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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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English
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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 )
City of Miami ( local )
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bibliography ( marcgt )
non-fiction ( marcgt )

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Thesis (Ph.D.)--University of Florida, 1997.
Bibliography:
Includes bibliographical references (leaves 223-242).
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Typescript.
General Note:
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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TRANSSEXUAL AND TRANSVESTITE SEX WORKERS:
SEXUALITY, MARGINALITY AND 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
DECEMBER, 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 Burns, Dr. John Moore, Dr. Brian DuToit, Dr. Elizabeth Guillette, 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
page
ACKNOWLEDGMENTS iii
LIST OF TABLES vii
LIST OF FIGURES viii
ABSTRACT ix
CHAPTERS
1 INTRODUCTION 1
2 LITERATURE REVIEW 6
Gender Variation: Expression 6
Gender Variation: Etiology 14
Anthropology and the HIV Epidemic 18
Theoretical Approaches 20
Commercial Sex 25
Transsexual and Transvestite Sex Work 28
Clients of TTSWs 33
Body Modification 35
HIV/STD Epidemiology 36
3 STUDY DESIGN AND METHODS 44
Study Design 44
Sampling Methodology 46
Data Collection Instrument 47
Enrollment and Data Collection 52
Data Analysis 56
Project Timeline 57
Language and Terms 57
4 FINDINGS 59
Demographics and Background 59
Lifetime Sexual Behaviors 65
Six-month Sex with Males 68

Sex with Male Exchange Partners 71
TTSW Venues 71
Sex Work Initiation 75
Occupational Behaviors and Clients 77
Positive and Negative Aspects of TTSW 88
Risk Reduction with Exchange Partners 93
Sex with Non-Steady and Steady Partners 98
Sexual Attraction and Relationships 101
Sex with Females 102
Medical Considerations 104
Health Care Access 104
STD and HBV Vaccination History 105
HÍV/AIDS Experience and Perceptions 106
HIV, HBV and Syphilis Results Ill
Alcohol and Drug Use 114
Hormone and Silicone Use and SRS 117
Sex Reassignment Surgery: Attributes 121
Gender Identity and Sexual Orientation 123
Positive and Negative Aspects 126
Psychosocial Scale 134
Other Modalities of TTSW 141
Social Considerations and Future Orientation 143
5 DISCUSSION AND RECOMMENDATIONS 148
Access Issues 148
Demographics and Background 149
Sexual Behaviors 150
Sex, Gender and Identity 158
HIV Perceptions and Psychosocial Indicators 171
Medical Considerations and Test Results 173
Intervention 181
Social Implications 189
7 CONCLUSIONS 193
APPENDICES
A INSTRUMENT 200
B INFORMED ASSENT FORM 220
REFERENCES 223
BIOGRAPHICAL SKETCH 243
vi

LIST OF TABLES
Table Page
4-1. Sample characteristics of HIV+ participants 112
4-2. Relative characteristics of HIV-positive and HIV-negative
participants 113
4-3. Mean and median age by test results 114
4-4. Risk perception 135
4-5. Condom norms 136
4-6. Perception of safer sex 136
4-7. Safer sex efficacy 137
4-8. Self homophobia 138
4-9. Perceived community homo/transphobia 138
4-10. Identity salience 139
4-11. Social support 140
vii

LIST OF FIGURES
Figure Page
4-1. Description of living arrangements 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 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
4-30. Six-month history of alcohol, marijuana, amphetamine,
barbiturate/tranquilizer, ecstasy, LSD, poppers, cocaine,
crack, heroin, ketamine and rohypnol use 116
4-31. 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 -
GID -
HBV -
HIV -
IAI -
IDU -
MSM -
RAI -
SRS -
STD -
TTSW -
UAI -
UIAI -
URAI -
Acquired Immunodeficiency Syndrome
Gender Identity Disorder
Hepatitis B Virus
Human Immunodeficiency Virus
Insertive Anal Intercourse
Injection Drug User
Men who have Sex with Men
Receptive Anal Intercourse
Sex Reassignment Surgery
Sexually Transmitted Disease
Transsexual/Transvestite Sex Worker
Unprotected Anal Intercourse
Unprotected Insertive Anal Intercourse
Unprotected Receptive Anal Intercourse

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, MARGINAL!TY 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 HIV, 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 semistructured interviews; blood samples were collected by venipuncture
and tested for evidence of HIV, hepatitis B, and syphilis infection. Participants received
pre- and post-test HIV 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 HIV 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 Miami 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 HIV epidemic, including a population-specific risk reduction
program that stresses community building and social support.

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 (HIV), 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 HIV 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 1997c). Sexually Transmitted Diseases (STDs) are significant
cofactors in HIV transmission (Royce et al. 1997); STD rates in the U.S. are the highest in
1

2
the industrialized world (Watanabe 1997). Miami continues to be an HIV epicenter (CDC
1997a), 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 1997a), it
is imperative that HIV 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 Hispanic majority.
Currently, over 51% of Dade’s 2.1 million are Hispanic; 23% are black, and 26% non-
Hispanic 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 African-
Americans 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 semistructured 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 HIV 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 HIV-1 antibodies and for Hepatitis-B and syphilis markers.
Risk reduction counseling, as required by Florida law, followed each interview and

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 STD/HTV 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: Expression
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.1
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 gender-
linked 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).
1 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,
¿/«other) 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 Strathem 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 modem societies, they
responded to {their} existence (1986:20).

8
One immediately recognizable violation of the dominant gender paradigm is cross¬
dressing,2 “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).J 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; rattier, 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. Hirschfeld coined the term “transvestite”
in 1910 (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 fully
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 cross¬
gender 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).
5 The DSM-IV 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).

11
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 “cross¬
dressing is cross-dressing,” (1993:134) regardless of sexual orientation. Male cross¬
dressing may occur among masculine or feminine men, and among heterosexuals,
bisexuals and homosexuals.7 The common thread among these diverse groups of cross¬
dressing men is that they have “a soothing image of themselves as women” (1993:131).
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-fema.le 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
description for them becomes “transsexual” (1993:131).
Docter’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 transsexualism) 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” will 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 gender-
variant 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). Bomstein (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 Ceceo and Elia 1993; De Ceceo 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 Ceceo 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,
9 Herdt continues: “sexual dimophism is certainly prominent in Western biological and
evolutionary thinking since Darwin... perhaps (it) seems so natural that our culture and—therefore--
Westem 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 which 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 bom
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 look 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-to-
female 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 Ceceo 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 nature-
nurture 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 GDD 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 HIV Epidemic
Some anthropologists have pointed to the discipline’s general attention to sexuality
only in non-Westem settings, and to a reluctance to address it within our own societies—
particularly when it involves same-sex sexual behavior (Carrier 1986). As the HIV/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 1994:931).
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 HIV-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.10
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 Magaña (1991) have used ethnosexual data gathered among Mexican and
Mexican-American Men who have Sex with Men (MSM) to inform HIV 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; Scheper-
Hughes 1994), Mexico (Taylor 1985), Nicaragua (Lancaster 1988), Africa (Sheperd
1987), and the Mediterranean (Whatham 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 m 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 II (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). Treichler describes a continuum of medical anthropological
approaches to HIV:
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 FUV as a discrete and knowable part of physical
reality which cultures merely label.” On the opposite pole is the radical idealist approach,
which “portrays HIV 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 HIV-related behavior:

23
“clearly, 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 self-
efficacy (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 HIV 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 AIDS
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
HIV/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 self¬
esteem 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 HIV epidemic has changed the discipline as anthropologists have
responded to a dearth of information regarding HIV 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 biocultural, 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 well-
established; loneliness, lack of social skills, a desire for variety, or a wish for
specific sex acts not enjoyed by a regular partner, are reasons often given by men
who are clients (World Health Organization 1989:377).
11 Troung (1990) provides a bnef 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 HIV epidemic, sex workers have been recognized to be at
elevated risk (CDC 1987) and have increasingly become the focus of research. With
respect to HIV 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 then-
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 HIV
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 1991). 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 HIV epidemic, 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 1989-
91 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 HIV 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:
12 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 reffame 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 disempowenng 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 (Calaña 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, Fieras and Resurrección
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 HIV/STD education materials (Mott and Cerqueira 1996).
In a Rio de Janeiro study of 46 transvestite sex workers; 63% were positive for HIV-
antibodies. 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
EDUs were HIV-positive. Eleven percent Of transsexuals were HIV-infected, including
9.4% of non-CDUs. 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 mention 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 thfe transgendered. Rekart, Manzon and
Tucker (1993) reported on a convenience sample of 40 “street inyolved” 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). He 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 bom: 35% came from North Africa, 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 (91%), 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
HIV-positive

33
In Rome, Gattari et al. (1992) interviewed 67 TTSW/EDUs (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 HIV-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 HIV-
seropositive, and 79% and 76% had seromarkers for syphilis and for hepatitis-B . These
results were contrasted with 1988-91 research (Elifson, Boles and Sweat 1993:79) among
non-transgendered male sex workers in the same area that showed much lower HIV/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 HIV/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:
15 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).

a male’s propensity to be sexually aroused by the thought or image of himself with
female attributes. The best known form of autogynephilia 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 (1993b:301-302).
Blanchard maintains that “partial autogynephiles evince a particular sexual interest in those
individuals known in the vernacular as she-males” (1993a: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
16 As 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 Zarem 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).
HIV/STD Epidemiology
HIV (in the Americas, almost exclusively the H3V-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 HIV-antibodies,
following standardized screening and confirmatory testing procedures) and exhibits one or

37
more AIDS-defming conditions (CDC 1997a). As such, AIDS has a biological base—
HIV-but the disease itself is a biomedical and sociocultural construct. As Singer says,
“AIDS is present only when those with authority to define disease say so” (1994:941).
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 HIV 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 STDs and substance abuse-related immunosupression (Stine 1998).
Among street-based sex workers frequent use of crack cocaine has been linked with oral
HIV transmission (Wallace et al. 1996); a number of other STDs 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 HIV 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, HBV and syphilis transmission from infected mother to child occurs either
in útero 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 immunosupression 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 HIV-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 HTV devastation
continues to accelerate. At the end of 1997, over 30 million people are estimated to have
been HIV-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).19 Stein and Susser state “the formidable prospect of this transmissible,
chronic, and disabling disease spreading to many more individuals is certain” (1997:901).20
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 HIV, 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. 1997:A21).
20 Referring to the growing number of global infections, they continue: “these figures are no less
relevant to the United States than famine in the Sahara and civil wars in Yugoslavia and Rwanda”
(Stein and Susser 1997:901).

39
355,000 of the estimated 650,000 to 900,000 HIV-positive individuals in the U.S. have
not been tested for HIV (CDC 1997c). At the same time, the US is experiencing a
“second wave” of new HIV 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 HIV/STD statistics. African-
Americans now account for 41% 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-Hispanic whites. Among young African-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 STD rates to
“poverty, 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, Vanable and McKiman (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
for some.22 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,
21 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.
22 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

41
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,
Miami 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
HIV/AIDS epidemic since the earliest reports” (1995:21). 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 African-
Americans (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 H3V in Dade
County, and an estimated 1209 (range 483-1814) will have become newly infected in 1997
(Holmberg 1996:646).2^
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
2j 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 HIV 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 HIV epidemic continues to grow, commercial sex work has
increasingly become the focus of HIV-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 HIV epidemic emphasizes the compelling need for population-
specific 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 HIV/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 H3V 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
recruitment of 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 instalment is based on the instalment
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). I reasoned that the potential comparative value of the data made duplicating a
number of YMS questions worthwhile.1 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, lists 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.
1 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 C14
and Cl9, 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 C14 and Cl9—were more informative.
In section D, medical history, question D1 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 D13 (“Have you ever been tested for HIV?”) 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.
D19 (“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
the question. Since other variables (HI, H9 and HI7) 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.
G1 (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 G1
responses, and became confounded by the multiplicity of answers in Gl.
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 {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 G10-G12 (“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, masculinity/femininity, sexual
attraction, working life, negative aspects of sex work, clients and behaviors, HTV/AIDS,
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, Hispanic 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 Hispanic chain was begun with a referral from a street-
contacted 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 University 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 HIV

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 HIV pre-test counseling component,
following CDC guidelines, as required by Florida law. Counseling included information
about HIV transmission, HIV risk reduction, and the meanings and limitations of the HIV
antibody test, including the three-to-six month “window period” between HTV infection
and the appearance of detectable antibodies. During the HIV 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, HIV 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
Vacutainer® 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 RV2 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
“ The RV is used for a mobile HTV 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 African-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 Hispanics, for an initial total sample of 50 TTSWs. Since Caucasians represent a
relatively insignificant component of the active TTSW population in Miami-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.
J All project costs were funded by the researcher, who was employed by a CDC/Florida
Department of Health-funded HTV/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 ENEO 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
Biemacki 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 HBV 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; Jilg 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 -
Project proposal, supervisory com¬
mittee approval, and IRB application -
IRB approval -
Observational data collection -
Interview data collection -
Analysis and write-up -
November 1995 - February 1996
March 1996
July 1996
September 1996 - December 1996
February 1997 - June 1997
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 “Hispanic” 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 “HIV” should be considered strain HIV-1 unless otherwise noted,
and language such as “HIV-positive” should be construed to mean “positive for antibodies
to HIV-1.”
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=33). 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 Miami Beach, and 11 (42%) live in predominantly Hispanic areas on the
mainland. Only one Hispanic participant was bom and raised in Miami; twenty-three (88%)
were bom outside the U.S. Twelve (46%) Hispanics were bom in Cuba, the most
frequently reported country of birth. Others were bom 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 African-
Americans were bom in the United States. The one exception was bom on an English-
speaking Caribbean island, though she nonetheless self-identifies as African-American and
holds U.S. citizenship. Fifteen (68%) have lived their entire lives in Miami. Of the
remaining six, three were bom in the southern U.S., and three in the northern U.S. All but
two non-Miamians 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=l 1), while African-Americans report a mean of 11.8 years (range 10-17,
medianil 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 African-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 African-
Americans 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 gender-
atypical 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
family primarily attributed them to their own femininity and cross-gender behavior (CGB).
Juana, who recalls calling herself “Wonder Woman” 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. I was forced to
leave, 'cause my father used to beat me for it.” llena, 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
Brígida 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 Í 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 betwen African-Americans, of whom 55% live alone, in contrast to
19% ofHispani.cs. 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
% 30
20
10
0
Alone w/parents w/relative w/roommate w/sex partner
HI African-American (n=22)
111 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; African-Americans, 10 (5) months.
Most participants rely on street-based sex work as their sole source of income. Thirty-
seven 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
in the U.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 for jobs 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< 01) 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).
Hispanics 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 HIV 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 HIV-related posters. This is a significant
gap in local HIV prevention efforts.

65
Never <1x/mo 1x/mo 2-3x/mo 1x/wk 2-3x/wk >3x/wk
IHi African-Americans (n = 22)
HI Hispanics (n=26)
Figure 4-2. Attendance at bars.
Never <1x/mo 1x/mo 2-3x/mo 1x/wk 2-3x/wk >3x/wk
|||j African-Americans (n=22)
HP 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 unaprosituta1 —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 6-
month sexual histories.
1 600
1 400
1 200
1 000
800
600
400
200
0
Mean M ed ia n
llll Africa n-Am e rica ns (n = 22)
lllil 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 Hispanic participants report having engaged in both insertive anal intercourse
(IAI) and receptive anal intercourse (RAI), as well as in unprotected insertive anal
intercourse (UTAI) and unprotected receptive anal intercourse (URAI) .
1 Note that in Spanish, Diana refers to herself in the feminine gender.

67
16
14
12
10
8
6
4
2
0
â– 
Oral Anal
African-Americans (n=22)
Hispanics (n=26)
Figure 4-5. Mean age at first episode of oral and anal sex.
%
i | African-Americans (n=22)
H! 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 African-
Americans reported only being the recipient). Thirty-one percent of Hispanics reported

68
having shared objects for anal penetration, vs. 9% of African-Americans. Aiiobrachial
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 (“fisting”). Of these 7, five had also
received fisting; 2 additional Hispanics reported only receptive fisting. This is not a
comprehensive list of participants’ sexual activities: a number of other acts performed with
clients are discussed in following sections.
Oral-anal Finger anus Share toys Fist (give) Fist (rev)
[||| African-Americans (n =22)
III 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 African-Americans (73%) and 15 Hispanics (58%).
Of these, two-thirds had experienced forced sex by two or more different people.
Six Month Sex with Males
There are significant (P<01) 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.
300
250
200
150
100
50
0
Mea n
M e d ia n
African-Americans (n=22)
Hispa nics (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 (91%) and Hispanics (42%) reporting sex in street or alley.
100
Hotel Vehicle Partner's Home Street/alley Park
African-Americans (n=22)
Hispanics (n=26)
Figure 4-9a. 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
HI 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 Insertive Unprotected IAI
Hi African-Americans (n=22)
Ü! 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 (3DU)
within the past six months. Combined, roughly half said they had not had EDU contact, and
one-third said they did not know. Two Hispanic participants said they had sexual contact
with an HIV-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 HIV-infected partner. Frequencies for sex with IDU or
HIV-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
comers, 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 TTSWI
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 less-
dense 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 TTSW 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.”

75
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. Brígida, 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 my jobs. 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 (21). 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.

76
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.” llena, 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 la piedra, y en
dos meses allí estás con la pinga en la garganta” (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. African-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 street-
based 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
80
60
40
20
0
Af-Am (N=22) Hisp (n=26)
HI 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.

78
300
250
200
150
100
50
0
Mean
M e d ia n
African-Americans (n=22)
Hispa nics (n = 26)
Figure 4-12. Number of exchange partners in the past 6 months.
250
200
150
100
50
0
F/T PfT No, seeking No, n ot see king
HH 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%) African-
Americans 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

79
with exchange partners; they comprise 10 of the 11 TTSWs who do not insert orally
(Pc.00001).
Oral (rev) Oral (Ins) Anal (rev) Anal (ins)
HI African-Am ericans (n=22)
IH Hispanics (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 fuck me.
I don’t get pleasure out of them fucking me. I get pleasure out of me fucking them.
Getting fucked, 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 fucked. 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
fuck’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.

80
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 cornin’ 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 carjackin’ 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 cornin’.” 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:

82
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 10 pargos
(clients; literally, “snappers”) per day. It’s easy. I just go to the comer, 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 fun. 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?
llena 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). llena doesn’t
like the work:

83
I 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. I don't do nothing for free.
llena 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 a pargo 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.” Brígida 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
fuck 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 fuck
somebody without a condom, especially if I’m high. Latin guys like to get fucked
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 fuck you”
but then we get somewhere, and they say “this is gonna be our little secret” and
they want me to fuck 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,

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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 (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 fuck
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 fuck. 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 if I don't think I can get over on them with a slick leg, then I’ll tell
‘em.
I don't let ‘em 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 fuck
you, too?} To me, never.
Lucila said “About one-fourth want to suck my dick and get fucked. 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 truco).
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

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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.
(What are the monsters?} 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 fucked 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. {Even
though they know you’re a guy?} 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 himself:
That’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

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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
mí, no me gusta el hombre con dick. A mí me gusta la mujer con dick” (“I don’t
like men with a dick. I like women with a dick”).
Angela continued:
La mayoría son casados. Entre latinos, hay mucho homosexualismo. Se ven muy
macho, pero después, 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 “Mam/, 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

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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 BMWs, 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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Kandi likes the streets as well, and for her there is also a social function:
My friends do this, too. You can talk about what’s going on, and we watch each
other’s back. You meet a lot of men, and a lot of people will respect a drag queen
because of what they are. I really want society to see how many men I have slept
with, and what I was how good I looked, I could get this many men. And the
majority of the men know. They know. Workin’ the street, I don’t have to do
nothin’ I don’t want, and the money’s good.
Most, like llena, say sex work is their only option for survival: “The streets are
dangerous, but it’s the only way for us to survive. Without papers (allowing her to work in
the U.S.) people pay maybe $2 an hour. But on the street, I see a guy, he gives me $100
for 15 minutes.”
Emilio is ambivalent about sex work, and described his thoughts:
Why do I do it? It’s a bunch of things altogether. Altogether. It’s not just the
money. We make good money, but we’re not gonna get rich out of this. It’s more
like, it’s a bunch of things. It’s attraction. I can mention 3 or 4 or 5, or maybe 100
reasons, good ones and bad ones, and altogether comes this. Comes the excuses-
comes this comedy—comes this tragedy.
Despite the positive aspects of the work, all but a few participants described many more
negative ones, regardless of where they work. On the Beach, Diego says, “The pargos hit
us and rob us. It’s very hard. You have to walk a lot, you have to take a lot of drugs, you
have to run. It’s dangerous. {Why the drugs?} You have to be awake.”
Lydia is in her mid-30s, and began working the streets within the last year when she
moved to Miami. She says:
I would rather work at something decent, but there’s no money. You have to do it.
But I don't see myself as a street prostitute. I do stand on the streets, but I also go
in the bars and make friends. If they want to do something, I ask them if they
could help me pay this bill or that.
A number of TTSWs on the Beach described being in dangerous situations. Ana said:
I’ve had bad experiences. Sick people do sick things to you. I had a guy point a
gun at me one time. We’re all afraid on the beach, 'cause one of our friends got
killed on Calle Ocho. There’s a guy going around, picking up the girls. He likes to

