Transgender HIV prevention: Community involvement and empowerment

by Walter O. Bockting, Ph.D. B.R. Simon Rosser, Ph.D., M.P.H. Eli Coleman, Ph.D.

Citation: Bockting W.O., Ph.D., Rosser S., Ph.D. , Coleman E., Ph.D. (1999) Transgender HIV prevention: Community involvement and empowerment IJT 3,1+2, http://www.symposion.com/ijt/hiv_risk/bockting.htm

• Abstract
• Acknowledgements
• Introduction
• Planning
• Needs Assessments
• Recruitment
• Intervention
• Evaluation
• Celebration
• Replication
• Discussion
• Conclusion
• References
   

Abstract
In the context of a paradigm shift toward transgender coming out and empowerment, we mobilized a core group of transgender community representatives to develop targeted HIV prevention education. Focus groups assessed transgender-specific prevention needs and enabled participants to become invested in the project. Community members designed and distributed recruitment materials. Trained peer educators facilitated a workshop. A video created by transgender artists personalized HIV/AIDS for participants, a panel of transgender persons living with HIV/AIDS enhanced perceived susceptibility to HIV infection, and sexually explicit materials depicting transgender role models eroticized safer sex. A transexual community activist facilitated a special segment on empowerment and building community. Community involvement ensured cultural sensitivity of program intervention and evaluation. Together, these strategies helped the community take ownership of the project and raised the credibility of the prevention message. Further university-community collaboration in HIV prevention research is recommended.

Keywords: Community involvement, HIV prevention, transgender Walter Bockting is Assistant Professor and Coordinator of Transgender Services, Simon Rosser is Associate Professor, and Eli Coleman is Professor and Director of the Program in Human Sexuality, Department of Family Practice and Community Health, Medical School, University of Minnesota. Address correspondence to Walter Bockting, PHS, 1300 South Second Street, Suite 180, Minneapolis, MN 55454, phone (612) 625 1500, fax (612 626 8311, e-mail bockt001@gold.tc.umn.edu.
  

Acknowledgments
The authors thank the following transgender community and HIV/AIDS service organizations for their collaboration: The City of Lakes Crossgender Community, the Minnesota Freedom of Gender Expression, the Aliveness Project, and the Minnesota AIDS Project. Individuals who gave generously of their time and of themselves include: Aaron, Celie, Debbie, Dotty/Kevin, Jane, Mira, Sander, and Susan, who served on the planning committee; Kate Bornstein, Steven Grandell, and Paul Stravinsky who created the video and artwork; the workshop facilitators and panelists; and the focus group, workshop, and evaluation participants. It has been a true privilege working with you. We thank the American Foundation for AIDS Research for funding this project (#100108-12-EG), and Margaret Reinfeld, Susan Leaf, and Charles Fuss for their encouragement and support. Finally, we acknowledge the assistance of Lynn Marasco, Anne Marie Weber-Main, and Libby Frost in preparing the manuscript.
  

Introduction
In collaboration with transgender and HIV/AIDS community organizations, our university-based program developed one of the first HIV prevention education interventions targeting the transgender population and piloted it in the Minneapolis/St. Paul metropolitan area, Minnesota, U.S.A. Transgender persons are affected by HIV/AIDS, yet virtually no prevention education had been provided (Bockting, Robinson, & Rosser, 1998). Therefore, we developed a psychoeducational workshop based on the Health Belief Model, the Eroticizing Safer Sex approach to HIV prevention, and principles of personal and community empowerment. Community involvement was key to the success of this project. We offer this experience as a case study of collaboration between a university and community organizations. "Transgender" is an umbrella term that refers to people who cross or transcend culturally defined categories of gender. They include crossdressers or transvestites (those who desire to wear clothing associated with another sex), male-to-female and female-to-male transexuals (those who desire or have undergone hormone therapy and/or sex reassignment surgery), transgenderists (those who live in the gender role associated with another sex without desiring sex reassignment surgery), bigender persons (those who identify as both man and woman), drag queens and kings (usually gay men and lesbian women who "do drag" and dress up in, respectively, women's and men's clothes), and female and male impersonators (males who impersonate women and females who impersonate men). Minnesota has a large transgender population due to the availability of transgender-specific health care (Hastings, 1969; Bockting, 1997a; Bockting & Coleman, 1992). Minnesota also was the first state in the United States to specifically include transgender people in human rights legislation (Human Rights Act, 1993).

