Boston: Especially Shunned, Especially Vulnerable -- Fighting HIV by Reaching Out to Transgender Prostitutes

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," said Tatiana, a male-to-female transgender and former prostitute who does street outreach through Gender Identity Support Services for Transgenders, one of the only programs in Boston assisting transgender sex workers.

Anecdotal reports and a handful of recent studies indicate that transgender prostitutes have very high rates of HIV/AIDS. 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, said that HIV 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. 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. In contrast, the rate of infection among men who identify themselves as having sex with men ranges from 3 percent for white men to 14 percent for African-American men, the CDC estimates.

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.

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