Education and Soul-Searching: The Enterprise HIV Prevention Group

by Douglas Hein, B.A., Program Manager, AIDS Services, Boston Public Health Commission, 1010 Massachusetts Avenue, Boston, MA 02118 USA
and Michael Kirk, B.F.A., Founder, Enterprise, P.O. Box 2204, Jamaica Plain, MA 02130 USA

Citation: Hein D., Kirk M. (1999) Education and Soul-Searching: The Enterprise HIV Prevention Group. IJT 3,1+2, http://www.symposion.com/ijt/hiv_risk/hein.htm

• Abstract
• Introduction
• A Brief History of Enterprise
• Paradigm Shifts in HIV Prevention
• The Enterprise Prevention Workshops
• Conclusion
• Acknowledgments

Abstract
This paper will describe a series of HIV prevention workshops for Enterprise, an ongoing support group for female-to-male transsexuals of different sexual orientations and stages of gender transition in Greater Boston. The workshops are based on the premise that information-based HIV prevention strategies have limited efficacy in helping individuals sustain behavior change over time, and that marginalized populations require interventions that address their particular psychosocial issues and needs. The intervention focuses on core issues in HIV prevention and risk management:

1. HIV/STD transmission and risk reduction information;
2. disclosure of personal information in relationships and sexual encounters;
3. verbal and nonverbal negotiation skills;
4. the connections between cognitive learning and human sexual response;
5. the meanings of sexual behaviors; 6) the value of sexual pleasure;
6. the relationship between sexual desire and personal identity; and
7. mobilizing ongoing support for managing HIV/STD risk.
     

Introduction
Education and Soul-Searching is adapted from a prevention model developed for HIV-negative gay and bisexual men by the Boston Public Health Commission and the Fenway Community Health Center in 1994. Although the structure of the Enterprise workshops is based on the 1994 intervention, the issues addressed in workshop sessions are determined by female-to-male (FTM) participants. The workshops include education, discussion, and participatory exercises focused on:

1. HIV/STD transmission and risk reduction information;
2. testosterone therapy and its impact on sexual behavior;
3. social and cultural issues that marginalize FTMs and affect their risk for infection;
4. disclosure of transsexual identity to sexual partners;
5. coping with gender-discordant strategies for managing behavioral risk;
6. developing language that accurately describes sexual desire and intention;
7. understanding the role of sexual pleasure and its connection to FTM identity;
8. using risk management strategies that focus on the values and meanings of risk behaviors; and
9. forming connections with people outside the FTM community as allies, sexual partners, and significant others.

This paper will focus briefly on Enterprise's membership, mission, and history as well as recent paradigm shifts in HIV prevention. The workshop sessions will be described fully, including key issues for workshop participants.
  

A Brief History of Enterprise
Enterprise was formed in 1993 by members of the FTM community in Greater Boston. Since its inception, Enterprise has functioned as a peer support group for transsexual men in various stages of gender transition. The group meets weekly and provides a supportive environment for members to socialize, mentor each other, address medical issues related to hormonal therapy and surgery, and offer emotional support. Enterprise members report many of the same difficulties as FTMs from other parts of the United States:

1. fear of lack of access to competent medical care and social services;[1]
2. fears about disclosure of one's transsexual status;
3. social marginalization; and
4. fears regarding physical violence.

Enterprise also provides opportunities for community visibility and individual empowerment. Group members are active locally and nationally in promoting awareness about FTM issues through participation in educational forums, conferences, art exhibitions, and performances. In 1997, Enterprise sponsored four events in Greater Boston that significantly increased the organization's visibility. A few hundred people attended an evening of music and celebration in late March to commemorate the publication of Loren Cameron's book, Body Alchemy: Transsexual Portraits.[2] In early April, the New England Film Festival premiered You Don't Know Dick: Courageous Hearts of Transsexual Men [3] and named the film Best Documentary of 1996. In June, Enterprise co-sponsored the first FTM contingent for Boston Gay Pride. In August, Enterprise shared sponsorship of The Hero's Journey: The Third Annual FTM Conference of the Americas with two other FTM groups, the Officer's Club and the local chapter of American Boyz.