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take ‘em and burn ‘em and cut their face. I told the girls we need to go to the
police.
Emilio agrees:
The streets are risky. There’s this guy, he does things to us. One guy take my
friend to a hotel, he tied her up and burned her with a cigarette all over her face.
The police said she’s lucky, 'cause he’s already killed 4 other girls.
Not long ago, Emilio was bound, drugged and raped by two pargos, who left him naked,
still tied and immobilized, near a busy street.
Maria got started on the street over 20 years ago, and plans to retire. She just
qualified for disability payments, and is waiting for the checks to start arriving. She is
pleased:
When you’re working the street, it’s a whole lotta stress. You gotta worry about the
cops, you gotta worry about who you're with and what they’re gonna do to you,
you gotta worry when you get out of the car somebody’s gonna jump you and take
your money. It really is a lot of stress.
At first, you don't think about it. It all starts out as a game, and you make some
money, make money, make money. But the streets are getting harder and harder.
It’s a malicious circle, and there’s no way out. It’s all work, work, work, and it’s no
way to live. You take a break from it, and what do you have left to do—you gotta
go back to the comer. That’s what these girls don't understand.
Justinia is a tall 21-year old, working the Beach for four years:
I do it because it’s easy money. But the truth is, I don't like it. There are days when
I cry, there are days when I feel guilty because my mother raised me... I’m my
mother’s son, and I will always be her son, even if I’m in a dress and high heels. I
look back at my baby pictures, and see me with my mother, and I compare myself
to them as I see myself now—my mother doesn’t know what I do, and I don’t want
her to know—and I’m a mess. I’m a nobody.
Despite the negatives described by Beach TTSW, those on the Stroll face daily
circumstances that are decidedly more difficult. Shavonne described them from her
perspective:
You get robbed, you get shot, you get hurt. But I’m cool with the police. They say
we’re gonna have a sting tonight, and if you’re gonna work you’re gonna be on this

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corner right here. I stop ‘em and tell ‘em who’s doing what and what cars are
robbing people. I’m cool with them. I have did some of the police. Basically it’s
not the cops, it’s the robbers.
Glitter also has experience with being robbed:
There’s some guys in a white Cadillac, robbin’ us and our dates. Two girls got shot
in the last 2 weeks. We tell the police, but they act like they don't wanna do nothin’.
And a girl got killed about 6 months ago.
Coco described what she dislikes about the Stroll:
Having to be with a lot of people that disgust you. Fat men, old men. And I hate to
be touched when I tell you don’t. We’re not here to make love or anything. I’m here
to get you off, and I’ll do all the work. Every now and then when you’re gonna
fuck and you put a condom on the guy, and you reach back there and he took it off.
I don’t date you anymore and you don’t get your money back.
Twice, I was raped at gunpoint on the street. I’ve had 3 cops tell me if I don't do it
(perform oral sex), I’m going to jail. {Did you do it?} Yes.
I’ve been arrested a million times. You get put in a cell with gay guys or
transsexuals. I’ve been to jail about 200 times. It’s $100 to bail out. I’ve never
been charged—out of all the years I’ve been on the street—I’ve never gone up on a
pros’ (prostitution) charge. I’ve never been caught in the act, never caught with my
pants down. They always charge you with—what do you call it—obstructing the
highway, causing confusion with traffic.
Princess explained that:
Most of the girls just keep on. Their expenses are high and they like that lifestyle,
so they take it seriously and have to be out all night. You also got some 16, 17 year
old girls out there. Lotta girls just gettin’ started. Some girls get hurt and killed out
there and it makes me think and I’ll say OK, I’m not gonna do this no more—but
then when the bills come and I’m under pressure, I’ll say I’ll go out and make some
money. Guys shoot girls in the head. I’ve been tied up and thrown out a car. My
girlfriend got tied up and dragged behind a car.
While working the street, Princess has been raped-by an estimated 40 different people.
So has Melissa: “I’ve been robbed at gunpoint many times, and been raped a few times.
They just pull a gun, and you have to.” Jasmine reported having been forced to have sex by
“at least 100 different men. They say they want to date you, you get them behind a

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building, then they put a gun to your head. I been shot before.” And indeed, she had been
shot in the leg just a week before; she showed me.
Shanika said “It’s a livin’ hell. You gotta worry about makin’ it through the night—
about not gettin’ robbed or killed—worryin’ about your life.” Shanika was missing part of a
front tooth. She explained that a few days earlier, she was pistol-whipped in the face, as she
was being robbed by 3 men on the street.
Like almost everyone who works the Stroll, Roanne has been robbed by a date:
I was on a date about 2 weeks ago, and we had parked somewhere, and when we
got done he tried grabbed me and tried to rob me. And then he shot me (in her
upper thigh) when I wouldn’t give him my money.
I believed her. Like Jasmine, she showed me where the bullet entered her body.
When Antwanette told me what she fears about the Stroll, she was sitting on a bed,
arms around her legs, balled up in a comer. She spoke to me in a low voice, clearly
conveying a sense of helplessness:
I wish I could keep the robbers from gettin’ me. I get robbed at least three times a
night. I don't know how people let they children out to do that kind of thing, but
they be doin’ it. They have guns, they beat us. They knocked out my girlfriend’s
teeth and beat her in the head. They shot at me last week.
Vanya uses cocaine daily, because she needs it to work. She is a petite 19 year old, and
on the Stroll for five years. She has been raped at gunpoint three times, and has been
robbed “more times than I can count.” She said:
I hate working the streets. Before, I could play. Now it’s serious. I got bills and
responsibilities. Can’t have fun, can’t go shopping. Got no time.
Eight out of ten know I’m a guy. They’re freaks. I call ‘em names. “Child, honey,
you ain’t got enough money for me.” I really hate men. I get tired of sucking their
dick and I’m like, “you’re messing up my lipstick—that’s it.” I like to cuss them out.
They want to fuck me for $20! You gotta be mean to ‘em.

93
I hate men. I hate men sucking my dick and I hate to fuck them. I actually hate
sucking a dick, 'cause it makes me sick, and I hate to get fucked. The only thing I
like is a slick leg.
Rhonda, with 12 years on the Stroll, is very familiar with its violent nature:
I been shot twice. I had a guy say “give me your fuckin’ money” and I said “hell no,
you’re gonna have to shoot me,” so he did. That’s the first time I got shot.
The second time I was with my friend, and we was dealing with drugs, too, and we
got robbed. She died.
Risk Reduction with Exchange Partners
TTSWs recognize the value of condom use for disease prevention, and they use them:
almost every participant was carrying a condom at the time of interview. Their use,
however, is inconsistent (see figures 4-15 through 4-18). Condoms are used more
consistently for anal sex than for oral. Forty-four (92%) reported that they used a condom
during the last episode of anal sex: 2 (9%) African-Americans and 2 (8%) Hispanics did
not.
Never < 50% > 50% Always
III African-Americans (n =22)
IH Hispanics (n=25)
Figure 4-15. Condom use for receptive oral exchange sex.

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60
50
40
% 30
20
10
0
Never <50% >50% Always
African-Americans (n=16)
Hispanics (n=21)
Figure 4-16. Condom use for insertive oral exchange sex.
Never
< 50%
> 50%
ill African-Americans (n=19)
H| Hispanics (n=20)
Always
Figure 4-17. Condom use for receptive anal exchange sex.

95
%
100
80
60
40
20
0
nn
Never < 50% > 50% Always
¡ j African-Americans (n=11)
| Hispanics (n=15)
Figure 4-18. Condom use for insertive anal exchange sex.
TTSWs report that, in most cases, they wish to use condoms. Eliana told me:
I take care of myself, ‘cause I think of my mom and my family. When guys get
smart with me (about condom use), I tell them to stick that $40 up your ass—I don’t
care. Sometimes they try to take the condom off, and I say leave it alone, I know
what I’m doing and let me work.”
Gigi said “how can I put a dick in my mouth I don't know where it’s been? Nice
people don’t do that.” For receiving oral sex from clients, however, “to tell you the truth, if
a guy’s really cute, he can do it with no condom.”
Though TTSWs most often prefer to use condoms, clients often do not. Coco says:
they offer more money for no condom, but it’s not worth it. I tell them “We’re not
gonna exchange words about it. Go find somebody that don’t want to put one on
and go with them. But I don't have to.”
Jasmine says that, in her experience, clients often pressure her to “do it without a
condom,” and that, during sex “a lot of clients yank it off-.” So does Princess: “Some guys
try to bust the condom, or fidget the condom off-that’s happened to me numerous times.”

96
She sometimes puts the condom on the client with her mouth. Lani said “I have to put one
on them, ‘cause they’ll just want to go ahead.”
On the other hand, sex without condoms sometimes occurs willingly. Marcela said:
the guys complain, and say “No, baby, not with a condom.” But sometimes if I like
the guy, I’ll forget the condom—just for oral sex—but I tell them ‘if you come in my
mouth I’ll bite your dick.’
Jasmine has several regular clients, and she will do it without a condom with them
“sometimes,” because she “knows them.” Tommi never uses a condom when receiving oral
sex from clients, and says “most guys want me to cum in their mouth, and they want to
swallow it.” For insertive anal sex, but not for receptive, he sometimes doesn’t use them:
“it depends on how long I’ve know them. If we’re like a constant thing and I’m out, I
won’t use one.” Lydia says it happens sometimes, because “I know them, and they look
good, and they look clean.”
Roanne “slipped up” twice in the past 6 months:
One time, the condom broke. Another time I got into it with a guy and he looked
good, and he couldn’t get hard with a condom on, so I just did it. Sometimes if they
look clean, I’ll blow them (without a condom), ‘cause for them it’s not the same.
Despite the best of intentions, Macy says, “there’s always gonna be the time when you
don’t have condoms, and you’re gonna do it without one.” Justinia says unprotected sex
occurs regularly with her friends:
They think that if a guy looks so cute and so clean, he doesn’t have it, but he can.
I’ll be honest—I’ve been with really cute guys. They’re really beautiful, and I’ve said
“fuck it, I don’t want to use a rubber.” The girls need to know that it’s not all the
image. That behind the image, there’s a virus.
For some, condom use is not entirely within their control; this reflects a power
imbalance between worker and client widely discussed in the context of sex work. Diego

97
said “sometimes, there are no condoms. And clients demand no condoms, and only
sometimes you can insist.” Emilio explained a recent instance of unprotected receptive anal
sex: “a few months ago, these two guys drugged me and raped me. I couldn’t stop them.”
50
45
40
35
30
%25
20
15
10
5
0
Recoral Ins oral Ins Anal Recanal
African-Americans (n=22)
Hispanics (n=26)
Figure 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.
Overall, a significant proportion of TTSWs report unprotected sexual contact with
exchange partners within the past six months (Figure 4-19). Eleven (23%) had unprotected
anal intercourse, including 4/22 (18%) African-Americans and 7/26 (27%) Hispanics.
Of these 11, all reported having sex at partner(s) home(s) (P<03), and 9 had reported
running away or being forced to leave home (82%; P< 09). They initiated oral sex earlier,
at mean (median) 14.9 (16) vs. 12.9 (13) years compared to those not reporting UAI
(P< 09). They also initiated anal sex earlier, at 15.5 (16) vs. 14.2 (14) years compared to
those not reporting UAI (P=. 15). Several variables in Section H were associated with UAI;
these are presented in the Psychosocial Scale section of this chapter. Several other factors
also influence these rates, and are reviewed and summarized in Chapter 5.

98
Sex with Non-Steady and Steady Partners
Non-steady partners are defined as non-exchange partners with whom participants had
sex once or twice. Steady partners are non-exchange partners with whom participants had
sex three times or more. Fourteen (29%) participants reported having sex with non-steady,
non-exchange partners, including 7 (32%) African-Americans and 7 Hispanics (27%). For
these individuals, the number of nonsteady partners over the past six months averages 18
(range 2-100; mode = 2, median 8.5). African-Americans reported a mean of 25 (range 3-
100; median=12; mode=3); Hispanics, a mean of 11 (range 2-50; median 4; mode=2;
P-10).
Oral sex was universally practiced, with condom use somewhat less consistent than with
exchange partners, though more consistently among African-Americans. Figure 4-20 is a
composite illustration of condom use for receptive and insertive oral sex.
100
80
60
40
20
0
Never
< 50%
> 50%
] African-Americans (n=7)
j|| Hispanic s (n=7)
Always
Figure 4-20. Condom use for oral sex with non-steady partners.

99
Of the 14 who report sex with non-steady partners, 5 (36%) have insertive anal sex,
including 2 African-Americans and 3 Hispanics. All 5 report 100% condom use with non¬
steady for insertive anal sex. Of the 14, 10 (71%; 5 African-Americans and 5 Hispanics)
also have receptive anal sex. Each of the African-Americans report 100% condom use; of
Hispanics, two report using condoms more than 50% of the time; three report 100%.
Twenty participants (42%) report sex with one or more steady partners, including 9
African-Americans (41%) and 11 Hispanics (42%). Though the term was defined as any
non-paying partner with whom participants had sex with three times or more, for the
majority these are long-term relationships. In three of these cases, steady partners were
unaware of participants’ commercial sex activities. Sixteen of the 20 reported only one
exchange partner, with no significant difference between African-Americans and Hispanics.
Oral sex is practiced by 19 (95%), though in 13 cases participants reported performing only
the receptive role. Composite condom use is illustrated in Figure 4-21.
Never < 50% > 50% Always
_J African-Americans (n=8)
¡¡j Hispanic s (n=11)
Figure 4-21. Condom use for oral sex with steady partners.

100
Receptive anal sex is universally practiced by those with steady partners, in contrast to
lower rates of RAI with exchange and non-steady male partners. Condom use varies, but is
much lower than with other types of partners (see figure 4-22). Six participants (30%; 2
African-Americans and 4 Hispanics) also practice insertive anal sex with steady partners.
Of these, 4 (67%) report never using condoms for IAI.
Lower rates of condom use by female, male, and transgendered sex workers with their
steady partners than with exchange partners has been widely reported, as is the case in this
study. There is a general assumption that condoms have little place within the context of a
steady sexual relationship, and that negotiating their use would be impossible.
Never
< 50% > 50%
African-Americans (n=9)
Hispanics (n=11)
Always
Figure 4-22. Condom use for receptive anal sex with steady partners.
Frequent comments were like Ilena’s: “He knows I take care of myself (use condoms
with exchange partners), and he doesn’t like them” and Emilio’s: “We felt like a couple.”
Michelle, however, is an exception—she and her steady partner discussed using condoms.
Even though she left the street 5 months before, they decided to have a safer-sex

101
relationship “because of both our pasts.” Though this sounds ideal, Michelle added, “but if
he didn’t want to, I would do it to keep him. I would have to.”
Sexual Attraction and Relationships
Sex for pleasure occupies a subordinate role in most participants’ lives. Though most
reported that they enjoy sex with non-exchange partners, a number of other facets in their
lives clearly take precedence. Those with steady boyfriends often retain a more traditionally
“female” gender role than with their exchange partners, in sexual as well as social behavior.
A recurrent theme is that most boyfriends prefer to not even acknowledge participants’
male genitalia. Participants generally accept, and sometimes prefer this arrangement. Maria
had a 5-month relationship, and her “boyfriend never saw it. He didn’t want to see it.”
Tiffany also has a “straight” boyfriend, and has receptive, but not insertive, anal sex with
him. She confided, however, that he “gives me oral sex a little bit... but if they (indicating a
general “those” out on the street) found out, he would kill me!”
Having a steady relationship was expressed as desirable by most participants, but also as
problematic. As Justinia expressed, “the one thing that I don’t have is a boyfriend — it’s
hard. I’m sort of envious of gay people, 'cause it’s so easy to find a boyfriend.” Eliana had
much more to say on the subject of relationships with men:
I dated one guy for one month without him knowing. Then I told him, in a very nice
way, and tried not to make it like, I’m a faggot. I just made it sound like, I’m not a
perfect girl, like I have a different part. I had told him that from the beginning. He
worried so much, why am I so different?
After a month, things were going so well, and he asked again “how are you so
different?” and I asked him “do you think that all womens are perfect?” He said
“no,” and I asked “do you think that a vagina makes a woman?” and he said “yes.”
And I said “what if a woman is bom with the opposite sex?” and he knew.

102
He was very shocked and very sad. He almost cried, and he left. He called me the
next day and said ‘let’s try to work this out.’ So we were together for about four
months, and then he was going through some problems with his ex-wife and he
wants custody of his kids, so I decided that since he’s having so many problems that
I’ll just go my way.
I couldn’t handle being a mommy—he wanted to go out and leave me with his
mother and his sister, and I feel so—like they’re looking at me too much. Those
people never knew nothing and never figured anything out—but you know, you
never know, you know what you are and so you always think they might know.
You’re afraid they’re gonna look at you and find out what you are.
Transsexuals like straight men. It’s rare for a transsexual to fall in love with a gay
boy, but it happens to almost all of us at least once. It never works—a gay boy
doesn’t like you 'cause you look like a girl. There’s always that drama. A gay boy
won’t like you in bed and the way you look. He can go out with you, and no one
can tell he’s gay, but they don't like us for a relationship or in bed. But we would
like to be with them, for a relationship and in bed. But that never works.
For a relationship, being a transsexual is not that good. We always go out with guys
who are straight and they’ve been with girls. You’re always like the first one—
they’ve never been with a transsexual before. You try to make him fall in love with
you, and after a while he’ll have to accept you. But you know, you always have
that feeling that he’s gonna get tired of it and go back to what he had before. You
always have in mind that he’s gonna leave you for a woman, because eventually he
will.
Sex with Females
Though all participants reported currently being sexually attracted to men, they may not
be exclusively attracted to men. Eliana self-identifies as a bisexual, as do some of her
transsexual friends, as well as her transsexual sister. She described this night out:
My friend, who also looks very much like a girl, and I, met a woman in a club and
she was good looking. She was so into us—like “you’re so nice, you’re so sweet.
And like, what are you people?” like, are we gay or straight women. So we lied, we
said, we’re lesbians. She’s like, I’m a gay woman, too. And we go to my friend’s
home. When we got inside, that girl got naked. Then my friend tells the girl that
she has a male part. The girl was like, she couldn’t believe it. She wanted to see,
and she said T never saw a woman with a male part.’ She said T wanna try and see
how it works,’ so we were having sex with her. It was different, ‘cause it’s the first
time I did it with a woman, when I was looking like a girl. I said to myself, T feel
weird.’ But my friend does it all the time - she likes girls.

103
Having had female sexual contact fairly recently, Eliana is an exception. However,
lifetime sexual contact with a female was fairly common, with nineteen participants (40%)
vaginal or anal contact with one or more females. Eighteen (38%) had vaginal sex, with
mean and median ages at initiation of 14 and 17 for African-Americans and Hispanics. For
most, sex with a male preceded sex with a female. Of the 19 who reported sex with
females, 6 (2 Hispanics and 3 African-Americans) reported female contact prior to male
contact. From the 19,1 excluded two participants from analysis, one African-American and
one Hispanic, who each reported 50 female partners. Eliminating these outliers, the mean
(median) number of female partners is 2.7 (2.5) for African-Americans and 2.1 (2.0) for
Hispanics. Overall, 80% of participants had only 1 or 2 female partners in their lifetimes,
and this contact normally occurred years earlier.
Two Flispanics reported having exchange sex with females. One of these is a
transsexual, reporting no other female contact, who was paid by a female to receive oral
sex. Another transsexual was paid to participate in a “threesome” with a married couple in
1994, and to perform unprotected vaginal sex with the female, as well as unprotected anal
sex with her husband.
Only one participant reported sexual contact with a female in the past 6 months
(protected vaginal intercourse with only one woman). This individual self identifies as a
bisexual transvestite; he cross-dresses only to work the streets, and reports 50 lifetime
female sex partners.

104
Medical Considerations
Health Care Access
As a whole, participants do not access health care: just one in five receives regular
care. The most common health care delivery site is the public health clinic (figure 4-23),
which is normally visited only with a specific complaint. Just one-third are covered under
an insurance plan or Medicaid; the rest have no coverage (figure 4-24). The relative
proportion of African-Americans insured is likely to decline within 2 years as four teenage
participants, currently covered under parents’ policies, reach 21. Though for most there is
a financial obstacle to health care, several participants also reported a reluctance to visit a
doctor for fear of transgender-related discrimination and resulting embarrassment. HIV-
related stigma also discourages health care access; as discussed in the following section.
African-Americans, in particular, may avoid seeking health care because it may “mean they
are infected.”
[_J African-Americans (n=22)
HI Hispanics (n=26)
Figure 4-23. Regular health care delivery sites.