Historically, the various subgroups of this diverse population have not always cooperated or felt comfortable with each other. For example, male-to-female transexuals generally distanced themselves from crossdressers because they felt that, unlike themselves, crossdressers are "just into the clothes and don't genuinely feel like women." Postoperative transexuals distanced themselves from preoperative transexuals in order to blend in with society as "new," no longer transexual, women and men. Heterosexually-identified transexuals and crossdressers separated themselves from gay-identified drag queens and lesbian-identified drag kings. A hierarchy existed in which those who conformed most to nontransgender members of the desired gender were at the top and those who conformed least were at the bottom of the pecking order. Homophobia, transphobia, and shame reinforced these divisions. Like other marginalized groups, transgender people turned oppression inward, and infighting was common, making for a fragmented community.

Subgroups defined on the basis of these divisions congregated in separate quarters and founded corresponding community organizations. The City of Lakes Crossdressers Club (CLCC) was founded in 1984 by crossdressers who met through association with our outpatient mental health clinic. They started to meet for support and socializing at private homes and later in a hotel. In 1988 several members of the CLCC founded a sister organization, the Minnesota Freedom of Gender Expression, which met at a community center. Female impersonators and drag queens gathered at a local gay and lesbian nightclub and in 1990 formed a chapter of the International Court System, an organization creating cultural, charitable, and recreational activities for drag queens, impersonators, their partners and friends, and named it the Imperial Sovereign Court of the Ice Castle.

In the 1990s, in the context of a paradigm shift toward affirmation of transgender identity and coming out (Bockting, 1997b; Bolin, 1994; Stone, 1991), the boundaries between these subgroups and divisions within the transgender community began to blur. Transgender people gained greater visibility, organized and empowered themselves, and sought coalitions with the gay, lesbian, and bisexual communities. In 1992 in Minnesota, this was reflected in the new name of the Gay & Lesbian Pride Festival: it became the Gay, Lesbian, Bisexual, and Transgender Pride Festival (see Figure 1). The City of Lakes Crossdressers Club became more inclusive of transexual people, changed its name to the City of Lakes Crossgender Community, and moved its meetings to a local HIV/AIDS service organization. The Minnesota Freedom of Gender Expression began to meet at the offices of the Gay and Lesbian Action Council. Consistent with this paradigm shift and trend in community building, we decided to bring representatives of the various subgroups and community organizations together under the transgender umbrella to initiate targeted HIV prevention.

Figure 1. Logo illustrating the inclusion of the transgender community in the Twin Cities Pride Festival. Copyright 1992 by Gay, Lesbian, Bisexual, and Transgender Pride/Twin Cities. Reprinted with permission.

The rationale for community involvement in our HIV prevention project was based on the belief that "the most effective center of gravity for health promotion is the community" (Kreuter, 1992). Community involvement ensures acceptability, appropriateness, and relevance of the intervention to the target population, and evidence suggests that people are more committed to initiating and upholding changes that they help design or adapt to their own purpose or circumstances (Wong, Alsagoff, & Koh, 1992). Furthermore, we shared the belief that fostering a sense of ownership raises the credibility of the prevention education message, promotes self-efficacy, and creates community norms that support protective behaviors (Corby, Enguidanos, & Kay, 1996; Mantell & DiVittis, 1990; Person & Cotton, 1996; Simons et al., 1996). To facilitate community involvement, we built on existing relationships between the university and local transgender community and HIV/AIDS service organizations.

Collaboration between community and researchers has been emphasized strongly in the second decade of the AIDS epidemic (e.g., Adrien et al., 1996; Bouie, 1993; House & Walker, 1993; Mantell & Divittis, 1990; Molbert, Boyer, & Shafer, 1993). The best-known example is the Centers for Disease Control's HIV Community Planning Process, in which U.S. state health departments share the responsibility for identifying and prioritizing HIV prevention needs with representatives of the communities for whom the services are intended (Valdiserri, Aultman, & Curran, 1995). Among the principles that guide this collaboration are these: (1) that differences in background, perspective, and experience are essential and valued; (2) that roles and responsibilities are clarified at the outset, and policies and procedures for resolving disputes and avoiding conflicts are developed proactively; (3) that resources are allocated for community involvement; and (4) that shared priority setting is based on an accurate needs assessment, a firm scientific basis for intervention, consumer characteristics and values, and evaluation findings. Challenges in this partnership between community representatives, scientists, prevention workers, and health officials include the complexity of participatory processes, the potential for conflict to decrease administrative efficiency, and the mistrust in marginalized communities of government, scientists, and health authorities. In working with the transgender community--a community even more marginalized than the gay, lesbian, and bisexual communities--we committed ourselves to these challenges and set out to foster involvement and empowerment.

