexuals or in gays is once again, discrimination… which leads to drugs (and) alcohol abuse, which leads to unprotected sex.” Needle sharing among IDU sex workers was mentioned by several transgender women participants. “Well, street drugs… mainly it’s just the use of needles, intravenous injections and sometimes people just aren’t real careful.” One participant mentioned needle sharing as the way she became HIV-infected. “When I was 17 and first came out here to Virginia, I shared needles with somebody who was HIV positive – that’s how I contracted it. (I didn’t clean needles) then, and I don’t know why I didn’t. I didn’t think.” The need for more prevention education was expressed by many participants, but especially by the Latina transgender women in northern Virginia. Some of them mentioned the need to break down the cultural barriers that prevent condom use. Other Latina participants reported some specific unmet needs such as HIV education workshops, condom distribution by outreach workers, HIV counseling and testing, and individual and group level interventions. 32

“They have to go to DC, because here in Virginia, we don’t have any groups, we don’t have any support groups, we don’t have any type of educational program of any sort that would help educate the transgender Latino community, or any community for that matter.” “If the state (could) give us something here in Virginia, where we will be able to have focus meetings, where they will be able to educate them about HIV, about different kinds of stuff, it would be easier… Having something here in the Virginia area, where we will be able to just walk or take the bus, instead of traveling to Washington or traveling to Maryland.” Participants also identified FTMs and transgender youth as groups with unmet needs for prevention education. Although only a few of the participants mentioned attending an HIV prevention workshop specifically for transgender people, many knew of the educational work of various AIDS service organizations in Virginia and DC. Some also learned about HIV prevention through their transgender support groups or friends, and several participants were or had been HIV educators and outreach workers. Some participants had seen HIV prevention posters and flyers in clubs, and still others mentioned their doctors or the internet as information resources. Condom distribution by outreach workers was reported, specifically in Richmond, Norfolk, Northern Virginia and Washington, DC. “I see now you have the sense that now the community outreach is trying to come out and touch base with the transgender girls. (They) even come out into the streets, into the clubs, to different functions, (to) provide condoms and stuff to protect themselves.” “We have a small army in this area, particularly the Fan, that I personally go out on a bicycle with a backpack full of condoms… Everybody here is very good about helping anybody with anything that prevents it.” However, some participants felt the state was not doing enough to prevent HIV transmission among transgender people, and they had some specific suggestions. “You have to create groups in which they can come and talk to people, HIV/STD educators who will answer your questions, who will teach you how to protect yourself and educate yourself and preventing these diseases… Virginia needs to do more than just advertisements and flyers at a club, churches, or wherever you can find them at. We need focus groups, we need funding to pay educators to bring the community together and teach them on a one-to-one basis.” “The whole needle exchange programs are essential, particularly for trans people who are maybe using injections that maybe have access to clean needles.” “I think the level of employment is really a high prevention factor. If you don’t have to work on the street for some reason, you’re not that at risk, and then you’re not one of those (at risk).” Some participants felt there was a need for more cultural competency training for providers of HIV prevention education and HIV treatment, which would do more to create a comfortable, welcoming atmosphere for them. 33

“I think it would be great if the state can create programs for transgender people where they will feel comfortable and not be discriminated against by the organization.” “A transsexual will feel more comfortable knowing that they’re accepted in whatever organization they go into. If they’re focusing on transsexuals, you will feel more comfortable, more open to answer or ask questions.” HIV Testing Barriers to getting tested reported by the participants included not knowing where to get tested, fear of hostile or insensitive HIV CTR (counseling, testing and referral) counselors, and fear of being HIV positive. Fears of testing positive, and perceptions of the negative consequences, were commonly expressed. “It’s always scary to go get tested. And it’s scarier that you know that society is going to treat you different if they were to know of your HIV status… I’m not so much afraid of the disease because we all have to die of something… If I was HIV positive, I would be more afraid of the way society or my peers would treat me than the disease itself. So of course that’s why it’s always fearful to me.” Fears of even more discrimination were a barrier for some participants. “It’s already hard for them because society is discriminating (against) you… that imagine if you were HIV positive, what more discrimination would come upon you by them knowing that you are that?” Some participants mentioned that due to their overt status as transgender people, going to get tested was more difficult for them than gay men. “Gay men are more successful at going into a clinic and being treated fairly, because (they are) not necessarily seen that they’re gay. But transgender people going into a clinic, we have qualms about going to the clinic as far as the way that we’re treated.” The most common barrier expressed by many participants was the fear of not being able to keep their test results private. “The fact that you go there and you’re not sure you’re going to receive an anonymous test, or you’re not sure that this is going to stay (between) you and your counselor, then you’re afraid to go get tested because you don’t want anyone else to know your status. That’s what makes them afraid.” “They’re scared somebody may find out, (and) they don’t want nobody to know their business. They think (if) they go to the doctor, everybody’s going to know, and they’re going to be ostracized and all that.” Fears of disclosure of getting tested were especially true for participants in rural areas, towns and small cities. Some felt they could not trust their local health departments. 34

“I think a lot of it is gossip too. When you go get tested and a lot of people talk about you after your results come back. Because it does leak out…. People in the health department gossip and that’s why a lot of people don’t want to get tested at the health department.” “When I found out I had it, it was out quick, and I didn’t tell nobody. How could anybody know that? Somebody in the health department had to have said something.” The Latina participants again mentioned the lack of specific resources for them. “Because we don’t have any organizations here in Virginia, we won’t be able to recommend transgenders to do it here… All of them have to travel to DC or Maryland in order for them to get tested. There are organizations (there) that will be able to take care of transgenders. Here, there’s only hospitals and clinics. If we recommend (that) somebody (go) there, they will just look at you like (you) are crazy or strange.” “The fact (is) that they don’t have any place where they can go and get tested and get treated (for) the disease or their HIV status. They don’t know that they are able to get on medication and continue living their lives as normal. I think that has a lot to do with them. Some participants had no issues with testing and got tested regularly. Incentives for getting tested included wanting to know their status and qualifying for sex reassignment surgeries. Due to their concerns about privacy, however, only a few participants recommended their local health departments as places to get tested. Most participants recommended either going to a private physician or to AIDS service organizations in Washington, DC, for the security of anonymous testing. “There’s a certain anonymity to the urban environment that you can just go and get yourself tested, and you’re not seeing the local doctor or asking anybody in a smaller community or a more personally oriented community.” “Basically, if you’re going out and getting tested for HIV all the time, you maybe are doing something that’s like putting you at risk for getting it. Otherwise you wouldn’t need to be getting tested all the time. So I always try to get it done anonymously. I do it (in DC) usually, just because they have the 20 minute ones and I just wait for it.” Some participants mentioned the importance of having a safe space for testing to lessen the accumulation of fears around testing. “If you are in an unsafe surrounding, you’re less likely to go to a doctor because you do not only fear the doctor and the other people around you talking about you. You also have the fear of being fired from your job, (and) you have the fear of having no privacy at all.” “(If) people are feeling more comfortable and safe, and (the same counselor) is going to see them and repeat it, (someone) who is very responsible, very discreet, and most of the girls give such good feedback about the clinic… I think they could mostly come here and be very comfortable.” One Latina participant recommended a specific program targeting her population that would include education on the need to get tested. 35

“I would try to create a program to make all those people who have never been tested to actually come and get tested because there (are) a lot of people who, because of their lack of knowledge on the HIV virus or the STDs, they don’t want to get tested. So we have to create programs in which you educate them, but not only educate them, you have to educate them on getting tested.” Improving Access to HIV/AIDS Treatment Services The participants had many suggestions about how the state and local organizations might improve HIV-related service delivery to transgender people. Some participants suggested new organizations and funding to improve services. “We need to focus on the transsexual group because there are enough funds, groups, (and) organizations helping heterosexuals…gay, lesbians, and bisexuals. But there (are) not enough organizations focusing or targeting the transsexual community in general. That’s what Virginia needs to provide – funds to help create organizations, groups that will make the transsexual community feel comfortable…” Many participants had issues with social service providers who treated them poorly. “I believe that social services probably needs to be educated about the population, (you need people who are) open and willing to deal with transgenders to make them feel more comfortable and give them all the opportunities that they’re entitled to without judgment.” “I think maybe case managers or social workers who are more caring, and who have (compassion). I’ve had clients who tell me that case workers and social workers have told them that they got what they deserved because of the lifestyle that they lived.” Some participants thought that more sensitivity and awareness training was needed for doctors, social workers and other staff to improve their service relationships with them. “I think… that social worker, that doctor, it’s not that they want to make you feel uncomfortable. They just don’t know how to make you feel comfortable… This needs to be included in diversity training…” “The HIV care workers, people who visit in people’s homes, just getting them used to dealing with transsexual people. So educating them on how to deal properly with somebody who is transsexual, making sure they use the right pronouns, that sort of thing.“ Many felt their medical providers needed more technical training about transgender people and transgender care service delivery. “The doctors, they need to be educated… (about) some of the transgender concerns, the care, the side effect of certain treatments…“ Some participants felt that their difficulties were not just with HIV-related medical services but all medical services. “Making going to the doctor not an issue…I know many more trans people who won’t go to the doctor because they’re trans than I know people who won’t seek out healthcare in general. You 36

have bad experiences, or you hear of people with bad experiences, or you don’t want to come out every single place you go to every single person… So people just don’t go to the doctor.” The solution for some was transgender staff or even a transgender-specific HIV clinic. “When we walk into a place… we feel alienated and feel shunned from the beginning, because typically they don’t understand what we’re all about. So they can’t service us wholly… Just having somebody there (who is) transgender to speak to us, on staff, that we could connect with and really open up to, I think would make it better for services.” “You might (even) have gay people on staff, but there’s a lot of gay people that still don’t understand what we do. So I think that’s a very good point. I think if they incorporate more transgender people when we’re coming into a place to be tested or whatever, and you see another girl there, it’s just ‘hey girl.’ ” “I think one of the things that would really help the trans community would be a very, very trans-specific clinic that was open for the trans community all the time.” One participant suggested a state intervention program that would address low self esteem and substance abuse. “It’s a shame that in the state of Virginia, we don’t have some sort of program or group or meeting of some sort that enables us to be able to work together as a group or as individuals who are trying to transgender… (to help) us with our self esteem or educating us or giving us some sort of advice within each other within our transgender community, so we can build up our self esteem. By the state doing that, I think it would help to reduce the amount of substance abuse, whether it be with drugs or alcohol.” Still other participants saw job training and vocational rehabilitation for transgender people to be a priority. “I believe there need to be more training programs that are available for our community because I think that because we have so many poorly educated transgender person out there, I think that we should offer more educational services for that population, as well as services to help them just to build a resume, because some people don’t even know how to structure a resume to be able to even go out and get a job… Someone should assist them in getting job placement.” One participant living in a rural area spoke about the need for a comprehensive program she accessed in Florida. “(They) had this HIV place where you go and they help you, and if you need help with your bills, or if you need help with your medicine, or anything like that, but they don’t have anything like that here… I think they should set up a program (like that) here, a place (that’s) a food bank, (where) you can get food once a month if you need it, counseling, condoms, classes… education about if you do have it, how to deal with it, if you have a partner and how not to give it to that partner.” Another participant saw the need to extend treatment services to the incarcerated. “The treatment would go into the jails and treat the trans and the people who are HIV positive in the cells, because they take you to certain parts of the jail, put you in a cell, and they don’t 37

come in. You get shorted on your treatment and your medication you should have... A lot of the girls have been down to Richmond City Jail and died because of the way they were treated with their diet… You have to have a full meal to take your medicine in the mornings, and I have never seen a jail have a full meal on any tray they ever gave a person, much less someone who is dying and trying to keep the medication in.” Those in the Roanoke focus group expressed a great need for services, but they also were somewhat pessimistic about getting them. “I think in the city of Roanoke alone, there should be more programs set up for the HIV community… because once your job finds out that you’re HIV positive, you lose your job a lot of times, then you lose your home because you don’t have the money to pay for it. So there should be programs, just like the welfare system, there should be something set up where these people can get the help and support financially not only physically and spiritually and mentally…” “I had a friend who had to go outside the state when they found out they were HIV positive… they had to learn to live with it, and they had to go to Los Angeles to get the support and the drive that they needed… There (should) be a program in the City of Roanoke where if you’re HIV positive, you can sit down with a person one on one and share with that person your fears, and your nightmares, and ask them what can I do to make my everyday life and my routine better. There’s nothing here in the City of Roanoke, there’s a lot of prejudice toward the HIV community here.” Many participants talked about their difficulties covering the costs of their HIV treatment. Some had exhausted their insurance benefits and others lost coverage. “With more funding, we would be able to provide… a better program which will extend more benefits, because the benefits are limited. I know of health insurances that will not cover your HIV treatment medicine. So you have to go through organizations that will help you with that. But in Virginia, there is not enough funds or enough money to cover those treatments.” “People who are HIV positive, if they check off HIV, you’re denied your health insurance. And that’s wrong. HIV is not really your death sentence – you can die from anything… Once your health insurance finds out that you’re HIV positive, that’s a door shut in your face… There (should) be some kind of program set up where HIV positive people and transgender people can get the insurance benefits just like a heterosexual person that may have cancer or diabetes can get, and not (at) high cost.” A Latina participant spoke of being classified as a gay male in order to be eligible for HIV/AIDS services. “There are no funds specifically for the transgender Latino community, so a lot of people would have to be put into another group, considered a gay male, or a feminine gay male, or some sort of, there is not something specific for the transgender Latino community.” 38

Summary of Key Findings Social stigma, discrimination and victimization are constants in the lives of the transgender people who participated in these focus groups. Access to transgender care services – principally hormone therapy – was a priority need for most of the participants, since it allowed many to pass in their chosen genders, avoiding discrimination and victimization associated with the social stigma. However, many participants experienced barriers to its access, including a lack of insurance, identity documentation issues and the lack of willing providers. The lack of insurance itself was often related to a lack of employment in connection with discrimination, or sex work as an alternative means of earning income. Those with insurance had either no or limited coverage of the costs of their transgender care. Due to these insurance problems and the lack of providers, self-medication of hormones and injection silicone use were frequently mentioned by participants, both of which involve their own health risks. Although not specifically mentioned by participants, sharing of needles to inject hormones and silicone also carries viral transmission risks of HIV and Hepatitis B and C. Some participants mentioned hostility, insensitivity, disrespect and even discrimination by medical providers as barriers to accessing regular medical care. Some participants had negative experiences with insensitive or hostile doctors, especially female-to-male participants when trying to access gynecological care. Fears of negative reactions caused some participants not to disclose their transgender status, and to avoid medical care when necessary. Fewer participants were out to their doctors, but they enjoyed comfortable relationships with them, staying with the same doctor over time. Lack of insurance, connected with a lack of employment, was also a barrier to access, as were identity documentation problems. The participants expressed mixed attitudes about mental health care. Those who had negative experiences with their psychotherapists were treated very poorly, due to either a lack of experience with transgender people, or a belief that transgenderism is a mental illness. Many who chose not to access mental health care had very negative attitudes towards it, due to traditional mental illness stigma and their feelings that being transgender was not a mental illness. Those seeking psychotherapy had great difficulties finding mental health providers who were compassionate, experienced and competent. Many participants had experienced employment discrimination and difficulties in employment, including job loss and failures to be hired. A non-passing physical appearance was often linked to job discrimination and difficulties with co-workers. Hostile work environments, with harassment and sometimes physical abuse by co-workers, were reported by many participants. Generally, those in white collar positions, with employment longevity and/or who were good at their jobs, were more fortunate in keeping their jobs when they came out as transgender. Housing discrimination was experienced by 39

fewer participants than employment discrimination, with common barriers of employment difficulties and the stigma associated with being transgender or transsexual. Some African-American and Latina transgender women mentioned discrimination in public housing and shelters. Many participants were survivors of violence, with murders of peers often reported. African- American transgender women sex workers experienced the most violence. Many participants also spoke of harassment and intimidation in their own neighborhoods. Some complained about secondary victimization by the police when they reported the violence, and others reported discrimination by the police, including being blamed for their own assaults. High levels of substance abuse were reported by participants, with alcohol and marijuana use most commonly mentioned. Many of the individual reasons given by participants for drinking and drugging could be summed up as the need to cope with the many interrelated life stressors of being a member of a socially marginalized, heavily stigmatized sexual minority. Other reasons included coping with depression and internalized transphobia. Several participants also mentioned using drugs as a means of coping with the pressures of sex work, and peer pressure. Some participants also spoke about how gender transition eased their depression and reduced their substance abuse. Passing in their chosen genders during or after gender transition was the most significant means of improving self-esteem for many participants, especially for most of the transgender women. Passing allowed them to avoid the social stigma, affording the societal acceptance previously missing in their lives, as well as the means to lead a normal life. Passing was also important for the self- esteem of the FTMs, yet some were ambivalent about being perceived as non-transgender men. Having sex was another means of improving self-esteem, since it also included affirmation of gender identities for many participants. Most of the African-American and Latina transgender women felt their gender identities were affirmed by having sex with non-transgender men. Gender identity affirmation through having sex with non-transgender women and men was also expressed by some but not all of the FTM participants. The sexual orientations reported by the participants should be viewed with secondary importance over their sexual behaviors, because labeling them might not be accurate nor imply sexual risks. Transgender people in gender transition also question and experiment with their sexualities, and changes in sexual orientation are commonplace. Despite high levels of HIV knowledge among participants, many still engaged in unprotected sex. Transgender women had unprotected sex with non-transgender men, and FTMs had unprotected sex with non-transgender men, non-transgender women and other FTMs. Other risk factors included substance abuse and unprotected sex in prostitution due to extreme financial need. Sex workers were mostly transgender women, but there were also some FTMs who did sex work. Reasons for sex work included lack of regular employment, economic vulnerability and a fast, easy means to earn income. 40

