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Transgender Identity And HIV : Resilience In The Face Of Stigma

Il s'agit d'un article de Walter Bockting, publié en 2008 dans Focus, une publication du AIDS Health Project, affilié à l'University of California, San Francisco.

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v23 n2   Spring 2008
                         FOCUS
                       A Guide to                            Research and Counseling



Transgender Identity and HIV:                                           venience samples.1 This meta-analysis
                                                                        also indicated that HIV infection rates are
Resilience in the Face of Stigma                                        higher among African American transgen-
                                                                        der women (56 percent) than among Latina
Walter O. Bockting, PhD, LP                                             or White transgender women (17 percent
                                                                        and 16 percent, respectively). Common
                                                                        risk behaviors among transgender women
                          Transgender people—people whose gen-          included unprotected receptive anal inter-
                       der identity or expression differs from          course (44 percent), having multiple sex-
                       their birth sex—have existed throughout          ual partners (32 percent), sex work (42 per-
                       history and across cultures. In modern           cent), casual sex (48 percent), and the use
                       times, however, this natural gender diver-       of injection drugs (12 percent), hormones
                       sity has been reduced to the binary classi-      (27 percent), and silicone (25 percent).1
                       fications of men (who should be masculine)          Few studies have examined HIV risk
                       and women (who should be feminine).              behavior in transgender men, but the HIV
                          While everyone suffers when gender            prevalence for this subgroup appears rela-
                       is reduced to only two confining catego-         tively low (2 percent).1 One exception is the
                       ries, transgender people experience mul-         minority of transgender men who have sex
                       tiple forms of oppression for transgress-        with men (17 percent), for whom behaviors
                       ing gender norms. This article explores key      that can transmit HIV are prevalent and
                       aspects of this oppression—including invis-      include unprotected anal and vaginal inter-
                       ibility, economic hardship, stigma, and iso-     course (45 percent), substance use immedi-
                       lation—that make transgender people espe-        ately before or during sex (27 percent) and
                       cially vulnerable to HIV infection and trans-    multiple partners (71 percent). 2
                       mission. It also explores the need for HIV
                       prevention and service efforts that address      Oppression, Economics, and HIV Risk
                       transgender people’s HIV risks in the con-          Societal oppression of gender noncon-
                       text of their overall health and lives.          formity makes transgender people espe-
                                                                        cially vulnerable to HIV infection and
                       Vulnerability to HIV Infection                   transmission.1 This oppression reduces
                          One example of transgender people’s           transgender people’s visibility and creates
                       invisibility is that, until recently, the Cen-   economic hardship, which can lead to HIV
                       ters for Disease Control and Prevention          risk.1
                       (CDC) did not include “transgender” as a            Many transgender youth flounder aca-
                       category for the collection of surveillance      demically or drop out of school because
                       data. The lack of such data is a serious         they lack role models and support for their
                       barrier to assessing the prevalence of HIV       developing gender identity. 3 This in turn
                       in this population.                              affects their future job prospects. Outright
                          There is mounting evidence, however,          employment discrimination is common.1
                       that HIV prevalence is high among cer-           Thus, many transgender people fear apply-
                       tain subgroups, particularly transgender         ing for work as openly transgender people,
                       women—as high as 28 percent, accord-             while others are afraid to undertake a gen-
                       ing to a recent meta-analysis of stud-           der role transition because it might jeopar-
                       ies conducted with mostly inner-city con-        dize their employment.

                                                                                                 Spring 2008   FOCUS   1
Editorial: It’s Not a Silent “T”                                                       people literally do not count. Yet.
                                                                                          As with so much of the journey
Michelle Cataldo, LCSW, Clinical Editor                                                toward cultural competence, per-
                                                                                       haps achieving transgender sensi-
                                                                                       tivity means making both the obvi-
       Recently I attended a confer-         sage without doing so, and because        ous structural changes that welcome
    ence featuring a compelling, articu-     they felt that protection for gay, les-   everyone we serve and the more
    late panel that was slated to speak      bian, and bisexual Americans was          subtle and individual adjustments. It
    on working with “LGBT” clients.          better than protection for none of        seems to me that Bockting and Oper-
    As each panelist began, he or she        the LGBT community.                       ario each emphasize slightly differ-
    noted that the talk would cover les-         Transgender invisibility and          ent approaches to facilitating sexual
    bian and gay issues, and that while      exclusion also happens during             minority health. Bockting under-
    bisexual and transgender people          health and mental health service          scores the undeniable empowerment
    face some similar challenges in          provision, and I’m not always the         that strong identification with the
    receiving care, the talk would not       first to notice the subtle and bla-       transgender community brings many
    address their specific concerns.         tant ways this occurs. Last year our      people. Operario reminds us that
       I’m not sure if the panelists         agency, whose direct-service clients      we’ll miss the boat with many sexual
    decided to frame the panel as            are predominantly gay men, created        minority clients if we deny the com-
    “LGBT,” or if the conference organiz-    its first gender-neutral bathroom.        plexity of their identities, or assume
    ers did, but it wasn’t the first time    This simple change helped open            that they feel an affiliation with one
    that transgender issues have got-        my eyes. Now I notice whether the         “category” or another. These views
    ten lost in the mix of a nominally       building I’m in offers such facilities.   are not mutually exclusive—nor are
    inclusive group. I believe that there        In this issue, Don Operario dis-      they relevant only to work with sex-
    are many goals toward which les-         cusses the importance of gender-          ual minority clients. Affiliations can
    bian, gay, bisexual, and transgender     neutral bathrooms, inclusive intake       be empowering—and if forced on
    people (and other sexual minorities)     forms, and other measures in mak-         clients, stifling.
    can, and should, work together, and      ing services friendlier to clients who       But transgender people are not
    other times when our needs may           don’t fit into our preexisting boxes      only clients. As more transgender
    not overlap. But too often transgen-     of gender and sexuality. Of course,       researchers and service providers
    der concerns are lost—as if putting      it is not only LGBT service provid-       come to the forefront, all kinds of
    the “T” in “LGBT” were enough. We        ers who must respond better to the        services will become more inclu-
    saw this division play out politically   needs of transgender consumers. As        sive and appropriate. When those
    when sponsors of the Employment          Walter Bockting notes in his article,     designing and delivering services
    Non-Discrimination Act jettisoned        in the Centers for Disease Control        understand both group needs and
    transgender rights because they          and Prevention’s national HIV sur-        individual concerns, our services
    feared they could not achieve pas-       veillance data reports, transgender       become far more client-centered.



References                    As a result, many transgender people             sexual behavior. Each of these factors can
1. Herbst JH, Jacobs       struggle to make a living. Some, after hav-         influence HIV risk.
ED, Finlayson TJ, et
                           ing been very successful in their careers,             Transgender children and youth whose
al. Estimating HIV
prevalence and risk        lose their jobs after coming out. Unemploy-         outward appearance, mannerisms, and
behaviors of trans-        ment of transgender people is estimated             interests conflict with traditional gender
gender persons in
                           at 23 percent.1 A scarcity of employment            roles experience overt stigma from an early
the United States: A
systematic review.         options increases the likelihood that some          age. Other people recognize this difference
AIDS and Behavior.         transgender people will engage in sex work.         even before the children are old enough to
2008; 12(1): 1–17.