Personal and community empowerment has been shown to positively affect HIV risk reduction. Effective interventions provide HIV prevention education in a context that promotes self-efficacy and affirms self-esteem and pride (DiClemente & Wingood, 1995; Kelly, 1995). The pedagogy of Freire (1970) has guided empowerment approaches in HIV prevention (e.g., Cranston, 1992; Ferreira-Pinto & Ramos, 1995). Educators often define and control the content of the intervention to be delivered to passive participants; Freire argued that participants know their own realities better than anyone else and should be actively engaged in their own education. Fundamental to his approach is the process of raising consciousness among participants through a critical dialogue out of which change and growth emerge. To facilitate empowerment, we involved a core group of community representatives in the development of the intervention, used focus groups, trained peer educators, and included a segment on empowerment in the workshop curriculum.

Establishment of a core group, usually in the form of an advisory board or task force, has been widely applied in HIV prevention. A core group of community leaders, key health professionals, and members of the target population, provides input throughout the program development process and shares in making decisions, prioritizing prevention needs, reviewing intervention materials, and disseminating information about the program to potential participants. As the group becomes more invested in the project, core group members who endorse the intervention secure trust and community support (e.g., Bouie, 1993; House, 1993; Kegeles, Hays, & Coates, 1996; Mantell & DiVittis, 1990). Focus groups, a method that originated in market research, involve members of the target community to qualitatively assess prevention needs, to evaluate the sensitivity and appropriateness of intervention materials, and to obtain suggestions on logistics of program implementation (Mantell & DiVittis, 1990).

Training peer educators to deliver intervention is empowering in more than one way. Peer educators have the opportunity to develop and practice prevention skills. Through their similarities with program participants, they more easily gain participants' attention and respect, promote feelings of self-efficacy through positive role-modeling, and intervene on the level of peer norms, creating the expectation that safer sex and needle practices are socially accepted and valued. In addition, education by peers who are living with HIV/AIDS has the potential to enhance perceived susceptibility to HIV infection (McKusick, Hortsman, & Coates, 1985; Kelly, 1995). Peer education has been shown to be effective in targeting gay men (Kelly et al., 1991; Kelly, Murphy, Sikkema, & Kalichman, 1993), youth (Baldwin, 1995; Kegeles et al., 1996; Rickert, Jay, & Gottlieb, 1991), women (DiClemente & Wingood, 1995; Kauth, Christoff, Sartor, & Sharp, 1993; Stevens, 1994), sex workers (O'Reilly & Piot, 1996), and injecting drug users (Simons et al., 1996).

We will first describe community involvement in each phase of program development--planning, needs assessment, recruitment, intervention, evaluation, celebration, and replication--then discuss the impact of our project on community building and the lessons we learned, and conclude with recommendations for future collaboration between community organizations and university faculty.
  

Planning
Representatives of the transgender community, the collaborating community organizations, and the university-based investigators formed a planning committee that included preoperative and postoperative male-to-female and female-to-male transexuals, a transgenderist, a bigender crossdresser, a transgender sex worker, and a female impersonator/drag queen and a transexual both living with AIDS. Committee members reflected a spectrum of sexual orientation, relationship status, and ethnic identification. Bringing these representatives with varying experiences of identity and sexuality together served to unite them in the fight against AIDS, to enable the community to take ownership of the project, and to tailor intervention and evaluation strategies to the characteristics and needs of the target population. Tasks were divided into three subcommittees focusing on (1) recruitment, (2) intervention, and (3) evaluation, each reporting in biweekly meetings to the full committee. Group process and consensus guided decision making. Committee members were reimbursed for their time.
  

Needs Assessment
To inform the intervention, we involved members of the target community in a needs assessment through the use of focus groups. We recruited participants through advertisements in general community newspapers, transgender organizations' newsletters, and personal networks of planning committee members. We conducted four focus groups with a total of 19 transgender persons (10 transexuals, 6 crossdressers, 2 transgenderists, and 1 drag queen/female impersonator), four of them living with HIV/AIDS, according to a method developed by Krueger (1988). Planning committee members helped develop interview questions, focusing on four main areas: (1) impact of HIV/AIDS on transgender persons, (2) risk factors, (3) information and services needed, and (4) recruitment strategies. Results were reviewed with the planning committee and incorporated in the intervention.