105
One public health clinic near the Stroll enjoys a reputation of cooperation with TTSWs.
At the clinic, participants may receive substantial quantities of free condoms—they need only
come with an empty bag. They are encouraged to visit the office during a 2-hour, mid-
afternoon lunch break: during this time, there are no other clients in the waiting room, and
they will be spared the harassment and catcalls they would otherwise experience. Though
clinic personnel told me that they try to express a genuine sense of concern, and that they
make extra efforts to encourage TTSWs to come in for health care services, they rarely
meet with success.
Insured Medicaid None
| African Americans (n=22)
â– IH Hispanics (n=26)
Figure 4-24. Health insurance coverage.
STD and HBV Vaccination History
Nineteen participants (40%) report ever being diagnosed with any sexually transmitted
disease (STD), including 7 (32%) African-Americans and 12 (46%) Hispanics. None
reported herpes or genital warts; 19% reported having had gonorrhea at least once, and
35% reported a history of syphilis. African Americans reported having had more episodes
of gonorrheal infection, with 1.2 (1) mean (median) occurrences, compared to 0.7 (0) for

LOÓ
Hispanics (P< 10). Participants reporting a history of any STD were significantly (P<001)
older than those who did not, with a mean (median) age of 32.6 (34) versus 25.8 (24).
They initiated sex work a mean (median) 123 (144) months ago, compared to 67 (36)
months ago for those with no STD history (P<02). Eight participants (17%) reported
having received the three-shot hepatitis-B vaccination series. Figure 4-25 illustrates
reported STD and HBV vaccination history. Results from blood tests contradict reported
syphilis and HBV vaccination data; these are discussed in Chapter 5.
|H African Am ericans (n = 22)
11 Hispanics (n=26)
Figure 4-25. Reported STD and HBV-vaccination history.
HIV/AIDS Experience and Perceptions
Personal knowledge of HIV-infected people is clearly within participants’ experience:
almost all knew someone with HIV, and over three-fourths reported personally knowing
someone who died from HIV (see figure 4-26). Though no participants reported having
tested HIV-positive, 41% of African-Americans, and 41% of Hspanics, believe it is
“likely” or “very likely” that they are currently infected with HIV (figure 4-27).
Thirty-nine (81%) participants reported having voluntarily taken an HIV test in the past.
HIV testing was not associated with age, HIV status, number of sex partners, or rates of

107
With HIV Died from HIV
L-j African Americans (n = 22)
lUj Hispan ics (n = 26)
Figure 4-26. Participants reporting knowing an HTV+
person and knowing someone who died from AIDS.
No chance v. unlikely unlikely likely v. likely HIV+
African Americans (n=22)
B Hispanics (n = 26)
Figure 4-27. Probability of current HTV infection.
unprotected sex. Though several reported having been tested in jail or prison, test results
were not given to them. In such cases, though participants assumed that they would be
notified of positive test results; these tests were excluded from this analysis. Seventy-
seven percent of African-Americans and 85% of Hispanics reported having been voluntarily
tested. Of these, the average number of times tested was 6.4. This figure is skewed,
however, by one Hispanic participant who reported being tested 95 times over the past 11

108
years (and indeed, showed me a stack of perhaps 30 HIV test results). Discarding this
outlier, the mean number of HIV tests was 3.97, including 2.8 for African-Americans (range
1-8; median-2; mode=2) and 4.95 (range 1-20; median=3; mode=2) for Hispanics.
Hispanics and African-Americans reported 15.6 (9) and 16.1 (14.5) mean (median) months
since their last HIV test, respectively.
Participants are well aware of the existence of HIV/AIDS and its transmission
modes. Perceived severity and relative concern, however, vary among participants.
Princess told me that she thinks often about HIV, but believes one can be too cautious:
Oh most definitely. I’m very safe, but it’s the cautious person that is the one that
gets it. Being too cautious can cause accidents. I think about HIV every day of
my life. My life is basically as average person’s life, and I don’t want to have HIV
and deteriorate and die. There’s a lot of girls out there, and they have it, but they
don’t tell anybody.
For many, HIV is a common, even daily element of consciousness, but there are severe
social pressures to avoid acknowledging or discussing it. Coco explained:
Every time a friend of mine gets sick, I think about it. But I say to myself, I’m well
today. I don't know what tomorrow plans for me. All I can do is live each day as I
possibly can, and be as careful as possible, and I know I’ll be taken care of (by
God). It’s not really discussed. We don't talk about it.
Melissa says “I worry about HIV, but not all the time. I always use condoms, and when
they break I usually catch it.” Towanda seems to be relatively concerned: “Yeah, I worry
about it. I just hope I never get it. I’ve seen it happen a lot. I just hope they cure it.
Who’s that basketball player, Magic? I heard he got cured. That’s good.”
Glitter is concerned about HIV, but believes that she is doing a good job of protecting
herself. She has never had receptive anal sex (unique in this sample), and is adamant about
condom use for oral sex. Plus, she says:
I can look (and tell if a person is HIV-infected) from being around my stepbrother
(who died from HIV-related illness). I can look at the symbols if a person has it,

109
‘cause I saw what he went through. They get that ashey look in their face, and
people always start showing. It’s in their face if they got it. I don’t worry about
kissing, ‘cause you got to get so much slobber to get it. But I pray to God when
I’m suckin’ on somebody that he don't have it and I don't know about it.
Lani says “I try not to think of it. And I won’t go with somebody who looks dirty or
scummy.” Though they’re fully aware of HIV, Nila said “the girls get stupid when they
drink and do drugs. All of‘em are doing drugs, and they lose their head. But they don't
listen.”
Some TTSWs are reacting to the constant presence of HIV. Roanne said “I’ve got
more serious about what I do out there, ‘cause there’s a lot of people dying.” Jasmine
agrees: “most of the girls have passed away with HIV.” Maria said:
If you’re out there, it’s all a game you gotta play. And sometimes you play, you
pay. I know I oughta know, but I’d freak out if I was positive. Even with the
new drugs, you’re fucked. Your life’s over, ‘cause you can’t do shit. It’s all over.
Ana described a number of physical symptoms that concerned her, and she was serious
when she softly said “I’m scared, ‘cause I’m feeling a little bad. And I’m scared to get
tested, ‘cause I’m afraid.” She did not choose to receive her results. Eliana knows a
number of HIV-infected TTSWs who continue to work the streets: “It happens. There’s
girls out there who are sick, and they’re still working. They’re sick in the head. That’s not
right. They’ll make the guys sick, and then they’ll go spread it to someone else.”
The most common reaction when we discussed HIV and HIV testing was “I don’t want
to know if I have HIV.” Michelle told me “some girls catch HIV, and they feel they can’t
go out, and they kill themselves. I’ll be a better person if I don’t know, than if I know. It’s
just not discussed. People don't want to know.” Towanda felt that she was very likely to be
infected, but said “I really don’t want to see my results. It’s like the thought would bring
me down faster. I’d have to live with all that, and I don't wanna know.”

no
Kandi feels she protects herself with condoms as best she can, and if she becomes
infected she would rather not hear about it:
A lot of the girls, they catch the cum {ejaculate} in their mouth and they don’t care.
I feel like if I do get it, it’s ‘cause somebody rapes me, ‘cause I use condoms. (Do
you think about it a lot?} No, not really. I don’t want to know about it. I think if I
was HIV I would try and commit suicide. Being around somebody else like I have
and seeing what they went through. I don’t want to know. {You don't want your
results?} I don’t do nothin’ to catch nothin’ and I don’t want to know. {Even
though I could help arrange free medical care?} But I’d have to know, though. I
really don’t want to know if I’ve got it.
Lala, like many, refused to consider getting her HIV results:
Yes, I worry. That’s why I leave myself in the hands of God, ‘cause when the time
comes, you’re going, no matter what you are, no matter where you are. I been
working the streets since I was 16 {she is now in her mid-30s) before AIDS even
came out, so I could have it and not even know it, ‘cause you can have it for 10
or 15 years and not know it. I don't want to know. I had close friends go, and it
hurt me so bad. If it be me, I’d rather let it be a sickness coming down to me - but
as far as me going out of my way to find out, I wouldn’t want to know that way.
Among African-American TTSWs there is extreme social pressure to publicly deny the
possibility of being HIV-infected; this pressure means people avoid being seen entering a
clinic, to avoid stigma. Macy, who also did not elect to receive her test results, explained
the reluctance to seek care from her perspective:
Out of 100 girls, you may have 5 or 6 go get check-ups. Everybody’s afraid to
find out what’s wrong with their systems. They think that medicine makes you
sick, and it will kill you faster. A lot of the girls are so ignorant. It’s all about
your nails and hair and a nice car, trying to look like a real woman - that’s all
that’s important. Going to the doctor - if people are gonna say something, I’m not
gonna go—or going to the clinic to get a check-up, you see me coming out,
something’s wrong so I’m not gonna go, ‘cause I don't need you to know my
business. A lot of the girls won’t come in here {this interview was conducted in
an RV with health-related lettering on the side and rear of the vehicle} ‘cause
its got health somethin’ on it—cause it’s gonna mean something.
Rhonda has been on the Stroll for 12 years, and at the age of 33, has been surrounded
by HIV for some time:

Ill
It’s on my mind. It’s right there in front of you. It’s right at your door. Lotta
people—my friends—died of AIDS—close friends of mine over the years. My whole
crew of girls— they’re all dead. Some got killed, some—the majority—died of
AIDS (she paused, then named 11 friends}. They’re all gone. I’m the last one
left.
HIV, HBV and Syphilis Results
Overall, 40% tested positive for HIV antibodies. African-Americans have HTV-
infection rates double that of Hispanics: 55% of African-Americans are HIV-positive,
compared to 27% of Hispanics (P<06; figure 4-28).
100
90
80
70
60
% 50
40
30
20
10
0
HBV HIV Syphilis
III African-American (n=22)
IÜ Hispanic (n=26)
Figure 4-28. Hepatitis B, HIV, and syphilis positive results.
Table 4-1 illustrates some characteristics of HIV-infected participants. HIV infection is
more likely among those older than 25 (P<04), and among those with higher education,
though this figure is skewed by the relative education and infection levels in African-
Americans. HIV infection is significantly (P<04) associated with age younger than 14 at
first episode of anal sex. The prevalence of HIV infection also increases with time in sex
work, and among those reporting a history of forced sex. HTV infection is higher in those
with HBV and syphilis infection. Being “out” to more than half of the people participants

112
Table 4-1. Sample characteristics of HIV+ participants.
No. HTV+
% HIV+
Prevalence
Ratio
P
Age, years
19-25
6/24
25
1.0
26-49
13/24
54
2.2
<.04
Education, years
1 -11
9/27
33
1.0
12-17
10/21
48
1.5
=.42
Age at first episode <14
11/19
58
2.1
of anal sex
14+
8/29
28
1.0
<.04
Months since
6-24
5/15
33
1.0
initiation of
25-48
3/8
38
1.2
sex work
49-288
11/25
44
1.3
<.80
Ethnicity Af-American
12/22
55
Hispanic
7/26
27
<.06
History of
yes
15/32
47
forced sex
no
4/16
25
<15
Unprotected
receptive anal
yes
9/22
41
sex in last 6 mo
no
10/26
38
<.86
Unprotected
insertive anal
yes
3/10
30
sex in last 6 mo
no
10/38
26
<.56
Syphilis
positive
4/9
44
negative
15/39
38
<51
Hepatitis B
positive
14/33
42
negative
5/15
33
<56
“Out” to more than 50%
17/35
49
“Out” to less than 50%
2/13
14
<.04
know is significantly (P< 04) associated with HIV seropositivity: of the 19 HIV+
participants, 17 (89%) are out to more than half. Compared to HIV-negative participants,
HIV-positives began their involvement in commercial sex over three years earlier, initiated

113
oral sex earlier, and initiated anal sex (P< 07) two years earlier. Marijuana use at least once
per week is significantly associated with HIV seropositivity (table 4-2) in the combined
sample (P< 03) and among Hispanics (P< 02).
Table 4-2. Relative characteristics of HIV-positive
and HIV-negative participants.
HIV+
HIV-
P
Mean (median) age at
initiation of sex work
19.5 (20)
21.8(20)
<.50
Mean (median) age at
first oral sex
12.4 (12)
14.0 (14)
<.24
Mean (median) age at
first anal sex
13.3 (13)
15.3 (15)
<.07
Marijuana Use >=lx/wk
Hispanics
5/7 (71%)
4/19 (21%)
<.02
African-Americans
4/12 (33%)
1/10 (10%)
<.22
Combined
9/19 (47%)
5/29 (17%)
<.03
Over two-thirds of the combined sample have seromarkers for past or present HBV
infection. African-Americans (19/22; 86%) are significantly more likely (P<.02) to have
been infected with HBV than Hispanics (54%). Three participants, all African-Americans
(P< 09), showed current infection with HBV (i.e., positive surface antigen; BsAg+); each
was also HIV-positive. Just 2 participants, both Hispanics, tested positive for surface
antibody only (BsAb+), indicating vaccination against HBV.
Syphilis prevalence for African-Americans is 18% (4/22); for Hispanics 19% (5/26).
One African-American showed current, untreated syphilis infection (titer 64:1) and
subsequently received treatment for it; the rest had already been treated. Table 4-3
compares the mean and median ages of those with detectable HIV, HBV and syphilis

114
Table 4-3. Mean and median age by test results.
Mean
Median
P
fflV +
28.3
27
HIV -
28.5
24
<52
HBV +
29.7
28
HBV -
25.7
23
<13
SYP +
32.6
35
SYP -
27.5
25
<.07
markers. HBV and syphilis (P< 07) infection are associated with older age; HIV-positive
and HIV-negative participants exhibit less age difference.
Eighteen participants (36%) did not receive the results of their blood tests. These
included 11 African-Americans (50%), of whom 6 are HIV-positive, and 7 Hispanics
(27%), of whom 4 are HIV-positive. Post-test rates and their influences are discussed in
Chapter 5.
Alcohol and Drug Use
To evaluate substance use, data were gathered using a drug grid. Participants were
asked if they had ever used a substance (figure 4-29), if they had used it within the past six
months (figure 4-30), and if they had used it during sex work in the past 6 months (figure 4-
31). Most reported that they had ever used alcohol: only 1 African-American and 2
Hispanics had not. Marijuana use is also normative: 83% reported lifetime use, including
17/22 (77%) African-Americans and 23/26 Hispanics (88%).
For other drugs, Hispanics were significantly more likely to report lifetime use than
were African-Americans. These include amphetamines (15% vs. 0%; P<08),

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barbiturates/tranquilizers (50% vs. 0%; P< 001), ecstasy (27% vs. 0%; P<01), LSD (31%
vs. 0%; P< 01), nitrite inhalants or “poppers” (50% vs. 9%; P<01), cocaine (73% vs.
36%; P< 02), crack (38% vs. 18%; P<13), heroin (19% vs. 0%; P<.04), ketamine (23%
vs. 0%; P<02), and rohypnol (15% vs. 0%; P<08). Frequency of marijuana use is
significantly associated with HIV seropositivity, as discussed earlier; history of lifetime use
of other substances was not significantly associated with HIV status.
100
90
80
70
60
% 50
40
30
20
10
0
African-Americans (n=22)
HH Hispanics (n = 26)
Figure 4-29. Lifetime history of alcohol, marijuana, amphetamine,
barbiturate/tranquilizer, ecstasy, LSD, poppers, cocaine, crack,
heroin, ketamine and rohypnol use.
Reported use within the past 6 months of all substances except LSD was just slightly
less frequent: those who have ever used a particular substance were likely to have also
recently used it (figure 4-30). Only 2 participants, both Hispanic, reported ever injecting
any of these drugs; both report no such injection for several years. Higher frequency of
substance use is not statistically associated with risk or risk reduction behaviors.

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ALC MAR AMP BRB X LSD POP COC CRK HER K RHYP
African-Americans (n=22)
H is pa nics (n =2 6)
Figure 4-30. Six month history of alcohol, marijuana, amphetamine,
barbiturate/tranquilizer, ecstasy, LSD, poppers, cocaine, crack, heroin,
ketamine and rohypnol use.
Hispanics used substances during sex work much more often than African-Americans
(figure 4-31). These include alcohol (12/26; 46% vs. 5/22; 23%; P< 10), marijuana (9/26;
35% vs. 4/22; 18%; P=37), cocaine (12/26; 46% vs. 2/22; 9%; P<04) and crack (4/26;
15% P< 05). Hispanics also reported using poppers (8/26; 31%), barbiturates/tranquilizers
(6/26; 23%), crack (4/26; 15%), amphetamines (3/26; 12%), heroin (1/26; 4%), and
ecstasy (1/26; 4%) during sex work. Reported substance use during sex work is not
significantly associated with condom use in this sample, though 4 of 8 (50%) TTSWs
reporting poppers use during sex work also reported URAI with exchange partners in the
past 6 months (P=.33). Qualitative data, however, do suggest a relationship between these
variables. Combined, 29% reported being intoxicated at the time of their last episode of
anal intercourse, including 42% of Hispanics and 14% of African-Americans (P=.03). This
variable was not associated with condom use during that episode.

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ALC MAR AMP BRB X LSD POP COC CRK HER K RHYP
H Afri can-Am erican
Figure 4-31. Six month history of alcohol, marijuana, amphetamine,
barbiturate/tranquilizer, ecstasy, LSD, poppers, cocaine, crack, heroin,
ketamine and rohypnol use during sex work.
Hormone and Silicone Use and SRS
Oral and injectable hormones are widely available in the underground market, through
prescription diversion or through illegal import, generally from Latin American countries.
Though I did not ask to see them, participants showed me Premarin® (Wyeth-Ayerst;
conjugated estrogens) tablets, two different brands of Mexican-made tablets, and bottles of
injectable estrogens and estradiol. Most, however, do not know the names of the hormones
they use; tablets, for example, are known primarily by their color (i.e., “yellows” or
“purples”). Tablets, taken daily, are available at $1-2 each; injections, taken weekly, are
available individually at $10, and also in bottles for multiple injections. Only one participant
receives her hormone therapy through a physician.
Among Hispanics, only four report no history of hormone use—each cross-dresses only
to work the street—and one other is not currently using hormones. Twenty (81%) report
ever injecting hormones; all but one of these continues to self-inject weekly. All who inject

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also use oral hormones daily. Sixteen African-Americans are currently using both oral and
injectable hormones.
The mean age at first hormone injection is 21.5 years. Three participants, all Hispanic,
report a history of ever sharing injection equipment. One shared needles for heroin injection
in the early 1980s; two others have more recently shared needles for hormone injection with
friends, but not within the past 6 months.
Subcutaneous silicone injections are also popular, most often in the breasts, face
(cheeks and lips), hips and buttocks. Sixty percent report having silicone injections;
African-Americans (86%) significantly (P< 003) more than Hispanics (38%). Though
illegal in the US, it is available: at least 4 individuals in the Miami area perform silicone
injection. Prices normally begin at about $200 per treatment, and increase depending on
how much silicone is used. Erica reported that most spend $200 to $400 at a time. One
participant reported having spent over $10,000 on silicone, though this is a rarity. Michelle,
for example, has “about $500 in my titties, and about $500 in my hips.” Lifetime history of
hormone use and silicone injection are illustrated in figure 4-32.
100
80
60
%
40
20
0
Hormones-oral Hormones-lnj Silicone Inj
HI African-Americans (n=22)
HH Hispanics (n=26)
Figure 4-32. Lifetime history of hormone use and silicone injection.

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Hormone and Silicone Use: Attributes
For the majority, body feminization is a constant process that occupies a central—
perhaps the central—focus in their lives. Gigi speaks for many when she says “I love my
body, and I love to show my body!” Glitter told me, that beside the enjoyment she gets
from “doing her body,” for a TTSW there are other motivations: “you got to have titties,
cause that’s what the men like—they like to see ‘em, touch ‘em, suck on ‘em. You got to
have titties.” Jasmine agrees: “men, they like it. They want more, more, more, and so do
I, and I keep getting better every year.” Eliana explained some of the details for me:
You have to do silicone injections. There are implants, but they’re very expensive.
And if you don't have breasts, and you put in implants, they’re gonna look ugly-
like 2 coconuts inside of you stretching your skin. Silicone doesn’t go bad. It
stays for life where you put it, but sometimes when you get older it goes down a
little bit.
There’s this lady—she’s a doctor. She used to study silicone when it first came
out, but since they made silicone illegal, ‘cause of the effects it has, she retired. But
she’s doing silicone to transsexuals, to women, to men. It’s legal in other
countries, only here it’s illegal. But she’s kinda old, so you think about it. There’s
a transsexual who does it, too, but you think maybe she’s gonna be jealous of you
and mess you up.
They make models—if you know the people they do, you’ll go crazy. They’re very
professional and they do a good job.
Michelle described a woman from central Florida who travels to different cities to
perform silicone injection. A “hostess” will then invite others to her house to receive
treatments. In turn, she gets free silicone for her efforts, depending on how many she
recruits.
Hormone use has a number of desired effects. Lani said she takes them “to make my
skin soft and my body more feminine, and it’s working, ‘cause I used to be really muscular.”
She also explained, “but if I come, I lose the hormones, so I don’t want to come.” Most

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participants share this view: hormones are seen to concentrate in semen. Eliana agrees:
“When you come, that means your hormones go to waste. You get rid of your hormones
when you come, so you’re not supposed to come.”
Hormones may also cause diminished sexual function; as Rhonda says, “‘Mones
(hormones) takes away your male comes.” Michelle said, “Hormones dry up your sperm,
they take away the male in you.” Some welcome this as a benefit, like llena: “hormones
make me feel so good—I don’t get so hard (indicating penis). I can come—not too much,
but sometimes I do.” Others quit hormones for this reason, like Antwanette: “it changed
me. I couldn’t come or nothin. I wanna get it off.” Several described occasionally taking a
hormone “holiday” to recover from diminished sexual function.
Hormones’ functions, however, go far beyond the realms of softer skin, enlarged
breasts and other physical feminization. Justinia explained:
I love hormones. Hormones make you feel more pussy, like you have a period,
but you’re a boy. You throw up, you get moody and cranky, and you have an
appetite for strange things, like ice cream and pickles.
Rhonda has taken hormones for almost 20 years, and for her they impart happiness and a
feeling of well-being:
When I take a ‘mone (hormone) pill, I like to look in the mirror and fantasize the
things that men bought me. Like I look around my house and everything I got,
mens bought me. It make me feel good about myself.
Princess told me that, although she had been using oral hormones, “my friend
introduced me to the shots, ‘cause they’re stronger and go straight to the bloodstream, and
they’re better than pills.” She sees a medical doctor for a chronic condition, but is ashamed
to tell him that she injects hormones bought illegally.
Coco, while highly feminized with silicone injections, chooses not to use hormones.
Her reasoning:

