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Transsexual and transvestite sex workers

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Transsexual and transvestite sex workers sexuality, marginality and HIV risks in Miami
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Bay, James Alvah, Jr., 1959-
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xii, 243 leaves : ill. ; 29 cm.

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African Americans ( jstor )
AIDS ( jstor )
Condoms ( jstor )
Disease risks ( jstor )
Hispanics ( jstor )
HIV ( jstor )
Human sexual behavior ( jstor )
Sex workers ( jstor )
Transsexualism ( jstor )
Women ( jstor )
Anthropology thesis, Ph.D ( lcsh )
Dissertations, Academic -- Anthropology -- UF ( lcsh )
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bibliography ( marcgt )
non-fiction ( marcgt )

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Thesis (Ph.D.)--University of Florida, 1997.
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Includes bibliographical references (leaves 223-242).
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Typescript.
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Vita.
Statement of Responsibility:
by James Alvah Bay, Jr.

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TRANSSEXUAL AND TRANSVESTITE SEX WORKERS: SEXUALITY, MARGINALITY ANT) HIV RISK IN MIAMI










By

JAMES ALVAH BAY, JR.














A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA

DECEMER, 1997
























Copyright 1997

by

James Alvah Bay, Jr.
















ACKNOWLEDGMENTS


I wish to first express my gratitude to the 50 individuals who chose to place their trust in an outsider, and to participate in this study. They were willing to divulge extremely sensitive and personal information, and to place themselves at risk though I could promise little in return. I sincerely appreciate their confidence, and will do my best to repay what I gained from them.

I would also like to thank the members of my supervisory committee at the University of Florida for their encouragement and guidance throughout my graduate career. Dr. Leslie Sue Lieberman has made a substantial contribution, and I very much appreciate her commitment, expertise, and tireless involvement with my thesis and dissertation research. Dr. Allan Bums, Dr. John Moore, Dr. Brian DuToit, Dr. Elizabeth Gufllette, and Dr. Steve Dorman have individually influenced my growth in many ways, and I would like to express my deepest gratitude for their generous efforts and encouragement. I would also like to express my thanks to the Department of Anthropology, particularly for the several teaching opportunities I was afforded while in Gainesville.

I gratefully acknowledge the Centers for Disease Control and Prevention and the

Florida Department of Health for making a number of crucial resources available. Yusef Junquera, Donovan Floyd and Joe Delgado made important introductions to community members, and Ivan Bernstein and Susan Biersteker both made valuable contributions to









this effort. I am grateful to them for their help and friendship. I also wish to express my sincere appreciation to my friend and colleague, Dr. David Forrest, for his constant encouragement. Finally, I gratefully acknowledge the influence of family members, particularly my parents, and many friends, who remained supportive throughout this process.









































iv













TABLE OF CONTENTS
ga e

ACKNOW LEDG M ENTS ............ ..................................................................... iii

LIST OF TABLES ............................................................................... ............ Vii

LIST OF FIGURES ........................................................................................... viii

A B S T R A C T ...................................................................................................... ix

CHAPTERS

I INTRODUCTION ....................................................................................... 1

2 LITERATURE REVIEW ............................................................... ............ 6

Gender Variation: Expression ...................................................................... 6
Gender Variation: Etiology ........................................................................... 14
Anthropology and the HIV Epidemic ............................................................ Is
Theoretical Approaches ...................................................................... ........ 20
Commercial Sex ........................................................................................... 25
Transsexual and Transvestite Sex W ork ...................... ........................... 28
Clients of TTSW s ................................................. ................................ 3 3
Body M odification .................................................................................. 35
HIV/STD, Epidemiology .................................................... ......................... 3) 6

3 STUDY DESIGN AND METHODS ............................................................. 44

S tu dy D e sig n ................................................................................................. 4 4
Sampling M ethodology .................................................................................. 46
Data Collection Instrument .................. I I ........................ .......................... ... 47
Enrollment and Data Collection ................................................................... 52
Data Analysis .................... ................................................................... ...... 56
Project Timeline ............................... ............................................................. 57
Language and Terms ........... ........................................................................ 57

4 F IN D IN G S ........................... ....................................................................... 5 9
Demographics and Background .................. .................................. ............. 59
Lifetime Sex" Behaviors ............................................................................ 65
Six-month Sex with M ales ............................................................................ 68


V









Sex with M ale Exchange Partners .................................................... ............ 71
TTSW Venues ............................... ............................ ............................. 71
Sex W ork Initiation ................................................................. ....... ........ 75
Occupational Behaviors and Clients ........................................................... 77
Positive and Negative Aspects of TTSW ................................................... 88
Risk Reduction with Exchange Partners ...................................................... 93
Sex with N on-Steady and Steady Partners ..................................................... 98
Sexual Attraction and Relationships ................................................................ 101
Sex with Females ........................................................................................... 102
M edical Considerations .................................................................................. 104
Health Care Access .................................................................................... 104
STI) and HBV Vaccination History ........................................................... 105
HIV/AID S Experience and Perceptions ..................................................... 106
HIV, FIBV and Syphilis Results ................................................................. III
Alcohol and Drug Use ................................................................................ 114
Hormone and Silicone U se and SRS .......................................................... 117
Sex Reassignm ent Surgery: Attributes ....................................................... 121
Gender Identity and Sexual Orientation .......................................................... 123
Positive and Negative Aspects .................................................................. 126
Psychosocial Scale ......................................................................................... 134
Other M odalities of TTSW ............................................................................. 141
Social Considerations and Future Orientation ............................................... .. 143

5 DISCU SSION AND RECOM M END ATION S ........................................... 148

A cce ss Issu e s ................................................................................................. 14 8
Demographics and Background ......................................................... ............ 149
Sexual Behaviors ........ .................................................................................... 150
Sex, Gender and Identity ........... ................................................................ 158
HIV Perceptions and Psychosocial. Indicators .................................................. 171
M edical Considerations and Test Results ......................................................... 173
In terv en tio n ................................................................................................... 1 8 1
Social Implications ......................................................................................... 189

7 CON CLU SION S ........................................................................................... 193

APPENDICES

A IN STRUM EN T ............................................................................................. 200

B INFORMED ASSENT FORM ...................................................................... 220

REFEREN CES .................................................................................................. 223

BIOGRAPHICAL SKETCH ............................................................................... 243


Vi














LIST OF TABLES


Table Page

4-1. Sample characteristics of HIV+ participants ................ ............................... 112

4-2. Relative characteristics of FHV-positive and FHV-negative
p a rticip an ts .......... ....... ............................................................................ 1 13

4-3. M ean and median age by test results ............................ ............................... 114

4-4. Risk perception ........................................................................................... 135

4-5. Condom norm s ............................................................................................ 136

4-6. Perception of safer sex ................................................................................ 136

4-7. Safer sex effi cacy ........................................................................................ 137

4-8. Self homophobia ......................................................................................... 138

4-9. Perceived community homo/transphobia ...................................................... 138

4-10. Identity salience .......................................................................................... 139

4-11. Social support ............................................................................ I ............... 140

















Vii















LIST OF FIGURES

FigurqPg

4-1. Description of living arrangements.............I.................................. 62

4-2. Attendance at bars ........................................................ 65

4-3. Attendance at dance clubs........................................................ 65

4-4. Number of estimated lifetime male sex partners................................. 66

4-5. Mean age at first episode of oral and anal sex................................... 67

4-6. Lifetime history of insertive, unprotected insertive, receptive,
and unprotected receptive anal intercourse with males....................... 67

4-7. Lifetime history of oral-anal contact, anodigital penetration,
sharing of penetrative instruments, and insertive and receptive
anobrachial penetration.......................................................... 68

4-8. Six-month estimated total male sex partners .................................... 69

4-9a. Locations of sex with males in the past six months............................ 69

4-9b. Locations of sex with males in the past six months............................ 70

4-10. Six-month history of receptive, unprotected receptive, insertive,
and unprootected insertive anal sex with any partner type ................... 70

4-11. Months since initiation of commercial sex work................................ 77

4-12. Number of exchange partners in the past 6 months............................ 78

4-13. Number of 6-month exchange partners by employment....................... 78

4-14. Six-month oral and anal sex with exchange partners .......................... 79

4-15. Condom use for receptive oral exchange sex ................................... 93




Viii









4-16. Condom use for insertive oral exchange sex ..................................... 94

4-17. Condom use for receptive anal exchange sex.................................... 94

4-18. Condom use for insertive anal exchange sex .................................... 95

4-19. Percent reporting less than 100% condom use for receptive
oral, insertive oral, insertive anal and receptive anal
intercourse with exchange partners in past 6 months......................... 97
4-20. Condom use for oral sex with non-steady partners ............................ 98
4-21. Condom use for oral sex with steady partners.................................. 99
4-22. Condom use for receptive anal sex with steady partners...................... 100
4-23. Regular health care delivery sites ..... ........I.....................104

4-24. Health insurance coverage....................................................... 105
4-25. Reported STD and HBV-vaccination history .................................. 106

4-26. Participants reporting knowing an HIV+ person
and knowing someone who died from AIDS .................................. 107

4-27. Probability of current HIV infection............................................. 107

4-28. Hepatitis B, HIV, and syphilis positive results.................................. 111

4-29. Lifetime history of alcohol, marijuana, amphetamine,
barbiturate/tranquilizer, ecstasy, LSD, poppers, cocaine,
crack, heroin, ketamine and rohypnol use ..................................... 115
4-3 0. Six-month history of alcohol, marijuana, amphetamine,
barbiturate/tranquilizer, ecstasy, LSD, poppers, cocaine,
crack, heroin, ketamine and rohypnol use ..................................... 116

4-3 1. Six-month history of alcohol, marijuana, amphetamine,
barbiturate/tranquilizer, ecstasy, LSD, poppers, cocaine,
crack, heroin, ketamine and rohypnol use during sex work.................. 117

4-32. Lifetime history of hormone use and silicone injection ....................... 118

4-33. Sexual identities of African-Americans ......................................... 124

4-34. Sexual identities of Hispanics ................................................... 124





ix















KEY TO ABBREVIATIONS AIDS Acquired Immunodeficiency Syndrome GID Gender Identity Disorder HBV Hepatitis B Virus HIV Human Immunodeficiency Virus IAI Insertive Anal Intercourse IDU Injection Drug User MSM Men who have Sex with Men RAI Receptive Anal Intercourse SRS Sex Reassignment Surgery STD Sexually Transmitted Disease TTSW Transsexual/Transvestite Sex Worker UAI Unprotected Anal Intercourse UIAI Unprotected Insertive Anal Intercourse URAI Unprotected Receptive Anal Intercourse












x














Abstract of Dissertation presented to the Graduate School
of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy


TRANSSEXUAL AND TRANSVESTITE SEX WORKERS: SEXUALITY, MARGINALITY AND HIV RISK IN MIAMI By

JAMES ALVAH BAY, JR.

December, 1997


Chair: Leslie Sue Lieberman
Major Department: Anthropology

Transsexual and Transvestite Sex Workers (TTSWs) are a distinct category of

commercial sex workers. Limited research from other geographic areas documents that they are severely marginalized and at risk for a range of negative health outcomes, including infection with the Human Immunodeficiency Virus (HIV) and other sexually transmitted diseases (STDs). In Miami, TTSWs had never been the focus of research.

This cross-sectional study examines the lives and behaviors of 48 street-based TTSWs in the Miami area. Primary objectives included the measurement of variables associated with participants' backgrounds, identities, sexual behaviors, substance use patterns, knowledge of and attitudes toward IRV, risk-related psychosocial indicators, and health care issues. The study also seeks to inform the development of appropriate intervention programming.



Xi









TTSWs were recruited through a strategy of targeted sampling. Enrollment was voluntary, and participants were paid. Data were collected through observation and structured and semnistructured interviews; blood samples were collected by venipuncture and tested for evidence of MJV, hepatitis B, and syphilis infection. Participants received pre- and post-test HMV counseling, as required by Florida law, and referrals to medical and social services.

The majority of TTSWs' clients specifically seek this type of sex worker. With clients and with non-paying partners, TTSWs engage in a range of sexual risk behaviors, including unprotected insertive and receptive oral and anal intercourse. Client resistance is a main barrier to consistent condom use. Among TTSWs, 40% were MHV seropositive; 69% and 19% had seromarkers for hepatitis B and syphilis, respectively. Older (>25 years) age, younger (<14 years) initiation of anal sex, African-American ethnicity, and other variables are associated with HIV infection. Subcutaneous silicone injection and non-injection substance abuse are prevalent.

Transsexuals and transvestites, by definition, cross culturally prescribed gender

boundaries. Those who are also sex workers in Mami are a heterogeneous population who face severe adversity, including family rejection, social isolation, discrimination, urban poverty, and extreme violence. This study contributes to the limited body of knowledge about these individuals, their behaviors, and their subculture. Further, recommendations are made for addressing the MVl epidemic, including a population-specific risk reduction program that stresses community building and social support.






xii
















CHAPTER 1
INTRODUCTION


Transsexual and Transvestite Sex Workers (TTSWs) represent a distinct category of commercial sex workers. Their occupational and personal behaviors, as well as the contexts within which these behaviors occur, differ markedly from those of other types of sex workers. TTSWs challenge predominant cultural assumptions about sexuality and gender, and face significant developmental and daily challenges. As a subculture bound by several identity and behavioral similarities, they are intensely and nearly completely marginalized, living outside of the mainstream in almost every respect. Though research among TTSWs has been limited, studies conducted in several cities around the world have documented numerous and severe threats to their well-being. These include sexual and other behaviors that place them at high risk for the transmission of sexually transmitted diseases (STDs), including the Human Immunodeficiency Virus (HIY), as well as a range of other negative consequences: family disaffiliation, social isolation, violence, poverty and discrimination (Elifson et al. 1993; Kulick 1997; Pettiway 1996).

Now nearly 20 years into the global HILV epidemic, there are an estimated 650,000 to 900,000 HIV-infected people in the U.S.; as many as 355,000 of these do not know they are infected (CDC 1 997c). Sexually Transmitted Diseases (STDs) are significant cofactors in HIV transmission (Royce et al. 1997); STD) rates in the U.S. are the highest in






2


the industrialized world (Watanabe 1997). Miami continues to be an FHV epicenter (CDC

1 997a), which has long-lasting consequences that reach far beyond the immediate area, given local migration and tourism patterns. Despite recent advances in biomedical treatment options, the virus remains one of the most deadly. As the virus increasingly and disproportionately affects ethnic minorities and marginalized populations (CDC 1 997a), it is imperative that FHV intervention target, and be informed by, population-specific needs and behaviors. Toward this end, techniques used by applied and medical anthropologists have proved increasingly valuable: they have opened the doors to accessing these invisible populations, and have formed a bridge between actual human experience and the sometimes context-sterile methods traditional in public health and epidemiology (Herdt and Boxer 1991).

In the two generations since the Cuban revolution, local demographics have changed dramatically. Approximately 80% percent Anglo and 20% African-American in 1960, in 1995 Dade became the first major metropolitan area in the US with a Hi-spanic majority. Currently, over 5 1% of Dade's 2. 1 million are Hlispanic; 23 % are black, and 26% nonHispanic white. The area's population continues to swell: five hundred thousand more-most will be Spanish-speaking immigrants--are expected to arrive in Dade by 2005, representing nearly a 25% increase in less than 10 years (Sell 1997:26).

These changes have required major adjustments in the social fabric of the community, and have resulted in the continued marginalization of African-American residents. Dade is one of the poorest major cities in the US, crime and housing costs are high, and public services are already overburdened (Sell 1997). The influx has "strained South Florida's









schools and hospitals to the breaking point and left many longtime residents feeling disenfranchised" (Robinson 1996:30). Overall, unemployment among Dade AfticanAmericans is 13%, compared to 8% for Hispanics and 6% among Anglos (Health Council of South Florida 1997:3). Unemployment in some areas is much more extreme: one estimate places joblessness in the Little Haiti neighborhood at 42%, though this is "lower than in nearby African-American neighborhoods" (Robinson 1996:34). For the near future, the situation does not look promising: for the half-million new arrivals, the economy is projected to create only 135,000 jobs, mostly low wage. Most of these new jobs, as now, will require bilingual skills (Sell 1997). Thirty percent of African-Americans live below the poverty level in Dade, compared to 19% of Hispanics and 14% of Anglos (Health Council of South Florida 1997:3).

As in many metropolitan cities, TTSWs are actively represented in the Miami area. The ethnic composition of the area, together with its STD/HIV epidemiological patterns, combine with larger issues of sexual identity, sexual orientation, gender, and power to make this population unique. They are, however, hidden and very difficult to access, and have never been the focus of specific research efforts. There was a complete lack of information about the local TTSW population: about their behaviors, motivations and lives, as well as their health status. This research indicates that existing public health efforts and prevention methods do not reach this population. Even if they did successfully access these individuals, current practices would not adequately address their specific needs.






4


This study examines and documents a range of variables integral to local TTSWs'

personal lives and occupational behaviors. Quantitative data gathered through structured and semnistructured interviews were combined with observational and ethnographic data that describe the culture and shared knowledge of these individuals, from both internal and external perspectives, in order to provide a context within which their behaviors and attitudes may be interpreted. The study explores what a decidedly marginalized subpopulation can teach us about access and barriers to care and intervention, about resource allocation, and about the cultural, social, and economic issues that must be taken into account in mediating the advances of the FHV epidemic. It also sheds some light upon the consequences of a continued and ill-informed persecution of sexual minorities in our society.

The project is a cross-sectional study of 48 TTSWs in the Miami area. Participation criteria included male sex at birth, minimum age 18 years, and acknowledged participation in street-based commercial sex work while deliberately feminized (i.e., through female clothing, make-up, hormones or other body alteration) within the six months prior to interview. Participants were recruited through targeted sampling techniques (social mapping and chain referral), and were paid for their participation in the study. The sample is opportunistic and representative of the estimated 100-125 active street-based TTSWs in Dade County.