Focus group findings confirmed the importance of community involvement. Participants suggested the use of transgender role models (e.g., peer educators, transgender-identified health providers, transgender celebrities) to raise the credibility of prevention messages. Participants stressed the value of bringing people together in an environment where it is safe to express their transgender identity; they felt this would be an incentive to attend and serve to combat isolation and alleviate shame stemming from social stigmatization. They recommended that the intervention affirm transgender identity, improve self-esteem, foster a sense of community, and emphasize that life is worth living. Participants suggested that building community based on commonalities between subgroups of the transgender population be balanced with sensitivity to individual differences.

We discovered that the focus groups facilitated community involvement beyond the obvious purpose of gathering useful information directly from members of the target community; they also encouraged the community to become invested in the project. A number of focus group participants became advocates for the project, encouraging others to participate. Half the focus group participants attended the intervention, and several of them took an active part. For example, participants living with HIV/AIDS volunteered to serve on a panel and share their stories with workshop participants.
  

Recruitment
The needs assessment focus groups generated several suggestions for recruitment of workshop participants, including advertisements eroticizing safer sex, personal networking, street outreach, and incentives such as food and money. The planning committee reviewed these suggestions and decided to use the following: advertisements and short articles in newsletters, magazines, and community newspapers; posters in locations frequented by the target population; personal and street outreach using wallet-size cards with pertinent information; announcements on a local transgender computer bulletin board called Carolyn's Closet; and distribution of flyers to clients of key health providers. Homemade snacks were served during the workshop. Unfortunately, budget constraints did not allow us to pay those who attended the workshop for their participation.

Transgender-identified graphic designers produced a logo and prototypes of advertisements eroticizing safer sex with a transgender image. The planning committee reviewed these prototypes and selected a series of four advertisements that potential participants could identify with, that would attract them to the workshop, and that would simultaneously have a preventive effect by eroticizing safer sex. We faced our first hurdle when the university administration deemed three of the four advertisements inappropriate and too explicit, and refused to approve them. This criticism pertained to both the visuals and the text. For example, one ad depicted a transgender person dressed in lingerie with the slogan "Let's get down to basics--hot sex is safer sex"; it was intended to attract, among others, those who crossdress for sexual excitement (fetishistic crossdressers). We reached compromise with a less revealing image an

Planning committee members wrote short articles that, along with advertisements, appeared in newsletters of the transgender community organizations they represented. Committee members placed posters--enlarged versions of the advertisements--in nightclubs, adult bookstores, public bathrooms, and other establishments. Committee members also conducted personal and street outreach at club meetings, in bars, and in hangouts and strolls of transgender sex workers. To ensure access, promote safety, and provide an opportunity for training, much of this outreach was conducted in pairs of an experienced outreach worker and a transgender peer.

We offered the intervention, a four-hour psychoeducational workshop, three times during the course of six months. After satisfactory recruitment for the first workshop (of the projected 50, 36 transgender persons participated), attendance at the second workshop was disappointing (of the 34 registrants, 16 participated), due in part to the extreme winter weather conditions on the day of the workshop. Evaluation findings of the first two workshops showed that personal outreach accounted for the majority (55%) of recruits. Therefore, we increased our outreach efforts, and committee members invited their own personal networks through specially designed invitation cards. Because evaluation findings showed that we had primarily attracted preoperative transexuals (53%) and crossdressers (21%), we added advertisements using such terms as "postop transexuals," "female impersonators," and "drag queens,"--instead of the more general term "transgender"--to appeal directly to specific subgroups of the transgender population. To prevent diluting the primary purpose of attracting people to the workshop, these new advertisements did not attempt to eroticize safer sex. As an extra incentive, planning committee members organized a community celebration immediately following the third workshop. These combined efforts doubled recruitment for the third workshop, proving community involvement invaluable.
  