Perception of HIV risk greatly varied and was highest among African-American transgender women, who also had the highest frequency of condom use. The lowest level of condom use seemed to be among Latina transgender and transsexual women. Reasons given for not using condoms or other barriers included monogamy, denial, substance abuse, fluid bonding and cultural and societal factors. Needle sharing among IDU sex workers was mentioned by several transgender women participants. Barriers to getting tested for HIV included not knowing where to get tested, fear of hostile or insensitive HIV CTR counselors, fear of doctors and needles, and fear of testing positive and its consequences. The most common barrier expressed by many participants was the fear of being unable to keep their test results private, especially for participants in rural areas, with some participants unable to trust their local health departments. As a consequence, many participants recommended either going to a private physician for testing or to AIDS services organizations in Washington, DC, for the security of anonymous testing. Latina participants were particularly vocal in expressing many unmet prevention education needs for them, including HIV education workshops, condom distribution by outreach workers, HIV counseling and testing, and individual and group level interventions. Other groups with unmet needs for prevention education identified by participants were FTMs and transgender youth. Many participants thought additional cultural competency training for doctors, social workers, prevention education and HIV care providers was necessary. Many also felt that medical providers needed more training in transgender care service delivery. Some participants felt that their difficulties were not just with HIV- related medical services but all medical services, and some suggested hiring transgender staff, or even starting a transgender-specific clinic. Other participants viewed education and job training for transgender people to be a priority, to give sex workers an alternative means of earning income. Many participants also felt the need for financial assistance to cover the costs of their HIV treatment. Recommendations to VDH and the VHCPC This population faces a multiplicity of interrelated risks that must be dealt with holistically. Multi- level interventions are needed to improve the response of Virginia’s public health system, increasing the likelihood that transgender persons will receive appropriate healthcare that will lower these risks. However, the participants of these focus groups identified many broken relationships with medical, mental health and social service providers that must first be addressed before other steps can be taken. Demand for access to transgender care – principally hormonal therapy – was very high and offers potential as a risk reduction method. The General Theory of Risk Reduction in Transgender 41

4 Populations is based upon the simple premise that people who are happier in their bodies tend to take better care of them. Affording transgender people a medically safe means of transforming their bodies would improve their self-esteem and bodily comfort, producing bodies worth protecting. Possible results of the application of this theory would include a lower likelihood of engaging in self medication of hormones, injection silicone use and substance abuse, and a greater likelihood of practicing safer sex. Study results support the following recommendations for consideration by VDH and VHCPC. Successful implementation of some of these recommendations would require high levels of cooperation between state and local agencies. 1. Cultural competency training for medical, social service, shelter and transitional housing staffs. This training would be focused on raising sensitivity and awareness to the needs, issues and concerns of transgender people at risk, with an emphasis on creating safe spaces for them. 2. Medical service delivery training for medical providers in transgender care services. This training would inform doctors, nurse practitioners, physician assistants and nurses about transgender hormonal therapy: patient expectations, its risks, contraindications, adverse reactions, and drug interactions. It would also stress the importance of providing sensitive gynecological care to FTMs. 3. Training for mental health providers. This training would emphasize the need to treat the mental health needs of transgender people in a non-stigmatizing, non-judgmental way. 4. Local clinical transgender care programs operating on a harm reduction model. With transgender hormonal therapy as a magnet, transgender patients could be screened for HIV and other STDs. An organizational environment that attracts transgender persons through trans-specific health services may facilitate awareness and assessment of other chronic illnesses, while providing sensitive and appropriate wellness care. Hiring and training transgender staff members would facilitate a welcoming environment. 5. A vocational rehabilitation program for transgender sex workers. Many of the participants’ problems stemmed from a lack of employment opportunities. A pilot program with a state or local agency to give transgender sex workers an alternative to working the streets should be implemented. 6. Expansion of outreach and condom distribution to transgender subpopulations, especially Latinas, commercial sex workers, youth and FTMs. Ideally, transgender people from these subgroups should be hired and trained to provide culturally appropriate prevention education and condom distribution in their respective locales. Since many transgender people usually frequent their 4 The General Theory of Risk Reduction is attributable to Ben Singer (in Xavier et al, 2005). 42

support groups and providers, these new programs might differ from traditional street and venue-based outreach in their efforts to connect with these often hard-to-reach groups. 7. Developing transgender-specific HIV/AIDS prevention materials and implementation of transgender-specific prevention workshops. As with other populations, materials must be culturally-appropriate and sensitive to transgender populations if they are to be effective. Program evaluation is also required to assess the effectiveness of these new materials and workshops. 8. Educational programs for transgender people about transgender care. Given the popularity of injection silicone use by many participants, it is likely that they do not completely understand their risks and medical alternatives that might be available to them. 9. Improvement of HIV testing for transgender people. The concerns expressed by many participants over the lack of confidentiality when they are tested must be addressed, in order to provide HIV treatment and implement secondary prevention for those who test positive. 43

References Bockting WO, Robinson BE, Rosser BRS. (1998). Transgender HIV prevention: A qualitative needs assessment. AIDS Care, 10(4), 505-526. Boles J, Elifson K. (1994). The social organization of transvestite prostitution and AIDS. Social Science and Medicine, 39: 85-93. Clements K, Katz M, Marx R. (1999). The Transgender Community Health Project: Descriptive Results. San Francisco Department of Public Health. Available online at http://hivinsite.ucsf.edu/InSite.jsp?doc=2098.461e Clements K, Wilkinson W, Kitano K, Marx R. (1999). HIV Prevention and Health Service Needs of the Transgender Community in San Francisco. International Journal of Transgenderism, 3, 1&2. Available online at http://www.symposion.com/ijt/hiv_risk/clements.htm Clements-Nolle K, Marx R, Guzman R, Katz M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health, 91(6), 915-921. Elifson K, Boles J, Posey E, Sweat M, Darrow W, & Elsea, W. (1993). Male Transvestite Prostitutes and HIV Risk. American Journal of Public Health, 83(2) 260-262. Hendricks M, Bradford J, Xavier J. (2004) The Virginia Transgender Health Initiative: Assessing Needs (Symposium), the 2004 American Psychological Association Annual Convention, Honolulu, HI. JSI Research and Training Institute, Inc., and GLBT Health Access Project. (2000). Access to Health Care for Transgendered Persons in Greater Boston, July 2000. Available online at: http://www.glbthealth.org/documents/transaccessstudy.pdf Kammerer N, Mason T, Connors M, Durkee R. (1999). Transgender Health and Social Service Needs in the Context of HIV Risk. International Journal of Transgenderism 3 (1+2). Available online at: http://www.symposion.com/ijt/hiv_risk/kammerer.htm Kenagy G. (2002). HIV among transgender people. AIDS Care, 14 (1), 127-134. Kenagy G, Bostwick W. (2001). Health and social service needs of transgendered people in Chicago. Chicago: Jane Addams College of Social Work, University of Illinois at Chicago. McGowan CK. (1999). Transgender Needs Assessment. New York: The HIV Prevention Planning Unit of the New York City Department of Health. Nemoto T, Operario D, Keatley J, Han L, Soma T. (2004). HIV Risk Behaviors Among Male-to-Female Transgender Persons of Color in San Francisco. American Journal of Public Health, 94,(7), 1193-1199. Nemoto T, Operario D, Keatley J, Villegas D. (2004). Social context of HIV risk behaviors among Male- to-Female Transgender Persons of Colour. AIDS Care, 16(6), 724-735. 44

Reback C, Simon P, Bemis C, Gatson B. (2001). The Los Angeles Transgender Health Study: Community Report. Los Angeles: University of California at Los Angeles. Rodríquez-Madera S, Toro-Alfonso J. (2000, October). An exploratory study regarding social vulnerability, high risk sex conduct, and HIV/AIDS in Puerto Rico’s transgender community. Roundtable presentation at the 2000 United States Conference on AIDS, Atlanta, GA Simon P, Reback C, Bemis C. (2000). HIV prevalence and incidence among male-to-female transsexuals receiving HIV prevention services in Los Angeles County. Journal of Acquired Immune Deficiency Syndrome, 14(18), 2953-2955. Xavier J, Bobbin M, Singer B, Budd E. (2005). A Needs Assessment of Transgendered People of Color Living in Washington, DC. International Journal of Transgenderism, 8 (2/3), 31- 47. 45

Appendix I: Glossary of Transgender Terminology Crossdresser: Someone who wears the clothing of the other sex, formerly called a transvestite. It usually refers to a man who crossdresses, but there also are women who crossdress. Drag Queens/Drag Kings: performers who crossdress to perform the art of female and male illusion, often in highly competitive shows. Drag performers are usually gay men or lesbians, and while some consider themselves to be transgender, many do not. Female-to-Males, FTMs, F2Ms: transgender persons born into female bodies with non-female gender identities and/or gender expressions. Some FTMs identify themselves as transgender men, transsexual men or transmen, but many others resent being perceived as non-transgender men, whom they regard as sexist oppressors. Gender: a psychosocial construct used to classify a person as male, female, both or neither. Although gender and sex are commonly used interchangeably by most people, gender is very distinct from sex. Gender Dysphoria: intense, persistent feelings of anguish resulting from the inappropriateness of one’s birth sex, or from being forced to conform to rigid gender norms based upon one’s birth sex. Gender Identity: someone’s personal sense of being a man or a woman, or a boy or a girl, or for some transgender people, something entirely unique. Gender identity is commonly communicated to other people by means of one’s Gender Expression. Gender Identity Disorder: a controversial classification in the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. GID is used to treat transgender persons but it also stigmatizes them, since it regards their gender variance as a psychopathology. Gender Queer: a self-identification term embraced by many transgender youth, who totally reject the gender binary system and do not use the gender vector terms (FTM/MTF) to identify themselves. Gender Transition (or simply, Transition): the period when transsexual and transgender persons begin living in the gender congruent with their gender identities. Injection Silicone Use (ISU): receiving or self-administering unencapsulated injections of silicone or other heavy oils in the cheeks, breasts, chests, hips and buttocks to modify the body to resemble that of the other sex. Banned by the U.S. Food and Drug Administration in the 1960s, ISU involves immediate viral and bacterial transmission risks, and later serious systemic health risks, including disfigurement and even death from multiple complications. ISU is viewed as a fast, cheap alternative or adjunct to transgender hormonal therapy that preserves sexual virility in MTFs. While ISU is very popular among Latina and African-American transgender women, there are also reports of FTM ISU in the drag ball cultures along the eastern coast of the U.S., as well as ISU in HIV positive non-transgender men to conceal HIV wasting syndrome. Intersex: the preferred term for hermaphroditic, pseudo-hermaphroditic and other persons born with non-standard bodies, which may include ambiguous genitalia and/or chromosomal anomalies. Many intersex infants and children have their ambiguous genitalia surgically quot;normalizedquot; without their consent, which results in loss of sexual response in adulthood. Some intersex infants are also sexually reassigned without their consent, and like transgender persons, must deal with gender identity issues later in their lives. 46

Male-to-females, MTFs, M2Fs: transgender persons born into male bodies with female gender identities and/or gender expressions. MTFs may also identify themselves as transgender, transgender women, transsexual women or transwomen. Passing: a common goal of most transgender persons, passing is successfully altering one’s gender expression to resemble that of the opposite sex. Sex: the anatomy and biology that determines whether a person is male, female or intersex. Sex Reassignment: hormonal and surgical modification of the body to make it as much as possible like that of the other sex, in order to facilitate living in the social role congruent with one's gender identity. Sex Reassignment Surgery (SRS): the permanent surgical refashioning of genitalia in MTFs and FTMs, and the removal of the breasts in FTMs, to achieve congruency between somatic status and gender identity. Standards of Care: a set of guidelines formulated by the Harry Benjamin International Gender Dysphoria Association, now in its sixth version. The Benjamin Standards were originally intended to safeguard both transsexual persons and their service providers (endocrinologists, surgeons and psychotherapists) by imposing various requirements. However, the Benjamin Standards today are controversial, and many transsexual persons regard them as a gatekeeper system that restricts access to sex reassignment services. Sexual Orientation: an individual’s romantic and physical attraction to members of the same, opposite or either sex. An individual may be heterosexual, homosexual, lesbian, bisexual, or asexual. Transgender: an umbrella term used to describe gender variant people, who have identities, expressions or behaviors not traditionally associated with their physical sex or their birth sex. It is preferred by most transgender people over the clinical terms transvestite and transsexual, which do not accurately describe all transgender people and also have a clinical, stigmatizing connotation. Transgender is commonly mistaken to mean transsexual, and it is important to note that most transgender people do not wish to change their sexual anatomy. Transgender Care: also called Trans Health, it includes transgender-specific medical procedures, such as Transgender Hormonal Therapy and Sex Reassignment Surgeries, various cosmetic procedures, psychotherapy, and speech therapy. Most transgender care is not covered by health insurance. Transgender Hormonal Therapy: the medical administration of estrogens (for male to female transsexuals) or androgens (for female to male transsexuals) to affect the development of secondary sexual characteristics of the other (non-birth) sex. Transphobia: hatred of transgender people, manifested by acts of discrimination, harassment, and violence, including murder. Transphobia also creates multiple barriers to access to all types of medical care. It differs from homophobia in that it carries an implicit justification: that by “flaunting” their feminine or masculine appearances – i.e., by being themselves – transgender people are simply asking for it. Internalized transphobia, a profound unhappiness with being transgender, is similar to internalized homophobia, and manifests as depression, suicidal ideation, substance abuse and sexual risk taking. Transsexual: persons who are profoundly unhappy with their birth sex, and who seek to change or have already changed their body to be congruent with their gender identity. Transsexual usually implies access to sex reassignment surgery, and thus transsexual persons have the highest level of need for access to transgender care services among all transgender persons. 47

Appendix I1: HIV Community Planning in Virginia Historical Overview In 1994 the Centers for Disease Control and Prevention (CDC) changed the manner in which federally–funded state and local HIV prevention programs would be planned and implemented. State, territorial and local health departments receiving HIV prevention funds through the CDC were asked to share with representatives of affected communities and other technical experts, the responsibility to develop a comprehensive HIV prevention plan using a process called HIV Prevention Community Planning. The basic intent of the process was to increase community involvement, improve the scientific basis of program decisions, and target resources to those communities at highest risk for HIV 5 transmission. Although the CDC had two primary components embedded within the process – targeting populations for which HIV prevention activities will have the greatest impact and reducing HIV transmission in populations with highest incidence, state and local jurisdictions were encouraged to prioritize prevention needs as indicated by their own epidemiological data. HIV Community Planning Groups (CPGs) were to be developed and would work in conjunction with public health agencies to carry out this process. HIV Prevention Community Planning had three major goals that provided the overall direction for community planning: (1) supporting broad-based community participation, (2) identifying and prioritizing needs and interventions, and (3) ensuring that available resources were used to address the needs of the targeted populations and interventions. Jurisdictions were required to create and maintain at least one CPG that met the goals, objectives, and operating principles set forth by the CDC. If there were more than one community planning group in a jurisdiction, the health department would be responsible for deciding how best to integrate cross-jurisdictional community planning. If there were multiple jurisdictions within a state, state and local CPGs were expected to have ready access to and review each other’s comprehensive plans. CDC has maintained its commitment to the concept of HIV prevention community planning and monitors the progress health departments and CPGs are making in meeting these expectations. VHCPC Structure and Operations While the CDC mandated that HIV Community Planning Groups be developed, it left the design of those groups to the individual states and territories. Virginia is one of a growing number of states that have one statewide planning body, while other states opt for regional planning bodies reporting to a 5 National Center for HIV, STD and TB Prevention: Division of HIV/AIDS Prevention. HIV Prevention Community Planning – GUIDANCE. 48

statewide planning committee or to have multiple planning committees within the state based on regions. Virginia opted for one statewide planning group with representation from each of the five regional health planning districts across the Commonwealth. The Virginia HIV Community Planning Committee (VHCPC) is composed of education and service providers, clients, state agency representatives, clergy, and private citizens who work cooperatively with VDH to develop an annual plan for comprehensive HIV prevention and to advise VDH on its implementation. The Committee is led by an elected community co-chair and an appointed Virginia Department of Health co-chair. Representation also mirrors the HIV epidemic within these regional districts. The VHCPC as described in its bylaws must be comprised of no less than 25 and no more than 35 members. Members are selected from a pool of nominees to represent the population of HIV-positive Virginians in terms of age, race, sex, sexual orientation, HIV risk, geographic locality, and professional expertise. The VHCPC has four subcommittees, for research, standards and practices, Ryan White, and STDs. The research subcommittee was established at initiation of the VHCPC and is responsible for establishing and monitoring the research and evaluation agenda. Target populations are identified and thoroughly discussed before being brought to the consideration of the full committee. The standards and practices subcommittee is responsible for developing minimum standards, based on established best practices that contractors must meet in order to receive VDH funding for prevention interventions. In September of 1995 the VHCPC was asked by VDH, in concurrence with a request from the CDC, to expand their activities to include planning for Ryan White Care funds and STD prevention. Since the VHCPC already utilized data derived from Ryan White Care and STD reporting to develop the comprehensive plan, it was logical to enhance the Committee’s mission specifically to address these issues. Role of the Survey and Evaluation Research Laboratory and the Community Health Research Initiative The Survey and Evaluation Research Laboratory (SERL), the applied research division of Virginia Commonwealth University’s Center for Public Policy, has been a partner with VDH since the initiation of its HIV/AIDS response in the late 1980s. SERL staff conducted the first Knowledge, Attitude, Belief and Behavior (KABB) surveys in Virginia; wrote the proposal for and continue to administer the Central Virginia HIV Care Consortium (funded by RWCA Title II); assisted HRSA in the design of the RWCA Title II data reporting system; and continues to capture and report a variety of care and prevention data to HRSA, CDC and to VDH. When HIV Community Planning was first funded in 1994, SERL began what is now over a decade of collaboration with the VHCPC. In part due to the extensive HIV research and technical assistance programs in SERL, the community health emphasis in SERL had grown steadily over the past decade. Effective September 2005, this component of SERL’s work was established as the 49