                           Sex work and lack of employment are both            understand what their transgender identi-
2. Bockting WO. Gen-       associated with HIV infection among trans-          ties mean. These children are often subject
der identity and HIV
risk: Report from an       gender people.1,4                                   to ridicule, and as a result, many develop
Internet-based study                                                           psychological resilience at an early age. Nev-
of the U.S. transgender    Developmental Issues                                ertheless, they often internalize the stigma
population. Presenta-
tion at the Univer-           Stigma and invisibility can negatively           and develop feelings of shame.
sity Consortium for        influence psychosexual development and                 Transgender young people whose out-
Sexuality Research and     mental health, lead to loneliness and isola-        ward appearance, mannerisms, and interests
Training Inaugural
Conference, Blooming-      tion, and prompt transgender people to val-         conform more closely to traditional gen-
ton, Ind., April 2007.     idate their gender identities through risky         der roles are able to “pass” as belonging to

2   FOCUS    Spring 2008
the gender they were assigned at birth and          results in mood swings that can lead to
                           often keep their transgender feelings secret        risky sexual behaviors. Some transgender
                           to avoid social stigma. Because these chil-         women who are the insertive partners dur-
3. Mallon GP, ed.          dren do not visibly challenge societal gen-         ing sex may not use condoms because femi-
Social Services            der expectations, they typically do not come        nizing hormones already make maintaining
with Transgender
Youth. Binghamton,         out as transgender until much later in life,        an erection difficult. Illicit silicone injections
N.Y.: Harrington           often midlife or later. Yet the secret is isolat-   at “pump parties” achieve quick results, yet
Park Press, 1999.          ing, and gender-conforming children do not          often lead to serious medical consequences
4. Operario D, Soma T,     escape internalized stigma.                         and sometimes death.7 In contrast, when
Underhill K. Sex work
and HIV status among
                              While gender-nonconforming children are          qualified medical providers administer treat-
transgender women:         targets of overt stigma, they also benefit          ment, hormones and surgery are safe and
Systematic review and      from the consistency between their internal         highly effective.8 Unfortunately, with nota-
meta-analysis. Journal
of Acquired Immune
                           and social identities. They receive accurate        ble exceptions in Minnesota and California,
Deficiency Syndromes.      social mirroring, while the gender-conform-         most health insurance policies in the United
2008; 48(1): 97–103.       ing child does not. For gender-conforming           States exclude transgender-specific medical
5. Bockting WO, Cole-      children, the mirroring of the “false self”         care from coverage.
man E. Developmental
                           can result in an identity split. These two dif-
stages of the trans-
gender coming-out          ferent developmental paths affect not only          Isolation and Loneliness
process: Toward an         the management of transgender feelings and             The social stigma associated with gen-
integrated identity.
                           identity, but also personality development,         der nonconformity leaves many transgender
In Ettner R, Monstrey
S, Eyler E, eds. Prin-     attachment style, and overall mental health.5       individuals isolated and lonely. Isolation can
ciples of Transgender                                                          occur before a person comes out as trans-
Medicine and Sur-          The Quest to Affirm Gender Identity                 gender, or after gender-role transition—
gery. New York: The
Haworth Press, 2007.          Developing a sense of attractiveness and         when a person tries to “pass” and limits
6. Kammerer N, Mason       sexual competence is a key aspect of sexual         association with other transgender people or
T, Connors M, et al.       development. For many transgender individ-          when he or she experiences overt stigma.
Transgenders, HIV/         uals, discomfort with gender roles or with             Shame associated with gender noncon-
AIDS, and substance
abuse: From risk group     their primary and secondary sex character-          formity can lead some people to feel unlov-
to group prevention.       istics complicates this task.5 This discom-         able or to feel insecure about their abilities
In Bockting WO, Kirk       fort causes some to delay sexual experimen-         to establish and maintain intimate relation-
S, eds. Transgender
and HIV: Risks, Pre-       tation, while others attempt to affirm their        ships. Many men involved sexually or roman-
vention, and Care.         gender identity through sexual activity. For        tically with transgender women are hesitant
Binghamton, N.Y.: The      example, for a transgender woman, attention         to publicly acknowledge these relationships
Haworth Press, 2001.
                           from a male partner may serve as a strong           or introduce these partners to their families.
7. Restrepo CS,
Martinez-Jimenez
                           validation of her femininity.6 This desire          Living as “a man without a penis” may cause
S, Carillo J, et al.       for validation may either undermine sexual          some transgender men to feel insecure about
Illicit cosmetic sili-     negotiation or result in compulsive sexual          dating and relationships.
cone injections carry
lethal consequences.
                           behavior, or both. Together with economic              Many people struggle with how and
Presentation from the      hardship, it can increase the likelihood that       when to disclose their transgender iden-
Annual Meeting of the      some transgender people will engage in sex          tity and anatomy to potential partners.
Radiological Society of
North America, Chi-
                           work, which often leads to substance abuse.         Fear of rejection and a perceived shortage
cago, November 2006.       Moreover, “the stroll” itself has long been         of accepting partners impede sexual nego-
8. Gijs L, Brewaeys A.     one of the few places where transgender             tiation. Some people may not want to risk
Surgical treatment of      people, particularly transgender women of           rejection twice, first by revealing a trans-
gender dysphoria in
                           color, could find validation through a sense        gender identity and then by insisting on
adults and adolescents:
Recent developments,       of community with others like themselves.           safer sex. Often, early in the coming-out
effectiveness, and chal-   Fortunately, a surge in transgender commu-          process, transgender individuals may use
lenges. Annual Review
                           nity organizing facilitated by the internet         alcohol and drugs to cope with isolation
of Sex Research.
2007; 28: 178–224.         has resulted in a growing number of alterna-        and loneliness, thus lowering inhibitions
9. Bockting WO, Cole-      tive ways to affirm identity and obtain peer        and increasing risk. However, support from
man E, Benner A.           support without resorting to sex work.              peers, community, and family can help
Stigma, mental health,        The quest to affirm gender identity leads        transgender individuals conquer these chal-
and resilience among
the U.S. transgender       some individuals to use hormones or sili-           lenges and find love and acceptance.5
population. Presenta-      cone to feminize or masculinize their bod-
tion from the First        ies, often without adequate medical super-          Supporting Transgender Mental Health
World Congress for
Sexual Health, Sydney,     vision. In addition to the risks associated           Many transgender people are vulnera-
Australia, April 2007.     with sharing needles, erratic hormone use           ble to anxiety, depression, and substance

                                                                                                          Spring 2008   FOCUS   3
abuse, all of which are associated with HIV       vice providers have developed sex-positive
                           risk behavior.1 In an online study of trans-      and transgender-affirmative approaches
                           gender adults in the United States, 35 per-       to HIV prevention, such as the All Gender
                           cent of participants reported anxiety and         Health Seminars of the University of Minne-
                           44 percent reported depression.9 Trans-           sota.11 This intervention combines education
                           gender women, who may suffer greater              with entertainment, confronts internalized
                           levels of overt stigma than do transgen-          transphobia, and promotes sexual self-effi-
                           der men, reported significantly higher lev-       cacy, dating, and relationship skills—thus
                           els of depression (37 percent for transgen-       emphasizing the full humanity of partici-
                           der men versus 49 percent for transgender         pants and their relationship to their part-
                           women). Prevalence of anxiety did not dif-        ners and community, and not just their indi-
                           fer by gender. Participants who were resil-       vidual HIV risk behavior.
