HIV Risk Behaviors of Male-to-Female Transgenders in a Community-based Harm Reduction Program

by Cathy J. Reback, Ph.D. and Emilia L. Lombardi

Citation: Reback C.J., Ph.D. and E.L. Lombardi (1999) HIV Risk Behaviors of Male-to-Female Transgenders in a Community-based Harm Reduction Program. IJT 3,1+2, http://www.symposion.com/ijt/hiv_risk/reback.htm

• Abstract
• Overview of the Community-based Program
• Method
• Conclusion and Discussion
• References
• Acknowledgements
    

Abstract
This paper analyzes data collected from a transgender HIV Harm Reduction Program located in Hollywood, CA. Over an eighteen-month period, from January 1996 to June 1997, 209 male-to-female transgenders participated in the program. Demographic data and baseline HIV risks were collected at first contact and first intervention session, respectively. Within this sample, HIV infection risk seems to be related to whether participants engaged in sex work. The sex workers were more likely to have used alcohol and other drugs, including injection drugs, within the previous 30 days than the non-sex workers.

Running Head: HIV Risk Behaviors of Male-to-Female Transgenders
  

Overview of the Community-based Program

The Van Ness Recovery House and Van Ness Prevention Division
The Van Ness Recovery House is a non-profit corporation dedicated to serving the needs of gay, lesbian, bisexual, and transgender/transsexual substance users. The recovery house, which was founded in 1973, is a 90-day, 20 bed residential drug and alcohol treatment facility. The Van Ness Recovery House served its first transgendered resident in 1984. Between 1984 and 1988, the Van Ness Recovery House served one to two transgendered residents per year. Since 1988 to present, the Van Ness Recovery House has consistently served from 10 to 20 transgendered residents per year. Additionally, since 1988 we have had a minimum of one transgendered person of staff.

In December 1994, the Van Ness Recovery House began its Prevention Division which offers HIV and substance abuse prevention interventions to gay, lesbian, bisexual and transgender/transsexual drug users in the Hollywood and West Hollywood areas of California. The Van Ness Prevention Division (VNPD) is based on the philosophy of harm reduction. The overall objective of the prevention programs is to reduce the harm that can result from drug use by preventing HIV infection and managing the physical, psychological and psychosocial manifestations of drug use without the requirement of abstinence or recovery. Success is evaluated by any change in behavior that reduces physical, psychological or psychosocial harm to our participants, their loved ones, and/or their community.

The staff of the VNPD conduct face-to-face street outreach, counseling interventions, immediate linkage to services, pre- and post-test counseling, education/prevention groups, community workshops, art exploration groups and support groups. These services are provided on the streets in identified high-risk areas of Hollywood, in natural settings where participants congregate including street corners, bars, fast food stands, parks, bathhouses, and sex clubs, and at the Prevention Division site located at the intersection of the Hollywood/West Hollywood stroll district.

The Transgender Harm Reduction Program
The VNPD Transgender Harm Reduction Program was initiated in October 1995 and is designed to reach a variety of male-to-female (MtF) transgendered individuals including persons living on the streets or in low-rent hotels, sex workers, bar queens, as well as those integrated and living in the suburbs. The specific prevention interventions offered are based on a needs assessment done prior to program implementation that included in-depth interviews and a focus group with members of the target population.

Staff conduct face-to-face outreach with transgendered persons on the streets in identified high-risk areas and in specific venues such as hotels and "queen bars" where transgendered persons are known to congregate. Efforts are made to have repeated contacts with clients to enhance trust and encourage participation in the community workshops and mentoring support group.

The workshop topics include grooming and hygiene, legalization and documentation, health care, and hormone therapy. These areas were chosen based on the results of the needs assessment. The program consists of an outreach component and a series of four community workshops designed to promote skills-building and behavior change to reduce HIV risk, a weekly mentoring support group, and job training. Implicit in each workshop topic is the importance of increasing self-esteem as an important precursor for adopting safer behavior. Each workshop also includes an explicit HIV/AIDS risk reduction component. Concurrent with the community workshops is the weekly mentoring support group. The format of the support group is open thereby providing an opportunity for participants to choose the topic for discussion. The program participants who complete the four community workshops and maintain ongoing participation in the support group are encouraged to serve as mentors to the newer participants. Job training is available to each participant after they complete the four community workshops. Participants are also referred for HIV counseling and testing and other services as needed.
  

Method
During the first 18 months of the program, January 1996 through June 1997, 861 MtF transgender/transsexual persons were contacted through street outreach. Of those, 209 participated in the Transgender Harm Reduction Program. Demographic data was collected during the first outreach contact and a more in-depth HIV risk assessment, including drug and sex behaviors, was conducted at a baseline intervention session. Follow-up risk assessments were conducted at each subsequent intervention session.

