by Barbara E. Warren, Psy.D.

Director, Mental Health and Social Services Lesbian and Gay Community Services Center Introduction

Citation: Warren B.E., Psy.D. (1999) Sex, Truth and Videotape HIV: Prevention at the Gender Identity Project in New York City. IJT 3,1+2, http://www.symposion.com/ijt/hiv_risk/warren.htm

• Program participants
• Peer-driven assessment of needs
• Prevention strategies
• Training, advocacy, and empowerment
• References

In the videotape produced by the Gender Identity Project of New York City's Lesbian and Gay Community Services Center, Safe T Lessons: HIV Prevention for the Transgender Communities, transgender activist Riki Ann Wilchins talks frankly about her own experiences of looking for sex as a rite of passage into womanhood and the risks she would take in order to be accepted as a desirable female. "You want to be accepted and sex feels like acceptance . . . even for a night, even for fifteen minutes . . . lots of Trans people will have unsafe sex to feel desirable, to feel loved, to be validated as a woman or a man . . ." Tony Baretto-Neto tells other transexual men that coming out of a lesbian identity, he never thought of himself as at risk even though he was trained as a police officer to educate other cops about HIV. Crossdresser Terri McCorkel tells a story about Joe who when dressed up as a woman dares to have new erotic experiences, including unprotected sex with a man, something he would not risk doing as Joe.
Imperial Court Empress Philomena, self-identified drag queen, reveals that drag is all about the illusion of being a female, and for some drag queens and their partners, using condoms might call too much attention to male genitalia. Peer educator Nora Molina worries about the HIV positive transexual sex workers who may be not using condoms with their customers in order to make more money and be at greater risk for secondary infection and other diseases.

All of these issues and more are being discussed and addressed by the HIV prevention and intervention efforts of the Gender Identity Project. Since 1990, the Lesbian and Gay Community Services Center of New York City has been serving transgender persons through the Gender Identity Project (GIP), the first, and still one of the few, transgender peer counseling and empowerment programs in the country. The GIP's constituency is inclusive of a wide range of transgender identities; crossdressers, femme and butch queens, bigenders, drag kings and queens, and transexuals.

Transgender people, like gay men and lesbians, experience prejudice and exclusion from the larger society. In this respect the Gender Identity Project fits in with the Center's overall mission to protect and preserve lesbian and gay rights and culture. The GIP mirrors the Center's mission in its efforts to enable transgender persons an opportunity to affirm who they are in an atmosphere of self-acceptance, and an opportunity to build community. The GIP has developed as primarily a peer-support, peer-driven project that relies on transgender people to help other transgender people to assess community needs and create support mechanisms. Peer counselors, some of whom are human service professionals, work with other Center staff to deliver individual, group and other support services. For many recipients the peer counseling is the first time they encounter a peer who not only shares their experience but is also a role model for the successful resolution of their gender identity issues.

Although more data on HIV/AIDS in transgender populations is needed, recent studies indicate that the transgender community is at high risk for both substance and HIV (Yates, 1998; Mason, et al., 1995). Clements, Marx and Katz (San Francisco Department of Public Health, 1998) found that HIV risk behaviors are common in transgender men and women; that HIV prevalence is higher for the transgender population than for both men who have sex with men and injection drug users in San Francisco; that HIV infected transgender women continue to engage in high risk sexual behaviors; and that there is a distinct lack of transgender affirmative services available even in San Francisco, a city known for its innovative programs. Boles and Elifson (1993) found a high rate of non-HIV sexually transmitted diseases among transgender-identified sex workers, which is correlated to additional risk for HIV transmission. Anecdotal data on the use of shared needles for injection hormones and the need for hormone needle exchange (Positive Health Project, 1998) also indicates that transgender persons are at significant risk for HIV.
 