                           ient—that is, who reported good mental               The diversity of the transgender popula-
                           health despite experiencing high levels of        tion makes creating relevant and effective
                           stigma—reported more support from family          interventions a continuing challenge to HIV
                           and peers and greater pride in transgender        service providers. Gender identity (trans-
                           identity than did participants who were not       gender woman versus transgender man),
                           as resilient.10                                   sexual orientation, stage of coming out, eco-
                              Psychotherapy can facilitate transgender       nomic status, and substance use behaviors
                           mental health and HIV risk reduction, but         all shape the context of risk. Yet prevention
                           the transgender community has a complex           services must bring this diverse population
                           relationship with the field of psychotherapy.     together to affirm transgender identity, build
                           Transgender people must undergo evalua-           community, and foster empowerment.
                           tion by a mental health professional in order        The key to promoting transgender HIV
                           to gain access to feminizing or masculiniz-       prevention and sexual health is a greater
10. Bockting WO,
                           ing hormone therapy and transgender sur-          understanding of transgender sexuality as
Huang CY, Ding H, et       gery. This requirement can set up an adver-       distinct from male and female sexuality—
al. Are transgender        sarial dynamic between client and provider.       as well as homosexual or heterosexual sex-
persons at higher risk
for HIV than other
                           Some argue that the mental health diagno-         ual scripts. Transgender sexuality must
sexual minorities? A       sis of Gender Identity Disorder perpetuates       be explored and valued in its own right in
comparison of HIV          stigma, yet this diagnosis is often a prereq-     order to assist transgender people and their
prevalence and risks.
International Journal
                           uisite for access to transgender-specific care.   sexual partners in reducing risk and experi-
of Transgenderism.         In fact, treatment of anxiety, depression,        encing sexuality as a positive force in their
2005; 8(2/3): 123–131.     and other mental health concerns in the con-      lives.
11. Bockting WO, Rob-      text of a transgender-affirmative therapeutic
inson BE, Forberg JB, et                                                     Conclusion
                           relationship allows for successful resolution
al. Evaluation of a sex-
ual health approach        of developmental tasks, acceptance of trans-         Greater visibility and affirmation of trans-
to reducing HIV/STD        gender identity, and a different personal         gender identity are critical to promoting
risk in the transgender
                           relationship to sex and HIV risk.4                transgender health and HIV prevention. Over
community. AIDS Care.
2005; 17(3): 289–303.                                                        the past 15 years, transgender people have
                           Lessons for HIV Prevention                        come out, challenged gender norms, cre-
Authors                       For many years, the invisibility of trans-     ated community, and established coalitions
Walter O. Bockting,        gender people translated into an invisibil-       with the gay, lesbian, and bisexual commu-
PhD, LP, is Associ-
ate Professor in the       ity of the extent to which HIV and AIDS has       nities. Many mental health and HIV service
Department of Fam-         affected them.6 Transgender people with HIV       providers have responded to these changes,
ily Medicine and           disappeared into other epidemiological cat-       creating environments that are increas-
Community Health
at the University of       egories of risk. For example, transgender         ingly responsive to transgender individuals’
Minnesota Medical          women who had sex with men were catego-           unique identities, needs, and strengths.
School. He coordi-         rized as men who have sex with men. Yet              But individual change is not enough.
nates the Program in
Human Sexuality’s          the same people were excluded from ser-           Many of the factors that create HIV risk
Transgender Health         vices for men who have sex with men—and           for transgender individuals are societal.
Services there. He is      no other appropriate services were avail-         In order for transgender people to become
the president-elect
of the World Profes-       able. Similarly, the unique risks of transgen-    less vulnerable to HIV, structural barriers
sional Association for     der men who have sex with men (such as the        must be addressed through public aware-
Transgender Health,        possibility of vaginal intercourse) were not      ness, improved access to competent health
www.wpath.org. To
contact him, e-mail        addressed by prevention messages.                 care, and equal education and employment
bockt001@umn.edu.             In response to this invisibility, some ser-    opportunities. n

4   FOCUS    Spring 2008
Outside the Box: HIV Prevention                                      transgender women exists. Individual trans-
                                                                     gender women may or may not, for exam-
with Hard-to-Categorize People                                       ple, wish to undergo sex reassignment sur-
                                                                     gery, show overtly feminine characteristics,
Don Operario, PhD                                                    or be sexually attracted to men. Amidst this
                                                                     diversity, an unfortunate commonality is
                                                                     social discrimination and victimization that
                       Conducting HIV risk assessment is often       can lead to HIV risk.2
                    a matter of ticking off boxes. Participants         Transgender women are under-
                    complete surveys describing their sex-           researched relative to their potential for
                    ual practices, demo-                                                    HIV infection. Often,
                    graphic characteris-                                                    HIV prevention pro-
                    tics, and identities—                                                   grams do not address
                    usually by selecting
                                                        Transgender clients                 transgender individu-
                    one option from a pre-                                                  als at all. No known
                    specified list. Identi-
                                                            often experience                randomized controlled
                    fying “high-risk” indi-                                                 trials have tested
                    viduals allows for use
                                                         environmental and                  the efficacy of health
                    of group-based coun-                                                    promotion interven-
                    seling protocols and
                                                     interpersonal barriers                 tions for transgender
                    for efficient target-                                                   women. Prevention
                    ing of public health
                                                         to care. Everything                services must there-
                    resources.1 But pro-                                                    fore be informed by
                    viding HIV preven-
                                                  from an agency’s intake                   guidelines developed
                    tion services to peo-                                                   for other groups, such
                    ple whose behaviors
                                                   forms to its bathrooms                   as gay men or non-
                    or identities cannot                                                    transgender women,
                    easily be categorized
                                                           communicates its                 which are often inap-
                    remains a challenge.                                                    propriate given the
                    This article explores
                                                        openness to serving                 unique societal experi-
                    some of the issues                                                      ences shared by many
                    HIV prevention ser-
                                                        transgender people.                 transgender women.
                    vices must consider in                                                     Transgender peo-
                    order to serve these                                                    ple who do receive
                    hard-to-categorize individuals adequately.       services often experience environmental
                                                                     and interpersonal barriers to quality care.3
                    Hard-to-Categorize People                        From intake forms to bathrooms, the envi-
                       Many people at risk for HIV undermine         ronment of a service agency either dimin-
                    the conventional social categories of female/    ishes or promotes transgender comfort. Ser-
                    male and heterosexual/bisexual/homo-             vice providers’ adherence to an inflexible
                    sexual. Transgender women and their male         notion of gender also contributes to sub-
                    partners, as well as non-gay-identified men      standard service delivery. For example, pro-
                    who have sex with men (MSM)offer three           viders might assume transgender women
                    clear examples of hard-to-categorize people.     are sexually attracted to men or desire sex
                    HIV prevention interventions rarely serve        reassignment surgery, beliefs that reflect
                    these groups adequately. These individuals       the providers’ confusion of gender iden-
                    reveal some of the limitations and fallacies     tity, sexual orientation, and anatomy. When
                    of group-based approaches to HIV risk iden-      counseling transgender women, a more
                    tification and intervention. Whereas group-      fluid approach is preferable.
                    based research is essential for clarifying the      Male Partners of Transgender Women.
                    characteristics of people who are similarly      Men who have sex with transgender women
                    situated (based on their gender presenta-        also defy easy categorization and pose
                    tion or sexual behavior, for example), find-     intriguing questions about sexuality, sex-
                    ings from these studies do not often yield       ual behavior, and gendered attractions. Lit-
                    client-centered guidelines to help these peo-    tle research has been done with this pop-
                    ple avoid HIV.                                   ulation, so HIV prevalence in this group
                       Transgender Women. No simple profile of       is unknown. However, these men engage

                                                                                              Spring 2008   FOCUS   5
in both unprotected insertive and recep-        tity, and include activities to support their
                           tive anal intercourse with their transgender    “coming out.”
