Transgender Health and Social Service needs in the Context of HIV Risk

by Nina Kammerer, Theresa Mason, and Margaret Connors

Citation: Kammerer N., Mason T., Connors M. (1999) Transgender Health and Social Service needs in the Context of HIV Risk. IJT 3,1+2, http://www.symposion.com/ijt/hiv_risk/kammerer.htm

• Abstract
• Introduction
• Research methods
• Health and Social Service Needs
• Problems in Obtaining Appropriate Services
• Implications and Recommendations for HIV Prevention
• References

Abstract
This article describes difficulties transgenders encounter in obtaining health and social services, including targeted HIV prevention. Based on an anthropological HIV/AIDS needs assessment for the transgender community of Boston, Massachusetts, we identify misperceptions that interfere with the provision of caring and appropriate services, including for the most economically vulnerable male-to-female transgenders who were the focus of the study. Drawing on the work of a Boston-based transgendered activist, Rebecca Durkee, we recommend specific steps for HIV/AIDS prevention that can contribute to reducing transgenders' risks of HIV infection. These steps can also contribute to community building and pride and thereby to diminishing the social stigma and discrimination that shape both transgenders' HIV risk and their difficulties in obtaining health and social services.

Introduction
The qualitative anthropological research on which this article is based was commissioned by Rebecca Durkee, founder of Gender Identity Support Services for Transgenders (GISST), an advocacy and service program located in Boston. In 1995, Ms. Durkee obtained funding for an HIV/AIDS needs assessment for the transgender community of Boston from the Massachusetts Department of Public Health, AIDS Bureau. The authors, all medical anthropologists who have done HIV/AIDS research in the United States or abroad, were hired by Ms. Durkee to conduct the study. Our research and the resultant report focused on the segment of the transgender community served by Ms. Durkee, namely, economically and psychologically vulnerable male-to-female transsexual and transgendered individuals, many of whom end up in the street at some point in their lives, engaging in commercial and survival sex (Mason et al. 1995).

Central to our research was unraveling the structuring of risk for HIV infection among transgenders. Transgenders' sexual and injection risks for HIV arise from three main sources: (1) social stigma and related negative self-image, (2) economic vulnerability and related prostitution and substance abuse, and (3) the quest for a feminine body and the need for identity affirmation. We found that for many economically vulnerable male-to-female transgenders substance abuse was precipitated by participation in prostitution rather than the other way around. Transgenders' needle risk for HIV stem not only from the injection of illicit drugs, but also injection of hormones for bodily transformation or silicone for breast augmentation as part of the quest for a feminine body. The need for identity affirmation through sexual expression can lead to unsafe sex.

Elsewhere we have discussed transgenders' HIV risks (Mason et al. 1995; Kammerer et al. in preparation). The focus here is on the kinds of health and social services transgenders require, problems specific to the transgender community in getting such services, and, finally, insights that providers and transgenders themselves have into how services can be improved, especially in AIDS prevention and risk reduction.

In this article, the noun transgender and the adjective transgendered are used in a broad way, encompassing individuals who self-identify as transsexual, whether pre-operative, post-operative, or non-operative, that is, not desirous of having sex reassignment surgery, and individuals who self-identify as transgender. Our research focused not on transvestites who cross-dress but on transgenders who cross-live (Woodhouse 1989). Since the 1980s, a grassroots political movement, sometimes labeled transgenderism (Rothblatt 1995, p. 16), has grown up seeking transgender rights and affirming transgender pride (Bolin 1994; Feinberg 1996). For many in the transgender - or "trans" - movement, the label transgender encompasses not only transsexuals and transgenders, as it does here, but also cross-dressers or transvestites, drag queens, intersexed individuals, and anyone non-conventionally gendered (Feinberg 1996). For some, trans unity is within the "queer" nation, with the term queer being expanded from meaning homosexual only to meaning non-conventional sexual orientation and/or gender identity (Valentine forthcoming).

After describing our anthropological research methods, we consider health and social service needs. Our contention is that the difficulties transgenders have in gaining access to shelters, securing safety in prisons, obtaining appropriate mental health counseling, as well as other health and social services, are related to their risks of HIV infection. This is a continuation of our argument, outlined above, that discrimination and social stigma shape transgenders' HIV risk behaviors. Next we identify and correct some misinterpretations held by health and social service providers that contribute to transgenders' difficulties in obtaining caring and appropriate services. We conclude with specific recommendations for HIV prevention and risk reduction, particularly for the most economically vulnerable male-to-female transgenders who often end up in the streets and/or in prostitution. HIV prevention by and for transgenders can help reduce the incidence of AIDS at the same time that it provides positive role models and contributes to community building.