Data collection was conducted solely by the researcher. Blood samples were collected by venipuncture, and tested for IV- 1 antibodies and for Hepatitis-B and syphilis markers. Risk reduction counseling, as required by Florida law, followed each interview and






5


preceded venipuncture. At that time, and in post-test counseling sessions in which participants received their test results, appropriate referrals for medical evaluation and treatment were made.

While the documentation of disease STDIHV seroprevalence rates is one goal of the study, its primary purpose is to contribute to the limited body of knowledge about these individuals, their culture, and their behaviors, and to gather data to inform the design and implementation of health and intervention targeting this population. It contributes to the disciplines of anthropology and public health--and overall, it tells a story, in the words of those who experience it, of how one subpopulation functions in the face of extreme social adversity.













CHAPTER 2
LITERATURE REVIEW

Gender Variation: EUression

As one of the most complex aspects of the human experience, sexuality is expressed in a range of behaviors, identities and orientations. Accordingly, anthropologists have been interested in sexuality since the beginnings of the discipline. Cross-cultural studies from Bateson (1936), Malinowski (1929), and Mead (1935), for example, were among the first to illustrate the wide variations in human sexual expression and the cultural constructions that surround and regulate sexuality and gender. The ethnographic record provides a wealth of information about sexual behaviors and the cultures that shape these behaviors; it is replete with examples of sexual and gender variation. Worldwide, the expression of human sexuality transcends a simple dimorphic system, with two sexes linked with two mutually exclusive genders. I

Ramet (1996) uses the concept of gender culture to frame discussion of gender variation. Gender culture includes:

a society's understanding of what is possible, proper, and perverse in genderlinked behavior, and more specifically, that set of values, mores, and assumptions
which establishes which behaviors are to be seen as gender-linked, and with which
gender or genders they are seen to be linked, what is the society's understanding of
gender in the first place, and, consequently, how many genders there are (1996:2).



Though the terms "sex" and "gender" are sometimes used interchangeably in both popular and academic literature (Lewins 1995), there are important distinctions. Sex refers to the "biological classification of being male or female," while gender refers to "the culturally determined behavioral, social, and psychological traits that are typically associated with being male or female" (Brown and Rounsley 1996:19).

6





7


Gender variations include both apparent, observable characteristics, as well as internal markers such as identity. Gender "reversals" are "understood to be any change, whether 'total' or partial, in social behavior, work, clothing, mannerisms, speech, self-designation, or ideology, which brings a person closer to another (or in the case of polygender systems, another) gender" (Ramet 1996:2).

Such variations have been reported by anthropologists for decades (Bolin 1996a,

1996b; Gray and Ellington 1984; Munroe 1980; Turner 1967, 1977; van Gennep 1960). For example, Native North American "Two Spirits" (Jacobs 1994), also known as the Berdache (Hauser 1990; Whitehead 1981), the Hijras of India (Nanda 1990), and the Sambia of New Guinea (Herdt 1987), among dozens of other cultures, have been used to illustrate the exceptions to the Western concept of a universal sex-gender linkage and the constructed nature of gender (Coleman, Colgan and Gooren 1992; Herdt 1990, 1996; Jacobs and Cromwell 1992; MacCormack and Strathern 1980; Ortner and Whitehead 1981; Ramet 1996).

Gender variations are not isolated or recent occurrences. To the contrary, they seem to occur as a natural manifestation of human variation. They have been noted throughout history, and within most cultures, with varying degrees of institutionalization and acceptance (Bullough and Bullough 1993; Docter 1988; Green and Money 1969; Pauly 1992), though their functions and the meanings ascribed to them vary across space and time (Ramet 1996). Whitham and Mathy state:

In short, the literature on the berdache tells us that the North American tribes
produced the same types of sexual variants as do contemporary societies. Native
American societies did not consciously create homosexuality, transvestism, or
transsexualism, as is sometimes suggested, but like modern societies, they
responded to {their} existence (1986:20).






8



One immediately recognizable violation of the dominant gender paradigm is crossdressing,' "a simple term for a complex set of phenomena. It ranges from simply wearing one or two items of clothing... to attempting to live most of one's life as a member of the opposite sex" (Bullough and Bullough 1993 :vii). Woodhouse states "the common assumption is that sex and gender fit, that gender appearance is the accurate reflection of biological sex. These unwritten laws of fit are encapsulated in the social expectation we have about clothing and appearance (1989 :xiii).3 Dress has traditionally been "a ubiquitous symbol of sex differences, emphasizing social conceptions of masculinity and femininity," and cross-dressing "therefore, represents a symbolic incursion into territory that crosses gender boundaries" (Bullough and Bullough 1993:viii). Contemporary Western societies, in particular, generally exhibit a rigid gender dichotomy, which results in acute discomfort with individuals who violate gender norms.

The contemporary Western gender paradigm began to crystallize within the

medicalization of sexuality in the nineteenth century. This medicalization "brought with it new 'conditions' and the emergence of new identities. Increasingly, gender blending experiences and behaviors were made sense of in terms of the categories of 'science,' most



2 Ramet states that cross dressing, "while nowadays narrowly construed to refer but to dressing across gender lines, was at one time a much broader concept, referring to any breach across the rigid regulations governing attire. These regulations, found in all ancient societies including the Aztec and Inca, as well as in European society as late as the seventeenth century, were designed to keep people in their assigned places, and included often precise prescriptions relating to class, trade and lineage, as well as gender" (1996:3).

3 Woodhouse continues: "rarely, if ever, do we pause to wonder if an individual is 'really' a man or a woman; rather, perception is immediate and simple because, although we may not have direct knowledge of a person's genital sex, we 'know' what a man or woman looks like. In short, gender appearance is a key factor in social communication" (1989:7).






9


notably those of the 'transvestite' and the 'transsexual"' (Ekins and King 1996:5). Bullough and Bullough state:

Early researchers, most of them physicians or psychiatrists, tended to utilize a
medical model that conceptualized variations from the norm of sexual behavior as
an illness or, in more recent years, as a behavior problem. Such definitions have been emphasized in an effort to arrive at the causes of a "disease" or "problem"
and, once having achieved this, to take steps to "cure"~ the patient or client
(1993 :vii).

Cases of discomfort with one's anatomic sex were described by German clinicians beginning in the early 19th century. Important early contributions were made by Hirschfeld and Ellis, who focused on diagnosing and curing the perceived disorders through psychoanalysis and aversion therapies. Hiischfeld coined the term "transvestite" in 19 10 (Bullough and Bullough 1993) and applied it largely to heterosexual men who were focused on the erotic aspects of cross dressing (Hirschfeld 1991). Ellis (1928) followed with the term "eonism," which he felt went further in describing the more complex psychological aspects and functions of the phenomenon, including feminine identity factors. Following these early traditions, a large body of clinical research has been published in the psychological, psychiatric and biomedical literature.

Early clinicians tended to categorize all cross-gender manifestations under the rubric of transvestism (Brown and Rounsley 1996), until the period of increased awareness that followed Christine Jorgensen's highly publicized 1952 "sex-change" surgery in Denmark. The early disease models have evolved to the more contemporary models that more fuldly recognize the wide spectrum of gender variant expression (see Person and Ovesey 1978;Stoller 1985), and emphasize acceptance of gender variation (Bockting and Coleman 1992). Other terms have been applied to the phenomenon of cross dressing in the second






10


half of this century, including "gynememisis (literally 'woman mime') and its counterpart andromimesis, gender dysphoria, female or male impersonation, transgenderist, femmiphile, androphile, femme mimic, fetishist, crossing, and transsexual" (Bullough and Bullough 1993 :vii).

In 1966, Harry Benjamin applied the term "transsexual" to the most extreme form of gender variation--to those who not only cross-dressed, but who also described crossgender self-identity. His landmark publication The Transsexual Phenomenon (1966) has been called "the first serious work on transsexualism.., and as such was instrumental in demystifying and depathologizing the condition" (Brown and Rounsley 1996:28). This work laid the foundation for the Standards of Care (SOC), developed in 1979 and regularly updated, which contain recommendations for therapeutic treatment of transsexuals. The SOC contain guidelines for hormone administration and the Real Life Test (RLT), in which transsexuals live full-time in the gender role that matches their identity, that precedes sex reassignment surgery (SRS).4

Transsexualism, the incongruity between mind and body, is also referred to as gender dysphoria, and more recently, as Gender Identity Disorder (GID). Long considered mental illnesses, fetishistic transvestism and GID5 remain on the DSM-IV list of mental


4 The Standards are used by most gender therapists, physicians and surgeons today, though they are increasingly challenged as an instrument of medical control that forces transsexuals to "jump through hoops" to obtain treatment and surgery (Brown and Rounsley 1996). The DSM-LV states that fetishistic transvestism has been "described only in heterosexual males" (American Psychiatric Association 1994:531). A GID diagnosis requires "evidence of a strong and persistent cross-gender identification, which is the desire to be, or the insistence that one is, of the other sex... there must also be evidence of persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex." There must also be "evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning" (American Psychiatric Association 1994:532-533).









disorders (American Psychiatric Association 1994). However, a recent review of the clinical records of 435 gender dysphoric individuals led to the conclusion that they "appear to be relatively 'normal' in terms of an absence of diagnosable, comorbid psychiatric problems. In fact, the incidence of reported psychiatric problems is similar to that seen in the general population" (Cole et al. 1997:16).

Within the illness model community, there is some disagreement about the precise meanings of the terms "transvestite" and "transsexual," and debate about who should be included in which category. Levine contends that cross-dressing "usually expresses a male' S6 developing or already well-developed feminine identification, and that "crossdressing is cross-dressing," (1993:134) regardless of sexual orientation. Male crossdressing may occur among masculine or feminine men, and among heterosexuals, bisexuals and homosexuals.' The common thread among these diverse groups of crossdressing men is that they have "a soothing image of themselves as women" (1993:13 1). He states:

The confusing differences among cross-dressing males may be explained by their diversity along three dimensions: 1) the ambition for heterosexual intercourse; 2)
the natural history of their sexual arousal to female clothing; 3) their current
capacity to integrate their masculine and feminine strivings into separate

6 Male-to-female transgendered 'individuals are the focus of this dissertation, and much of the literature cited is specific to this group. There are many female-to-male transgendered individuals, and language and orientation herein are not intended to overlook their existence or to slight their relevance.
7 Transsexualism is often confused with homosexuality, and it is important to emphasize the distinctions between gender identity and sexual orientation. Sexual orientation is determined by the sex of those to whom one is erotically and emotionally attached; people may be heterosexual, bisexual, homosexual, or asexual. Gender identity refers to the inner awareness that one is either male or female. As Brown and Rounsley state: "the only way to know a person's gender identity is if he or she tells you" (1996:21). Money and Ehrhardt (1972) were among the first to emphasize that sexual orientation and gender identity are distinct qualities that develop independently.






12


compartments. When cross-dressers give up all vestiges of male gender role behaviors and successfully live and work full-time as women, the appropriate
descri ption for them becomes "transsexual" (1993:13 1).

Doctor's (1988) contemporary model of cross-dressing males includes 9 behavior

patterns within the phenomenon, including 5 heterosexual variations (fetishism, fetishistic transvestism, marginal transvestitism, transgenderism, and secondary transsex"ism) and 4 homosexual variations (primary transsexualism, secondary transsexualism, drag queens, and female impersonators). He argues that primary transsexualism is largely confined to homosexually oriented males, with an onset in early childhood. Secondary transsexualism is viewed as a developmental stage in an ongoing process of transsexualism, occurring in males with heterosexual and bisexual orientation.

These perspectives are not intended to represent all clinical perspectives, but to

establish a conceptual and semantic framework. While these models may be conceptually useful, the existence of such schematic variability in this field speaks to the constructed and nonessentialist nature of human sexuality, which has long tested the boundaries of categorization. The term "sexuality" itself must be taken' as a set of human constructs that have biological bases, accompanied by culturally derived explanations that provide the meanings we associate with behaviors.

In the interests of clarity, the terms "transsexual" and "transvestite" win be used as

described by Warren (1993) and Bolin (1987). Transsexualism is most often differentiated from transvestism, in that "transvestites maintain an inner identity that is consistent with their sexual anatomy;" transsexuals are "people who find their gender identity (the inner sense of self as 'male or female') in conflict with their sexual anatomy" (Warren 1993:14).






13


Bolin emphasizes the origin and use of the term "transsexual" within the confines of a

dichotomous gender system: "the term transsexual refers to individuals in Western

societies with a cross-sex identity, regardless of their pre- or post-surgical status"

(1987:42).

"Transgender" is an emerging, less restrictive term, which is perhaps more inclusive of

the range of behaviors and actual human experience than that reflected in clinical

terminology:

Through recent research, it has become apparent that there has been a movement
in which people of various gender-transposed identities have come to organize
themselves as part of a greater community, a larger in-group, facing similar
concerns of stigmatization, acceptance, treatment, and so on. This recognition of
similarity fostered by growing political awareness of gender organizations has facilitated the burgeoning of new gender options, such as the "transgenderist."
Transgenderist is a community term denoting kinship among those with gendervariant identities. It supplants the dichotomy of transsexual and transvestite with
a concept of continuity (Bolin 1996a:3 8).

Transgendered people, then, may exhibit a full spectrum of experiences, that range

from occasional, part-time cross-dressing to living full-time in another gender, to taking

hormones or surgically altering the body. Lawrence et al. state that "transgendered

individuals live full- or part-time in the gender role opposite to the one in which they were

born"' (1996:874).8



8 Feinberg states: "Today the word transgender has at least two colloquial meanings. It has been used as an umbrella term to include everyone who challenges the boundaries of sex and gender. It has also been used to draw a distinction between those who reassign the sex they were labeled at birth, and those whose gender expression is considered inappropriate for our sex" (1996:x). Feinberg also asked "self-identified gender activists" to name who they believed were included in the term; they named "transsexuals, transgenders, transvestites, bigenderists, drag queens, drag kings, cross-dressers, masculine women, feminine men, intersexuals, (people referred to in the past as 'hermaphrodites'), androgynes, cross-genders, shape-shifters, passing women, passing men, gender-benders, gender-blenders, bearded women, and women bodybuilders who have crossed the line of what is considered socially acceptable for a female body" (1996:x). Bornstein (1994) also discusses the construction and composition of the emerging transgendered community.






14


in summary, gender variations have been recorded across cultures and throughout history. The anthropological record is replete with examples of the wide variation in gender-linked behavior and gender norms, which indicate their constructed nature. In contemporary North American society, the dominant gender paradigm closely articulates with a rigid, sex-linked dichotomy. Often confused, sexual orientation and gender identity are distinct human qualities that develop and exist independently of each other. Male gender variants are a diverse group whose cross-gendered behaviors vary in range and degree. In transsexualism, the most extreme form of gender variance, gender identity as well as gender-linked behaviors are at odds with anatomic sex.


Gender Variation: Etiology

Studies of gender variance have come from a range of perspectives. The study of transsexualism "cross-cuts disciplinary boundaries and includes a diverse array of fields such as psychiatry, endocrinology, plastic surgery, nursing, social work, counseling, clinical psychology, sociology, education, sexology and anthropology" (Bolin 1987:41). Despite this range of multidisciplinary attention, no particular theoretical perspective or theory can satisfactorily account for the etiology of gender variance.

Theoretical frameworks, in the nature-nurture tradition, have ranged from the purely environmental to biologically deterministic. Sociocultural approaches have historically resisted "biologically reductionist" (Herdt 1990:433), essentialist explanations of gender identity development, asserting the primacy of environmental influences over biological






15


factors. Included in the postnatal environment is the "power of our dimorphic two-sex code" (Herdt 1990:434). 9

Money maintains that, through some mechanism or combination of factors, "gender coding in the brain is bipolar. In Gender Identity Disorder (GID), there is discordancy between the natal sex of one's external genitalia and the brain coding of one's gender as masculine and feminine.., causality with respect to gender identity disorder is subdivisible into genetic, prenatal hormonal, postnatal social, and postpubertal hormonal determinants, but there is, as yet, no comprehensive and detailed theory of causality" (1994:163).

As the etiology of gender dysphoria is unclear (Lewins 1995, Docter 1988), so are the determinants of sexual orientation (De Cecco and Elia 1993; De Cecco and Parker 1995). Recent research, however, increasingly indicates that biological factors may play a significant role: "a great deal of evidence has been accruing that nature sets a predisposition for these sexual developments and within such limits the environment works" (Diamond 1997:199). Research with twins (Bailey, Pillard and Knight 1993; Bailey and Pillard 1991; Whitam, Diamond and Martin 1993), with the sex reassignment of children with ambiguous or traumatized genitalia (Diamond 1997), and with the brain (Zhou et al. 1995), supports some degree of physiological causality for transsexualism., as well as for sexual orientation (De Cecco and Parker 1995; LeVay 1993; Weinrich 1995). Giordano and Giusti state there is growing evidence that "hormonal factors (gonadal and adrenal hormones, hormone receptors, transduction mechanisms of the hormone signal,



SHerdt continues: "sexual dimophism is certainly prominent in Western biological and evolutionary thinking since Darwin... perhaps (it) seems so natural that our culture and--therefore-Western science have scarcely considered the absolutism which this piece of common sense (Geertz 1983) exercises over research" (1990:343).






16


neurosteroids, neurotransmitters, etc.) play a determining role in the formations of gender identity" (1995-165). Gooren points to a "profound biological element" (1991-16) in gender identity. Summarizing the dimorphic sexual differentiation in the brain, he states:

Sexual differentiation in the brain is a sequential process beginning with the
establishment of chromosomal sex at the moment of fertilization and finding a
preliminary completion with the formation of a gender identity/role. Disturbances of the process can interfere with normal development in a male or female direction at different stages, leading to ambiguity. Only a narrow window of time exists for
each phase of the differentiation process, during wffich there is a sensitivity to
particular stimuli. The residual effect is immutable and cannot be induced at a later
point (1996:9).

