Gender Spectrum, Gendered Epidemic | Community HIV/AIDS Mobilization Project

Gender Spectrum, Gendered Epidemic:

The impact of sexism and gender discrimination

on women, gay and transgender people

in the HIV epidemic

When we look at who is most impacted by the HIV/AIDS epidemic in the United States and around the world, it becomes clear that gender plays a significant role in who is infected and affected. Although sex and gender play out differently depending on the national and cultural context, there is no doubt that sexism and gender discrimination are global phenomena that deeply affect the lives of women and girls, transgender people, and gay men. What does this mean for the HIV epidemic? What do gender and gender identity have to do with a person’s vulnerability to HIV/AIDS?

Tuesday, March 6th
6:30 - 8:30PM
LGBT Community Center
New York City

Speakers:
Melissa Hope Ditmore, Network of Sex Work Projects
Click here for PowerPoint presentation
Kenyon Farrow, Board Member, Queers for Economic Justice
Tracie Gardner, Women’s Initiative to Stop HIV (WISH-NY) - Legal Action Center
Click here for PowerPoint presentation
Bali White, Columbia University, Sylvia Rivera Law Project
Moderated by: Jalan Washington, Advocates for Youth, Harlem Health Promotion Center

Co-sponsors:

Center for Health and Gender Equity (CHANGE)
Gay Men’s Health Crisis (GMHC)
LGBT Community Center
Pro-Choice Public Education Project (PEP)
Queers for Economic Justice
Sylvia Rivera Law Project
Women’s Initiative to Stop HIV (WISH-NY) - Legal Action Center

Summary:

Welcome, Jalan Washington

I'm honored to be here tonight. Discussions on race and gender and HIV are very important to me. I have been working with young women of color and reproductive rights and HIV issues with Advocates for Youth for years, and it’s a pleasure to be a part of this forum. Thank you to all the co-sponsors of tonight’s event.

This discussion is on gender. Gender has a significant role on who is infected and who is affected by the epidemic. Although sex discrimination is a global phenomenon, it affects different people according to various locations and contexts.

Melissa Hope Ditmore, Network of Sex Work Projects

I'm the coordinator of an international network sex work projects. We deal a lot with gender discrimination against sex workers. I'm going to talk about international stuff mostly, and I'm going to talk about US funding policy and then specific nastiness concerning transgender people.

There are severe funding restrictions regarding sex workers because the US is the world's largest donor of HIV. One-third of it has to go to abstinence-until-marriage programming. Another condition on all this money is any organization that accepts the money has to have an organizational policy against prostitution. In effect, all their programming-- not just with US money-- absolutely everything that they do has to include this. Therefore, you cannot advocate for any legal reform of prostitution laws and no organizing (no unionizing). You can give out condoms but not much else.

So how have we seen this play out? There have been examples within a clinic for MSM in Bangkok, where known sex workers were verbally humiliated and expelled. The people who have the most trouble accessing services have been given an even harder time than they already have.

Organized sex workers in India are protesting an organization with US money that detained children of sex workers. Brothels were raided and these two children were kept out of school for two weeks--they basically kidnapped and detained them for weeks. One of the girls dropped out of school entirely because of the intense stigma. This is the sort of discrimination we see. This fifteen-year-old girl isn't even a sex worker.

In Cambodia there is a clinic that MSM go to whose families told them that they will go crazy if they have anal sex with men. They wanted to know from the doctor if this is true. The doctors, who get money from US, cannot give information to poor, gay men who sell sex-- many of them are homeless and they can't even ask a doctor who is funded to do this sort of thing for them.

The next picture [referring to slide] is a happy one. Sex workers in Bangladesh were not evicted from the brothel that they were threatened to leave. However, some of them had gotten trained through US funding to run clinics, and 18 of those clinics have closed. They don't have health care now.

