Many transgendered men and women face unique challenges that make them highly vulnerable to violence, mental illness, substance abuse, poverty and HIV infection. Now, a growing number of specialized programs are working to support one of society's most marginalized communities.
Twenty-one years ago, Christine was diagnosed with HIV. But learning to live with the virus was just one of many challenges she faced. Then in her mid-30s, Christine was living in a man's body -- specifically, a gay man's body. Outside of the gay community, she was almost always mistaken for a woman.
In 1998, during a trip to Atlantic City with her mother and some friends, Christine went to the men's washroom in the casino. The custodian told her she was in the wrong place. "I came out of there and said, 'I can't do this anymore. I can't live in this world and that world,'" she now recalls. Her family was extremely supportive of her decision to make a full transformation into a woman (though "Mother had trouble with the pronouns," she says) and Christine, now 55, does public speaking about her life and about HIV.
Many other trans men and women -- people who cannot identify with their birth gender and who take any of a number of steps to live as the gender they identify with -- are not as fortunate. Even in cities like Toronto, Montreal and Vancouver, many trans men and women face unique and relentless challenges every day -- challenges that render them far more vulnerable to violence, mental illness, substance abuse, poverty and more.
And though there is little in the way of trans-specific statistics gathering, the trans community also appears to be more vulnerable to HIV than the general population. Some U.S. studies indicate that rates of HIV may be as high as 20 percent among trans women in New York, Chicago and Los Angeles, and as high as 30 percent among trans women in San Francisco and Washington. Another study, of trans women sex workers in Atlanta, found HIV rates soaring to 68 percent.
When you step back and look at the reality of many trans peoples' lives, it might be surprising that the numbers aren't higher. Trans men and women are one of the most marginalized communities. Many aren't embraced by the gender with which they identify. Neither are they heartily embraced by -- nor do they necessarily identify with -- the gay and lesbian community.
According to Anna Travers, manager of the LGBTT (lesbian, gay, bisexual, transsexual and transgendered) program at the Sherbourne Health Centre in Toronto, it is important to ask what world the person comes from. "There are quite a number of MTF [males to females] who have come out of a straight marriage," points out Travers. "If you have lived in a straight world and you transition and you're still into women, in some ways you're going to be perceived as lesbian, but you have no experience of that community and you may not fit into that."
The program at the Sherbourne Health Centre, which has hundreds of trans clients, is one of a small but growing number of specialized programs across the country. These safe spaces are still largely associated with the gay and lesbian community, however, and are confined to Canada's largest cities (see Highway to health).
The Passing Lane
Out in the broader community, the single most important key to a successful transition is whether or not you "pass." Almost everything follows from that. But passing is complicated. Many of those who are most successful have gone through their transformations at a younger age.
Not passing can be devastating for trans men and women: many will be overlooked by prospective employers and, as a result, some will end up without money or a home. It's a vicious cycle, because a loss of income makes it harder to follow through on the medical steps -- from hormones to surgery -- that make it possible for many trans people to pass. Not passing can also present a real problem at shelters and on the street, and trans men and women are at much higher risk for experiencing violence. "It's a domino effect," says Christine. "Once you've been refused employment and housing, everything goes kaplooey."
For many reasons, a substantial number of trans women turn to sex work. For some, it's a way to make money to live or to put toward surgery. For others, it's a way of getting off the street at night. Still others choose sex work because they find it empowering. "It's incredibly powerful when you've been called a freak your whole life to then find yourself being desired," explains Rebecca Hammond, a researcher currently working on Trans PULSE, a large community-based project examining the challenges trans people face in accessing health and social services. (For more information on the project, go to www.transpulse.ca.)
Anecdotally, many people involved with the trans community agree that HIV infection rates are substantially higher among trans women sex workers than among other trans groups. The reasons are complicated. Certainly there are concerns that HIV education is lacking in the trans community but because solicitation is illegal, sex workers -- trans or not -- are often forced to get into a car quickly to avoid being picked up by police and before they have a chance to negotiate safer sex.