Transsexuals "have the strong feeling, often from childhood onwards, of having been born the wrong sex" (Zhou et al. 995:68). Glausiusz quotes neurobiologist Swaab, who believes that biomedical research "shows that transsexuals are right. Their sex was judged in the wrong way at the moment of birth because people took only to the sex organs and not to the brain" (1996:83).

Despite recent advances in biomedical research, there are few certainties. There may well be salient biological influences that explain the development of cross-gender identity. However, even the most ardent essentialist explanations cannot controvert the obvious influences of the postnatal environment, even if such influences did no more than determine the range of behavioral possibility that builds on a biological base.

Summarizing the major components of the large body of clinical literature concerning transsexualism, Lewins notes two characteristics:

The first is the absence of any serious consideration of the role of social factors in
examining the aetiology of transsexualism. Second, there is the nature of the
vantage point of the clinical observer, who starts from the assumption that
transsexualism is, medically, an abnormal state (1995:21).





17


In sociocultural approaches, transsexualism is "not viewed as a syndrome but as a category of people who are stigmatized in our culture but not necessarily others. Therefore, they are investigated as a group of people existing within the broader confines of gender parameters constructed by society" (Bolin 1987:59). Bolin studied 16 male-tofemale transsexuals during their process of becoming women, which included SRS, primarily using participant observation, with additional life history and questionnaire instruments. Participants generally viewed their female identities as developing over the course of changes in physical appearance. This work also details developmental aspects of transsexuals' lives--including the absence of some commonly held assumptions about early family life--such as the "dominant mother--absent father" development perspective, exclusive homosexual identity, disgust with penis, and hyperfemininity (1983, 1996b).

No single theory definitively addresses GED etiology. Accordingly, De Cecco and Elia propose a synthesis of biological essentialism and social constructionism that "views sexual and gender expression as a product of complementary biological, personal, and cultural influences" (1993:1). While such a multifactorial, interactionist theory--a naturenurture combination--seems most logical within the present state of knowledge, it should be noted that through whichever mechanism(s), gender identity is formed early in life. Typically, gender identity appears as early as two years of age (Whitam and Mathy 1986), and GID and accompanying behavioral manifestations are normally established by age 2 or 3 (Zucker and Green 1992). While further research will no doubt shed additional light on GID etiology, one final point deserves emphasis. "Nurture" is often popularly linked with






18


"choice." However, it would seem that if nurture has worked its way so early in life, and if cross-gender identification is evident at such a young age, the etiology of primary transsexualism could hardly be ascribed to individual choice.



Anthropology and the }{JV Epidemic


Some anthropologists have pointed to the discipline's general attention to sexuality only in non-Western settings, and to a reluctance to address it within our own societies-particularly when it involves same-sex sexual behavior (Carrier 1986). As the HI V/AIDS epidemic has accelerated, however, anthropologists have responded to a relative dearth of global information about risk practices (Abramson and Herdt 1990; Feldman 1990), and have become increasingly involved in HIV-related research and intervention, reflecting "a significant redirection in anthropological focus and is reflective of a broad turn toward the study of American society by North American anthropologists" (Singer 1994:93 1).

Anthropological holism and methodologies have proved valuable in HIV-related

applications, including epidemiology, health education, service and care evaluation, social change analysis and risk reduction (Feldman 1989). Work from a number of anthropologists has provided the crucial link between HIV-related behaviors and the cultural and social conditions that influence them (see, for example, Parker 1987, Farmer 1990, and Page 1990a, 1990b). A number of researchers have called for increased use of ethnographic and cultural data in HI V-related research and intervention (Carey 1993; Herdt and Boxer 1991), as survey-type quantitative data alone do not address the cultural






19


meanings and experience that influence the behaviors and attitudes they document."1 Parker, Herdt and Carballo maintain that sexuality is a culturally informed experience, and should be understood within the concept of sexual culture, that is, "the systems of meanings, of knowledge, beliefs and practices, that structure sexuality in different contexts" (1991:79).

Carrier and Magafla (199 1) have used ethnosexual data gathered among Mexican and Mexican-American Men who have Sex with Men (MSM) to inform IV intervention in California. They point out that ethnicity and culture may have a marked effect on sexual identity. For example, in some Latino cultures men who assume only the insertive role in anal intercourse with other men may retain their culturally sanctioned heterosexual identity. This has also been reported among African-Americans (Peterson 1995); similar reports have resulted from anthropological fieldwork in Brazil (Parker 1990; ScheperHughes 1994), Mexico (Taylor 1985), Nicaragua (Lancaster 1988), Afica (Sheperd 1987), and the Mediterranean (Whathamn and Mathy 1986), among other areas. Singer describes the shortcomings of biomedically-based conceptualizations of homosexuality as a "fixed inverted behavioral pattern rooted in genetic makeup, hormonal malfunctions or specific developmental psychodynamics and family patterns" (1994:938). Such essentialist views of homosexuality have often stifled understanding of the actual diversity within the MSM population, hampering AIDS research and prevention:


10 Agar states "the ties between epidemiology and ethnography, then, represent a conceptual shift, a transformation in epidemiology that responds to diseases that are more than biological, hosts whose subjective experience influences outcomes, environments that are perceived in addition to material and worlds that are interconnected rather than linear. The ties are more than a blend of methods, though such blends are useful. Instead, they signal a new epidemiology, one better equipped to renew epidemiology's power with infectious disease in the domain of the diverse and complex 'diseases'--if diseases they are--of the late twentieth century" (1996:402).






20




Consequently, despite being lumped together by the homophobia of dominant society, it is evident that men who have sex with men do not constitute one or
even two distinct social groups, rather they comprise a broad range of individuals
and include those organized into several different (in part overlapping, in part mutually exclusive) activity/identity oriented subgroups and those who did not identify with any specific subgroup or embrace a homosexual identity (Singer
1994: 938).


AIDS research has "created new opportunities for anthropologists to use method and theory as tools for practical problem solving. In the process, AIDS research has redrawn the boundaries which formerly surrounded the subfields, and has made it even more difficult to characterize the distinctions between 'theory' and 'practice"' (Leap and O'Connor 1993:3). Singer describes the shift in anthropological theoretical, conceptual, and geographical focus as having "taken anthropologists into a new domain of human biocultural experience" (1994:933).



Theoretical Approaches

Medical anthropology began its development as an anthropological subdiscipline in the period following World War 11 (Foster and Anderson 1978), and may be defined as "the study of human health and disease, health care systems, and biocultural adaptation" (McElroy 1996:759). Early work in the field was generally clustered on either the biological side (including research on human growth and development, the role of disease in human evolution, and paleopathology), or in the sociocultural realm (including ethnomedicine, illness behavior, the doctor-patient relationship, and the introduction of Western medicine into traditional societies. Between the poles were anthropologists interested in epidemiology and cultural ecology. However, medical anthropology "should






21


not be thought of as two loosely joined fields--the biological and the sociocultural-because at innumerable points the problems of both require the intrusion of data and theory from the other" (Foster and Anderson 1978:2).

Accordingly, a number of medical anthropologists have called for the use of

biocultural approaches, which view health actions, disease and health systems as existing within interacting biological, environmental and cultural realms (Armelagos et al. 1992;Armelagos, Ryan and Leatherman 1990; McElroy 1990; Wiley 1992). The strength of this approach lies in its "comprehensive view of humans as biological, social and cultural beings" (McElroy 1990:244). Treichier describes a continuum of medical anthropological approaches to I-IV:

First, the virus is a stable, discoverable entity in nature whose reality is certified
and accurately represented by scientific research: a high degree of correspondence
is assumed between reality and biomedical models. Second, the virus is a stable, discoverable entity in nature but is assigned different names and meanings within
the signifying systems of different cultures; all are equally valid though not all are
equally correct. Third, our knowledge of the virus and other natural phenomena is inevitably mediated through our symbolic construction of them; biomedicine is
only one among many, but one that currently has privileged status (1992:67).


At one end of this continuum is what Singer (1990) describes as the mechanist

materialist view, which "understands Ifly as a discrete and knowable part of physical reality which cultures merely label." On the opposite pole is the radical idealist approach, which "portrays MIV as a fully human construction, an abstraction from a whirling buzzing world that is not directly knowable but must be responded to by an encultured being" (Singer 1994:942). Treichler states that most conventional medical anthropologists "seem more comfortable with the notion of a single, stable underlying biological reality to which






22


different cultures assign meanings than with the view that everything we know about reality is ultimately a cultural construction" (1992:68). Increasingly, medical anthropologists work in the applied realm, which "deals with intervention, prevention, and policy issues and analyzes the socioeconomic forces and power differentials that influence access to care" (McElroy 1996:759).

Singer maintains that the HIV epidemic must be understood in terms of class, ethnic, and gender relations, and linked with broader political, economic, and social problems. He structures the crisis in terms of unemployment, poverty, homelessness and overcrowding, substandard nutrition, violence, drug abuse, family disruption, and access to health care: "There is a critical need for longer-term, more comprehensive, systemic public health efforts that address the root causes of the crisis, causes that lie in the oppressive structuring of class, ethnic, sexual orientation, and gender relations in US society" (1994:937). Criticized in some quarters for emphasizing social transformation and activism (Wiley 1992), Singer counters: "suggesting that many diseases have a social origin does not imply that they lack a biological reality, nor does it undermine the importance of studying that reality" (1993:188).

From the perspectives of Public Health and behavioral epidemiology, a number of risk reduction models have been applied to HIV intervention. Fishbein and Guinan discuss the importance of theoretical grounding of HIV prevention, and recognize that "having information about a particular disease and how it is spread does not necessarily increase the likelihood that one will take preventative action" (1996:5). They call for behavioral science to more carefully examine contextual variables that affect fRV-related behavior:






23


"cclearly, the more one understands the factors influencing (or underlying) a person's decision to perform (or not perform) a given behavior, the more likely one is to develop interventions that can effectively change that behavior" (1996:6).

Currently prevailing risk reduction models include the Health Belief Model (HBM;- see Rosenstock 1990), the Theory of Reasoned Action (TRA; see Carter 1990), Social Cognitive theory (see Bandura 1986; Perry, Baranowski and Parcel 1990), and the Stages of Behavior Change model (Prochaska et al. 1992). In the HBM, health behaviors are determined by the interaction between perceived susceptibility, severity, benefits, and barriers involved in taking a particular action, together with other variables such as selfefficacy (Bandura 1977). Social Cognitive models address 2 primary factors: self-efficacy and expected positive outcome with respect to a particular behavior. The TRA structures health behavior as primarily determined by a person's intention to perform a particular action, which is influenced by personal attitudes and peer norms regarding the behavior. Based on these three models, Fishbein and Guinan (1996) identify four primary factors that influence individual intentions and behaviors; these are described in Chapter 5.

Unfortunately, traditional twentieth century STD intervention under the predominant medical model has ignored social prophylaxis (Darrow 1997). Beginning in the 1980s, three innovations evolved: social marketing, community involvement and behavioral change models based on social and psychological concepts and theoretical models. Darrow states:

Health promotion for STD prevention in the future will be characterized by careful
assessments of the social and behavioral determinants of sexual risk taking,
development and implementation of targeted interventions designed to reduce risk
taking, and evaluation of social and behavioral interventions for improvements in
STD prevention (1997:88).






24



While theoretical structure is an important component in MV intervention, the fact that we still have an escalating epidemic is grim testimony to the efficacy of some theoretical and applied approaches. Standardized constructs that assume rational choice or lack of information as primary risk factors may not acknowledge the underlying social and structural causes of risk, Unfortunately, these models have dominated ADDS prevention programs. Their primary shortfall is that they focus attention on the individual level and ignore context and community, "treating the targets of intervention as if they were not members of families, peer groups, communities and the broader society" (Singer and Weeks 1996:489). This critical point must be considered in the development of future MV/STD intervention.

Several models address these shortcomings, including an ethnographically-informed model used in the Latino Gay Men's Health Project (Singer and Marxuach-Rodriguez 1996). It involves the use of less formal, participatory group sessions, combined with social activities and creative approaches to risk reduction, and support groups using selfesteem and empowerment models. Social support is a critical variable in maintaining risk reduction, and may be enhanced through small-group programming (St. Lawrence et al. 1994). An empowerment approach has been successfully used with Mexican MSM to increase sense of control, skill development and social network support (Zimmerman et al. 1997).

In summary, the MV epidemic has changed the discipline as anthropologists have responded to a dearth of information regarding IUV risk behaviors and the need for holistic methods in approaching the epidemic. These changes have resulted in significant






25


geographic, conceptual and theoretical redirection of the discipline. Within the subdiscipline of medical anthropology, the most comprehensive approaches to human health and disease are blocultural, considering biological, environmental and cultural influences; advocates of a critical medical anthropology also stress the inclusion of political and economic influences in research and analysis. The effectiveness of some theoretical perspectives in Public Health may be limited by their individual-level application, and their inattention to role of social and underlying causal factors in the epidemic. Community-level empowerment and social support models have been effectively used to address this gap.


Commercial Sex

From anthropology, as well as other disciplines, there is a growing body of literature on female and male commercial sex work (see Bullough and Bullough 1987).11 Sex work is a global industry, in which participants (workers and clients) are heterogeneous in their motivations to participate:

Prostitution occurs virtually worldwide, but there is considerable variation around
the world in the organization and characteristics of prostitution. The various
patterns of prostitution (female, male and transsexual) reflect the social
organization of sexuality in societies, specifically the demand by clients for the sale
of sexual services... most prostitutes are motivated by economic considerations
(e.g., support of family, cost of illegal drugs, a comfortable living standard).
Reasons for persons' becoming clients of prostitutes have not been wellestablished; loneliness, lack of social skills, a desire for variety, or a wish for
specific sex acts not en oyed by a regular partner, are reasons often given by men
who are clients (World Health Organization 1989:377).



Troung (1990) provides a brief historical overview of sex work, followed by a thorough review of the sex industry through the eyes of the major theoretical perspectives in the social sciences, including sociobiology, functionalism, historical materialism, structuralism and feminist critique.






26


Since the inception of the FHV epidemic, sex workers have been recognized to be at elevated risk (CDC 1987) and have increasingly become the focus of research. With respect to FHV risk reduction through condom use, several common themes emerge. Sex workers worldwide report that the main reason they do not use condoms with paying partners is client resistance to condoms (Campbell 1991). This is reflective of the inherent power differential between the client and sex worker in most commercial sex transactions which inhibits workers' ability to negotiate or enforce condom use (Bay 1993; Truong 1990). Sex workers in Western societies tend to maintain distance between their working and private lives, reflecting a growing professionalization of sex work. This division may influence both sex workers and researchers to focus solely on risks incurred in their working lives, and to ignore their private lives (Day 1988). Worldwide, condom use is generally much less consistent with non-paying partners (Bay 1993; Campbell 1991), which places workers at particular risk when those partners are at other risk for MV infection; this calls for different approaches to risk reduction measures with steady partners (Day 1988, de Zalduando 1991).

Street-based sex work has several defining characteristics (Campbell 199 1). Sexual transactions usually occur near the street locations used for solicitation, and often in cars. This may place workers in more vulnerable positions, both for their immediate physical safety and for HIV transmission. Peer outreach using sex workers (or ex-sex workers) as educators has been successfully used in a number of risk reduction and health interventions with female sex workers and their clients (Campbell 1991).






27


Until the FHV epideriiic, male sex work had never received the attention accorded its female counterpart, though Kinsey, Pomeroy and Martin (1948) noted that male prostitutes were probably as numerous as female prostitutes in the U.S. Based on 198991 fieldwork in San Francisco, Waldorf and Lauderback (1992) identify two general types of male sex workers. These include hustlers, who "solicit clients face to face in public places, most particularly on certain streets, in bars, and in erotic book stores in certain areas of the city", and call men, who "solicit clients by telephone and operate from a list of clients or advertise services in newspapers and magazines." In first category, there are three types of hustlers.- youths, who "present themselves to clients as gay identified and provide a wide range of services including anal intercourse;" trade hustlers, who "present themselves as heterosexual and provide limited services, do not profess to enjoy sex with men, and provide services only for the money," and transvestite and transsexual hustlers, "who were born as men but dress in women's clothing and identify themselves as females or females in men's bodies" (Waldorf and Lauderback 1992: 109).12

Morse et al. (1996) argue that male sex workers have been deemed worthy of research only in their roles as vectors of FHV into "normal" society, and not as valuable members of society in their own right. A work perspective, as opposed to a deviance model, may be a more fruitful approach to male sex work research:




Among the second type, call men, there are six subtypes: 1. Bisexual and gay-identified men, who operate from a list of clients. 2. Models and escorts, who advertise in local newspapers and magazines, and provide social as well sexual services. 3. Transvestites and transsexuals, who advertise for clients or operate from a list of clients. 4. Masseurs, who are usually gay identified and provide massage with a sexual twist. 5. Agency-affiliated call men, who operate from a formal agency. 6. Erotic stars and dancers, who often perform in pornographic movies or erotic dance productions" (Waldorf and Lauderback 1992:109).






28


Sex workers have been presented in the literature as both victims--of psychological
malfunction or economic necessity--and as threats to public health, two
perspectives which may disempower sex workers through reinforcement of the
ideology of deviance. In order to reframe research into male sex work, it is
necessary to proceed beyond bio-psychological models, and to examine the micro
and macro level forces on the conduct of male sex work and their safe sex
practices. Research which explores the immediate circumstances of the sexual
encounter, the wider impact of social and economic forces, social constructions of
male sexuality, and interpersonal communication and power is needed to shed
further light on the safe/unsafe negotiations of male sex workers and their clients
(Browne and Minichiello 1996:52).