                           women partners and unprotected insertive           Men who have sex with men who do not
                           vaginal intercourse with post-operative         embrace a gay identity may be viewed as “in
                           transgender women.4 They also report a          denial,” or worse. A few years ago, sensation-
                           range of unprotected sexual behaviors with      alized media coverage of African American
                           biological female and male partners. One        MSM who have steady female partners and
                           study of men who have sex with transgen-        who might be at risk for HIV sparked con-
                           der women found that                                                 troversy.7 Depictions of
                           these men’s sexual                                                   these men are mostly
                           orientation identities              One study of men                 negative: they are por-
References                 did not align with par-                                              trayed as vectors of dis-
1. Lyles CM, Kay LS,       ticular sexual behav-               who have sex with                ease transmission, dis-
Crepaz N, et al. Best-     iors.5 Another showed                                                honest partners, and
evidence interven-
tions: Findings from a     that they were equally           transgender women                   closeted homosexuals.
systematic review of       likely to identify as                                                Such portrayals influence
HIV behavioral inter-
ventions for U.S. popu-
                           heterosexual, homo-             found that they were                 some service provid-
lations at high risk,      sexual, and bisexual                                                 ers and ultimately taint
2000–2004. American        and that a notable                     equally likely to             services to clients. For
Journal of Public          number chose not to                                                  example, heterosexual-
Health. 2007; 97(1):
133–143.                   identify with any sex-       identify as heterosexual,               identified African Ameri-
2. Nemoto T, Oper-
                           ual orientation cat-                                                 can MSM have described
ario D, Keatley J, et      egory.4 Transgender                   homosexual, and                poor quality HIV coun-
al. Social context of      women indicate that                                                  seling, often delivered by
HIV risk behaviours
among male-to-female
                           these men use con-               bisexual—and many                   unsympathetic gay-iden-
transgenders of colour.    doms inconsistently,                                                 tified men or heterosex-
AIDS Care. 2004; 16(6):    especially if they               did not identify with               ual women, that is dis-
724–735.
                           are non paying part-                                                 paraging of their need to
3. Lombardi E. Enhanc-
ing transgender health
                           ners.2 Accounts from           any sexual orientation                maintain a heterosexual
care. American Journal     the men themselves                                                   identity.8 In response,
of Public Health. 2001;    showed different moti-                            category.          some of these men may
91(6): 869–872.
                           vations for using con-                                               opt out of HIV prevention
4. Operario D, Burton      doms with biological                                                 or other health promo-
J, Underhill K, et al.
Men who have sex with      females (for example, to prevent pregnancy)     tion services because of anxiety about being
transgender women:         versus transgender women and biological         confronted with this discrepancy between
Challenges to category-    men (for example, to prevent HIV with part-     their sexual behavior and sexual orientation
based prevention. AIDS
and Behavior. 2008;        ners of unknown status).4                       identities.
12(1): 18–26.                  Non-Gay-Identified Men Who Have Sex
5. Bockting WO, Miner      with Men. The “MSM” acronym describing          Building Effective Interventions
M, Rosser BR. Latino       men who have sex with men was adopted by           How do we work with people whose
men’s sexual behav-
ior with transgender
                           researchers as a more inclusive approach to     identities and behaviors defy tradi-
persons. Archives of       HIV prevention, because it refers to a spe-     tional standards of HIV prevention?
Sexual Behavior. 2007;     cific behavior rather than a subjective iden-      Investigate Needs: Research on hard-to-
36: 778–786.
                           tity.6 But the majority of studies of MSM in
6. Young RM, Meyer IH.
                           the United States include mostly homosex-
The trouble with “MSM”
and “WSW”: Erasure         ual or gay-identified men; few non-gay-iden-
of the sexual-minority
person in public health
                           tified MSM are represented in HIV prevention      Comments and Submissions
                           research. Perhaps these men are overlooked
discourse. American
Journal of Public          by researchers, or perhaps their absence             We invite readers to send letters re-
Health. 2005; 95(7):       reflects the difficulty in recruiting them to     sponding to articles published in FOCUS
1144–1149.
                           participate.                                      or dealing with current AIDS research and
7. Malebranche DJ.             Consequently, many evidence-based HIV         counseling issues. We also encourage read-
Black men who have
sex with men and the       interventions for MSM do not reflect an           ers to submit article proposals. Send cor-
HIV epidemic: Next         understanding of how to engage non-gay-           respondence to rob.marks@ucsf.edu or to
steps for public health.   identified MSM in services. Interventions are     Editor, FOCUS, UCSF AIDS Health Project,
American Journal of
Public Health. 2003;       sometimes based on the assumption that            Box 0884, San Francisco, CA 94143-0884.
93(6): 862–865.            participants have a fixed homosexual iden-

6   FOCUS    Spring 2008

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Transgender Identity And HIV : Resilience In The Face Of Stigma

  • 1. v23 n2 Spring 2008 FOCUS A Guide to Research and Counseling Transgender Identity and HIV: venience samples.1 This meta-analysis also indicated that HIV infection rates are Resilience in the Face of Stigma higher among African American transgen- der women (56 percent) than among Latina Walter O. Bockting, PhD, LP or White transgender women (17 percent and 16 percent, respectively). Common risk behaviors among transgender women Transgender people—people whose gen- included unprotected receptive anal inter- der identity or expression differs from course (44 percent), having multiple sex- their birth sex—have existed throughout ual partners (32 percent), sex work (42 per- history and across cultures. In modern cent), casual sex (48 percent), and the use times, however, this natural gender diver- of injection drugs (12 percent), hormones sity has been reduced to the binary classi- (27 percent), and silicone (25 percent).1 fications of men (who should be masculine) Few studies have examined HIV risk and women (who should be feminine). behavior in transgender men, but the HIV While everyone suffers when gender prevalence for this subgroup appears rela- is reduced to only two confining catego- tively low (2 percent).1 One exception is the ries, transgender people experience mul- minority of transgender men who have sex tiple forms of oppression for transgress- with men (17 percent), for whom behaviors ing gender norms. This article explores key that can transmit HIV are prevalent and aspects of this oppression—including invis- include unprotected anal and vaginal inter- ibility, economic hardship, stigma, and iso- course (45 percent), substance use immedi- lation—that make transgender people espe- ately before or during sex (27 percent) and cially vulnerable to HIV infection and trans- multiple partners (71 percent). 2 mission. It also explores the need for HIV prevention and service efforts that address Oppression, Economics, and HIV Risk transgender people’s HIV risks in the con- Societal oppression of gender noncon- text of their overall health and lives. formity makes transgender people espe- cially vulnerable to HIV infection and Vulnerability to HIV Infection transmission.1 This oppression reduces One example of transgender people’s transgender people’s visibility and creates invisibility is that, until recently, the Cen- economic hardship, which can lead to HIV ters for Disease Control and Prevention risk.1 (CDC) did not include “transgender” as a Many transgender youth flounder aca- category for the collection of surveillance demically or drop out of school because data. The lack of such data is a serious they lack role models and support for their barrier to assessing the prevalence of HIV developing gender identity. 3 This in turn in this population. affects their future job prospects. Outright There is mounting evidence, however, employment discrimination is common.1 that HIV prevalence is high among cer- Thus, many transgender people fear apply- tain subgroups, particularly transgender ing for work as openly transgender people, women—as high as 28 percent, accord- while others are afraid to undertake a gen- ing to a recent meta-analysis of stud- der role transition because it might jeopar- ies conducted with mostly inner-city con- dize their employment. Spring 2008 FOCUS 1