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The male body is stronger than a female body. So if there are any chances of
catching anything - and you’re messing up your body’s immune system, you’re
body weakens if you’re on them. That’s the way I think about it.”
Michelle also referred to female hormones’ immunosupressive effects on males: “If you
take hormones, you have to be sure to take vitamin B-12 and Centrum every day to keep
your immune system up.”
Like Coco, Luz stays away from hormones. She explained why:
Tomando las hormonas, muchas pierden la mente. Son locas. Los hombres que
toman las hormonas y they get the titties y they change completely. They lose la
memoria y la mente y they go crazy (Taking hormones, lots of girls go crazy.
They’re crazy. Men who take hormones, and they get the titties, and they go
crazy. They lose the memory and the mind, and they go crazy).
Sex Reassignment Surgery: Attributes
Only 4 TTSWs plan sexual reassignment surgery (SRS), including 3 Hispanics and 1
African-American. Glitter, says she would like to have the surgery “when I finish my titties
and body.” The majority, however, would not even consider surgery. Their reasoning falls
into 2 basic categories: the loss of sexual pleasure and religious objections. Gisela
explained that, after surgery, “you don’t feel anything (indicating groin area). They’re
dolls-pretty, but they don’t feel anything sexually.” Angela agrees: “a sex change won’t
feel anything. They change, and they don’t feel anything, absolutely nothing. I’ve had
many sex change friends, and they tell me, please, Angela, don’t change yourself—you’ll feel
like a vegetable!” Justinia says, “I wouldn’t get operated, ‘cause you don’t feel pleasure in
sex. That’s what happens. It’s true—you lose all your sexual feeling. I don’t want to have
a pussy for decoration only.” Diana, who would like surgery one day, finances permitting,

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also believes that sexual sensation might be affected, “but after all this time on the streets,
the last tiling I care about is feeling something down there.”
Shanika, too, believes that surgeries are rarely successful:
I don’t want to cut and throw away what God gave me. It’s like when you get
your surgery sometimes your pussy don't work out right or whatever—you bleed
when you try to pee—it’s uncontrollable—and you don’t have no sexual feelings.
For Melissa, surgery is not even a consideration:
It’s sickening. It defeats the purpose. It’s good to give the illusion, but I don’t
wanna lose the feeling of fucking and coming. I’m a man, and I want to live like a
woman, but I want to fuck like a man.
Macy has had extensive silicone work done, but will not consider SRS: “I believe
strongly in the Bible. That has a lot to do with it. He made me this way, and as far as me
going to tamper with that, that’s serious.” Roanne says simply, “I was bom as a man, and
I’m gonna leave the world this way.”
Kandi is 19, and keeping her options open:
This is the lifestyle I want to be with. And if it’s time for a change, I can go back.
(Do you want to go back?} Yes, but not now. {Why?} Cause this is not right.
Part of me knows the Lord Jesus does not want it. He accepts you as you are and
everybody’s forgiven, but me, I know it’s not right and it’s not what I want. I
always felt like a lady since I was little, but, I done did it. {You’re not happy like
this?} I am happy. But I can still be happy knowing that I want to make a change
one day.
Lala, now 33 and on the streets since she was 17, was a bit more reflective:
It’s fun from the beginning, but after so long you don’t want all that. You fixin’ to
give yourself back to God and you don’t want all this stuff in your face and your
chest. I got a friend, who’s a 44DD (brassiere size), he’s 6’2,” he gave himself
back to God and he’s miserable, I know, with all that stuff.
I’m havin’ fun. I like what I do, but this is not my life the rest of my days. I don't
know how long God will let me live here. This is not the rest of my days living as a
woman. Even if I had all the money in the world, I wouldn’t get no sex change.

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Gender Identity and Sexual Orientation
Question G1 asks participants to select their self-identity from a menu of sexual
orientations and gendered identities. I did not express that these categories were exclusive,
and asked participants to select as many as they felt applied to them. A multiplicity of
responses resulted (figures 4-33 and 4-34). Two Hispanics self-identified as bisexual, and
reported sex with women more frequently and more recently than others. While some
participants held clear understandings of these terms—and discussed them, often providing
unprompted justifications for their identities—in many cases these terms were met with some
degree of confusion. Overall, about 90% reported that their sexual identities and ethnic
identities were “very important” areas in their lives. The relative importance of religious
identity was somewhat lower, with about 60% responding “very important.” Eighty-eight
percent reported they were “very comfortable with their sexual attraction to men.” In this
section, there were no statistically significant differences between ethnic groups, and the
differences in responses is due largely to varying comprehension of the terms.
Though the term “transgendered” is not recognized, most think of the terms drag queen
(DQ), transvestite, and transsexual as conceptually related, in the sense of the umbrella term
“transgendered.” Specific understandings of these terms vary among individuals, though
there are some common concepts. As Justinia said, “a drag queen is an entertainer, a
fantasy. A transsexual is the wrong body—feels like they’re the wrong sex and want to be
the other sex.” A DQ, Michelle says, is “a person who creates the moment for that
particular time—flamboyant, outrageous—a show person. As a drag queen, you have to

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Straight
Gay & TV
Transvestite
HI Gay
¡H Gay & TS
11 Transsexual
Figure 4-33. Sexual Identities of Afirican-Americans (n=22).
Straight & TS
a
Gay & TV
â– Jill
Bisexual
m
Gay & TS
!:£:§!
Bisexual & TS
8
Transvestite
Is888§l
Gay
a
Transsexual
Figure 4-34. Sexual identities of Flispanics (n=26).
keep the eyes always on you.” Though Michelle self-identifies as a transsexual, she can
also be a drag queen when doing shows and entertaining.
Gigi’s comments indicate a distinction she makes with regard to internal identity:
A drag queen is an entertainer. A transsexual is very feminine. I was bom a man,
but I feel like a woman. I take my hormones, I don't have no man’s clothes, I’m
really a woman. A drag queen is a man, a transsexual is a girl.

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llena agrees, and adds a temporal aspect to the distinctions:
A drag queen dresses up for a few hours, with wig, makeup, fake titties, then they
take all off. A transsexual has a woman body, titties, nice face and legs, 24 hours a
day. A sex change is when you cut off the dick. I’m not that, I’m a transsexual, a
boy who lives as a woman. A transvestite is in-between, somebody who dress up,
but not all the time.
Shavonne s self-description indicates some of the semantic conflicts that arise:
I’m straight. I know that I’m a transsexual, but I really don’t feel like one. I carry
myself like a woman, go to the whole 9 yards to be a woman, at least I think that,
and I act like one. I don’t think I act like a transsexual. {How do transsexuals
act?} They’re too much. They do everything too much. They overwalk, they
overtalk too much, everything is too much, just to get noticed.
A number of participants self-identify as transvestite, sometimes in combination with
“gay,” but transvestite and transsexual are mutually exclusive. In general, the term carries
somewhat less of a commitment to transgenderism in participants’ minds. Many
participants do not have a clear idea about their own definitions of the terms: they chose an
identity because I asked them to choose one, without having given it much thought
beforehand. Though participants believe their own “identity” to be very important in their
lives, it is the identity as personally perceived, not the word attached to it, that carries the
importance: many simply feel no need to pick a label.
As discussed earlier in this chapter, regardless of identity, all but one participant recalled
feeling “different” at an early age. Over and over, participants, like Berta, reported “I was
bom this way.” Over ninety percent of the sample recalled multiple and specific examples
of gender-atypical behavior beginning at an early age, normally by 5 or 6 years. Mona
spoke for many when she said:
I’ve been very unhappy with my body all my life, and any changes I can make, I
will. I always knew there was something in me that was different—that my body—I
was bom a man, but in reality, in my form of thinking and everything, I was a
woman. I knew...

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Geisha, who also felt she was different as early as she can remember, said, “you can’t
block what’s inside of you, and you can’t block how you feel.”
All participants described being sexually attracted to males, though a few are also
attracted to females. Eliana described the difficulties involved when discussing sexual
orientation:
Everybody’s gay at the beginning, 'cause you’re not a woman, you’re just dressing
up in drag. Then once you go into it, you don’t want to go back. You decide to
become a woman, and you don't consider yourself gay anymore, because you’re
not gay.
If someone like us is with a guy, what that makes me? Gay or straight? See, I
don't even know. Or, if a person like me is with a girl. Gay or straight? I consider
people like us straight, 'cause we go out with the opposite. Not the opposite sex,
but the opposite outside of us, the opposite outside of the person. {So you
consider yourself straight?} Yeah, straight transsexual, not gay transsexual.
Actually, I like both. I like it with guys, but sometimes with girls. I’m bi.
Most people, they consider transsexuals gay people. Me, I don’t even think
they’re gay. Transsexuals are bisexual people, they like changing, but they might
like girls or guys. Most of us like guys, but some of us like girls. Most people
don't know that.
I lived like a boy and had a girlfriend ‘till I was 21, and then I just didn’t like it no
more. I just gave it up. I always had it in me, I just put it aside. After all this
time, I couldn’t put it down no more. I said I gotta live happy, so I did it.
I never had sex with guys before that. That’s what I like and I want a guy for a
relationship, but I will have sex with a girl, now still. With girls, I’m the man—with
guys, I have to be the girl—but, if I’m with gay guys, they have to use me as the
guy. It doesn’t bother me.
Positive and Negative Aspects
Without a doubt, participants most enjoyed discussing the following question: “What
are the good things about being a transsexual (or other identity)?” Almost every face lit
with excitement in response; body language relaxed, and they smiled. Clearly, this is who
they are, and what they are—and if there is a single thing that excites them, it is this aspect

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of their lives. The predominant themes centered around enjoying the increased attention,
feeling like a woman and being more attractive as a woman, including relieving feelings of
being “weird” or unattractive as a male. They also expressed enjoying being able to be
“who they are,” having more confidence, and living a fantasy of being a different person.
llena, like most, loves the attention she receives: “I like to go out, and I look pretty,
and people look at me and think I’m a woman.” Marcela explained “I like clothes and
makeup, and 1 like to feel feminine. I like to go walking in the street and guys say “Wow,
hey baby!” Shanika said “I like getting more attention than the real girls.”
Melissa explained the attraction of being both a man and a woman:
I love getting a lot of attention, and walking down the street and people think
you're a woman. I think it’s exciting that you can live life as a woman, but still have
your male parts. You can have your way with men and live on both sides—be a
man and a woman.
For Justinia, the added attention may compensate for some of the disadvantages:
As a girl, I get more attention. I like that I stand out, the fashion, and the clothes,
and always looking cute. Like you’re living a life that’s hard, that’s full of critique
wherever you go, like “she’s a man,” or whatever, but it’s fim 'cause you’re
noticed wherever you go. I like to talk a lot, and people always ask me if I’m a
model.
About being transsexual, Gigi says:
I love it, and I’m happy with my life. I feel 100%, I feel great. I’m a transsexual
and I’m proud. I don’t worry about what people think—people say “WOW!
You’re something different. Are you an actress?” I love doing my hair and my
makeup.
Jasmine, who self-identifies as a transvestite, said:
This is my life. This is who I am. People notice you. They pay attention, and they
make comments. You feel really important, 'cause the whole world’s lookin’ at
you 'cause you’re a transvestite and they have to look at you, you know what I’m
sayin’? See a female, they just keep goin’, but a transvestite, they got to stare at
you—this motherfucker got titties and ass and hips like a girl, but he’s a man. I
love the attention—people say “hey baby!” I love ‘em to look at me. It’s amazing!

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The concept of fantasy predominates in TTSWs’ self-perceptions, as well as in their
conceptualization of clients. Eliana, a transsexual who plans SRS, said:
It’s beautiful—it’s different. All this is science—it’s the future. We’re a work of
science. People like us are very smart in style and exotic things—and we have very
good ideas. We use them on ourselves. You feel happy—everything looks so nice
on you, and you dream a lot. It’s fantasy. It’s what you always had in mind since
you’re little, to wear something a woman wears.
Macy agrees, and is unusual in that she has the support of her family: “my whole family
enjoys what I do. They all see me as a superstar.” Coco, who legally changed her name 10
years ago, summarizes her feelings about life as a transsexual:
Whatever you want, you can make it happen—it’s just like a dream—anything.
When you first put that dress on and that makeup, it’s up to you to carry it
through.”
I live a straight life as a woman. I love me—it doesn’t really matter what I am. I
consider myself a normal, everyday person—I do the same things a woman does. I
don't consider myself a total woman, but I’m as close as I can get without having a
vagina. But I like having the masculinity of a man to dominate men. I like fucking
men, and I like men to suck me.
Roanne, a self-identified transvestite with extensive breast augmentation, beamed:
We look good, like they can’t believe we used to be a man. I really got into it
when I moved to Miami. I got here and I saw people really lookin’ good and I
wanted to do it, too. I have to look in the mirror about 15 times to see if they’re
gonna get my “T” (recognize that I’m not a “real” woman). You can really fool
people, and psych out they mind that they talkin’ to a woman, not a man. I like
when we’re havin’ sex and they’re makin’ love to me like I was a real woman, and
when they takin’ me out, buyin’ me gifts.
Kandi echoed “I like doing shows, going shopping for clothes, guys walking by and
thinking I’m a woman, and they talk to me. When you’re lookin’ good, people respect
you.”

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For some, being transgendered offers a number of practical advantages. As Princess
said, “women have it easier than men. Women don’t fight over petty things; men are out
there killing each other. Men have to pay more for insurance and things like shoes.”
Glitter, among many others, also finds it easier to meet men:
Like, you can go up to guys that you like and say stuff to ‘em, but you couldn’t go
up to them as a gay boy. I love that. I look like a woman and carry myself like a
woman, that’s the most important thing. Anybody can put on a dress and be a
sissy—but you got to know how to carry yourself and know how to act around
men.
Lala said, “Oh, guys always come up to you and say you’re beautiful. I like meeting men;
I can get a man quicker dressed up as a woman, and it gets a lot of attention.” Shavonne
agrees: “I like the attention I get from men—that makes me feel more better about myself.”
Several expressed unhappiness with their appearance as a male, and find that cross¬
dressing relieves this anxiety. As a woman, Towanda said, “I feel very, very, very attractive
to men—all men. In female clothes, I feel natural. If I put on boy clothes, I feel rough and
unattractive.” Emilio also describes this contrast: “As a boy, people stare and I’m weird. As
a woman, I’m beautiful and interesting. I’m more attractive, sweet and fragile like I am
now. Michelle also describes feeling very different as a female:
As a boy, I’m boring, unadventurous, can’t express myself, you know, I’m very in a
comer, balled up in a fetal position. I’m not as free a spirit as when I have the
makeup on. As a female, I feel like I’m attractive. Someone will look at me and
say “she’s pretty.”
Others describe their transgendered behaviors as merely expressing who they are. Mona
for example, said “I don’t need a dress or makeup to make me feel like a woman. My
feelings don’t change, but I like everything, the clothes, going to the beauty shop, the
makeup.” Serena believes that “it’s fun. How you can change to a woman. I feel like I’m

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acting like myself, just my regular self.” Lili softened her posture and smiled: “I like feeling
like a woman inside.”
Ana dresses 4-5 days a week; about half her friends use her female name even when she
is in male clothes:
I like that it makes me feel better about myself, feel myself. People do appreciate
what I’m doing. When they see a really good professional drag queen, with an
expensive nightgown and a really good number, everybody’s gonna clap.
I’m totally different—it’s like 2 personalities that are totally different. Ana is
totally different from (male name)—she’s crazy, wild, happy. She loves to dance
and have fun. Everybody loves Ana. (Male name) is just here in this house—takes
responsibility about his life.
These feelings of having a completely different personality when cross-dressed were also
described by those who dress only to work the streets. Lani said:
I like that I get more attention from guys—that makes me feel good. They say “oh,
you’re so beautiful” and I love that. “When I’m dressed, I feel like almost a totally
different person. It’s weird— almost like I have a split personality. When I get
dressed to work, I feel like I’m becoming a totally different person.
Diego: “I do it for work, that’s it. But still I feel different dressed as a woman, more
like a woman inside.” Tonia, who used a female name though in decidedly masculine attire,
said “it’s an exhilarating feeling. It’s a rush, and you’re in the spotlight.”
Several participants described a Active kinship arrangement among some TTSWs: drag
mother/drag daughter. The drag mother, who is already experienced in transforming herself
from male to female, transfers this knowledge to a neophyte drag daughter. The drag
mother/daughter arrangement functions not only to solidify social and reciprocal
relationships, benefiting both parties, but to introduce new transsexuals to the practical
knowledge necessary for transformation. Tiffany, who introduced me to two of her

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daughters (one is older than she, incidentally), says their roles are to “show respect and take
care of one another.” Eliana described the process involved with her daughter:
The one I’m making, I’m telling him how to do it. {You’re making him?} “Making
him” because I’m the one that will help him and I will talk to him, and advise him
and transform him. He graduates from high school next year, so he’s trying to do
everything slow. When he graduates, he’s gonna have a name change. But he’s
gonna start looking weird in his senior year.
They have to know about work—and about not working. They have to know
which surgeries to have first, cause it has to go step by step. If you don't go step
by step, you end up doing the last things first, and you end up looking like a
woman with a mustache, and that’s not cute. The first thing, you have to do hair
removing if you have any. Electrolysis. Then while doing that, you take the
hormones. Like maybe 6 months after the electrolysis you can start doing
hormones. Then, 8 to 10 months after hormones, you can have silicone.
Then when you start having silicone, you have to apply for a name change. As
soon as you start silicone. Then you get your name change, and you already have
breasts because of the hormones, and you’re enlarging them with silicone. That
means they’re gonna be more noticeable. Now your name is changed, your face is
clean, so you go straight to work and you can make your life normal.
But some of them are dumb. They’re not on hormones and they put silicone and
their skin doesn’t stretch right, so that’s dumb. Or they get big breasts, nice body,
but all the hair on their face is there so you have a woman with a beard. Or they
don’t get their name changed after everything is done, and you have to work the
streets, ‘cause you can’t get hired if you’re a woman with the name of a man.
When you’re changing, you want to show off all of your work. Then, some of us
settle down. We wear jeans and shirts and stuff, and we cover ourselves. I like to
blend in with the girls, just like every other girl. I don't want to stick out and look
different, 'cause if you look too different you have people thinking and looking and
wondering.
Despite the positive reinforcements they describe, living a transgendered life has a
number of drawbacks. Predominant themes were social discrimination, the amount of
expense and effort required to maintain feminized appearance, relationship difficulties
(previously discussed in this chapter), and feelings of gender discord. llena is unusual, in
that she expresses a level of disgust with her male genitalia:

132
I don’t like to see my front. And I think it’s weird for a transsexual to fuck a man.
I talk to my friends, they like to be 50-50—you know what I mean?—but I got a
different mind.
Brígida, who has been dressing for less than a year, also expresses mixed emotions. She
said, “sometimes it feels weird. (My roommate) looks like a woman, but when she comes
out of the bathroom and has a dick, it looks weird.”
Most participants mentioned feeling severe social discrimination. As Serena told me: “I
don’t like society. I don’t like how people react when they see you. People act like it’s
funny and call you a faggot, and say you’re crazy.” Ana agrees: “people can’t let people
live. They see us in the street and make us feel bad.” Lydia said, “The truth is, we really
can’t go out in the daytime, because of the people...” After several years of feeling this
discrimination, Marcela wishes she had a “normal” life:
I’m not really comfortable, 'cause I would like to have a normal, regular life. I
don’t like the discrimination. Most of us don’t have a day-life, just night-life. I
don't like that. I want to do something, like go to school or something. We go to
the clubs at night, but we don’t go to the street in the day. We don’t have nothing
to do.
Shavonne also expressed anxiety over being “discovered,” and the resulting reactions:
I don’t like when someone gets your “T”—when they clock you (recognize that
she is not a “real woman”}. You get rejections. Not that much if you know what
you're doing. But you feel uncomfortable in some places if someone knows,
they’re gonna tell this person and that person. And if I put on boy clothes, I look
like a lesbian.
Justinia objects to being categorized under stereotypes of transsexuals:
People say you’re crazy, that you’re a sinner, and that you have AIDS. Plus, a lot
of people think that all the transsexuals are prostitutes—which, the majority it’s
true—but a lot of them have jobs and everything.
Glitter said she has experienced discrimination from authorities: “police give you a hard
time, like when I go to court. They always take me through a bunch of shit 'cause I look

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like a woman ” Michelle explained: “I don’t like the way society judges me and disrespects
(my boyfriend) for being with me. There are a lot of places that I can’t go in female clothes,
‘cause I’m not done yet. Melissa also feels “ridicule from people who don't understand.
People think you’re a freak and call you names.”
For some, the extra effort required to maintain their appearance is a disadvantage. Lani:
“It gets hard staying out ‘till 6 in the morning, redoing the makeup every time you finish
doing somebody, and all the preparing—the shaving and the makeup. Two hours to get
ready.” Shanika dislikes “tucking your dick between your legs” (male genitalia are hidden
by tucking them backward toward the anus and securing with padding).
Lucila described the general inconvenience she feels: “this life is very difficult overall-
more difficult for work, everything costs more—the hormones, the clothes, the makeup, the
surgery.” There is pressure within the transgendered community to maintain the feminized
norm, according to Princess: “I dislike altering my body—I hate all that, like getting shots in
my titties, but you have to, ‘cause everybody’s really into that.”
Overall, 19-year-old Vanya is unhappy, she says:
I don’t really like it. I do it, but it’s not fun no more. Since I been doin’ it so long,
I hate to think I have to take it seriously. You gotta do what you gotta do—your
titties and your hair and everything. It’s not fun, but you got to do it. I’d rather
not deal with it. And people are gettin’ sick. They’re droppin’ like flies. They
doin’ what they always wanted to do and now they all dying. {Could you go back
to being a boy?} No, I can’t no more. I just got out of being a boy. I just got my
face done (indicates silicone-injected face). I just had my last chance.
Finally, Mona articulated what many others expressed to me:
If I could have had sex with a woman, life would have been easier. Get married,
have kids, live my life — if I could have. No problems with society, without
thinking about getting old and a future alone, since I have no children. That would
have been much easier. Why would I choose to be a freak?