HIV studies of male sex workers have been of limited scope (Elifson, Boles and Sweat

1993). A 1988-91 study of 235 male sex workers in Atlanta found that they are at high

risk for HIV /STDs through high-risk sexual behaviors--particularly anal sex--with

multiple paying and non-paying sex partners. In terms of HIV risk, "the number of a

person's sexual partners is less relevant than is the type of sexual acts in which that person

engages" (Elifson, Boles and Sweat 1993:82).


Transsexual and Transvestite Sex Work

That some transgendered individuals are sex workers is not a recent or uncommon

phenomenon. Boyer (1989) refers to transvestite prostitution in France in the early 1700s;

transgendered sex workers in the U.S. in the mid-twentieth century were noted by

Benjamin (1966). In some areas, Transsexual and Transvestite Sex Workers (TTSWs)13





13 Reflecting the evolving terminology used to refer to transgendered people and sex workers, the orientations of the various disciplines, workers' self-identities, and the degree of attention to those identities, they may be called transvestite, transsexual, transgendered, or cross-dressing sex workers or prostitutes in these accounts. I have chosen TTSWs, which collectively reflects participants' self-identities and the view of commercial sex work as an industry, while avoiding the often pejorative and disempowering term "prostitute."






29


constitute significant proportions of the sex workers. For example, about 25% of the street-based sex workers in San Francisco are transgendered (Calafia 1997).

"She-males" may constitute a subcategory within the TTSW umbrella. Blanchard and Collins (1993) state that in visual pornography, there are two types of images featuring feminized men:

One of these is she-male pornography. 14 The term she-male, in the vernacular,
refers to men who have achieved a female chest contour with breast implants or
hormonal medication but still retain their male genitals. She-male pornography, as
one would expect, emphasizes the simultaneous presence of male primary and
female secondary sex characteristics (Blanchard and Collins 1993:570).


Following Blanchard (1993), Brown and Rounsley state: "she-males may make their living based on the dual nature of their hormonally or surgically altered bodies. Typically, they are distinguished by flamboyant feminine attire, makeup, and hair styling while signaling an unmistakable male body beneath the costume. Their dramatic dress and appearance serve as advertising to potential 'dates' and also as a way to feel more attractive" (Brown and Rounsley 1996:16).

TTSWs' geographic distribution is global; they are "found in major urban areas

throughout the world" (Elifson et al. 1993:260). Recent mentions of TTSWs in countries other than the U.S. include Argentina (Faas and Barreda 1992), Brazil (Inciardi and Surratt 1997; Kulick 1997; Mott and Cerqueira 1996; Parker 1989; Pinel 1989; Szterenfeld, Peterson and da Silva 1994), Canada (Montreal: Gobeil and LaPalme 1996; Vancouver: Rekart, Manzon and Tucker 1993), France (Serre et al. 1994), India



14 The other type is transvestic, which includes "photographs of men dressed as women, sometimes with their clothing arranged to reveal the presence of penis and scrotum" (Blanchard and Collins 1993:570).






30


(Bullough and Bullough 1993; Nanda 1996), Italy (Gattari et al. 1992), Israel (Modan et al. 1992), Malaysia (Slamah 1996), the Philippines (Raymondo, Fleras and Resurreccion 1996), the Netherlands (Gras et al. 1997; van Roosmalen et al. 1996), Singapore (Ratnam 1986; Tsoi 1990), and Tahiti (Bolin 1996a), among other locations. Excerpts from several of these reports are provided to illustrate general characteristics, sexual and drug-related risk behaviors, HIV/STD prevalence, and intervention/social needs of TTSWs. Unfortunately, many were presented only in poster form at AIDS conferences, and details are sparse. With few exceptions, these studies are limited in scope; ethnographic data concerning TTSWs and the realities of their lives are conspicuously lacking.

Brazil has an estimated 5400-7200 "transvestites" in sex work, averaging 4 clients per night. Among 113 workers in Bahia, 33% reported one or more "silicone applications;" another 42% are planning silicone. This intervention project reported "excellent results" with a community-based program, including the development of culturally-appropriate printed IV/STD education materials (Mott and Cerqueira 1996).

In a Rio de Janeiro study of 46 transvestite sex workers; 63% were positive for HIVantibodies. Workers engaged in both insertive and receptive anal sex with clients. The authors suggest that participants may be factors in the spread of HIV, and call for specialized intervention (Inciardi and Surratt 1997). Also in Rio de Janeiro, Szterenfeld, Peterson and de Silva (1994) report that participation in the Health Project in Prostitution led to the organization of the Association for Transvestites and the Liberated, with a membership of 98 transvestite sex workers. They conducted a survey with 134 workers, then used "a select group" to keep field notes on client profiles for a study of non-use of






31


condoms. Sex workers, who engage primarily in insertive anal sex with clients, increased their levels of preventative behavior through increased risk perception and increased negotiating power developed through peer organization and exchange of information.

In a study of 216 street-based prostitutes in Tel Aviv, including 180 females and 36 transsexuals, HIV infection rates were much higher in the latter group. None of the 128 female sex workers who were not injecting drug users (IDUs) was infected, while 3.8% of IDUs were HIV-positive. Eleven percent of transsexuals were HIV-infected, including 9.4% of non-IDUs. These differences were attributed to the practice of receptive anal intercourse, which had been practiced by all of the transsexuals, while less than 10% of the female prostitutes reported a history of anal intercourse. There was no mer-?o'n of insertive anal intercourse by transsexuals. Most transsexuals had either been castrated or were planning castration; 25% reported SRS (Modan et al. (1992).

TTSWs face a number of problems related to both their employment in commercial sex, and the more specialized issues particular to tle transgendered. Rekart, Manzon.and Tucker (1993) reported on a convenience sample of 40 "street involved" transsexuals! in Vancouver (90% of whom reported involvement in sex work) recruited through a medical clinic, and concluded:

Street-involved transsexuals comprise an extremely high risk subpopulation with severe social and personal impediments to behavior change. At a minimum this
group requires counseling, social support, medical care, access to gender
dysphoria care, opportunities for education, training and participation, more
sensitivity in their care givers and access to sex change surgery (1993:1).


In an ethnographic account of TTSWs and their lives, Kulick recently reported on

Brazilian transgendered sex workers, "one of the most marginalized, feared and despised






32


groups in Brazilian society" (1997:575). H~e discusses a number of salient issues for TTSWs in Brazil, among them gender construction, body modification and occupational and personal sexual behaviors, each within cultural context. Further, he uses this example to call for a sex-role based redefinition of gender in Latin America. In Chapter 5, a number of Kulick's discussion findings are described and compared with results of this research.

There are few reports of intervention programs designed to target TTSWs.

Community outreach, including peer education, has been successfully used to increase TTSW empowerment in Kuala Lumpur. The creation of a "safe space" in which workers could discuss behavior change and public sensitivity efforts were key components of the program (Slamah 1996).

Serre et al. (1994) interviewed 206 TTSW in Paris in 1993 in an intervention

feasibility study. Most were foreign born: 35% came from North Afica, 20% from Latin America, 11 % from southern Europe, and 8% from Asia. This indicates both the widespread geographic origins and apparent international mobility of TTSWs, which may have profound HIV/STD epidemiological implications. International migration of TTSWs was also reported in two studies in the Netherlands. In Amsterdam, Gras et al. (1997) reported that among 25 TTSWs, 84% came from Latin America, almost all from Ecuador. Behaviors with clients included oral (88%), receptive (9 1%), and insertive (92%) anal intercourse. Of the 25, 24% tested HIV-positive. In Rotterdam (van Roosmalen et al. 1996) reported that 25 of 40 TTSW were Ecuadorian; of the total sample, 8% tested HI V-positive.






.3


In Rome, Gattari et al. (1992) interviewed 67 TTSW/IDUs (49 Brazilians and 18

Colombians) recruited from a clinical population. All participants reported over 500 sex partners in the last year; two-thirds reported 5- 10 partners per day, resulting in over 1500 partners in the last year. Overall, 66% were HV-positive.

Elifson et al. (1993) conducted street-level research with 53 "transvestite prostitutes" in Atlanta, GA in 1990-91. Over 80% of those in the sample were African-American, consistent with the ethnic composition of the population. Sixty-eight percent were fHlseropositive, and 79% and 76% had seromarkers for syphilis and for hepatitis-B These results were contrasted with 1988-9 1 research (Elifson, Boles and Sweat 1993:79) among non-transgendered male sex workers in the same area that showed much lower HV/STD prevalence (29%, 25% and 58%, respectively). In an analysis of the effects of social networks of the same population of 53 sex workers in Atlanta, Boles and Elifson contrast a number of variables that distinguish the geographically distinct groups studied. Some were positively associated with higher levels of FIIV/STDs, including a higher commitment to transvestitism, which results in social and physical isolation, participation in risky sexual encounters, and "adverse life experiences with concomitant feelings of vulnerability and helplessness" (1994a:93).



Clients of TTSWs

Though clients are an obvious necessary component in all commercial sex

transactions, they are rarely studied or targeted with specific intervention. Clients are "traditionally absolved of all responsibilities in relation to the commercial sex sale," though






34


they are "the largest group of people involved in the sex industry" (Brown and Minichiello 1996:43). Not surprisingly, there is very little information about the clients of TTSWs.

Among 150 regular clients of transvestite sex workers in Sao Paulo, 68% were

married or had regular female partners, and 97% self-identified as heterosexual. Of the 150, 18% engaged only in insertive anal sex with transvestite sex workers, 21% only in receptive, and 57% in both; 4% did not engage in anal intercourse (Pinel 1989).

Men who may specifically seek transsexual and transvestite sex partners may be

considered a distinct behavioral category. Money and Lamacz (1984) may have been the first to publish reports of men with specific sexual interest in transvestites and transsexuals, naming this phenomenon "gynemimeophilia."15 Blanchard and Collins followed, with "Men with Sexual Interest in Transvestites, Transsexuals, and She-Males:"

We will use the term gynandromorphophiles to designate all men with distinct sexual interest in feminized men, including in the latter men wearing women's
attire and men with surgically or hormonally feminized bodily contours but intact
male genitalia (1993: 570).

These Toronto researchers reviewed available pornography and "personal ads" placed by TTSWs and men seeking sex with transgendered partners, and conclude that gynandromorphophilia is not "extremely rare," and that it constitutes a distinct erotic interest. They note that this population has been accorded little attention "despite the celebrity accorded the objects of their desire" (1993:570). Autogynephilia, which is often associated with gender dysphoria, may explain the motivations behind some clients' specific interest in TTSWs (Blanchard 1993a; 1993b). Autogyneophilia is defined as:



IS Gynemimetics, the objects of their attention, are viewed as homosexual, attracted to heterosexual men, and not sexually stimulated by female attire (Money and Lamacz 1984).






35


a male's propensity to be sexually aroused by the thought or image of himself with
female attributes. The best known form of autogynepliilia is transvestism, that is,
recurrent cross-dressing in heterosexual males that, at least in puberty or
adolescence, is associated with sexual arousal (Blanchard 1993a:69).

There are 3 three types of autogynephiles, who differ in the type of self-image that stimulate arousal:

Some (commonly called transvestites) are most aroused by the image of themselves as clothed women. Others are most aroused by the image of
themselves as nude women. A third group, whom I have called partial autogynephiles, are sexually aroused by the image of themselves with a mixture of male and female anatomic features, usually women's breasts
and man's genitals (199'3b: 301-3 02).


Blanchard maintains that "partial autogynephiles evince a particular sexual interest in those individuals known in the vernacular as she-males" (1993 a: 69). 16 If his speculation is correct, and autogynephilia applies to at least some component of TTSWs' clients, this may offer some interesting insight into their involvement with TTSWs: they specifically seek a sex worker that approximates an arousing image of themselves.



Body Modification

Body modification through the use of feminizing hormones (e.g., estrogens) and silicone application, as well as Sex Reassignment Surgery (SRS), 17 has been widely reported among transsexuals and some TTSWs (see Asscheman and Gooren 1992; Denny 1995; Kulick 1997; Mott and Cerqueira 1996). Hormones' effects include reduction in



1As Blanchard and Collins note, however, in the Toronto personal ad study, "the majority of men who placed advertisements for cross-dressers, transvestites, transsexuals, or she-males were not cross-dressers themselves" (1993:574).

17 SRS options and procedures are briefly reviewed in Brown and Rounsley 1996, and widely discussed elsewhere.






36


body hair, reduction of testicular volume, inhibited erection, skin smoothness, breast development and changes in body fat distribution. They are also associated with a range of psychological effects, including emotional calming (Cohen-Kettenis and Gooren 1992). Hormones are often obtained illegally; hormone administration in the absence of medical monitoring is associated with a number of risks. Adverse effects include "chronic nausea, headaches, heart palpitations, burning sensations in the legs and chest, extreme weight gain, and allergic reactions" (Kulick 1997:576).

Direct silicone injection for body feminization is also widely practiced by TTSWs. It is associated with a range of negative outcomes (Sadusk 1996), including systemic illness, immuno- supression, and disfiguration due to hardening and migration of the silicone; short-term effects include respiratory distress and death (Denny 1995; Greer 1993; Rapaport, Vinnk and Zaremn 1996). Since silicone injections are illegal in the U.S., medical grade silicone is not available (Denny 1995). The Oakland Tribune reported that the most common source of injected silicone is a non-sterile industrial grade, purchased from hardware stores or automotive supply houses (Anonymous, Feb. 18, 1993). Injected silicone can be removed only surgically (Ohtake, Itoh and Shioya 1992).


I-IV/STD Epidemiology

HIIV (in the Americas, almost exclusively the HIV- 1 strain) is the virus that leads to

AIDS. HIV is transmitted through contact with infected body fluids, principally blood and semen, in three ways: through sexual, parenteral and perinatal contact. AIDS is a medical diagnosis made when an individual is HIV-positive (i.e., tests positive for ILV-antibodies, following standardized screening and confirmatory testing procedures) and exhibits one or






3 7


more AIDS-defining conditions (CDC 1 997a). As such, AIDS has a biological base-1-IlV--but the disease itself is a biomedical and sociocultural construct. As Singer says, "cAIDS is present only when those with authority to define disease say so" (1994:94 1).

Sexual transmission of HIV occurs primarily through anal18 and vaginal intercourse, and less frequently through fellatio (Ostrow et al. 1995; Royce et al. 1997). The use of condoms has been widely promoted for risk reduction during the HJIV epidemic. Though condom failures preclude 100% effectiveness, latex condoms are considered "highly effective when used consistently and correctly" (CDC 1995: 1). Transmission of HIV is influenced by factors in the "three corners of the classic epidemiological triangle--host related factors (susceptibility and infectiousness), environmental factors (the social, cultural and political milieu), and agent factors (HIV type 1)" (Royce et al. 1997:1072). The likelihood of sexual HIV transmission is affected by a number of cofactors, including the presence of other STIs and substance abuse-related immunosupression (Stine 1998). Among street-based sex workers frequent use of crack cocaine has been linked with oral H-IV transmission (Wallace et al. 1996); a number of other STIs are more commonly transmitted through oral sex (American Public Health Association 1990).

Both Hepatitis B Virus (HBV) and syphilis are also transmitted sexually. Parenteral transmission of IHILV and HBV occurs primarily through the sharing of needles, syringes and other equipment by Injection Drug Users (IDUs); such transmission of syphilis is rare. Perinatal HIV, H!BV and syphilis transmission from infected mother to chid occurs either in utero or during birth (American Public Health Association 1990). 18 Anal intercourse is the most efficient sexual transmission mode, receptive more than insertive, due to rectal trauma, seminal alloantigens transmitted through anal intercourse have been linked with imunosupression in female and transsexual sex workers (Ratnam 1994).






38


Links between HIV infection and injecting drug use (IDU) are well established;

however, those between the use of non-injection drugs and HIV transmission are not as clear. Paul, Stall and Davis (1993) review a number of recent studies of Men who have Sex with Men (MSM) and substance use; they conclude that those who combine sex with drug and alcohol use are more likely to engage in high-risk sex. While this does not prove that substance use causes risky behavior, MSM with higher rates of substance use are more likely to become FIIV-infected (Stall 1996). Use of poppers by MSM has been linked with lapse to unsafe anal sex (Valleroy et al. 1993). Cocaine and poppers use has been linked with HIV seroconversion in MSM (Ostrow et al. 1995).

Now on the threshold of the third decade of the epidemic, the global EIV devastation continues to accelerate. At the end of 1997, over 30 million people are estimated to have been HI V-infected (Brown 1997). The epidemic is accelerating: cumulative infections are expected to reach 60 to 70 million by the end of 2000, if current trends continue (CDC 1997b).'9 Stein and Susser state "the formidable prospect of this transmissible, chronic, and disabling disease spreading to many more individuals is certain" (1997:901 ).21

In the U.S., 612,078 cases of AIDS have been reported through June 30, 1997;

379,258 are dead (CDC 1997a). Hundreds of thousands more are infected with HILV, but have not yet developed AIDS. Many are not aware of their infection, and cannot take advantage of treatment options: CDC's Patricia Sweeney estimates that 141,000 to



19 An estimated 90% of AIDS cases are in developing nations; they receive 6% of global treatment spending (Jackson, D.Z. 1997A2 1).
20 Referring to the growing number of global infections, they continue: "these figures are no less relevant to the United States than fam-ine in the Sahara and civil wars in Yugoslavia and Rwanda" (Stein and Susser 1997:90 1).






39


355,000 of the estimated 650,000 to 900,000 HV-positive individuals in the U.S. have not been tested for HIIV (CDC 1997c). At the same time, the US is experiencing a ccsecond wave" of new HV infections, concentrated largely in ethnic minorities and young people. As new generations of young people are becoming sexually active, unprotected sexual behaviors are common in some at-risk populations (CDC 1996b; Lalota 1997; Valleroy et al. 1996). Reported gonorrhea cases in MSM have increased almost 9% since 1993 (CDC 1997), while overall cases have decreased. The Miami Herald quotes Dr. Helene Gayle of CDC, who speculates that this trend is "an indicator that people are returning to unsafe sexual behavior" (Anonymous 1997c: 5A).