  • 2. Editorial: It’s Not a Silent “T” people literally do not count. Yet. As with so much of the journey Michelle Cataldo, LCSW, Clinical Editor toward cultural competence, per- haps achieving transgender sensi- tivity means making both the obvi- Recently I attended a confer- sage without doing so, and because ous structural changes that welcome ence featuring a compelling, articu- they felt that protection for gay, les- everyone we serve and the more late panel that was slated to speak bian, and bisexual Americans was subtle and individual adjustments. It on working with “LGBT” clients. better than protection for none of seems to me that Bockting and Oper- As each panelist began, he or she the LGBT community. ario each emphasize slightly differ- noted that the talk would cover les- Transgender invisibility and ent approaches to facilitating sexual bian and gay issues, and that while exclusion also happens during minority health. Bockting under- bisexual and transgender people health and mental health service scores the undeniable empowerment face some similar challenges in provision, and I’m not always the that strong identification with the receiving care, the talk would not first to notice the subtle and bla- transgender community brings many address their specific concerns. tant ways this occurs. Last year our people. Operario reminds us that I’m not sure if the panelists agency, whose direct-service clients we’ll miss the boat with many sexual decided to frame the panel as are predominantly gay men, created minority clients if we deny the com- “LGBT,” or if the conference organiz- its first gender-neutral bathroom. plexity of their identities, or assume ers did, but it wasn’t the first time This simple change helped open that they feel an affiliation with one that transgender issues have got- my eyes. Now I notice whether the “category” or another. These views ten lost in the mix of a nominally building I’m in offers such facilities. are not mutually exclusive—nor are inclusive group. I believe that there In this issue, Don Operario dis- they relevant only to work with sex- are many goals toward which les- cusses the importance of gender- ual minority clients. Affiliations can bian, gay, bisexual, and transgender neutral bathrooms, inclusive intake be empowering—and if forced on people (and other sexual minorities) forms, and other measures in mak- clients, stifling. can, and should, work together, and ing services friendlier to clients who But transgender people are not other times when our needs may don’t fit into our preexisting boxes only clients. As more transgender not overlap. But too often transgen- of gender and sexuality. Of course, researchers and service providers der concerns are lost—as if putting it is not only LGBT service provid- come to the forefront, all kinds of the “T” in “LGBT” were enough. We ers who must respond better to the services will become more inclu- saw this division play out politically needs of transgender consumers. As sive and appropriate. When those when sponsors of the Employment Walter Bockting notes in his article, designing and delivering services Non-Discrimination Act jettisoned in the Centers for Disease Control understand both group needs and transgender rights because they and Prevention’s national HIV sur- individual concerns, our services feared they could not achieve pas- veillance data reports, transgender become far more client-centered. References As a result, many transgender people sexual behavior. Each of these factors can 1. Herbst JH, Jacobs struggle to make a living. Some, after hav- influence HIV risk. ED, Finlayson TJ, et ing been very successful in their careers, Transgender children and youth whose al. Estimating HIV prevalence and risk lose their jobs after coming out. Unemploy- outward appearance, mannerisms, and behaviors of trans- ment of transgender people is estimated interests conflict with traditional gender gender persons in at 23 percent.1 A scarcity of employment roles experience overt stigma from an early the United States: A systematic review. options increases the likelihood that some age. Other people recognize this difference AIDS and Behavior. transgender people will engage in sex work. even before the children are old enough to 2008; 12(1): 1–17. Sex work and lack of employment are both understand what their transgender identi- 2. Bockting WO. Gen- associated with HIV infection among trans- ties mean. These children are often subject der identity and HIV risk: Report from an gender people.1,4 to ridicule, and as a result, many develop Internet-based study psychological resilience at an early age. Nev- of the U.S. transgender Developmental Issues ertheless, they often internalize the stigma population. Presenta- tion at the Univer- Stigma and invisibility can negatively and develop feelings of shame. sity Consortium for influence psychosexual development and Transgender young people whose out- Sexuality Research and mental health, lead to loneliness and isola- ward appearance, mannerisms, and interests Training Inaugural Conference, Blooming- tion, and prompt transgender people to val- conform more closely to traditional gen- ton, Ind., April 2007. idate their gender identities through risky der roles are able to “pass” as belonging to 2 FOCUS Spring 2008
  • 3. the gender they were assigned at birth and results in mood swings that can lead to often keep their transgender feelings secret risky sexual behaviors. Some transgender to avoid social stigma. Because these chil- women who are the insertive partners dur- 3. Mallon GP, ed. dren do not visibly challenge societal gen- ing sex may not use condoms because femi- Social Services der expectations, they typically do not come nizing hormones already make maintaining with Transgender Youth. Binghamton, out as transgender until much later in life, an erection difficult. Illicit silicone injections N.Y.: Harrington often midlife or later. Yet the secret is isolat- at “pump parties” achieve quick results, yet Park Press, 1999. ing, and gender-conforming children do not often lead to serious medical consequences 4. Operario D, Soma T, escape internalized stigma. and sometimes death.7 In contrast, when Underhill K. Sex work and HIV status among While gender-nonconforming children are qualified medical providers administer treat- transgender women: targets of overt stigma, they also benefit ment, hormones and surgery are safe and Systematic review and from the consistency between their internal highly effective.8 Unfortunately, with nota- meta-analysis. Journal of Acquired Immune and social identities. They receive accurate ble exceptions in Minnesota and California, Deficiency Syndromes. social mirroring, while the gender-conform- most health insurance policies in the United 2008; 48(1): 97–103. ing child does not. For gender-conforming States exclude transgender-specific medical 5. Bockting WO, Cole- children, the mirroring of the “false self” care from coverage. man E. Developmental can result in an identity split. These two dif- stages of the trans- gender coming-out ferent developmental paths affect not only Isolation and Loneliness process: Toward an the management of transgender feelings and The social stigma associated with gen- integrated identity. identity, but also personality development, der nonconformity leaves many transgender In Ettner R, Monstrey S, Eyler E, eds. Prin- attachment style, and overall mental health.5 individuals isolated and lonely. Isolation can ciples of Transgender occur before a person comes out as trans- Medicine and Sur- The Quest to Affirm Gender Identity gender, or after gender-role transition— gery. New York: The Haworth Press, 2007. Developing a sense of attractiveness and when a person tries to “pass” and limits 6. Kammerer N, Mason sexual competence is a key aspect of sexual association with other transgender people or T, Connors M, et al. development. For many transgender individ- when he or she experiences overt stigma. Transgenders, HIV/ uals, discomfort with gender roles or with Shame associated with gender noncon- AIDS, and substance abuse: From risk group their primary and secondary sex character- formity can lead some people to feel unlov- to group prevention. istics complicates this task.5 This discom- able or to feel insecure about their abilities In Bockting WO, Kirk fort causes some to delay sexual experimen- to establish and maintain intimate relation- S, eds. Transgender and HIV: Risks, Pre- tation, while others attempt to affirm their ships. Many men involved sexually or roman- vention, and Care. gender identity through sexual activity. For tically with transgender women are hesitant Binghamton, N.Y.: The example, for a transgender woman, attention to publicly acknowledge these relationships Haworth Press, 2001. from a male partner may serve as a strong or introduce these partners to their families. 