Intervention
The development of the workshop was based on (1) findings from the needs assessment focus groups; (2) 25 years of experience in providing Sexual Attitude Reassessment seminars and the Transgender Health Seminar (Held, Cournoyer, Held, & Chilgren, 1974; Lief, 1970; Bockting, 1997a; Bockting & Coleman, 1992); (3) the Health Belief Model and the Eroticizing Safer Sex approach to HIV prevention, and principles of empowerment (Janz & Becker, 1984; Rosenstock, Strecher, & Becker, 1994; Palacios-Jimenez & Shernoff, 1986; Fahlberg, Poulin, Girdano, & Dusek, 1991); and (4) input from the planning committee. Based on our experience with offering the Sexual Attitude Reassessment seminar and the Transgender Health Seminar to transgender clients, we chose a four-hour workshop format, combining three large-group and two small-group meetings. The first large-group presentation aimed to increase the health beliefs of perceived severity and susceptibility to HIV infection and transmission, followed by a small-group discussion to process feelings and identify personal risk. The second large-group meeting promoted risk reduction and eroticized safer sex, and, consistent with the Sexual Attitude Reassessment seminar's methodology, used sexually explicit videos featuring, whenever possible, transgender persons enjoying sex safely. The third and final large-group presentation addressed personal and community empowerment by affirming transgender identity, instilling self-confidence and pride, and fostering a sense of community (see Table 1). The planning committee created and adapted educational materials to appeal directly to the concerns and HIV risks of the transgender participants.

Community involvement in the workshop curriculum and implementation consisted of:

1. Peer Education We recruited two large-group and ten small-group leaders from the target community. A well-respected male-to-female transgenderist who enjoyed a leadership role in the community was co-facilitator of the large-group presentations with the first author. She served as a role model by relating the presented information to her life as a transgender person and as the parent of a son who died of AIDS. Small-group leaders, who reflected the diversity in sexual identity, ethnicity, age, and relationship status of the target group--pre-operative and post-operative male-to-female and female-to-male transexuals, crossdressers, transgenderists, bigender persons, drag queens and female impersonators--attended a day-long training (see Table 2). The morning program focused on learning the goals and content of the workshop; increasing comfort in talking about sex; developing sensitivity to the diversity in transgender identity and sexuality; increasing HIV/AIDS knowledge and desirable attitudes; and understanding risk behavior, safer sex, and risk reduction in the use of injection paraphernalia. The afternoon program focused on developing facilitation skills in group discussion, exercises, and role play. Through small-group simulations, peer educators rehearsed their skills.

2. Videoclip Personalizing HIV/AIDS To involve a transgender celebrity as a role model, we invited transexual performing artist Kate Bornstein to conceive a videoclip to personalize HIV/AIDS. Kate met with a group of community members to learn about their perceptions of how HIV/AIDS applies to them as transgender people. In writing the script, she incorporated themes and comments that surfaced during this meeting. A local transgender video artist filmed and edited a nine-minute infomercial that featured, along with Kate, three local people (a male-to-female transexual, a female-to-male transexual, and a drag queen/female impersonator), each playing a transgender person uniquely at risk for HIV. Among the HIV co-factors addressed in this video are: identity confusion or conflict, shame and isolation, secrecy, and fear of discovery and rejection. Toward the end of the video, Kate affirms participants' self-worth and empowers them to confront their HIV risk (Bockting, Grandell, & Bornstein, 1992): "Trust yourself. Trust yourself to know that you're a good and decent human being. Trust yourself to know that your life counts in this world. Trust yourself to protect yourself around HIV and AIDS. And the next time a voice comes up and tells you to be silent, please remember how very loved you are in the scheme of this world, and speak up in spite of the voice that might silence you. You're my family. I can't tell you how glad I am that you're at this workshop. Please be proud of yourself. Please speak up about AIDS and HIV. Please keep on living."

3. Panel of Transgender Persons Living with HIV/AIDS We accepted the offer of focus group participants with HIV/AIDS to make a panel presentation during the workshop. Two individuals, a transexual and a drag queen/female impersonator, introduced themselves and engaged in a question and answer session with workshop participants. We asked panel members to focus on the personal, on their adjustment, identity, and sexuality, and to avoid intellectualizing and lengthy hospital stories. For example: Q: "What, if any, of your crossgender issues affected your contracting the HIV virus?" A: "I think for me it would be being in denial of my transexualism for a long time, having to repress that and having to repress my sexuality, feeling really ashamed about the whole thing. It is really easy to have unsafe sex when you feel that way, because those feelings of shame can override anything, because they are very strong. The biggest thing that anyone can do is deal with that, accepting themselves and loving themselves, knowing that they're worth it, you know, all of that." Q: "Does your family know?" A: "My family knows. My mother never accepted that I have AIDS. She can't understand that her eldest son is really a female. My brother says it's a bunch of bullshit. My sister is real supportive. My sister says she doesn't know why it took me so long to decide to grow up to be a woman. My sister is my biggest support." The panel presentation was so successful that several other workshop participants also living with HIV/AIDS volunteered to be on the panel during subsequent interventions.