For groups of trans men, the issues may be somewhat different. "Some of them are vulnerable and have low self-esteem," explains Kyle Scanlon, trans programs co-ordinator at The 519, a Toronto LGBT community centre. Scanlon is also working on the Gay Bi Queer Trans Men's Working Group study, which involves interviews with trans men who identify as a gay or bisexual and have sex with men. "These men described how important it was for them to be accepted as men, to be desired as men, and that they might be willing to have unsafe sex to get it," notes Scanlon. He adds that, "Self-esteem is one of the largest factors as to whether someone has safer sex or not."
In the Driver's Seat
Access to health and social services is another huge issue for trans men and women, HIV positive or not. "Trans people get treated very badly even when they're going for routine things," says Travers. "They're asked inappropriate questions; they have a sore throat and someone's questioning them about genital surgery. It's brutal ... "
From the many trans men and women who use the Sherbourne Health Centre, Travers has heard that many health- and social-care providers are "extremely ambivalent, sometimes hostile, sometimes uncomfortable, sometimes unsure of themselves when working with trans people." Such ordeals set up a dynamic in which trans people avoid using the health-care system unless they're really desperate. "So you may not be getting health education, normal preventative tests and screenings and I guess it's a whole environment in which there's a feeling of a lack of entitlement to health," Travers adds. "When you feel that marginalized by a system, it's hard to have a substantial investment in it."
Finding a doctor can be a real challenge. According to Hammond, many trans people in Ontario travel to Toronto just to get healthcare; in Ottawa, there is only one doctor who sees trans patients -- and he's 70 years old. But there are ways to get help. In Quebec, Montreal's Project 10 maintains a trans health database of physicians, therapists and other providers who care for trans patients. HIV Edmonton maintains a similar list for trans people in Alberta. In British Columbia, Vancouver Coastal Health's Transgender Health Program provides services to any trans man or woman in the province, giving priority to those in an emergency or crisis situation, and to people who experience multiple barriers -- physical, geographic, linguistic and so on.
To find a trans-positive doctor, particularly if you live in a smaller town or city, Scanlon suggests looking for practitioners who have worked with people with HIV/AIDS and with those from the lesbian, gay and bisexual communities. "They may not have any experience working with trans people yet, but often they have proven themselves to be patient-centred, progressive and willing to research what they don't already know."
With some searching, HIV-knowledgeable doctors can be found, says Christine, who has had an excellent specialist for five years. "I need someone I can talk to and who will treat me as a human being," she says. "He listens to what I have to say and advises me." Christine found that other doctors told her what to do; her current doctor gives her all the options and she makes the decisions. "If you're HIV positive and have a doctor you don't like, get rid of him," she advises.
So, what happens when a trans person becomes HIV positive? Often, it's just one more thing on a very long list of things to deal with. "For a lot of people," Hammond says, "particularly given the number of challenges they experience, HIV is at the bottom of the list in terms of priorities."
Unfortunately, there's not a lot of information about how HIV and anti-HIV meds affect trans people specifically. Some anti-HIV meds are known to interact with the female sex hormones that some MTF trans people take to promote body changes. And, points out Travers, little research has been done on the long-term effects of hormones on HIV-negative trans people, never mind those who are positive.
For his part, Scanlon feels positive steps are being taken to support the trans community to make healthier lifestyle choices. The 519 hands out condoms and lube, holds safer sex workshops and support groups, and has put together The Happy Transsexual Hooker, an HIV/AIDS resource guide for trans sex workers. Much of this progress is the direct result of the trans community creating services for itself, says Scanlon, and the result has been better access to housing, healthcare and legal support as well as a place for trans youth to hang out and feel normal. But there's still a long way to go when it comes to meeting the needs of the trans community, he points out. "It's a real challenge just to be trans."
Photograph: Todd Pearson / Digital Vision