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As discussed in Chapter 3, being “out” is a problematic concept for many in this sample,
since it can refer to either gender identity, transsexual status, or sexual orientation/
Overall, 35 (73%) respondents, including 17 (77%) African-Americans and 18 (69%)
Hispanics, report being “out” to more than half the people they know. Those reporting
being “out” to more than half the people they know report a mean (median) of 1362 (1000)
and 202 (100) male lifetime and six-month partners, compared to 785 (1000) and 109 (40)
for those who are “out” to half or less than half of the people they know. They are also
much more likely to be HIV-positive (P<001): 49% of those out to more than half are
HIV-infected, compared to 15% of those out to half or less. African-Americans and
Hispanics are out in virtually identical proportions to their mothers and siblings (83% and
85%) and to their fathers (66%).
Psychosocial Scale
All but the final two questions in this section were taken from the Psychosocial Scoring
Profile section of the Young Men’s Survey data collection instrument. Though the
questions were ordered randomly (see Appendix A) they are clustered here in categories of
Risk Perception, Safer Sex Efficacy, Self-Homophobia, Identity Salience, Condom Norms,
Perceived Community Homophobia, and Social Support. These profiles are used to inform
and guide individual counseling with respondents, particularly in those areas where
composite scores indicate areas of concern (“flag scores”). For each section, answers to
individual questions are presented in percentages, and proportions of those participants
meeting the criteria for flag scores are provided. In most cases, the numbers meeting flag
3 Since disclosure of these discrete qualities cannot be reduced to a single term, particularly
in this heterogeneous sample, being “out” was broadly operationalized as follows: if another
person knows about their status as (TTSWs’ self-identity}, they are considered “out” to
them.

135
score criteria were insufficient to generate statistically significant associations. Answers to
individual questions, however, did reveal some significant associations. All responses were
scored on a 5 point Likert scale, from 1 (“Do not agree at all”) to 5 (“strongly agree”).
Analyses in the following section may refer to these score values, which are presented in
italics for clarity.
Table 4-4. Risk perception (%),
1. Strongly
Disagree
2. Disagree
3. Neutral
4. Agree
5. Strongly
Agree
HI. I don’t do things that could cause me or others to become infected with HIV.
African-Americans (n=22)
18
5
23
14
41
Hispanics (n=26)
12
12
8
8
62
H9. My sexual behavior is risky in terms of HIV.
African-Americans (n=22)
27
9
9
14
41
Hispanics (n=26)
8
12
15
4
62
HI7. There is little chance I could become infected with HIV, or infect others, from what I do sexually.
African-Americans (n=22)
23
9
36
5
27
Hispanics (n=26)
19
8
27
4
42
Four African-Americans (18%) and 1 Hispanic (4%) meet flag score criteria in the Risk
Perception (table 4-4) category, suggesting that they do not perceive their behavior to
places themselves or others at risk for HIV infection. In many cases, participants indicated
that they perceive lower risk because they use condoms. They may not, however,
accurately assess the heightened risks they incur through condom failure, inconsistent
condom use, and forced sex. HI is associated with HIV infection: 31% of HIV-positive
participants answered 1, compared to 3% of HTV-negatives (P< 09). HI is significantly
associated with age: 24% of those 25 or older answered 1, compared to 4% of those under
25 (P<05). On H9, 9 of 11 (82%) participants who reported unprotected anal intercourse,

136
in either role, with exchange partners with the past 6 months answered 5, suggesting they
recognize the risk of UAL
Table 4-5. Condom norms (%).
1. Strongly
Disagree
2.Disagree
3. Neutral
4. Agree
5. Strongly
Agree
H5. Most of my friends think you should always use a condom for anal sex.
African-Americans (n=22)
-
-
5
9
86
Hispanics (n=26)
-
-
15
8
81
H13. Most of my friends think that condoms are too much of a hassle to use.
African-Americans (n=22)
59
14
9
5
14
Hispanics (n=26)
35
8
12
8
38
H21. Most of my friends think you should avoid anal sex without a condom.
African-Americans (n=22)
27
-
9
14
50
Hispanics (n=26)
8
4
19
8
62
Table 4-6. Perception of safer sex (%)
1. Strongly
Disagree
2.Disagree
3. Neutral
4. Agree
5. Strongly
Agree
HI 1. Safe sex is unsatisfying.
African-Americans (n=22)
82
9
-
-
9
Hispanics (n=26)
50
8
12
12
19
H26. Having to put on a condom disrupts sex.
African-Americans (n=22)
82
9
-
9
-
Hispanics (n=26)
62
8
15
-
15
Condom norms (table 4-5) were generally high, though more so among African-
Americans. Three participants, all Hispanic, met flag score criteria, which indicates that
they may perceive that their friends do not highly value condom use. In HI 3, 8 of the 11
responding 5 were Hispanics. HI 3 is significantly associated with age: of those 25 or over,
46% answered 5, indicating that they perceive their friends to be condom-negative,
compared to 8% of those under 25 (P<03). H21 is also associated with age: 25% of those

137
25 or older answered 1, indicating they perceive their friends to support avoiding
unprotected anal sex, compared to 8% of those under 25 (P< 07). Hispanics had somewhat
more negative views of safer sex (table 4-6). Overall, deficiencies in these categories may
contribute to Hispanics’ lower rates of consistent condom use.
Table 4-7, Safer sex efficacy (%).
1. Strongly
Disagree
2.Disagree
3. Neutral
4. Agree
5. Strongly
Agree
H3. I find it difficult to limit myself to safer sex all the time.
African-Americans (n=22)
68
5
14
18
23
Hispanics (n=26) P<.10
38
8
15
4
35
H7. It’s easy for me to tell a sex partner what I like or don’t like during sex.
African-Americans (n=22)
18
-
9
18
55
Hispanics (n=26)
12
4
4
15
65
H15.1 can get a man I’m having sex with to use a condom if I want him to.
African-Americans (n=22)
4
-
-
9
86
Hispanics (n=26)
5
-
8
15
73
H23.1 find it difficult to tell a sex partner not to do something I think is unsafe.
African-Americans (n=22)
77
5
-
5
14
Hispanics (n=26)
46
8
8
4
35
In safer sex efficacy (table 4-7), 2 African-Americans and 7 Hispanics meet flag score
criteria. Safer sex efficacy refers to the confidence in one’s ability to negotiate safer sexual
activities or enforce condom use; individuals scoring low may find it difficult to negotiate
condom use and/or less risky sexual activities with sex partners. Of those whose composite
scores indicated low self-efficacy, one-third did not use a condom during their last anal sex
episode; 97% of those with high self-efficacy scores did use a condom during this last
episode. Those who reported having had URAI within the past 6 months scored a lower
composite mean in this section (17.7), compared to those who did not (21; P< 07).

138
Table 4-8. Self homophobia (%).
1. Strongly
Disagree
2.Disagree
3. Neutral
4. Agree
5. Strongly
Agree
H4. Sometimes I dislike myself for being participant's self-identity>.
African-Americans (n=22)
59
18
9
5
9
Hispanics (n=26)
69
12
12
-
8
HI2.1 feel stress and conflict within myself over having sex with men.
African-Americans (n=22)
55
9
9
18
14
Hispanics (n=26)
73
-
4
8
15
H20. Sometimes I wish I were not participant’s self-identity>.
African-Americans (n=22)
45
14
18
5
18
Hispanics (n=26)
58
4
8
8
23
H27.1 sometimes feel guilty over having sex with men.
African-Americans (n=22)
59
9
9
-
23
Hispanics (n=26)
69
-
12
4
15
Table 4-9. Perceived community
íomo/transphobia (%).
1. Strongly
Disagree
2.Disagree
3. Neutral
4. Agree
5. Strongly
Agree
H6. Most people feel that participant’s self-identity> contribute positively to society.
African-Americans (n=22)
14
5
27
14
41
Hispanics (n=26)
23
4
8
12
54
H14. Discrimination against people like me is increasing.
African-Americans (n=22)
14
9
18
9
50
Hispanics (n=26)
23
4
15
8
50
H22. I fear that ‘gay bashing” is on the increase.
African-Americans (n=22)
27
-
14
18
41
Hispanics (n=26)
23
8
8
12
50
H28. Most people of my ethnic back
ground disapprove of participant’s self-identity>.
African-Americans (n=22)
27
9
9
9
45
Hispanics (n=26) P<07
4
-
23
12
62

139
Table 4-10. Identity salience (%).
1. Strongly
Disagree
2. Disagree
3. Neutral
4. Agree
5. Strongly
Agree
H2. Being is very important to my sense of who I am.
African-Americans (n=22)
-
-
5
5
91
Hispanics (n=26)
-
12
-
4
85
H10. Being makes me feel part
of a community.
African-Americans (n=22)
23
5
9
14
50
Hispanics (n=26)
23
4
8
12
54
HI 8. Being has had a positive effect on me as a person.
African-Americans (n=22)
9
-
9
14
68
Hispanics (n=26)
12
-
15
15
58
H25. It is very important to me that some of my friends are
.
African-Americans (n=22)
9
9
5
9
68
Hispanics (n=26)
15
-
8
12
65
In self-homophobia (table 4-8) Six African-Americans (27%) and 4 Hispanics (15%)
meet flag score criteria, suggesting a level of internalized discomfort with their sexuality.
Answers to individual questions are not significantly associated with risk behaviors in this
sample, but do indicate substantial issues to address in intervention. In Perceived
Community Homophobia (table 4-9), 5 (23%) African-Americans and 3 Hispanics (12%)
achieve flag scores, suggesting a perceived high level of community oppression. This
perception may contribute to risk behavior: both H6 and H14 are associated (P< 10;
P=. 10) with URAI within the past 6 months. For each, 50% of those reporting URAI
answered 3 or less, compared to 29% of those not reporting URAI. Two participants, 1
African-American and 1 Hispanic, met flag score criteria for identity salience (table 4-10).
Four African-Americans (18%) and 1 Hispanic have low composite scores for social
support (table 4-11), suggesting they feel a sense of isolation from the community, or
perceive that they are unpopular or not accepted. HI6 is significantly (P<02) associated

140
with URAI within the past 6 months: 45% of those reporting UIAI answered 1, indicating
that they are linked with another person who knows them well, compared to 8% of those
who did not report UIAI. In these cases, URAI may have occurred with this person,
though this answer was not significantly associated with having a steady partner within the
last 6 months. Hi6 is also significantly (P< 01) associated with UIAI within the past 6
months: 70% of those reporting UIAI answered 1, also suggesting a close association, as
opposed to 5% of those not reporting UIAI. H24 is significantly (P< 004) associated with
HIV infection: 42% of HIV-positive participants answered 1, indicating they do not feel “in
tune” with others, compared to 3% of HIV-negatives. For some participants, this
association may occur as a result of known HIV infection. H24 is also significantly (P<05)
associated with URAI in the past 6 months: of those reporting URAI, 32% answered 4 or
5, compared to 63% of those who did not report URAI.
Table 4-11, Social support (%).
1. Strongly
Disagree
2.Disagree
3. Neutral
4. Agree
5. Strongly
Agree
H8. I can find companionship when I want it.
African-Americans (n=22)
14
-
18
14
55
Hispanics (n=26)
4
4
12
12
69
H16. No one really knows me well.
African-Americans (n=22)
23
14
-
10
55
Hispanics (n=26)
27
8
8
12
46
H24.1 feel in tune with the people around me.
African-Americans (n=22)
32
-
27
4
36
Hispanics (n=26)
8
12
23
8
50
H29. I feel isolated from others.
African-Americans (n=22)
50
14
10
14
14
Hispanics (n=26)
50
8
12
4
27

141
Other Modalities of TTSW
In addition to street-based work, in this area transsexual and transvestite sex work also
occurs in at least 3 other ways: a specialty magazine sold in sex shops, escort services, and
“girlfriend” and “call girl” arrangements.
After years on the street, some participants, like Juana, no longer find it necessary to
constantly work the streets. They may have a steady supply of referred clients, or they may
have “friends” who call and visit regularly, and who provide regular financial support. In
some cases, these relationships have existed for years, and clients might not categorize them
as commercial. For participants, however, the basis for the relationship may remain
primarily material, regardless of their fondness for their partners. Condom use with these
partners, Juana reports, is much more problematic, due to relationship complexities
including trust issues, and hence more difficult to maintain.
Several months after I interviewed llena, she decided to leave the streets and work
through a local escort service. Her experiences illustrate the general mechanisms of this
modality, though escort services’ terms and operations may vary. Services place ads in the
Yellow Pages and other listing services, and in the mainstream and alternative press. Ads
sometimes allude to the availability of transsexuals or transvestites, or clients may call a
male or female escort service and request one. Sexual services are never discussed over the
telephone.
After making arrangements with the agency for a date, clients pay with a credit card
over the telephone. llena’s agency charges clients a flat fee of $165 for one hour. Lana
receives $100 of this fee, with the agency keeping $65 as a commission. Should she need a
ride to the client’s location, the agency will send a car with driver; this costs llena an

142
additional $20. In these cases, she is driven to the client and given a cellular telephone. The
driver will wait nearby in case of trouble. Once they arrive, workers are expected to
provide both oral and anal sex, depending on clients’ wishes—though they may negotiate
additional fees for “kinky” activities. If the date is not finished within the allowed hour,
llena must collect another hour’s fee (at the same $165 rate) either in cash, or by calling in
to the agency to adjust the credit card billing.
Escort service work is better, she says, because she has more control over what happens
on escort dates than on the street. She can count on making at least the minimum pay, and
the clients are “higher class.” The service does, however, expect her to be available at any
time, and to leave for a date with 15 minutes of their call. That is the rule, she says: clients
never call for a date in advance. Her major complaint is that business is erratic; in one
recent week, she was sent on just 2 dates. Her hope is that, as she becomes better known
to the clients, she will generate repeat customers. llena estimates that there may be 30-40
TTSWs working through several different agencies in Dade.
Other TTSWs advertise their services in a Florida-based specialty magazine, sold in sex
shops, whose cover states “for those with different desires!” and “loaded with direct contact
ads!” This magazine exists primarily to facilitate transsexual and transvestite commercial
sex, though it also contains a number of ads for 900-line telephone sex services, and text-
only ads from individuals and couples (mainly in Florida, but also a few in other
southeastern states) desiring a range of sexual arrangements. TTSWs place ads,4
including seductive and revealing pictures of themselves, with their telephone number and
sometimes price ranges. The ads generally state any sexual specialty areas, such as bondage
4 Photo “personal” ads cost $5 for a 4 issue “run.”

143
and domination, and sometimes include body measurements such as breast size or penis
size. Princess and Yolanda currently have ads in the magazine, and report that while they
may make “outcalls,” visiting clients’ homes or hotel rooms, clients may also come to their
homes. Clients generally pay $100-150 for a date. Michelle, who used to work through the
magazine, agrees: “You say give me $150, and they’ll do it. They’re skipping all the trouble
and the police, and coming straight to you. And it saves me the jumpings, beatings and the
robberies.”
A recent issue of the magazine included photo ads from over 200 transgendered
individuals offering sex for money. Over half were located in Dade and Broward Counties,
about 30% in other Florida counties, and 20% in other southeast states.
Social Considerations and Future Orientation
A few participants had suggestions about how to address TTSWs’ social needs. Mona,
who has survived four suicide attempts,5 believes TTSW need suicide prevention, including
through more social interaction with each other: “What finally saved me was finding another
transsexual. I though I was the only one.” Eliana has seen several her friends attempt
suicide as well:
Almost all of them at least think about it. Cause they don't like working the street,
and they know they have to , because there’s no choice. Some of them would
rather kill themselves than work the street. Some of them get so depressed
because they get no counseling. Some of them have no one to talk to, because
their parents kicked them out and they can’t be around their family.
Marcela agrees:
A lot of girls try suicide, but nobody wants to talk about it. The girls need jobs.
They need people willing to give them jobs and to let them work as they are, and not
discriminate that they’re in women’s clothes. Also some support—give them some
3 Estimates of attempted suicide by transsexuals range from 17 to 20% (Brown and Rounsley
1996:11).

144
money to get them a place to stay—that will get them off the street. What about the
girls whose parents don't accept them, and they can’t go home.
No one wants to hire a man dressed in women’s clothes. It’s not fair—they want
me to cut my hair, and work for minimum wage. I won’t do it—I’m gonna be who I
am and I want people to see me and say “that person has guts.”
Michelle said “the girls really just want to be accepted, and not have people laugh at
them and give them such a hard time. A lot of the girls have no family and no support.”
Kandi suggested:
We could do a little group that talks about the nicer things in life, and why not
leave the street, about how AIDS is important and not gettin’ it, and about changing
our lifestyle and how good it could be. All of us would like that.
According to Princess, “most girls out there, they have everything but they’re lonely.
They’re scared of society, and feel that they can’t go out in the daytime. Most of them are
uneducated, but they know what they’re getting themselves into.” Despite their relative
isolation, however, Princess has a sense of newly emerging community among transsexuals:
We’re hot in the market this year, ‘cause a couple of years ago no one really
thought about us. In my race, we’ve been secluded from one another —
transsexuals usually keep themselves apart. But we go to pageants and stuff out of
town, and see the girls from other places helping each other out, so the
transsexuals are starting to stick together.
In some interviews, I asked participants what they would tell the world about
themselves, or about what life as a transsexual (or other identity) is like. Gigi answered
simply that “transsexual people need respect.” Kandi believes:
I think that it’s important that a man can dress as a woman, and show people that—
some people treat us like we’re not human—and there’s nothing really wrong with
us. I think it’s important for us to be good at it, and let people know that we’re
human just like them. People look at us, and they should be lookin’ at people
killin’ kids and, you know, we’re very nice people, but straight society is against
us.

145
Eliana welcomed this opportunity:
What would I tell people? I would tell them, what is a penis. What is a vagina.
They’re to make babies—that’s their only function, and to have sex. But it means
nothing about who the person is. A person is not defined by what is between
their legs.
Geisha also had an immediate answer:
People should know we’re regular people, just like them, we’re just out there to
get money. I feel it should be legal, 'cause it’s all about pleasure. We’re not out
there to hurt nobody, we don’t mean no harm.
Participants’ views about the future reveal very much a short term outlook; very few
have plans past the immediate term. Most, when asked about the future, responded as
Shanika: “Plans? No, not really” or as Lili: “I don't know about my future. I don't think
much about it.” Towanda, more than anything, wishes for “titties.”
Emilio does not express much hope about the future:
I don’t trust the future. I used to have a huge future. I used to make plans, and
them I realized that life will just cut you off-poof, it’s all gone. Life is nothing,
you never know. You go out, you get hit by a car, you're gone. Some people save
money in mutual funds and CD investments. But what’s the point. I might be
negative, but that’s part of life. Maybe that’s just an excuse I’m using to be
dressing as a woman, to look like this, to be charging money on the street.
Two exceptions are Brígida, who would like to go to college, and Princess, who plans
to return soon to technical school. Gigi, in contrast, likes things just as they are: “I just
want to keep on having fun. I’m doing great.” Others’ goals include continuing with the
positive aspects of transgendered life. Michelle says “I want to be a diva, and I want to get
all my (body) work done. Maybe go on the road full time, and do shows, ‘cause I have a
talent. I want to win a lot of shows, and make a lot of money”. Ana looks forward to
winning the Miss Florida (female impersonator) Crown.

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A number of participants expressed a desire to “normalize” their lives, like Shavonne:
“I’d like to have a hair salon, and have lots of customers.” llena wishes for stronger family
support: “I want my mother close to me. I’m lonely even with a boyfriend, and I want to
live with my mom and be happy.” Justinia expressed a wish for “my own place. I want to
go back to school, and have a boyfriend. I want to have a regular job, not prostitution or
doing shows.” Roanne speaks for many when she says “I want a straight guy, to have a
relationship.” Eliana, unlike most, wants SRS as well as a regular life:
Surgery. I can’t be like this, cause I don’t work well. Like for a relationship with a
guy~they like you for your inside, but in bed they just can’t handle it. So you have
to complete yourself, so you feel comfortable with your body—with every part of
your body.
I just want to keep up with my life—have my house, my apartment of whatever,
and have a relationship with someone, and hopefully adopt kids.
Marcela sounds similar wishes, short of surgery:
A big house, and to have friends who care. I don't have anybody. I want a guy
who wants me for me, and wants to take care of me. I don't know how long I’m
going to have to wait, but that’s what I want. I want to have a regular life.
For others, the future can look like anything but the present. Diego looks forward to
eventually going back to Cuba, though health concerns may preclude this. Melissa hopes to
reduce her street involvement, and to get into the (TTSW) magazine. I asked why she
didn’t place an ad now, and she said “‘cause I just got my place, and I don’t have a phone.
Plus, you got to get your picture taken and stuff.” Lilia wants to leave sex work, “to do
something decent, not such dirty work.”