4. Sexually Explicit Videos Featuring Transgender Models During the second large-group presentation designed to promote risk reduction, we showed sexually explicit videos eroticizing safer sex. Previous research demonstrated that such videos reinforce behavior change (Quadland, Shattls, Schuman, Jacobs, & D'Eramo, 1987). Although finding educational videos portraying transgender persons having sex was hard, we managed to locate a video of a female-to-male transexual and a nontransgender female partner practicing safer sex (Jaccoma, Armstrong, & Sprinkle, 1990).

5. Transgender Physician We invited a female-to-male transexual physician to discuss HIV testing and answer medical questions. We were amazed by the number of medical questions, suggesting that future interventions address medical aspects more extensively. Questions specific to transgender concerns included: "What are the effects of hormone therapy on HIV risk and disease progression?" and "What is the risk of HIV infection through electrolysis?"

6. Transgender Community Activist In the third large-group presentation, a male-to-female transexual local politician and community activist fostered community and empowerment. She stressed commonalities between subgroups of the transgender community, creating a sense of unity. She affirmed the coalition of the gay, lesbian, and bisexual communities and the transgender community by reminding participants of the role drag queens played in the 1969 Stonewall rebellion (which marked the beginning of America's gay rights movement), and by pointing out the shared struggle for social acceptance, for human rights, and against AIDS. She facilitated a ritual. As participants stood in a circle, she wrapped a red ribbon around their hands, nurturing feelings of solidarity, affirming transgender identity and sexuality, and instilling self-confidence and gender pride. All participants got a piece of the ribbon to remind them of being part of a community and a future worth living for.

7. Video Affirming Transgender Expression and Promoting Condom Use To end the workshop, we showed a video titled "Condoms Are a Girl's Best Friend," a parody of Marilyn Monroe's "Diamonds Are a Girl's Best Friend" performed by a female impersonator interspersed with scenes of transgender persons and their partners (Lane & Kay, 1991).
  

Evaluation
We assessed community support, participant satisfaction, and changes in participants' AIDS knowledge, attitudes, and HIV risk behaviors both quantitatively and qualitatively. Quantitative evaluation consisted of comparisons between participants' responses on pre-workshop, post-workshop, and two-month follow-up questionnaires. The evaluation subcommittee of the planning committee drafted the questionnaires, which were pilot-tested and reviewed by the entire committee for cultural sensitivity and relevance. It was particularly rewarding to free questions from conventional assumptions of sex and gender in order to account for the unique anatomies and realities of transgender persons. The outcome was an instrument with clear, descriptive questions that reflected the notion that the risk of HIV is behavior-based and not dependent on gender or sexual orientation. For further clarity, the committee defined a list of transgender-specific and other key terms to guide respondents.

During this process, tension between community representatives and evaluators on the planning committee arose. Several community representatives felt strongly that the service we were providing--the HIV prevention intervention--should not be overshadowed by the research component, the questionnaire evaluation. They argued that too obtrusive an evaluation process would make participants feel like guinea pigs and compromise the intervention by affecting participants' trust and comfort. Others pointed out the value of evaluation of our model program for future interventions and for the long-term welfare of the community. Resolution of this conflict benefited from the community and research expertise represented on the committee, resulting in a substantially shorter questionnaire.

Planning committee members assisted in data collection by staffing the evaluation booth at the workshop together with investigators, providing an opportunity for training in administering program evaluation. After analyzing the data, investigators discussed with the planning committee aggregate results and their implications for future intervention and research. Results showed an increase in AIDS knowledge and in positive attitudes toward AIDS, sex, safer sex, and condoms. Results also showed that participants socialized more than before with transgender persons in the months following the workshop, suggesting a decrease in isolation and a positive impact on community building. Participant satisfaction with the workshop was high (Bockting, Rosser, & Scheltema, in press).