Research methods
Adhering to an ethnographic research approach, we attempted to understand HIV risks and health and social service needs from transgenders' and service providers' perspectives. Between April and August, 1995, the researchers did focus groups and open-ended interviews with transgenders and interviews with health and social service providers. In addition, we visited three transgender bar scenes in person to observe first-hand. One of us also attended two of a series of trainings for service providers led by Ms. Durkee on transgender health issues; these were funded by the Massachusetts Department of Public Health and held throughout the state.

Transgendered interviewees and focus group participants ranged in age from mid-twenties to forty and included African Americans and Anglo Americans, as well as a person living with AIDS and an eighteen year-old recently arrived in Boston and currently a street sex worker. Individual key informant interviews were held with four transgendered individuals, including an Anglo former escort service sex worker and a Latina living with AIDS. The service providers interviewed all worked in the field of HIV prevention and/or services for street youth. Additional interviews were done with Ms. Durkee and four other local transgender activists, including one female-to-male, in part to clarify the varieties of transgenderism.

While the data focus on the economically most vulnerable transgenders, some of the findings, especially concerning the barrier that stigma and discrimination pose to appropriate care (Green et al. 1994), are likely to be valid even for more economically advantaged transgenders. Similarly, while the findings cannot be assumed to be applicable to female-to-male transgenders, other sources suggest that discrimination diminishes the quantity and quality of care they receive.
  

The economically vulnerable male-to-female transgenders who were the focus of our needs assessment reported that they rarely seek medical care except as it relates to their quest for a feminine body. There are numerous reasons for this, with lack of insurance and lack of acceptance prominent among them. Transgenders' fears of rejection by medical practitioners and facilities are founded either on personal experience or on gossip about the degrading and even dangerous encounters that others like themselves have had with doctors and hospitals. One self-identified pre-operative transsexual told a horrifying story of being sent away from a well-known Boston emergency room after a car accident even though she was suffering from serious injuries, including fractured vertebrae and a concussion. When her male genitalia were discovered under her female clothing, she was discharged without treatment!

Transgenders know well from experience or from their peers that "homeless shelters won't let a queen in. They say 'dress like a man or get the hell out!' So you're forced back into the element," that is, back onto the street. Staff at shelters will not accept male-to-female transgenders in women's shelters, and most will not permit them in men's shelters unless they wear men's clothes. If transgenders are allowed to wear their own clothes in men's shelters, they are subject to derision and possible violence by fellow clients and sometimes by staff. Even if they disguise their core personal identity by dressing in men's clothes, they still run these risks. Service providers interviewed attested that it was nearly impossible to refer transgenders to shelters; one even used the adjective "ludicrous." This same provider reported that when he worked in Worcester, the state's and region's second largest city, he could not find shelters willing to take transgenders but could sometimes find sympathetic service providers willing to put them up in their own homes for a night. Ms. Durkee has successfully placed a male-to-female transgender at Rosie's Place, a shelter for women in Boston.

In Boston, there are no alcohol or drug treatment groups or facilities specifically for transgenders. Some find support in 12-step programs run for and by the gay community; yet historical friction between transgenders and the gay community means that this is not always a workable fit. 4 Residential detoxification programs present the same problems as homeless shelters: transgenders are rarely placed in women's programs, and in men's programs they are either forced to hide their core personal identity or risk scorn and possible physical abuse. The only case we learned about of a male-to-female transgender being placed in a women's program was for Worcester rather than Boston. As one interviewee said: "[We] can't get into detox without going completely against our nature. How would you like to be called 'sir' all day long?"

Obviously, the problems for transgenders in prison are similar and likely to be more serious. Only those few who have not only completed sex reassignment surgery but also legally changed their sex from male to female on their birth certificate, which is, in fact, only possible in some states, would be put in a women's prison (Stuart 1991, pp. 67 and 71). In a men's correctional institution, male-to-female transgenders are vulnerable to various forms of abuse, including forced sex with inmates or guards. One of the respondents in a focus group who had recently gotten out of prison told such stories, observing that when she complained to a guard she was told to "deal," since the guard felt that she was the one who wanted to be a woman. The risk of physical abuse, including sexual abuse, is very real not only inside correctional institutions but outside in society. Some interviewees told of being forced to have sex with prison guards or others whose duty was supposed to be to protect them, while others told of being physically assaulted on the street. Lacking financial resources and knowing society's disdain for them, these individuals do not seek redress through the legal system.

