Perception is everything. Are you a boy or a girl? Blue or pink? People view you as male or female, and this view is crucial to the way our society thinks, identifies, categorizes and defines each other. It's woven into the fabric of our daily existence, and God help anyone who challenges this two-party, male/female system. History has shown that you will be beaten verbally, spiritually, emotionally and/or physically if you challenge it.
Rosalyne Blumenstein, Director of the Gender Identity Project (GIP) at the Lesbian and Gay Community Services Center, and a female of transgender experience remembers, "When I was a child, I was told boys don't play with dolls and to stop crying like a girl. I thought the way I was, was wrong. Most transgenders experience a sense of difference at a very early age, and that this difference is wrong. If you don't fit into your category (boy or girl), you're going to internalize that there's something wrong with you."
Some transgender people defy categorization. This tends to disorient people who need to neatly define the world. According to Rosalyne, many people ask transgenders why they aren't either a man or a woman, and if they are unhappy with their gender, why they don't just have a sex change? When a transgender has a sex change, people then say, "but you're not a real woman or man." Nora Molina, a peer educator at GIP and a self-identified Hispanic transexual woman adds, "We are looked at as neither female nor male . . . we are treated like a foreign entity, a freak of nature." (Note: Rosalyne explained that one "s" in the word transsexual has been dropped to depathologize the word, and to empower and embrace the community).
What defines a real woman or a real man and who makes up these definitions? What happens when a transgender person becomes HIV-positive and stigma is placed on top of stigma?
Definition of Transgender
GIP, along with many other service providers, uses the term transgender as an umbrella term encompassing a diversity of gender expression including drag queens and kings, bi-genders, crossdressers, transgender people and transexuals.
Transexuals are defined as people who find their gender identity -- their sense of themselves as male or female -- in conflict with their anatomical sex. Some transexuals may live part-time in their self-defined gender. Many desire to live fully in their self-identified gender. Some undergo hormone therapy and sex reassignment surgery.
Because of stigma, many transgender people who have been marginalized and oppressed have difficulty with self-acceptance and live secret lives. Rosalyne, Nora, and Arbert Santana, the assistant coordinator of the House of Latex Project at Gay Men's Health Crisis, agree that one of the keys for transgender people to take better care of themselves is empowerment. It is also the foundation of GIP's mission.
Having "out" role models "seen" in public will help to change the stereotypes and is a big part of what GIP tries to do. According to Rosalyne, "Being out challenges the face of pathology and stigma that surrounds transgender people. People like RuPaul are doing wonderful things for part of the transgender population because they are out and they are successful and they are not pathologized."
Gaining accessibility to information and resources is a big part of the empowerment process. Arbert is Mother of the House of Latex and works with the House/Drag Ball Community -- a predominantly African-American and Latino group of young people who are gay, lesbian, bisexual and transgender. He says, "Information doesn't get filtered down to these young people. Their information is going to come from their sisters and from the black market on 125th Street."
As soon as a person of transgender experience walks into an office to access medical services, the male/female question comes up. Do you have a penis or a vagina? Being identified by others as a gender, other than how you identify yourself, can be humiliating, embarrassing, and hurtful. This alone can keep many transgender people out of medical service providers' offices.
Nora, Arbert and Rosalyne all recommend that transgender people tell their service providers, if they can, the personal pronouns (he or she) they prefer others use in addressing them. "Introductions are important," says Nora, "How you feel on the inside is identified by the words you call yourself and you allow others to call you."
Not all transgender people need to interact with the medical community around being transgender. The two main areas transgender people address with the medical community are hormone therapy and sexual reassignment surgery. Being HIV-positive makes each of these that much more difficult to obtain.
When it comes to being HIV-positive, hormone therapy for a transexual (pre-operative) can be a crucial issue. Rosalyne believes a transexual male-to-female should be on hormone therapy. She uses treating depression with prozac as an analogy: "There's an imbalance in the brain, and prozac helps people to feel a sense of balance: it relieves the imbalance. Hormone therapy can do the same thing for a transgender person. The stress and turmoil of this imbalance in a person can be like poison. Producing testosterone because you have testicles producing male hormones creates tension."
Hormone treatments can be taken three different ways: orally (pill form), intramuscularly (with a needle in liquid form) and transdermally (through the skin with a patch). Ideally, all three forms of hormones should be prescribed by a physician.
Estrogen therapy can cost from $60 to $100 each month. There is little information available on either women or men who have taken hormone therapy for long periods of time (for example, over thirty years to a lifetime). There is also little information available about the drug interactions between antiretroviral therapies (e.g., AZT, ddI, ddC, and 3TC) and the different kinds of hormone therapies, to say nothing of the newer drugs like protease inhibitors. "A young HIV-positive femme queen who starts AZT therapy," says Arbert, "and starts to have . . . side effects, might have to make a decision about whether to continue treatment, and which treatment to stop. This brings up large emotional issues about being able to finish the process -- of being able to fulfill your dream of gender reassignment -- and we need more information about this so people can make better decisions."
