HIV/AIDS and Female to Male Transsexuals and Transvestites: Results from a Needs Assessment in Quebec

by Viviane K. Namaste, Ph.D.

Citation: Namaste V.K., Ph.D. (1999) HIV/AIDS and Female to Male Transsexuals and Transvestites: Results from a Needs Assessment in Quebec. IJT 3,1+2, http://www.symposion.com/ijt/hiv_risk/namaste.htm

Correspondence and requests for materials to:
Viviane Namaste, Ph.D.
c/o CACTUS Montreal
1250 rue Sanguinet
Montreal, Quebec, H2X 3E7, Canada

• Abstract
• Introduction
• Background to the project
• Methods
• Results
• Conclusion
• Acknowledgments

Abstract
This article presents the results of a study of transgendered people and HIV/AIDS in Quebec, summarizing the data from the needs assessment relevant to FTMs. Using qualitative research methods (interviews and a discussion/focus group), FTMs were asked to identify their needs with respect to health care and social services more broadly, and HIV/AIDS more specifically. The needs assessment identified five salient issues with respect to FTMs and HIV: 1) there is a lack of informational and educational materials about FTM bodies and sexualities; 2) many FTMs do not consider themselves to be at risk for HIV; 3) poor access to intramuscular needles, used to inject hormones, creates conditions which put FTMs at risk of HIV transmission; 4) low self esteem may prevent FTMs from adopting safe behaviors with regards to drug use and sexual activity; 5) the administrative practices of social service agencies exclude FTM transsexuals. The paper concludes with some recommendations in terms of health care policy, program delivery, and research methods.


Introduction
In recent years, public health and epidemiological researchers have focused some attention on transgendered people with respect to HIV/AIDS. The available research, however, generally limits itself to male-to-female (MTF) transsexual and transgendered people, especially those individuals who work as prostitutes. The unique needs of female-to-male (FTM) transsexuals and transvestites are neglected within the existing literature. This article reports on some of the preliminary results of the particular needs of FTM people (transsexual, transvestite, and/or transgendered)
with regards to HIV/AIDS, drawn from individual interviews conducted with 5 FTM individuals in Quebec, as well as a discussion group on this topic with FTM individuals at a FTM conference, The Hero's Journey, held in Boston in August of 1997. The research yields five major conclusions:

1) there is a lack of informational and educational materials about HIV/AIDS, particularly in reference to FTM identities, sexual practices, and bodies,

2) many FTMs do not consider themselves at risk for HIV/AIDS,

3) a social, administrative, and political context of health care creates conditions wherein FTMs are vulnerable to HIV/AIDS, as evidenced in
a lack of access to intramuscular needles (used for the injection
of hormones) within needle exchange programs,

4) issues of self
esteem which may prevent individuals from adopting low risk
behaviors with respect to the transmission of HIV, and

5) an
administrative context of health care and social service delivery
which excludes FTM transsexuals and transvestites.

Background to the project
This research is part of a provincial needs assessment of transsexuals and transvestites in relation to HIV/AIDS in Quebec.  Funded by the Centre Quebecois de Coordination sur le SIDA, a provincial government coordinating body, the project sought to identify the primary needs of transsexuals and transvestites in relation to HIV/AIDS within the province of Quebec. The needsassessment targeted three cities in Quebec: Montreal, Quebec City, and Hull. The research was institutionally located in the community organization CACTUS, Centre d'action aupres des toxicomanes utilisateurs de seringues, a needle exchange located in downtown Montreal. A transsexual outreach worker employed by CACTUS
identified the need for such a project, and coordinated the effortsof transsexuals and tranvestites, researchers, public health representatives, as well as provincial and federal health officials to begin to address this issue. A community-based advisory committee, with a majority of transsexual/transvestite members, supervised the research in the development, implementation, and interpretation of the results. This needs assessment particularly focused on how transsexuals and transvestites relate to and experience health care and social services. Building on an existing research literature of marginalized populations such as prostitutes and drug users, the project situated HIV within a global context of health care.
Within such a paradigm, it is argued that members of marginalized populations must fulfill their primary health care and social service needs first; they can integrate low HIV risk behaviors only once their more immediate needs have been met. Quebec's
national policy with respect to HIV adopts this orientation. While the existing literature on HIV and transgendered people is primarily limited to an epidemiological and/or public healthperspective, this research project offers a sociological investigation of the problem. Thus, rather than focusing exclusively on individual behaviors, the research examines the social, political, and economic factors which marginalize transsexuals and transvestites in Quebec, and which may place these
individuals at increased risk of HIV transmission. A review of the XI International AIDS Conference in Vancouver makes clear the importance of such a focus:

Although some efforts beyond the provision of information and the targeting of individual decision-making were described, there continues to be a great deal of interest, particularly shown in media attention during the conference, on the psychological and individual factors determining 'risk,' rather than social and
economic factors that create conditions for 'vulnerability.'
The needs assessment aims to offer precisely such a sociological explanation of social, economic, and political factors which create conditions of vulnerability to HIV for transsexuals and transvestites in Quebec. This article reports on the results explicitly concerned with FTMs; a more general overview of transsexual/transvestite health care in Quebec is available in the final report of the project.