Qualitative evaluation consisted of a focus group of randomly selected workshop participants. Questions focused on intervention impact, satisfaction, and suggestions for improvement. Results indicated a dramatic increase in AIDS awareness, with participants teaching their respective communities what they learned in the workshop. They reported many conversations about safer sex with friends and family, and on the Internet. The panel presentation of transgender persons living with HIV/AIDS turned out to be powerful in raising perceived severity and susceptibility. The involvement of peer educators as small-group leaders was well received; participants valued the leaders' skills in making people feel comfortable and safe to open up. Participants showed great enthusiasm for more targeted HIV prevention education to protect and care for their community. They recommended that future prevention education take a more contextual approach, integrating HIV prevention in efforts to improve overall health and psychosocial adjustment. Participants asked for a further tailoring of intervention strategies to the different subgroups of the transgender population and wanted to hold the workshop at community sites. The focus group itself seemed to have a preventive effect; during the discussion, participants reinforced prevention messages for each other (Bockting, Robinson, & Rosser, in press).

We involved planning committee members in disseminating evaluation findings to the community. We distributed a program manual outlining the intervention and evaluation findings to interested community members (Bockting, Rosser, & Coleman, 1993). Together with the first author, transgender community representatives shared findings with family physicians at the university, and with researchers, funders, prevention workers, and representatives from communities nationwide at the HIV Prevention Research Development Meeting in conjunction with the 17th National Lesbian and Gay Health Conference and the 13th Annual AIDS/HIV Forum.
  

Celebration
Although the impetus for the community celebration following the third workshop was to boost recruitment, it also served to acknowledge the successful completion of our project. Planning committee members organized the gathering at their regular meeting site, which had shifted during the course of the project to a gay, lesbian, bisexual, and now transgender nightclub. All workshop participants, staff, and the wider transgender community were invited. During this celebration, we honored planning committee members and peer educators for their contributions and presented them with an AIDS ribbon pin. The female impersonator with HIV/AIDS who served on the committee provided entertainment. This was a proud and well-attended community-building event.
  

Replication
Upon completion of our one-year project, we discussed future endeavors with the planning committee. We agreed to shift the responsibility for the intervention further to the community, with university-staff retreating into an advisory role. One committee member offered the workshop at the annual convention of the International Foundation for Gender Education in 1996. Attended by representatives of national and international transgender communities, this workshop had a twofold purpose: to address HIV for convention attendees, and to give them an experience to build on to implement HIV prevention efforts in their own communities. We trained two new large-group leaders, a crossdresser and a female-to-male transexual, and fifteen transgender-identified small-group leaders to facilitate the workshop. Additional video material was incorporated (The Gender Centre, 1995). This particular workshop was dedicated to two transgender community activists, Louis Sullivan and Jennifer Richards, both of whom died of AIDS. As an outgrowth of this event, the first author was invited to write an article for Transgender Tapestry, the magazine of the International Foundation for Gender Education, which enjoys a large worldwide distribution (Bockting, 1996).

Since the completion of our project, we have received numerous requests for the program manual. This led to the establishment of an international network of grassroots initiatives in transgender HIV prevention with which we have shared intervention materials; collaborative projects are under way.
  

Discussion
Impact on Community Building Our project had a positive impact on community building. We brought representatives of the various segments of the heretofore fragmented transgender community together and united them in the fight against AIDS. The planning committee and peer educators became a team. Transgender participants living with HIV/AIDS started an informal support group. Workshop participants from various backgrounds and with various transgender identities and sexualities bonded during the intervention and celebration.

Throughout and following our project, relationships between the various subgroups of the transgender community have strengthened. The City of Lakes Crossgender Community moved with the Minnesota Freedom of Gender Expression to a local gay, lesbian, bisexual, and now also transgender nightclub. The Imperial Sovereign Court of the Ice Castle crowned a transexual woman as their empress, and the planning committee member who identified as a transgenderist (the former President of the City of Lakes Crossgender Community) joined the Court and performed as a female impersonator. Three new transgender community organizations formed. One planning committee member founded the Gender Education Center, the first local transgender community organization with nonprofit status and the first to receive funds for sensitizing, among others, health providers and prevention workers to transgender issues. Transexuals founded the New Men and Women of Minnesota; Tri-Ess, a national organization of crossdressers and their partners, formed a local chapter. In addition, drag kings and male impersonators gathered at Vulva Riot, a local cabaret. These groups now maintain unprecedented cooperative relationships and together hosted the convention of the International Foundation for Gender Education entitled "Minnesota Pride, 1996" where their coalition with the gay, lesbian, and bisexual community was cemented in a keynote address by Melinda Paras, executive director of the National Gay & Lesbian Task Force. Important differences between these groups notwithstanding, they all cross or transcend culturally defined categories of gender. Together they are stronger in the pursuit of equality and human rights. Lessons Learned Although community involvement in our project built on long-standing relationships with the local transgender community, the target group's distrust of health researchers, practitioners, and policy makers indeed surfaced. Like communities of color and the gay, lesbian, and bisexual community, transgender people haven't always felt that authorities are on their side. As one transgender person said during our needs assessment: "My contention is that the AIDS crisis was allowed to happen by the U.S. government, the result being that sexual minorities are especially vulnerable to contracting this disease and dying. Hence, AIDS is society's punishment for being queer." The transgender community has had its share of negative experiences with researchers and health providers. For example, research was used in 1979 to discontinue sex reassignment services at Johns Hopkins (Meyer & Reter, 1979; Money, 1991). Transgender persons report many negative experiences with health care providers based on ignorance and prejudice. Moreover, the medicalization of transvestism and transexualism, and the gatekeeping role of mental health professionals without whose written recommendation a physician cannot initiate hormone therapy or perform sex reassignment surgery, are subjects of growing tension between providers and consumers (Walker et al., 1990; Bolin, 1988, 1994).

