Often, when online communities of trans people discuss “access to health care,” we lazily slip into single-track thinking about our access to hormones and surgeries. We’re thinking about the “technical” parts of our lives as transitioning transsexuals. But there are a host of issues that are relevant to our health beyond “transition.” Some of us are fearful about outing ourselves to our family physicians, so we never go in for that prostate exam or pap smear we really ought to have. There are doctors who won’t give us the full physicals we ask for because they’re too disgusted to touch us. There are also the M.D.s who just won’t take us on as clients at all if they know of our transsexual histories. Our health may be jeopardized on a regular basis because of the transphobia that permeates the medical model of health care across the (North American) continent.

Lower Income Trans Health ConcernsBut there’s more than just transphobia lurking around every corner. There are also the social determinants of health to consider. When we think of health, we usually think of just the “physical” factors that impact an individual in a personal way. (Does he smoke? Does she do drugs? Has she had her flu shot?) But more and more studies are pointing to the fact that there are larger “social” issues that can contribute either positively or negatively to someone’s wellness and health. Some of the commonly understood factors that affect our overall health are:

  • early life conditions (did the child have lots of quality time with caregivers)
  • education (did this person have the opportunity to finish high school, or attain some kind of higher education)
  • employment working conditions (does this person work in an office with computers or outside on a construction site with live electricity)
  • food (does this person get lots of vegetables and fruit in their diet, or are they living on junk food)
  • housing (does this person have shelter that is safe, affordable, clean or is she dealing with cockroaches, and five roommates who won’t clean up after themselves)
  • income (is this person able to afford the perks that come with higher incomes, like visits to the dentist, buying sunblock, skin moisturizers, and high quality healthy meals)
  • social in/exclusion (is this person secure in a community of people with common frames of reference (like a religious community, an ethno-cultural community, or a familial community, or is this person mostly isolated from any potential peer groups)
  • social safety net (does this person live in a society where there is financial assistance, medi-care and available shelter beds should the need arise, or is this person left to their own devices when things go bad)
  • job security (does this person have the peace of mind knowing that they won’t get downsized tomorrow, or are there constantly on the edge of stress wondering where the next contract will come from)

How does all that come together to influence someone’s health?

I know one trans woman, Bernadette (not her real name) who was socially excluded in her high school because of her trans identity, so she ended up not being able to finish grade 12. From there, she had a hard time being hired for “traditional” work because of her lack of education and because she was visibly gender transgressive. She did earn money, though, through her choice to work in the sex trade where working conditions included violence from tricks, police targeting, muggings, and higher risk for sexually transmitted infections. Eventually those working conditions brought her to the choice to leave the sex trade. Because she was once again without a job, she couldn’t afford housing in Toronto where rent is sky high, yet also could not access supportive housing facilities like shelters and hostels that are often “women-only spaces.” Bernadette, in the truest sense of the words, operated without a safety net. But she also operated with a tremendous willingness to help other women like herself. Bernadette recognized that she needed to connect with some kind of community of trans people who would accept her, include her, and appreciate her. Bernadette now volunteers with our service, Trans Programming at the 519.

Here at “Trans Programming at the 519” we’ve done a lot of thinking about the social determinants of health. Trans Programming began as a simple weekly meal drop-in called Meal-Trans. Meal Trans was established about five years ago by a sex-worker rights activist and trans activist, Mirha-Soleil Ross, who was angered and frustrated by the lack of services for homeless, lower-income, street involved and sex-working trans people (predominantly trans-women and MTFs). She negotiated with the 519 Church Street Community Centre, located in the heart of Toronto’s gay village, and asked them to take a proactive stance by creating programming for this vastly under-served community. Meal Trans has been running ever since, and is now just one piece of a larger programme called Trans Programming at the 519. Our peer-run programme still focuses on the needs of lower-income, sex-working, and street-involved trans people and now includes a legal clinic, a housing clinic, and a peer support team, an outreach programme for trans women in the sex trade, the Trans_ Youth_ Toronto! drop-in for trans youth aged 26 and under, and a whole range of trainings for service and health care providers on trans issues (including policy development, youth specific workshops, and sex-worker specific workshops) as well as trainings for shelter and hostel residents.) And we spend a lot of time addressing the social determinants of health for trans identified people with particular attention to issues around housing and homelessness.