Program participants

Since its inception, the GIP has collected demographic data on program participants. A recent analysis of this data set has helped to inform GIP HIV prevention efforts. The data is unique in that it documents a wide variety of variables from 1990 through the present, for are latively large, non-clinical sample of clients (n=357) in a community-based setting (Valentine,1998). Fifty-five percent of GIP clients are white, 20% Latino/a, 14% African American and 10% report being biracial or multiracial. The mean age for white clients is 36 years, for African Americans 32 and for Latino/a 28. This does not include data on 13-21 year olds who are tracked from the Center's Youth Enrichment Services (YES) program which reports young persons identifying as transgender in the YES program at about 3%.

Data collected on the genders of sexual partners indicates that transgender people are sexually active across the spectrum of sexual orientation with 45% reporting sexual attraction to men, 29% reporting sexual attraction to women and 20% reporting bisexual attraction. Substance abuse, a known risk factor for HIV transmission, is high among transgender people with 27% self-reporting alcohol abuse and 24% reporting drug abuse, across all ethnic groups and gender identities. This is twice the rate found in the general population and comparable to the higher rate of substance abuse found in the research on the lesbian and gay communities (McKirnan and Peterson, 1989).

HIV status in the earlier years of data collection was poor because nearly half of the sample declined to report their status and as it was not a requirement of program participation, peer counselors did not pursue the information. With the development of the GIP's HIVprevention education program, HIV training for peer counselors and greater awareness in the transgender communities about the need for HIV education, more consistent data has been collected recently with 40% reporting HIV negative status and 6% reporting HIV positive status. The majority of transgender persons do not know their HIV status. As previously described, anecdotal and ethnographic evidence suggest a higher rate of HIV infection in these communities, particularly among sex worker populations. All of the above indicates the need for more intensive HIV-related services being directed toward and available to transgender populations.
  

Peer-driven assessment of needs

The Gender Identity Project's roots in peer education and community building make it an ideal vehicle for HIV education. It is well documented that peer-delivered outreach and education are essential tools to successful HIV prevention and intervention. As previously stated, at the time that the GIP undertook development and implementation of an HIV outreach and education effort, there was very little data on HIV risk available, and only a one-year project conducted at the University of Minnesota (Bockting et al., 1993) to use as a resource. Through using GIP peer counselors and GIP participants as informants, we learned that different identity-groups within the transgender community needed to hear different messages. As exemplified in the video, many crossdressers engaged in fantasy role-plays in which they tended to disassociate from the reality of risk. Transexual sex workers were paid more by their customers not to use condoms. Transexuals in transition were not the only persons sharing needles for hormone injections; some crossdressers and drag queens were also at risk. Using substances as a risk factor for HIV transmission cut across all transgender population groups. Transgender men, females to males, did not perceive themselves at risk even though many reported engaging in risky sexual practices such as unprotected oral sex, and vaginal and anal penetration. Transgender persons who were HIV positive needed access to primary care and education about secondary prevention.
  

Prevention strategies

Several strategies were employed as outreach and education. Through a grant from New York State AIDS Institute, the GIP created a multicultural, multi-identity outreach and education team of peer counselors who then developed palm cards targeted to transgender women in the sex industry, on the street and in the club scenes. The image depicted a "fab but not fierce sister" advocating community affiliation and self-care. Peer educators put together safer sex kits that were packaged in a reusable, clear vinyl cosmetic bag, (with different colored trims so it became fashionable to collect one in each color) containing a variety of latex barrier protection, flavored lubes, and a condom guide. The guide illustrated with "phallic women" demonstrating correct use. Kits also contained lip-gloss donated by the Body Shop. Club outreach, house ball outreach, drag event outreach, street outreach and transgender conference outreach were, and still are points of dissemination.

The 40-minute video funded by the New York State AIDS Institute focuses on HIV prevention in the context of community building. The making of the video became a community-based education event. Development of the script, hiring of the production crew, locations, interviewees, even the makeup, were all tasks of the GIP peer outreach team and other transgender program participants. The video is used as both an education and training tool and over 150 copies have been distributed around the world.

