Fighting HIV by Reaching Out to Transgender Prostitutes

[BOSTON, MA] - Tatiana, Alexis and Tinoyia got dolled up one evening last week and headed to Jacques, the racy transgender bar in Bay Village. But instead of selling sex, they handed out condoms and advice, hoping to prevent yet another case of HIV in transgender prostitutes, their straight male clients, and the men's wives and girlfriends.

''We want to tell people, `Just have safe sex,''' said Tatiana, who is a male-to-female transgender and former prostitute who does street outreach through Gender Identity Support Services for Transgenders, or GISST, one of the only programs in Boston assisting transgender sex workers.

Transgenders exist at the far margins of society, hidden to most people except for those who seek them out. Largely shunned, many live in extreme poverty. Many abuse drugs and work as prostitutes, performing acts that other sex workers avoid. And many inevitably contract and spread HIV.

''Quite often, the transgender woman doesn't think of using condoms. They live for the moment,'' Tatiana said.

Alexis, a member of the GISST team, had a good job with the state Department of Mental Health until she realized she wanted to be a woman full time. She didn't feel comfortable dressing as a woman at work, so she quit her job and soon became homeless. ''At least at the shelter I was able to be me,'' she said. Portia, another team member, found work at peep stores in Chinatown. ''They put a coin in and I shimmied,'' she said. All three want to bring more dignity to their lives, and GISST is helping them.

Anecdotal reports and a handful of recent studies indicate that transgender prostitutes have very high rates of HIV and AIDS.

''Those of us seeing transgenders know it is a significant problem,'' said Dr. Gregory Fenton, medical director of the Sidney Borum Jr. Community Health Center of Boston, a clinic for disenfranchised youths, including gays, lesbians, bisexuals and transgenders.

Fenton said that HIV has existed within the transgender community for years, but unlike other populations with high HIV rates, there has been little outreach to them and little recognition of their dire need for health services. He has between 20 and 30 transgender patients, he said.

One reason there are few services and funds available is the lack of data describing exactly how big the transgender HIV problem is, said Martin Risteen, program manager of GISST. Risteen's group keeps its own numbers, based on its outreach. Risteen estimates there are 50 to 100 transgender prostitutes working in Boston and at local escort services.

According to Risteen and his team members, the vast majority of the sex workers' clients are ''straight'' men, many married or with girlfriends.

The state Department of Public Health has disbursed funds to groups assisting transgenders for about eight years. Last year, Boston identified HIV in transgenders as a public-health issue in need of more attention. But given current budget constraints, more funds, especially for data collection, are not likely to come from the state, said Jean McGuire, assistant commissioner at the Department of Public Health and director of the HIV and AIDS Bureau.

''In a time of very limited resources, it's a big deal that we say this is a commitment of ours,'' McGuire said.

Fenton estimated that 30 percent of the transgender prostitutes he treats are HIV-positive, with the rate higher among adolescents. Two studies in San Francisco have placed the HIV rate of transgender sex
workers at 19 percent and 35 percent, respectively. This can be compared with the federal Centers for Disease Control estimates of the rate of HIV among men who identify themselves as having sex with other men, which is also high and which may include gay and bisexual men, as well as transgenders. The rate of infection among these men ranges from 3 percent for white men to 14 percent for African-American men.

Why transgenders engage in risky sex in the first place, despite decades-old messages about its relationship to HIV, is due to complex psychosocial and economic factors that cannot be remedied easily, said Belser Louie, a psychologist, founder of the GISST program, and executive director of the Beacon Hill Multicultural Psychological Association.

''Many are coming from such dysfunctional places, much of their behavior and attitudes are unhealthy,'' said Louie, who has counseled Boston's transgenders for decades.

''Many [transgender] people seek validation from a sex partner. If he's the only one saying, `I see you as you are; you are a girl, you are a woman,' that is intensely important,'' said Grace Sterling Stowell, a transgender who is the executive director of the Boston Alliance of Gay, Lesbian, Bisexual and Transgender Youth.

Tinoyia agreed: ''They made us feel whole like we wanted to feel.''

But money also plays a big role. Many transgender sex workers are homeless, or using narcotics or sex-changing hormones. The temptation to do what is necessary for more money is strong.

''Time after time they've told us they get paid more for doing something unsafe,'' Stowell said. ''It's hard to turn down when it is a freezing cold night in winter and you don't have a place to stay.''

Physicians who treat transgender sex workers say that, because of the often horrifying circumstances of their lives, their overall physical and mental health is poor and their rate of drug abuse, HIV, hepatitis C and tuberculosis is high.

Getting them the services they need, however, is not a simple matter of taking them to the doctor, Louie said. ''That's been an uphill battle.''

Louie said transgenders have faced discrimination at local clinics, including being harassed in the waiting room and bullied into declaring themselves either a male or a female. Currently, just a handful of clinics are openly accepting of transgenders, Louie said.

Fenton said that some transgenders avoid doctors out of fear that they will be forced to stop taking hormones.

Fenton treats transgenders, but even from his empathetic perspective, it isn't easy. It is difficult to treat an HIV-positive person who is taking hormone supplements because adding HIV drugs to the mix can cause liver damage. ''How do you balance the treatment for transgenders' anatomical changes with their need to live?'' Fenton said.

In the meantime, the GISST team will continue to try to build a community of transgenders who together can advocate for their needs.

''We're trying to bring them to a place,'' Tatiana said, ''where they no longer have to live in the underworld.''