7. Restrepo CS, Martinez-Jimenez validation of her femininity.6 This desire Living as “a man without a penis” may cause S, Carillo J, et al. for validation may either undermine sexual some transgender men to feel insecure about Illicit cosmetic sili- negotiation or result in compulsive sexual dating and relationships. cone injections carry lethal consequences. behavior, or both. Together with economic Many people struggle with how and Presentation from the hardship, it can increase the likelihood that when to disclose their transgender iden- Annual Meeting of the some transgender people will engage in sex tity and anatomy to potential partners. Radiological Society of North America, Chi- work, which often leads to substance abuse. Fear of rejection and a perceived shortage cago, November 2006. Moreover, “the stroll” itself has long been of accepting partners impede sexual nego- 8. Gijs L, Brewaeys A. one of the few places where transgender tiation. Some people may not want to risk Surgical treatment of people, particularly transgender women of rejection twice, first by revealing a trans- gender dysphoria in color, could find validation through a sense gender identity and then by insisting on adults and adolescents: Recent developments, of community with others like themselves. safer sex. Often, early in the coming-out effectiveness, and chal- Fortunately, a surge in transgender commu- process, transgender individuals may use lenges. Annual Review nity organizing facilitated by the internet alcohol and drugs to cope with isolation of Sex Research. 2007; 28: 178–224. has resulted in a growing number of alterna- and loneliness, thus lowering inhibitions 9. Bockting WO, Cole- tive ways to affirm identity and obtain peer and increasing risk. However, support from man E, Benner A. support without resorting to sex work. peers, community, and family can help Stigma, mental health, The quest to affirm gender identity leads transgender individuals conquer these chal- and resilience among the U.S. transgender some individuals to use hormones or sili- lenges and find love and acceptance.5 population. Presenta- cone to feminize or masculinize their bod- tion from the First ies, often without adequate medical super- Supporting Transgender Mental Health World Congress for Sexual Health, Sydney, vision. In addition to the risks associated Many transgender people are vulnera- Australia, April 2007. with sharing needles, erratic hormone use ble to anxiety, depression, and substance Spring 2008 FOCUS 3
  • 4. abuse, all of which are associated with HIV vice providers have developed sex-positive risk behavior.1 In an online study of trans- and transgender-affirmative approaches gender adults in the United States, 35 per- to HIV prevention, such as the All Gender cent of participants reported anxiety and Health Seminars of the University of Minne- 44 percent reported depression.9 Trans- sota.11 This intervention combines education gender women, who may suffer greater with entertainment, confronts internalized levels of overt stigma than do transgen- transphobia, and promotes sexual self-effi- der men, reported significantly higher lev- cacy, dating, and relationship skills—thus els of depression (37 percent for transgen- emphasizing the full humanity of partici- der men versus 49 percent for transgender pants and their relationship to their part- women). Prevalence of anxiety did not dif- ners and community, and not just their indi- fer by gender. Participants who were resil- vidual HIV risk behavior. ient—that is, who reported good mental The diversity of the transgender popula- health despite experiencing high levels of tion makes creating relevant and effective stigma—reported more support from family interventions a continuing challenge to HIV and peers and greater pride in transgender service providers. Gender identity (trans- identity than did participants who were not gender woman versus transgender man), as resilient.10 sexual orientation, stage of coming out, eco- Psychotherapy can facilitate transgender nomic status, and substance use behaviors mental health and HIV risk reduction, but all shape the context of risk. Yet prevention the transgender community has a complex services must bring this diverse population relationship with the field of psychotherapy. together to affirm transgender identity, build Transgender people must undergo evalua- community, and foster empowerment. tion by a mental health professional in order The key to promoting transgender HIV to gain access to feminizing or masculiniz- prevention and sexual health is a greater 10. Bockting WO, ing hormone therapy and transgender sur- understanding of transgender sexuality as Huang CY, Ding H, et gery. This requirement can set up an adver- distinct from male and female sexuality— al. Are transgender sarial dynamic between client and provider. as well as homosexual or heterosexual sex- persons at higher risk for HIV than other Some argue that the mental health diagno- ual scripts. Transgender sexuality must sexual minorities? A sis of Gender Identity Disorder perpetuates be explored and valued in its own right in comparison of HIV stigma, yet this diagnosis is often a prereq- order to assist transgender people and their prevalence and risks. International Journal uisite for access to transgender-specific care. sexual partners in reducing risk and experi- of Transgenderism. In fact, treatment of anxiety, depression, encing sexuality as a positive force in their 2005; 8(2/3): 123–131. and other mental health concerns in the con- lives. 11. Bockting WO, Rob- text of a transgender-affirmative therapeutic inson BE, Forberg JB, et Conclusion relationship allows for successful resolution al. Evaluation of a sex- ual health approach of developmental tasks, acceptance of trans- Greater visibility and affirmation of trans- to reducing HIV/STD gender identity, and a different personal gender identity are critical to promoting risk in the transgender relationship to sex and HIV risk.4 transgender health and HIV prevention. Over community. AIDS Care. 2005; 17(3): 289–303. the past 15 years, transgender people have Lessons for HIV Prevention come out, challenged gender norms, cre- Authors For many years, the invisibility of trans- ated community, and established coalitions Walter O. Bockting, gender people translated into an invisibil- with the gay, lesbian, and bisexual commu- PhD, LP, is Associ- ate Professor in the ity of the extent to which HIV and AIDS has nities. Many mental health and HIV service Department of Fam- affected them.6 Transgender people with HIV providers have responded to these changes, ily Medicine and disappeared into other epidemiological cat- creating environments that are increas- Community Health at the University of egories of risk. For example, transgender ingly responsive to transgender individuals’ Minnesota Medical women who had sex with men were catego- unique identities, needs, and strengths. School. He coordi- rized as men who have sex with men. Yet But individual change is not enough. nates the Program in Human Sexuality’s the same people were excluded from ser- Many of the factors that create HIV risk Transgender Health vices for men who have sex with men—and for transgender individuals are societal. Services there. He is no other appropriate services were avail- In order for transgender people to become the president-elect of the World Profes- able. Similarly, the unique risks of transgen- less vulnerable to HIV, structural barriers sional Association for der men who have sex with men (such as the must be addressed through public aware- Transgender Health, possibility of vaginal intercourse) were not ness, improved access to competent health www.wpath.org. To contact him, e-mail addressed by prevention messages. care, and equal education and employment bockt001@umn.edu. In response to this invisibility, some ser- opportunities. n 4 FOCUS Spring 2008