From 1993 to 1996, Enterprise members met weekly in each others' homes. During 1996, the membership used a community room in Boston for meetings. Since December 1997, Enterprise meetings have been held in Waltham, Massachusetts at the International Foundation for Gender Education (IFGE), an organization focused on support and advocacy for the MTF/ FTM transgender/transsexual community.
  

Paradigm Shifts in HIV Prevention
In 1991, HIV test sites in Boston began to see more gay men engaging in repeat or routine testing.[4] HIV counseling staff realized that concerns about HIV were affecting their clients' quality of life, and some men seemed to be experiencing difficulty in sustaining safer sex practices.[5] Mental health clinicians treating gay and bisexual men began to publish articles citing the psychological effects of ten years of behavioral vigilance and personal loss. Psychotherapists reported patients with AIDS-related depression, anxiety, hypochondria, impotence, survivor guilt, sexual anorexia, alcoholism, and drug use.[6]

Research and popular journalism about HIV prevention between 1991 and 1995 focused on four areas of concern:

1. Many uninfected gay men were survivors of trauma and loss;
2. HIV-negative gay men experienced confusion about generalized prevention messages that failed to differentiate between the needs of infected and uninfected men;
3. HIV prevention strategies employed during the first ten years of the epidemic were information-based and did not seem to help men sustain behavior change over time; and
4. Prevention strategies based on harm reduction and risk management were designed to promote sustained behavior change by addressing the cultural meanings of risk behaviors in specific populations.[7]

The Boston Public Health Commission and the Fenway Community Health Center began a three-week support and education group for uninfected gay men in 1994.[8] The group model was designed to extend HIV-negative post-test counseling for men at risk and is based on an existing support and education group for HIV-positive individuals in Boston.[9] The HIV-negative support and education group continues to meet monthly at the Fenway Community Health Center.

Although the 1994 intervention targets uninfected gay men, project staff developed the model with the intention that it be replicated for other populations at risk. Group members contribute significantly to the content of each session, prioritize issues they want to address, and develop prevention strategies based on their particular needs.

In the process of planning an HIV prevention group for FTMs, we realized that some of their concerns and experiences were similar to the concerns of gay men in 1991:

1. Many FTM transsexuals experience both loss and renewal as they transition towards living fully as men;
2. HIV prevention education based on gender and sexual orientation does not address the specific needs of FTMs;
3. Information-based prevention strategies do not address the complexity of transsexual bodies, cultures, and sexual relationships;[10] and
4. Harm reduction and risk management strategies can be used to address the specific health concerns and sexual practices of FTM transsexuals.
     

The Enterprise Prevention Workshops
The authors met through a local AIDS services organization in 1995. They agreed that most HIV prevention programming in Boston for transgenders and transsexuals focused on the needs of the MTF community, and that FTMs needed programs focused on their particular risks. Periodically for the next two years, the authors offered to conduct an HIV prevention group at Enterprise. Enterprise members responded with ambivalence; HIV did not seem to be a priority in their lives during this time. In 1997, the membership decided that they wanted a series of prevention workshops, and Education and Soul-Searching [11] was promoted through a mailing by an Enterprise member.

The two-year time period is mentioned because it seems to correlate with some of the issues discussed later by men in the prevention workshops. The authors discussed four possible reasons for the men's ambivalence:

1. Members found it difficult to trust someone from outside the group, especially a non-FTM facilitator associated with health care;
2. They were focused on their gender transition and needed to devote their time, energy, and resources to helping each other manage those changes;
3. HIV was one of many health issues that concerned and marginalized them; and
4. Dealing with HIV meant facing their fears about infection.

Two series of workshops were conducted in 1997 and 1998. Each series consisted of three sessions that spanned a two-month period, with a one, two, or three week interval between each session. Scheduling was based on the needs and time constraints of Enterprise members. Each session was approximately two hours long.