First, it needs to be said: trans men and women who are homeless, lower-income, or working in the sex trade are still facing all the same crap that every other trans person deals with on a regular basis. Doctors who aren’t informed. Stigma. Problems with ID, etc. Unmonitored use of “street” hormones. But homeless/street-involved/sex-working trans people are also facing a hell of a lot more.

A few quick facts about homelessness and health taken from the website: Delivering Health care to the Homeless:

  • The mortality rate for the homeless is 3-10 times the mortality rate seen in the general population.
  • Alcohol abuse in the homeless ranges from 3 to 9 times higher than in the general population.
  • The homeless are admitted to psychiatric hospitals 100 times more often than the general population.

Add trans-related stigma to the mix (and, oh, racism, stigma around disability, stigma around mental health issues, etc) and you’ve got a real sweet blend of toxicity that these good people have to breathe in daily.

When I met Janice (not her real name) she was in severe distress. She was a Native trans-identified youth who had hitchhiked her way to Toronto. In her city of origin, she’d been in the child welfare system, specifically in foster care. She ended up in foster care when she was in her pre-teens because of physical and sexual abuse in her family. In her first foster placement, the cycle of abuse continued. Her most recent foster placement was in a “lesbian” household. The Youth workers felt that the lesbian couple would understand Janice’s life situation and be supportive. In fact, Janice felt devalued and misunderstood. In Janice’s words, the lesbian couple believed that Janice was “a young gay man who could not deal with being gay.” For all these reasons, Janice was frustrated, isolated, and angry. At the same time, she kept hearing about the vibrant transsexual community in Toronto. She made the decision to walk away, leaving behind the bulk of her worldly possessions and bringing only a small knapsack and less than $50 dollars.

Once in Toronto, Janice stayed her first night at a youth shelter. Because of her youth, Janice usually passes as a non-trans female. Nevertheless, because of her native background, some of the other young women on her floor harassed her, even telling the staff that she had slapped them. Janice felt the shelter worker automatically assumed that Janice was the aggressor (all that “male energy,” don’t you know) without taking into account the racism of the other young women on the floor. Janice left and took to the streets.

Out on the streets, Janice connected with some goth and punk kids and negotiated to stay with them for a few nights. They didn’t know she was transsexual and accepted her completely as a woman. Her safety was jeopardized, though, after the police— in an example of targeted policing— approached the group of loitering youths. The police asked for her name. She told them her legal female name. Upon checking her out on their computer, they found her old name listed. They loudly announced her old name and her old identity, and in so doing jeopardized her physical safety with these youth (not to mention ruining her chances to get housing for a few nights.) The kids called her a freak and took off, leaving her stranded. In tears she made her way to the Meal Trans program. Thank goodness it was a Monday night or else I have no idea where she would have gone or what might have happened to her. (note the positive effect of the factor of “community” as a social determinant of health!)

As Programme Coordinator, I contacted many agencies. One agency said that there was only one room in its facility with a separate bathroom, and that room was occupied. I asked about other rooms and was told that unless my client had genital surgery, she wouldn’t be allowed in the women’s spaces. I did suggest that if my client had money for genital surgery, I doubt she’d NEED a shelter. The shelter worker didn’t budge. Another facility refused her saying they knew there was still space available at a men’s shelter and that she could “dress as a boy for one night to access one of those beds.” Janice feared for her safety in any men’s facility and knew she’d be at increased risk for sexual, verbal and physical harassment so she decided against those options. A third shelter worker I spoke with made an off-hand comment about trans-women’s “male privilege.” I tell ya… when a person has to beg to get a flea-infested mattress in an over-crowded shelter, “privilege” is not a word which comes to mind.

That night— as a short term measure— we ended up getting her a place on someone’s couch. And long-term? We’re still working on that. Janice has showed amazing resiliency and courage throughout this ordeal. Like many trans people in her position, Janice survives because of her strength of will and because— in her words— she’s “too sexy not to.” Gotta love her.

Shelters and Hostels

We’ve already talked about shelter and hostel issues in Janice’s story. There are also a number of health issues directly related to the hostel and shelter system. Shelters are often overcrowded, which leads to the potential spread of communicable diseases, scabies, and lice. Lice is particularly common since few homeless people have access to laundry facilities on a regular basis. Taking ANY medications will be challenging for many homeless trans people who are involved in the shelter and hostel system because of the lack of storage areas, the fact that their medications are often stolen or lost, that they have difficulty getting medications in the first place, and that they sometimes forget to take medications because they don’t have a standard routine.

