Transphobia Impact on HIV Health Care Lydia A

Overview It’s 2007! Updating Our Lens and Language n HIV in the Trans Community

Moving Beyond A Binary View of Trans n Most historical and medical literature categorized Transgender/Transsexual people into only 2 boxes: n Male to Female (MTF) n Female to Male (FTM) n Today we know that Trans includes a wide variety of different gender identities (over 100 have been documented). ¹²³� n Let’s talk about trans people in more inclusive ways than simply re-creating another 2 box system. Reference: ¹ Grossman & D’Augelli (2006). ² Vade (2005). ³ National Center for Transgender Equity (2005). �Kreative Korporation (2006). Copyright 2007 Lydia A. Sausa 3

Quick Question! Have you ever had a gay man come out to you? Copyright

Did he say… n A) Hi, I’m gay. n B) Hi, I am Hetero-to-Gay.

Updating Our Language n Let’s stop using language that forces trans people to state what others assigned them at birth, and may no longer be relevant to them now. n Focus on a person’s present identity n Cheat sheet for the “special people”: n n Male to Female (MTF) = Transwoman or female Female to Male (FTM) = Transman or male Copyright 2007 Lydia A. Sausa 6

True or False? The rate of HIV reported among transwomen is lower than that

False! HIV prevalence among transwomen is higher than estimates from studies with gay men, as well as injection drug users of the same age in San Francisco. ¹ Reference: ¹Clements, K. , Marx, R. , Guzman, R. , & Katz, M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health, 91(6), 915 -921. Copyright 2007 Lydia A. Sausa 8

MSM & Transwomen n In 2005, the San Francisco Department of Public Health reported that based on estimated population size for 2006 that about 1 in 4 MSM (24. 3%) and transwomen (22. 8%) are living with HIV. ¹ n n Caveat: Population size for trans people is often underestimated, since many trans people do not feel comfortable coming out Most striking, the incidence for new infections estimated for 2006 is higher for transwomen (3. 78%) vs. MSM (1. 75%), and especially for transwomen IDU (6. 08%) vs. MSM IDU (2. 58%). ¹ n Thus, transwomen are 2 times (2. 16 - 2. 35) more likely to contract HIV compared to MSM. References: ¹ San Francisco Department of Public Health (2005). Copyright 2007 Lydia A. Sausa 9

HIV Among Trans People n Estimated 1 in 250 people are living with HIV/AIDS in the United States, and 24 -27% are undiagnosed or unaware of their HIV infection. ¹² n The trans community is disproportionately affected by HIV. 6 n For transwomen is estimated about 1 in 4, mostly transwomen of color. ³ �� n African-American (35 -47%) and Latina (23 -28%) transwomen have the highest prevalence in San Francisco, compared to other racial/ethnic groups. ³� n For transmen is estimated 1 in 50, mostly trans. MSM and transmen who engage in sex work and/or injection drug use. � � References: ¹ Centers for Disease Control and Prevention (CDC) (2006). ² Glynn & Rhodes (2005). ³ San Francisco Department of Public Health (2005). �Bemis, Simon, Reback, & Gatson (2000). �Clements, Marx, Guzman & Katz (2001). 6 Nemoto, Operario, Keatley, Han, & Soma (2004). �Xavier (2005). Copyright 2007 Lydia A. Sausa 10

Transphobia A discomfort with or fear of trans people, or an inability to accept

Transphobia on Many Levels Self - internalized transphobia, low-self-esteem and self efficacy. For example: “I can’t leave an unhealthy relationship/employment because I won’t find someone/something else since I am trans. ” Interpersonal Level - specific acts of discrimination, bias, lack of acceptance. For example: A family member telling you to hide who you are or that you are confused; A person being hostile toward you about using the bathroom, dressing room, or other gender segregated space; A health care provider refusing you service. Copyright 2007 Lydia A. Sausa 12

Transphobia on Many Levels Community/Societal Level – norms, resources, access to services or events. For example: Deaths of Tyra Hunter in DC and Robert Eads in Georgia due to lack of health care access; Michigan Women’s Music Festival not allowing transwomen to attend; Stating that trans people are all MTF or FTM. Systemic/Institutional Level - legal, policy, religion. For example: Shelters not allowing trans people; The “transpanic defense” as a legal defense to killing a trans person as was allowed in the Gwen Araujo Murder Trial. Copyright 2007 Lydia A. Sausa 13

Impact of Transphobia on Health Care & HIV n Impact on the Patient/Client: n Lower self-efficacy and self esteem¹ n Higher rates of depression, sucidality, self-mutilation²³ � n Lower adherence to HIV medication� 6 n Higher rates of violence, drug use, HIV risk behaviors²� � n Avoiding care for preventive and urgent/life-threatening conditions� References: ¹ Clements, Wilkinson, Kitano & Marx (2001). ² Sugano, Nemoto, & Operario (2005) ³ Newfield, Hart, Dibble, & Kohler (2006). �Clements, Marx, Guzman & Katz (2001). �Melendez, Exner, Ehrhardt, Dodge, Remien, Rotheram-Borus, Lightfoot, Hong, et al. (2005). 6 Sausa (2006). �Nemoto, Operario, Keatley, Han, & Soma (2004). �Shaffer (2005). Copyright 2007 Lydia A. Sausa 14