Community Health Research Initiative (CHRI), an independent department with the new L. Douglas Wilder School for Government and Public Affairs. CHRI and SERL are closely linked, with SERL’s data management and survey divisions continuing to provide ongoing support for CHRI projects. SERL/CHRI staff have designed and implemented more than 40 research and evaluation projects sponsored through the VDH by HRSA and/or CDC, and continue to work closely with VDH and the CPG to integrate related efforts wherever possible, in order to enhance the efficiency and effectiveness of Virginia’s overall response to HIV/AIDS. Thus, when community planning activities were initiated in 1994, Virginia already had an applied social science research partner fully integrated into the process. SERL/CHRI’s annual work plan is developed in conjunction with members of the research subcommittee, who have a special responsibility to monitor SERL/CHRI’s performance. Specifically on behalf of the VHCPC, SERL/CHRI has conducted extensive literature review and bibliographic research to provide population profiles and sub-population intervention best practices to assist with prioritization. SERL/CHRI staff members conduct quantitative and qualitative studies to gather population-based data for prevention planning and implement evaluation studies to assess the readiness of funded contractors to carry out effective programming. VDH, the VHCPC, and SERL forged a relationship that has helped to build an infrastructure to support effective community planning. From the beginning of the research collaboration, all entities recognized the need to involve affected populations and health care providers in the planning process. This direction will receive increased emphasis with emergence of the Community Health Research Initiative. VHCPC/CHRI research studies typically happen over a period of 1-3 years and in a sequential manner. Literature review and careful discussion are used to assess the sufficiency of available data to support HIV prevention planning and to provide a foundation for primary research deemed necessary and/or desirable prior to new program initiatives. 50

Appendix III: Virginia Transgender Health Initiative Study Focus Group Questions 1. ACCESS TO REGULAR MEDICAL SERVICES • Getting good health care can be hard for us, due to discrimination, lack of doctors who understand our needs, and lack of health insurance coverage. What have you heard from transgender people you know about getting health care? PROMPT: Are you comfortable telling your doctor you’re transgender? PROMPT: Is health insurance an issue among transgender people you know? □ 2. ACCESS TO TRANSGENDER CARE SERVICES • Many transgender people often have trouble getting hormone therapy or mental health care. Do transgender people you know have these difficulties? Do you know anyone who has received hormones from someone other than a doctor or licensed health care provider? PROMPT: Do you know anyone who has gotten silicone injections instead? IF HORMONE OF SILICONE INJECTION USE MENTIONED, PROMPT: Did they get it with friends at the same time from the same needle/injector? What have you heard from transgender people you know about getting mental health care? □ 51

3. EMPLOYMENT DISCRIMINATION • Employment discrimination is a big concern for many of us. Have you or anyone you know ever been the victim of employment discrimination due to being transgendered? • A transgender participant in a New York focus group said “A lot of trans- girls and boys are forced into a profession that they may not want because they have no job opportunities.” What do you think about this comment? □ 4. HOUSING DISCRIMINATION • Finding housing can be difficult for many transgender people. What have you heard from transgender people you know about their housing situation? □ 5. VIOLENCE • You’ve probably heard the reports of many acts of anti-transgender violence, including murder. • Have you or anyone else you know ever been a victim of violence due to being transgender? • PROMPT IF YES: Was it reported to the police? Why or why not? □ 52

6. SUBSTANCE ABUSE & SELF-ESTEEM • A study of the transgender population of Washington, DC found that one third believed they had a drug or alcohol problem. Are drugs and alcohol a problem for transgender people you know? If so, why? IF INJECTION DRUG USE MENTIONED, PROMPT: Did they share needles when they injected drugs? IF SHARED, PROMPT: Did they clean their needles? How? • Researchers have found a connection between substance abuse and low self- esteem, but self-esteem generally seems to improve in transgender people after we pass in our chosen genders. How important is passing to transgender people you know? Why? Do transgender people you know feel more real when they have sex with someone who’s not transgendered? IF YES, PROMPT: Why do you think that is? □ 53

7. HIV KNOWLEDGE & PERCEPTION OF RISK • Knowledge is generally believed to be a powerful weapon in fighting the spread of HIV. What do you know about HIV/AIDS? PROMPT: Where do transgender people you know get their information about HIV/AIDS? Have there ever been any HIV education workshops in your area? IF YES, PROMPT: Do you know if they were transgender specific? PROMPT: If you could design your own HIV prevention program, what would you do to keep transgendered people you know from getting infected with HIV? • Studies of urban transgender people have found that 22 to 68 percent are HIV positive. What would put a transgender person in danger of becoming infected with HIV? PROMPT: Do you think transgender people are more at risk for HIV/AIDS than gay men or less at risk? Why? PROMPT : Do you think most transgenders use condoms when they have sex? □ 54

8. HIV TESTING • Many people are uncomfortable thinking about getting tested for HIV. What concerns do you and other transgender people you know have about HIV testing? What have you heard from other transgender people you know when they get tested for HIV? PROMPT: If a friend of yours was interested in being tested for HIV, where would you recommend they go to be tested? Why there? □ 9. ACCESS TO HIV/AIDS TREATMENT SERVICES • With so many of us HIV positive, getting treatment for HIV/AIDS is critical. What would you suggest doing to improve healthcare and social services for HIV positive transgender people in your community? □ Thank you for your participation! 55

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Authors: Stephen Whittle, Lewis Turner and Maryam Al-Alami Contributors: Em Rundall and Ben Thom

February 2007 A Research Project and Report Commissioned by the Equalities Review The views expressed in this report are those of the authors, not necessarily those of the Equalities Review. To enquire about alternative formats please contact alternativeformats@communities.gsi.gov.uk or telephone 0870 1226 236. This report is available online from www.theequalitiesreview.org.uk © Crown Copyright 2007 Copyright in the typographical arrangement rests with the Crown. This publication, excluding logos, may be reproduced free of charge in any format or medium for research, private study or for internal circulation within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as Crown copyright and the title of the publication specified. Any other use of the contents of this publication would require a copyright licence. Please apply for a Click-Use Licence for core material at www.opsi.gov.uk/click-use/system/online/pLogin.asp or by writing to the Office of Public Sector Information, Information Policy Team, St Clements House, 2-16 Colegate, Norwich NR3 1BQ. Fax: 01603 723000 or e-mail: HMSOlicensing@cabinet-office.x.gsi.gov.uk. Product Code XX XXX XXXXX

CONTENTS Foreword 5 Acknowledgements 5 Chapter 1: Introduction 6 1.1 How many Trans People are there? 7 1.2 Experiencing Transphobia 7 1.3 Recent Developments in the Trans Community 8 1.4 Trans People Seeking Equality Now 9 1.5 InEqualities InAction: The case of the Prison Service disappearing Guidelines 12 1.6 The Future of Trans Equality and Non-Discrimination 13 Chapter 2: Executive Summary 14 2.1 Summary report 14 2.2 Trigger Points 14 2.3 Sectors and Spheres of Life 15 2.4 The Workplace 15 2.5 Changing Documents 15 2.6 Confidence in the NHS 16 2.7 Safety in Public Spaces 16 2.8 Goods, Services and Housing 16 2.9 The School Experience 17 2.10 In the Home and Neighbourhood 17 2.11 Conclusion 17 2.12 Recommendations 18 Chapter 3: Background to the Report 21 3.1 Other Recent Research on Inequalities and Discrimination 21 3.2 Defining Inequalities and Discrimination 21 Chapter 4: Findings – A Tale of Ordinary Folk 25 4.1 The Where and When of Discrimination 25 4.2 Great Expectations: the Online Survey Response 26 Chapter 5: Not fit to be seen in Public: Work, Papers, Health and Social Life 31 5.1 Workplace Discrimination 31 5.2 Problems at Work 34 5.3 Changing Documents 40 5.4 Accessing Healthcare 42 5.5 Going Out: the Street and Bar 51 Chapter 6: Nowhere’s Safe: Services, School, or Home 58 6.1 Housing, Goods and Services 58 6.2 The Best Days of your Life: School? 62 6.3 Experiences of Trans people in Domestic spaces 67 1

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Chapter 7 Accessing Equality: What do we want and how do we get it? 71 7.1 What do Trans People Want? 71 7.2 The Possibility of Claims under the Disability Discrimination Act 71 7.3 Gender Recognition Act (GRA) 2004 73 7.4 The Civil Partnership Act 2004 73 7.5 The Sex Discrimination Act 1975 74 7.6 The Equal Treatment Directive (2004/113/EC) 74 7.7 The Housing Act 2002 Part VII Homelessness Provision 75 7.8 The Equality Act 2006 75 7.9 Conclusion 76 Chapter 8: A Long Trans Life of Inequalities and Discrimination 77 Chapter 9: Bibliography 80 Appendix 1: Glossary 85 Appendix 2: Methods 89 Introduction 89 Data Sources 89 Online Survey 93 Problems, Successes and Limitations of the Study 94 Data Analysis 95 Appendix 3: Online Survey of Inequalities and Discrimination 96 Figures and Tables Figure 4.1: Top sectors in which people experienced discrimination 25 Figure 4.2: Top 9 spheres of life in which people experienced discrimination 25 Figure 4.3: Top 9 trigger points 26 Figure 4.4: Ethnicity of respondents 27 Figure 4.5: Age of respondents 27 Figure 4.6: How respondents identified their trans selves 28 Figure 4.7: The intentions of the 329 respondents not living permanently in their acquired gender 28 Figure 4.8: Percentage of respondents who were disabled compared with disabled people in the UK 29 Figure 4.9: Percentage of respondents claiming benefits compared with percentage of UK population claiming benefits 29 Figure 4.10: Occupational class of respondent group compared to national population 30 Figure 5.1: Respondents living / not living permanently in their preferred/acquired gender 32 Figure 5.2: Respondents not yet living in their preferred gender role, who stated that their job or workplace prevented them from doing so 32 Figure 5.3: Percentage of respondents who were required to use the toilets of their former gender or the disabled toilet at work, after transition 35 2

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 5.4: Respondents’ experiences when using the toilets of their preferred/acquired gender at work 36 Figure 5.5: Respondents’ treatment by co-workers because of their acquired gender 37 Figure 5.6: Respondents who changed job or intended to change job because of their transition 38 Figure 5.7: Experiences at work by gender 38 Figure 5.8: How GPs responded when patients sought advice on gender reassignment 44 Figure 5.9: Percentage of respondents whose GP did not appear to want to help or refused to help access gender reassignment services by date of transition 45 Figure 5.10: Percentage of respondents refused treatment by a doctor or nurse because they did not approve of gender reassignment 46 Figure 5.11: Percentage of respondents who faced problems in obtaining funding from their primary care trust, by date of transition 48 Figure 5.12: Percentage of respondents refused or made to wait far longer than 6 months after referral from GP, for initial assessment for possible gender reassignment, by date of transition 49 Figure 5.13: Percentage of respondents refused access, or made to wait longer than expected, for trans-related healthcare after clinical recommendation 49 Figure 5.14: Percentage of respondents who felt that being trans had affected the way they could access non-trans related routine treatment on the NHS 50 Figure 5.15: Percentage of respondents who felt being trans adversely affected the way they were treated by healthcare professionals, by date of transition 50 Figure 5.16: Harassment experienced by trans people in public spaces 53 Figure 5.17: Harassment by gender 54 Figure 5.18: Genderpac survey results 54 Figure 6.1: Type of housing compared to UK national average 59 Figure 6.2: Top eight sectors in which enquiries relating to services were made to PFC 59 Figure 6.3: Respondents who had been asked to use different toilets or changing rooms at a health centre or sports centre as their preferred/acquired gender 60 Figure 6.4: Respondents refused services in a pub, restaurant, hotel or any other place providing leisure services such as a gym, because they were recognised as being trans 61 Figure 6.5: Respondents asked to not use or to use different changing rooms at a shop or retail outlet when in their preferred /acquired gender 62 Figure 6.6: Young trans people’s experiences of bullying at school by gender 63 Figure 6.7: Trans children’s experiences at school by gender 65 Figure 6.8: Educational achievements of respondents compared to national average 66 Figure 8.1: Respondents who reported attempting suicide or self harm, as an adult, resulting from being a crossdresser, transgender/transsexual person or because of other people's reactions to them being trans 78 3

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Table App 2.1: Sectors coding 91 Table App 2.2: Spheres of life coding 91 Table App 2.3: Trigger points 91 Table App 2.4: Keywords used for Press for Change data 92 Table App 2.5: Keywords used for FTM network data 92 4

Foreword This research project was undertaken for the Equalities Review between the period of July 14th and September 1st 2006. During this 6 week period, the researchers undertook a mixed quantitative/qualitative approach to collecting and analysing information on transgender and transsexual people’s experiences of inequality and discrimination in the UK. This report is an analysis and summary of the results obtained, and it outlines the levels of inequality and discrimination that trans people face. The work undertaken is certainly the largest data collection ever analysed and the largest survey response ever received when doing research on trans people’s lives. One can never claim that research data is entirely representative of a community, even less so when the community being studied consists of many small sub- communities as is the case with trans people. However, as will be alluded to in the introduction, the reality of the estimated number of transsexual people in the UK means that this piece of work reflects the experiences of a substantial section of the trans community. As such, we are proud of this research, and would claim that it is as near a reflection of the reality of trans people’s lives as is possible through data collection. Acknowledgements Our contributors, Em Rundall of the Department of International Relations, Politics and Sociology at Oxford Brookes University for her extensive contribution to our understanding of contemporary issues in Employment for trans people. Also Ben Thom, Barrister at Law, who helped again extensively, with our outline of the current position of trans people within the law. Christine Burns from Plain Sense1 for providing a significant amount of the qualitative data analysed, and for other key ‘memory moments’. Angela Clayton from Press for Change, Emma Cole and Rosie Seymour from the Equalities Review, and Catherine Little and Melanie Latham from Manchester Metropolitan University for their guidance and advice. The Equalities Review for commissioning this work. 1 http://www.plain-sense.co.uk/diversity/. 5

1 Introduction Transgender is an umbrella term, coined in the US, used to include people whose lifestyles appear to conflict with the gender norms of society. It includes many types of people and lifestyles. In the use of the broad term, a transgender person crosses the conventional boundaries of gender; in clothing; in presenting themselves; even as far as having multiple surgical procedures to be fully bodily reassigned in their preferred gender role. In this report we will normally use the term ‘trans people’ to describe those people who might be described as falling broadly within this context, as it has become the term of normal use since the coining of it by Press for Change for their 1996 mission statement: “seeking respect and equality for all trans people”. In this research project, we endeavoured to be as inclusive as possible of different ‘types’ of trans-identified people. The three categories generally used to describe trans people – transvestite, transgender and transsexual – are very simplistic, and the results of this research will add to the understanding that trans people often have complex gender identities, and may move from one ‘trans’ category into another over time. The work is intended to provide a snapshot of the current issues raised by trans people as they seek help from the major provider of legal help and advice in this area, alongside a deeper view of their experiences over their lifetimes exploring the means and mechanisms behind the inequality and discrimination that results from prejudice about trans people. As such the work is an analysis of quantitative results combined with qualitative and illustrative words from trans people themselves, analysed in the context of the major legal and social changes of the last 10 years. The main sources of qualitative data are the Electronic Materials Databases (EMDs) of Press for Change and the FTM Network, covering the period 1998- 2005. This was supplemented with quantitative and some further qualitative reporting from an Online Survey of 873 trans self-identified respondents, which was available for completion during the month of August 2006. Because of the nature of those people who contact Press for Change for advice and information, there is more focus in the qualitative data on those people who live their lives permanently in their preferred gender role. This includes those people who would be identified as transsexual by themselves or others, and who wish to have, intend to have, are having or have had gender reassignment which includes some hormonal therapies and may include surgical gender reassignment. However, another reason for this focus is that trans people who live permanently in their preferred gender frequently experience victimisation through on-going discrimination, and are treated differently because other people are able to identify them as a trans person, and it is as such that they seek help or support through these groups. The online survey provided some balance as almost 40% of its respondents were not living permanently in their preferred or acquired gender role, thus presenting the views of some of those who identified as temporary cross dressers, transgender individuals and others who self-identify as transsexual but who had not lived, or were not yet living permanently in their new gender role. 6

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination 1.1 How many Trans People are there? There has been considerable work on estimating the number of transgender and transsexual people within the UK population (see the discussion in Witten et al, 2003) and the conclusion must be that there is simply no publicly available statistical data on which to make firm estimates. In 2000, after informal consultations with the Passport Section of the Home Office, Press for Change estimated there were around 5,000 transsexual people in the UK, based upon numbers of those who had changed their passports (Home Office 2000), though a Scottish Needs Assessment Survey in 2001 would indicate half that number (Scottish Needs Assessment Programme 2001). As of November 2006, 1,660 people had already been awarded a Gender Recognition Certificate (GRC).2 Nevertheless, there is no substantive knowledge of how many people in the UK identify as transgender or transvestite, or use any other gender identity descriptor, but estimates vary considerably, with a quick internet search suggesting figures from about 1 in 100 to as many as 1 in 20 in the male population. 1.2 Experiencing Transphobia It is the ‘transphobic’ response of other members of society that results in trans people experiencing inequality or discrimination. Whatever the basis for that response, the evidence from the many cases that have gone before UK tribunals and courts, and the European courts, indicates that trans people’s experiences of inequalities and discrimination should not be dismissed as them being ‘over-sensitive’. Recent research by Hill and Willoughby (2005) reviewed the current academic knowledge on the experience of the effects of transphobia in various settings. Most research on the subject of transgender has reported high levels of victimisation including harassment by strangers on the street, verbal abuse, assault with a weapon, and/or sexual assault (Gagne et al. 1996 and Lombardi et al. 2001 cited in Hill and Willoughby 2005), trauma and sexual assault as children and adolescents (Gehring and Knudson 2005, Ryan and Rivers 2003) and this is further supported by the work of Moran and Sharpe 2004, Xavier 2000 and Whittle 2002. Hill and Willoughby (2005) critique some of the data they review, questioning whether it was representative and whether the results relating mostly to trans women could be transferred to represent the experience of trans men. They also cite a 1986 study which showed that, as a group, health professionals appeared to now: support the basic human rights of transsexuals with only minor and specific reservations about transsexuals as a group (Franzine and Casinelli 1986). This assumption is just one of many that this study will challenge. 2 Correspondence between Press for Change and the Gender Recognition Panel Secretariat, November 2006. 7