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Kandi is sure “this is not the lifestyle I want. I want an honest job, and I don't have to
worry about the police and them robbing you”. Finally, at 33, Rhonda expressed that her
life would change for the better, whatever form it may take:
I just hope when I turn 35 that I’ll be situated better. I don't want to die on the
streets. You got the guys killin’ us, and you got AIDS killin’ us. You gotta
expect what’s gonna happen at the end.

CHAPTER 5
DISCUSSION AND RECOMMENDATIONS
Access issues
Establishing initial access to this population was difficult. As described in chapter 4,
street recruiting never proved successful; the first enrollments were made through personal
introduction by knowledgeable community informants. TTSWs of both ethnicities were
understandably suspicious of an outsider who suddenly showed an interest in talking with
them about their lives and behaviors, and then taking a blood sample. Barriers to
enrollment included a desire for privacy, distrust of my motivations, fear of needles, and
not “wanting to bother.” There may be others related to HIV status (i.e., already aware of
HIV+ status and fearful for confidentiality, or not wanting to know), immigration status,
ethnicity, or other barriers. Fifty dollars in two hours, including a blood draw with a
needle, was simply not that attractive an offer when balanced against the potential negative
consequences of enrollment, or the higher earning potential on the street. Without the
initial introductions from community members, and the development of well-connected
key informants who resulted from these introductions, I might never have gained
meaningful access to these tightly-knit populations. There are, however, more TTSWs I
did not enroll. These are less immersed in peer networks and more dispersed, and may be
at higher risk due to drug addiction and other factors (Inciardi 1995). Continued and
sustained recruitment efforts might have proved successful, as they did with other TTSWs.
148

149
Participants were motivated to enroll for different reasons. Many did it simply for the
money, though by enrolling they subjected themselves to considerable legal and personal
risk. Many expressed a desire to do something for their community, including by sharing
“what people should know about us,” and some wanted to know their HIV/STD results.
Generally, once I gained their trust, participants enjoyed the attention and enjoyed talking
about themselves. Several were flattered that someone cared enough to find out about
them, despite the potential risk of that information being used against them in the future.
Demographics and Background
Responses in the demographics section reflect some of the changing social and
environmental characteristics of Miami. While most African-American participants were
bom in Miami, and all are monolingual, all but three Hispanics immigrated to the U.S., and
all are bilingual. African-Americans have been particularly affected by the social
disruption and rapid cultural change of the past four decades, and the resulting increases in
unemployment, poverty, instability, and marginalization.
Most participants reported generally unstable childhoods, which many attribute to
family difficulties that arose from their gender variant behavior or sexual orientation:
almost every participant reported feeling “different” at a very young age. For most, the
lack of family and social support at this developmentally critical time began a path of
marginalization that continues today. While education levels are generally high among
both groups, transgender-related discrimination and higher income potential on the street
limit their participation in conventional employment and support their involvement in
commercial sex work.

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Overall, African-Americans in the sample are significantly younger than Hispanics.
While this difference could be attributed to the nonrandom nature of targeted sampling
techniques, I believe these figures fairly represent the relative ages of the two groups.
There are several under-18 African-American TTSWs, actively working the street; I was
unable to enroll them due to ERB restrictions which required a minimum age of 18.
Conversely, I am aware of no under-18 Hispanic TTSWs in the area, though there are
more older ones that I did not enroll. The age difference between the groups likely results
from attrition among African-Americans, due largely to AIDS-related mortality. Where
are the older African-American TTSWs? Stated simply: they are dead.
Sexual Behaviors
As mentioned, estimating the number of different lifetime male oral or anal sex
partners was difficult for all participants. While shorter time frames would seem more
reliable, 6-month, past week and even one-day recall were impossible for some individuals.
Lifetime figures were estimated through “decomposing” (as reviewed in Catania et al.
1990; they caution that estimating large numbers of partners may prove problematic).
Decomposing involves arriving at a number for a shorter, specific period of time, then
simply multiplying to estimate contacts for a longer period. These estimates are
nonetheless subject to bias from faulty recall, social desirability or presentation bias,
denial, or other effects. The number of actual contacts may be underrepresented, since
some sex acts involve interaction with a client but do not qualify as “sex” under the

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present definition.1 Further, I was deliberately conservative in decomposing. For
example, if a participant reported 5 oral or anal contacts per night, 4 nights per week for
two years, and no other partners, this multiplies out to 2080 partners in just two years.2
To allow for repeat clients, for not working on some nights and other factors, in this case I
would halve the number and round down to 1000. In many cases, participants’ reported
behaviors would have resulted in many times more partners than were recorded: it was
often difficult to admit to having sex with thousands of partners. Lifetime figures should
be considered to be very conservative lower boundaries of actual ranges.
Hispanics reported more lifetime male partners (mean 1445) than African-Americans
(mean 923). Though this difference was not statistically significant, it is consistent with
Hispanics’ older age and longer time in commercial sex work. Age of initiation for both
oral and anal sex did not significantly differ ethnically, suggesting that sexual initiation is
subject to other factors. African-Americans report less variation in sexual practices than
Hispanics.
Reported places where sex occurred were similar, with the exception of street or alley.
This is attributable to the relative amount of pedestrian traffic in work locations; on the
beach there are few dark or private places at any time. Significantly, fourteen percent of
African-Americans and 8% of Hispanics reported having sex in jail or prison; condoms are
not permitted behind bars.
1 For example, Shanika reported just 3 partners in the past 6 months, all oral, but another 500
“slick legs” which do not qualify as “sex.”
2 When I asked Glitter to estimate her total male partners, she initially said “a million.” Then she
continued: “look, I’ve been out there 4 years, 20 guys a night times 6 nights a week—you do the
math.” In this case, if each contact was a different client, “the math” works out to nearly 25,000
partners. She was coded as having 1000 partners, the number she felt most comfortable with.

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As anticipated, both oral and anal sex were universally practiced. Hispanics were
more likely to have ever practiced insertive anal sex, and unprotected anal sex in either
role, with any lifetime partner. In the past 6 months, all but one African-American and
one Hispanic practiced receptive anal sex with any partner type. While fewer African-
Americans (36%) report less then 100% condom use for RAI than Hispanics (54%), these
figures show that substantial proportions of each group engage in the highest sexual HIV-
risk behavior. Substantial but somewhat lower proportions of both groups reported
insertive anal sex (50% vs. 69%), with African-Americans again reporting more consistent
condom use; 15% and 27% report unprotected insertive anal intercourse. Due to
potential presentation bias influences, these condom use estimates should be considered
the higher boundaries. These figures indicate significant potential for the bidirectional
transmission of HIV and other STDs with sex partners.
For most participants, entry into commercial sex was preceded by a significant degree
of childhood instability. The majority had well-developed transgendered identities and
sexual attraction to men, which had contributed to familial disaffiliation and a range of
other social difficulties. Financial need preceded entry into commercial sex, which for
most was facilitated by friends in the business. They are motivated to continue in sex
work primarily for its financial rewards, though other aspects of the work are sometimes
attractive: the attention, the convenience of setting one’s own schedule, and the social
functions of engaging in the work, as well as habituation. But this is primarily survival
sex, and most would prefer not to engage in it if there were equally available and equally
viable options. Both groups are faced with extreme adversity on the streets, African-

153
Americans much more so than Hispanics. On the Stroll, assault, shootings and robberies
are commonplace occurrences, danger and death a part of daily life.
African-Americans are as a whole more committed to working the streets, and they
take their work seriously. They speak in terms one would associate with more formal
employment, such as “I’m off on Mondays” or “this job has its rewards.” They more
strictly separate business and pleasure; once they leave the streets, work is over. In
contrast, on the Beach, going out to nightclubs, socializing on the streets, and looking for
pargos are the way of daily life in the neighborhood. TTSWs on the beach do not create
the same degree of distinction between their personal and private lives. What they do with
clients, however, is similar. Both groups exhibit disparaging attitudes about clients,
particularly about those who want to be sexually penetrated, and emotionally separate
themselves from clients during sex.
Acts performed include some which present little or no low risk for HIV/STD,
including “hand jobs,” “dressing” clients, exhibitionist acts, intercrural intercourse (slick
legs), and some sadomasochistic acts. Oral-anal contact is associated with transmission of
HBV and other pathogens, but HIV transmission is unlikely in most cases.
From the TTSW perspective, insertive oral sex involves risk for STDs but relatively
little risk for HIV transmission. Receptive oral sex is generally considered a lower risk
activity for HIV transmission, compared to anal sex, but multiple exposures, variable
dental and oral health, and other factors may elevate unprotected receptive oral sex to
medium risk for TTSWs.

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The sharing of penetrative instruments and anobrachial penetration, though practiced
by a minority, involve anal trauma and concomitant high risk for HIV and STD
transmission. But without question, the highest risk activity for these individuals is anal
intercourse, the receptive role somewhat more than insertive, and this commonly and
regularly practiced.
African-Americans report significantly (P< 02) more 6-month partners than Hispanics
(mean 263 vs. 105). Though these figures may also be subject to bias, African-Americans’
relative position was also corroborated by qualitative data regarding exchange sex.J
Larger numbers in this category constitute most of the ethnic difference in numbers of 6-
month total partners. With exchange partners, receptive oral sex is near-universal, and
insertive oral sex is also reported by most participants (73% of African-Americans and
81% of Hispanics). Combined, over three-fourths report receptive anal sex, and over half
(50% of African-Americans and 58% of Hispanics) report insertive anal sex with paying
clients. Though condoms are used more often than not,4 significant proportions of the
total sample, and in each case more Hispanics than African-Americans, report less than
100% use for receptive oral (41% vs. 46%), insertive oral (32% vs. 42%), insertive anal
(5% vs. 19%) and receptive anal (14% vs. 23%) intercourse with exchange partners.
” African-Americans more often report date higher numbers of clients in a given night; Hispanics
more often attempt just one or two dates in a given night, consistent with their relative degrees of
commitment to sex work and conceptualizations of sex work as formal employment.
4 During fieldwork I discovered that a favorite lubricant among African-Americans was Victoria’s
Secret®, a skin moisturizer that contains mineral oil. Mineral oil degrades latex rapidly, and
causes condom failure. Though this was always discussed in the pre-test counseling session, to
reach those who did not participate in the study I notified staff and posted notice at the “condom
clinic,” and made other attempts to get the word out on the street about this additional risk.

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Condom use is less consistent for oral sex than for anal, which may reflect the
relatively lower risk perceived by both TTSWs and clients. Twenty-five percent of
participants strongly agreed that it is easy to get HIV from oral sex, compared to 88% for
anal sex. When the TTSW is inserting orally or anally, condom use is more consistent
than when the TTSW is receptive. This differential supports the assertion that TTSWs
have less power in the decision to use condoms than clients—when clients perceive
themselves to be more at risk, through receptive sex, they use condoms more consistently.
If the client wants to insert orally or anally, he may perceive less risk and be more willing
to proceed without condoms. However committed to using condoms TTSWs may be,
some clients will always resist, including by offering more money, and TTSWs are not
always able to overcome clients’ resistance. Even if they were successful in using them
100% of the time—and this is clearly not the case—they would still be at substantial risk for
HIV/STDs due to condom breakage and spillage, unnoticed removal by clients, and rape.
Condom use, however consistent, cannot overcome these risk factors.
One in three participants reported sex with nonsteady partners within the past 6
months, in much smaller but significant numbers. Condom use is again inconsistent.
Though the frequencies of reported anal sex are too small to draw statistically significant
conclusions, available data suggest that the absence of the power imbalance between client
and worker in non-paying situations may contribute to more consistent condom use.
Receptive anal sex is twice as commonly reported as insertive anal sex, indicating a
preference for receptive behaviors among some participants that is substantiated by
qualitative data.

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Similar proportions of both ethnic groups report sex with steady partners. Four in 10
have at least one steady partner; 80% report having just one. As with non-steady partners,
there is a significant sex role separation, with about two-thirds of TTSW reporting only
receptive behaviors and one-third reporting both insertive and receptive. Qualitative data
support TTSWs’ and their partners’ preference for this separation; none is solely insertive
with steady partners. Condom use is much lower, consistent with a number of studies that
report lower rates of condom use with sex workers’ steady partners (Bay 1993; Campbell
1991; CDC 1987). This represents a significant HIV/STD risk factor, and one of the most
difficult to address. Sex that occurs with relationships is subject to a host of other factors
that do not support the use of condoms, including trust, intimacy and financial
considerations. Having a steady partner is an idealized goal, though this is very difficult to
achieve and maintain for many TTSWs. For some, the negative aspects of being without a
partner are likely to outweigh the immediate risks of not using condoms; for those in (or
desiring) primary relationships, “safe” sex may be perceived as unsafe if it endangers the
stability or the potential of the relationship.
Those with a steady partner (or partners) report significantly (P<01) lower numbers
of exchange partners in the past 6 months, with a mean (median) of 73 (32.5) compared to
244 (110) among those with no steady partner. They also report fewer 6-month non¬
steady partners (mean 7.6 vs. 2.0). They are significantly (P<02) more likely to have
engaged in unprotected receptive anal intercourse (URAI) with any partner type: 70% of
those with steady partners report URAI, compared to 30% of those without steady

157
partners. They are also more likely (P< 02) to have a “regular” job: 9 of the 11 TTSWs
with either a full- or part-time job report having one or more steady partners.
Overall, 41% of African-Americans and 54% of Hispanics report having engaged in
unprotected anal sex in either role, with any partner type, within the past six months.
In this sample, six month condom use rates for oral and anal intercourse are not
significantly associated with number of partners or HIV/STD status. Unprotected anal
intercourse (UAI) is also not statistically associated with age, though those reporting
URAI are somewhat older (mean/median age 28.6/26.5 vs. 27.9/25), as are those
reporting UIAI (mean/median age 32.3/33 vs. 27.5/25). Early initiation of oral and anal
sex, having sex at partners’ homes, and having run away or been forced from home are
associated with 6-month UAI with any partner type.
Psychosocial scale variables associated with inconsistent condom use are low self-
efficacy, low social support, and perceptions of high community homophobia, as shown in
Chapter 4. TTSWs are subject to clients’ greater relative power in their interactions,
which greatly influences condom use. They are also subject to a number of personal
factors that may lead them to accept higher risk, including the perception of lower
infection risk based on partners’ appearance or familiarity with partners. Steady partner
sexual relationships that include unprotected anal intercourse mean greater risk, depending
on the partners’ infection status; this may be partially mediated by lower numbers of 6-
month sex partners among those with steady partners.

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Sex , Gender and Identity
TTSWs in this sample are heterogeneous in their identities, as seen in Chapter 4.
When asked, they chose a range of identities, alone and in combination, to identify
themselves. This variation is largely semantic; they are not primarily concerned with
labeling themselves, and have not been exposed to “official” definitions. The terms
“transvestite” and “transsexual” are recognized, and by some, fairly well understood in
their popular usage; “gay,” “straight,” and “bisexual” are salient categories for TTSWs.
“Transgendered,” on the other hand, was not recognized. What participants do
understand, and quite well, is that they are different from the mainstream; for them, the
label is insignificant.
From an etic perspective, and recognizing the difficulties inherent in labeling identities
and orientations, 44 (92%) participants could be considered transsexuals, that is, they
describe having female gender identity. As discussed, few intend to have sexual
reassignment surgery, for reasons discussed in Chapter 4, and as such might be termed
“non-op” transsexual, as opposed to the popular “pre- or post-op” distinction. Four
participants could be called gay transvestites, though they may more accurately be
described as “opportunistic” cross-dressers, in that they dress solely to earn money as sex
workers. All participants, as did transsexuals in Bolin (1983, 1996b), made a distinction
between female and male internalized gender identity. Some may correspond to
Blanchard’s (1993a, 1993b) description of “she-males.” Participants recognize, but rarely
use, this term to refer to themselves.

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When discussing transsexuals, specifying sexual orientation becomes a semantic
quagmire. If a person is transsexual, and sexually attracted to men, is such a person
homosexual or heterosexual? Bolin quotes a “pre-op” transsexual: “When you’re a
transsexual, every sex is the opposite sex” (1996b:482). Diamond proposes using the
terms androphilic, gynecophilic and ambiphilic, since “they emphasize the sex of the
partner rather than focusing on the individual’s sex in relation to the partner” (1997:207).
Given that, 42 of the 44 transsexual participants self-identify as exclusively androphilic,
and 2 as ambiphilic. Each of the 4 transvestite sex workers is exclusively androphilic.
TTSWs comprise only one segment of the at-risk population. Clearly, their clients
also participate in, and often exacerbate, risk behaviors. I did not attempt to quantify
client data; their motivations and actions are herein described solely from the TTSWs’
viewpoints, which suggests an opportunity for further research. While directly reaching
many of the clients would be very difficult, other options might include taxonomic
analysis, or training TTSWs in data gathering and in the use of a diary system.
Clients are a heterogeneous population. Tourists make up a significant component of
the client base, on the Stroll and more so on the Beach. Clients are often “older” (and
possibly outside the conventional dating pool), and married or otherwise in heterosexual
relationships. They are likely to be missed by existing narrowcast HIV prevention; for
example, messages that target MSM may fall on their deaf ears, since clients may not
identify as MSMs. Drug use among clients is common, particularly poppers and cocaine,
and they seek a variety of sexual services from TTSWs. Enumerating the client
population is problematic. However, there are enough clients to support a Miami-area

160
population of at least 250 TTSWs (including street, escort service and magazine ad-based
modalities; adding Fort Lauderdale’s population may double this estimate), so it is not
unreasonable to assume that there are at least several thousand clients in the area at any
given time.
What drives these clients? This research cannot account for all the potential variation
in clients, if such an account would ever be possible, and they may not be discretely
categorized. Nonetheless, and while generalization is problematic, several themes emerge.
In general, the majority of clients are specifically seeking a male sex worker dressed as a
female. There are exceptions; a few participants reported that most of their clients do not
“know,” and the sex acts performed with them are consistent with this assertion. Some
TTSWs are able to “pass” as women, and it is not unrealistic to believe they could clients
may perceive them as such. Some clients are simply seeking sexual release; some may
enjoy exploiting the power imbalance between client and sex worker. They may or may
not know that the sex workers have penises, and they may not care. TTSWs are available
to serve their purposes, and clients opportunistically buy their services.
Some may be operating within the active/passive penetration dichotomy, in which
males may penetrate another male and retain heterosexual identity. For these, the anus of
a male is culturally as equally available a choice for sexual intercourse as a woman’s
vagina. In these cases, these clients are behaving in a culturally appropriate manner, using
an available sexual outlet in a way that that reinforces their heterosexual identities. For
others, access to drugs, and perhaps an incidental sex act, is the prime motivator.
Together, these scenarios account for a significant part of the client base.

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A relatively smaller proportion of clients may not be sexually attracted to TTSWs at
all, and use their services within a scenario of fetishistic transvestitism or non-sexual
fantasy play. These clients may be heterosexual, and enjoy the convenience and expertise
—and the extensive clothing inventories—of TTSWs who “dress” them in female attire and
makeup.
The above scenarios are common, but altogether they do not account for the bulk of
the aggregate interactions between TTSWs and clients. A substantial proportion of the
clients, if not the majority, wish to be orally and/or anally penetrated by the penis of
someone with the appearance of a woman. They may seek any number of specific sexual
services, including insertive or receptive, oral or anal sex, voyeuristic, exhibitionist, or
sadomasochistic activities. Some clients may be gynandromorpophiliacs: their specific
sexual interest is in cross-dressed or anatomically feminized males. This may or may not
result from some degree of cross-gender identification and autogynephilia on the part of
the client.
Some clients actually prefer sex with a male, but for some reason it must occur with a
male dressed as a woman. They may fear being seen in a “gay” setting, including male
hustler areas, for fear of exposure. Others, perhaps more commonly, are unable to accept
their desire to have sex with a man. Picking up an apparent female may circumvent either
of these barriers, by allowing for the ostensible possibility that either the client believes the
sex worker is a woman, or that the client intends to penetrate her, and not vice-versa.
They may take this illusion to the extreme, by acting surprised that their “date” has a
penis, by insisting that this is their “first time” to “try something different,” or by asking

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the TTSW to keep this (impending penetration of the client) “our little secret.”5 For them,
internalized and social homophobia most strongly influence the expression of their
sexuality. But what forces contribute to the homophobia?
I will argue that the same cultural forces that drive TTSWs also influence this
homophobia-driven client. First, a greatly simplified view of the popular assumptions
about sex and gender that are the basis for our society’s construction of sexuality, and a
description and discussion of TTSWs self-identities.
At birth, our sex is determined by a visual inspection of genitalia.6 What we are is
now established, and we can answer that all-important first question: “girl or boy?”
Our gender identity, that is, the internal knowledge that one is either a boy or a
girl, matches our sex. For our entire lives, gender identity will be enforced and
reinforced through almost every social action.7
Our gender role matches our gender identity, and by definition, our sex. We are
permitted little variation in what is expected and appropriate for what we are.
These roles may become more restrictive after childhood. Males are generally held
to more strictly defined gender roles.8
5 In this category I include the sexually “adventurous” older client often described by TTSWs as
“just wanting something different,” a claim I tend to view with some skepticism. Sexual
orientation is normally established early in life, and little “experimentation” occurs after the
adolescent years. For most of these clients, the behavior may not be actualized, but the orientation
has been firmly in place for quite some time.
0 Among perhaps 1 in 2000 individuals, an “intersexed” condition causing ambiguous genitalia
(Johnson 1997:30) confounds this “basic” distinction. Often, a decision must be made as to “how
the child will be raised.” This normally results in the creation of a vagina, to facilitate the child’s
socialization: “You can dig a hole, but you can’t build a pole,” according to one surgeon.
(Hendricks 1993:10).
7 For example, through language: in both English and Spanish, gendered pronouns are used. We
must first know a person’s gender before we can correctly use language to refer to them.
8 Boys are boys: they have boy names, wear boy clothes, do boy things. Maria may be allowed to
play in the mud with little Rod, but she will be expected to outgrow this before long. Rod, on the
other hand, may create a scandal if he presses the limits of his gender role, by “mothering” a doll,
for example.