The first series of workshops was held in Boston during the winter of 1997. The second series was held in Waltham during the spring of 1998. There were four to six men in each workshop session, and all identified as FTM transsexuals. Although heterosexual, bisexual, and gay men attended the workshops, most of the participants identified as gay or bisexual. Heterosexual men were more likely to drop out before the third session.

Participants were in different stages of gender transition. Some had been taking testosterone for years, undergone multiple surgeries, and were living fully as men. Other participants were just starting their transition, taking low doses of testosterone, and contemplating surgical options.

For purposes of coherence and clarity, we will combine content from both the 1997 and 1998 series of workshops in our descriptions of workshop components. The descriptions of sessions imply that topics were discussed sequentially in a predetermined order. In reality, group discussions were loosely organized around the multiple themes addressed in this paper. Each workshop was facilitated by a non-FTM HIV prevention counselor and a peer facilitator from Enterprise.

During the first workshop session, facilitators employed simple ground rules, asked participants to talk about their reasons for attending the group, and discussed the risks and benefits of participation. They used the beginnings and endings of each session as check-in time regarding members' needs and expectations. Participants' discussion responses were written on an easel chart during each session.

SESSION I
Understanding social and cultural risk factors:

BY YOUR RESPONSE TO DANGER IT IS
EASY TO TELL HOW YOU HAVE LIVED
AND WHAT HAS BEEN DONE TO YOU.
YOU SHOW WHETHER YOU WANT TO STAY ALIVE,
WHETHER YOU THINK YOU DESERVE TO,
AND WHETHER YOU BELIEVE
IT'S ANY GOOD TO ACT.[12]

The above epigram is used to initiate discussion about:

1. life circumstances that increase personal vulnerability;
2. life circumstances that contribute to personal strength; and
3. the effect of gender transition on one's ability to manage health concerns.

Participants seemed to value the opportunity to talk about themselves as well as their concerns about HIV. Some expressed relief that the workshop offered more than generalized information about safer sex and prescriptive advice about condoms and dental dams.

Building trust between FTM participants and the facilitator:
As stated previously, one of the facilitators was a non-FTM HIV prevention counselor. Although he had discussed FTM issues extensively with the peer facilitator and read most of the existing literature on FTM culture and sexuality, his experience with FTMs from different backgrounds and stages of gender transition was limited.

Part of the first session involved a conscious dialogue between the non-FTM facilitator and participants. This facilitator spoke briefly about what he had learned so far, and asked group members to share as much information as they wanted about their lives as transsexual men. Although workshop participants knew each other well, they willingly shared their personal stories with the facilitator. This included information about their jobs, gender histories, current stages of transition, sexual orientation, and the impact of hormones and surgery. They also talked about relationships with co-workers, parents, siblings, significant others, spouses, and children.
  

SESSION II
Describing HIV testing experiences:
Most of the men in the group had been screened for HIV at least once, and some were contemplating testing again in the future. The facilitators asked the men to talk about their testing experiences as well as any other concerns they had related to testing. Participants described the difficulties of dealing with intake forms and health care practices that did not include transgender and/or transsexual as gender categories. Group members also expressed ambivalence about disclosing their transsexual status during pre- and post-test counseling; they valued being perceived as men and found it difficult to trust counseling staff. Facilitators provided information about standards of care for HIV counseling and testing, and group members described their experiences with testing programs in Boston that specialize in the needs of transsexuals.

Sharing personal stories related to HIV:
People talked about their fears and confusion about managing risk for HIV infection. Some participants knew people with HIV; others had marginal contact with the epidemic and limited knowledge about safer sex. People perceived HIV risk in relation to their concerns as transsexuals and identified and discussed the following themes:

1. disclosure of transsexual identity to sexual partners;
2. disclosure of HIV status to sexual partners;
3. talking with sexual partners about testing;
4. coping with gender discordant strategies for managing risk; and
5. developing sexual language consistent with gender identity.

Educating about HIV/STD transmission:
Participants had specific questions about safer sexual behaviors, and some men needed basic information about the prevention of HIV and STDs. Men expressed concerns about new sexual behaviors, especially ones that correlated with changes in sexual orientation or involved sexual experimentation. This seemed particularly true for participants who were having sex with men, and their questions reflected an increased interest in oral/penile and oral/anal sex.