In terms of transgender sex work, what we see now for gender and HIV in surveillance of HIV, is all the transgender women are being lumped with MSM. It is insulting that UNAIDS and the World Health Organization (WHO) would say that they are being lumped with their birth genitals. It disrespects all of these people's self-definition and autonomy. But there is a lot of impact for epidemiology that no one is talking about. At the Bangkok clinic for MSM, we know that HIV rates are shooting up, particularly among MSM. But one of the things we've seen, and it is only anecdotal, is that we can't tell from the data if transgender people have a higher increase in HIV rates. All the doctors think they do too, and so do the people attending the clinics, but they are just lumped in with men. We think the rates have gone up by 40%, but we cannot document this. This has serious issues by hiding an epidemic for transgender people. It means that there is no funding and no resources specifically devoted to transgender people. There is nothing for getting them health services. Hiding transgender women among men in the epidemiology means that there is no attention to anything that might complicate HIV treatment-- hormone levels, any kind of medical issues that come with transgender surgery or sex or stigma--are all not considered. This is a big gaping hole in HIV prevention and access to treatment for trans people worldwide. In the US we have it a little easier because people have been paying attention to gender identity and HIV for a long time. But what has just been starting has just been squelched in the rest of the world.

Bali White, student, Columbia University, board member, Sylvia Rivera Law Project

I’m a part of an organization called the Sylvia Rivera Law Project, which provides free legal advice for poor, trans people of color. I’m also a student at Columbia, and I recently worked with The Transgender Project as a research associate. Some of the work I do is with Indian trans sex workers. It’s appropriate that I’m following Melissa because I’ll add to much of what she has brought up.

Melissa talked about prostitution. She mentioned a large proportion of sex workers were transgender. Why is that? People might not be aware of the kind of stigma she mentioned. Transgender women of color usually come out in adolescence, and there is usually a reaction from family and schools. This sets up a cycle that results in them leaving those networks and having to fend for themselves with trans people of the same age bracket. They can usually only enter sex work to make a living. Because of that, the number of transgender people who are HIV positive is really, really high.

One of the things I wanted to talk about is the historical and global perspective. Often young trans women aren't even aware of it, which is one of the barriers to community organizing and programs. Often trans women are African American, Caribbean or Latina and they come from different parts of the country and world, which brings up issues of immigration. Because they have limited access to formal education, there are very few options they have as adults. They have limited access to medical resources and surgeries. Often because they are involved in sex work, there is some value placed on the "she male" identity—having a penis and breasts. What we found is that many women might be interested in completing surgeries but lack the resources and finances.

You can't talk about trans women of color and not talk about the house/ball community. The ballroom scene is not a space owned and controlled by transgender women; they are still at the mercy of gay men and what they should do with their bodies.

In terms of HIV prevalence and risks, there are not many studies about trans women and HIV, as Melissa mentioned. Part of the reason is that CDC places transgender people in the MSM category, and this is a barrier for funding for trans projects and for prevention programs. It is hard to outreach to them and use this antiquated language about like what they used to be 10 years ago. They're not going to hear you, there's a barrier there, and they won't be welcomed to that area. It's not a safe space for them. There are painfully high rates of HIV infection -- 35% in trans women in 2001. 63% of that population was African American. Often they didn't realize they were infected and had no or little access to care. Or the care was transphobic.

Why are transgender women more at risk? Isolation and shame. There is a hierarchy of people who pass at their target gender better than others. Those that don't are lower in the hierarchy. But the reality is that no one is 100% passable. There will always be a time that people realize that you are transgendered. Passing now for trans women is like African American people trying to pass as white if they could during Jim Crow. They’re not exactly the same, but it’s a similar situation. The murder of trans women is 2.3 per month on average and is 11 times the rate of a non-transgender woman. A lot of these murders happen with people they are involved with intimately, and isolation and shame exacerbates this. There is quest to be desired and loved, and this ties into the prostitution and sex work aspect. You look around at the passability thing and hierarchy of how you look and all the stigma, and I think this means that you're willing to do certain things that might be more hazardous to their health--like injecting or not using condoms. There is a real push for acceptance, and if it's tied into upping your number of tricks it makes sense that you would try to increase this number (bigger breasts = better, etc), and lots of times girls don't have access to legitimate surgeries like implants. Often they go to bad providers, which results in further health problems. Dissociation from their own bodies occurs, as do social marginalization and fringe existence.