Methods
In recent years, public health research has recognized the value of qualitative research methods, particularly with respect to marginalized populations. While an epidemiological framework can offer important data on the prevalence of particular diseases within a population, the reasons for the transmission of such diseases, either within a population or outside of it, are not always evident from aggregate statistical data. Qualitative research can play a useful role in this regard, both in furthering
our understanding of how diseases are conceptualized and experienced, as well as in the evaluation of community-based programs.
The needs assessment identified several topics for investigation: hormone therapy, gender identity clinics,addictions, prisons, ethnocultural minorities, HIV/AIDS, FTMs, and civil status. The data was gathered in two ways:
1) through individual interviews with five FTM transsexuals or tranvestites in Quebec, and 2) through a discussion group with FTMs, researchers, social workers, and health care professionals at a FTM conference in Boston held in August of 1997. Although the American location of this conference is outside the terms of the needs assessment, the data is nonetheless worthy of consideration given a dearth of
research on the topic of FTMs and HIV/AIDS. Moreover, such a comparative analysis is further useful since attention to health care within an American context can illuminate the social and administrative organization of health care in Quebec.
In addition to responding to questions posed by an interviewer, or topics introduced by the facilitator of a focus/discussion group, however, FTMs were involved in the
generation, validation, and interpretation of this research. InQuebec, FTMs were represented at the advisory committee, which reviewed and approved the interview guide. Once the initial interviews were completed in Quebec, participants were invited toattend a public session in order to verify the preliminary results;
a session was held in each city of Montreal, Quebec, and Hull. 
These forums sought to solicit the feedback and comments of participants, and to validate the research results before they were presented to the government in a final report. FTMs who attended the focus/discussion group at the conference in Boston were asked to validate the research by reviewing a written summary of the workshop to be prepared by the researcher; it was promised that any modifications or errors would be corrected, and alternate interpretations of the findings would also be recorded before the research was published. Moreover, as part of a research contract, I agreed to publish a summary of the results in a forum widely accessible to American FTMS, such as The FTM Newsletter or the American transsexual magazine Transsexual News Telegraph.
Although time-consuming and labor-intensive, the process of generating, collecting, interpreting, and verifying the data sought
to transform the relations FTMs have with health care and social services, by giving them an opportunity to formulate their own
research questions, identify their own needs, and offer their own interpretations. In this regard, the research process hoped to
implicate FTMs as active subjects, rather than as mere objects of inquiry. Such a strategy attempts to forge collaborative relations
amongst researchers and members of marginalized communities, a relation which has immediate and practical relevance in the
development, implementation, and evaluation of community-based programs which may emerge as a result of the research.