According to service providers, transgenders are disproportionately represented among street youth, as are gays and lesbians. Given that problems in school and at home often contribute to a young person being on the street, this disproportionate representation is not surprising. Unfortunately, however, we found only one self-identified transgender service provider working directly with youth in the Boston metropolitan area. Fortunately, however, Boston's providers of services to street youth recognize the need for transgendered workers, although they have had difficulty finding and retaining such workers.

To get off the streets, transgenders, whether youth or adults, need jobs to provide the financial resources to pay for housing, food, and other necessities. But society makes it extremely difficult for transgenders to hold down jobs, especially those who do not pass well. Job training and placement are thus useless unless accompanied by efforts to ensure that transgenders will be retained on the job even with a five-o'clock shadow. Such efforts would need to include education to alter social attitudes towards transgenders and legal changes to prevent and punish discrimination against them. Currently such discrimination is not illegal. Transgenders often have trouble getting on welfare because, as one provider explained, "from the minute you write in your name, welfare will say, 'No, what's your real name?' And right there it's downhill."

The social stigma that transgenders face from early in life is translated via internalization and fear into psychological problems, notably, low self-esteem and even loathing, often to the point of suicidal tendencies. Transgenders are thus frequently in need of sensitive and knowledgeable counseling. Unfortunately, their issues and problems are often little understood by providers of psychological services. One service provider, who had himself sought such services in his youth, noted that in practice,

Service providers who serve adolescents really don't encourage people to experiment far from the norm. . . . I think they say, "Well, this is nice and everything, but your goal is to act as conventional as possible by the time you're out of our hands." So, you know what I mean? So it's like "that sounds great and everything but ditch the eye make-up," you know?

While this comment was made with respect to providers of services to adolescents, similar failures to acknowledge and respect the seriousness of transgender issues can also be found among counselors serving adult transgenders.

Various forms of outreach that might be thought to serve transgenders do not do so effectively. For example, given the existence of friction between the gay and transgender communities and the fact that most transgenders do not self-identify as gay, gay organizations can have trouble reaching them. It is also important to point out, as one gay service provider did, that gays are not necessarily any more knowledgeable about transgenders and their issues than anyone else. After listening to a colleague give a nuanced and thorough overview of transsexual, transgender, and related categories, he commented, "I can tell you that the average gay man living in the South End [a gay neighborhood in Boston] would not have said anything other than people who have a sex change operation." His colleague, himself a drag performer, pointed out that gay men also mistake transgenders for drag queens, that is, for homosexual men who wear women's clothes for performance (see Newton 1972).

Organizations that target prostitutes are often run by women for women, and transgenders are left out. As Janice Raymond's attack on transsexuals in her book The Transsexual Empire testifies, some women, more particularly, some feminists and lesbian feminists, are antagonistic towards transsexuals -- "artificial women" in Raymond's (1994[1979], p. 69) terms -- because they are seen as representing a retrogressive vision of womanhood.

Cruising zones for female, gay, and transgendered commercial sex workers are geographically separate. One particular Boston neighborhood is known as the transgender zone; indeed, one transgendered interviewee said that she assumes that any man who does a pick-up there knows that the prostitute is transgendered. This geographical specialization means that outreach workers in a zone traditionally used by women sex workers or by gay street hustlers are not likely to run into transgendered sex workers. The same is true for drug outreach. While many transgenders have drug problems, they are not reached by services targeted to the drug-using population because, as one transgender observed, "They are in different areas, keep different hours."

Another reason that transgenders may not be reached effectively by drug outreach is that, in the words of one service provider, it is for "people who are about needles" and transgenders are not primarily about needles. Thus, transgenders often "don't identify as drug users . . . even though they're using a pretty high amount of recreational drugs." For them, their primary issue is a "gender issue" rather than drug use. People who are about needles are likely to go to substance abuse outreach workers who "talk that talk." What transgenders need is outreach workers who talk gender issue talk.