Analysis
Data from the 209 intervention participants was analyzed by comparing individuals who reported exchanging sex for money and/or drugs sometime in the previous 30 days with those who did not. Analysis of variance was conducted upon demographic factors such as age, ethnicity, marginal living situation (living in a low-rent hotel, rooming house, shelter, or the streets), and whether they were monolingual Spanish speakers. The difference in substance use was assessed by identifying which substances were used by the intervention participants. Finally, differences in sexual activity were analyzed by identifying the number of exchange and non-exchange male sexual partners the participants reported within the previous 30 days and the percentage of reported condom used during these sexual encounters.

Demographics
Of the 209 participants in the Transgender Harm Reduction Program, 40% are Latin/Hispanic, 28% Caucasian/white, 22% African American/black, 6% Asian/Pacific Islander, and 3% Native American. Their ages ranged from sixteen to 55 years and the mean age was 31 years. Twenty-six percent of the participants reported a marginal or transitional living situation at baseline intervention such as a low-rent hotel (13%); on the streets (5%), for example "squatting" in an abandoned building, finding shelter in a vacant lot or abandoned car, sleeping in a park; or living in a shelter or other service facility (2%). Seventy-nine percent of the participants identified as heterosexual, 10% as bisexual, 8% gay, and 2% lesbian. Sexual identity takes on varied meaning within transgender communities and must be considered when creating transgender-specific programs. For example, an HIV intervention participant could be a MtF transgender who identifies as lesbian and has a penis.

Alcohol and Drug Use
Table two summarizes the extent of drug and alcohol used by participants in the previous 30 days. At baseline intervention almost half (45%) of the participants reported some alcohol and/or drug use in the previous 30 days. Alcohol was the most frequently used substance by the program participants, with 37% reported use. Thirteen percent reported using marijuana at least once in the previous 30 days. The third most frequently used drugs were crack and crystal methamphetamine with 11% of the participants using each in the previous 30 days. Seven percent of the participants reported cocaine use and 2% reported heroin use within the time period measured. (See Table 2.)

Approximately 5% of the participants reported injection drug use in the previous 30 days, as seen in Table 3. The most frequently injected drug was methamphetamine "crystal" (4%) and only a few individuals reported injecting either cocaine or heroin. Only a small proportion of those within the intervention were at risk of HIV infection due to injection drug use. Of those reporting any injection use in the previous 30 days only one third reported using a needle exchange program or bleach to clean their needles and 20% reported never sharing needles.

Sex Work
Baseline data from the 209 program participants was analyzed by comparing those who reported sex work (n=76) with those who did not (n=133). Although 44% identified as a sex worker at outreach contact, at baseline intervention session only 36% reported exchanging sex for money and/or drugs in the previous 30 days.

The differences between sex workers and non-sex workers are summarized in Table 4. The mean age of sex workers was younger than non-sex workers (26.9 versus 32.9). Sex workers were more likely than non-sex workers to be Latin/Hispanic (60.5% versus 28.6%), were significantly less likely to be Caucasian/white (10.5% versus 38.4%), and equally likely to be African American/black (21.8% versus 21.1%). Among the Latin/Hispanic transgenders in the program, those who engaged in sex work were more likely to be monolingual Spanish speakers (18.4% versus 7.5%). Additionally, sex workers were significantly more likely to be homeless or live marginally than non-sex workers (42.1% versus 14.6%).

Sex work was also associated with greater substance use.

Those who engaged in sex work were significantly more likely to report alcohol use in the previous 30 days (51% versus 29%), marijuana use (20% versus 8%), crack use (25% versus 3%), crystal use (21% versus 5%), and cocaine use (12% versus 5%). Additionally, sex workers were significantly more likely to be injectors than non-sex workers (9% versus 2%); this also included injecting crystal (8% versus 2%). In a recent study of methamphetamine use, the transgender respondents reported using the drug to enhance sexual encounters during sex work (Reback 1997).

There are also differences between sex workers and non-sex workers in their sexual activity with non-exchange male partners. Those engaged in sex work reported having a greater number of non-exchange male sexual partners (21 versus 3) in the previous 30 days. However, the sex workers demonstrated greater understanding of HIV transmission risks as well as a greater personal perception of risk as is evidenced in their reported condom use. Sex workers reported a high use of condoms with their exchange partners (95%) and were more likely to use condoms with their non-exchange male sex partners (94% versus 56%). Consequently, among this sample, although sex workers reported significantly more male partners, their HIV risk through sexual behavior may be lower than non-sex workers as a result of their higher use of condoms.