If a transgender woman has been kicked out of her home and school and is in a relationship with a guy, then there is pressure for her to maintain a certain stereotypical role. She cannot discuss condoms openly. For trans sex workers, sometimes they use condoms for work and no condoms with their intimate partners. In terms of black market hormones, there is a push to overmedicate yourself with hormones to speed up the process, which can be dangerous. But also, it has to do with money. So we see a lack of targeted services towards transgender people. There are many LGBT organizations that add T but there's no outreach done for T. And lastly, there are many hostile and unknowledgeable providers.

Kenyon Farrow, Queers for Economic Justice

QEJ works around economic issues for LGBTQ people in NYC. We do leadership development in three projects: 1) Welfare rights campaign 2) Homeless LGBTQ work in shelters and 3) Immigrant rights project (national)--policy advocacy for LGBTQ immigrants, specifically around the HIV ban.

So, why am I, as a man, speaking on this panel about HIV and gender discrimination? From a black, gay male perspective, I think that men of color are impacted in particular ways by misogyny within a white racist society. If we consider that white men are the ideal of what it means to be civilized and appropriately masculine, and you look at the way that men of color are treated in that scope, we do not fit that ideal. Black men who are hyper-sexualized have complicated relationships with our bodies and our sexualities. At the same time, we perpetuate misogyny and transphobia within ourselves.

Richard Pryor used to tell this joke about "fucking faggot:" the reaction of the primarily black crowd. Everybody knows and likes him in the neighborhood. At the time there wasn't this revulsion. They were laughing out of a sense of knowledge, knowing that these things were happening in the black community. While uncomfortable, it was being acknowledged. You can see it in pop culture from the 70s and the early 80s in terms of black gay bodies doing disco and stuff. I remember when I was a kid, one of my mother's best friends, Uncle Roger, this big old queen, would go out in full drag in Cleveland, Ohio in the early 80s, and they would go to the bar. Everyone knew who he was. But something has shifted. HIV was one of those things that shifted our black community understanding of these differently gendered, even if male-identified bodies.

In the early 90s with the rise of ARV cocktails, the idea of the "Chelsea boy" and super buff jock and the whole aesthetic of the hyper masculine white gay man became more pervasive. People wanted to look healthy, virile, and strong because HIV was associated with death, wasting, and weakness. In the black gay community we had a similar thing-- yet it was the "thug." You see kids who came in fab glitter sequin outfits in the 80s switched up to timbs and fitteds in the 90s. This says something about HIV being associated with death and wasting but also being associated with being feminine.

That notion of HIV having a gender in a black male framework still pervades to this very day. In terms of black gay men, some of the qualitative data shows comments about being racially oppressed, being oppressed as black men and wanting to really be seen as a full part of the black community. Some of that I think is problematic because the language of black gay male -- even within organizing-- is why can't we just be men? And if it fits the masculinities I see on BET, I don't know if that's necessarily helpful. But there is this sort of need to identify and be accepted in problematic masculinities. People want to belong to the black community in a very specific way and this is real. HIV forces us to think about these things. At this point, we're not talking about behavior. At this point, with HIV rates as high as they are among black gay men, you're talking about structural issues and not just whether or not folks aren't contracting HIV because the kids didn't bring a condom on Saturday night.

The behavioral model is limited in terms of how it can be applicable. Feeling completely marginalized from the black community, religion (being alienated from the Christian church) and different levels of physical instability are all serious factors to consider. Issues of physical violence and safety impact people's mental health. The ability to move about the world and even create a community is compromised when the threat of violence is present.