Despite the significant HIV/AIDS risks faced by transgenders, we could locate targeted prevention programs in only a handful of locations around the country. Besides Ms. Durkee's work locally in Boston and statewide in Massachusetts, these include efforts in Minneapolis, Minnesota (Bockting et al. 1993); San Francisco, California (Green et al. 1994, p. 29; Lockett 1995, p. 213); New York City (Withers 1995; Newsline 1996. p. 38); and Philadelphia, Pennsylvania, where ActionAIDS (1994) has Care in Action Transgendered Program, which includes street outreach, a telephone information line, and support groups by transgenders for transgenders. In Boston, there are no AIDS prevention messages posted at the primary drag queen and transgender bar. Transgenders report that condoms distributed free to this establishment are kept behind the bar out of sight instead of being openly available on the counter like in many other bars. The service organization founded by Ms. Durkee is the only transgender organization locally, or, indeed, in Massachusetts as a whole, dedicated to HIV/AIDS prevention for this community.

Once transgenders are infected with HIV, they confront the problem with which this section began, namely, lack of access to standard medical care. One HIV-positive self-identified transsexual interviewee, who is unusual in having the benefit of membership in a health maintenance organization (HMO), recounted a sad saga of trying to find a participating physician to treat her. She called every provider listed in a lengthy booklet sent out by her HMO. Some hung up on her; others refused to accept her as a patient. She found only one doctor on the list willing to take her on as a patient. Fortunately for her, he is not only willing to treat her but also familiar with transsexuality, having worked in the past at The Johns Hopkins Gender Identity Clinic. What would she have done if she hadn't found him?

Problems in Obtaining Appropriate Services
Problems in obtaining services, such as discrimination, lack of acceptance, and absence of legal protection, are already evident from the preceding discussion. Many of these stem from the social stigma carried by transgenders. For example, placement in shelters for either women or men would not be a problem if society accepted transgenders wholeheartedly. Here we correct some misperceptions commonly held by service providers that may inhibit the provision of appropriate health and social services. Before so doing, we want to stress that in our interviews with Boston area providers we found great concern about transgender issues, overwhelming interest in learning more about transgenders and their needs, and sincere desire to improve and expand services for them. In this spirit, we identify some misperceptions that can hamper the efforts of well-intentioned providers.

1. To be transgendered is not necessarily to be gay.

Transgenderism concerns gender identity rather than sexual orientation (Bolin 1988, p. 13; Stuart 1991, p. 5; Griggs 1998, p. 1). There are heterosexual, bisexual, and homosexual transgenders, though sources report that the majority of transgenders are heterosexual (Stuart 1991, p. 55). Some providers equate transgendered gender identity with gay sexual orientation. Yet information and approaches appropriate to gay men may not fit the many transgenders who are not homosexual and may be ignored or actively rejected by them.

Historically, transgenders have gravitated to gay spaces and communities, where, as Stuart (1991, p. 41) observes, they "find some measure of acceptance." Indeed, some transgenders not only spend time within the gay community but also consider themselves gay for at least a period of their lives. Stuart (1991, p. 47) reports that most of the heterosexually identified transsexuals she interviewed "had explored the homosexual world." Some male-to-female transgenders consider themselves gay men only later to realize and/or acknowledge that they are female rather than effeminate. As the category transgender becomes more widely known, this phenomenon of a gay phase in the life cycle of those transgenders whose sexual orientation is not homosexual may become less common.

Given the co-existence of transgenders and gays in the same social space and the gay phase in some transgenders' lives, it is easy for service providers and others to mistakenly equate being transgendered with being gay. It is also important to point out that what appears to outsiders as a same sex encounter may be perceived by one or more of the partners as heterosexual. Thus, for a heterosexually self-identified male-to-female transgender, whether possessing male genitalia or surgically constructed female genitalia, having sexual intercourse with a genetic male is a heterosexual act: she is a woman having sex with a man.

2. Many, perhaps most, transgenders do not consider themselves drag queens.

Another misreading found among the gay community and elsewhere is to equate transgenders with drag queens. Drag queens, as one gay service provider who is himself a drag performer explained, "do it for the show only, they don't try to pass in real life, and the whole purpose of the show is look. . . . there's a wink that goes on with the audience through the whole show." Even those male-to-female transgenders for whom life's exigencies - "grave concern over the potential loss of jobs, family, and friends" (Griggs 1998, p. 39) -- prohibit living full-time as women are not dressing for show but, rather, to express their core gender identity. To read a transgender as a drag queen is to trivialize her female self-identity, misinterpreting it as simply dress or performance.