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Our sexual orientation—that is, our heterosexual orientation—emerges in time.
Sex is something males “do” to females: males penetrate, females are penetrated.
The obvious purpose for sex is reproductive; any emotional, recreational or social
function is incidental.
As the most basic assumptions about who we are, and what we are as humans, these
lines are the least flexible in our lives: variations from the norm cause turmoil, ridicule, and
censure. Admittedly, this is a generalized model. It does, however, represent the basic
framework of the reproduction-based model of the Western construction of human
sexuality, long embedded in positivism, Cartesian duality9, male dominance, and
patriarchy. Women are devalued; being penetrated, as what happens to females, is
equated with denigration.10 This model has framed popular thinking for centuries: we are
dichotomous, man or woman, one or the other, never both or in-between. This is the way
things are, this is the natural order; why would anyone question it?
And for the majority of people, the assumption that sex, gender, gender role, and
sexual orientation will manifest in a “natural” congruence holds true. Phenotypic sex
usually matches gender identity, the transfer of gender role from the community to
individual level occurs without existential dilemma, and most people are heterosexually
oriented.11 There is, however, a growing popular awareness that this model is not
9 The primacy given the body over mind is reflected m our concepts of gender variation: if the
mind and body don’t match, we use the term “gender dysphoria,” not “body” or “sex dysphoria.”
10 As a linguistic example, how many phrases in English can match the vitriolic “Fuck you”?
11 Transsexualism is fairly rare, incidence has been estimated as 1 in 30,000 in the DSM
(American Psychiatric Association 1994), to 1 in 11,900 males, and 1 in 30,400 females m the
Netherlands (van Kesteren 1996). Same-sexual activity occurs much more frequently:
approximately 5-7% of male adults in the US have sexual contact with other males; this should be
considered “the lower bounds of the actual prevalence of such contact” (Rogers and Turner
1991:491). Given the reports of higher levels of male-male contact in some populations, one might
suspect that in the aggregate such contact may be even more frequent in Miami.

164
adequate, that it does not include the variation that occurs in the “real world.” Publicity
about intersexed children, public debates about homosexuality, and a recent spate of “drag
queens” and gender variants in the media all are examples and causes of a continual
reexamination of sexuality. There is no question that norms are changing, but change
comes slowly. Change often applies to “other” people: we may accept the gay man who
lives on the same block, but still be most uncomfortable if, for example, our mother
announces that she is a lesbian. The rigidity of our assumptions has made modifying them
on the basis of new information a slow and laborious process. We are reluctant to
internalize new assumptions about the most basic of our understandings, and herein lies
the explanation for some of the behaviors of TTSWs and their clients.
TTSWs and their clients are bound by the cultural constraints that define the possible
variation in gender identities and roles. This is true even for those who stress these limits
of these constraints. How, then, do TTSWs and their clients negotiate their identities and
behaviors within the confines of cultural possibility? In this regard, they share a
commonality.
The gender dichotomy is so rigid that they must completely cross gender lines, at
some level, to be able to vary their identities or orientations from the possibilities dictated
by the dominant model. Within a culturally binary system, they are doing what they must
in order to validate themselves and their behaviors. They are operating from a perceived
fixed “hard-wiring,” following an available path that allows them the cultural space to be
who they are. To do so, they reinterpret, and in the process, recreate, gender.

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To accomplish this redefinition of gender, they simply remove from genitalia the
power to specify gender identity. Rather than by genitalia, gender and its accompanying
appropriate gender roles and behaviors become defined by a person’s exterior
presentation: by their clothing, their mannerisms, their language. Once across the gender
divide, TTSWs assume female names and refer to themselves in the feminine. If, for some
reason, they "‘go butch” (as a male), they normally revert to male names and pronouns.
Several participants carry this a step further, describing feminine linguistic redefinition of
body parts (for example, the client who referred to the TTSW’s penis as “pussy;” and the
several African-American TTSWs who referred to their anuses as “womb” or “pussy”).
This gender redefinition occurs through another primary component of cultural
emphasis in our society: appearance. This emphasis is obvious in our daily lives: beauty
products, hair dyes, skin creams, diet aids, and advertisements for cosmetic surgery are
ubiquitous. One need only pass through the cashier line in a grocery store to experience
this emphasis, which is even more specifically directed at women. Magazines, talk shows,
the internet, and door-to-door salespeople all testify to our obsession with the body
beautiful. Some individuals are driven to eating disorders to maintain an idealized,
unattainable appearance; the aged, having lost their youthful beauty, are no longer
valuable.
Some TTSWs and some clients dance this redefinition of gender through the lens of
fantasy. Stepping into a fantasy role allows one to traverse rigid gender lines that
otherwise could not be crossed: one would never be allowed to do it really, so it must be
expressed as a fantasy. There was one common thread in the conversations with every

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participant, across age, across ethnicity, across identity. Whether talking about their lives,
their work, their future, their clients, everything becomes possible because “it’s a fantasy.”
The homophobia-driven clients are well aware that that they are sexually attracted to
men. They do what they must, within the limits of cultural possibility, to allow themselves
to have male-to-male sex. They redefine what it is to be a woman; they tell themselves
that their partner, who looks like a woman, is a woman. In this way, they retain male
identity even while being penetrated by a penis—because the penis is attached to a woman.
Other clients who do not require this redefinition may subscribe to it as well.
These transsexuals go through a similar process. For them, “hard wiring” means that
they know categorically that they are women, independently of their genitalia, and of their
sexual orientation. Sexual reassignment surgery is not a viable or desired option, so they
cannot be defined as women by having vaginas. Redefining gender by virtue of exterior
presentation makes it possible for them not only to have a penis, and to use it sexually, but
to exist as who they know they are. Commitment to the gender redefinition varies; some
have completely internalized it, others have not. Some definitively said “I am a woman;”
other might admit that they are not women women, but that they are women of a different
category of women.
For the redefinition to function, they completely and emphatically cross the gender
dichotomy to hyperfeminize themselves. This is the common thread, the glue that binds
their world: daily life revolves around conducting and reinforcing12 this ritual of gender
12 As Pettiway states, “Imitation is an important part of that cluster of transvestites who take care
of each other, who bond by their desire to emulate each other, and who display a fascination with
glamour and illusion. They craft their own identities by closely observing, learning, and giving
expression to the imagined styles they encounter (1997:xxxiii).

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redefinition. In this way they remain in constant articulation with the period of margin, or
liminal state, described in 1908 by van Gennep as the central component in transitional
rites of passage: “So great is the incompatibility between the sacred and profane worlds
that a man cannot pass from one to the other without going through an intermediate
stage” (van Gennep 1960:1). Following van Gennep, Turner regards this period as
interstructural: “one of ambiguity and paradox, a confusion of all the customary
categories” (1967:97) and one in which reversal of society’s structure into antistructure
occurs (1967, 1977). Bolin states: “Liminallj positions are symbolically dangerous as it is
possible that transformation may be an outcome of experiencing antistructure,” and quotes
Turner:
The liminal areas of time and space... are open to the play of thought, feeling and
will; in them are generated new models, often fantastic, some of which may have
sufficient power and plausibility to replace eventually the force-backed political
and jural models that control the centers of a society’s ongoing life (1977, cited in
Bolin 1996a:34).
Herein lies the basis for society’s shock and revulsion at the idea of a man who dresses
like a woman: upsetting the basic order that we know and understand might destroy it,
and then what?
This ritual female gender redefinition involves not only the appropriation of
unquestionably female clothing and mannerisms, but the artificial creation of the most
emphasized feminine quality in North America: large breasts. For most, breasts are central
to their feminine identities and are the most symbolized aspect of their feminization. The
quest for perfect breasts will most often include the acceptance of health risks from
13 Liminality has been conceptually applied to gender variation by a number of other scholars,
including Besnier (1996), Herdt (1996), and Nanda (1996).

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unmonitored hormone administration and silicone injection: the beauty and the breasts—
the visual—override unseen health consequences. Hormones also function to reinforce
feminine identity through their psychological effects. As evidence of hormones’
importance in their lives, participants have formed a number of folk belief systems that
surround hormone use. As symbols, they represent freedom of expression and escape;
their use is reinforced through social interaction.
The 4 TTSWs who opportunistically cross-dress, that is, who temporarily appropriate
female attributes solely for financial reward, are easily able to incorporate cross-dressing
into their identities. There are no deep internal conflicts; for them, it is merely an action
within the range of possibilities in their lives. They do so, however, within the gender
redefinition common to both the transsexual sex workers and the penetrated client: they
too report undergoing a complete transformation when they dress, with the accompanying
attribution of female qualities.
For some clients, gender redefinition may occur on a transitory basis. For the
transsexuals, the recreated gender has become more completely internalized. As an
example, they are generally vocal in their contempt for penetrated clients. While clients
who penetrate have no separate linguistic designation, and are referred to simply as men,
this is not the case for penetrated clients. They, in contrast, are “freaks;” they’re “not
normal,” and they are “more fucked up than we are.” Why? Because the clients, who
have not crossed the exterior-defined gender line, remain men (they look like men,
therefore they are men). And in their behaviors, they’re doing what men cannot do; men

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do not get penetrated. They are violating the constraints of the gender dichotomy, albeit
redefined.
A notable exception to this redefined gender distinction is made for those men who
admit that they are sexually attracted to men. These become “gay boys,” or gay, or
bisexual men—but not “men” men. They exist in a separate linguistic and cultural category
of men, having removed themselves from the role expectation of “straight” men. The
client who presents himself as straight, but wants to be penetrated—but is really not
straight, because he cannot be straight and get penetrated—becomes the “freak.”
Transsexuals see themselves in the same way: they look like women, and they are
women, just in another category of women. This woman can have a penis and use it to
penetrate a man, because the woman in this category is not defined by her genitalia or by
any particular sexual behavior. She is defined by her appearance.
With regard to their sex partners, these TTSWs have internalized some aspects of the
gender distinction between “men” (who are not penetrated) and “not-men” (including
women and men who are penetrated) described by Kulick (1997). However, their basic
categorization of gender remains firmly entrenched within a man-woman dichotomy.14
The existence of an institutionalized “third gender” or multiple gender category described
in non-Westem settings (Besnier 1996; Herdt 1996; Jacobs and Cromwell 1992) is not
supported by TTSWs in Miami, and they do not perceive themselves to “blend” elements
of both genders either in identity or presentation.
14 Transsexuals’ paradoxical support of the two gender system they appear to defy has also been
discussed by Bolin (1987), and Kessler and McKenna (1978).

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In some ways, these TTSWs are similar to those in Salvador, Bahia (Kulick 1997); in
others they are not. Miami and Salvadoran TTSWs often engage in anal penetration of
clients. Salvadoran TTSWs also inject silicone, but rarely in their breasts;13 this is often
the first and primary area of concentration among Miami TTSWs. Kulick also describes a
“strong consensus among travestís in Salvador that any travesti who claims to be a woman
is mentally disturbed” (1997:577); this is not the case in Miami. Both groups in general
value their penises, and express horror at removing them. Kulick describes travestís’ not
wanting their steady boyfriends to acknowledge the travesti’s penis, and a general
avoidance of using the penis. While this holds true for most Miami TTSWs, one-third of
those with steady partners do not fit this model. Salvadoran TTSWs enjoy sex with
clients; most in Miami do not. Kulick believes Brazilian travestis also maintain a binary
gender system, rather than a third gender category, though he conceptually redefines it as
a men-not men dichotomy.
15 “The strategic placement of silicone is in direct reference to Brazilian aesthetic ideals that
consider fleshy thighs, expansive hips, and a prominent, teardrop-shaped bunda (buttocks) to be
the hallmark of feminine beauty. The majority of travestis do not have silicone in their breasts,
because they believe that silicone in breasts (but not elsewhere in the body) causes cancer, because
they are satisfied with the size of the breasts they have achieved through hormone consumption,
because they are convinced that silicone injections into the chest are risky and extremely painful, or
because they are waiting for the day when they will have enough money to pay for silicone
implants surgically inserted by doctors. A final reason for a general disinclination to inject silicone
mto one’s breasts is that everyone knows that this silicone shifts its position very easily. Every
travesti is acquainted with several unfortunate others whose breasts have either merged in the
middle, creating a pronounced undifferentiated swelling known as a “pigeon breast” (peito de
pomba) or whose silicone has descended into a lumpy protrusion just above the stomach” (Kulick
1997:576).

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HIV Perceptions and Psychosocial Indicators
Data discussed in this section were gathered in open-ended conversations, as well as in
the structured Section H of the instrument. In practice, many of these structured Likert-
scale questions were not culturally or linguistically appropriate, and were subject to
interpretation by participants and variables that confound interpretation. In chapter 4,1
described “flag” scores, at which level an individual’s aggregate scores within a category
were at a “level of concern.” This is admittedly an imperfect measure, since, for example,
a participant might answer 4 instead of 5 on a given question--a distinction of marginal
value—which might cause the total score to remain just outside the “flag zone.” Further,
not achieving a flag score does not indicate that an individual would not benefit from
exploring these issues. In view of their limitations, I chose to use them in their respective
categories primarily to illuminate areas for consideration at the intervention level.
Participants are well aware of the existence of HIV, of its transmission modes and
how they can prevent infection through the use of barrier methods. Not only do most
personally know someone with HIV, most personally know someone who has died from
HIV infection. Though HIV is a part of daily life, most say they try not to think about it.
Many have a fatalistic view of infection; though they pray and hope they avoid infection,
they feel it may lies outside the boundaries of their control. Though knowledge levels
about the virus are generally high, there are some misconceptions that could be clarified.
These include the ability to visually “tell” that a person is HIV-positive—several
participants make critical decisions on the basis of appearance only. Some may be

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reacting to a growing perception that HIV is not as serious as it once was, or that there
will soon be a cure.
Whether they perceive themselves to be at risk for HIV is difficult to measure
quantitatively. Given their experience seeing friends die from HIV and their comments
about HIV infection, I find it difficult to argue that they would not perceive themselves to
be at risk. Individual factors, however, may come into play, including the fatalistic
attribution of HIV infection. Four African-Americans and 1 Hispanic met flag score
criteria in Section H, indicating they may not perceive their behaviors to place them at
risk. Comments that accompanied their answers, however, lead me to believe that
decreased risk perception is based on their consistent condom use and faith in condoms,
and not denial that the virus could infect them.
Though HIV is a part of daily life, there is a clear resistance to acknowledging its
presence through talking about it. Having watched HIV devastate their numbers, there is
a substantial resistance to even allow others to think one might be infected; this
contributes to an almost phobic reluctance to visit a clinic or receive health care. Being
aware of their HIV infection is also perceived by many as having the potential to “bring
me down faster,” through excessive worry about the condition.16
Perceived, severity of HIV is high. Considering recent treatment advances, it might be
considered too high, in that this perception prevented some from receiving their results
and then seeking treatment. Most people would still rather not know they are infected,
even though they are aware that new and effective treatments exist, and even though
10 There is some biomedical basis for this reasoning: depression has been associated with
immunosupression in HTV-positive people (Burack et al. 1993). Current treatment options,
however, far overshadow the benefits of “not knowing.”

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waiting too long might mean waiting until too late. Overcoming this “death sentence”
perception about HIV infection is critical: breakthrough medical treatments are of no use
unless they are accessed.
Composite and individual scores in self-efficacy, social support and community
homophobia were significantly associated with several key risk and outcome variables, as
shown in Chapter 4. Answers in this category indicate particularly fruitful areas to
incorporate in intervention. Within the other categories, some answers in each of these
categories, together with corroborative qualitative data, also suggest areas that might be
effectively addressed with this population. These factors are included in the intervention
section of this chapter.
Medical Considerations and Test Results
The medical needs of this population are clearly not being served. Just 31% have
private insurance or Medicaid coverage, and this figure will soon decline as several
participants now insured under parents’ policies reach age 21. For this reason, financial
limitations may influence TTSWs’ reluctance to access health care, as they as do other
marginalized populations. Perceived discrimination and transphobia, distrust of
biomedicine, and denial may also play a part in their limited interaction with the health care
system.
Drug use is much more common in Hispanic participants. While lifetime use data are
probably reliable, current use frequencies in many cases were most likely understated;
these should be taken as lower boundary estimates. What contributes to the much higher
prevalence of drug use by Hispanics? One explanation is the Beach milieu, where

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“recreational” drugs of all types are much more commonplace. Further, African-
Americans say they have to maintain a “clear head” on the Stroll, a reasonable precaution
given their descriptions of the area.
Preliminary Young Men’s Survey data also document substantially less drug use by
African-American MSM in the Miami area (Lalota 1997). A partial explanation may be
the attention given to drug use in African-American families and churches, and the
resulting social norms that discourage drug use. In contrast, sexuality and HIV are not
afforded the same levels of community acknowledgment and attention.
Some self-reported health data were inaccurate, including (1) past syphilis infection,
which was reported higher than actual, (2) ever any STD diagnosis, which was lower than
actual (by virtue of HBV infection if nothing else) and (3) hepatitis-B vaccine history (only
2 of the eight participants reporting vaccination had detectable antibodies). These
conflicts may have resulted from faulty recall or from presentation bias, or participants
may never have received correct information about these subjects.
Hepatitis-B infection is common: 69% are presently, or have been, infected with HBV.
African-Americans (86%) were significantly (P<02) more likely to have been infected
than Hispanics (54%); the three participants with current infection were all African-
American. Syphilis rates were similar for both groups at roughly 19%. Other infections
that were not surveyed in this project, such as chlamydia, gonorrhea, herpes, or Human
Papilloma Virus (HPV), among others, are also likely prevalent. The potential
consequences of not receiving treatment are dire, even if only in terms of complicating
present or facilitating future HIV infection; there are many more immediate and long-term

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considerations. The reluctance or perceived inability of this population to access medical
care, due to embarrassment, discrimination, or inability to pay, will have serious health
consequences in terms of these STDs alone.
HIV infection is alarmingly high among both groups. Fully 55% of African-Americans
are HIV-positive, compared to 27% of Hispanics (P<06). These rates may underrepresent
infection levels in the larger TTSW population due to participation bias; the stigma of
infection, combined with the potential breach of confidentiality, may have discouraged
HIV-positive TTSWs from participation.
No participants reported already knowing they were HIV-positive. They may either
have not known, or may they have been reluctant to discuss their infection. Compressing
the responses to question D12 (estimated likelihood of current HIV infection) into “low”
(“no chance,” “very unlikely,” or “unlikely”) or “high” (“likely” or “very likely”) reveals a
significant (P< 04) association between HIV seropositivity and perceived likelihood of
infection. Of those reporting “high” probability of infection, 63% were infected; of those
reporting “low” probability, 37% were infected. This association may have resulted either
from accurate assessment of personal risk behaviors, or from prior knowledge of
infection.
How did such a significant proportion of TTSWs become infected? Most likely, not
through IDU, though most inject, or have injected hormones. Needle sharing is clearly
recognized as dangerous; these TTSWs consistently report they do not share needles or
other equipment. New, sterile needles are available from their hormone sources, and the
urgencies of addiction that contribute to equipment sharing do not factor here: one can

176
wait to inject hormones. Silicone injections could be a suspected source of parenteral
infection; however, TTSWs report that new, sealed needles are always used for silicone
injection.
TTSWs become infected through sexual behaviors, primarily anal sex, combined with
less-than-consistent condom use, condom failures, and rape. Risk behaviors and infections
are facilitated by a number of cofactors, including STDs, substance abuse and
multifactorial immune suppression. In turn, TTSWs’ reported behaviors strongly suggest
that they may be transmitting HIV/STD infections to their sex partners.
Several variables are statistically associated with HIV infection. They include age
greater than 25 years (P< 04), age under 14 at first episode of anal sex (P< 04), marijuana
use greater than once per week (P< 03), and being “out” to more than half the people one
knows (P< 04). Other trends are meaningful, but lack statistical power. HIV-infected
participants initiated commercial sex earlier, and report longer times since initiation of sex
work. They were younger at first episode of oral sex, and have a history of forced sex.
They are more likely to have engaged in URAI within the past 6 months, are more likely
to be infected with syphilis and HBV. TTSWs in Miami work in a primary HIV epicenter,
(and thus come into contact with populations at much higher risk for HIV), which is
strongly influenced by local factors. These include substance use, with related immune
suppression and behavioral implications, and tourism- and migration-related mobility.
This mobility also contributes to a “party” atmosphere and a reduced sense of
permanence. This is a significant factor in inconsistent safer-sex norms in some

177
populations; this gap is not being adequately met by the community. Circumcision rates
may also influence the local epidemic.17
There are no real surprises here: nearly twenty years into the HIV epidemic, we know
what behaviors lead to HIV infection in humans, whether sex workers or not. We have
known, for all too long and all too clearly, what these behaviors are; recalculating their
odds ratios for HIV infections among this population was never a goal of this project. I
believe the primary question to be asked is not how so many infections occurred, but why.
This leads us to the social factors that shape the HIV epidemic.
In discussing the factors that influence the urban HIV epidemic, Singer cites such
factors as high unemployment, poverty, homelessness, residential overcrowding,
substandard nutrition, infrastructural deterioration, forced geographic mobility, family
breakup and social service network disruption, youth gang and drug-related violence, and
health care inequality (1994:933). All of these factors are unfortunate realities in urban
areas nationwide, and you need look no further north than Miami to find extreme
examples of each.
They, in turn, lead to a number of negative health consequences, including infant
mortality, diabetes, hypertension, cirrhosis, TB, substance abuse, STDs, and HIV. Lack
of access to health care contributes to the prevalence of HIV infections, through illness-
17 Royce et al state “Male circumcision consistently shows a protective effect against HIV
infection. This may be due to the abundance of Langerhans cells in the foreskin or to a receptive
environment for HTV in the foreskin and glans. The prevalence of HIV is 1.7 to 8.2 times as high in
men with foreskin as in circumcised men, and the incidence of infection is 8 times as high. A
greater proportion of the sex partners of uncircumcised men than of circumcised men are infected
with HTV, which suggests that the presence of the foreskin may also increase infectiousness
(1997:1075). Anecdotal data suggest that circumcision is less common among men in Miami than
in the U.S. in general.