Talking to partners about HIV status and safer sex:
Participants wanted to talk to sexual partners about HIV status and safer sex. They also asked for strategies that would help them negotiate sexual boundaries. Facilitators helped participants discuss:

1. ways to introduce information about HIV early in the encounter or relationship;
2. the risks and benefits of disclosure;
3. the meanings of disclosure for both negative and positive people;
4. the anticipation of one's reactions and responses to partner disclosure; and
5. the establishment of trust with sexual partners.

At first, participants seemed focused on HIV disclosure as a strategy to avoid infection. As group members talked more extensively about the meanings of disclosure for infected and uninfected people, they asked more questions about psychosocial issues for people with HIV. Some of the men expressed appreciation regarding similarities between coming out as HIV-positive and disclosing one's FTM identity.

Participants also began to understand the limitations of disclosure as a prevention strategy, and that in the absence of established trust, negotiating safer sex was an essential part of self-protection.[13] Discussion focused on simple ways to set sexual boundaries:

1. introducing HIV risk management as mutually beneficial for both partners;
2. expressing appreciation of a partner's sexual skill, physical attributes, erotic capacity, and/or emotional sensitivity;
3. stating clearly one's boundaries regarding safety; and
4. asking one's partner to assist in identifying mutually pleasurable sexual alternatives.

Participants also discussed nonverbal strategies for sexual risk management. Some men stayed partially clothed during sex to avoid intercourse as well as the disclosure of their transsexual status. Other men used body language to convey sexual boundaries. The facilitators reinforced the effectiveness of using one's body to change power dynamics, avoid unprotected sex, and send signals to partners about sexual alternatives.
  

SESSION III
Defining HIV prevention strategies:
This didactic section defined three different levels of HIV prevention:

Risk reduction is the informational component of behavior change where education about HIV transmission and risk reduction supplies like condoms and bleach are provided for people at risk.

Risk management is supportive education and counseling that empowers individuals to make decisions about behavior change by considering both risk reduction guidelines and issues related to the social, cultural, and personal meanings of sexual behaviors.[14]

Harm reduction is an intermediate intervention, especially useful for substance users, in which avoiding infection and injury takes priority over drug treatment and abstinence.[15]

Often the terms risk reduction, risk management, and harm reduction are used interchangeably. In this section, we present these methods as related but fundamentally different prevention practices. Risk reduction promotes behavior change through guidelines provided by an external source. Risk management and harm reduction are client-centered, focus on sustaining behavior change over time, and help internalize the process of behavior change by shifting the locus of control back to the individual.

Understanding the links between sex and the brain:
This section provided information about human sexual response and addresses why education about HIV transmission does not always result in successful behavior change.

Education is a cognitive function that happens in the brain cortex. The cortex controls knowledge and awareness and is the learning center of the brain. Sexual behavior is a limbic function that happens in the brain stem. This part of the brain controls one's emotions, behavior, and motivation as well as one's sense of smell and other involuntary actions of the body. Anger, rage, fear, hunger, and satiation are all instinctual responses connected to the brain stem. Sexual response (including penile and clitoral erections, pre-ejaculation, ejaculation, and vaginal lubrication) is an involuntary response to stimuli.[16]

The following pairs of words are used to illustrate the differences between cortical and limbic function. Facilitators asked group members to brainstorm their own lists of comparative responses under the headings thinking and feeling.

Participants in one of the workshops formulated a different interpretation of the above exercise. These men viewed thinking as risking death, and correlated facts and knowledge about HIV to avoiding infection. They viewed feeling as risking life and correlated the expression of sexual desire to their survival as new men. These participants considered sexual energy as essential to their survival as breathing. They also valued sexual experimentation and desire and regarded sexual feelings as fundamental elements of masculine expression and identity.

Using risk management and harm reduction:
The following table illustrates a preparatory exercise used to help participants express personal values about pleasure and meaning. The use of a sport like rollerblading is intentional. Usually someone in the group had engaged in the sport, and rollerblading parallels sexual activity in that it can be both hazardous and exhilarating. Participants were asked to brainstorm responses to four headings while one of the facilitators recorded their responses on an easel chart.