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination It will be taken as an assumption in this study that those people who appear to the onlooker as more ‘trans’ are more likely to experience prejudice and/or discrimination. Thus whilst the (ftm3) trans man will experience some social problems in the first year or so of transition, these often fade away as they quickly come to look physically very masculine (at least whilst clothed). On the other hand, many (mtf4) trans women will face difficulties for many years of their life as they struggle with the limitations of medicine and surgery to facilitate their passing as an ordinary woman in their day to day life. Consequently, they are more likely to become victims of transphobia and are more likely to experience the social stigmatisation that comes with it. That is not to say that trans men do not experience prejudice and its results, but rather that many of them will be more quickly able to escape into a public world where no one knows of their past except in those circumstances such as employment where they are required to prove their identity. However, they also face isolation as for many the ‘big secret’ they carry with them will quickly limit their social and emotional lives and contacts. Many trans women who eventually live in their acquired gender, early on in the process will face an often unpleasant divorce and the loss of family home, access to children, and financial problems associated with it. This adds further burdens to their transition. From the vast amount of data we discovered we could have addressed these issues, as well, many times over, but instead have concentrated on the other aspects of daily life that impact upon personal well being. 1.3 Recent Developments in the Trans Community The last 16 years have seen a major change in the trans community. The growth of home computer use in the 1990s, and the encouragement of many trans women at the forefront of information technology and internet development was to be crucial in the development of a new, geographically spread but no longer isolated, trans community (Whittle 1998). More recently, it has become a community with an understanding and an awareness of common experiences, through the use of the internet5, and the increasing media coverage of trans stories relating to inequalities and discrimination. As such, there is now an awareness of the legal mechanisms which can be used to claim ‘rights’ and some individuals know that they can successfully seek reporting restrictions within the legal system, so retaining their privacy. This has also led to increasing demands for rights which led, in part, to the Gender Recognition Act 2004, and which is fuelling further demands for discrimination protection in goods, services and housing, better healthcare access and full inclusion within the ‘rights’ agenda. 3 Female to Male. 4 Male to Female. 5 See the websites of Press for Change www.pfc.org.uk and TransgenderZone www.transgenderzone.com. 8

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination The most obvious results of this are court judgements which require action from government or other public or private bodies, and the increasing use of consultation processes to ‘talk back’ to the public and private sector. The Gender Trust6, a support group primarily for trans women, now has 26 corporate sponsors including, amongst others; CapGemini, Morgan Stanley, HM Prison service and Sefton Council for Voluntary Services. Activists from Press for Change have become ‘experts’ in acting as stakeholder consultees in relation to government functions, and actions, and have access via email to over 2000 trans identified people. This legal and lobbying expertise of the community was clearly evident in 2002, when proposals for new ‘UK relevant standards of care’ for transsexual people were thrown out after successful lobbying and public demonstration (Whittle, 2006b). The physician group which provides Gender Identity Clinic services was forced to turn to the Royal College of Psychiatry for help, and new proposals are now being drawn up in full consultation with all providers and the community itself. Many members of the trans community now participate fully in policy development whether at local parish council level, or government departmental level. This is evident through the work of the Parliamentary Forum on Transsexualism on new Health Commissioning Guidelines (Parliamentary Forum 2005), through every stage of the drafting and implementation of the Gender Recognition Act, and the Royal College of Psychiatry working group. 1.4 Trans People Seeking Equality Now Many trans people feel strongly about equality issues. As will be seen from this report, they experience high levels of inequalities and discrimination in all walks and aspects of life. Ever since the victory in the European Court of Human Rights in P v S and Cornwall County Council,7 many members of the trans community have felt disappointed at the apparent unwillingness to extend the principle of non-discrimination in the workplace to the other aspects of life: goods, services, facilities and housing, and to other trans people: cross dressers, transgender people and those whose gender representation is simply different from that of the expected ‘norm’. This disappointment was first expressed on a wide scale when, with only 3 weeks’ notice of submission, Press for Change was able to broaden the consultation on the proposed Sex Discrimination (Gender Reassignment) Regulations’ 1999 to incorporate the trans community (DfEE 1998). The initial proposals included extending the right to managers to decide when a transsexual person looked ‘reasonable enough’ to use the appropriate gender toilets; a general exclusion from working with children, and an exclusion for trans doctors and nurses providing any personal care. Over 800 trans people responded within the 3 weeks, showing a new-found confidence and determination to no longer be marginalised members of modern society. Though many of the worst aspects of the proposals were eventually abandoned, they set the tone for the debates on trans equality that have continued to this day. 6 www.gendertrust.org.uk. 7 P v S and Cornwall County Council [1996] IRLR 347. 9

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination The public debates around the Gender Recognition Act 2004 provided little reassurance, and the Government’s apparent deference to the Religious and Faith lobby, particularly in The Gender Recognition (Disclosure of Information) Order,8 has not helped to reassure a community which feels that nothing will be given to it without extensive lobbying and, often, a victory at the senior courts. This general disappointment was compounded after the Equality Act 2006 only included minor provision in the public sector gender duty and did not include proposals, as for sexual orientation, to provide protection against discrimination in goods and services. Similarly, the amendments to the Sex Discrimination Act 1975 (Women and Equality Unit 2006) to implement the Equal Treatment Directive9 were felt to be minimal. Now, after the pension victory of the trans applicants Richards10 and Grant11 in the European Courts, older trans people have become politically active. They contend that the Pension Service is very much dragging its feet over the possibility of backdated pensions for those trans women who had to stop working at 60, but who were advised that they could not claim a pension until 65.12 One letter sums it up: like all politicians they quote official regulation and subsection and attempt to baffle the recipient with officialise. However, the bottom line is that I was conned tend (sic.) years ago, by them, into not claiming and they are now using that as a weapon. Fairly typical of these sort (sic.) of people. Despite my making sure they were fully informed that I did not claim because of their instructions in 1995/96. (Personal correspondence to Press for Change, from pensioner, dated 5/09/06) Several of the pensioners who were advised not to claim when they reached 60 are also married, and have not yet decided to apply for a gender recognition certificate, and all that comes with it – the complications of applying for an annulment and then applying for a civil partnership. As one put it: we are now 75 and 76. We can’t risk a trip out to town to get unmarried and then just trot over to another building to get partnered – we might drop dead on the way. (Personal discussion with author 14/09/06) The letters this individual is now receiving from the Pension Service state: Because no Gender Recognition Certificate has been issued in your case you are still regarded as a man for the purposes of a claim to State Pension ... (further) as there was no claim to State Pension at the age 60, the claim was made after the time for claiming. (Correspondence from the Pension Service to applicant for backdated pension, 1/09/06) 8 The Gender Recognition (Disclosure of Information) Order 2005. 9 Equal Treatment Directive (2002/73/EC). 10 Richards v Secretary of State for Work and Pensions (Case C-423/04) ECJ (2006). 11 Grant v The United Kingdom (Application No. 32570/03) ECtHR (2006). 12 Extensive private correspondence between the ‘Pensioners Group’ and Press for Change, May – September 2006. 10

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination This is despite both the Richards13 and Grant14 judgements being about the right to receive a pension when living as a woman for all purposes, regardless of legal gender recognition (which was not available at the relevant time to the applicants). More specifically, Richards extended the principle of equal work- related benefits which are now determined under the precedent in P v S and Cornwall County Council15 and therefore the principles relate to those “intending to undergo, undergoing or having undergone gender reassignment” and not to legal recognition in the acquired gender. The final decision of the Social Services Commissioner, as to the national position, in the Richards case was unfortunately not forthcoming as the parties settled rather than seek a final decision. The proposed Single Equality Act (SEA) is seen as surely, the place where provision would be made to end all arbitrary and unreasonable discrimination, no matter on what grounds. The six strand approach has however, once again, left the trans community feeling left out, despite the reassurances that that is not the intention. In early discussions between Press for Change, the transition body of the Commission for Equality and Human Rights, implied that the SEA would not meet the level of protection trans people had hoped for. Trans people instead are left hoping that the European Equal Treatment Directive implementing the principle of equal treatment between men and women in the access to and supply of goods and services,16 in which it was minuted that: the Council and Commission recall the jurisprudence of the Court of Justice in case C-13/94 P v S and Cornwall County Council, where the Court held that the right not to be discriminated against on grounds of sex cannot be confined simply to discrimination based on the fact that a person is of one or other sex, and may include discrimination arising from the gender reassignment of a person.(re item 3, para 2)17 might enthuse the Government to consider extending some substantive goods and services protection beyond the currently restrictive grounds of gender reassignment used in employment cases. This could confirm that legal recognition for all purposes, can now be obtained without medical treatment, as such, and it will only be with such an extension of the legal principle beyond gender reassignment that we shall see the vast majority of the UK’s trans people, who are not transsexual, obtain rights as individuals, which they can enforce. 13 Richards v Secretary of State for Work and Pensions (Case C-423/04) ECJ (2006). 14 Grant v The United Kingdom (Application No. 32570/03) ECtHR (2006). 15 P v S and Cornwall County Council [1996] IRLR 347. 16 2004/113/EC Equal Treatment Directive banning gender discrimination in the area of goods and services. 17 Minutes of the 2606th meeting of the Council of the European Union (EMPLOYMENT, SOCIAL POLICY, HEALTH AND CONSUMER AFFAIRS), held in Luxembourg on 4 October 2004. 11

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination 1.5 InEqualities InAction: The case of the Prison Service disappearing Guidelines Action counts. In 1996, a report was prepared at the invitation of the Home Office, by members of the Gender and Sexuality Alliance18 and Press for Change as part of a proposed review of Prison Service Guidelines relating to the treatment of Transsexual Prisoners. In an answer to the House of Commons in 1997, the Prison service stated that it was currently engaged in drawing up guidelines for issue to establishments on the care, management and treatment of prisoners with gender dysphoria (Hansard, Written Answers: 9 Dec 1997 col.503) In 2000 the Prison Inspector, Sir David Ramsbotham stated that trans prisoners risked serious health problems “because they have been denied treatment and should be given the same access to surgery as members of the public” (Goodchild 2000). And in 2001, the Home Office Research Directorate commissioned a pilot study relating to the Probation Service and questions of incarceration (Stephens, Whittle 2001). The resulting report made quite clear proposals for guidelines. During that time, Press for Change has been asked to advise on 5 separate versions of the ‘new’ Prison Guidelines, most recently in early 2006. A letter to Press for Change arrived while we were writing this report. The letter was from a trans woman, a prisoner, still housed in a male prison despite having received a gender recognition certificate. She says: I am in a male prison, but have recently been granted my full gender recognition certificate, and am now seen as female. As this is a new thing for the prison service no one knows what to do as there are no guidelines or anything for them to follow. ... ... there about 20-30 transgender-ed (sic) prisoners ... and more people will have their gender recognition certificates granted. So, if the prison service and relevant authorities are at a loss with how to deal with ... Gender recognition certificates then I can only see this problem escalating in the future and this is why I believe something needs to be done about this by creating guidelines etc. (Personal correspondence to Press for Change, from prisoner, dated 25/09/06) So 10 years later the promised Prison Guidelines have yet come to nought.19 In the meantime, another prisoner in the same position contacted one of the authors in July 2006 asking for advice on how to take the Prison Service to task through the courts in order to have her legal recognition recognised, citing their ongoing failure to do so as ‘cruel and unusual punishment’. How long before the courts become involved, as has happened in the numerous prisoners’ cases in the USA? 18 The Gender and Sexuality Alliance, Middlesborough, is now no longer in existence having closed in 1998. 19 13 November 2006, A letter from Patrick Hunter on behalf of Gerry Sutcliffe, the Under-Secretary for Justice, states the Prison Service is “working towards publication in the new year”. 12

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination 1.6 The Future of Trans Equality and Non-Discrimination The Gender Recognition Act 2004 is a great step forward, but it was not given freely. Every legal gain made by the UK trans community has been through the courts rather than through the good will of a government pledged to equalities for all. This report, and what the Equalities Review makes of it, will be a rare opportunity to influence future policies to recognise the existence of trans people as citizens. It is the largest and most definitive overview ever taken of trans people’s experiences of inequalities and discrimination. As such it will hopefully be used as a central reference point, highlighting issues and informing decisions which would hopefully, like the Gender Recognition Act, ‘push the envelope’ for trans people’s equality, regardless of their gender identity, expression and presentation. To date the history of trans equality in the UK has been a case of Inequalities Inaction. The authors of this report had expected there to be significant reporting of inequalities and discrimination, but the extent of what we have discovered far exceeded the expectations even of the lead author, who has been working in the field and providing legal advice to trans people for over 15 years. The future needs to be different. 13

2 Executive Summary 2.1 Summary report This report is based upon a qualitative review of 86,000 emails to Press for Change and 16,000 online postings to the FTM UK email list. A quantitative analysis of responses from 872 self-identified trans people, to an online survey. We are satisfied that the analysis of the Electronic Materials Database (EMD) produced results which were representative of the issues raised with Press for Change, by trans people seeking advice or information over the period 1998 to 2005. We are further satisfied that the respondent group to the online survey correlated closely to previous research, and is significant enough in size to draw the conclusions we highlight. The categories transvestite, transgender and transsexual are commonly understood as discrete. This research has found that trans people have complex gender identities, often moving from one ‘trans’ category into another over time. Our survey found that 44% of respondents not living permanently in their preferred gender (who would be understood as transvestites), intended to do so in the future. This has implications for current law which offers some legal protections only for those who are understood as transsexual. Appendix two shows the method of analysis of the Online Survey and the Electronic Materials Database analysis. This was done using keywords to discover in what sectors and spheres of life people experienced the results of prejudice and the trigger points which resulted in those prejudices being manifested, leading to the trans person experiencing inequalities and discrimination. 2.2 Trigger Points The main trigger point for inequality or discrimination was discovered, not surprisingly, to be the point of transition in the workplace. Transition takes a lengthy period of time for most people. It commences on the day they start work or full-time education in their new gender role and finishes when they are happy that all of the procedures they require are complete. The period of transition may be as little as one year for someone who accesses their health care privately, but may be as long as 6 to 10 years for someone seeking gender reassignment surgery through the NHS. Other trigger points were when a person started cross dressing publicly, during the periods of gender reassignment surgery, or when a person’s intention to cross dress or to transition to living permanently in their acquired gender was discovered within the family home. 14

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination These were all crisis points when other people acted on their prejudices. The trans person experienced inequality, and in many cases, unlawful discrimination as a consequence. 2.3 Sectors and Spheres of Life The sectors of life in which discrimination and inequality most impacted trans people’s lives were employment and the workplace, healthcare access and leisure and education. The spheres (times) of life which were problematic were, again, in employment, when young people were in their own accommodation without family support, or during a marriage when the cross gender identity became a significant relationship issue. 2.4 The Workplace We found that despite the over-representation of trans people in the senior occupation classes compared to the UK National average, the workplace affords a poor experience for many trans people. Bearing in mind that working is a crucial part of the transition process, it is worrying to discover that 42% of people not living permanently in their preferred gender role were prevented from doing so because they feared it might threaten their employment status. This is not surprising when we find that almost 1 in 4 trans people are made to use an inappropriate toilet in the workplace, or none at all, in the early stages of transition. At work over 10% of trans people experienced being verbally abused and 6% were physically assaulted. As a consequence of harassment and bullying a quarter of trans people will feel obliged to change their jobs. More research is needed to discover why employers are failing to protect their trans employees. 2.5 Changing Documents The changing of one’s documentation is a crucial part of the transition process, which should be relatively easy in this time of automated computerised systems. Banks and other financial institutions all too often fail to promptly change the details on people’s records. The proposed new NHS Spine, which will be key to providing electronic NHS Care Records for every patient, will have failed badly if it does not manage to resolve the problem of changing people’s gender and name on records. The arrival of the Gender Recognition Act and certificate has added another layer of complication. For many years a whole range of institutions have routinely changed people’s details on production of a doctor’s note and a formal change of name. The Gender Recognition Act has confused this process. Many organisations, including universities, the police and health authorities now falsely claim that no change of name, gender or pronouns can be made without a gender recognition certificate. There is a real need for government to provide an easily accessible point of information for employers and others to reinstate a simple process which had been in existence for many years. 15