Out on the Street

Many homeless trans people don’t end up being able to access the shelter and hostel system at all. Often it’s because they’re refused access to those heavily gendered facilities. Think about it. Shelters and hostels are normally divided up into women’s floors, men’s rooms, women’s hours, etc. And trans people who are on the streets haven’t generally had the cash to get the surgical procedures which will allow them to change their legal ID. This can leave many trans people with no other options but to stay on the streets, leaving them at risk for a whole laundry list of diseases. Skin disorders are exceptionally common in the homeless. Foot problems, ringworm, nail infections, frostbite, and leg ulcers are frequent problems since homeless and street-involved people tend to walk everywhere, having no money for transportation costs. The homeless are at increased risk of developing lower-leg vein problems partly because they are frequently unable to lie flat on their back at night. The homeless who sleep on park benches are particularly vulnerable.

Mental Health

Like many other trans people, lower-income, sex-working, and street-involved trans men and women are often facing multiple personal battles including depression, anxiety, suicidal thoughts/behaviours, self-harm, drug and alcohol use, and eating disorders. For many homeless and lower-income trans people, these problems are made worse by the constant anxiety about some of the most fundamental needs in life, like food and shelter.

There’s a young trans man I know who I’ll call Bill. (and no, I’m still not using real names here— you people catch on quick!) Bill had been facing depression for most of his adult life. It isn’t “because” he’s trans, though any time he’s admitted his depression to the doctors he encountered in the shelter system, they began to question the legitimacy of his transition. Bill thinks it’s ironic. He once commented “I’d like to see that shrink get fired from his job, stay in this crowded shelter for a week, not have money to take public transit, have to walk in the snow in shoes with the heel falling off, and then deal with some asshole psychiatrist who wants to talk about fucking gender identity being the cause of his bad mood.” Bill is one smart guy, and his smarts ended up getting him a job working at an organization doing outreach to street involved people. He hands out hot meals, blankets and information about community health clinics and shelters. Bill has begun to realize he’s got a great deal of empathy, and some genuine nurturing qualities that he never had the chance to explore before. Bill is starting to consider a career in social work.

Alcohol and Drug Use

Most of us have used alcohol or drugs as a coping mechanism at one point or another. Sometimes life is painful, and a good stiff drink or a toke of a joint provides a short-term solution. But there can be a long-term cost. Alcoholism and long-term drinking increase risks for pancreatitis, hepatitis and fibrosis. And since most shelters do not allow alcohol inside, clients who need shelter often quickly ingest any alcohol they possess to avoid having it confiscated, which only furthers the damage to the internal organs. Drug use— especially needle-sharing— is a problem in the trans homeless and street-involved community. Medical risks associated with shared needles and intravenous drug use are also a concern for homeless, street-involved, sex-working trans people. These risks include Hepatitis C (HCV) and HIV from needle sharing, spreading skin infections at the injection site, opportunistic infections, and overdose causing extremely low blood pressure and death. And let’s not forget— for homeless trans people, those aren’t just “illicit” drugs they’re sharing needles to inject. It’s also hormones. Homeless trans people don’t usually have the cash to buy the hormones, nor the needles, nor the place to properly store them. That leads to needle-sharing.

Sex Work

Some of our clients are sex-workers. I’m going to be frank. Sex work is upgrading, not degrading, for some of these women. In North American culture, trans people often internalize the messages that they’re untouchable, unlovable, and incapable of having healthy sexual relationships. How amazing it is to suddenly realize that not only are there people who are attracted to trans-women and men for their “gender-enhanced” selves, but actually want to PAY for it! And a paycheck can be hard to come by as a visible trans person in this culture. But sex work does come with some potential health risks. Violence on the job is common. Many trans women are assaulted physically, sexually and verbally by their tricks. Some are robbed. Lots of trans women in the sex trade use drugs and alcohol as coping mechanisms to get them through the long cold winter nights.