After the preparatory exercise, the group participants were asked to choose a sexual behavior for discussion. During the first workshop cycle, all the men who participated in this exercise identified as gay or bisexual. Participants chose to discuss performing oral sex on a man.

Participants stated that the italicized responses were connected to their identities as FTMs.

Key Issues for Workshop Participants
Education and Soul Searching provided a structured environment for participants to address the complex relationship between FTM identity and HIV risk management. Group members engaged in frank discussion about their bodies, current sexual relationships, and meaningful sexual behaviors. Themes evolved that require further examination and discourse.

The roles and meanings of sexual behaviors:
Participants attached meaning and value to behaviors that:

1. expressed their masculine identity;
2. validated their maleness;
3. celebrated their lives as men; and
4. affirmed their sexual identity and orientation.

For FTMs who identified as gay and bisexual, sexual encounters with biological males provided opportunities to experience gender equality. Gay sex was described as man-to-man and reciprocal for both partners regarding power, control, and submission. Sex with men also allowed participants to develop affinities with their partners' genitals. One group member described viewing his partner's penis as a friend. Other participants experienced vicarious enjoyment of male genitals. Group members also valued sexual intimacy with other men because it provided access to what one participant called cock energy. Some participants felt that having male energy was as important to their transition as having a male body. Semen had significant value as a source of male energy and nourishment.[17]

The emotional risks of sexual behaviors:
HIV prevention usually focuses on the physical and health-related risks associated with unprotected sex. Although the facilitators provided factual information about HIV transmission, group members expressed several issues related to the emotional risks they experienced as FTMs:

1. fear of disclosing one's transsexual identity during sexual encounters;
2. fluctuating self-esteem related to the incremental nature of gender transition;[18]
3. gender-discordant sexual language and prevention strategies;
4. objectification of male sex partners and their genitals; and
5. envy of their male partners' genitals.

One participant related that simply being perceived as a man by potential male or female sexual partners predisposed him to emotional and physical risk. He described the profound validation he continues to feel being recognized as male, and the difficulty of asserting his needs when his gender identity is at stake; doing so might jeopardize his acceptability as a sexual partner, complicate the encounter, and end in rejection.

Other participants described sexual encounters in which they chose not to disclose their transsexual status. This usually involved staying partially or fully dressed during sexual acts. One man recounted keeping his briefs on during an encounter and gaining sexual pleasure by rubbing against his partner's body. Other participants reported feeling frustrated by sexual experiences focused primarily on their partners' pleasure. While group members enjoyed performing oral sex and masturbation on other men, their needs for attention and release were sometimes deferred or ignored.

Participants talked about the incremental nature of their gender transition and its affect on self-confidence in sexual situations. Some men stated that their sexual self-esteem fluctuated, and that variations in sexual confidence seemed linked to concerns about ambiguous gender presentation. They were not interested in passing as men; they wanted to be men, and sometimes felt understandably at odds with the stages involved in becoming men.

One participant reported being at risk for HIV early in his transition. He described responding to sexual situations with passivity and felt that this reflected his years of being socialized as female. This man told the group that acquiring male social behaviors was one of his strategies for managing risk; acting male equated with being male, and he felt more confident with both male and female partners in asserting his needs.

Group members struggled with gender-discordant language when describing sexual situations. Most group members were living fully as men, and many had undergone testosterone therapy, chest surgeries, and hysterectomies. None of the participants had completed genital reconstruction. Group members described sexual experiences in ways that felt consistent with their socialization as new men. Participants referred to some sexual acts as fucking and acknowledged that actual penetration was limited. They referred to masturbation as jerking off and their genitals as cocks or dicks with the recognition that their choices regarding genital reconstruction were yet to be resolved. [19]

Group members valued condoms because they provided male-identified options for safer intercourse and oral sex, but found them difficult or impossible to use. When one group member related his struggles with safer sex, other participants raised the possibility of adapting dental dams for different sexual acts. He shuddered as he told the group that he associated dental dams with vaginal sex and being female; they were not an option, even if it meant contracting HIV.