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination 2.6 Confidence in the NHS The health care system of the UK is key to many trans people managing to fulfil their lives. Clearly for some the expertise, help and care they receive is very positive. Around 21% of trans people start the process by seeking help from a knowledgeable GP to begin the process of obtaining GRS, or other relevant services. However this research also found, that another 21% of respondents’ GPs either did not want to help, or in 6% of cases actually refused to help. This is an improvement of 50% compared with the experience of services over 15 years ago, but it still presents a considerable barrier. In the more general health care sector 17% of respondents had experience with a doctor or nurse who did not approve of gender reassignment, and hence refused services. Some 29% of respondents felt that being trans adversely affected the way they were treated by health care professionals. Trans people continue to face problems receiving funding for treatments from PCTs and waiting times for assessment or treatment have not improved over the last 15 years. 2.7 Safety in Public Spaces Trans people fear for their safety, to the extent that those not yet living permanently in their new role do not go out into public spaces in their preferred gender. 73% of respondents experienced harassment, with 10% being victims of threatening behaviour when out in public spaces. General confidence in the police among members of the trans community is quite high, however, 18.5% of those who actually had interactions with the police felt they were not treated appropriately. 2.8 Goods, Services and Housing Accessing goods and services figured high on the list of sectors in which trans people face problems. We found that 47% of trans people do not use public social or leisure facilities for fear of discriminatory treatment – by being refused access, or having their access limited in some way. Trans people are also situated in the most vulnerable of housing provision. We found that one in four trans people live in private rented accommodation, which is double the figure for the UK general population. Private sector housing provision is often of poorer quality with less security of tenure. 16

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination 2.9 The School Experience The young trans person, who is forming their identity in school, faces bullying and harassment. Some 64% of young trans men and 44% of young trans women will experience harassment or bullying at school, not just from their fellow pupils but also from school staff including teachers. These are higher rates than shown in many studies on young lesbians and gay men at school. The research also counters the commonly held belief that there is less tolerance of ‘sissy’ boys than tomboys, finding that females who become trans men later in life faced the most harassment and bullying at school. The research shows a major difference in final educational achievement levels in the trans population compared to the UK average. Many trans people leave school after completing Level 2, but 34% obtain a degree or higher degree (later in life), compared to the UK national average of only 27%. 2.10 In the Home and Neighbourhood We found that trans people experience many problems at home and in their neighbourhood, with some losing their family support network, their home and friendship circles. Some 45% of respondents reported family breakdown which was due to their cross gender identity. 37% are excluded from family events and have family members who no longer speak to them because they have transitioned to their acquired gender, and 20% of respondents felt informally excluded from their local community and neighbourhood since their transition. 2.11 Conclusion This research is the most comprehensive study ever undertaken of trans people and their lives. It raises questions about the impact of government policy and legislation to date and challenges existing knowledge and beliefs about who makes up the trans community and the important issues they have to face in life. It demonstrates the need for effective solutions to be developed, as to date the solutions presented appear to have changed the quality of trans people’s lives very little. Anti-discrimination legislation, as seen with the Sex Discrimination Act, the Race Relations (Amendment) Act and other Acts, is the first step in a much larger educational programme of creating acceptance of diversity and difference. This research clearly demonstrates the need for the government to act upon various recommendations made throughout the report. 17

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination One of the aims of the Equalities Review is that everyone be enabled to reach a ‘capability threshold’ in order to have a role that they value in modern society – for example having reached a minimum standard of education as well as an entitlement to work (when able) and a decent place to live. Our research has found that many trans people exceed this criteria in their level of educational achievement (see Figure 6.8) and occupational class (Figure 4.10). Yet, more are living in the most vulnerable of housing compared to the national average (Figure 6.1). Our findings suggest that post-transition, trans people’s ability to play an autonomous role in society can diminish, through discrimination in employment and access to healthcare, difficulties changing documentation, harassment in the workplace and public spaces and neighbourhoods, as well as a potential loss of the support systems of family and friends. Another aim of the Equalities Review is to remove the unfair penalties associated with gender, race, disability or sexual orientation. We hope that based on the evidence of this report, gender identity will also be included in this list and that policy makers take into account the penalties that trans people face. Many of our recommendations offer simple solutions and some are long-term projects requiring further research and policy development. However without these, young trans people will continue to face a lifetime of inequalities and discrimination which, as the attempted suicide figures show, puts lives at risk. We hope that our recommendations will be implemented to improve the life chances, equality of aspiration, opportunity and achievement for all trans people. 2.12 Recommendations The Workplace More research needs to be done on why employers are failing to comply with the law and protect trans employees. Trans awareness raising and training for employers and those working in Human Resources. Our research finds that high numbers of trans people (38% of our sample) fall outside of the legal definition of ‘transsexual’ and are not offered that legal protection. We have also found people within this group are intending to transition but current workplace conditions are preventing them from doing so. We further recommend: That the legal limitations defined under statutory law should be revised so as not to be as definitive or exclusionary, and should be extended to protect many more trans people including those not intending to undergo gender reassignment surgery. Changing Documents That a government resource be made easily accessible to trans people and others, which stipulates the legitimate protocol for name and gender changes and the legal consequences for failing to comply. 18

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Confidence in the NHS All healthcare providers, including ancillary and support service staff need: A staff development structure that regularly raises training about trans people’s issues; An understanding that because someone is presenting with a trans issue, there is no basis, such as a conscience clause, for any doctor to refuse help whether referring onwards, providing regular hormone prescriptions, or ordinary health care; Education on what it is to be a trans person, on trans patient’s rights, including the right to dignity, decency and respect, and especially the right to privacy as afforded by the Gender Recognition Act 2004; Training to ensure an awareness that once a person’s trans issues have been addressed, they will still have the ordinary health problems that other people face; Training on recognising that trans people, when presenting with non-trans related health problems, need treating equally alongside other patients; Simple education and leaflet guidance for doctors, nurses and other health care staff on how to work with trans patients on issues of dignity, particularly the right to be treated as a member of their new gender, and privacy obligations. Safety in Public Spaces Police services should make a priority response when a trans person calls for help; Police services should not assume the trans person is the cause of any incident; Police services need further informing and educating about the nature of trans identities; Transphobic Crime should be recorded in all police authorities; The CPS needs information to enable it to determine whether it is in the public interest to prosecute a trans person who has been a victim of a crime, in the same incident; More research is needed to determine the basis of transphobic crime, to develop responsive policies and to ensure appropriate intervention when individuals are vulnerable e.g. providing alternative housing; Education on trans lives needs to start in school, and transphobic bullying or language needs quick action to curb it. Goods, Services and Housing Legislation is needed to ensure trans people are protected from discrimination in the provision of goods, services, housing and facilities; Because of under-reporting due to the acceptance that there is no legal protection, the true extent of discrimination is unknown. Consequently more research is needed to evaluate how far-reaching discrimination is; 19

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Priority in housing needs to be afforded to trans people experiencing abuse and harassment in their accommodation; Clear guidance needs to be given to ensure service providers are encouraged to welcome trans people. Schools Transphobic bullying is rife and there is a need for education, not just of children but also school staff and other workers. Research needs to be done into the experience of trans identified or masculine female adolescents, and their need for protection from bullying. There is a need for projects to ensure trans identified young people are helped to stay on at school, rather than leave and seek education later as ‘second chancers’. Research should explore the reasons why trans people appear so well educated as adults, and to discover whether less able trans identified youth are ill- equipped to fully transition later in life. In the Home and Neighbourhood Families need access to good straightforward information about what is going to happen to their family member; There need to be opportunities for families to meet with other families; and for ‘Family’ information, workshops and other activities to encourage the retention of the family structures. 20

3 Background to the Report 3.1 Other Recent Research on Inequalities and Discrimination There has been little evidence-based research on the nature of inequality and discrimination experienced by trans people, but the available evidence suggests that discrimination and prejudice are pervasive (Lombardi et al 2001; Hill and Willoughby 2005). Research has shown that inequality and discrimination are experienced by trans people in employment (Whittle 2000) and that prejudice and marginalisation are barriers to accessing health care (Scottish Needs Assessment Programme 2001; Inclusion Project 2003; Lombardi 2001) and housing (Xavier 2000). Trans people are over-represented in the prison population in proportion to the estimated trans population and in every sphere of life, are subject to high levels of abuse and violence (Genderpac 1997; Xavier 2000; Lombardi et al 2001). 3.2 Defining Inequalities and Discrimination 3.2.1 Transphobia Transphobia is now recognised by the police service as a factor in Hate Crimes and Hate Incidents. The national True Vision initiative launched in 2004, to encourage the reporting of Hate Crimes against minority communities, records Transphobia as a separate category of hate crime. In this context, transphobic hate crime is defined as: Any incident which is perceived to be transphobic by the victim or any other person. (http://www.online.police.uk/english/description_hate_crime.asp). One useful conceptualisation of prejudice towards trans people, by social psychologists, identifies three elements: ‘transphobia’, ‘genderism’ and ‘gender- bashing’. Transphobia is defined as follows: Transphobia is an emotional disgust toward individuals who do not conform to society’s gender expectations... Note that the use of the “-phobia” suffix does not imply that a transphobic person suffers clinical phobic reactions; nor does it imply that the transphobic person is suffering from a disorder. The “phobia” suffix is used to imply an irrational fear or hatred, one that is at least partly perpetuated by cultural ideology. (Hill and Willoughby 2005: 91). 21

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Thus transphobia is an irrational reaction to those who do not conform to the socio-cultural ideology of gender conformity. ‘Genderism’, the belief that non- conformity to conventional notions of masculinity and femininity is pathological, can be forced upon others or internalised. Hill and Willoughby (2005) argue that Gender-bashing is the violent manifestation of transphobia in the harassment or assault of trans people. Although there is a paucity of research on the prevalence of transphobia, recently conducted research on attitudes toward trans people found that anti-transgender views were neither rare, nor difficult to elicit. One study of a sample population of well-educated residents of a cosmopolitan city with a reputation for liberal attitudes towards sexuality and gender, demonstrated ‘extremely intolerant attitudes toward gender variance’ (Hill and Willoughby 2005: 99). This evidence is backed up by another empirical study conducted in the UK which found that an ideology of gender conformism based on biology was strongly linked to an opposition to trans people’s civil rights (Tee 2006). As will be seen, this report supports much of this data, though by concentrating on aspects of life other than those which might form the basis of criminal prosecution, it throws up some new and interesting data highlighting the aspects of life which are most impacted, at which stages of life, and the trigger point that causes the irrational reaction to take place. 3.2.2 Violence The first national survey on violence against trans people conducted in the US, and the largest sample on record, documents the high levels of violence and abuse that trans people face. The study found that 48% of respondents had been victims of assault, including sexual assault and rape, and 78% had experienced verbal harassment (Genderpac 1997). Other research conducted in the US found that 43% of the participants had been a victim of violence or crime, with 75% of those attributing a motive of either transphobia or homophobia to it (Xavier 2000). It has also been suggested that young trans people are particularly vulnerable to victimization and harassment, compared to adults (Ryan and Rivers 2003). 3.2.3 Employment Discrimination and Prejudice Although little empirical work has been done in the area of employment, available studies provide strong evidence that ‘harassment and other forms of discrimination in the workplace, from recruitment to promotion, is endemic when it comes to transsexual people’ (Whittle 2000: 12). Despite the legal obligations of employers to comply with the sex discrimination legislation introduced between 1996 and 1999, a survey of transsexuals in employment found that many employers of transsexuals failed to have anti-discrimination or anti-harassment policies for gender (Whittle 2000). This neglect was demonstrated most acutely in the failure by many employers to provide toilet facilities appropriate to participants’ new gender role at the time of transition. Half of respondents reported that they were denied access to toilets appropriate to their gender role when they began their transition (Whittle 2000). 22

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination This research also found discrimination in terms of retention, promotion and recruitment, pay and evidence of harassment and abuse. In terms of retention for example, over half of respondents had changed employers either because they were forced to leave by their previous employer, or felt compelled to leave due to the working conditions post-transition. Respondents to a survey also reported that they were now doing lower paid work since their gender transition. Moreover, 38% had experienced harassment at the time of transition and 25% had experienced it at work for a period after transition. Some reported experiencing verbal abuse (23%) and physical abuse (6%). In terms of recruitment, 49% of respondents who had transitioned after the legal protection for transsexual people in employment was introduced, reported that they were discriminated against frequently in recruitment on the basis of their gender change. Research in the US also found that 37% of transsexuals taking part in a survey had been demoted at work or lost their jobs due to their gender transition (Lombardi et al 2001), and another US study found only 58% of trans people in paid employment, with 15% of respondents reporting their trans status as the reason they lost their job (Xavier 2000). The overall socio-economic discrimination experienced by trans people, as a result of poor pay, job loss or low income support has been strongly linked with experiencing a transgender-related violent incident (Lombardi et al 2001), suggesting that poor employment protection for transgender people can compound their vulnerability to discrimination and harassment in the workplace and violence in other spheres 3.2.4 Criminal Justice Research has found that trans people are over-represented in the prison population – more than twice what would be expected with the available estimates of the size of the trans population in the UK as a whole (Poole et al 2002). Many of the offences trans people were incarcerated for involved gaining money for surgery (for example, handling stolen goods). Poole et al’s research called for transgender people to be included in diversity policies in the criminal justice system and for training on transgender issues for probation and prison officers. There has been no statistical collection of data in the UK concerning the trans prisoner’s experience of violence, however there have been several high profile trans prisoner claims made in the USA which sought damages after a prisoner had faced brutal violence, including rape, after being knowingly placed in a vulnerable situation (Peek 2004). One of the authors of this report has had regular contact with 8 UK prisoners and (now) ex-prisoners over the last 15 years, and can report that in all but one case they were a victim of assault by other prisoners. In one case this led to a 5 figure out of court settlement from the Prison Service. 23

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination 3.2.5 The Vulnerability of Young Transgender People Young transgender people are particularly vulnerable to discrimination and harassment. In the US, research has found that transgender youth are particularly vulnerable to harassment and abuse in school and community settings (Ryan and Rivers 2003; Haldeman 2000). One study found that school psychologists have little understanding of transgender issues, as much literature in the field of psychology has a tendency to pathologise young people who are non-conforming in their gender (Haldeman 2000). In another study, Jeltova and Fish (2004) highlight the need for systemic change in schools with the establishment of anti- harassment and LGBT-friendly environments in schools. Other work has suggested the need for a knowledge-base of good practice to be incorporated into the social work curriculum, as social work practitioners have very limited knowledge or training to inform their work with young transgender people (Mallon 1999). Other research in the US suggests that young trans people are highly at risk of victimisation, violence and multiple health problems which are strongly related and cumulative. For example, in the US, the rates of HIV infection among transgender youth are the highest at 14.3% compared with African American young men – the next highest group amongst HIV+ young people – at 14.1% (Ryan and Rivers 2003). 3.2.6 Accessing Gender Reassignment Services and other Health Care There is strong evidence that access to good healthcare for trans people is sporadic in the UK. At best, there is widespread ignorance of the healthcare needs of trans people and at worst, there is prejudice. Two studies of the health needs of trans people in Scotland found services for treatment and support were haphazard, with many GPs having no knowledge of transgender issues and a lack of information in health centres. One of the studies found that professional isolation and ignorance of gender identity problems are widespread: Professionals hold widely polarised views of transsexualism and gender dysphoria, ranging from strong moral disapproval to considerable empathy. (Scottish Needs assessment Programme 2001:15). This research recommended the establishment of an integrated programme of audit and research on transsexualism in Scotland and that ‘services should be community-based and patient-centred, taking into consideration a social model of health’. Another study of transgender healthcare in Scotland found that many health professionals confused transgender issues with issues of sexual orientation and that prejudice and discrimination were common experiences for trans people. It concluded that: the health needs and service experiences of Scotland’s Transgender population remain one of the most neglected areas of research in relation to LGBT health. This reflects the marginalisation of Transgender individuals and groups in Scotland. (The Inclusion Project 2003:18) Both studies in Scotland have recommended further research and a range of initiatives have been launched to improve understanding of the healthcare needs of trans people. 24

4 Findings – A Tale of Ordinary Folk 4.1 The Where and When of Discrimination The Figures below illustrate the top sectors and spheres in which trans people experienced discrimination, drawing from the Electronic Materials Database (EMD), as well as the most frequent trigger points. Figures 6.1–6.3 show that the most problematic areas for trans people are transitioning at work, healthcare and being a young person in one’s own accommodation. These will be analysed in more detail in the appropriate sections of the report. Figure 4.1: Top sectors in which people experienced discrimination 50 Work: public sector employment Work: private sector 40 employment GP healthcare Primary Care Trust funding 30 refusal Criminal justice: police Leisure sector, general 20 Education, university Financial services: insurance company 10 Financial services: banking Gender Identity Clinic healthcare 0 Total Numbers Figure 4.2: Top 9 spheres of life in which people experienced discrimination 50 Transition: at work Transition: in public settings Young adult: in own 40 accommodation Married or partnered: with children 30 Married or partnered: without children Growing older: financial 20 matter e.g. pensions Transition: at home Social life: pubs, bars and 10 clubs (of all sorts) Marriage or partnership after transition: family 0 Total Numbers 25

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 4.3: Top 9 trigger points 50 Transition at work Cross-dressing or transition in social life 40 (Undergoing) gender reassignment surgery Starting cross-dressing or 30 transition at home Changing name on documentation 20 Seeking assessment for gender reassignment Starting hormone therapy 10 (Being known by) community (Moving) job 0 Total Numbers 4.2 Great Expectations: the Online Survey Response The response to the online survey exceeded our expectations. With a final total of 872 respondents (after removal of duplicates and incomplete responses), the survey constitutes the largest sample to date of any sociological study conducted on trans people globally. The national survey on trans violence in the US had 402 respondents (Genderpac 1997); the Washington needs assessment of the health and housing needs of the transgender residents of the District to Columbia had 252 respondents (Xavier 2000); Whittle’s (2000) survey of employment discrimination of transgender people in the UK had 208 respondents. The only other large scale study was conducted by Pflafflin and Junge (1992) which was a literature review of over 70 clinical studies on sex reassignment from 1961 to 1991 of 2000 patients in 13 countries. 4.2.1 Who Responded: A tale of Ordinary Folk? The online survey data was analysed statistically using Excel and was compared with our findings from the EMD to see if there was a commonality of trans people’s experiences in sectors and spheres of life. The sections of the survey where we asked respondents to describe an incident or explain an answer were extracted and used for the case studies. The respondent group was not completely representative of the UK population: for example, the survey was under-representative of non-white people (Figure 4.4). 26