Tracie Gardner, Women's Initiative to Stop HIV of the Legal Action Center

HIV prevention in the stepchild of the discussion about the "HIV industrial complex". When we talk about the gender spectrum and the impact of sexism, on women, gay and transgender people, what is the common denominator? The common denominator is sex with men—this is the common risk. At the local, state and international level, it is the dimension and interface between these three groups and men. The economic imbalance and the issues around an ability to negotiate equitable sexual relationships are key. HIV is the most visible evidence of gender inequities. Penetrative males have dominance and that impact is so globally clear. People talk about HIV as a women's epidemic, because we as primary sex partners of men, are at risk by virtue of this. But this also obscures the fact that anyone--whatever identity, whatever gender, is at risk.

"Women in Peril": NY State AIDS advisory council. This report got started with reporting of HIV. In newly diagnosed cases between 2001 and 2003, 48% of the cases in 13-19 year olds were girls. Why did this happen? In 20-24 years old, 43% are girls. Equalization of male and female cases is pretty unusual at this stage of the epidemic. We hadn't looked at women and HIV since the early 1990s. We developed standards of care around women in their childbearing capacity, and that's the last time we looked seriously at women in terms of HIV prevention and treatment. Where the numbers also spike are among women in ages 40 and higher. That's an interesting skew because women from 25-40 are okay. The reason why is we have made a great inroad there. We can prevent perinatal transmission mother-to-child. Almost no babies are born with HIV in this country. The hospital is liable if they don't talk to you about HIV and you’re pregnant. But if you're younger than that, or older than that, no one is talking to you in a routine way about HIV--so why are we surprised that HIV spikes are there?

You are out of that 20-year marriage and back into the dating scene. Your doctor is not talking to you about it. You get a mammogram and that's it. Either way, these women are being done a disservice. With no methods beyond condoms, we cannot control what happens to us in each and every sexual encounter. And I did inquire about having condoms sewn on during circumcision, but there is no way to ensure.

The HIV testing that we talk about is "responsible" or "not responsible." The people who are "not responsible" are young women, young men, and trans people for whom no providers have any competency. The challenge, as we try to break out of the silos, are that our lives are cut across many of the silos. They want to see only MSM. They want to see only IDU (intravenous drug users). They want to see only girls. Everything that is in-between gets lost. The other endemic health problems are those who fall outside of the need categories. Unless we continue to have these kinds of forums where we can talk about the cross section of our issues-- we're either gay or pro-choice, we don't stand a chance of getting what we need. We are ripe for divide and conquer and that's part of the reason why we're in the state we are in now in 2007.

Questions and Discussion

Question: As far as doctors who carry out trans surgeries, is there a trans rights organization or any resource referral guide?

Bali: Check out the gender identity project at the Center. There is a group that meets weekly too here. When we talk about implants, it's expensive and girls can do that when they have access to resources. But it's much faster to do the injections. Word of mouth is very powerful for trans people, but a lot of times doctors don't advertise that they provide services for transgender people. Silicone injecting is free floating and not in bags. Just injected into flesh and not in protective casing, and before there was a chance they would burst. Transgender women are a throwaway community for most people. There was a big fear around not using clean needles, and sometimes they repeat use the needles. The main health problem is the act itself even if the needle is clean.

Question: I think that Tracie aptly pointed out the problem. I'm a doctor who works with women and some trans folks, and the one thing you always end up talking about is relationship dynamics. You're talking about relationships of self-esteem and control, and in poor communities it is exacerbated, regardless of what background you are. And men who are usually the ones who are the penetrators, they have a lot of the same issues that they're also compensating for. I keep seeing a theme and I don't know how to say it but it's just skills in dealing with relationships. How do you take that to a mobilization level? Identity within relationship taken to a community or advocacy level is a little more difficult and complicated to do.