One participant described sexual encounters in which he felt objectified or "used" his male partners. He recounted situations in which he focused solely on his partners' genitals and ignored their needs as people. He seemed to understand that his fascination with erections and ejaculation was normal and one way to gather information about male sexual function. He also expressed concern about treating men like sexual objects because this felt inconsistent with some of his values about relationships and intimacy.

Another group member talk about the profound envy he felt during sexual contact with other men. He described never being able to "measure up," always feeling "inadequate," and his ongoing struggle to accept himself fully as a man.

Dealing with grief and loss:
Participants agreed that sexual intimacy created opportunities to express their maleness, experiment with new behaviors, and achieve gender authenticity. Group members also described the challenges they sometimes experienced when having sex with other men. As stated previously, some participants envied their partner's genitals and felt anger and resentment about the adjustments and compromises that FTMs are often forced to make regarding genital reconstruction. Sex with men also seemed to reawaken existential conflicts for group members. They experienced moments when they continued to feel cheated by nature, disappointed by their bodies, and unfairly limited regarding sexual function and pleasure.[20]
  

Conclusion

This paper documented an HIV prevention program for FTM transsexuals. The purpose of the intervention was to help participants manage HIV in healthy ways. Implicit in that goal is the value of staying uninfected. Group members were encouraged to define health in their own terms, and for most men, remaining HIV-negative was a primary goal. They seemed to perceive HIV as synonymous with stigma and loss, and being HIV-positive was considered one more strike in addition to being FTM. The content of workshop sessions focused as much on sexual health as HIV prevention. Participants valued the opportunity to talk about transsexual health, sexual orientation, and human sexual response.

One unstated goal of Education and Soul Searching was eventual peer leadership of a prevention project based on the intervention. Transsexual professionals and peers have been essential in the provision of culturally competent HIV prevention both nationally and internationally. However, using a non-FTM facilitator had value for group members. Although he needed additional information from group members about their lives, he was knowledgeable about FTM culture. He understood issues related to sexual orientation, had years of experience in HIV prevention, and wanted to advocate for transsexual health services. Some participants viewed him as a male role model; others saw him as a community ally worthy of trust.

This intervention has not been evaluated regarding program efficacy and prospective outcomes for group members. However, the 1994 prevention project for uninfected gay men has been qualitatively evaluated.21 This document examines how theories of life stress, cognitive escape, social learning, psychoeducation, and social networks inform this intervention. These issues may have some relevance for FTM transsexuals, especially gay male FTMs.
  

Acknowledgments

The authors would like to thank Buck, Mykael Hawley, and all the men who participated in Education and Soul-Searching. Their honesty and "courageous hearts" made the prevention workshops possible.

Correspondence and requests to: Douglas Hein (doug_hein@bphc.org)

[1] Enterprise members report significant changes in their ability to access competent transsexual health care in Boston since 1993. Members actively educate the local medical and social service community about the needs of FTMs.

[2] Cameron L. (1996) Body Alchemy: Transsexual Portraits. Cleis Press.

[3] A Northern Light/Candace Schermerhorn Production, 1050 Commonwealth Avenue, Boston, MA 02215 (1996) You Don't Know Dick: Courageous Hearts of Transsexual Men. This film profiles six FTMs, one of whom is a founding member of Enterprise.

[4] McFarland W., Fischer-Ponce L., Katz M. (1995) Repeat negative HIV testing in San Francisco: magnitude and characteristics. American Journal of Epidemiology. October: 719-723. This study found that repeat testers are more likely to be gay or bisexual men, and that these individuals are three times more likely to seroconvert in the future.

[5] Prieur A. (1990) Norwegian gay men: reasons for continued practice of unsafe sex. AIDS Education and Prevention.

[6] Odets W. (1995) In the Shadow of the Epidemic: Being HIV-Negative in the Age of AIDS. Duke University Press: Durham.

[7] Odets W. (1994) AIDS education and harm reduction for gay men: psychological approaches for the 21st century. AIDS & Public Policy Journal. Volume 9. No 1.