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 4.4: Ethnicity of respondents 800 White British 89.6% White Irish 2% 700 White Other White 5.7% 600 Asian or Asian British 0.2% Black or Black British 500 Caribbean 0.1% Mixed Other Mixed B/G 400 0.3% Chinese 0.3% 300 Mixed White and Asian 0.2% 200 Mixed White and Black Caribbean 0.3% 100 Other Ethnic Group 0.8% 0 Total Numbers However, the respondents did, on the whole, mirror the bell curve of age in the general population. Of course there were very few young respondents, and there was a slight upward shift, with transsexual women being on average older than the general population figures. Figure 4.5: Age of respondents 160 20 140 120 15 100 80 10 60 40 5 20 0 0 <18 18-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 > 75 Number in age group Percentage in age group Our sample is comparable to other data on trans people. The majority of respondents were aged 36-40 and had transitioned permanently to their acquired gender less than 10 years ago. The majority age of respondents for Genderpac’s (1997) study was 30-44. A longitudinal demographic study in the Netherlands (Van Kesteren et al 1996; found that the majority of female-to-males transition at 20-25 years old and male-to-females at 25-30 years old. Another longitudinal study in Germany of applications for gender reassignment following the German Transsexuals’ Act found that the average age was 33 (Weitze and Osburg 1996, based on 1422 judicial decisions). 27

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 4.6: How respondents identified their trans selves 4% 19% Man with a transsexual background Female-to-Male transvestite, transgender, transsexual person 3% Other trans identitfied 59% Woman with transsexual background Male-to-Female transvestite, 15% transgender, transsexual person The largest respondent group in our sample, 74% (646) identified as a male-to- female transvestite, transgender, transsexual or trans person, or woman with a transsexual background and 22.6% (197) of respondents identified as a female- to-male transvestite, transgender, transsexual or trans person or man with transsexual background. This gender ratio of 1:3.46 corresponds with surveys in other European and North American states in the expected ratio of trans women to trans men, between 1:4 (Pauly 1968) to 1:3 (Walinder 1968, 1971) (Gooren et al. 1992) (Weitze and Osburg 1998). 39.3% (342) of respondents were not living permanently in their acquired gender, in other words they would currently be classified or identified by the outside world as cross-dressers or transvestites. We analysed what the future intentions were of these people, to evaluate whether they would continue to identify as a cross dresser or whether they would prefer to move on into the transsexual grouping. Figure 4.7: The intentions of the 329 respondents not living permanently in their acquired gender Intend to live permanently in acquired gender in future 46% 54% Do not intend to live permanently in the future 28

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination These findings suggest that the categories ‘transvestite’ and ‘transsexual’ may not be such discrete groups – 46% of those not living permanently in their new gender answered ‘yes’ when asked if they intended to live permanently in their acquired gender in the future. This group would currently be categorised as ‘transvestite’ or ‘cross dresser’ and as a consequence not benefit from the recent legal protection that being categorised as ‘transsexual’ grants. We compared characteristics of the survey respondents with those expected for the UK population. Some sections of our sample matched UK statistics quite closely, others were significantly different. For example, the percentage of respondents who stated that they were disabled corresponded with UK population statistics (see Figure 4.8), as did the percentage in receipt of social security benefits. Figure 4.8: Percentage of respondents who were disabled compared with disabled people in the UK20 20% 15% 14.40% 15% % respondents reporting a disability 10% % respondents of UK population reporting a disability 5% 0% Figure 4.9: Percentage of respondents claiming benefits compared with percentage of UK population claiming benefits21 20% 15% 13.90% 12.70% % respondents claiming benefits 10% % respondents of UK population claiming benefits 5% 0% 20 National Statistics (Census 2001). 21 National Statistics percentage of the population of working age claiming a key social security benefit: May 2003. 29

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination However, other statistics in our survey did not match those for the UK population. The highest educational level exceeded the national average (see Section 6, Figure 6.8), as was the percentage in professional and managerial occupations (see Figure 4.10). This corresponds with previous research on trans people in employment, which found that a high percentage of respondents were in senior managerial positions (Whittle 2000). Figure 4.10: Occupational class of respondent group compared to national population22 50% 40% 33.0% Respondents percentage in professional occupations 30% UK population percentage 26.4% in professional occupations 22.0% Respondents percentage in 20% managerial occupations UK population percentage 10.8% in managerial occupations 10% 0% We cannot claim that our sample is representative of the trans population as a whole. Rather, we would suggest that given the number of respondents and the correlations with previous research we can claim that it is significant enough to draw some conclusions which allow us to highlight: where inequalities and discrimination are experienced by trans people. areas in which future research can usefully be undertaken to discover the real extent of inequalities and discrimination experienced by trans people. trigger points which lead to inequalities and discrimination, which in turn suggest sectors in which positive action could be taken now to reduce the extent of inequalities and discrimination experienced by trans people. 22 National Statistics 2003. 30

5 Not fit to be seen in Public: Work, Papers, Health and Social Life 5.1 Workplace Discrimination ... most firms “claim” to be trans friendly... but, although it is illegal to discriminate they do ... but they find another reason to justify it. The Gender Identity Clinics (Charing Cross especially) want you to have a full time position ... the employers want you in your original gender ... never the twain shall meet! (Survey respondent) was Managing Director of my own group of companies at the time immediately pre- social transition. The fact of my social transition was deemed a failure of fiduciary duties, and I was required to resign by the board. (Survey respondent) I had to leave job after transition due to being told I would have to continue using male facilities such as toilets and changing rooms. (Survey respondent) 5.1.1 A Job for Life: Which life? Our research found that the area of employment was the most problematic for trans people. In the searches of the Electronic Materials database (EMD) we found messages where trans people repeatedly described harassment at work, dismissal from employment or a significant change in working conditions at the point of beginning to live in their acquired gender. These findings were backed up by the results from the survey. Transition at work is a crucial part of the process of gender reassignment as trans people are assessed by their ability to maintain employment, voluntary work, education or training.23 Moreover, those who assess people’s suitability for gender reassignment play a significant part in the process for applications for the Gender Recognition Certificate.24 In other words, if a trans person undergoing gender reassignment cannot function well in their acquired gender at work, their application for a Gender Recognition Certificate, with all the legal protection it grants, may be jeopardised. Our research finds that transition in a place of work is a major trigger point for experiencing inequality and discrimination. For trans people, discrimination and inequalities seem to occur from the point of transition and not before in their career. In other words, our survey and the materials from our EMD suggest that many trans people have successful careers (see Figure 4.10 for numbers in professional or managerial occupations) up to the point of beginning to live in their acquired gender – the transition is the point where problems occur. 23 East Sussex, Brighton and Hove City PCTs Transgender Mental Health and Gender Reassignment Care Pathway (draft September 2006). 24 Applications for the Gender Recognition Certificate normally have to be accompanied by a letter from the consultant psychiatrist who has monitored the person’s gender transition from the beginning. 31

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 5.1: Respondents living/not living permanently in their preferred/acquired gender 600 531 400 342 Number of respondents not living permanently in their preferred gender role: 39% Number of respondents living permanently in their 200 acquired gender: 60.8% 0 Bearing in mind that research has found that gender reassignment results in considerable benefits in terms of quality of life for people with gender dysphoria (Pflafflin and Junge 1998)25 our findings suggest that many trans people are not fulfilling their potential because of the current climate in the workplace. Moreover, of those respondents who stated they were not living full-time in their acquired gender, 42% stated that it was their job or workplace which was preventing them from doing so (Figure 5.2). Figure 5.2: Respondents not yet living in their preferred gender role, who stated that their job or workplace prevented them from doing so Respondents not living permanently in their new gender role 42% who claimed there was some reason other than the workplace for not living permanently in their preferred gender Respondents who stated the 58% workplace prevented them from commencing living permanently in their preferred gender role The 4 out of 10 trans people who do not live permanently in their preferred gender because of their workplace, are not covered by current employment law, nor indeed the legal protection granted by possession of a Gender Recognition Certificate. 25 Pflafflin and Junge’s (1998) research constitutes the most comprehensive longitudinal review of gender reassignment covering 30 years and reviewing over 70 studies of 2000 patients in 13 countries. The review looked at the quality of life in terms of subjective satisfaction; mental stability; socioeconomic functioning; and partnership and sexual experience. 32

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination These findings suggest that despite the recent legislation regarding transsexual people in employment, employers are either failing to prevent inequality and discrimination for trans employees, or respondents lack faith in their employer’s ability to support them in their transition or comply with employment protection legislation. 5.1.2 Current Obligations under Employment Law The Sex Discrimination (Gender Reassignment) Regulations 1999 (SD[GR]R) which amended the Sex Discrimination Act 1975, were introduced expressly to protect transsexual people who were proposing to undergo, were undergoing, or had undergone gender reassignment, from discrimination in employment or vocational training.26 However, the amended SDA made special provisions for areas where: it may not be unlawful to discriminate on grounds of gender reassignment, both temporarily during the period of gender reassignment treatment (for example regarding accommodation and vulnerable people and personal care) and overall (for example statutory searches). (Whittle 2002: 108). The Gender Recognition Act 2004 (GRA) removed the bar from performing personal care, work for vulnerable adults or searching when performing a statutory duty, for those with a Gender Recognition Certificate. However, the limitations relating to religious organisations still exist, and since the case of Croft v Consignia,27 (see below on the use of toilet facilities) it has yet to be seen whether sharing of accommodation is still a problem area. The Employment Equality (Sex Discrimination) Regulations 2005, protect transsexual individuals from harassment or the creation of ‘an intimidating, hostile, degrading, humiliating or offensive environment’) in relation to gender reassignment, regardless of stage (EE[SD]R 2005, 5[3][a ii]). Exceptions to gender- based ‘genuine occupational qualifications’ have been redefined as a distinction is made between individuals who have not started gender reassignment treatment, individuals who have acquired their gender under the GRA 2004, and by proxy, individuals in the process of gender reassignment treatment and who are not in receipt of a GRC for whatever reason (EE[SD]R 2005, Reg. 9). The Gender Equality Duty Draft Code of Practice 2006 (GEDDCP) (coming into force in 2007), clarifies the employer’s duty to ensure transsexual employees are adequately covered by workplace policies (GEDDCP 2006, 2.66), an area in which many employers have been slow to make changes.28 It also reiterates existing protection related to gender reassignment (GEDDCP 2006, 1.20) as well as the employer’s statutory duty to prevent discrimination against transsexual employees, regardless of the stage of gender reassignment they are at (GEDDCP 2006, 2.67). Unfortunately, the Duty makes clear that such protections only apply to individuals who fit the current legal definition of transsexual, thus continuing the exclusion of transgender and other gender variant people, even though the duty acknowledges that they too face discrimination and harassment based on their gender (GEDDCP 2006, 1.22). 26 SD[GR]R 1999 2A[c]. 27 Croft v Consignia [2002] All ER (D)179. 28 In terms of confidentiality, harassment, access to development, occupational insurance and pensions. 33

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination The Equality Act 2006 (EA) mentions individuals who have proposed, commenced or completed gender reassignment as a group which falls within the remit of the new Commission for Equality and Human Rights (EA 2006 1, 10 (2d)). Again there is no express mention of transgender or gender variant people other than those individuals who fit the statutory legal definition, which clearly is intended to only afford protection to the small sub group of transsexual people who seek medical supervision for gender reassignment. 5.2 Problems at Work Despite the legal protection for those who are living full-time in their acquired gender, our research suggests that current workplace practices are not protecting trans people. Indeed, it would seem that although organisations may claim in their diversity policies that they assist people in their gender transition, many do not have procedures in place that do so. Messages from the EMD reported harassment, problems with toilet facilities and difficult or impossible working conditions at the point of gender transition. The following story exemplifies these problems: I work for the ******* store and have been there for 7 years, last December I was diagnosed with gender dysphoria, and approached my personnel manager about transitioning at work... We had a verbal agreement that I would use the ladies locker room and the customer disabled toilet, I started back to work as ****** (new name) put my stuff away and started work. Half an hour later I was summoned to Personnel, told there was no way I could use the locker room and was made to take my stuff out and carry it though the whole shop and keep it in a computer games cupboard... I was not allowed a key and had to ask a supervisor every time I needed my bag or coat, I was also sitting on the checkouts and getting abuse from customers which led to panic attacks, but they refused to take me off them. I managed to get in touch with my regional Manager and he arranged a meeting with the Manager, my store manager and myself, they told me they had wasted too much time and money on me and that they didn’t know what to do with me and that they would not be supporting me... I was given a filing cabinet in the car park attendants office for my bag and, they also decided to keep the disabled toilet locked because it had been vandalised so often and my only alternative was to cross the car park and use the garage toilet. (Correspondence with Press For Change) The working conditions had become so difficult for this trans woman that eventually she was rude to a customer and was suspended. When she returned to work she felt that she could not complain any more about her working conditions as she was on a final warning. This trans woman was in danger of losing her job after 7 years of working for this large supermarket store because the employer failed to have a procedure to deal with her transition – as stated, they ‘didn’t know what to do’ with her. This story was typical of many we read in the EMD. 34

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination 5.2.1 Toilets Problems using toilet facilities consistently appeared on the EMD and this was backed up by our survey data. Using the toilets of one’s acquired gender is an entirely appropriate and necessary part of the ‘real life experience’ protocol of gender transition.29 The question of toilet access in one’s new gender role has been considerably complicated by the Employment Appeal Tribunal decision in Croft v Consignia.30 The decision has left a lacuna which even those who are undergoing, intending to undergo or who have undergone gender reassignment can fall through, as the ‘reasonableness’ test first proposed in the SD(GR)R 1999 consultation paper (DfEE 1998) appears to have been embodied in law. It could be argued by those assessing a patient’s readiness for surgery or further treatment through the Real Life Experience that using the toilets of one’s former gender or a disabled toilet did not constitute living in one’s appropriate gender role. It would also impact on the period of time a person could claim they had been living ‘permanently’ in their new gender role when applying for a Gender Recognition Certificate. Figure 5.3: Percentage of respondents who were required to use the toilets of their former gender or the disabled toilet at work, after transition 22% Yes No 78% 29 The real life experience is intended to usually last for a minimum 12 months (see Harry Benjamin: International Gender Dysphoria Association Standards of care, version 6, 2001). During this time a trans person needs to be living full-time in their acquired gender and have changed the gender and name on all their documentation. 30 Croft v Consignia [2002] All ER (D)179. 35

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 5.4: Respondents’ experiences when using the toilets of their preferred/acquired gender at work 90 40 80 35 70 30 60 25 50 20 40 15 30 10 20 5 10 0 0 Treated Inappropriate Verbal abuse Physical abuse Nothing like -5 differently comments this Number Percentage These (cumulative) figures show that over 1/5 of trans people are asked to use the toilets of their former gender or disabled toilets whilst at work, and of those using toilets appropriate to their acquired gender, a significant number experience being treated differently in a negative way or subjected to inappropriate comments or abuse. Research on trans people at work conducted shortly after the Sex Discrimination (Gender Reassignment) Regulations 1999 employment protection legislation came into place found that only 76% of respondents were permitted to use the toilets appropriate to their acquired gender at work (Whittle 2000) which is close to our figure of 78%. These findings show that little has changed in terms of appropriate toilet facilities for trans people in the last 6 years. At the time this report was going to press, Press for Change received a letter which exemplifies what some trans people experience regarding toilet and changing facilities at work. It concerns a trans woman who transitioned at work 3 years ago whose employer, a large Public Sector organisation, continues to refuse to let her use the appropriate toilets. The letter from Human Resources reads: **** confirms that you cannot legally change your sex from that which is on your birth certificate until you have undergone the operation to remove your penis, therefore I have to inform you that you will not be able to use the female changing facilities until this has taken place’. This employer is misinformed. It is not legally necessary to undergo genital surgery for legal recognition of one’s acquired gender and to receive a Gender Recognition Certificate. Neither is there any law about what genitals you need to access gendered facilities. 36

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination 5.2.2 Harassment There has also been little improvement in the last 6 years in terms of other forms of harassment at work. Our research found that many respondents experienced harassment from co-workers and employers. The following excerpts from the EMD exemplify the experiences of trans people in our sample at work: I finally threw the towel in at work (civil service) because of almost five years of harassment and discrimination. I was left for months, unable to use male or female toilets because no one liked it and warned off wearing ‘frocks’ to work! My employer, an equal opportunities employer, could not offer me a job free from harassment anywhere. (PFC Corres 1999 B1956) I have a few jerks in work that think its (sic) amusing to call me over the tannoy using my former name. (FTM UK F6) I started work with ****** who had team meetings and outed me [as trans] to everyone in team meetings before I started in my department and also told them my birth name! This resulted in me receiving anonymous threatening notes at my desk. (FTM UK F4) The findings from our EMD concerning harassment of those transitioning at work were also backed up by our survey. Figure 5.5: Respondents’ treatment by co-workers because of their acquired gender 180 35 160 30 140 25 120 100 20 80 15 60 10 40 5 20 0 Treated Inappropriate Verbal abuse Threatening Physical abuse Nothing like 0 differently comments this Number Percentage We can see from Figure 5.5 that nearly 29% of respondents experienced verbal harassment (comments) at work and some also experienced verbal abuse (name calling) and threatening behaviour or physical abuse. These figures are comparable to research conducted in 2000 (Whittle) which found that 24% of respondents experienced harassment at work. This suggests that in the 7 years since employment protection legislation for trans people was introduced, many employers are failing in their legal duty to protect employees living in their acquired gender from harassment. If we also compare our findings of over 23% of respondents who had changed their job or planned to because of their 37