In sum, a drag queen, in the sense of a cross-dressing performer, may identify as a woman while dressed as one. However, transgenders by definition experience their gender as either distinct from or in opposition to their biological sex all the time. This is true even if they are unable to live out that gender identity full-time. Some transgenders do perform in drag shows. Since transgendered performers and gay drag queens often share the same stage, equating the two is an easy mistake for outsiders to make. Some transgenders self-identify as drag queens while recognizing their difference from their fellow drag queens who are non-transgendered. Some transgenders and gay drag queens insist on remaining united within the trans movement. At the Stonewall 25 march, in which drag queens were placed in front and transgenders further back, one transgender carried a sign saying "DRAG AND TRANSGENDER WILL NOT BE DIVIDED. QUEER UNITY = HUMAN RIGHTS" (Feinberg 1996, p. 99, photo and caption, emphasis in the original).

3. Male-to-female transgenders do not necessarily live full-time as women.

At least one service provider defined transsexuals as living as the opposite gender full-time. It is important to remember that many exigencies, financial and otherwise, can prevent a male-to-female transgender from always dressing as a woman even if she wants to. So it would be wrong to assume that someone presenting at a service provider in men's clothes could not be a male-to-female transgender.

Transgendered interviewees reported that there are providers who believe that some or all transgendered prostitutes wear women's clothes to attract clients and/or get more money per trick. This view depicts female presentation of self as something put on and thereby refuses to recognize that for transgenders wearing women's clothes is an expression of their core personal identity. It is possible that this view derives either from the misinterpretation of transgenders as gay or as drag queens or from a mistaken analogy between them and those male street hustlers whose sexual orientation is heterosexual but who act homosexual for money, engaging in sex with men only when hustling.

4. Transgenders' adolescent confusion is not the same as other adolescents' confusion.

An additional misperception is to equate transgenders' adolescent problems with typical adolescent soul-searching and rebelliousness. On the surface the confusion of a non-transgendered adolescent who is experimenting with identities and/or sexual orientations may appear similar to that of a transgendered adolescent. Yet they spring from vastly different sources, and transgenders can suffer from both sorts of confusion.

Adolescence is recognized as a time of searching, experimentation, and rebellion as self-identity is defined and independence established. An adolescent, whether transgendered or not, may be unsure of their identity. Yet there is a significant difference between confusion arising from not knowing who you are and confusion arising from a disjuncture between your personal self-knowledge and the categories and roles society presents and accepts. Whereas the confusion of a typical teenager falls into the first, the so-called confusion specific to a transgendered teenager falls into the second.

Transgenders typically know themselves to be different from an early age (Stuart 1991, pp. 38-50), as young as three years old for one of our informants. As Griggs (1998, p. x), herself a male-to-female transsexual, notes, most of her transsexual informants "believe that it is something they were born with." Transgenders may not have the categories with which to think about and understand their difference until much later in life, however. For such individuals, knowing that there are others like themselves can be a lifeline which, quite literally, prevents them from committing suicide. Vivian Allen, formerly of the Waltham-based International Foundation for Gender Education (IFGE), reported that "every day someone calls up and says 'Oh, my God, I thought I was the only one'."

During a state-funded training on transgender health led by Ms. Durkee in Worcester, Sterling Stowell of the Boston Alliance for Gay and Lesbian Youth emphasized that there is a difference between playing with gender identity and/or sexual orientation as part of adolescent exploration and "seriously exploring" sexual orientation by gay, lesbian, and bisexual youth and gender identity by transgendered youth. What it means to provide a safe space for playful adolescent exploration and for serious exploration is different. Many service providers steer clear of labels -- gay, lesbian, heterosexual, homosexual, and the like -- so that adolescents can find themselves rather than being pigeon-holed by others. Yet precisely what youthful transgenders may need is categories to help them name what they already know but for which they have no label. For transgendered youth to discover other transgenders can be transformative, as one transsexual we interviewed recounted:

And then I had met a transsexual. . . . I met her and I saw a little of myself in her. I looked at her, admired her for her going out and doing what she wanted to do for her self-comfortability [sic], and how she saw herself within.