Ethnic minorities are disproportionately represented in FIIV/STD statistics. AfricanAmericans now account for 4 1% of AIDS cases, and have surpassed whites to account for the largest proportion of cases in the nation (CDC 1997a). In the 1995-96 Young Men's Survey in Miami, randomly sampled African American 15-22 year old MSM who attend public venues were found to be HIV-infected at a rate more than double that of Hispanics, and five times higher than Caucasians (11.5, 5.4, and 2.3% respectively; Lalota 1997).

In 1995, African-Americans accounted for 79% of reported gonorrhea cases, with a

rate of 1087 cases per 100,000 population. This compares with a rate of 91 for Hispanics, and 29 for non-Hi-spanic whites. Among young Afican-Americans, the rates were much higher: for 15-19 year old females and males, the rates were 4433 and 3267, respectively. Combined, this gonorrhea rate is 27 times higher than that of same-age whites (CDC 1996a:2).






40


Noting that "there are no known biologic reasons to explain why racial or ethnic

factors alone should alter risk for STDs," CDC attributes the differences in STI) rates to c4poverty, access to quality health care, health care seeking behavior, illicit drug use, and living in communities with high prevalence of STDs" (CDC 1996a: 1).21 Higher HIV infection and AIDS rates among ethnic minorities in the US, and some explanations for these disparities, have been discussed by Peterson and Marin (1988), Peterson et al. (1993), Stokes, Variable and McKirnan (1996), and Whitfield (1997). These are reviewed in Chapter 5.

In the US, the epidemic is rapidly changing. While there is still no cure, recent

medical advances have caused some to hope that HIV may soon be a chronic, manageable disease. In the aggregate, AIDS diagnoses and HIV-related deaths have declined since the development of protease inhibitor drugs and their successful use in multiple-drug "cocktails" (CDC 1997a). Unfortunately, the new treatments are financially unattainable

22
for some. Even for those with the means to access care, some find the drugs' side effects to be intolerable. There is recent evidence that new treatments are beginning to fail in some cases, due both to noncompliance with complex treatment regimens and viral resistance of the drugs (Bor 1997; Anonymous 1997d). Ethnic minorities do not benefit proportionately in the more favorable morbidity and mortality picture: from 1995 to 1996,





2' Reporting bias may influence these rates; public-source reporting may be more complete than private, and minority populations rely more on public health clinics for care. Protease inhibitor regimens alone can cost $15,000 to $20,000 per year (Gallagher 1997; Nyhan 1997); this does not include regular examinations and blood tests, other prophylaxes and treatments, etc.









US AIDS-related death rates dropped 28% among whites, 16% among Hispanics, and 10% among African-Americans (CDC 1997a).

Florida has been particularly hard-hit by the epidemic. The state's AIDS rate of 416

per 100,000 is double the national average. Over 64,000 people have been diagnosed with AIDS in Florida; half have died (Dade County Health Department 1997). Three South Florida counties--Dade, Broward, and Palm Beach account for over half of the state's AIDS cases, and their principal cities, Miami, Fort Lauderdale, and West Palm Beach, are consistently among the top 10 cities in the country in terms of AIDS rates. In 1997, Miamni reports the second-highest AIDS rate of major cities in the nation (CDC 1997a).

Shultz et al. state "Miami/Dade County has been a primary epicenter for the HIIV/AIDS epidemic since the earliest reports" (1995:2 1). The local epidemic is comprised of several discrete subepidemics, with infection pools concentrated within behavioral categories: injecting drug users, MSM, and increasingly significant heterosexual component. Dade alone accounts for one-third of Florida's AIDS cases, though it holds less than 15% of the state's population. African-Americans are increasingly the most infected and affected ethnic group: they account for half of the cumulative AIDS cases, though they comprise approximately 23% of the total population. A staggering 72% of AIDS diagnoses reported from 1992 through July 31, 1997 were among AfricanAmericans (Dade County Health Department 1997).

Until 1997, Florida HIV infections were not reportable to public health authorities, so we must rely on estimates and seroprevalence surveys for these rates. Results from several studies suggest that South Florida is again overrepresented, with relatively high






42


rates of HIV infections, particularly among ethnic and sexual minorities, and that risk behaviors remain prevalent in some populations (Lalota 1997; Webster 1997; Valleroy et al. 1996). An estimated 17,000 persons (range 7000-28,000) are living with HIIV in Dade County, and an estimated 1209 (range 483-1814) will have become newly infected in 1997 (Holmberg 1996:646).3

In the US, HIV is increasingly becoming a disease of the marginalized and the

disenfranchised. As we address treatment of the hundreds of thousands more who are already infected, this gap is likely to widen as treatment resources become more scarce. Rationing of drugs and limited drug availability due to funding limitations24 are becoming common (Gallagher 1997). Thirty-five of 52 state-administered AIDS Drug Assistance Programs (ADAPs) have been forced to reduce the series of drugs available in the last year (Pedersen and Larson 1997:60). All these factors underscore the importance of a continued emphasis on primary, as well as secondary, prevention measures. Some populations at highest risk remain "hidden," and difficult to access. They often distrust, and are excluded from, the mainstream of society and public health. Particularly for them, population-specific data are essential prerequisites to effective intervention.

This chapter establishes several key points. Gender is a culturally constructed quality that encompasses a range of assumptions governing male and female behavior. The


23 These figures are derived through triangulation of several population modeling techniques. This methodology has been critiqued by Mills et al. (1997) and responded to in Holmberg (1997). As Holmberg states, "there are unavoidable limitations to any comprehensive attempt to collect and analyze HTV prevalence and incidence data" (1997:866). 24 Further, those receiving the drugs are living longer; their reduced mortality means fewer new spaces become open in assistance programs (Stolberg 1997). Without increased funding or a drop in drug costs, current trends seem likely to continue or accelerate.






43


dominant expectation in our society is that sex, gender identity, gender role and sexual orientation adhere to a bipolar, biologically based linkage. However, the natural variation in humans exceeds the limits of this model, despite the power of these culturally-derived assumptions. Transsexualism, a biomedically-based concept which reflects a dichotomous gender system, represents an extreme example of variance from this model. Its etiology is most likely multifactorial, resulting from an interaction between biological substrata and postnatal influences.

Medical anthropologists have responded in multiple ways to the HIV epidemic, driving a significant redirection of the subdiscipline. Biocultural approaches to the analysis of human health and disease focus attention on the sociocultural realities that contribute to disease, as well as biological factors; these approaches exemplify the holism of anthropology. As the IV epidemic continues to grow, commercial sex work has increasingly become the focus of MII-related research. Though there is a relative paucity of information about the sizable population of transgendered sex workers worldwide, limited research from several countries suggests that that these individuals are at particularly high risk for a number of negative outcomes. TTSWs are actively represented in Miami, but have never been the focus of specific research. Miami 's status as an epicenter in the expanding IRV epidemic emphasizes the compelling need for populationspecific research and intervention, particularly among those at elevated risk.















CHAPTER 3
STUDY DESIGN AND METHODS


Study Design

Limited studies of TTSWs in other areas have documented high rates of risk behaviors and HIV/STD infection. In general, these studies have been narrowly focused on behavioral risk and resulting disease seroprevalence. They lack a holistic and comprehensive approach to understanding TTSWs' lives--of which sex work is only one component--as experienced by TTSWs themselves. This includes their views about themselves and their work, including risk behaviors and clients, and their social interactions and intersubjective feelings about themselves within society. This research attempts to address this gap, and to examine TTSWs' experiences in this nexus of gender, sexuality and marginalization, with a biocultural approach that combines ethnographic and behavioral epidemiological methods. As a result, it makes both applied and theoretical contributions to medical anthropology and public health.

The project was designed to explore channels of access to this local population, and to gain knowledge about their culture, their behaviors, and their articulation with the HIV epidemic. It functions as a needs assessment, in determining baseline HLV/STD seroprevalence rates, TTSWs' levels of access with health care, and their barriers to health. It also seeks to determine the knowledge levels, and occupational and




44






45



nonoccupational risk behaviors of these individuals. Other central questions, however, occur at a different level. By definition, transgendered people challenge a predominant assumption we make about being human: that one is either male, or one is female. Being transgendered must, in and of itself, present a number of challenges to daily life. Being a transgendered sex worker must multiply those challenges. Yet very little was known about these individuals. Accordingly, this project asks: What is it like to be transgendered and a sex worker in Miami?

On the epidemiological side, the principle research objectives include the estimation of:

1. HIV, Hepatitis B and syphilis prevalence
2. Prevalence of sexual and drug use behaviors
3. The association between these behaviors and HIV/STD prevalence 4. The association between psychosocial measures and risk behaviors
5. The association between these measures and HIV/STD status

in TTSWs in the Miami area. Principle outcome measures include unprotected sexual contact, multiple partners, history of exchange sex, needle and drug use, including body modification, HIV/STD seroprevalence, and a range of psychosocial factors. Hypotheses include:

1. Behavioral outcomes are associated with HIV/STD infections
2. HIV infection is associated with current or previous HBV, syphilis and other
reported STD infection
3. Psychosocial factors: self-efficacy, social support, self-esteem, identity salience,
and perception of condom norms are inversely associated with risk behaviors
and HIV seroprevalence
4. Psychosocial factors: internalized homophobia and perception of HIV risk are
positively associated with risk behaviors and HIV seroprevalence.






46



Participation eligibility criteria for the study included male sex at birth, and

acknowledged participation in street-based commercial sex work (within the past six months) with deliberately feminized appearance (through makeup, body modification such as silicone implants or injection, hormones, false breasts, etc., or female attire). A minimum age of 18 years was required by the University of Florida Institutional Review Board (IRB), which must approve research with human subjects.


Sampling Methodology

Gathering data on hidden populations and covert behaviors presents a number of methodological problems, Since these populations cannot be accurately enumerated. generating a truly random sample for research is not possible. To recruit as representative a sample as possible, I used procedures adapted from Targeted Sampling (Watters and Biernacki 1989), which was also used by Elifson et al. (1993) in their Atlanta TTSW study. The designers of the technique state: "while they are not random samples, it is particularly important to note that they are not convenience samples. They entail, rather, a strategy to obtain systematic information when true random sampling is not feasible" (Watters and Biernacki 1989:420). Targeted Sampling requires the initial mapping of geographical areas of population activity, following personal observation and ethnographic data collection from knowledgeable informants. Initial sampling chains are begun with recruitmentof participants from these areas. These participants are then asked to refer someone who meets eligibility criteria,






47



Data Collection Instrument

The quantitative section of the data collection instrument is based on the instrument used by the Young Men's Survey (YMS; CDC n.p.). YMS is a cross-sectional study of age 15-22 MSM being conducted in several major cities in the U.S., and sponsored by the U.S. Centers for Disease Control and Prevention (MacKellar et al. 1996; Valleroy et al. 1996). 1 reasoned that the potential comparative value of the data made duplicating a number of YMS questions worthwhile.' In designing the tool for this study, a number of questions were added to the YMS instrument, and others were deleted. Other questions were later added and deleted in the field.

Response cards containing frequencies or Likert-type evaluations were used for some questions. Response cards were printed, and English and Spanish versions were available. An English-language summary of response cards appears in Appendix A.

The following is a review of changes and revisions made to the original instrument, and a brief discussion of problems encountered with some questions (see Appendix A).

Section A collects basic demographics; questions are self-explanatory. Each of the questions in this section was retained throughout the project.

Section B, venue attendance, is designed to elicit specific points of contact to facilitate the implementation of future intervention programming. For these questions, fists of specific venues shown to participants, but frequency of attendance was not limited to these particular venues. For reasons of confidentiality they will not be reported.




' This will by necessity be a future endeavor; as of this writing the initial YMS data set is still being analyzed.






48



In section C, sexual behaviors, "sex" was defined as oral, vaginal or anal intercourse, in either insertive or receptive role. Using this definition, a participant could have qualified for enrollment without ever having had sex. This was not the case for any participant. In many cases, language used on the instrument was not appropriate. In these cases, with agreement from participants, more understandable and less cumbersome terminology was employed.

Partner types were divided into three distinct categories. Exchange partners were defined as those with whom participants had sex in exchange for something, such as money, food, shelter, drugs, etc. Steady partners are non-exchange partners with whom participants had sex three times or more. Non-steady partners are those non-exchange partners with whom participants had sex just once or twice.

Questions C23a and C23b measure frequency of condom use for oral intercourse. This contained a shortfall that became apparent in the first interview, and one of several that illustrated some of the limitations of the instrument. It also provided an immediate example of researcher bias: I did not expect TTSW to receive oral sex from clients, only that they would provide it. C23 as originally planned did not separately evaluate condom use for performing and receiving oral sex. I changed this question to C23a, condom use frequency for receiving oral sex, and C23b, for performing.

Questions C24 and C30, in which participants specified places in which they perform oral and anal sex with exchange partners, became repetitive and redundant. To facilitate interview flow, I deleted them in favor of inferring these responses from questions C 14 and C19, in which participants specify places in which they engaged in oral and anal sex






49



with any partner type, and gathering these data qualitatively. More often than not, the qualitative data--much of it gathered in the form of stories and conversation that accompanied questions C 14 and C 19--were more informative.

In section D, medical history, question D I asks participants to name the places they usually go to seek health care. This is asked as an open-ended question, using venues as prompts as needed. In question D 13 ("Have you ever been tested for HIVT') I discovered that a more specific question was needed, since a number of individuals had been tested in jail or prison, but were not given their results. I modified this question to assess only intentional, voluntary testing.

D 19 ("Which of the following best describes how likely it is that you will get HIV at some time in the future?") was unwieldy, and some early participants became annoyed at thequestion. Since other variables (HI, H9 and H17) evaluate similar HIV risk perceptions, I deleted the question.

In section E, sexual history, no changes were made.

In section F, drug and alcohol use, no changes were made.

In section G, a number of questions were problematic, illustrating the inherent methodological weakness in asking people to place themselves and their identities in predetermined categories. These issues were much more informatively assessed in less structured discussion.

GI (which asks participants to select their self-identities from a menu of sexual identities and orientations) answers were explained to be not mutually exclusive;






50



participants could pick as many as they felt applied. G2 is a numerical evaluation of GI responses, and became confounded by the multiplicity of answers in G1.

G3 )-G5, which asked respondents to numerically value the importance they place on their sexual, ethnic, and religious identities, were most useful as prompts for discussion.

G6 ("How old were you when you first thought of yourself as {identity)?") was

confounded by a number of participants who relied that they "always knew." Again, this issue was better addressed qualitatively.

Questions G8-G12 presented similar problems. G8 requests a numerical evaluation of how "out" participants are about being f identity). This became highly confounded, as discussed in Chapter 5. G9 ("How old were you when you first came out?") refers to intentionally disclosing identity, as do GIO-GI2 ("Have you ever come out to your {mother, father, sibling)?"). In many cases, disclosure was not necessary, since participants' sexual identities or behaviors were disclosed by someone else, or it was assumed (i.e., "everybody always knew").

These were among a number of questions that I took to the field that illustrated the effectiveness of qualitative methodology with this population in realms such as identity and orientation. As an example, while being "out" to other people about one's sexual orientation is a fairly straightforward concept among other groups, such as gay men or lesbians, this question can become more complicated among the transgendered. Sexual orientation hinges on gender identity, and the two often become mixed. As an example, Eliana is a male-to-female transsexual, who self-identifies as a woman, and is bisexual. For Eliana, being "out" could mean (1) disclosure of male biological sex, (2) disclosure of





51



female gender identity, or (3) disclosure of having sex with partners of either sex. Salient issues for this entire section were much more effectively assessed in open-ended discussion.

In Section H, Attitudes and Personal Beliefs are measured on a 5-point Likert Scale, whose poles were "do not agree at all" and "strongly agree." Many of the questions are difficult, in terms of language and comprehension, and required clarification. For example, H23 states "I find it difficult to tell a sex partner not to do something that I think is unsafe." While the question is logical, in the field it often had to be restated with lower complexity. Section H questions were particularly useful as discussion points for qualitative data collection.

Overall, the quantitative section of the instrument proved to be a reasonably good and efficient tool. Questions in the interview guide are divided into topical sections, but the answers came more randomly in discussion that always accompanied them. Many of the salient issues that TTSW face are not included, or are insufficiently probed, as collection points in the quantitative section; I attempted to address these issues qualitatively.

The second, qualitative section of the interview instrument is subdivided into 10 categories: language, gender identity, growing up, mascuhnity/femininity, sex" attraction, working life, negative aspects of sex work, clients and behaviors, HIV/A11DS, and social needs/future. Each section includes a number of questions that were used as discussion guides. Not all questions were specifically asked of all participants, as these conversations more naturally flowed.






52



Enrollment and Data Collection

Initial geographic mapping resulted in the identification of two TTSW work areas (ethnically differentiated, Flispanic and African-American) as described in Chapter 4. Once the two areas are were identified, I began systematic observation of the areas on different days and at different times to determine periods of activity and to gain familiarity with the workers and their activity patterns. After several weeks of observation, I began to randomly approach TTSW to talk with them, and to ask them to enroll them in the study. Initial results from repeated street-based recruitment attempts were not encouraging. In many cases, after discovering I was not a prospective client, TTSWs had no more to say and walked away. The successful initial recruitment chains in each district were begun with personal introductions from non-TTSW community informants: Another early but subsequent fEspanic chain was begun with a referral from a streetcontacted TTSW who was also professionally employed, and was fearful of enrollment.