Although many of these strategies are still in effect, efforts must constantly be modified to meet emerging needs and respond to lessons learned. Although the safer sex kits are still quite popular, what is in them is changed. Sex workers need more unlubricated, unflavored condoms for oral sex, and inclusion of chewing gum (with the GIP phone number printed on the package) for after oral sex is greatly appreciated. Dental dams and gloves have been eliminated since no one reports using them. Outreach workers find that the more they frequent a particular spot, the more likely on the fifth, or sixth encounter they will have a meaningful conversation and make a referral that is followed through upon. More concrete services are needed, like help to access primary care, benefits, food and housing. Relationship issues are of great concern - particularly lover and partner issues. Substance use counseling is also needed, with a harm reduction and recovery readiness approach rather than an abstinence model.

Currently, the Gender Identity Project serves about 1000 participants annually. Clients have tripled from 1995 through 1998, with GIP participants requesting assistance for many concerns - with housing, benefits, medical and social services, job seeking skills, legal issues, and more in-depth counseling for substance use issues, relationship issues and family concerns. All services include education about HIV, risk reduction and harm reduction counseling, and free condoms and other latex barriers.
  

Training, advocacy, and empowerment

There continues to be a lack of transgender sensitive and relevant treatment services for the whole range of concerns this community faces, especially outpatient and residential substance abuse services. In the past year, the GIP has conducted 70 sensitivity trainings for 50 social services organizations seeking to better serve transgender clients. Although sensitivity training is a step in the right direction, transgender clients need ongoing services advocacy, counseling support and peer group support which the GIP would be better able to offer if more funding for transgender services were available.

To accomplish this, the Lesbian and Gay Community Services Center sees its role inserving the transgender community program as more than service delivery. The Gender Identity Project is an opportunity to build leadership in the community that enables transgender activists to speak out on issues of concern, including HIV prevention and intervention, and take steps toward change. Through the Center, GIP Director Rosalyne Blumenstein and GIP peer counselors have also been afforded visibility and a platform from which to advocate to public and private funding sources about the need for developing better resources, to agencies and other organizations about policy changes that will include affirmative services for transgender consumers and in the community itself, in order to raise consciousness and activate others. These kinds of activities clearly go beyond the traditional approach, which focuses on changing individual behavior. Facilitating community empowerment to change environments that are oppressive to transgender persons and to establish community norms that advocate HIV prevention, should also be the goals of any program or agency serving transgender clients.
  

References

Bockting, W., Coleman, E. and Rosser, S. (1993) Transgender HIV/AIDS Prevention Program Manual, Program in Human Sexuality, Department of Family Practice and Community health, Medical School, University of Minnesota.

Clements, K., Kitano, K and Marx, R. (1998) HIV Prevention and Health Service Needs of the Transgender Community in San Francisco. Report to the San Francisco Department of Public Health, AIDS Office.

Elifson, K., Boles, J., Posey, J., et al. (1993) Male transvestite prostitutes and HIV risk. American Journal of Public Health. 83(2):260-262.

McKirnan, D.J. and Peterson P.L. (1989) Alcohol and drug use among homosexual men and women: Epidemiology and population characteristics. Addictive Behaviors. 14(5):545-553.

Mason, T.H., Connors, M., and Kammerer, N. (1995) Transgenders and HIV Risks: Needs Assessment. Massachusetts Department of Public Health, AIDS/HIV Bureau.

Valentine, D. (1998) Gender Identity Project Report on Intake Statistics. Lesbian and Gay Community Services Center of New York and New York University, Department of Anthropology.

Yates, R. ( 1998) Male to female sex workers associated risk factors and specific HIVrisks, in Group HIV Education For Male To Female Sex Workers: A Facilitators Manual.Beacon Hill Multicultural Psychological Associates, Boston, Massachusetts.

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