Shifting identities, often including a period of gay self-identification, are evident in the life histories of transgenders collected by us and by other researchers (e.g., Stuart 1991:47-48). These must be understood, at least in part, as expressions not of fluid personal identity but of the quest for a fit between individual self-perception and social categories. There are no legitimized existing social categories for who transgenders are. Transgendered adolescents confused about where they fit into society may well need affirmation that they are not experimenting but rather expressing their fundamental personal identity. This affirmation may be particularly important coming from service providers. It may help transgenders to avoid seeking social acceptance in risky ways, including through unprotected sexual encounters with male paying or non-paying partners who treat them like women (Mason et al. 1995; Kammerer et al. in preparation).

5. Male-to-female transgenders are not necessarily feminists.

Providers can go overboard in affirming the womanhood of a male-to-female transgender. That a transgender considers herself a woman does not mean that she is a feminist. A feminist and/or lesbian may not be the most appropriate service provider for "a queen" who, in the words of one interviewee, " tries to be the perfect girl" whose idea of femininity may be retrogressive from a feminist and/or lesbian perspective. At the Worcester training led by Ms. Durkee, a service provider had an epiphany in which she laughed at herself for assigning a male-to-female transsexual to a radical lesbian service provider.

Implications and Recommendations for HIV Prevention
Both transgenders and service providers pointed to community building as the foundation not only for HIV/AIDS prevention but also for improved health and social services more generally for transgenders. Pointing to the model of the gay community, they stressed that without a strong sense of community and mutual responsibility transgenders cannot get the kind of support they need as individuals. In addition, they pointed out that self-respect and pride promote changes in social attitudes towards members of the community by outsiders which, in turn, foster self-respect. Since many HIV/AIDS risks among transgenders arise from social stigma and resultant self-loathing, community building is fundamentally related to HIV/AIDS prevention, as well as to other health and social service needs (Mason et al. 1995; Kammerer et al. in preparation). Transgenders and providers also identified having transgendered leaders and role models, transgendered outreach workers, transgender 12-step programs, transgender support groups, and trainings in transgender health like those conducted by Ms. Durkee as being vital to HIV/AIDS prevention and to improving health and social services more broadly.

The following recommendations draw directly on Ms. Rebecca Durkee's ideas, insights, and work on HIV/AIDS prevention.

1. Training on transgender issues.

In order to create a more socially accepting and supportive environment for transgenders most at risk of HIV infection, key HIV-related service providers should be trained in and sensitized to transgender perspectives, issues, and circumstances. Based on the state-funded trainings she conducted for service providers, Ms. Durkee (1995) produced a curriculum on HIV prevention for transgenders. The trainings themselves, which were well attended and highly rated by service providers, involved transgendered volunteers, including one woman living with AIDS. These volunteers spoke in public, in some cases for the first time, about the tremendous challenges they have faced with different facets of the health and social service systems. Such trainings clearly need to be continued in Massachusetts and inaugurated elsewhere. Given staff turnover at health and social service providers, they should be offered on a regular basis.

2. Transgender-targeted HIV prevention outreach.

Outreach is needed to the streets and bars where transgenders commonly encounter "tricks" or sexual partners. The outreach should be conducted by transgender-identified individuals themselves in order to establish the connections of trust and rapport necessary for the HIV education and risk reduction process to have an impact. This is also imperative because of transgenders' tremendous need for role models and for developing a sense of community. Transgenders offering escort service advertisements in local papers, such as the Boston Phoenix, should also be targeted. Outreach is a crucial aspect of HIV prevention among those who have been marginalized and who must struggle with poor self-images. The outreach teams should be ethnically mixed to facilitate engaging the diversity of transgenders in a variety of neighborhoods, especially the younger and perhaps more isolated ones. Collaborations should be pursued with local agencies that may be intersecting with but perhaps not adequately addressing transgenders in their areas. In the Boston metropolitan area, for example, an agency such as Centro Hispano de Chelsea, which is already involved with Latino cross-dressers, might be enlisted.

3. Risk network-targeted HIV prevention.

Outreach should also work to have an impact on the customers at the bars and the clients of transgender prostitutes as well. It is Ms. Durkee's idea that a transgender outreach worker should visit the transgender bars on weekend evenings and on special event nights, which draw a larger clientele. These outreach workers would carry around baskets of condoms and generally strive to integrate the spirit, vocabulary, and materials of HIV prevention into these scenes. Another intriguing idea from Ms. Durkee and the transgendered volunteers with whom she has been working is to introduce educational skits containing HIV prevention messages into the shows by transgendered and drag performers. This would have a powerful impact on the culture of the bars. In anticipation of the need to engage the bars in the HIV education and risk reduction process, Ms. Durkee placed one of the bartenders/managers on the board of the transgender community-based service organization she formerly headed. Another advantage of having transgendered outreach workers in the prostitute stroll areas is the likelihood that they would be approached by clients and could begin the process of making them more aware of the need for prevention, providing them with condoms and HIV educational brochures.