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related immunosupression as well as cofactor STDs.18 Some STDs, such as chlamydia
and gonorrhea, are easily treated, or might be incidentally treated with antibiotics received
for other reasons. Others, for example, the herpes virus (HSV-2), are incurable. HSV-2
infection is present in 22% of the U.S. adult population and in 45% of African Americans
(CDC 1997d). Singer (1994:936) describes the relationships between social factors and
disease:
Poverty leads to poor nutrition and susceptibility to infection. Poor nutrition,
chronic stress, and prior disease produce a compromised immune system,
increasing susceptibility to new infection. A range of socio-economic problems
and stressors increase the likelihood of substance abuse and exposure to HIV.
Substance abuse contributes to increased risk for exposure to an STD, which can,
in turn, be a co-factor in HIV infection. HIV further damages the immune system,
increasing susceptibility to a host of other diseases.
African-American TTSWs are infected with HIV at twice the rate of Hispanics. This
may result from higher numbers of sex partners, and associated condom-related shortfalls,
as well as the sex acts they perform. Qualitative data suggest that African-American
TTSWs have more African-American clients and steady partners; they in turn have several
times the HIV infection rates of Hispanics and Anglos. A number of factors that
contribute to a higher HIV prevalence in African-Americans have been examined
(Peterson et al. 1992; Peterson 1995; Stokes, Vanable, and McKiman 1996) and are still
not fully understood.
18 In both men and women, chancroid, syphilis and herpes prevalence is associated with increased
relative risk (range 1.5-7.0) of HTV infection; gonorrhea, chlamydia and trichonomas infection
increase risk by 60 to 340% (Royce et al. 1997:1074). CDC’s Judith Wasserheit, noting that STD
rates in the U.S. are the "highest in the industrialized world,” points to the urgent need to find new
tactics to reduce STD rates (Watanabe 1997:18).

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These factors include the effects of social marginalization and poverty resulting from
ethnic discrimination, resulting in higher rates of drug use and related incarceration, as
well as possible cultural resistance to condom use and predilection toward anal
intercourse19 as the preferred sexual activity. Recent research suggests a possible
biological influence that may contribute to a resistance to HIV infection and disease
progression in some Caucasians, the CCR-5 genetic mutation (Dragic et al. 1996; Huang
et al. 1996). A lingering distrust of the Public Health establishment, related to the
Tuskeegee Syphilis Study, has been postulated (Thomas and Quinn 1991). This distrust
may lead some individuals to ignore prevention messages, to underestimate HIV risk, and
to avoid health care and treatment.
None of these factors occurs alone; they combine with the devalued social status and
resulting marginalization resulting from institutionalized racism to form a particularly
unhealthy combination. Dressier states “African-Americans suffer by comparison with
white Americans on essentially every indicator of morbidity, mortality and access to health
care” (1993:325). That ethnic minorities are overrepresented in prisons (Jackson, K.L.
1997) has been well-documented; prisons are notorious pools of HIV infection. As of late
1994, prisons reported an HIV prevalence almost 6 times that of the US adult population.
In all but a few prisons, condoms and bleach are prohibited (Gaiter and Doll 1996:1201).
Hispanics are subject to each of these factors as well. In this sample, they also report
higher levels of other potential risk factors, such as drug use and lower rates of condom
use. Their reported behaviors suggest that, other factors unchanged, infections among
19 Also reported Latino men by Carrier and Magaña (1991) and Caceres et al. (1991).

180
them will rise. Contributing to their lower seroprevalence rates, at least for the present,
are African-Americans’ higher numbers of current sex partners and the much higher
overall HIV/STD seroprevalence in African-Americans in general.
Few of the limited studies conducted with TTSWs in other areas are comparable.
Boles and Elifson (1994a) note that these studies have several limitations:
the samples are small and adequate descriptions of the populations from which
they are drawn were not provided. Further, potential risk factors were either not
identified or measured consistently nor was a context for understanding the
transvestites’ risky behaviors provided (Boles and Elifson 1994a: 86).
Elifson et al. (1993) and Boles and Elifson (1994a; 1994b) reported on the most
comparable published research with TTSWs, which was conducted with 53 “transvestite
prostitutes” (80% Black and 20% White) in Atlanta in 1990-91. In Atlanta, participants
were more likely to engage in receptive anal sex with clients (77%) than with steady
partners (47%; Elifson et al. 1993).20 Miami TTSWs report these behaviors in higher
proportions (81% and 100%). This may result from fundamental differences in identity
and sexual orientation between participants in the two groups.
In Atlanta, participants’ “social identity (varied) along a continuum from bisexual to
transsexual, with the majority identifying as homosexual.”21 Workers in Atlanta preferred
to “engage in oral sex in order to minimize the risk of a customer discovering they are
‘really’ males” (Boles and Elifson 1994a:85). They reported levels of drug use, mainly
20 Boles and Elifson allude to workers’ practice of insertive anal intercourse with clients, but do not
report on separate evaluation of this behavior: “while these respondents primarily engage in oral
sex with their customers, many also participate in anal sex, primarily in the receptive role” (Boles
and Elifson 1994a: 89). Intercrural intercourse was not reported in the Atlanta research.
21 This indicates that the Atlanta researchers did not differentiate between sexual orientation and
gender identity in “social identity,” possibly reflecting a difference in disciplinary perspective.

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crack cocaine, in much higher proportions than Miami TTSWs. In Atlanta, street-level
interviews were conducted, and blood samples were tested for HIV (68%), HBV (76%)
and syphilis (79%). In comparison, rates of HIV (40%), HBV (69%), and syphilis (19%)
among Miami TTSWs are lower in all categories. These differences may result from a
number of factors, including the ethnic composition of the samples, increased HIV/STD
and risk reduction awareness in Miami (the Atlanta study was conducted earlier in the
epidemic), drug use, and other factors.
In Atlanta, HIV infection was associated with syphilis seromarker, with Black race,
and marginally associated with a lifetime history of crack use (66% reported crack use).
Condom use was not significantly related to H3V status (Elifson et al. 1993). HIV status
was connected to:
commitment to transvestism, in that high commitment leads to: (a) social and/or
physical isolation; (b) participation in risky behaviors, i.e., receptive anal sex to
enhance feelings of femininity and meet customer expectation; (c) adverse life
experiences with concommitant feelings of vulnerability and hopelessness (Boles
and Elifson 1994:93).
Brazilian TTSWs’ behaviors are also comparable to those in Miami. Both insertive
and receptive anal sex are practiced with clients by TTSWs in Rio de Janeiro; their 63%
HIV infection rate (Inciardi and Surratt 1997) is higher. TTSWs in the Netherlands report
similar behavioral versatility; lower HIV infection rates were reported in 2 studies (Gras et
al. 1997; van Roosmalen et al. 1996).
Intervention
Several participants chose to not receive their blood test results: they did not want to
learn their HIV status. During pretest counseling I gave them the option to receive only

182
HBV and syphilis results; none took advantage of this offer. In one sense, then, IRB
requirements that prohibited my asking for contact information might have been an
obstacle to serving participants’ needs. I might have been able to speak with them by
telephone, and continue to discuss the benefits of receiving results.
On the other hand, participant knew how to contact me. Even if they lost my contact
information, I could have been reached easily through their friends. That almost two-
thirds did choose to receive results compares favorably with the return rate of another
local HIV seroprevalence study in which people are also approached to test, as opposed to
seeking HIV testing on their own.22 A number of factors could have influenced this
difference, including participation bias, convenience, risk or benefit perception, and the
more personal relationship I created with participants through longer encounters. These
are interesting questions for further research.
My first obligation in this research is to participants’ safety and well-being. I firmly
believe HIV-infected people should learn their status and receive appropriate health care,
and in pre-test counseling I emphasized this as well as the steps that could be taken if they
tested HIV-positive. These included my assistance in arranging case management for
medical and social services, even if they had no money or insurance. In short, I did my
best to stress the value of knowing their results (i.e., though it is never easy to hear that
one is HIV-positive, but there are new and effective treatments; if there were ever a time
to learn one’s status, it is now). However, learning one’s results is an intensely personal
22 In preliminary data from the Young Men’s Survey, about 35% return to receive their results
(Lalota 1997).

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decision, and despite my earnest intentions, the decision was theirs to make. Just as
people have the right to know their status, they have the right to not know.
Public health has a definite interest in finding and treating HIV-infected people, despite
the high cost of current treatments. Reducing future infections—even if only through
reduced infectivity resulting from antiviral therapy and STD treatment (Royce et al. 1997)
is clearly in the public’s interest. On the other hand, individuals have their own interests at
heart, and only they can say if they are ready to know they have a deadly virus in their
bodies. Participants in this research are well aware of new treatments, if not the details
about them. They have the right to make their own decisions, even if those decisions are
not the “correct” ones. And as we “target” interventions, we had best keep this and other
considerations in mind.
TTSWs are very independent people, accustomed to a lifetime of adversity in almost
every realm. To be who they are, they defy the strongest social norms (i.e., how they
should look, how they should conduct themselves, even if they should be men or women)
and will do so even when faced with harassment, discrimination and other negative
consequences. As a whole, they have a number of problems; they realize this. HIV risk
and infection are part of reality, though for most they may not be of primary concern.
TTSWs will not stand for being insulted by someone who claims to have the answer
to all their problems. They know they live dangerous lives; no one needs to explain this
reality. We can reduce risk and ameliorate some problems, but we cannot realistically
expect to eliminate them. They know full well that HIV is deadly: they see their friends
dying. They know condoms can help, and they generally want to use them. They realize,

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however, that their intention to adhere to 100% condom use, even if they had such an
intention, would not eliminate the potential for infection.
The circumstances are difficult, but not hopeless: there are valid actions to pursue. In
considering intervention strategies, I kept Bolton and Singer’s recommendations in mind:
Prevention works best when it promotes change through individual and community
empowerment strategies informed by holistic understandings of the local context,
when it acknowledges the positive contributions of local cultural values to the
process of change, and when it incorporates an array of options that permit
individuals to transform their lives in ways that enhance their physical, emotional,
and material well-being (1992:142).
Whatever efforts are put forth, and however ambitious the goals, an intervention
program with this population must above all be realistic. The problems faced by TTSWs
are multifactorial, as will be the methods used to address them. No single intervention can
address all the causal factors. The most effective intervention may not be enough, and the
structural impediments will be slow to change. Between these impediments and the
objects of their actions, however, there is room for action and empowerment. Continuing
to do nothing can no longer be an option.
Before discussing what can be done, I will first discuss what should not be done. We
must first rule out victim-blaming and simplistic solutions (i.e., “they get HIV-infected
because they have sex without condoms, so give them condoms”). Thinking that people
need merely avoid certain behaviors to avoid HIV infection, however logical this
reduction, fails to take into account the realties that continue to drive this epidemic. Other
short-sighted solutions might include “just getting them off the streets,” or the grandfather
of failed HIV interventions, “educating them.” TTSWs engage in multiple risk behaviors

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that are not equally responsive to intervention, and those changes that can be made are
likely to occur sequentially over time (Prochaska et al. 1992).
Removing them from the streets, such as with increased police enforcement of
prostitution laws, hardly seems viable: it has never been successful. These people need
money to survive, and this is what they do to get it. Police “heat,” as described herein,
merely serves to shift them around. Without well-paying jobs or other financial support,
to which there are innumerable obstacles, there seems to be little possibility of “just
getting off the streets.” What has been successful, possibly more than any other factor,
has been HIV: dead TTSWs cannot work the streets. But as an approach, however, this
one has its limits: history shows that new generations of sex workers will find themselves
in the same circumstances.
A lack of available condoms or AIDS information are not significant factors. TTSWs
do occasionally run out of condoms, and they borrow from friends. They are available,
free and in adequate quantities, with little effort. These individuals are well aware of HIV
transmission routes. With clients, they wish to use condoms: the clients are the problem.
A mobile “health wagon” approach, however well-intentioned, that merely dropped off
condoms and brochures without other related programming would be of little value: they
already have condoms and brochures. Further, a project too closely associated with HIV
will fail: people “don’t want to hear it,” and would be unlikely to risk the potential stigma
of being involved with such an effort.
I recommend an approach that holistically addresses TTSWs’ individual needs through
group interaction: a peer-driven, empowerment-based, community building program that

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emphasizes social interaction and social prevention. Following Zimmerman et al., it
should above all “create a context for people to work together to solve problems and
make decisions about issues of concern to them” (1997:178), thereby encouraging social
support and a sense of community. The program uses the interactive group approach to
empowerment and self-esteem building described by Singer and Marxuach-Rodriguez
(1996), which strengthens social support, as recommended by St. Lawrence et al. (1997).
Within this more comprehensive structure, a public health model may be useful to
structure specific information and skills development where appropriate. This may be
guided by the four factors derived from the Health Belief Model, Social Cognitive models
and the Theory of Reasoned Action, as described by Fishbein and Guinan:
1. The person’s perception that he or she is personally susceptible to acquiring a
given disease or illness.
2. The person’s attitude toward performing the behaviors, which is based on his or
her beliefs about the positive and negative consequences of performing that
behavior.
3. Perceived norms, which include the perception that others in the community are
also changing, and that those with whom the person interacts most closely
support the person’s attempt to change.
4. Self-efficacy, which involves the person’s perception that he or she can perform
the behavior under a variety of circumstances (1996:7).
Though they have many factors in common, TTSWs are heterogeneous in identity,
orientation, perceptions and behaviors. No single programmatic direction can address all
needs, particularly one generated from outside their realities. In recognition of this, the
program must involve its target population in all phases of planning, implementation, and
evaluation, and should encourage its participants to build and determine the program’s

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direction in a dynamic process. Due to local language differences two separate groups
should initially be seeded, though interaction between the groups is desirable and should
be encouraged.
The program begins by identifying and developing appropriate leaders from the
community, then accessing participants through their own social networks and word-of-
mouth recruitment. To overcome barriers to enrollment and participation, the program
must offer clear benefits: this involves assisting TTSWs with the achievement of their own
goals, using existing motivators. The idea is not to bait them into the room with the
promise of something interesting, then switch them to a lecture about HIV. This is not
about trying to “sneak” intervention into their lives; they’re not fools. They realize they
have needs (and several mentioned that helping their own community was a positive ideal);
this is an attempt to meet some of these needs. It is a sincere attempt to build community,
with social support, information flow and solidarity as its goals: it is about breaking the
silence, about giving space to create dialogue, and about encouraging positive changes in
their lives.
For example, successful program items might include gender-transforming
“sequencing” hints (i.e., how to legally change one’s name), “how and why to get
hormones from a doctor” (then further link with counseling and medical care), “kicking
ass for the girls” (self-defense training leading to increased confidence and safety), or
“how and why I got off the streets” (from TTSWs who have left sex work). Self-esteem,
social isolation, self-efficacy, and perceptions of community homophobia and oppression

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all shape these individuals and their behaviors, and can be addressed through appropriate
programming.
Through group interaction, less-competent TTSWs will be able to interact with their
more savvy peers. This interaction should be constructed in a mother/daughter scenario
(much as they already use drag mother/daughter) for mutual or one-way support. Gaps
that can be addressed include assertiveness and negotiation skills (some TTSWs are very
good at enforcing their wishes) or safer sex self-efficacy through daily contact and support
(reviewing what happened in a “slip-up” last night and how that might be avoided).
“Training” could occur through a number of interactive techniques, such as “performance”
role playing, and must foster group solidarity that (1) discourages anal sex with clients and
(2) encourages an “always-every time” condom use policy (“No Condom, No Date”). A
number of other issues should be targeted, including substance abuse harm reduction
(monodrug use, differential risk, separation of drug use from sex), clarification of HIV
issues (testing, treatment, and basic information—there are misconceptions), STDs,
relationship skills and related HIV factors, and correct and eroticized condom use
techniques.
Addressing internal needs is the main emphasis of the program. An effective means to
this end, and one that benefits both participants and the larger community, is externally
orienting some of its activities. TTSWs view themselves as “stars,” as entertainers. This
should be encouraged, through performance opportunities both inside the group setting
(“tonight’s experts on how to control a 200-pound porgo: Maria and Julia!”) and outside.
The program can take advantage of their exotic self-perceptions, generally gregarious

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natures, and desire to entertain, and train them as outreach educators. Appropriate
outreach to the public could be combined with “performance” opportunities at a number
of venues, from nightclubs to laundromats. Further, the program may provide structure
for influencing TTSWs’ clients. As this study suggests, clients are also a diverse group:
they come to TTSWs for a number of different reasons and from diverse circumstances.
We know little about these clients, other than the urgent need to address the high levels of
HIV risk behaviors in this difficult-to-reach population. The only common denominator
may be that they have contact with TTSWs. Outreach-trained TTSWs could not only use
the training techniques in safer-sex negotiation with them, but might be able to provide
some education to them as well.
While the program should continually seek to develop participants’ skills to reduce
dependence on “professionals,” outside cooperation is both necessary and desirable. For
example, links with social services (social workers might facilitate service availability and
access) and political groups (a transgender group representative could address identity and
community issues) could provide valuable information and contact with the larger
community. This could initially be facilitated by an advocate for the group. Similarly,
employment issues could be addressed; a concerned advocate might be able to uncover at
least some opportunities for those who wanted to try conventional employment. At the
same time, and combined with individual/group activities, the program’s advocate should
broker the community’s needs with the larger community.
Realistically, public health and social welfare authorities may not be remotely
interested in participating or supporting these efforts (ironically, members of many high-

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risk populations remain excluded from the “system, ” that is, until they become sick with
AIDS). Private AIDS Service Organizations (ASOs), however, are more likely to have
the will to participate and the discretionary resources to commit. The program might be
best “sold” in combination with a program to access all sex workers, with separate
elements for female and non-transgendered males as well. ASO involvement could then
facilitate the delivery of HIV-related services, including primary and secondary prevention,
as appropriate. Further, ASOs can use their resources to further public understanding of
the structural realities that contribute to the conditions faced by sex workers as well as
other marginalized people. These include resource injustice, drug-related issues (access to
addiction treatment, needle exchange, and legal reform) and the rights of ethnic and sexual
minorities.2j
Social implications
Recently, transgendered individuals and gender-variant behaviors seem to be receiving
more popular attention, perhaps indicating a social reexamination. In popular culture, for
example, movies such as “The Crying Game” and “The Birdcage” have enjoyed
mainstream success. “Macho” icon Clint Eastwood, now directing “Midnight in the
Garden of Good and Evil,” was quoted in Daily Variety: “ten years ago, I would have not
thought I would be directing a movie about a cross-dresser” (Anonymous 1997a: 10).
Gender-bending personalities RuPaul and sports figure Dennis Rodman are regularly seen,
though not without a certain amount of controversy.
23 The effects of social homophobia are devastating, even in terms of HIV alone. As a single
example, the lack of support structures for same-sex couples has discouraged monogamy and pair¬
bonding, leading to norms that foster multipartner sexual contact; the resulting impact on the HIV
epidemic is tragically obvious (Sullivan 1996).

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Receiving somewhat less media attention is a transsexual state employee in Ocala,
Sabrina Marie Theodora Robb, who has drawn the ire of U.S. Rep. Cliff Sterns. Robb is a
“biological male” who began wearing dresses to work.24 In July, 1997, Sterns formally
complained to Gov. Lawton Chiles.25 The Miami Herald quoted Sterns: “It’s antithetical
to our morals in Ocala to have a man reporting for work in artificial breasts and makeup.
It sends the wrong signals to our children and people in this county if we tolerate these
cultural values”(Anonymous 1997b:5B). State Rep. George Albright requested a meeting
with Robb, to “get to know Sabrina in person.” After conversing for over two hours,26
Sabrina reported, Albright was able to see that she was not what the Ocala Star-Banner
called “someone cross-dressing at work for sexual gratification... making a laughingstock
out of the government workplace” (Robb 1997). As a transsexual under the care of a
physician, and in a program leading to sexual reassignment surgery, Sabrina would be
permitted to come to work dressed as a female.27
This instance illustrates a number of social and legal questions (Green 1994) that we
will face as this reexamination continues. For example, who should be legally male, and
who female? What criteria should determine sex? What standards determine which
24 Robb requested and received advance written permission to dress as any woman in the office
(Robb 1997).
25 The Governor was reluctant to intervene: “We have a few women (in the governor’s office) who
wear pants once in a while, but I have not seen an attempt to crack down (Anonymous
1997b:5B).”
26 Rep. Albright’s first question was “Are you a homosexual?” Sabrina answered all of his
questions except one: “What did you wear when having sexual relations with your wife?” (Robb
1997).
27 Thus this gender crisis was resolved through biomedical legitimization. One would have to
speculate how the