At first contact with potential participants, I explained the scope, requirements, and benefits and potential risks of voluntary enrollment. Many first contacts occurred on the telephone (excluding street-based enrollment attempts, which were not successful except as noted above). In some cases, several telephone conversations preceded enrollment.

Once participation was agreed to, the interview session began with discussion and completion of the informed assent form (required by the Uffiversity Institutional Review Board; see Appendix B), which involved participants making a check mark accepting voluntary enrollment. Participants were given a separate copy of this form. Following completion of the assent form, the State of Florida consent form for anonymous FHV






53



testing was then completed; both forms were then witnessed by the researcher. Following completion of the paperwork, I requested permission to tape-record the interview; which was granted in every interview. Interviews began with the administration of the quantitative section of the instrument, followed by open-ended discussions guided by the qualitative sections. Often, participants initiated discussion of matters that I would have brought up later in the interview. In these cases, I allowed the conversation to flow naturally. These portions of the sessions averaged approximately 90 minutes in duration.

The next segment of the session was an MIV pre-test counseling component,

following CDC guidelines, as required by Florida law. Counseling included information about FHV transmission, FHV risk reduction, and the meanings and limitations of the HV antibody test, including the three-to-six month "window period" between H1ITV infection and the appearance of detectable antibodies. During the FHV pre-test counseling session, I provided participants with a several telephone numbers (beeper, office and dedicated telephone) to reach me, with the understanding that results would be available in two weeks. I stressed that I could also be reached through the person who introduced us. Under Florida law, IEIV test results may be given only in person. I expressed that I would arrange to meet with them at a time and place of their convenience, but that they should call to arrange this (IRB approval was contingent upon participants not providing their names or telephone numbers to the researcher, to protect their anonymity).

Phlebotomy followed the pretest component. Blood was drawn (by the researcher, a trained phlebotomist) by venipuncture, using a standard multiple sample needle or a VacutainerO blood collection set (a.k.a. "butterfly"), into three 7 ml. Vacutainer






54



collection tubes. Each collection tubes were labeled with the same unique scan number, which was also given to participants. Blood samples were stored in a chilled environment, and transported to the Miami Branch Lab of the Florida Department of Health on the next business morning following venipuncture.

In all, six distinct chains of referrals were initiated among 26 Hispanic TTSWs. There is significant network cross-over between chains, since most TTSWs in a given area know each other. Of these six chains, the most referrals made by a single participant was six; I deliberately did not encourage additional referrals in this chain, to increase the representativeness of the sample. The least number of referrals in a chain was one.

Among African-Americans, recruitment was more problematic. The initial participant ("Michelle") referred two additional TTSW, who enrolled. After the first three interviews, however, there were no further African-American referrals for about two months. Subsequent street-level recruitment was again disappointing, until I was able to again communicate with Michelle. She referred one additional TTSW, who enrolled. Though additional TTSWs expressed interest in enrollment after several telephone conversations, I was unable to schedule interviews with them.

This called for another approach, so I decided to make enrollment as convenient as possible. I used an RV' parked near their work area on a Saturday night, and hired Michelle to assist in recruitment. This resulted in four interviews that night, and generated




2 The RV is used for a mobile HIYV research project in the Miami area, and is specially modified to conduct interviews and phlebotomy. TTSWs may have seen the RV on previous occasions at a venue near their work location; this may have generated an additional sense of trust.






55



sufficient word-of-mouth to complete the balance of the Afican-American interviews over the next 6 weeks.

All participants were interviewed between early February through late June, 1997. Interviews were conducted in several different locations, at the convenience of the participant. These locations included private homes, the researcher's office, and, in four cases, in a modified recreational vehicle "on site" near the working area. Each participant received $50 in cash as an enrollment incentive?

Just two Caucasian TTSWs were interviewed, in addition to the 22 African-Americans and 26 i-spanics, for an initial total sample of 50 TTSWs. Since Caucasians represent a relatively insignificant component of the active TTSW population in Miamni--I found no evidence of more active Caucasian TTSWs--and any discussion of them or their activities could compromise their anonymity, these two interviews were excluded from analysis.

Interviews were conducted in English or Spanish, depending on the comfort level of the participant. All 22 African-Americans were interviewed in English. Of the 26 Hispanics, 10 interviews were conducted entirely in Spanish, 6 in a mixture of both English and Spanish, with more than 50% in Spanish, and 10 in English. The researcher is fluent in Spanish, and these interviews were conducted by simultaneous translation of the English instrument.






All project costs were funded by the researcher, who was employed by a CDC/Florida Department of Health-funded HIV/AIDS research project at the time of the research. The Miami Branch Lab of the Florida Department of Health processed all blood samples at no charge to the researcher.






56



Data Analysis

Quantitative data were compiled and analyzed using EPI INFO 6 (CDC and WHO 1997), a public-domain database and statistics program oriented toward public health applications. Statistical analyses of relationships between variables were conducted using the chi-square test or equivalent and the Fisher's Exact Test where appropriate.

For qualitative data, notes taken during the interviews were combined with the transcriptions of the tape recordings of the interviews, and divided by subject area. Fieldnotes were taken during all aspects of the project, including during subsequent interviews with key informants; these notes were merged into the data set as appropriate.

This sample should be considered a representative "middle ground" between random and convenience samples. Specific efforts were made to increase its representativeness, and it is opportunistically and reasonably representative of the local TTSW population. Nonetheless, as the developers of Targeted Sampling caution, "targeting samples can reduce the analytic freedom available.., researchers may find that they have violated the assumptions that must be met in order to use many statistical procedures" (Watters and Biernacki 1989:427). Therefore, inferential statistics should be applied to the larger population of TTSWs in the Miami area with caution.

All blood samples were processed at the Miami Branch Lab of the Florida Department of Health, using standard testing and confirmatory protocols and procedures. Tests for Hepatitis-B 'surface antibody (BsAb), core antibody (BcAb) and surface antigen (BsAg) were performed by solid phase radioimmunoassay. Past or present HIBY infection is defined by positive BsAg or BcAb; potentially infectious carriers are indicated by positive






57



BsAg and BcAb tests (American Public Health Association 1990; Julg et al. 1995). Syphilis screening included the RPR (rapid plasma reagin), followed by MHA-TP (microhemoagglutination-Treponoma palladium) confirmation of reactive (positive) samples. Samples were screened for HIV using the ELISA (enzyme-linked immunosorbent assay) and recombinant ELISA (for positive initial results) with confirmation by synthetic peptide. In addition, positives were again confirmed using the Western Blot test.

Project Timeline

Preparation, instrument design,
initial field and support contacts November 1995 February 1996

Project proposal, supervisory committee approval, and 1kB application March 1996

1KB approval July 1996

Observational data collection September 1996 December 1996

Interview data collection February 1997 June 1997

Analysis and write-up June 1997 December 1997


Language and Terms

As I requested, all participants identified themselves only with a false first name. Nonetheless, I have chosen another pseudonym for each, attempting to preserve the "spirit" of the name I was given. Most participants refer to themselves with feminine names and pronouns, and I have been careful to respect this through maintaining their use






58



of gender. Most participants, then, will be referred to in the feminine, and a minority in the masculine gender.

Though the terms "African-American" and "i-spanic" have received their share of critical attention, they are the locally predominant terms for these groups, and more importantly, for participants. They may be imperfect, but for consistency will be the terms of reference in this dissertation.

References to "Miami" should be interpreted as inclusive of metropolitan Miami-Dade County, unless otherwise indicated in text.

All references to '111V" should be considered strain HV- 1 unless otherwise noted,

and language such as "KEY-positive" should be construed to mean "positive for antibodies to mv-i1. "

The term "transgendered" might be more inclusive of this heterogeneous sample, and its community-level focus and grass-roots usage also seem more appropriate. It was, however, not recognized by any participant. For this reason, I chose other terminology that reflects participants' self-identities for the dissertation title.














CHAPTER 4
FINDINGS

Demographics and Background


The hidden nature of this population, and its members' sometimes transitory involvement in commercial sex, make a precise enumeration of active TTSWs impossible. However, data gathered through observation and from study participants suggest that there are approximately 100-125 actively working street-based TTSWs in Dade County at this time, and that the ethnic composition of the study sample (54% Hispanic; 46% African-American) approximates that of the TTSW population.

Participants ranged in age from 19 to 49 years at time of interview. African-Americans are significantly younger (mean 24.9 years; range 19-35; median=-24.5) than Hispanics (mean 31.5 years; range 21-49; median-3 3). Study cohorts are also reasonably representative of the ages of the TTSW populations. Aside from the sampling error due to the nonrandom nature of targeted sampling, a number of other factors may contribute to the populations' relative age difference. These factors are discussed in Chapter 5.

All African-American participants reside in mainland Dade County, and all but one in the predominantly Black corridor adjacent to downtown Miami. Of the 26 Hispanics, 15 (58%) live on Miamni Beach, and 11 (42%) live in predominantly Hispanic areas on the mainland. Only one Hispanic participant was born and raised in Miami; twenty-three (88%) were born outside the U.S. Twelve (46%) Hispanics were born in Cuba, the most frequently reported country of birth. Others were born in El Salvador (2), Mexico (2), 59






60


Nicaragua, Guatemala, Costa Rica, Colombia, and Honduras, and one in Europe, though raised in Cuba. As a whole, they are long-term Miami residents: of the 25 who moved to Miami, the mean number of years in the area is 11.28. Sixteen (64%) have lived in Miami over 10 years; only 4 (16%) have lived in Miami 3 years or less. Twenty-one AfricanAmericans were born in the United States. The one exception was born on an Englishspeaking Caribbean island, though she nonetheless self-identifies as Afican-American and holIds U.S. citizenship. Fifteen (6 8%) have lived their entire lives in Miami. Of the remaining six, three were born in the southern U.S., and three in the northern U.S. All but two non-Miamnians moved to the area by age 13.

Education ranges from 1 year to 17 years. Excluding the one outlying Hispanic

reporting one year of formal education, Hispanics report a mean of 10.5 years (range 8-14, median= 11), while Afican-Americans report a mean of 11. 8 years (range 10- 17, median=-1 1.5; P<.06). African-Americans were also more likely to have continued some studies beyond high school, with 23% reporting one or more years of post-secondary education, compared to 7% of Hispanics.

In general, participants reported fairly turbulent childhood years: just 7 (4 Hispanics and

3 Afican-Americans) could characterize their home life as "good" or better. Conversely, 26 (54%) reported poor or extremely poor family relations. During open-ended discussion, participants mentioned specific problems such as living in more than one household, in foster homes or in group shelters (12 participants), familial substance abuse (6), and multiple episodes of sexual abuse (3). In all, 62% of Hispanics and 50% of AfricanAmericans either ran away, were forced to leave by their parents, or were removed by authorities from their homes. Overall, younger participants were significantly more likely






61


(P<.04) to have left home before adulthood: the mean (median) age of those who did leave home was 26(24), versus 31.7(32) for those who did not. Nor surprisingly, reported education levels are lower among those who left home, with a mean (median) of 10.4 (11) versus 11.9 (12) years. Initiation of sex work involvement occurs much earlier for those who leave home, as discussed later in this chapter.

Forty-seven (98%) participants reported that by early childhood they were aware of being somehow "different," in terms of gender identity and/or sexual orientation. Statements such as Lala's: "I've always known something was different in me since I was real little" and Lydia's: "I was always more girl than boy" were common. While four (8%) participants felt distinctly male, forty-four (92%) reported feeling that they felt they were, or wanted to be, a female. One of these reported later changing in adolescence, and now feeling more like a male. Each of the 44 recounted multiple examples of early genderatypical behavior. Michelle recalls "I always played with dolls. I used to prance around in my underwear, in front of the mirror, and I would dance the way I wanted to. I used to say 'I have a girl's body."' Marcela remembers "when I was 5, having fantasies about being a woman and wanting to wear dresses. My mom bought me toys for boys, but I would use my sister's toys."

Without exception, participants who reported experiencing adjustment problems with farnily primarily attributed them to their own femininity and cross-gender behavior (CGB). Juana, who recalls calling herself "Wonder WomarC' at age 6, and wearing her mother's dresses in secret at age 12, stated "I had a terrible home life. I left at 14. 1 was forced to leave, 'cause my father used to beat me for it." Ilena, who left home at age 16, said "They didn't like the way I was and made me go. My family didn't talk to me, and didn't like me."






62


Brigida said "I was always different, a very feminine boy. I got kicked out at age 12. You know how Spanish people are, they think gay people are bad, 'cause of the Bible and religion. So they kicked me out when I was 12." Gisela told me "When I was little, I didn't know what was happening to me. I knew that I liked men, and I knew that I was supposed to be a woman."

Others had related social difficulties, like Justinia: "When I was little, I always felt like

this was the wrong body to be on me. School was really painful for me, because I never fit in. I felt like I was really ugly as a boy." In general, discussions of childhood elicited varying degrees of discomfort from participants. While a few were comfortable talking about their early years, most have made major changes in their lives, and do not relish childhood. As Berta stated, "I had terrible problems. It's all still painful, and I don't want to talk about it."

While two-thirds currently live either alone or with a non-sexual roommate, there are significant differences between Affican-Americans, of whom 55% live alone, in contrast to 19% of Hispanics. Fifty percent of Hispanics, but only one African-American, live with a roommate; others live with parents or other relatives, or with sexual partners (Figure 4-1).


60
50
40
0,630
20
779
10
0
Alone wl parents wt relative wl room mate w /sex partner
African-American (n=22)
Hispanic (n=26)

Figure 4-1. Description of living arrangements.






63


As a whole, participants are quite mobile in residence within the Miami area, with a mean (median) time at present address of 8.5 (4.5) months. Hispanics are slightly more mobile, with 7 (4) months; Affican-Americans, 10 (5) months.

Most participants rely on street-based sex work as their sole source of income. Thirtyseven participants (77%) report no formal employment; 3 (6%) report having a full-time job, and 8 (17%), a part-time job. Other income sources include female impersonator competitions ("doing shows"), mentioned by 8 participants, home-based hair care (4), and cleaning houses (1). Two also advertise their services in a sex work-oriented magazine, which is described later in this chapter. Six Hispanic participants (23%) cannot legally work intheU.S. Thirty-two percent of African-Americans work at a full- or part-time job, compared to 15% of Hispanics. Employment status is associated with number of 6 month exchange partners, as discussed later in this chapter, though not with rates of condom use.

Most participants describe job discrimination based on their transgendered appearance. Seven mentioned being fired, and others commonly stated that they are never even considered forjobs they seek. Accordingly, 25 of the 37 (68%) who are not employed report that they are not seeking a "regular job." Shavonne stated "the girls need jobs. I don't like working the street, but you gotta do what you gotta do. People just don't (hire us)... you go to a place, and try to get you a job, and they look at you funny. They got to start placing girls in jobs, 'cause a lot of them don't want to work the streets."

Dance clubs, generally large discotheques, are distinguished from bars, which are smaller and do not emphasize dancing. To elicit frequencies of attendance at bars and dance clubs, I prompted participants with standardized lists of bars and dance clubs. Hispanics were significantly (P<. 0 1) more likely to frequent bars, with 42% attending daily






64


or almost daily. In contrast, almost 60% of African-American never go to bars (figure 4-2). Hiispanics were also more likely to visit dance clubs: two-thirds visit a dance club once a week or more; 41% of African-Americans never attend dance clubs (figure 4-3). Generally, this difference may be attributed to place of residence--more Hispanics live near an entertainment district on Miami Beach (described later in this chapter), and to locations used for sex work.

The Beach offers a much more tolerant atmosphere for transgendered people, where "drag queens" are a part of daily life: they work as entertainers and as door personnel at nightclubs, and comprise the entire waitress staff in one restaurant. For these reasons, as well as geographic proximity, it is not surprising that Beach residents more frequently attend bars and dance clubs. TTSWs live within walking distance of most establishments, and some of these venues forego admission charges for patrons "in drag." For mainland residents, who have few such venues nearby, going to these venues requires more effort.

The questions about venue attendance were intended to uncover access points for

future TTSW intervention, and to evaluate the venues' potential influences on TTSWs and commercial sex. Generally, venues on the Beach receive regular MLV intervention programming, from local AIDS Service Organizations (ASOs) and the Health Department, in the form of posters and flyers, and some outreach including free condoms. Some TTSWs, though possibly those not at highest risk, can be accessed at these venues. In contrast, observational data reveal that venues on the mainland receive less attention from ASOs and public health authorities, other than EIV-related posters. This is a significant gap in local HIV prevention efforts.







65





60


40
% 30
20
10- M

0
Never <1x/mo 1x/mo 2-3x/mo lx/wk 2-3x/wk >3x/wk

Z] African-Americans (n=22)
Hispanics (n=26)


Figure 4-2. Attendance at bars.




60
50

40
% 30
20 10
0
Never <1x/mo 1x/mo 2-3x/mo lx/wk 2-3x/wk >3x/wk

African-Americans (n=22)
Hispanics (n=26)


Figure 4-3. Attendance at dance clubs.



Lifetime Sexual Behaviors


All participants reported a history of both oral and anal sex with males; 40% also


reported sexual contact with women. Estimates of lifetime numbers of male and female sexual partners were not easily determined: no one bothers to count, and the numbers are generally large. Responses, therefore, while reflective of actual experience, were subject to a number of potential response biases that could have induced measurement error (i.e., recall ability, social desirability, complexity of sexual experience, and others). Comments






66


like Diana's were common: "Mira, yo soy una prosituta' --no se puede contar (Look, I'm a prostitute--you can't count"). Mean (median) numbers of lifetime male partners were 933 (1000) for Hispanics, compared to 1445 (1000) for African-Americans (figure 4-4). Subsequent measures, involving shorter time periods, may more accurately represent actual experience. For this reason, most analyses of sexual behaviors were performed using 6month sexual histories.