4. Transgender-appropriate HIV prevention literature.

Another clear need is for the development of HIV prevention materials such as posters, brochures, and risk reduction packets targeted for transgenders. The tone and imagery, as well as the information, should take into account the serious need for transgenders to feel that they matter, that their health and safety are important, and that they have the power to protect themselves. Such materials should be posted and available in bars and clubs, and in health and social service agencies utilized by transgenders. Risk reduction packets could also be created to be handed out to the street sex workers and those transgenders frequenting bars.

5. Social acceptance and support.

Outreach is also needed as a means of engaging transgenders, especially transgendered youth, in a process of self-assessment and psychological support. Drawing individuals into an office or a space where they can feel comfortable or offering parties during which HIV education messages are conveyed can also encourage the empowering experience of feeling noticed and taken seriously. All of this can further advance the goals of HIV prevention.

These five recommendations are made in recognition of the substantial HIV risks faced by transgenders, especially male-to-female transgenders involved in prostitution and related substance abuse. The current near absence of HIV/AIDS prevention for transgenders in Boston and throughout the United States can be attributed in part to the invisibility of this population and to its social and economic marginalization. Due to that marginalization, it does not have the wherewithal to protect itself without outside assistance. Interviews with activists belonging to the economically more secure segment of the transgender community revealed an unwillingness to confront HIV/AIDS head on despite a recognition that male cross-dressers -- transvestites - and economically well-off transgenders are at risk like their less affluent transgendered sisters. As Vivian Allen, previously of the International Foundation for Gender Education, put it, "the problem always is ownership." More affluent transgenders are loath to "own" HIV/AIDS because it simply reinforces the stigma already attached to transgenderism, a stigma which their transgenderist political movement is trying to dispel (Bolin 1994; Feinberg 1996). Ms. Durkee, who represents the most at-risk members of the transgender community, has come forward to claim ownership of HIV risk and prevention, as have a few of her transgendered sisters in New York, Philadelphia, and elsewhere. AIDS prevention by transgenders for transgenders is the necessary first-step in ownership.

Nina Kammerer is a Senior Researcher at Health and Addictions Research, Inc. in Boston and a Resident Scholar in Brandeis University's Women's Studies Program, Waltham, MA. Theresa Mason is on the senior research staff at Abt Associates in Cambridge, MA. Margaret Connors is a Lecturer at Harvard Medical School in Boston.

GISST is housed at Beacon Hill Multicultural Psychological Association in Boston.

For example, in his keynote address to the 1997 Second New England Transgender Health Conference, organized by Rebecca Durkee, Leslie Feinberg, a well-known female-to-male transgender "warrior" and author (1993, 1996), recounted a saga of withheld and inappropriate care that almost cost his life (Gray 1997, p. A28).

Female-to-male transgenders also face HIV risks. Social stigma and its internalization as low self-esteem contribute to their risks, just as they do to male-to-females' risks. Partly because their hormonal transition is more complete, female-to-male transgenders often pass more easily than their male-to-female sisters (Griggs 1998, pp. 9 and 24). Whereas for male-to-female transgenders hormone replacement therapy does not raise the voice or eliminate the need for electrolysis, for female-to-male transgenders it lowers the voice and encourages facial and body hair growth. American gender ideology may also be a factor in relative ease of passing, since short men attract less notice than tall women. Greater ease of passing together with the gendered wage gap between males and females in the United States make female-to-male transgenders somewhat less economically vulnerable overall, though individual cases by no means always follow this general rule. A key risk for male-to-female transgenders is participation is prostitution, yet there is no market for female-to-male sex workers. Contributing to female-to-male transgenders' risks, however, is the sexual drive, sometimes both precipitous and strong, brought on by the use of male hormones to effect bodily transition, perhaps accentuated, as Griggs (1998, p. 34) notes, by "cultural reinforcement of masculine [sexual] expression."