  • 5. Outside the Box: HIV Prevention transgender women exists. Individual trans- gender women may or may not, for exam- with Hard-to-Categorize People ple, wish to undergo sex reassignment sur- gery, show overtly feminine characteristics, Don Operario, PhD or be sexually attracted to men. Amidst this diversity, an unfortunate commonality is social discrimination and victimization that Conducting HIV risk assessment is often can lead to HIV risk.2 a matter of ticking off boxes. Participants Transgender women are under- complete surveys describing their sex- researched relative to their potential for ual practices, demo- HIV infection. Often, graphic characteris- HIV prevention pro- tics, and identities— grams do not address usually by selecting Transgender clients transgender individu- one option from a pre- als at all. No known specified list. Identi- often experience randomized controlled fying “high-risk” indi- trials have tested viduals allows for use environmental and the efficacy of health of group-based coun- promotion interven- seling protocols and interpersonal barriers tions for transgender for efficient target- women. Prevention ing of public health to care. Everything services must there- resources.1 But pro- fore be informed by viding HIV preven- from an agency’s intake guidelines developed tion services to peo- for other groups, such ple whose behaviors forms to its bathrooms as gay men or non- or identities cannot transgender women, easily be categorized communicates its which are often inap- remains a challenge. propriate given the This article explores openness to serving unique societal experi- some of the issues ences shared by many HIV prevention ser- transgender people. transgender women. vices must consider in Transgender peo- order to serve these ple who do receive hard-to-categorize individuals adequately. services often experience environmental and interpersonal barriers to quality care.3 Hard-to-Categorize People From intake forms to bathrooms, the envi- Many people at risk for HIV undermine ronment of a service agency either dimin- the conventional social categories of female/ ishes or promotes transgender comfort. Ser- male and heterosexual/bisexual/homo- vice providers’ adherence to an inflexible sexual. Transgender women and their male notion of gender also contributes to sub- partners, as well as non-gay-identified men standard service delivery. For example, pro- who have sex with men (MSM)offer three viders might assume transgender women clear examples of hard-to-categorize people. are sexually attracted to men or desire sex HIV prevention interventions rarely serve reassignment surgery, beliefs that reflect these groups adequately. These individuals the providers’ confusion of gender iden- reveal some of the limitations and fallacies tity, sexual orientation, and anatomy. When of group-based approaches to HIV risk iden- counseling transgender women, a more tification and intervention. Whereas group- fluid approach is preferable. based research is essential for clarifying the Male Partners of Transgender Women. characteristics of people who are similarly Men who have sex with transgender women situated (based on their gender presenta- also defy easy categorization and pose tion or sexual behavior, for example), find- intriguing questions about sexuality, sex- ings from these studies do not often yield ual behavior, and gendered attractions. Lit- client-centered guidelines to help these peo- tle research has been done with this pop- ple avoid HIV. ulation, so HIV prevalence in this group Transgender Women. No simple profile of is unknown. However, these men engage Spring 2008 FOCUS 5
  • 6. in both unprotected insertive and recep- tity, and include activities to support their tive anal intercourse with their transgender “coming out.” women partners and unprotected insertive Men who have sex with men who do not vaginal intercourse with post-operative embrace a gay identity may be viewed as “in transgender women.4 They also report a denial,” or worse. A few years ago, sensation- range of unprotected sexual behaviors with alized media coverage of African American biological female and male partners. One MSM who have steady female partners and study of men who have sex with transgen- who might be at risk for HIV sparked con- der women found that troversy.7 Depictions of these men’s sexual these men are mostly orientation identities One study of men negative: they are por- References did not align with par- trayed as vectors of dis- 1. Lyles CM, Kay LS, ticular sexual behav- who have sex with ease transmission, dis- Crepaz N, et al. Best- iors.5 Another showed honest partners, and evidence interven- tions: Findings from a that they were equally transgender women closeted homosexuals. systematic review of likely to identify as Such portrayals influence HIV behavioral inter- ventions for U.S. popu- heterosexual, homo- found that they were some service provid- lations at high risk, sexual, and bisexual ers and ultimately taint 2000–2004. American and that a notable equally likely to services to clients. For Journal of Public number chose not to example, heterosexual- Health. 2007; 97(1): 133–143. identify with any sex- identify as heterosexual, identified African Ameri- 2. Nemoto T, Oper- ual orientation cat- can MSM have described ario D, Keatley J, et egory.4 Transgender homosexual, and poor quality HIV coun- al. Social context of women indicate that seling, often delivered by HIV risk behaviours among male-to-female these men use con- bisexual—and many unsympathetic gay-iden- transgenders of colour. doms inconsistently, tified men or heterosex- AIDS Care. 2004; 16(6): especially if they did not identify with ual women, that is dis- 724–735. are non paying part- paraging of their need to 3. Lombardi E. Enhanc- ing transgender health ners.2 Accounts from any sexual orientation maintain a heterosexual care. American Journal the men themselves identity.8 In response, of Public Health. 2001; showed different moti- category. some of these men may 91(6): 869–872. vations for using con- opt out of HIV prevention 4. Operario D, Burton doms with biological or other health promo- J, Underhill K, et al. Men who have sex with females (for example, to prevent pregnancy) tion services because of anxiety about being transgender women: versus transgender women and biological confronted with this discrepancy between Challenges to category- men (for example, to prevent HIV with part- their sexual behavior and sexual orientation based prevention. AIDS and Behavior. 2008; ners of unknown status).4 identities. 12(1): 18–26. Non-Gay-Identified Men Who Have Sex 5. Bockting WO, Miner with Men. The “MSM” acronym describing Building Effective Interventions M, Rosser BR. Latino men who have sex with men was adopted by How do we work with people whose men’s sexual behav- ior with transgender researchers as a more inclusive approach to identities and behaviors defy tradi- persons. Archives of HIV prevention, because it refers to a spe- tional standards of HIV prevention? Sexual Behavior. 2007; cific behavior rather than a subjective iden- Investigate Needs: Research on hard-to- 36: 778–786. tity.6 But the majority of studies of MSM in 6. Young RM, Meyer IH. the United States include mostly homosex- The trouble with “MSM” and “WSW”: Erasure ual or gay-identified men; few non-gay-iden- of the sexual-minority person in public health tified MSM are represented in HIV prevention Comments and Submissions research. Perhaps these men are overlooked discourse. American Journal of Public by researchers, or perhaps their absence We invite readers to send letters re- Health. 2005; 95(7): reflects the difficulty in recruiting them to sponding to articles published in FOCUS 1144–1149. participate. or dealing with current AIDS research and 7. Malebranche DJ. Consequently, many evidence-based HIV counseling issues. We also encourage read- Black men who have sex with men and the interventions for MSM do not reflect an ers to submit article proposals. Send cor- HIV epidemic: Next understanding of how to engage non-gay- respondence to rob.marks@ucsf.edu or to steps for public health. identified MSM in services. Interventions are Editor, FOCUS, UCSF AIDS Health Project, American Journal of Public Health. 2003; sometimes based on the assumption that Box 0884, San Francisco, CA 94143-0884. 93(6): 862–865. participants have a fixed homosexual iden- 6 FOCUS Spring 2008