Results
The needs assessment indicates five salient issues with regards to FTMs and HIV/AIDS. These five issues constitute a global situation in which FTMs are at risk for HIV/AIDS, and suggest some useful directions for the development of community-based programs.
Firstly, there is a lack of informational and educational materials about FTM bodies, sexualities, and identities. For instance, participants in the discussion group stated that although it is known that some FTMs enjoy and practice vaginal sex, little is known about the risk factors involved: do male hormones dry out the vagina of a FTM transsexual, thus requiring that any FTM who has penile-vaginal intercourse not only use a latex condom, but water-based lubricants as well?
Secondly, FTMs did not consider themselves to be at risk for HIV. This finding was especially remarkable in the individual interviews conducted in Quebec: participants often commented that HIV affected street people, intravenous drug users, and/or prostitutes. The absence of a penis and/or of semen in FTMs was cited as one reason why FTMs are not at risk for HIV.
A third finding relates to the social and political context of health care for FTMs, most particularly the availability of intramuscular needles for the injection of hormones. Participantsat the conference in Boston claimed that access to these needles remains difficult in the United States, since the possession or use of drugs is criminalized. Moreover, FTMs reported that many individuals use two needles to inject - a large gauge needle to withdraw the fluid from its container (it is immersed in oil and quite thick) and a smaller needle to actually inject the hormones into the body. If access to sterile syringes is an issue in the first place, then the risk of HIV transmission, hepatitis, and/or other health complications increases with the number of needles used for each injection. Intramuscular hormones needles are available through some needle exchange programs in the United States, although FTMs maintained that there were often tremendous difficulties in accessing them. In San Francisco, for instance, intramuscular needles are only available through a site for women (including male to female transsexuals). Although this program will bring intramuscular needles to another site for FTMs or other men (such as those who use steroids), such arrangements need to be made in advance. As such, in practical terms, there is a poor
availability of intramuscular needles for FTMs in San Francisco.
Access to hormones themselves was also raised as an issue by participants at the FTM conference. It was reported that FTMs who live near the Mexican border can buy hormones without a prescription in Mexico and transport them across the border into the United States. This strategy, however, raises the problem of potential legal difficulties upon entering the United States, since the transportation of hormones without a prescription can be considered the trafficking of contraband drugs across national borders. Furthermore, it does not necessarily resolve the issue of access to intramuscular needles.
The information presented by Quebec interviewees contrasts sharply with the data generated at the conference in Boston.  Intramuscular needles are readily available through some needle exchange programs, notably CACTUS in Montreal. These needles (as well as intravenous needles) can also be purchased at the pharmacy.  FTM transsexuals in Quebec can obtain sterile needles for injection - even needles of different gauges should they so desire. In this light, the socio-political context of health care is an important and immediate determinant of health. The criminalization and repression of (intravenous) drug use creates conditions of vulnerability to HIV. As other research has demonstrated, a lack of access to sterile syringes in a particular jurisdiction correlates to increased seropositive rates in the population of that region.A fourth finding of the needs assessment focuses on the issue of self esteem. FTM participants at the discussion group stated that FTMs experience difficulties in finding sexual partners.  Given such difficulties, FTMs may not protect themselves and/or their sexual partners during sexual intercourse for fear of rejection. FTMs who identified as gay and/or bisexual men statedthat some FTMs only offer oral sex to other men, so as not to compromise their own transsexual status. The threat of ridicule, harassment, physical violence, or sexual assault upon discovery or disclosure of one's transgendered status were cited as reasons an individual would not disclose their transgendered status. FTMs also remarked that some of them have "no touching" zones on the body: a criterion to which many gay men are not accustomed in their sexual relations. Other FTMs said that they enjoyed penile-vaginal intercourse, but that they could not broach this subject within a gay male context such as a support group. Finally, interviewees and participants of the discussion group at the FTM conference contended that the administration of social services excludes transsexuals and transvestites. FTMs can be (and are often) classified as women in the daily practices of different administrative agencies. Gender-exclusive forms or counseling practices are different examples of how transgendered people must categorize themselves as "men" or "women" and thus deny the complexity of their bodies, identities, and histories. 

Conclusion
In addition to documenting the needs identified by FTMs with respect to HIV/AIDS, the results of the needs assessment suggest some useful orientations for program and service delivery, as well as some significant reflections on the import of qualitative research methods.
Given that many FTMs do not consider themselves to be at risk for HIV/AIDS, community-based programs and services ought not to emphasize HIV/AIDS in their delivery, but rather integrate HIV/AIDS education subtly into a more global program of health care information and services. An approach which focuses on health promotion would attract a larger (and probably more diverse)
audience of FTMs than one which is marketed through the theme of HIV. The results also demonstrate that the socio-political context of health care create conditions of vulnerability to HIV. For instance, in regions where there is poor availability ofintravenous needles, there is often a higher seroprevalence rate among the population. This study extends this line of thought to a transgendered population: in jurisdictions where intramuscular needles are not easily obtainable, transsexuals are at increased risk for HIV. How health is understood politically translates directly into how it is administered, which in turn impacts on how and why people are at risk for HIV.
Finally, the study illustrates the value of qualitativeresearch methods in such an inquiry. The nature of the knowledge collected within this needs assessment could not be gathered through statistical, quantitative methods. Qualitative methods thus lend themselves well to research with marginalized populations, or populations about whom little is known.  Furthermore, the very process of research can help forge collaborative relations amongst researchers and their subjects: a collaboration which can facilitate the social integration of these individuals. In allowing marginalized individuals to ask their own questions, identify their own needs, and validate their own research, a qualitative research study contributes to a scholarly community of scientists and researchers, as well as the members of the population under investigation. As such, qualitative research methods can play an important role in a broader process of community development.

Acknowledgments
I would like to thank several individuals for assistance in gathering and interpreting this data, notably Henry Rubin, Doug Hein, Ben Singer, Matt Rice, and Dale Altrows.