1 600
1 400
1 200
1 000.......
800 600
400
200
0
Mean Median
EU Africa n-Americans (n=22)
l Hispanics (n=26)

Figure 4-4. Number of estimated lifetime male sex partners.


Hispanics and African-Americans initiated oral and anal sex with males at similar ages (figure 4-5). Just three participants initiated anal before oral sex. Hispanics exhibit somewhat more role versatility in anal sex history (figure 4-6). As a whole, higher proportions of I-Espanic participants report having engaged in both insertive anal intercourse (IAI) and receptive anal intercourse (RAI), as well as in unprotected insertive anal intercourse (UIAI) and unprotected receptive anal intercourse (URAI)







Note that in Spanish, Diana refers to herself in the feminine gender.






67






16
14
12 --X.
10
8

6

2
0

Oral Anal

[] African-Americans (n=22)
Hispanics (n=26)


Figure 4-5. Mean age at first episode of oral and anal sex.




100

80 60
40 .... X,
20



[Al UIAI RAI URAI

D African-Americans (n=22)
Hispanics (n=26)


Figure 4-6. Lifetime history of insertive, unprotected insertive,
receptive, and unprotected receptive anal intercourse with males.



Data were gathered on several other lifetime sexual variables (see figure 4-7).


Hispanics (85%) were significantly (P<.01) more likely to have engaged in oral-anal contact ("rimming") than were African-Americans (50%). Digital penetration of the anus was nearly universally reported (though for both this activity and rimming, several AfricanAmericans reported only being the recipient). Thirty-one percent of Hispanics reported






68


having shared objects for anal penetration, vs. 9% of African-Americans. Anobrachial penetration ("fisting," in which the fist and part of the forearm are inserted into the anus) was much less common, though more prevalent among Hispanics: seven participants (15%) reported engaging in insertive anobrachial penetration ("fi sting"). Of these 7, five had also received fisting; 2 additional Hispanics reported only receptive listing. This is not a comprehensive list of participants' sexual activities: a number of other acts performed with clients are discussed in following sections.



100
80
60
40 XXI
2 0
0
OralI-anal Finger anus Share toys Fist (g ive) Fist (rcv)
African-Am ericans (n=22)
Hispanics (n=26)
Figure 4-7. Lifetime history of oral-anal contact, anodigital penetration, sharing of penetrative instruments, and insertive and receptive anobrachial penetration.

Two-thirds reported a history of forced sexual contact (self-defined, any unwanted

contact) in their lifetimes, including 16 Afican-Americans (73%) and 15 Hispanics (5 8%). Of these, two-thirds had experienced forced sex by two or more different people.

Six Month Sex with Males

There are significant (P<.O1) differences between ethnic groups in total numbers of male oral/anal partners2 reported for the prior 6 months (see figure 4-8). In contrast to lifetime


2 As defined in Chapter 3, sex partners are classified as either exchange partners, non-steady partners, or steady partners. Exchange partners are those with whom participants had sex in exchange for something, such as money, food, shelter, or drugs. Non-steady partners are those non-exchange partners with whom participants had sex just once or twice; steady partners are non-exchange partners with whom participants had sex three times or more.







69



totals, six month mean (median) totals are higher for African-Americans, who report 263 (105) vs. Hispanics' 175 (50). Qualitative data support this difference, as discussed in Chapter 5. While these figures may be more reliable, since they reflect a shorter time frame, they too are subject to response bias.





250
200100
50
0

Mean Median

[]African-Am ericans (n=22)
[] Hispanics (n=26)


Figure 4-8. Six-month estimated total male sex partners. Figures 4-9a and 4-9b illustrate the places in which participants reported sex with any partner within the past 6 months. The only significant (P<.01) difference was between African-Americans (9 1%) and Hispanics (42%) reporting sex in street or alley.




100

80 i i!iii

60 : ;
40 .............. .
5 0 ......
0















HoteM Vehicle Partners Home Steet/alley Park
African-Americans (n=22)
Hispanics (n=26)


Figure 4-. Locations of sex with males in the past six months.
Note: "Partner's" refers to partner's home; "home" refers to participant's home.







70






100

80

60

40

20

Beach Jailprison bookstore restroom Bathhouse Gym

African-Americans (n=22)
Hispanics (n=26)


Figure 4-9b. Locations of sex with males in the past six months.


Receptive anal intercourse (RAI) with any partner type was reported by 46 (96%)


participants, including 21 (95%) African-Americans and 25 (96%) Hispanics (figure 4-10). Fewer African-Americans (n=8; 36%) than Hispanics (n=14; 54%) had engaged in RAI without a condom. Eleven (50%) African-Americans and 18 (69%) Hispanics reported insertive anal sex; 3 African-Americans (14%) and 7 (27%) Hispanics reported unprotected insertive anal sex. Overall, 41% of African-Americans and 54% of Hispanics had unprotected anal sex in either role with any partner type within the past 6 months.




100

80 60

40

20
0
receptive Unprotected RAI Insertve Unprotected AI

SAfrican-Am ericans (n=22)
Hispanics (n=26)


Figure 4-10. Six-month history of receptive, unprotected receptive, insertive, and unprotected insertive anal sex with any partner type.






71


Role specialization in anal sex is associated with age. Those who practiced receptive anal sex with any partner tend to be younger than those who do not, with a mean (median) age of 28.3 (25.5) versus 33.0 (33). Conversely, those who practice insertive anal sex with any partner are older, with a mean (median) age of 29.2 (26) versus 27.6 (25) years.

Seventeen percent reported having sexual contact with an Injection Drug User (IDU) within the past six months. Combined, roughly half said they had not had IDU contact, and one-third said they did not know. Two Hispanic participants said they had sexual contact with an HI V-positive person within the last 6 months; about one-fourth said they had not, and almost three-fourths reported they did not know. The 2 affirmative participants both reported condom use with this IHV-infected partner. Frequencies for sex with IDU or IFIV-positive partners should be considered the minimal boundaries, since participants are not likely to learn that clients fit these profiles



Sex with Male Exchange Partners
TTSW Venues

One of the two areas in which TTSWs work in concentrated numbers in Miami is

known as "The Tracks," or, alternatively, the "Ho Stroll" (whore stroll). The Stroll spans approximately two linear miles on two main streets, one perpendicular to the other, plus a number of side streets 1 or 2 blocks on either side. This is an economically depressed neighborhood, of mixed commercial and residential use, located in mainland Miami. The area has hosted various forms of sex work and drug dealing for over 20 years, according to local informants. After midnight, on most nights of the week--Monday and Tuesday are less active--TTSWs begin to arrive. Most continue to work until dawn, conducting "dates" as quickly as possible, and moving on to the next client. Generally standing on street






72


corners, but sometimes walking, they strike suggestive poses, and occasionally wave at passing cars. Initial contact with clients is generally made nonverbally, for example, through eye contact or an outstretched "hitchiker" thumb, though sometimes more aggressively. Late at night, there are few businesses open that might attract people to the area. Two fast food restaurants open for drive-through service only, and there are two bars which open only on weekend nights. With few exceptions, sex workers in this area are African-American transsexuals or transvestites. On occasion, a female sex worker, who might be African-American, Hispanic or Caucasian, will stray onto the fringes of the Stroll, but as Coco said, "the real girls are all strung out on drugs--they're not out there anymore."

Clients approach TTSW almost exclusively by car, and transactions are often conducted in the car. However, since robbery and abuse of workers are common, some TTSWs working the area report a reluctance to get in the car with clients, and a preference for conducting business in alleyways, behind buildings, or in bushes. Angel told me "since there's a lot of guys out there robbing, I don't get in the car unless I can handle you. So I make them get out and get beside a building." A number of hotels are located within a few miles, though hotel-based sex is not the rule. Alternatively, the "Seven-Dollar House"~ is nearby, where rooms are rented for $8 hourly (as Glitter explained, "they went up"). Generally, TTSW on the Stroll know each other, though they may not always be particularly friendly with one another. One participant, with over 10 years on the Stroll, tends to work on a particular stretch. Several others reported that "if you're not one of 'her girls' (i.e., her friend) she'll call the police on you." In general, however, there are no specific "territories," and as Coco says, "It's every girl for herself Mutual protection is practiced by TTSWs who tend to cluster when working; others are decidedly independent.






73


In contrast, a renovating section of Miami Beach has, in recent years, become an entertainment district with 24-hour activity. The "Beach" has a number of bars, dance clubs, cafes, shops and restaurants that cultivate an eclectic, urbanized atmosphere. The Beach is normally most active after midnight, and particularly on weekends. Bars and clubs rarely close before 5 a.m., with some staying open until after sunrise. TTSWs work in an area of several square miles, though most tend to concentrate within a single several-block area. As on the Stroll, TTSWs may either stand or walk, constantly keeping an eye out for a prospective customers. On the Beach, however, they often cluster and socialize, and may spend much more time talking and flirting with passersby and clients. Alternatively, they may seek clients in bars or clubs, some of which welcome the flamboyant demeanor adopted by many of the transgendered. Transactions occur in cars, in hotels, sometimes on the beach itself and much less frequently, in alleyways. Beach TTSWs, since they live nearly, are also able to bring customers to their homes. Two Beach participants mentioned a smaller population of sex workers, including several transgendered, who work a more northern section of the beach. This population is said to be crack cocaine-dependent, and "lower class." Efforts to sample members of this subpopulation were not successful. There may be a rare non-Hispanic among this population, though every Beach TTSW I encountered was Hispanic.

TTSWs also work in a much larger and less-defined area, generally on one of several main arterial roads in the predominantly Hispanic areas west of downtown Miami. For convenience, I will refer to these areas collectively as the "Thoroughfares," since, though they are not geographically discrete, the mechanisms of TTSW are the same. They are lessdense areas, in terms of both population and land use, and passing cars stop to negotiate






74


with sex workers who either walk or stand. TTSWs, as well as female and an occasional male sex worker, are all found in the Thoroughfares. They generally do not cluster in a particular zone, and there may be some overlap among these workers. Six Hispanic participants work in this area, and at least another 10-15 TTSWs are known to be active here.

Each TT SW generally works in just one of the three areas, with very little cross-over. Of those working the Stroll, just two had ever worked on the beach (though they might occasionally stretch the limits of the Stroll, depending on how "hot" the police presence is at a given time). Those who work the less-defined areas--who are older, and live near those areas--are cognizant of other TTSW zones, though they do not leave their habitual areas to work in other places. There is one area, however, that serves as a nexus of sorts: workers from all areas reported visiting a particular dance club located near one street in the Thoroughfares, and 5-7 miles from either the Stroll or the Beach. Various themes are promoted on different nights of the week, drawing attendance by either a predominantly Hispanic, or less frequently, an African-American clientele. Since the establishment's policy is to admit patrons as young as 15--but not to serve them alcohol--the venue has gained a reputation as a place where older men may meet younger males. The entertainment frequently includes "drag shows," and transgendered people are a fairly common sight. TTSWs may either stay inside the bar, or stand outside among the parked cars alongside the street. On busy nights, there is a constant procession of passing cars from midnight until five or six a.m. In every case, regardless of where they work, all TTSWs work "on their own," without the services of a manager or "pimp."






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Sex Work Initiation

With just 5 exceptions, participants had initiated cross-dressing before--often long

before--their first experiences with sex-for-money. Four of these, all Hispanics who work on the Beach, "dress up" only to work--because cross dressing offers much more earning potential. Brigida, now working the streets as a transvestite for six months, but who had previously worked for several years as a male hustler, said "my friend dressed me up, and I looked good. At first, it was weird, but now it feels normal." Lani (indicating "male" attire at the time), said "if I could make it looking like this, I would." Geisha, a 25 year-old transsexual now on the streets for a year, is also an exception. She explained:

I lost both of myjobs. I used to work at Winn-Dixie (a grocery store) and on a
phone-sex line. But I didn't want to lose my apartment and my car. So one of my
friends who works out there said "come on out with us and you can make some
money." I decided to become a woman just to make money. I was already gay, but I decided to live as a woman. Maybe I was always a woman, and I'm just figuring it
out now.


Most commonly, however, participants reported that financial necessity, usually

precipitated by family problems and/or transgender-associated difficulties, led them to sex work. Those participants who reported having run away, or being forced to leave home before adulthood, began sex work 3.1 years before those who did not, at a mean (median) ages of 19.7 (18), versus 22.8 (2 1). Their subsequent sexual risk behaviors, however, do not differ significantly.

Eliana summarized what became a familiar story:

The only way we can make money is selling our body. You have to risk your life-or you don't eat, you don't get nothing. You don't have nowhere to go, 'cause
your parents kicked you out. They all do. Always.






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Ana says "You get to the point when you got no more money, and it's easy to make

money like this. I do it 'cause I need the money." The oldest participant, Lilia, began in sex work at age 46. She stated that she was forced to begin working the streets, since she had gotten "too old" to do shows, and "the phone no longer rings" with requests for her drag performances. For most, once the financial need was established, entry into sex work was facilitated by friends. Macy is an example: "How did I get started? I met some friends, and that's what they were doing, and they got me started." Ilena, whose family forced her out at 16, says she had little alternative. Now 24 and with 8 years on the streets, she recalls:

When I started, I saw my friend. She has a nice apartment, and a nice car. My
friend introduced me to a massage parlor and I worked there. My first day a man made me show my titties and my dick, and he didn't touch me. He jacked off and gave me $50. Now I do it 'cause I need the money, I got my bills. I like the easy
money. That's all I like about it.

Though substance use is prevalent among some TTSWs, none reported that supporting a drug habit was an initial draw to the streets. Angela, a 38-year old transsexual with over 15 years in sex work, says that may be the case for some new workers (male, female and transgendered) on the Thoroughfares. She laughed and said "empiezas con lapiedra, y en dos meses alli estds con la pinga en la gargantd' (you start with the rock {crack cocaine} and in two months there you are with a dick in your throat).

Figure 4-11 illustrates time since initiation of sex work; participants reported a mean (median) time of 89 (60) months. Afican-Americans report less time since initiation than Hispanics, with 60 (36) months vs. 114 (96) months, respectively (P<.04). In some cases, these figures may not reflect total time in sex work for all participants. For example, at the time of interview, two had just resumed working the streets after relationship breakups, and






77




two had left the streets several months before (recall participation criteria required streetbased sex work at any time within the past 6 months). Time since initiation of sex work is associated with HIV/STD infection rates, as later discussed.



120 100

60 -.....

40
2 0
0
Af-Am (N=22) Hisp (n=26)

[] Mean Median

Figure 4-11. Months since initiation of commercial sex work. Occupational Behaviors and Clients

Combined, participants reported a mean (median) of 172 (77) different male exchange partners for oral or anal sex within the past six months (range 1-1000; figure 4-12). African-Americans report mean (median; range) totals of 256 (101: 2-1000) vs. 175 (49; 1-1000) for Hispanics (P<.02). Those with full-time employment report substantially fewer numbers of 6-month exchange partners (see figure 4-13).

Forty-seven participants (all African-Americans and 25 Hispanics) reported receptive oral sex with exchange partners. Seventy-seven percent also practice insertive oral sex, including 16 (73%) African-Americans and 21 Hispanics (81%). The one Hispanic that does not practice receptive oral sex does engage in oral insertion.







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300
250
200


100
50
0
Mean Median

African-Am ericans (n=22)
Hispanics (n=26)


Figure 4-12. Number of exchange partners in the past 6 months.




250

200

150

100

50

0
F/T P/T No, seeking No, not seeking

M Mean Median


Figure 4-13. Number of 6-month exchange partners by employment.


Anal sex with exchange partners is also normative (figure 4-14). Thirty-nine (81%) report receptive anal intercourse, including 19 (86%) African-Americans and 20 (77%) Hispanics. Twenty-six (54%) report insertive anal intercourse, including 11 (50%) AfricanAmericans and 15 (58%) Hispanics. Most (24/26; 91%) who engage in insertive anal sex also engage in receptive.


Fifteen TTSWs (9 African-Americans and 6 Hispanics) adhere to an exclusively


receptive model. Of the 39 who engage in receptive anal sex, these 15 (38%) do not also practice IAI with exchange partners. Ten of these 15 also do not practice insertive oral sex






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with exchange partners; they comprise 10 of the 11 TTSWs who do not insert orally

(P<.0000 1).



100
80 60
40

40

Oral (rcv) Oral (ins) Anal (rcv) Anal (ins)

M] African-Amnericans (n=22)
1MHispanics (n=26)

Figure 4-14. Six-month oral and anal sex with exchange partners.


While these are the predominant activities, giving and receiving "hand jobs" (manual

stimulation) were also reported, as well as a range of other behaviors. When I asked Coco, now 31 with over 10 years on the Stroll, "what kinds of things do you do with clients?" she responded:

In my line of work, whatever. This is a line of work. I do my sex for business, then I leave it behind me when I come home. But it's rare when I let someone flick me.
I don't get pleasure out of them fucking me. I get pleasure out of me flicking them.
Getting flicked, I don't get off that way. But with me being the top, I'm gettin' off.

I have a lotta guys who want to get flicked. Whatever, as long as you got the money. I'll beat them, dominate them. That's humiliating for me to do, so of
course you got to pay me more. I'll pee on them, whatever. I run into a lot of married guys. But I only date white guys. White men have a fantasy with black
women, and black guys take longer and they're not gonna take the shit I'm gonna
put them through.

There's a time limit. You got 10 minutes to do what you're gonna do, and if you're
not through with it, I gotta go. Sometimes it's longer, but it's up to me. If I want
to nut, you nut. If I don't want you to nut, you don't. A blow's 25 (dollars), a
flick's 50, both 100. You get 10 minutes. I'm in control. I'm always in control. If you're gonna be in control it makes no sense for you to pay me. You do what I tell
you to do.