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination transition with Whittle’s (2000) employment survey, which found that 29% had left their employer voluntarily or left because of conditions due to transition, we can see that little has changed in the last 7 years (see Figure 5 6). Figure 5.6: Respondents who changed job or intended to change job because of their transition 23% Changed Job/likely to Not changed job/nor likely to 77% These finding suggest that respondents were either forced to leave their place of work because of their transition or left because they did not feel that their employers would support them or comply with the law. Figure 5.7: Experiences at work by gender 30 23% 19% 20 Trans men 17% 15% Trans women 10% 10 7% 0 Changed job Missed Promotion Informally excluded Figure 5.7 compares the experiences of trans men and trans women (who had transitioned) at work in terms of changing job because of their transition, missing promotion and feeling informally excluded at work. Our findings are that slightly more trans women (23%) changed their jobs compared to trans men (15%) and that the differences were negligible in terms of missing promotion (trans men 7% and trans women 10% respectively) and feeling informally excluded (trans men 19% and trans women 17% respectively). 38

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Our findings suggest that many employers lack adequate procedures to support their employees undergoing gender transition, or follow employment protection legislation. Many messages from our EMD and respondents to our survey reported impossible working conditions, bullying and harassment after gender transition, some of which led ultimately to them losing their jobs – either by dismissal or resignation. When we asked survey respondents to say why they left their jobs because of their gender transition, most reported incidents of bullying and organisational incompetence in dealing with their gender transition. Below are some typical examples: I transitioned in December 2002. The consequential bullying and discrimination I experienced from my line manager resulted in my long term sickness. An internal grievance hearing in which he was found guilty of gross misconduct took place but insufficient action was taken to secure my safe return to work. An Employment Tribunal followed in which I settled out of court. This included my resignation in March 2005. (Survey respondent) I did not intend to change my employment but because of bullying and discrimination directly related to my transition I eventually felt compelled to resign. I have been looking for alternative employment since that time in September 2005. (Survey respondent) My previous employment was with a small private company. I announced my intended transition in 2003 and at the end of the same week my employer terminated my employment. (Survey respondent) The company claimed initially to be supportive, but ultimately I was subjected too (sic) bullying, and resigned. (Survey respondent) It is worth noting that three of the four people in the examples above document their problems at work occurring within the last 3 years – at least 4 years since the introduction of the employment protection legislation. It is also worth reiterating that prior to transition, these respondents did not encounter discrimination or inequality in the workplace – many had very successful careers. One of the aims of the Equalities Review is that everyone can reach a ‘capability threshold’ in order to have a role in modern society – for example achieving a minimum standard of education as well as an entitlement to work (when able) and a place to live. Our research has found that many trans people exceed this criteria and are outstanding in their level of educational achievement (see Figure 6.8) and occupational class (Figure 4.10). Yet, our findings on discrimination in the workplace suggest that post-transition trans people’s capability to play an autonomous role in society can diminish. Not only is this a significant waste of the talents and resources that these people have brought to an organisation, it can also mean burden on the judicial system and pension and benefit systems through employment tribunals and unemployment. Organisations and businesses need to understand that a change in gender does not equate a change in the value or skills of an employee. We recommend: More research needs to be done on why employers are failing to comply with the law and protect trans employees. 39

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Trans awareness raising and training for employers and those working in Human Resources. Our research finds that high numbers of trans people (38% of our sample) fall outside of the legal definition of ‘transsexual’ and are not offered that legal protection. We have also found people within this group are intending to transition but current workplace conditions are preventing them from doing so. We further recommend: That the legal limitations defined under statutory law should be revised so as not to be as definitive or exclusionary, and should be extended to protect many more trans people including those not intending to undergo gender reassignment surgery. 5.3 Changing Documents One of the first steps in the process of gender transition is usually the changing of name and gender on all documentation. Indeed, possessing documentation in one’s acquired gender is regarded as proof of fulfilling one of the protocols of the ‘real life experience’ at Gender Identity clinics. Moreover, when applications for a Gender Recognition Certificate (GRC) are assessed, the date when documentation changed is normally understood as the time when gender transition occurred. Since the mid- 1970s, at least,31 the procedure for changing gender on most documentation has involved obtaining a letter from a GP or other clinician stating that the holder is undergoing treatment for gender dysphoria, is now living in the gender that the applicant is requesting their documentation be changed to, and that this change is intended to be permanent. This is normally accompanied by a statutory declaration or deed poll as evidence of the change of name and gender title. Messages from our EMD consistently documented the failure of organisations to make these changes – for example banks, insurance companies, universities, doctor’s surgeries and even the DVLA. It would seem that for many organisations there is no set procedure – or not one that their employees are aware of. Thus, when a trans person presents a request for changes of gender on documentation they are often told that a change of gender is not possible. These examples from the EMD exemplify the problem: I tried to change my bank account details today but not only would they not change my title to Mr (they said I need gender recognition certificate) they wont even change my name even though I have legally changed it via deed poll. (FTM UK B5) He applied for a change of details on his driving licence, submitting his name change details and a letter from [consultant psychiatrist] which stated that his gender change was permanent. He received his licence back with only his name changed, but his gender code unchanged – included was a letter saying that gender codes would now only be changed after ‘completion of final surgical procedures’. (Corres 1999 1135) 31 Based on personal experience of lead researcher. 40

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination I have informed the local NHS hospital where I am employed that I would like the details changing on my health/medical records. I have given them the relevant statutory declaration. The clerk says that the name only can be changed and that my title and gender must reflect what is stated on my birth certificate. (Corres 2001 Q2 Docments B4) I have just changed my details at the Doctors, But they tell me that I cannot change my Title, It will remain as MR and not change to MRS. Can you advise me what if anything I am able to do, It will seem quite odd to people that when I phone up, I will have to say Mr. (Corres 2005 Q1 B5554) 5.3.1 The Problems Arising from Gender Recognition Certificates The Gender Recognition Act (2004) seems to have compounded the issue in some instances. It now seems that organisations are requesting a GRC or proof of surgical status, as proof of gender and name change, rather than a letter from a GP or consultant psychiatrist and a legal change of name document. A University for example recently refused to change the name on a Degree certificate until the former student obtained a GRC. Consequently, the trans man concerned was unable to take up a place to study a postgraduate course without disclosing his former status. Many organisations clearly do not understand that: Applications for a GRC require proof that a person has been living in their acquired gender – paradoxically, this involves proof of change of name. Surgery has never been a legal requirement for change of gender on documentation. Applications for a GRC do not require proof of surgery. Changes of title (from Mr to Miss or Mrs) are not changes affecting legal gender status. Under the circumstances described above then, many trans people cannot change their name and gender on a variety of ‘day to day’ documentation because some organisations are requiring a GRC before making the changes, yet one cannot apply for a GRC until there is proof that one has been living full-time in one’s acquired gender (by providing documents in one’s acquired gender). Moreover, GRCs have to be applied for and paid for in many circumstances – they are not automatically issued to all trans people, as many organisations seem to assume. It would seem then, that faced with a trans person requesting changes of documentation and without a procedure in place, many people in organisations supplying documentation, incredulous of the request, and lacking the appropriate knowledge, make unreasonable refusals to alter documents and/or unreasonable demands on the trans person requesting the change. This causes immense difficulty for a trans person beginning to live their life for the first time in their acquired gender. There needs to be a ‘map’ of appropriate procedures in place which organisations can follow. We recommend: That a government resource be made easily accessible to trans people and others, which stipulates the legitimate protocol for name and gender changes and the legal consequences for failing to comply. 41

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination This would also inform trans people of the correct procedures they should follow as well as helping them when faced with those who do not know the correct procedure. It should also be sent to large service organisations such as government departments, insurance companies, the DVLA, GP surgeries, banks and also to employers. 5.4 Accessing Healthcare My endocrinologist refuses to treat, recommend or monitor trans people. (FTM UK A11) I had to change GP because he just could not accept gender dysphoria as being real. (FTM UK A16) I was put in a side room on the Woman’s Surgical Ward. I was told that before I had even arrived on the ward the word had gone out that a man was being put on the ward. My stay was made a living hell by one Staff nurse which all the other seemed to follow. (Male-to-female trans woman describing her experience of non trans-related hospital treatment) (Health Stories B81) I have a beard, a very deep voice and have been a man for many years. The problem is that with years of testosterone, you get all sorts of genital problems as the skin around the ‘old’ genitals atrophies. My GP did not know what to do recently, when I was very sore, and sent me to the local STD clinic. I had to speak to a receptionist (not a nurse) on the phone to make an appointment. She insisted on knowing the problem. I explained to her very carefully – the first thing she said was ‘we have an appointment on Monday morning at the women’s session’. I didn’t go. (FTM network personal correspondence, 004 February 2006) ...there was the nurse explaining to her colleague as they left my room, ‘Oh, that’s a woman who wants to be a man’, clearly audible both by me and by other patients and visitors. (Female-to-male trans man) (Health Stories B71) 5.4.1 Introduction The question of healthcare access is crucial to trans people who wish to undergo hormonal or surgical treatments in order to live permanently in their preferred gender role. Although gender reassignment treatments have been available and used since the mid-1940s, they were always considered to be on a sort of moral border-line, with physicians and lawyers debating the possible liabilities for ‘maiming’32 the patient, and the implications of affording any sort of treatment for people who were seen as mentally disturbed. The debate was not helped by the inclusion of ‘Transsexualism’ in the Diagnostic Statistical Manual of the American Psychiatric Association in 198733. The debate has not abated, but regardless of its terms it is clear that the majority of authorities accept Professor Richard Green’s view that: Severe Gender Dysphoria cannot be alleviated by any conventional psychiatric treatment, whether it be psychoanalytic therapy, eclectic psychiatric treatment, aversion treatment, or by any standard psychiatric drugs. (Cited in Bellinger, 2001, para 32)34 32 Maiming originally meant the removal of a healthy limb or ‘member’, and was subject to punishment as a criminal act. 33 DSM-III-R, 1987. 34 Bellinger v Bellinger [2003] 2 All ER 593. 42

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination In almost all cases the only successful treatment is gender reassignment (Pfafflin and Junge 1998). Further, despite a psychiatric assessment and evaluation still being the start of most gender reassignment treatment routes, in 2002 the government announced a new policy on transsexual people in which it stated: “transsexualism is not... a mental illness.”35 Prior to this, the 1999 Court of Appeal ruling in the case of R v North West Lancashire Health Authority ex pA, D and G36 should have had significant ramifications for Health Authorities (now PCTs) in terms of the funding of treatment of any kind relating to gender identity issues. The ruling recognised that gender reassignment is the appropriate medical response to Gender Identity Disorder and that it would be unlawful for Health Authorities (PCTs) to operate anything that amounts to a blanket ban on funding in such cases. As such, one would normally expect of all the services that trans people use, that the health sector would be the least problematic – bearing in mind that gender dysphoria is a recognised medical condition. One would expect treatment for gender reassignment to be accessible within the normal remit of non-malfeasance and waiting list targets of the NHS. Unfortunately, for many trans people, nothing seems farther from the truth. Press for Change and the FTM Network receive many enquiries relating to health care access. Undergoing gender reassignment requires the support and services of general practitioners, endocrinologists, psychiatrists, surgeons, and nurses as well as support staff. Results from the EMD found that accessing healthcare was the third most common trigger point and the third highest sector where trans people encountered discrimination and inequality. 5.4.2 Seeking Help from the Family Doctor The situation finally came to a head about five weeks ago, when I made a polite request about having my hormone levels checked (I was a little concerned about testosterone); the GP blew up in my face for reasons I can’t guess at, continuing to talk about me to the nurse in front of me as if I wasn’t even there, using male pronouns (I filed my stat dec last October). (Health Stories, PFC CB e: 16-06-01: CB) It is crucial to have the support of one’s GP when undergoing gender reassignment – not only is the first step a referral from one’s GP to see a consultant psychiatrist, but they are involved in writing referral letters and monitoring general health at all stages. Many trans people encounter problems at this stage as GPs either lack the information, refuse to help, or state that the Health Trust does not have funding. 35 Government Policy concerning Transsexual People, 2002, http://www.dca.gov.uk/constitution/transsex/policy.htm. 36 R v North West Lancashire Health Authority ex pA, D and G [2000] 1 WLR 977. 43

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Recent research in Scotland found that professional isolation and ignorance of gender identity problems were widespread and that professionals held polarised views of transsexualism and gender dysphoria, ranging from strong moral disapproval to considerable empathy (Scottish Needs Assessment 2001). Other research on the commission of services for the assessment and treatment of trans people in England Scotland and Wales found that they were not uniform across the UK with some refusing to fund treatment – thus being in breach of a recent High Court ruling and the Human Rights Act (Murjan et al 2002). In studies in the 1960s, Richard Green discovered a very poor attitude amongst many local family doctors in the US (Green et al 1966, Green 1969). In his survey, over 25% of family doctors expressed an unwillingness to provide any advice or treatment at all for their trans patients, and 8 actually said they would rather their patient committed suicide than had any treatment that would enable them to live in the opposite gender. Today one would hope that no doctors would express a similar view about their patients but it is clear from the results of the survey that there is not sufficient knowledge held by GPs and there are some (6.3%, or 38 of 599 respondents’ GPs) who still refuse to help access to treatment services. Overall 19.5% (117 of 599) of GPs were not trans friendly, in fact the opposite. This is not significantly different from the figures obtained by Green in his studies in the 1960s. Consequently 1 in 5 trans people find their GP unhelpful. However, 80% (482 of 599) of GPs were willing to help, but 60% of those who wanted to help lacked appropriate information (365 of 599) (Figure 5.8). Figure 5.8: How GPs responded when patients sought advice on gender reassignment 400 70% 350 60% 300 50% 250 40% 200 30% 150 20% 100 50 10% 0 Wanted to help but Was informative Did not appear Refused to help 0% lacked information and helpful to want to help Number Percentage There has however been an improvement over the years, when comparing the responses of those who transitioned over 15 years ago, to those who transitioned in the last 3 years (Figure 5.9). 44

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 5.9: Percentage of respondents whose GP did not appear to want to help or refused to help access gender reassignment services, by date of transition 35% 33% 30% 25% 19% Transitioned 20% < than 3 years ago Transitioned 15% > than 15 years ago 10% 5% 0% 5.4.3 Other Healthcare I’m currently in dispute with my local PCT regarding the funding Postcode lottery, concerning treatment for transsexual patients.... There are guidelines specifically written by top UK medical & legal experts for commissioners, but the Mid Sussex PCT say until you adopt them or until someone takes them to court, they can ‘push them aside’ if they wish. (Correspondence with Press for Change) A couple of weeks ago now I received a decision from Health Commission Wales on funding my treatment – the answer was that they wouldn’t. At the moment I don’t know why other than a man from HCW telling me once more that they couldn’t justify paying for something of low clinical priority, even in spite of the fact that they looked at my referral request as an exceptional case, and that my local Psychiatrist had given them evidence of significant clinical distress and a potential for self harm or suicide unless I received treatment. I simply don’t know where I stand now, and have no specific information to work on. In any case, all the options I am left with are options I don’t like, and I’m sliding quite quickly into a far more severe depression. I’ve seen my GP who was no help at all. (Correspondence with Press for Change) Results from the EMD detailed many local health authority funding refusals or refusals for care from individual health service workers who expressed personal prejudices about gender dysphoria. This was backed up by the survey material when we asked if respondents had ever been refused treatment by a doctor or nurse because they did not approve of gender reassignment: 45

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 5.10: Percentage of respondents refused treatment by a doctor or nurse because they did not approve of gender reassignment 500 80% 70% 400 60% 300 50% 40% 200 30% 20% 100 10% 0 Refused or delay in No delay or refusal Don’t know 0% Treatment Number Percentage The process of undergoing gender reassignment involves frequent contact with health service professionals. Our research also found that trans people frequently had bad experiences – for example being addressed incorrectly, being put on the wrong ward for their acquired gender (see narratives above) or staff allowing their personal feelings about transsexualism to be known by the patient. We also found that those who have transitioned many years earlier encounter problems when accessing routine health care that is non-trans related as often health care professionals can only see their health through the lens of being trans. We found that 22% of survey respondents if they felt that being trans affected the way that they could access routine treatment that is not related to being trans. We also found that 29% of respondents if felt that being trans adversely affected the way they were treated by healthcare professionals: I went to a GP having persistent problems with my digestive system and getting an upset stomach a lot. The GP was very dismissive, did no tests and said it was my own fault for putting something into my system that is not meant to be there – Sustanon [hormones]. (Survey respondent) A doctor supposed to be treating me for appendicitis exposed my genitals for a group of students to see. (Survey respondent) Referral for knee surgery 2001 – the letter was mainly about my being trans and only mentioned my knee in passing. (Survey respondent) After tests following a head injury, the doctor wrote to my GP starting with: “This transsexual...” which was completely irrelevant to the injury. (Survey respondent) Cleary some healthcare professionals do not know how to deal with trans people appropriately. Indeed, the evidence above suggests that some healthcare professionals have a tendency to see trans people as transsexual first – regardless of the non-trans healthcare needs that they may present with. 46