4 Many transgenders feel that their contribution to gay liberation is either unacknowledged or insufficiently acknowledged. In 1969 at Stonewall in New York City's Greenwich Village, drag queens and transgenders "fought back against a police bar raid" (Feinberg 1996, p. 9). Transgenders and drag queens who were thus at the forefront at the Stonewall Rebellion, which is commonly considered the beginning of the gay rights movement, have felt pushed aside, even rejected, by the gay movement in its attempts to gain social and political respectability.

For example, an article on "Providing Sensitive Health Care to Gay and Lesbian Youth" observes that for those adolescents who do not accept their homosexuality "[i]t is still premature to label during this time of identity development" (Sanford 1989, p. 35). Another article on the same topic observes that "the 12-year-old boy who has physical and emotional attractions only to other males may question his identity as a male until he feels more secure and healthy about his gay sexual orientation" (Nelson 1997, p. 106). Interestingly, a sensitive service provider could misconstrue a male-to-female adolescent's female gender self-identity as a lack of self-acceptance of homosexuality.

References

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Bockting, Walter O., Roser, B.R. Simon, and Coleman, Eli (1993) Transgender HIV-AIDS Prevention Program: Manual. Program in Human Sexuality, Department of Family Practice and Community Health, Medical School, University of Minnesota in collaboration with City of Lakes Crossgender Community, Minnesota Freedom of Gender Expression, Minnesota AIDS Project, and Aliveness Aware: Minneapolis.

Bolin, Anne (1988) In Search of Eve: Transsexual Rites of Passage. Bergin & Garvey: New York.

Bolin, Anne (1994) "Transcending and Transgendering: Male-to-Female Transsexuals, Dichotomy, and Diversity," In Third Sex, Third Gender: Beyond Sexual Dimorphism in Culture and History. Gilbert Herdt, ed., pp. 447-486. Zone Books: New York.

Durkee, Rebecca Capri (1995) The Invisible Community - Transgenders and HIV Risks: Training Curriculum. Gender Identity Support Services for Transgenders: Boston.

Feinberg, Leslie (1993) Stone Butch Blues. Firebrand Books: Ithaca, NY.

Feinberg, Leslie (1996) Transgender Warriors: Making History from Joan of Arc to RuPaul. Beacon Press: Boston.

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Green, Jamison, with Brinkin, Larry, and HRC Staff (1994) Investigation into Discrimination against Transgendered People. Human Rights Commission, City and County of San Francisco: San Francisco.

Griggs, Claudine (1998) S/he: Changing Sex and Changing Clothes. Berg: Oxford.

Kammerer, Nina, Theresa Mason, and Margaret Connors (in preparation) "Transgenders, Substance Abuse, and HIV/AIDS: From Risk Group to Group Prevention," In Integrating Anthropological and Epidemiological Approaches in Prevention Research on HIV/AIDS and Drug Abuse. Patricia Marshall, Merrill Singer, and Michael Clatts, eds.

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Transgenders, prepared for the Massachusetts Department of Public Health, HIV/AIDS Bureau: Boston.

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Stuart, Kim Elizabeth (1991) The Uninvited Dilemma: A Question of Gender. Metamorphous Press: Portland, OR.

Valentine, David (forthcoming) "'We're Not about Gender': How an Emerging Transgender Movement Challenges Gay and Lesbian Theory to Put the 'Gender' Back into 'Sexuality'," In Anthropology Comes Out: Lesbians, Gays, Cultures. Bill Leap and Ellen Lewin, eds. University of Illinois Press.

Withers, Kristine (1995) "Notes from a Survivor," LAP Notes 3, p. 12. Lesbian AIDS Project of the Gay Men's Health Crisis: New York.

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Acknowledgments: Our sincere thanks to Rebecca Durkee, founder of Gender Identity Support Services for Transgenders (GISST). We are grateful to Rebecca for the opportunity to do the HIV/AIDS needs assessment on which this article is based and for her invaluable assistance in facilitating the research and in providing information and insight.

This article is a revision and expansion of sections of Transgenders and HIV Risk: Needs Assessment (Mason et al. 1995). An earlier version was presented at the 1997 American Anthropological Association Annual Meeting, Washington, D.C., on a panel on "Transgender Identity, Community Building, and Health." Our thanks to members of the audience, in particular David Valentine, for their helpful comments. Finally, our appreciation to our editors, Walter Bockting and Sheila Kirk, for their suggestions.

Correspondence and requests for materials should be addressed to:
Nina Kammerer at nkammerer@har.org.