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Antwanette said, "some of 'em want to eat your ass out (anilingus). Some of 'em just

want you to walk around in your bra and your dick hangin' out." Six participants--all of

whom work the Stroll--like Geisha, reported having "dated a guy who wants to lay on the

ground and he wants you to jump up and down on his dick, and then he comes." She

continued:

Some of them, they just want to look up your ass. There's this guy who buys me
stockings, takes me to a hotel, and wants me to put them on and he comes. Another guy likes feet, and he wants me to rub my feet on his dick. But I do not lick ass and
I do not kiss, unless you look really good.

Kandi described a predominant TTSW interpretation of clients' motivations:

A lot of guys want to give me a blowjob. The guy's probably tired of the same old
thing and wants something new. A guy that looks like a woman is a fantasy, and
they keep comin' back, 'cause it's so good.

Not all activities involve physical or sexual contact. Glitter explained:

Some of 'em pay you $75 just to dress them up like a woman. Some guys just want
you to stand in front of the headlights with your dick showing, and play with your
titties, while they sittin' in the car j ackin' off.

Princess, 27 and on the Stroll for 2 years, discussed what might happen on a

typical night:

You go up to the car--you first gotta find out if they're the police--so you got to
touch them to find out, 'cause 9 times out of 10 the police won't let you touch their
dick. Or you can ask "are you a cop?" 'cause they have to tell you.

I don't usually tell them (that I'm a man). If they ask me, I'll say something like "Well you don't know what you're gettin' yourself into?" but I don't confirm or deny. I'm not gonna mess around like that--you either know what you come out
here for, or you don't.

I've had guys who want to drink my pee and who want me to pee on them. But it's
mostly blowjobs. Most of them actually snort coke, and most of them use the
poppers. My preference is to date a white guy. You have to brain-wrestle with a
black guy--they want to see your pussy or your titties, even if they're not paying for that. A white guy, you say 40 and 80 (dollars for oral and anal sex) and they're like






81


"whatever." It's really 20 and 40, but you start high and sometimes they don't argue.
If you go to a hotel, it's 150 or maybe 100.

Sometimes I get lucky and get a white guy who wants to spend $ 100. Most of the white guys want to go to a hotel and get on drugs--for you to go and get the drugs
for them 'cause they're scared to go on certain areas. They give us money and say "I want $100 of crack," so I'll keep $50. Then they want more and I'll do it again. In
the black community, if they see a nice car and a white guy in the car, they know
he's got no business there anyway. So that's a perfect opportunity for them to rob
them, or whatever. That's why they use the girls to do that.


Michelle and Melissa, as well as several others, discussed drug connections: "A lot of girls sell drugs and get drugs for people. They know how to get them, and get the stuff for their date, but keep part of the money for themselves. Melissa said, "Lotta guys want you to get them drugs. They wanna party and do drugs when they're having sex with you, and they want you to do the drugs, too."

Princess also described a technique sometimes used by many TTSWs:

It's like a trick thing. Guys think they're doing it, but they're not. It's a method we
use on the street, where guys will actually think they're having sex but they're not
having sex. It's called a "slick leg." You can bend over, and it's like they're actually
having sex between your thighs, but they think they're having sex in my pussy or in
my butt. I'm standing up, but I'm crossing my legs so it's tight. It's a lot easier
with tourists.

Jasmine prefers to slick leg a date: "You just push your thighs up tight, and they

moanin', and I'm goin' 'oh baby, it hurts' and they be comin'." Geisha, who was amused that I had heard of the trick, laughed and said, "some boys don't know the difference between ass and pussy! So if they want pussy, you make it kinda loose, 'cause ass is tighter than pussy. Not too tight and not too loose, but just right." Shavonne added "sometimes the guys figure out I'm doing a slick leg, and they get mad, but they don't get no refund."

Some TTSWs reported significant differences between clients of different ethnicities, though they often conflicted. Melissa said:






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White guys are freakier. They'll do new stuff quicker. They get flicked a lot, and
they're willing to try new things quicker than a black guy would. Black guys might
touch your dick, but they won't suck it. White guys like to lick my ass and stuff.
Prices? 20/40, plus whatever you can get. You can always get more, especially when they take too long. I'm like, "I got to go--I'm not gonna be here an hour
Cause you can't nut--you gotta pay me for my time."

On the Beach, the mechanisms of TTSW differ in some ways. For example, participants

more often attempt just one or two dates in a given night, then socialize with friends or go

to a dance club. But like on the Stroll, drugs, as well as sex, draw clients. Nika said "most

of the guys want to do drugs. Then they get really high and sometimes they forget about

sex, or just want oral, but you have to do drugs with them."

In many other ways, things on the Beach are very much the same. Gigi said:

If they pay me, I'll do anything. But they can't be nasty and dirty or I won't go.
But penetration is very personal, so the money has to be good, and for me to bring them home, got to be more than $100. Some of the time I'll do un truco (a trick;
the Spanish-language equivalent of a slick leg).

I'm one of the best girls on the street, I have customers all the time--all I got to do is walk outside. I'm not playing games in the street, it's my job. Up to l0pargos
(clients; literally, "snappers") per day. It's easy. I just go to the corner, and the
guys start to come up and say "wow, you're sexy." I don't like it if they come up and say "how much?" 'cause I think that's cheap, you know? I don't think that's
nice.

I have so much fuin. I like being on the streets, you know? I love it when people
always say things to me. Sometimes they know I'm a guy, but 'cause I'm so natural,
sometimes they think I'm a girl. They have a fantasy. They try girls all the time, so they want to do something different. But no kissing. No licking ass. No pee. I'm
not that, you know?

Ilena leaves her apartment around midnight, 3 or 4 days a week, and dates one or two

pargos before beeping her boyfriend to come pick her up (she makes it clear, however, that

the money she earns is her own, and she is under no obligation to share it). ilena doesn't

like the work:






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1 don't enjoy it. It's the money I want. I wait in front of a bar. I never tell a guy
I'm working the street. I say "I work for a massage parlor," and they say "can you give me a massage?" and I say yes. And if they want something more, then maybe
they get that, too. For $40, 1 give them a blowjob. Ten minutes later, they cum
(ejaculate) and I'm gone. Sometimes they'll ask me if I'm a guy--they don't care. I always tell them, 'cause I don't want no trouble. Men like to see transsexuals 'cause they like to see the beauty and the body, and I think they like to see the penis. They
want a lot of things for $40. They want to see my titties and my dick, but they got
to pay. 1 don't do nothing for free.

Ilena is familiar with the truco, but never uses it "'cause they find out and get mad. I'm

always honest and I don't have any problems. She performs oral sex for her clients, and has

receptive, but not insertive, anal sex; though she occasionally allows apargo to perform

oral sex on her, she says, "it's weird for me to be with a man and they want to touch my

dick." Brigida described a typical night working the streets of the Beach:

Last night we went out at 3:00. We smoked weed, and just waited there and stood.
You know if they want you 'cause they look. You talk first, you say "you wanna do
something?" and you find out what they want and decide how much they have. If
they're fat or ugly they get charged more, like $ 100.

Most of the time they suck us. They want to be sucking the drag queen's dick. We
don't suck them that much. Most of them, they're married and they live a straight life. They wanna see a woman, dressed like a woman, but with a dick. I asked this guy why he doesn't pick up a butch hustler if he wants to suck dick, and he said he doesn't like that. One drag queen picked me up and he paid me $300 to pee in his
mouth.

Most of the time they want to suck us, and without a condom. Sometime I come,
sometime not. Sometime they want to jack me off. When they suck my dick, most
of the time they're jacking themselves off. The average blowjob is about $50, to flick it's $120 to $150. Most of the time they don't want to use a condom. I tell
him it's very dangerous, but... {Will you do it without a condom?) I will fluck
somebody without a condom, especially if I'm high. Latin guys like to get flucked
more. American guys like to suck you.

Marcela shared her experiences working the Beach:

Most of the time, they want to be feminine with me. They say "I want to flick you"
but then we get somewhere, and they say "this is gonna be our little secret" and they want me to flick them. Pargos say "do you think I'm gay 'cause I want to
suck dick?" and I say "I don't know, baby, maybe it's a fantasy." Most of the time,






84


they're older guys who are married. They can't go in a gay bar. They can't let
people see them.

I never go with anybody who doesn't know f that she's a man}. I say, "I'm not a
woman, baby" and I might say "but I can be your dream girl." Then I get in the car,
and they say "are you sure you're not a woman, let me see." And they touch my dick, and say "let me try to do something that I never did' and they suck my dick.
Or they say "what do you have here, baby?" and they do it. Guys want me to flick
them, but they say "don't take off your wig, 'cause I don't want to see that I'm with
a man. )

Data collected about participants' views of their clients, and their behaviors with them,

were among the most interesting. I opened the dialog with open-ended questions like these:

So what about the clients? Do they know (that you're a man)? Some people might say that if a client wanted a woman, he would find a one--and if he wanted a guy, he
would find a guy. Why would he pick up a man dressed as a woman? Are they
straight, or gay?

Responses suggest that there are few differences between the clients in different areas.

Melissa, like many, has had this conversation with some of her clients:

They ask me "am I gay 'cause I'm fucking a man?" and I tell them "no, you're not
gay, 'cause I consider myself a woman." They're like "so I'm not gay, right?" and I say "only if you think you're gay." I don't like to say people are gay, I just like to say
they want something new to fick. Because gay is a lifestyle--actually, it is the love
of a man by another man--and I think sex is just what it is--just fucking to get off.

They all know I'm a man. A lot of times they ask you--I believe in being honest, so I say "I'm a man, there's no girls on the street." Some of 'em don't ask. But if they wanna fuck, and ifI don't think I can get over on them with a slick leg, then I'll tell
'em.

I don't let 'emn touch me. I say get out of the car and put your hands on my hips, and
let me do it. If they try to touch me I say "don't do that--you're not paying for
that." I had a bad experience with that one time. I thought the guy knew, but he felt me and felt my balls, so he was chasing me down the street and I had to run.

Roanne, 22, and on the Stroll for 2 years, said:

The majority of the men know (I'm a man) 'cause they want to suck me, but some
of them think I'm a girl, and I do a slick leg, and they think it's a pussy. But there's
no women out here. But we look good. We wear makeup, and we have our nails
done and our hair, and we dress nice, and that's what they like. A lot of them are
married and they're secret gay.






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Shavonne, a 19-year old whose appearance is decidedly feminine, explains:

About half of them know, It's more of a turn-on when a guy sees a girl dressed up
as a girl but it's not a girl it's a guy. You see everything you're supposed to see in a
woman, but there's this thing in front. It's a turn-on.

Lala believes "Of course. They know. You can tell from what they do with you that it ain't the first time they got with a guy." On the Beach, Nila agrees: "they all know. It's just easier to take a drag queen, they pick the pretty ones with a big dick--that's their fantasy." For Diego, it may be more complex:

Almost all of them know. But me, when I transform myself, I'm a woman. The
people are very complicated, psychologically. They think they're gay, and in reality
they are gay. But to feel more tranquil, they look for us, the ones that look like women, but they want to suck a dick (mamar una polla). {Do they want to flick
you, too?) To me, never.

Lucila said "About one-fourth want to suck my dick and get flicked. They want to be with a transsexual because it's double pleasure. Most of them are married, and they're from here (not tourists)." I asked Eliana if she had practiced insertive anal sex with any of her pargos in the last few months. She said:

Almost all of them. If they want to do you, you try to trick them (with a fruco).
It's very safe. Also they pay us to dress them up as a woman. There's a married
guy, he has his wife and kids. He's an ex-basketball player. He used to pay me
$300 for an hour, just to dress him up like a girl, in a wig, pantyhose, high heels and makeup. But no sex. And there's guys who like to be beat and hit and spanked and
called bad names--like bitch and faggot. They expect that.

For Lani, clients' motivations are not important:

I just don't understand what they get out of picking up a male dressed as a woman,
but I'm making money out of it, so why not? I think some of them just get off on
buying you. But then they just look at me like I'm just a prostitute.

Justinia has similar views:

You don't think about what he is (gay or straight) or what he looks like. You just
think about the money. You don't see his blue eyes, or his handsome face. You just






86


see the money. I always tell them (that I am a man) 'cause I don't wanna get beat
up. But trust me, in front of a gay club--they know.

Some guys look for the cute ones, the beautiful, and some look for the monsters,
t What are the monsters? I You know what I mean. They don't all look too good.

But not all TTSWs detach themselves, Towanda is an exception, in that she reports

getting pleasure from sex with clients: "I love getting faced by a man." She says that "at

least half' of her clients know she's a man: "It's a fantasy. They know what they want, and

they know where to find it."

The distinctions between gay and straight become blurred, according to Geisha:

There are guys out there I see as straight 'cause they consider me a lady. JEven
though they know you're a guy? I Yeah, they know, but they don't care. We call them "trade." They're straight. They don't wanna give you oral and don't want you to do them. Then there's freak dates, who want you to do them and they do
you and everything.

Nila described what clients seek:

Pargos want a guy with a nice body, long hair, with a dick. Some are straight, some
are weird, some want to have a fantasy, and some of them just want to have fun.
They get you naked, you look like a woman, they just look at you and start touching you. That's what turns them on--being a woman, not with a vagina, but with a hard dick. They get crazy. Some of them, it's just fantasy. They have kids, they're with
their wife and just want to discover something else.

Ana says that though clients approach TTSWs near a gay bar,

The clients come from the straight bars. We just hang at (gay bar) 'cause that's
where they come to find us. We like to hang at (there). There's food nearby, they
let us in free, the customers know we're there. They know we're working--they
don't care.

Emilio, like many of the others, has wondered about the clients himselfThat's a very good question. They're supposed to take a woman, but they know
we're guys. It's a fantasy of having a woman, but the special part counts. Mostly
they want a man. They have the role as a woman in bed. Ninety percent of the
pargos want to suck your dick, or they want me to fuck them. Logically, you're the
woman, you're supposed to do the blowJob and the role of a woman, but it's not.
They touch you like you're a woman. They want to think you're a woman, but
when the part comes that they start to touch you, they know you're a man. And






87


they start touching more and getting more excited. Latin guys, it's always like that.
American guys, Italians, Germans, it's 50-50.

There was this guy -- he was standing behind me and feeling my dick, and he keeps saying "pussy, pussy, I love your pussy" when he was rubbing my dick. I guess he
was having his own fantasy.

Mona, and Angela, who work the Thoroughfare, tell similar stories. Mona said:

The majority say they're straight, but I don't believe it. One client said to me, "A mi, no me gusta el hombre con dick. A mi me gusta la mujer con dick." ("I don't
like men with a dick. I like women with a dick").

Angela continued:

La mayoria son casados. Entre latinos, hay mucho homosexualismo. Se yen muy macho, pero despuds, they say "Mami, please fuck me" (The majority are married.
Among Latinos, there is a lot of homosexuality. They look macho, but later they
say "Mami, please fuck me.")

Eliana reported:

Most of the pargos are married, most are very important people, like doctors and
lawyers. They're people with a lot of money. They know who we are. They don't
use us as a woman, they use us as a man in bed. So we gotta take the part of the
man, and they got to take the part of the woman. That's what they pay us for.
They look at us to do that. That's their fantasy. I think, really, that those people are
more sick than we are, because, come on, that's not right. That's not normal.

They like us 'cause we look like women, but we have a male part. So they can play with the mind and say I'm doing this but I consider myself straight 'cause she looks like a woman. But that's not straight if you use us as a man in bed. They want to do things that a straight man doesn't want to do. A lot of the guys who are in gay
bars are actually straight guys who come there looking for us. They're not gonna
find you in a straight club, so they go there.

Several TTSWs described negative attitudes toward clients. Tiffany was among them:

They ain't nothin' but freaks. I just think they're freaks, period. They're acting like they like girls and shit, then they get you behind closed doors and they wanna be the
girl. They wanna suck your dick and they want you to do them.

Finally, Ana described the gender-based discomfort she sometimes feels:

Pargos--they're sick. I don't know! Different people have different sexual tastes.
They like to see both things--the female in you, and they like you hard. First time I






88


did it, I felt uncomfortable. I'm like, "I should be doing him the (blow) job." You
see these beautiful guys who are out there wanting to suck a drag queen's dick. If
you're small, you got nothin' to go with--you gotta have a big dick, or forget it.
You show the guys how big your dick is and they go crazy. But sometimes I still
feel uncomfortable, 'cause I should be doin' it to them.


Positive and Negative Aspects of TTSW

While most participants are able to describe a number of positive attributes about

working the street, the economic benefits are the primary motivation. Michelle said:

You give away your body, not your mind. It's not something you live in, you just do it, just to get that dollar--that's it. You gotta separate your mind--not make it a
way of life--not get attached or addicted to it.

Coco explained the attraction:

It's like fast money, you like the fast money. That's what makes people go out
there. I make $1500 a month, sometimes more, sometimes less. I work 8 days a
month, Fridays and Saturdays. I leave home at 2 (a.m.), I'm back by 5:30 or 6:00.

Geisha compares the potential of traditional employment, and asks:

Why have a regular job? The money we make in one night on our job it takes
people with a regular job 2 weeks to get, or more. Why wouldn't I work the street?
It's dangerous, but it's rewarding and fun to be out on the street. If that money's
there, I have a good time. {So you're happy with the work?) Very happy. I get a lot of attention, and I make a lot of money. I look good! I got a lot of boys lookin'
at me. And some girls, they get BMffs, Acuras, and a lot of nice cars.

Shavonne also enjoys her work at times:

There's a lot of good things. You get to meet guys. When I first started, I didn't
do it for the money, just to meet boys. You get to know who does what with who, who's a freak, but they don't act like they do that type of thing. The money's good.
You get to meet a lot of different people, you meet stars.

Rhonda agrees that meeting different people is a benefit:

A friend of mine was doin' it, and I tried it, and I likeded (liked) it. It's good money, you get to meet a lot of famous people, like business people, doctors,
lawyers, officers. I enjoy them.




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