Tracie: I would just point out a different layer that I didn't get to address. If it's Bed-Stuy or Soweto, there are the same issues. When we talk about equality of relationships is the whole dynamic of age. Older and younger. And age, older men and younger women. Older men and younger men. Young gay men or young MSM – the same issues of partner violence, lack of resources, fear around reporting-- (statutory rape in the context of a consensual relationship)-- how do we get at that? It's also cultural. When we talk about black women, a lot of them are foreign born. An unaddressed area, and this is not about any more demonization of men of color, but our men tend to be more experienced with the criminal justice system. It's not about men but it's about how do we get men into the dialogue. What is the man's organization that you can get into?

Bali: The issue of men is central. But for trans women, men who are partners of trans women are invisible and overlooked. Part of that is because there is confusion about the men who have sex with trans women-- there are all kinds of barriers when people approach them in that way. In one focus group, there were six men who had sex with transgender women-- 45 to 25-- and they had never been in a room with other men who have sex with transgender women. A lot of times they were ostracized for having relationships with these kinds of women, and they might feel only comfortable in gay bars. It sets up a dynamic that can be explosive.

Kenyon: I would just add in terms of dynamics of power among older and younger, we also have to deal with a real sense of longing and people wanting very much to be in intimate, loving relationships even if what they have doesn't look like that. When they project that on someone else the relationship is complicated and people may give up things-- not asking that person to wear a condom-- but we cannot lose the sense of wanting to be loved.

Also, I have a gay doctor of color who is great. Particularly early on when I started going to him, the first time I met with him, he would ask: What's going on in your life? Where do you work? He would ask about relationships and stuff not related to my physical. There was that level of rapport, which was key.

Comment: Wanting to be loved is a basic need for people. When abuse happens it's because someone seems like they love them. That's a reality we have to talk about. I also think that as Tracie said there are a lot of people who should be indicted around this are parents and schools. New York State has a law that says there should be 6 classes a year around HIV. They say this is the law, but no one does it. We don't want to talk about the difficult questions: Men have to be a part of this conversation. Sexism doesn't change until men change sexism. Poverty doesn't change until rich people change poverty. Racism doesn’t change until white people change racism. People have to change the conversation. People have to say: This is wrong. The challenging thing about parents is we teach our sons to be sexist. Your fifteen-year-old son has three girlfriends and you laugh at him. For your daughter you tell her no. And so much of this is about men's satisfaction. In Albany they're getting theirs. It's a band-aid on a gaping wound. The men in power will get it twice as much because they are getting theirs.

Question: What culturally is going on here? What are these organizations dealing with health and HIV looking at in terms of new models and ways to talk about cultural issues related to HIV prevention and education? They teach people how to put on condoms but not really being able to and not knowing how to deal with murkier issues and talk about power dynamics? You also have religion in that.

Kenyon: Some of it is cultural but I think it is more structural than cultural. If you look at the project called the Black Youth Project out of University of Chicago. 1600 black youth were interviewed about everything-- education, politics, voting, sex, sex education, etc.-- and one of the things that was clear was the vast majority of these youth very much value education and saw a need for comprehensive sex education and condom availability in their schools, nationwide. Nobody ever asks them what they think. Decisions around condom availability are determined by people who don't live in those school districts and to me that's a structural issue, it's not about people not valuing those things. These white folks in Westchester or whatever don't think that any of us should be able to have this conversation or be able to access these things because of their own mores.

Melissa: My question is about revolution. Special interests are little boxes. If you're not in these little boxes then you're not there. But how do you get into people's lives? A sex worker is in your neighborhood, in your community. It is getting to the question of working together politically and taking it to political power and fighting for the resources that are cut and cut and cut and cut. Are we all members of society or are we a particular minority that is adjacent to society? That's the revolution that I want to get to.