And speaking of winter, clients aren’t as likely to choose a girl who is all bundled up in mitts, long-johns, and a parka. The tricks want to see a little flesh. So, the trans women I know tend to wear revealing clothing even on the coldest winter nights, thus potentially compromising their immune systems. To address this issue, Trans Programming at the 519 teamed up with PETA (People for the Ethical Treatment of Animals) to provide our trans sex-workers with the “cast-off” fur coats of guilt-ridden rich white women. Not only are these fur coats warm, but they have sex appeal enough to make our clients want to wear them on even the mildest of days. This way, none of the animals who gave their lives for those coats died in vain. Toronto, I’m proud to say, now has the best-dressed (and warmest!) hookers in all of Canada!

HIV

And then there’s a little thing like increased risk for HIV. Sex-working trans women are out there trying to survive and if a trick says he’s willing to pay substantially more for sex without a condom, many street-involved trans women will agree. If it means the difference between having food, or starving to death, their choice makes sense.

Another issue which arises for trans sex-workers is that sometimes these women want to show their boyfriends that even if they’re having TONS of sex outside of their primary relationship, they still save a little something-special for him. That often means that these women have sex without condoms with their boyfriends. And in small communities, it’s often the case that the boyfriends have been passed back and forth from girl to girl to girl. And with him, any sexually transmitted infection that one of the women carries gets passed around too. The lack of applicable sexual health information can lead to higher risk behaviours. Let’s face it, safer sex materials rarely target trans sex workers. (For The 519 CSCC’s safer sex pamphlet geared specifically towards trans sex workers, the Happy Transsexual Hooker, please check out our website.)

But HIV issues aren’t just about risk for contracting HIV. There are ongoing issues for those who do become HIV positive. Very few doctors in North America have experience treating trans clients at all, never mind trans clients who are HIV+. They might not be certain about how anti-retroviral meds will interact in conjunction with a trans-women’s anti-androgens and estrogen pills, or how that large cocktail combination will impact on her liver when she already has Hepatitis A. Not to mention the fact that a lot of sex-working trans women who are HIV+ aren’t receiving regular health care at all because they’re tired of dealing with the prejudice of judgmental doctors. And for those trans people who are homeless and HIV, there are a number of factors that make adhering to their HIV medications difficult, including the cost (the drugs cost between $8,000-$15,000 Canadian per year), the fact that no immediate benefit from the drug is felt so they stop taking them, the side effects, which are not anticipated by the patient, and often some confounding drug addictions and mental illness.

Conclusion

It’s a nightmare to be facing multiple oppressions in society. When looking at the social determinants of health for trans people, it’s easy to see how the journey for lower-income, sex-working, street-involved trans people is by far one of the more challenging ones. Physical transition is the least of their concerns. Higher priority needs include basic needs (food, shelter), accessible care (hostels and shelters that don’t use legal identity as a factor in determining who can access which beds) and fair medical treatment (doctors that are knowledgeable about HIV as it relates to homelessness or transition medications). But don’t for one moment think you should feel pity for any of these members of our community. These are trans people who are strong, resilient, courageous and determined. They’re survivors in the truest sense who demand respect, and have earned it. To help grant these folks the respect they deserve, here are a few things you can do to prove you value them as part of the community!

  • Push your local trans support groups to get behind supporting lower-income, sex-working, and homeless trans people.
  • Give of yourself! Volunteer your time with shelters and hostels.
  • Write letters to shelters and hostels and let them know you urge them to re-write their policies to be inclusive of trans people!
  • Offer your professional skills to agencies that work to assist and support sex workers.
  • Donate clothing, household goods, and other items to shelters, and to agencies that work with lower-income, street-involved, homeless and sex-working trans people.
  • Host an event to raise funds for a lower-income person’s hormones and surgeries.
  • Send letters to your government representatives to let them know you are in favour of decriminalizing sex work.
  • Send letters to your government representatives to let them know you want your tax dollars used to help build more affordable housing, provide more programmes for lower-income, street-involved and homeless people.
  • Support anti-hate-crime legislation which includes gender identity as a protected category.
  • Convince your local community health clinics to set up needle exchanges.
  • Write local shelters and hostels and ask them about their harm reduction policies. Make certain services are offered judgement free when it comes to alcohol, drugs, and sex work.
  • Don’t just work towards making the world safe for trans people, but also for people of colour, people in the sex trade, queer people, straight people, people with different ability levels, and people of different classes!