Impact of Transphobia on Health Care & HIV n Impact on the Provider: n Lack of knowledge, comfort, and skills to provide care to trans people¹²³ n Disregarding health policies and laws that regulate 6 health care access and service can lead to job loss�� n Poor provider service can lead to negative reputation of the clinic/organization and may jeopardize funding� References: ¹ Nemoto, Sausa, Operario, & Keatley (2006). ² Clements, Wilkinson, Kitano & Marx (2001). ³ Grossman & D’Augelli (2006). �Shaffer (2005). �Mottet & Ohle (2003). 6 National Center for Transgender Equity (2005). �Hussey (2006). Copyright 2007 Lydia A. Sausa 15

Impact of Transphobia on Health Care & HIV n Impact on the Health Care System: n Higher rates of HIV transmission and AIDS cases n Higher rates of morbidity and mortality n Additional financial burden on the system Copyright 2007 Lydia A. Sausa 16

References Bemis, C. C. , Simon, P. A. , Reback, C. J. , & Gatson, B. (2000). Relationship between selfassessed HIV risk, self-reported risk behavior, and HIV seroprevalence in a male-tofemale transgender population. Los Angeles, CA: Health Research Association, Health Assessment and Epidemiology, & Van Ness Recovery House. Centers for Disease Control and Prevention (2006). HIV/AIDS Surveillance Report, 2005. Vol. 17. Atlanta: US Department of Health and Human Services, CDC; 2006: 1– 46. Clements, K. , Marx, R. , Guzman, R. , & Katz, M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health, 91(6), 915 -921. Clements, K. , Wilkinson, W. , Kitano, K. , & Marx, R. (2001). HIV prevention and health service needs of the transgender community in San Francisco. In W. Bockting & S. Kirk (Eds. ), Transgender and HIV: Risks, prevention, and care (pp. 69 -89). New York, NY: Haworth Press. Glynn, M. & Rhodes, P. (2005). Estimated HIV prevalence in the United States at the end of 2003. National HIV Prevention Conference; June 2005; Atlanta. Abstract 595. Copyright 2007 Lydia A. Sausa 17

References Grossman, A. H. & D’Augelli, A. R. (2006). Transgender youth: Invisible and vulnerable. Journal of Homosexuality, 51(1), 111 -128. Hussey, W. (2006). Slivers of the journey: The use of photovoice and storytelling to examine female to male transsexuals’ experience of health care access. Journal of Homosexuality, 51(1), 129 -158. Kreative Korporation (2006). Accessed June 1, 2007 http: //www. kreativekorp. com/miscpages/gender. pl Melendez, R. M. , Exner, T. A. , Ehrhardt, A. A. , Dodge, B. , Remien, R. H. , Rotheram -Borus, M. , Lightfoot, M. , Hong, D. , and National Institute of Mental Healthy Living Project Team (2005). Health and health care among male-to-female transgender persons who are HIV positive. American Journal Public Health, 95(10), 5 -7. National Center for Transgender Equity (2005). California transgender bills signed. Retrieved October 11, 2005, from http: //www. nctequality. org/California. Sept 2005. pdf Copyright 2007 Lydia A. Sausa 18

References Nemoto, T. , Operario, D. , Keatley, J. , Han, L. , & Soma, T. (2004). HIV risk behaviors among male-to-female transgender persons of color in San Francisco. American Journal of Public Health, 94(7), 1193 -1199. Nemoto, T. , Sausa, L. A, Operario, D. , & Keatley, J. (2006). Need for HIV/AIDS education and intervention for MTF Transgenders: Responding to the challenge. Journal of Homosexuality, 51(1), 183 -202. Newfield, E. , Hart, S. , Dibble, S. , & Kohler, L. (2006). Female-to-male transgender quality of Life. Quality of Life Research, [Epublished ahead of print] PMID: 16758113. Mottet, L. & Ohle, J. M. (2003). Transitioning our shelters: A guide to making homeless shelters safe for transgender people. New York: The National Coalition for the Homeless and the National Gay and Lesbian Task Force Policy Institute. San Francisco Department of Public Health (2005). HIV/AIDS epidemiological annual report. San Francisco, CA. Accessed June 1, 2007. http: //www. sfdph. org/PHP/Rpts. HIVAIDS/HIVAIDAnnl. Rpt 2005. pdf Copyright 2007 Lydia A. Sausa 19

References Sausa, L. A. (2006). Translating research into practice: Trans youth recommendations for improving school systems. Journal of Gay and Lesbian Issues in Education, 3(1), 15 -28. Shaffer, N. (2005). Transgender patients: Implications for emergency department policy and practice. Journal of Emergency Nursing, 31, 405 -7. Sugano, E. , Nemoto, T. , & Operario, D. (2006). The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behavior, 38(3), 230 -236. Vade, D. (2005). Expanding gender and expanding the law: Toward a social and legal conceptualization of gender that is more inclusive of transgender people. Michigan Journal of Gender and Law, 11, 253 -316. Xavier, J. , Bobbin, M. , Singer, T. B. & Budd, E. (2005). A needs assessment of transgendered people of color living in Washington, DC. International Journal of Transgenderism, 8(2/3), 31 -47. Copyright 2007 Lydia A. Sausa 20