1. James Inciardi, Hilary, Surratt (1992). "Male Transvestite Workers and HIV in Rio de Janeiro, Brazil," Journal of Drug Issues 27.1: 135 - 146; P.Gattari, L.Spizzichino, C.Valenzi, M.Zaccarelli, G.Reeza (1992): "Behavioural patterns and HIV infection among drug using transvestites practicing prostitution in Rome, " AIDS Care 4.1: 83 - 87; Theresa Mason, Margaret Connors, Cornelia Kammerer (1995) "Transgenders and HIV Risks: Needs Assessment "(Boston, Massachussetts Department of Public Health ); W.O.Bockting, B.E.Robinson, B.R.S.Rosser: "Transgender HIV prevention: a qualitative needs assessment," AIDS Care 10.4 (1998): 505 - 526.

2. An innovative program on HIV/AIDS for FTMs was conceived and developed in Boston, however. See Doug Hein (Boston Public Health AIDS Services) (1997). "Education and Soul Searching: The Enterprise HIV Prevention Group," presentation at Hero's Journey Conference, Boston, MA , August 1997.

3. In French, the term "gender" does not exist, nor does its corrolary, "transgender." Since my research is based on the experience of the people in Quebec, a French speaking jurisdiction, I will not refer to an umbrella category of transgendered people, but rather to transsexuals and transvestites. This terminological choice is not to deny the existence of individuals who live in a gender other than that assigned to them at birth, and who may take hormones and/or have certain surgeries, yet who do not (in English) call themselves transsexual. It is, rather, to begin with the terminological categories employed by the francophone participants of this research project.

4. For a useful overview of different research studies and program evaluations which draw this conclusion, see Purnima Mane, Peter Aggleton, Gary Dowsett, Richard Parker, Geeta Rao Gupta, Sandra Anderson, Stefano Bertozzi, Eric Chevalier, Martina Clark, Noerine Kaleeba, Stuart Kingma, Geoff Manthey, Martina Smedberg and Susan Timberlake, "Summary of Track D: social science: research, policy and action, " AIDS 10 (suppl. 3) (1996): 123 - 132.

5. Ministere de la sante et des services sociaux, Direction generale de la sante publique, Strategie quebecoise de lutte contre le sida. Phase 4 orientations 1997 - 2002 (Quebec: Governement du Quebec, 1997).

6. Purnima Mane et al., "Summary of Track D: social science: research, policy and action," AIDS 10 (suppl. 3) (1996): 127

7. Viviane K.Namaste, Evaluation des besoins: Les travesti(e)s et les transsexuel(le)s au Quebec a l'egard du VIH/Sida (Montreal): SIDA, mai 1998). Due to space limitations, this article does not present some very important data with respect to the change of name and the change of sex for FTMs in Quebec, and how these administrative procedures marginalize FTMs and make them vulnerable to the transmission of HIV. Readers are invited to consult the final report cited above for an in-depth discussion of this question.

8. Ministere de la sante et des services sociaux, Direction generale de la sante publique, Strategie quebecoise de lutte contre le sida. Phase 4 orientations 1997 - 2002 (Quebec: Gouvernement du Quebec, 1997).

9. These substantive areas of inquiry were identified by the advisory committee of the project.

10. All of the FTM participants, however, lived in the Montreal region.

11. See Benoit Gauthier (1992): "La recherche-action, " in Benoit Gauthier, ed. Recherche sociale: de la problematique a la collecte des donnees (Sillery, Quebec: Presses de l'Universite de Quebec): 517 - 533.

12. See Henri Lamoureux, Robert Mayer, Jean Panet-Raymond: L'Intervention communautaire (Montreal: Editions Saint-Martin)

13. A methodological question must be poised at this point. Since the discussion group at the conference was clearly labelled as one pertaining to HIV/AIDS, it would only attract FTMs interested in addressing this subject. Thus, it is not that FTMs in Quebec do not consider themselves to be at risk for HIV while those in the United States do.

14. Field notes, September 12, 1997.

15. Personal correspondence with Matt Rice, October 14, 1997.

16. Alex Wodak, Peter Lurie (1996): "A Tale of Two Countries: Attempts to Control HIV among Injecting Drug Users in Australia and the United States," Journal of Drug Issues 27.1: 117 - 134.

17. A more in-depth discussion of valuable orientation of services for transsexuals and transvestites is available in Namaste (1998), Evaluation des besoins: Les travesti(e)s and les transsexuel(le)s a l'egard du VIH/Sida (Montreal: Report submitted to the Centre Quebecois de Coordination sur le Sida.)