Conclusion and Discussion
Little is known about the HIV risks of MtF transgendered persons although past studies have found a high HIV sero-prevalence rate among MtF transgendered women (Pang, Pugh, and Catalan 1994; Rekart, Manzon, and Tucker 1993; Modan, et al. 1992; Alan, Guinan, McCallum 1989). One of the primary reasons given for their high rate of HIV infection has been the high prevalence of sex work among the individuals within their samples. We also found a similar pattern within these data. Those who exchanged sex were found to use more drugs and alcohol, including more injection drug use, than those not engaged in sex work. In addition to their exchange sex partners, the sex workers reported a greater number of non-exchange male sex partners. However, the sex workers reported greater condom use than non-sex workers.

Past studies on transgender HIV risk factors have focused primarily on individual risk factors and have not dealt with the social context that could influence one’s individual risk factors. It is possible that the marginalization of these individuals creates a social context that places them at risk of HIV infection. For example, Sanjay (1996) concludes that much of the HIV risks experienced by transsexuals in India was due to their illegal status and, consequently, their limited access to legal and social resources. A similar situation exists in the United States. For MtF transgenders a legal identity that is inconsistent with one’s presenting gender may lead to employment discrimination which serves to drive many into illegal forms of employment. Boles and Elifson (1994) also note a relationship between transgender discrimination and sex work.

For transgendered persons it is often difficult and costly to establish a legal identity in one’s chosen gender. The inconsistency between one’s legal gender identity and gender presentation may force many trans-persons into the margins of society. For many, this marginalization may force them into work that does not require legal documentation. Of the participants in the Transgender Harm Reduction Program, 55% of those who were Latin/Hispanic and 58% of those who were monolingual Spanish speakers engaged in sex work. Furthermore, the current political climate for all undocumented immigrants in California creates difficulty in gaining legal documentation.

Transgendered persons currently have little protection from discrimination in the work place. A previous study found 37% of their sample reported some type of employment or economic discrimination such as not being hired or losing one’s job due to their presenting gender (GenderPAC 1996). Employment discrimination may force people into sex work due to the limited choices given to transgendered persons.

Another employment consideration is job accessibility. For many undocumented women, access to domestic jobs such as child care and other housework services is usually obtained through family support networks, and many transgendered women are estranged from their families. The lack of access to jobs could serve to pressure transgendered women into sex work.

The data from this study came from a community-based HIV harm reduction program. Given that only a limited amount of data can be collected prior to an intervention session, both the contact and intervention forms must be brief. Therefore, information was collected on participants’ current drug use and sexual behaviors. Further studies are needed to examine the legal, social and economic situations of transgendered persons.

Correspondence and requests for materials can be set to:
Cathy J. Reback, Ph.D., 113
  

References

1. Reback, C.J. (1997) "The Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual Males in Los Angeles." Report for the City of Los Angeles, AIDS Coordinator.

2. Pang, H., K. Pugh, and J. Catalan. (1994) "Gender Identity Disorder and HIV Disease." International Journal of STD and AIDS. 5:130-132.

3. Rekart, M.L., L.M. Manzon, and P. Tucker. (1993) "Transsexuals and AIDS." IX International Conference on AIDS. 9:734.

4. Modan, et al. (1992) "Prevalence of HIV Antibodies in Transsexual and Female Prostitutes." American Journal of Public Health. 82:590.

5. Alan, D.L., J. Guinan, and L. McCallum. (1989) "HIV Seroprevalence and Its Implications for a Transsexual Population." V International Conference on AIDS. 5:748

6. Sanjay, G. (1996) "HIV/AIDS Intervention Among Transsexuals in Bangalore, Medico - Legal Impediments for Effective Intervention." XI International Conference on AIDS. 11:52.

7. Boles, J. and K.W. Elifson (1994) "The Social Organization of Transvestite Prostitution and AIDS." Social Science and Medicine. 39:85-93.

8. GenderPAC. (1997) First National Survey of Transgender Violence. New York: GenderPAC.

All figures are percent, unless indicated

Acknowledgments

This research was funded by Contract No. H208837-2 from the U.S. Centers for Disease Control and Prevention and the County of Los Angeles Department of Health Services, Office of AIDS Programs and Policy. Dr. Reback would like to thank the field staff of the Van Ness Recovery House Prevention Division for their ongoing commitment and hard work and Kathleen Watt for her support of this program. Dr. Lombardi would like to thank Talia Bettcher, Shirley Bushnell and Jacob Hale for their support.