Question: I have a concern with the concept that the prevailing issue is sex with men. I work mostly with LGBT people and I feel that there is a large portion of female-bodied people who feel that having sex with other female-bodied people is safe. There are not a lot of safer sex techniques being taught despite whatever the gender identity of these people might be. Women aren't considered to have sex, like sex, enjoy sex if there isn't a man present. Until we teach females and female-bodied people that they can be comfortable with their bodies, they won't be receptive to safer sex techniques until a man is present.

Kenyon: I think there is an invisibility of HIV+ lesbians. Not even just in terms of sex, in terms of drug use too. You go to 125th street where there are 2 methadone clinics and you see black and brown butches going there every day.

Question: How does information get out to the community? How do you get your information out? My agency works with the AIDS Institute. Most of their clients get income through SSA, HRSA. We need to reach out to the people who are affected; information is not getting to the right areas.

Melissa: You have to make it easy for people to come to you for information. If that means that I go to Jackson Heights at 4 in the morning to hand out condoms, at Roosevelt and 74th, then I'm there. It's not easy and it's not fun. One thing that is really successful for sex workers is having events in beauty salons. Having an event at a manicure place gets a bigger turnout than a sterile office building. You have to keep the same hours that people keep at least some of the time.

Jalan: I just want to get back to the intersectionality that Tracie is speaking to. I don't think that we're preaching to the choir here.

Tracie: I would just say that this comes up a lot. I do a lot of work lobbying crusty old white men. They don't get it. It's 2007 and AIDS rages on. There is a mentality of "what the fuck is wrong with these people who are still getting infected?” While they're sympathetic and concerned (about girls), this is what I say, "it could be a birthright for any black or brown girl who chooses to have sex." And they say, okay. There is a sense of there's nothing we can do if these numbers can persist. Some of them have not been educated about HIV prevention and girls. We have always been queasy about talking about sex and women, women and prison, women and addiction. My organization—the Legal Action Center—focuses on criminal justice and addiction. HIV is there but our clients come for criminal justice and addiction, and we bring in the HIV issues because we know that is on the table for these folks. One good idea is to do cooking school, after school programs, or support groups where you talk about clothes. Then you bring in the HIV on the side. We talk about cultural issues, but we have to change the cultural value. Each one, teach one. If I hang around with a whole bunch of women who think Head Start is important, then women are sending their kids to Head Start. Hopefully we can instill our own cultural value into whatever we do.

Question: I'm doing research on college kids and outreach. What are ways to get across concrete information effectively to this population?

Kenyon: I feel like HIV on black college campuses is becoming a very critical issue. I'm going to take up Tracie's suggestion to throw a party. Build it into some other kind of activity that people value and you bring the stuff with you. I used to a lot of prison organizing and nobody wants to see someone with handcuffs on the flyer. We do these things like, show the people how oppressed they are because it seems powerful. But people know that and that's depressing and they're trying to party, so a new framework has to develop in order to engage folks in different messages. Instead of saying, "You should come to this HIV thing because you need it..."

Question: I hear a lot about research studies, and I get excited about new numbers and stuff. I get frustrated when there's no study that asks, "Why did you test positive?" Knowing that question will be a much better tool for prevention people to use than for "46% of you are positive." This is really useful for people to know-- the mistakes that people have made. If you know any research on this, let me know. Also regarding spending the time in Albany, I want to say we need to do this for ourselves and find our freedom. We never found our freedom relying on power structures.

Kenyon: This is a difficult question, but this may not necessarily solve the problem. There's a lot of blame. A lot of it is structural. There’s the whole question of throwing money at the problem. That’s what rich people are doing when they send their kids to private school. And it works. And I agree that we have to be self-reliant but also the government has some responsibility here and we should hold them accountable.

Question: At community health centers, there is a big push to be "culturally competent." We're working with really diverse groups of people. If you blame it all on structure it obscures this. Also working with youth. People don't know how HIV is transmitted. The basic information is not out there. I'm the only white person who they see all day, but they respect me or listen to me and I want to do what is safe to them.

Kenyon: Cultural competence is still a structural intervention.