Since we are the main providers of sex reassignment services in the community, this issue of distrust was especially challenging for us. Although we consciously avoided dual relationships, a member of our planning committee and small-group leader, while continuing to participate in the HIV prevention project, rallied a community protest publicly denouncing our clinical services. Another Committee member temporarily resigned out of solidarity with the protesters. Because of our obligation to protect client confidentiality and our desire not to aggravate the situation, we initially responded cautiously. As the conflict continued to escalate, we intervened with the planning committee, with individual members of the community, and eventually in a public forum. The crisis was not resolved until we articulated clearly what we stood for, set limits with regard to the accusations leveled against us, and negotiated boundaries in relationships with community members. We discovered that the community perceived our initial reserved response as uncaring. We regretted that we hadn't defined our working relationship and boundaries more clearly at the outset and agreed on how to handle conflict, as recommended by others (Adrien et al., 1996; Valdiserri et al., 1995). Working through this conflict forced both parties to examine issues from each other's perspective, recognizing potential and limits of collaboration, ultimately leading to a deepening of mutual respect and trust. Recommendations for Future Collaboration

1. Make a commitment to reciprocal collaboration. Successful, empowering community-university collaboration must be truly reciprocal. This requires a commitment on both sides to communicate, listen, respect each other's goals and values, and share in decision making. We recommend involving a core group of community representatives earlier than we did, in the proposal stage of the project, or, ideally, as an early, ongoing forum to identify and address community health needs. Group process allows Freire's critical dialogue to occur; group consensus allows participants to share in decision making. At the outset, define and agree upon roles and responsibilities, along with ways to deal with conflict (e.g., keeping and resolving conflict within the group so as to not jeopardize the project).

2. Strive for community-based intervention. We recommend that the intervention be designed and implemented as much as possible by the community. University-based interventionists can help mobilize the community, secure funding, apply relevant scientific knowledge, and facilitate skill development (e.g., by training peer educators). If the community lacks the infrastructure to initiate targeted prevention education, the university should not hesitate to take the lead. Once the community has gained sufficient cohesiveness, the university could fall back to a consulting or advisory position, shifting responsibility to the community.

3. Educate and involve the community in research and evaluation. Community-based interventions can benefit greatly from adequate formative and evaluation research. Epidemiological research is often needed to justify funding for prevention education; interventions informed by group-specific needs assessments are more likely to be successful; and evaluation can document effectiveness and provide helpful information for program improvement. We recommend that university-based researchers educate community representatives about these benefits and actively involve them in research and evaluation, while taking care to balance research and intervention priorities so that evaluation does not overshadow intervention.
  

Conclusion
We believe that as a result of our collaboration, both the university and the transgender community have grown (Bockting, 1993). We learned that affirmation of transgender identity, peer support, and empowerment are key in promoting transgender health; we now stress these elements also in our clinical services. The transgender community has come together and solidified its coalition with the gay, lesbian, and bisexual community. Aware of their HIV risk and supported by university faculty, transgender community members petitioned successfully for a seat on the State Commissioner's Task Force on HIV Prevention, the guiding body of Minnesota's HIV prevention community planning process. The seat that they proudly claimed as their own was named in honor of a transexual member of our planning committee, Celie Mahu Edwards, who died of AIDS. We look forward to continuing collaboration to promote community health.
  

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