Insurance companies will not cover hormone therapy for transgender people because, according to them, it is an elective therapy, not a necessary therapy. Because of this, many transgenders are forced to get their hormones on the street. Although Rosalyne doesn't recommend it, she acknowledges that, "It's easier to get hormones on the black market, but you also don't know what it is you're getting." The realities are clear for transgender people who don't have the money for or access to the medical community.
Rosalyne recommends that hormones be taken orally as opposed to intramuscularly, because you avoid the difficulties of having to obtain, use and clean injection equipment. For someone who is HIV-positive, this can be especially important because at its most basic level, a needle leaves a hole in the skin -- a hole through which invaders can enter the body. The needle used for hormone injections is considerably larger than those used for other drugs. Needles need to be cleaned (sterilized with an alcohol soak or in boiling water, or with a bleach kit) after each use and should not be shared. If they are going to be shared, they need to be cleaned between each use.
Books like The Pill Book, An Illustrated Guide to the Most Prescribed Drugs in The United States, published by Bantam Books, have been used by transgender people to find out how a specific drug should look. "If you're buying on the black market, know what your pills look like," says Rosalyne. "Try to be an educated consumer."
Sexual Realignment Surgery
Rosalyne calls the operation sexual realignment surgery as opposed to its official name, sexual reassignment surgery (SRS). "Realignment is much more empowering. It's saying you're just moving around pieces that were there that need to be in a setting with which you feel more comfortable. Realignment is better than saying 'male turns into female, female into male' as if it were front page news."
SRS is considered an elective surgery by the medical profession and by insurance companies, and therefore is viewed as a non-essential surgery. As with hormone therapy, insurance companies won't pay for SRS.
The estimated cost for a male-to-female SRS is from $7,000 to $15,000. The female-to-male SRS is considerably more - ranging from $40,000 to $70,000. Most medical professionals consider the surgery to be too intensive a blow to the immune system for surgeons to perform on people who are HIV-infected. Service providers disagree. "Number one, it's not a 10-hour operation," says Rosalyne, "and number two, the amount of stress involved in living with a body that doesn't conform to who you are is probably much worse for the immune system over time. Elective versus necessary surgery becomes critical when talking about stress reduction. This is necessary surgery. Why not perform a surgery that's going to provide more self-acceptance and reduce my stress?"
Mental Health Services
The first barrier a transgender encounters when trying to access mental health services, is the language that the mental health community uses to define them. The DSM3 classifies transgender people as having Gender Identity Disorder. "And when you're told you have a disorder, you sort of embrace it," says Rosalyne. Transgender people are pathologized before they even walk into a mental health practitioner's office.
"When we changed the language around (with regard to HIV) and said you can live with HIV (instead of dying from it), some people stopped taking it as a death sentence" says Rosalyne. "The stigma wasn't lifted but more people started going on with their lives and not dying from it." Just as being gay or lesbian is no longer looked upon by the mental health and medical communities as being a pathological disorder (having been removed from the DSM3), the same thing needs to be done with regard to being transgender.
In seeking group support services regarding HIV issues, should a transgender person ask to be placed in a men's group, a women's group, or a transgender group? The rule of thumb is try to find a group in which you will feel most comfortable, whether it's male, female or transgender. Ask people to call you he or she, as you feel most comfortable being identified.
For many transgender people, the first obstacle they encounter at a drug treatment center is "the bathroom question." Which bathroom do you let "them" use? And then, with whom do you let them room? Many transgender people simply leave and never return while staff tries to figure out the answer to these questions.
When talking to service providers about this issue, Rosalyne confronts them with, "Why are you looking over the bathroom stalls to see who has a penis and who has a vagina? Why aren't you doing what you should be doing, and get the hell out of the bathroom? Why can't you just allow people to use the bathroom they are most comfortable using?"
Another ideal would be for the transgender to fight for the right to attend a transgender specific support group, while still in treatment at an outside location (such as at GIP) so, "you can feel a sense of okayness. Don't buy into the bullshit that says you're not worthy," Rosalyne reminds her clients.
Programs like GIP have been slowly educating staff at treatment centers, and many places are open to being educated about transgender issues. Twelve step programs can also be helpful in a number of ways. According to Rosalyne, they can be safe havens where you can talk, people won't do anything but listen, and everybody can have a chance to speak.
For those who are HIV-positive, there are programs out there that will be transgender-friendly. The problem is, you have to find them. Treatment programs won't come to you, and they are too few and far between. Still, there are some out there. "Find the places that are going to be supportive, ones that will treat you the way you deserve to be treated," says Rosalyne.
"We must be an amazing group of people," says Rosalyne, "because we are still out there living. Empowerment is about letting the public know that we do exist. It's about telling myself, and others, we're not going to take the abuse anymore."
Joe Lunievicz is Assistant Director of Training for the National Drug Research Institute and an avid rugby player.