Ain’t I a Woman? Respecting self-defined gender identities for effective HIV prevention

by Suzy Subways, Editor, Solidarity Project

MARCH 2007 • Issue 3

Transgender women worldwide, and people whose gender expression doesn’t fit strictly into male or female, are among the groups with the highest HIV risk. Yet they are often marginalized—including within the AIDS community. To develop prevention programs that truly serve and empower these communities, we need to listen as they define their needs and their own identities.

Individuals and communities may define themselves using different words, but in general these definitions are useful in the United States and some other countries: Transgender is understood as a term for a range of identities, including people who may or may not choose surgical or hormonal treatment. Trans and gender non-conforming are terms often used to include people who, for varied reasons, don’t define themselves as “transgender.” MTF (male to female) refers to someone assigned male gender at birth, for whom the assigned gender does not fit. FTM (female to male) refers to someone assigned female gender at birth, for whom that does not fit. Transwoman and transman identify someone as being a member of the gender they live as every day, while also identifying them as trans.

“Tens of thousands of transwomen of color have died of AIDS, and the sad thing is, they have been counted as men who have sex with men (MSMs),” says Jessica Xavier, a Washington D.C.-based researcher on trans health issues and a transwoman herself. A lack of funding has prevented large-scale research, but small studies have shown HIV rates among transwomen in nine U.S. cities ranging from 4 percent to 47 percent, compared to well below 1 percent in the U.S. population as a whole.

Shut out of education, housing and employment, many transwomen and gender non-conforming people—especially those in the Global South and transwomen of color in the U.S.—rely on sex work to survive. A 2000 survey conducted in Buenos Aires, Argentina, found that 89% of travesti were sex workers. According to a 1993 study, 68% of transwomen sex workers in Atlanta were HIV positive.

In the U.S., most transgender women identify as just that—women. But gender non-conforming people in many countries define themselves differently. Although travesti in Argentina live every day as women, most travesti activists identify themselves as belonging to their own gender, Lohana Berkins of ALITT (Asociación Lucha por la Identitdad Travesti y Transexual) in Buenos Aires writes in a document prepared with the International Gay and Lesbian Human Rights Commission (IGLHRC). On the Indian subcontinent, a third gender has existed from the earliest Hindu and Islamic records. The hijra activist group Dai Welfare Society estimates that half of the hijra in Mumbai, India have HIV. In the Zapotec indigenous culture of Oaxaca, Mexico, muxhe “refers to the effeminate man with a feminine gender identity, as a similar identity to the transgender but with [unique] characteristics,” said Amaranta Gomez Regalado, a muxhe-identified representative from National Strategy about Prevention Care and Treatment in HIV/AIDS for Indigenous People in Mexico, in a presentation at the 2006 global AIDS conference in Toronto.

These diverse groups may share similar sex-related HIV risks to both MSMs and many non-trans women, just as their risks for violence are similar—transwomen often face both gay-bashing and domestic violence. But their prevention needs are different. The key to HIV prevention is to respect the identities and priorities expressed by each community for itself.

Among U.S. transwomen, gender identity comes first. Many have told researchers that they have unprotected sex because it validates them as women. San Francisco transgender activist Adela Vazquez said (also in a presentation at Toronto) that transwomen sex workers there use condoms with clients, but often not with lovers. “Loving and being loved—it’s not something that comes easy to a transgender, keeping in mind that rejection and oppression are present…from a very young age,” she said. “Unsafe sex and no limitations are given to him to show devotion.”

Xavier agrees: “Sex is a very deeply affirming thing for most humans. It’s easy to define yourself in terms of your relationship if you’re a woman. It’s especially precarious for transwomen. If you’ve got a man, the world sees you as a woman. If the guy leaves, what are you then?”

HIV prevention efforts that don’t recognize transwomen as women will never grasp this key concept. Low self-esteem has been proven a major factor in risky sex and drug use in other communities, Xavier argues, so the best programs for transwomen would improve self-esteem through access to transgender care, especially safe hormonal therapy. She cites a 1998 New York City study that provided hormones to HIV positive transwomen of color, who then substantially reduced risky behaviors like injection drug use, unprotected sex, sex work and needle-sharing for hormone injection. Funding is needed for a similar study with HIV negative transwomen.

Although free, safe hormonal therapy is not provided yet at most health programs serving trans communities in the U.S., several cities have clinics that do offer affordable hormone treatment to trans people using an informed consent process. Some syringe exchanges also provide hormone and silicone syringes, as well as education about hormone dosages and proper injection techniques.

Research and HIV prevention services are also needed for transmen, some of whom may be engaging in unsafe hormone injection or high-risk sex. There is little data available on the HIV risks of transmen. Many transmen have sex with men, and it has been estimated that as many as a third identify as gay men.

Drop-in centers in several cities provide safe spaces where trans people can relax, shower, socialize, eat, find counseling, learn about safe hormonal therapy, and participate in workshops facilitated by other trans people. Rick Feely of Philadelphia’s Trans-health Information Project (TIP) says that his program is one of two transgender demonstration projects funded and given special attention by the CDC; the other is in Los Angeles. TIP hopes to receive formal evaluation after this process, which would give it an opportunity to become a CDC Effective Behavioral Intervention, the officially sanctioned programs that most organizations have to choose between to get funding. None of them currently target trans populations. “It’s exciting,” Feely says. “At the same time, it can get tricky—the data collection involves assumptions about what genitals people have. But the fact that we’re going in this direction is very important.”

Globally, AIDS activists and funders must support the efforts of gender non-conforming people who are organizing to define their needs. And we all must demand that those needs are met.

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