  • 7. categorize individuals must be a priority. fixed and static categories for gender and Using different methodologies—qualita- sexuality might deter individuals who do tive interviews, cross-sectional and longitu- not adhere to these notions. Group-based dinal surveys, and randomized controlled workshops might be inappropriate for non- intervention trials—is helpful. This diver- gay-identified MSM, who might not per- sity of approaches yields clues about how ceive themselves as belonging to a commu- to best reach these individuals and engage nity of men with similar patterns of sex- them in services, the prevalence and con- ual behavior. HIV prevention counseling texts of risk they experience, and the pro- with these men may be most effective when grams that can effectively reduce their HIV counselors focus on specific sexual behav- transmission. There is a tension between the iors (such as insertive or receptive inter- need for more research about HIV risk and course) men may engage in with any part- prevention for hard-to-categorize individu- ners and on the context of high-risk sex- 8. Operario D, Smith als versus the tendency to construct sweep- ual episodes (such as sex while intoxicated) CD, Kegeles SM. Social and psychological con- ing generalizations about ways of deliver- rather than on sexual identities themselves. text for HIV risk among ing HIV services to these people. Although non-gay-identified Afri- it may be necessary to first understand indi- Conclusions can American MSM. To appear in AIDS Educa- viduals according to crude subgroup clas- By articulating their own identities and tion and Prevention. In sifications, findings must ultimately point expressing sexual behaviors on their own press. the way to client-centered approaches that terms, the people discussed in this article 9. Schiller NG, Crys- respect individuality and non conformity. destabilize basic assumptions about gen- tal S, Lewellen D. Structural Interventions: Structural inter- der dichotomy and the correspondence Risky business: The cultural construction ventions that acknowledge gender diver- between sexual behavior and sexual orien- of AIDS risk groups. sity and clients’ previous gender history, tation. They also question the legitimacy of Social Science and such as inclusive language on service intake working models of HIV prevention, which Medicine. 1994; 38(10): 1337–1346. forms and gender-neutral bathrooms, reflect often assume neat, bounded categories of a consideration of and respect for transgen- sexuality and gender.9 Authors der clients. Hiring staff members who mir- This analysis does not call for an end to Don Operario PhD, is ror client populations can facilitate access category-based approaches to HIV risk iden- Associate Professor of and trust. Training staff members to take tification, prevention, and counseling. Risk Medical Sciences at the Alpert Medical School, a holistic perspective on the lives of MSM group categories simplify a complex social Brown University. He is clients, and transgender women and their world and might be personally meaningful also Adjunct Professor partners, is also essential. Service orga- for some individuals. Rather, this analysis of in the Department of Social Policy and Social nizations must examine their own staff hard-to-categorize individuals reminds us of Work at the University and programmatic assumptions about the the often faulty assumptions that social cat- of Oxford. To contact fixed nature of gender and sexuality. egories are based on, and stresses that when him, e-mail don. operario@ Acknowledge the Fluidity of Identities: As we tick boxes to categorize clients, we should socres.ox.ac.uk. noted, intervention practices that assume do so lightly and be prepared to erase. n Related Resources Melendez RM, Pinto R. ‘It’s really a hard life’: Love, gender and HIV risk among male-to-female transgender persons. Culture, Health and Publications Sexuality. 2007; 9(3): 233– 245. Reports Garofalo R, Deleon J, Osmer E, et on findings from in-depth interviews al. Overlooked, misunderstood and with 20 transgender women attending at-risk: Exploring the lives and HIV a community clinic. Emphasizes that risk of ethnic minority male-to- stigma and discrimination create a female transgender youth. Journal of heightened need for love and acceptance Adolescent Health. 2006; 38(3): 230–236. among these transgender women. This Describes the life challenges and HIV-risk in turn leads to HIV risk, because these behaviors of young transgender women of women are willing to engage in unsafe color using a convenience sample of 51 youth sexual behaviors with partners who meet aged 16 to 25 years old. Among other risks, these needs. Offers a model illustrating nearly half the subjects reported unprotected how stigma and discrimination generate receptive anal sex in the past year. HIV risk. Spring 2008 FOCUS 7
  • 8. Mottet L, Tanis J. Opening the Door to of California, San Francisco (UCSF). the Inclusion of Transgender People: Contributions include professional training, The Nine Keys to Making Lesbian, capacity building, and research development Gay, Bisexual and Transgender to improve the access that transgender FOCUS Organizations Fully Transgender- people in California have to culturally Inclusive. New York: National Gay competent HIV prevention services. and Lesbian Task Force Policy Institute and the National Center for FTM International: http://www. Transgender Equality, 2008. Suggests ftmi.org/. Includes links to health Executive Editor; Director, ways that organizations can integrate information, personal stories, and AIDS Health Project transgender-sensitive perspectives. Gives publications about transgender men James W. Dilley, MD direction on how to create a welcoming as well as community resources for Editor environment, deal with prejudices, transgender men and their families. Robert Marks Clinical Editor acknowledge past mistakes, have more Michelle Cataldo, LCSW transgender-inclusive programming, and HIV InSite: HIV Transmission Founding Editor use fair employment practices. and Prevention in Transgender Michael Helquist People: http://hivinsite.ucsf.edu/ Medical Advisors Nemoto T, Sausa LA, Operario D, InSite?page=kbr-07-04-16. University Stephen Follansbee, MD George Harrison, MD Keatley J. Need for HIV/AIDS education of California, San Francisco web site Design and intervention for MTF transgenders: with links to HIV-specific resources, Saul Rosenfield Responding to the challenge. Journal provider and community education sites, Lisa Roth of Homosexuality. 2006; 51(1): 183–202. conference web sites, and publications. Production Carrel Crawford Uses qualitative and quantitative Lisa Roth measures to identify HIV-related needs World Professional Association for Lawrence Sanfilippo of 48 transgender women focus group Transgender Health: http://www. Circulation Stephen Scott participants. Participants reported high wpath.org/. A professional organization levels of HIV-related risk behaviors, devoted to the understanding and FOCUS is a free, quarterly, inadequate HIV transmission knowledge, treatment of gender identity disorders digital-only publication of a lack of sexuality education and health and includes medical, legal, mental the AIDS Health Project, affiliated with the University services, and persistent discrimination health, and other professionals. n of California, San Francisco. against MTFs of color in health services. It is published and distrib- uted with the support of the Office of AIDS of the Sausa LA, Keatley J, Operario D. California Department of Public Health and of the Perceived risks and benefits of sex Next Issue California Department work among transgender women of of Mental Health. color in San Francisco. Archives of Before the advent of effective HIV To register to receive Sexual Behavior. 2007; 36(6): 768–777. antiviral therapies, cognitive impair- FOCUS free, via e-mail, Seeks to explain the social context and ments were among the most devastat- go to http://ucsf-ahp.org/ epubs_registration.php determinants of sex work and related ing complications of HIV disease. In To access issues of FOCUS health risks among 48 transgender women our Summer issue, Tom Marcotte, from 1991–present online, go of color participants. Examines why and PhD, Associate Professor of Psy- to http://www.ucsf-ahp.org/ HTML2/archivesearch.html how participants became involved in sex chiatry at the University of Cali- For other information, or to work, risks associated with sex work, and fornia, San Diego, offers an update receive printed back issues of participant motivation to remain in sex on the role that cognitive impair- FOCUS, call 415-502-7270, work. Advocates for structural and social ment plays in HIV disease today. or e-mail stephen.scott@ucsf.edu. network-based interventions to minimize Also in the Summer issue of FOCUS, Printed on recycled paper. the vulnerability of transgender women of Lawrence McGlynn, MD, Clinical ©2008 UC Regents: color to social and public health harms. Assistant Professor of Psychiatry and All rights reserved. Behavioral Sciences at the Stanford ISSN 1047-0719 Web Sites University School of Medicine, and Center of Excellence for Transgender Maggie Chartier, MPH, MS, Director HIV Prevention: http://www.ucsf.edu/ of Research for the Stanford–Santa paetc/about/COE_transHIVprev.html. Clara County Methamphetamine Task A collaboration between the Pacific AIDS Force discuss medical assessment Education and Training Center (PAETC) and treatment options for patients and the Center for AIDS Prevention with HIV-related cognitive disorders. Studies (CAPS), both part of the University 8 FOCUS Spring 2008