[8] Hein D., Beverley G., Longo V., Burak M., (1995) A Short-Term Support and Education Group for HIV-Negative Gay and Bisexual Men. Boston Public Health Commission and Fenway Community Health Center. Unpublished.

[9] Brauer S. (1990) The HIV-infected individual: group work as a rite of passage. Smith College Studies in Social Work. Volume 60. No. 3: 233-243.

[10] Namaste K. (1997) Summary: HIV/AIDS Issues for FTMs. The Hero's Journey: Third Annual FTM Conference of the Americas. Unpublished.

[11] The flyer was created by an Enterprise member and has the following text: Dump your fears for an evening of education and soul-searching with Doug Hein, a professional HIV counselor who runs special workshops dedicated to helping us understand HIV, its impact on our lives, and what we can do.

[12] Jenny Holzer. Walker Art Museum Sculpture Garden: Minneapolis.

[13] Stein M., Freedberg K., Sullivan L., Savetsky J., Levenson S., Hingson R., Samet J. (1998) Sexual ethics: disclosure of HIV-positive status to partners. Archives of Internal Medicine. Volume 158: 253-257.

[14] Rofes E. (1995) Reviving the Tribe: Regenerating Gay Men's Sexuality and Culture in the Ongoing Epidemic. Harrington Park Press: New York and London. 208.

[15] Springer E. (1991) Effective AIDS prevention with active drug users: the harm reduction model. Journal of Chemical Dependency Treatment. Volume 4. No. 2: 147-149.

[16] Odets. 5-13. Odets promotes AIDS education that "acknowledges the social realities of the epidemic" and is "relatively free of homophobia, misrepresentation, and moralization." He writes, "Next among the psychological issues is called off line-on line by Australian psychologist Ron Gold. Put simply, this is the readily observed idea that people exist in different 'states' of consciousness when they are being educated and when they are having sex. In neurophysiological terms this is the idea that people are educated 'with' their cortexes and have sex(at least substantially(with their brain stems. Gold makes a convincing point: Our education is aimed at the cortex with little regard for how the cortex and brain stem interact during sex . . . Most acculturation and socialization involve establishing 'communication' between these two states of consciousness, and this can be done in the context of AIDS education if we stop educating the cortex as if it were the source of all human feeling and behavior."

[17] Herdt G. (1981) Guardians of the Flutes: Idioms in Masculinity. McGraw-Hill: New York. Herdt writes about the Sambia tribe in New Guinea in which young boys ingest the semen of older males to acquire male sexual energy and power.

[18] Martin J., Knox J. (1995) HIV risk behavior in gay men with unstable self-esteem. Journal of Gay and Lesbian Social Services. Volume 2: 21-41.

[19] Devor H. (1997) FTM: Female-to-Male Transsexuals in Society. Indiana University Press: Bloomington and Indianapolis. 467-468. Devor writes about the men in her study, "Within the spheres of their everyday lives, they ceased being transsexuals and simply became men . . . There were, however, three main areas in which all participants who lived as men were reminded of their transsexualism no matter what their stage of physical transition: in public toilets, in doctors' examination rooms, and in sexual intimacies. These were the areas of their lives wherein they were required to expose those parts of their bodies which proclaimed them to be other than physiologically average males."

[20] Prieur A. (1998) Mema's House Mexico City: On Tranvestites, Queens, and Machos. The University of Chicago Press: Chicago and London. 39. Prieur writes, "Representations form the body, but the body imposes its limits; sexual organs are objective facts that form the representations of gender and the identities . . . While bodies are not destinies in any absolute sense, they do form social experiences, and are formed by social experiences." Group members valued experiences with sexual partners who perceived them as male and appreciated their bodies as they were. The men reported feeling more self-accepting of their sexual anatomy after such encounters, and less focused on anger and grief.

21 Chen J. (1998) Final Report: Evaluation of a Three-Week Support and Education Program for HIV-Negative Gay and Bisexual Men at the Fenway Community Health Center. Harvard School of Public Health. Unpublished.