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination 5.4.4 Has access improved over the last 15 years? We considered therefore whether access to treatment was any easier now than it was over 15 years ago and did a comparison of survey respondents who transitioned less than 3 years ago with those who transitioned over 15 years ago. Those refused or made to wait for treatment relating to transgender or transssexual health care, including gender reassignment, were told that the local health authority or primary care trust did not have the funding for any, or all, gender reassignment services. The government stated on November 10th 2004 that the median waiting time was 3.72 months for a patient with a mental illness to receive an initial outpatient appointment with a consultant following a referral by a general practitioner’.37 Furthermore the 1977 National Health Service Act recognises Gender Identity Dysphoria to be a mental illness38 and in the case of A,D & G v N.W Lancashire Health Authority, December 21st 1998, Hidden J held that to require the applicants to suffer from a pathological psychiatric disorder before treating them was irrational, as it would preclude surgery for which mental stability is a precondition. The median waiting time for an initial outpatient appointment with a consultant specialising in Gender Identity Dysphoria is two years; for many it is far longer: My current earliest referral date to be seen at Leeds is December 2006 but more likely the spring of 2007. In April 2006 I will be eligible to change my birth certificate because I have documentation to prove that I have been in role since April 2004. Does that mean that I am then deemed in law to be female? If so would that allow mean [sic.] to by-pass the GIC [gender identity clinic) system and ask for referral for surgery? This would not be to ask for gender reassignment surgery, because the law as [sic.] categorised me as female, but requiring vaginaplasty as it is appropriate for any other women to access. Is that a sustainable argument? Since the Gender Act requires you to live in role for two years this situation shouldn’t arise unless of course you allow your waiting list for a first appointment to reach two years or more. My dispute with **** PCT is that they insist that I am treated at the **** Gender Identity Clinic. My objection to this being that there is approximately a three-year wait at **** for treatment and to me this is an absurd length of time to remain untreated. This was why I asked my GP if I could be referred to **** GIC which has a six month waiting list and the PCT have refused because they do not have a service agreement with ****. (Health Stories PFC STW e: 9-12-05: CE). 37 Reply by Rosie Winterton MP to Lynn Jones MP (Hansard [196604] 10/11/04). 38 Listed as such in the Diagnostic and Statistical Manual. 47

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Funding refusals by PCTs either for initial assessment or later surgical procedures are now a major problem for trans people. In the example above, Press for Change has been working for the last 2 years with a group of 5 trans women from the Calderdale Health Authority area. Using the services of a solicitor, their MP and the local Council, it was discovered that their PCT has a service agreement with the Leeds Gender Identity Clinic for the treatment of transsexual patients. It pays £13,323 a year to this clinic for gender re-assignment, patients’ psychiatric treatment and preparation for surgery. However, the hospital did not have anyone specialising in trans assessment and diagnosis for over a year and so no one was seen, despite the money being paid. Now the hospital is running 1 clinical session per week. But the people in the area have been told that the waiting list for them to be given an appointment for assessment is another 3 years.39 In one case, the trans woman will have been living permanently in her new gender role for 4 years, and could apply for a gender recognition certificate, except she will still not have had her assessment and diagnosis, which is needed for the GRC application (Sutcliffe 2006). The charts below indicate that access to healthcare for those respondents who transitioned within the last 3 years is very similar now to the levels of service for those who transitioned over 15 years ago: Figure 5.11: Percentage of respondents who faced problems in obtaining funding from their primary care trust, by date of transition 30% 26.90% 27.20% 25% 20% Transitioned < than 3 years ago 15% Transitioned > than 15 years ago 10% 5% 0% 39 Emails and letter received by Press for Change between 2004 and 2006 48

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 5.12: Percentage of respondents refused or made to wait far longer than 6 months after referral from GP, for initial assessment for possible gender reassignment, by date of transition 35% 30.3% 30% 26.90% 25% Transitioned 20% < than 3 years ago Transitioned 15% > than 15 years ago 10% 5% 0% Figure 5.13: Percentage of respondents refused access, or made to wait longer than expected, for trans-related healthcare after clinical recommendation 39.6% 40% 36.3% 35% 30% 25% Transitioned < than 3 years ago 20% Transitioned > than 15 years ago 15% 10% 5% 0% We can see from Figures 5.11-5.13 that there has been little improvement for those who transitioned less than three years ago compared to those who transitioned more than 15 years ago in terms receiving funding from their primary care trust, being made to wait for initial assessment and being refused or made to wait to access trans related healthcare. On the other hand, the figures appear to show much better access levels for non- trans related health care in the last three years (Figure 5.14). But one should not be too optimistic: the fall from 30.3% to 11% may be because those trans people who have recently transitioned may not as yet have had a need to access much non-trans related health care. 49

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 5.14: Percentage of respondents who felt that being trans had affected the way they could access non-trans related routine treatment on the NHS 35% 30.30% 30% 25% Transitioned 20% < than 3 years ago Transitioned 15% > than 15 years ago 11.10% 10% 5% 0% Overall, the health care access situation for trans people is difficult, with 30% or more facing difficulties whether trying to get information from their GP, obtaining funding for GRS, being made to wait for accessing health services or surgery, and accessing ordinary non-trans related health care. That is 1 in 3 trans people who do not get appropriate responses from health care professionals in the NHS, or have equal access to services. Of the respondents to the health care section, 1 in 7 trans people feel that they are treated adversely by health care professionals because of their trans status (Figure 5.15). There has been a very small drop of 0.6 from levels of adverse treatment reported by those who had transitioned over 15 years ago. Figure 5.15: Percentage of respondents who felt being trans adversely affected the way they were treated by healthcare professionals, by date of transition 20% 14.20% 15.10% 15% Transitioned < than 3 years ago 10% Transitioned > than 15 years ago 5% 0% 50

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Clearly, in light of the Equality Directive 2004/113/EC, action needs to happen soon and we would recommend that all healthcare providers, including ancillary and support service staff need: A staff development structure that regularly raises training about trans people’s issues; An understanding that because someone is presenting with a trans issue, there is no basis, such as a conscience clause, for any doctor to refuse help whether referring onwards, providing regular hormone prescriptions, or ordinary health care; Education on what it is to be a trans person, on trans patient’s rights, including the right to dignity, decency and respect, and especially the right to privacy as afforded by the Gender Recognition Act 2004; Training to ensure an awareness that once a person’s trans issues have been addressed, they will still have the ordinary health problems that other people face; Training on recognising that trans people, when presenting with non-trans related health problems, need treating equally alongside other patients; Simple education and leaflet guidance for doctors, nurses and other health care staff on how to work with trans patients on issues of dignity, particularly the right to be treated as a member of their new gender, and privacy obligations. 5.5 Going Out: the Street and Bar 5.5.1 Introduction: Experiences as Adults in Public Spaces Extracts from the EMD indicate that trans people were most at risk of discrimination and harassment in the following spheres of life: As young adults at school. As young adults in their own accommodation. As adults in public settings while undergoing transition. As trans adults who are in a marriage or partnership, after undergoing transition in social settings. The trigger points that tended to initiate the harassment were when the trans individuals involved: started cross-dressing; or transitioned in social life; or were starting puberty. The sectors within which most of the harassment was experienced were in dealings with the police, in the leisure industry sector and in the higher education sector. 51

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination The extracts below from the EMD illustrate clearly that the instances of abuse described were unprovoked. The physical abuse suffered included beating, punching, kicking, pushing and slapping. In some cases sharp objects such as knives were used. In 6 months I have a window broke, a shed set on fire, death threats, threats to be burnt out, assaulted, harassed, but there has been no crime scene. But now DPP prosecution over this: I dropped biscuits going down stairs at the arts centre... I subsequently went to leave a note to apologise for what happened, knocked over a box of poppies & also a Bonsai plant that was on a plate, the plate smashed. I waited to see someone to say what happened, someone came, told me to leave & go home. A few days later I was arrested & charged for criminal damage. I informed the arts centre of the reasons of my clumsiness & anxiousness. At this stage I was living as a woman. The whole situation was taken like a crime scene, photos of the items that I dropped/knocked over to make it like a real crime scene. I offered to pay for the item that broke which was the plate. (MTF Correspondent) I was attacked because I am MTF but a police officer asked me for my status. (MTF Correspondent) ... They followed and started hitting me again on the street I managed to get back on the bus but so did they. When it stopped again I again tried to escape and again I got a beating. This went on for at least 10 minutes in total. I took at least 20 punches in the head and about the same on my body. (MTF Correspondent) I was attacked in the Student Union at ‘x’ University for being “A transgender cunt” and had a knife thrown at me which hit me just above my right eye. Our Student Union does not have a good record of upholding equal opportunities to both the Student Union and the University itself. (MTF Correspondent) 5.5.2 Experiencing Other Adults in Public Spaces I’m afraid of the reactions of others. I am very afraid of the possibility of someone using violence against me. I’m afraid that I can’t take many more knocks to my self esteem. (Survey Respondent) Many trans people in our survey disclosed that they avoided public spaces when presenting in their acquired gender. We found that young trans people (ages 21- 25) suffered more instances of harassment in public spaces than the older age groups. Indeed those living permanently in their acquired gender, are more likely to avoid public spaces compared to those who do not cross dress at home (they only cross dress when they go out, and would then go to someone else’s home or a ‘safe’ bar or club). 52

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 5.16: Harassment experienced by trans people in public spaces 40% 35% 30% Inappropriate comments 25% Verbal Abuse Threatening Behaviour 20% Physical Abuse 15% Sexual Abuse Experienced no abuse 10% 5% 0% Total Numbers As Figure 5.16 shows, over a third – 36.8 % (277) of trans people (ages 18 – 75) who chose to present their acquired gender permanently, experienced negative comments whilst out socially, because of their acquired gender. Only 27% of respondents in the survey recorded that they had not experienced anything of the above while out in public spaces. This means that 73% of respondents experienced comments, threatening behaviour, physical abuse, verbal abuse or sexual abuse while in public spaces. It is worth giving further thought to the 27% (204) of trans people who present their acquired gender permanently who reported experiencing no abuse. Some may well have ‘disappeared’ and in day to day activities may now pass well enough to simply be treated as an ordinary man or woman. But many do not. On follow up with one trans woman who had completed the survey, she was asked why she had not said yes. The researcher knew her well, and knew of at least 2 instances when she had been mugged and robbed, and several more times when she had had problems in her neighbourhood. He reply was that she passed so well, it could not have possibly been related to being trans. It may be that trans women who do not pass well build up a personal story over many years that reflects a better passing than is reality. Another trans woman responded similarly on follow up. Thus it is possible that the figure of 27% is an under-reporting of the real situation. 53

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 5.17: Harassment by gender 80% 64% 57% 60% Verbal abuse Harassment 40% 24% 20% 20% 0% Trans men Trans women Figure 5.17 shows that there is little difference (7% or less) between the experiences of trans men and trans women in terms of harassment in public spaces. These findings counter the commonly held belief that trans men suffer much less harassment than trans women. According to Moran and Sharpe, trans people suffer abuse in social spaces in a way that other minorities do not.40 Genderpac’s survey of 402 trans respondents in the US seems to support this, reporting the following figures for experiences of transphobia: Figure 5.18: Genderpac survey results 90% 80% 70% 60% Verbal harassment Assault 50% Sexual assault 40% Attempted assault Sexual harassment 30% Assault with weapon 20% 10% 0% 40 Moran, L. J. and Sharpe, A. N. (2004) Violence, identity and policing: The case of violence against transgender people Criminal Justice Vol: 4(4): 395 – 417, p. 404. 54

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination However, trans people are not alone in being victims of hate crime: Stonewall’s 1999 survey41 recorded that 2/3 of a sample of 2656 lesbian and gay people reported themselves to be victims of homophobic incidents. There is a strong argument that much homophobic crime is actually transphobic, as it is a person’s gender presentation which attracts attention in public spaces rather than a prior knowledge of their sexual orientation. In other words, effeminate men or masculine women are more likely to suffer harassment and abuse (Mason 1996; Namaste 1996) than those whose gender presentation is more normative. Interestingly, proportionally less trans people reported experiences of abuse in response to our survey, than the figures in the Stonewall survey (1999). There could be two reasons for that – firstly the fact that the online survey did not have a focus on abuse in public spaces, and secondly an under-reporting of abuse experiences. As in the cases above, it could be that some deny that abuse is transphobic even to themselves, as a form of coping mechanism. This has been observed with other groups who experience discrimination but claim to be fine – perhaps because admitting they are not fine will stop them from being able to cope. Notably in the Stonewall survey: The biggest fears around reporting future homophobic incidents were ‘a homophobic reaction from police officers’ or ‘the police not taking the incident seriously’. (Stonewall, 2006) Respondents to our survey were asked ‘how confident are you that you would be treated appropriately by members of the police service as your preferred/acquired gender?’ 33.5% were not confident, but that leaves 66.5% as quite or very confident as to how the police would treat them. However, of those who had interactions with the police, 18.5% (68/367) felt they were not treated appropriately. Their individual responses covered a wide range of issues, from inappropriate remarks to inappropriate arrest: they don’t listen to me explaining over and over again my gender status – they just kept calling me what it says in my passport. (Survey respondent) I knew of a crime that had taken place & contacted the police. They took my details. Later an officer contacted me and, referring to my female name, asked what that was all about. It was totally irrelevant to the issue at hand and really irritating. (Survey respondent) Told by male police officer that I chose to be trans. When I tried to correct him he handcuffed me and read me my rights. (Survey respondent) I was attacked in front of a police officer, who simply shrugged when she witnessed the assault (is if to say ‘You brought it on yourself, the way you look’); then she turned around and walked off. (Survey respondent) Was asked to disclose if pre or post-op before being searched. They were informed I was pre op by 3rd party and searched by 2 men. I was so traumatised by this search and the comments that when released I went to Beachyhead to commit suicide. (Survey respondent) 41 Breaking the Chain of Hate. A National Survey Examining Levels of Homophobic Crime and Community Confidence towards the Police Service’ – National Advisory Group (1999) London: Stonewall. 55

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination local beat officer made inappropriate comments about me after I’d been subjected to threatening behaviour in my home by a neighbour. (Survey respondent) In reporting transphobic crime against me, the constable taking the report described me in her notes as a transvestite (a term I had not used) and referred to me as ‘he’. (Survey respondent) Reviewing paper correspondence with Press for Change brought to light three cases in the period 2004-2006 in which trans people were seriously assaulted. The cases were followed through by Press for Change which gave advice to the women for their solicitors. In all three cases, the women had been attacked and had fought back, as necessary, to protect their lives. All three reported the incidents to the police, and in all three cases when the police arrived they were arrested. Only one of the incidents was a serious assault resulting in grievous bodily harm. All three women were prosecuted, all went to trial and all were then acquitted – in two cases by a jury. To date not one of their attackers is known to have been prosecuted.42 What is clear is that trans people do fear for their safety, to the extent that 50% of trans people who only present in their preferred gender socially, do not go to public spaces in that gender role. They will go out, but only to a safe private venue such as someone else’s home. Well to be honest I never go anywhere alone when I’m out in my preferred gender, just in case. (Survey Respondent) I am leaving my home town due to the intolerance from locals and family. (Survey Respondent) Well my parents don’t want anyone in the neighbourhood to know so I have to move out before I can begin my transition properly. (Survey Respondent) When asked what they would like to see happening if they could wave a magic wand, most survey respondents stated that they wished that people in British society were more tolerant towards them: For the media to stop portraying trans people as freaks and deviants, and give society the right information. (Survey Respondent) a society that values and nurtures gender diversity and views it as normal, over binary gender systems. (Survey Respondent) Changes are clearly needed to ensure that individuals are allowed to live their lives in peace with the support of their local services, especially consistent support from local police services. As such: Police should make a priority response when a trans person calls for help; Police should not assume the trans person is the cause of any event; Police Services need further informing and educating about the nature of trans identities; 42 Private correspondence with 3 trans women, Press for Change, SW, 2004-2006 56

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Transphobic Crime should be recorded in all police authorities; The CPS needs information to enable it to determine whether it is in the public interest to prosecute a trans person who has been a victim of a crime, in the same incident; More research is needed to determine the basis of transphobic crime, to develop responsive policies and to ensure appropriate intervention when individuals are vulnerable e.g. providing alternative housing; Education on trans lives needs to start in school, and transphobic bullying or language needs quick action to curb it. 57

6 Nowhere’s Safe: Services, School, or Home 6.1 Housing, Goods and Services Refused admission to local swimming pool. (Survey Respondent) Was told by the manager of the establishment that my sort wernt (sic) allowed in because whenever he’s allowed my sort in there’s always trouble. (Survey Respondent) At a beauty college where I was receiving electrolysis the college principle intervened and told me I could not be treated there because I had not had GRS and the college was for women only. (Survey Respondent) Visitng [sic.] Weymouth, group of 4 trans women, empty restaurant, said they were full and closed, shoved us out, locked the door, re-opened for business five minutes later after we had left. (Survey Respondent) Asked to leave a pub when with another trans woman who was just starting her transition. (Survey Respondent) I was refused a membership at a local self defence group for women (Survey Respondent) I was barred from a pub for using the ladies after I had grs [Gender Reassignment Surgery] and even with “a note from my doctor”. (Survey Respondent). I was told – ‘we don’t serve your sort here’. (Survey Respondent) One health club refused me membership due to my being pre-op. (Survey Respondent) Accessing goods, services, housing and facilities figures high on the list of sectors where trans people face problems. Excluding problems accessing health care, many of the issues appearing in the EMD related to goods, services, facilities and housing. Housing is a particular problem, because of the extensive aggression experienced by many people from neighbours and others in the area and the break up of many families on discovering a member of the family is trans (see Section 6.3) Moreover, higher numbers of trans people in our survey – almost 1 in 4 (22%), live in the private rented sector or private lodgings, the least protected housing and tenancies there are, compared with only 13% for the population at large (Figure 6.1). 58

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination Figure 6.1: Type of housing compared to UK national average43 60 60 55 55 50 50 45 45 40 40 35 35 30 30 25 25 20 20 15

Rencontre du CRIPS / Act Up-Paris "Personnes trans : quels enjeux de santé ?" - Dossier documentaire

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Rencontre du CRIPS / Act Up-Paris "Personnes trans : quels enjeux de santé ?" - Dossier documentaire Document Transcript