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Book Reviews: Providing HIV and Substance Abuse Care to Transgender People

Bockting, Walter, and Sheila Kirk, eds. Transgender and HIV: Risks, Prevention, and Care. New York: Haworth Press, 2001.

Finnegan, Dana G. and Emily B. McNally. Counseling Lesbian, Gay, Bisexual, and Transgender Substance Abusers. New York: Haworth Press, 2002.

Emerging scholarship in health and social service provision suggests that trans people are a distinct group with particular, if diverse, needs and concerns. While there are issues which affect all trans people, such as access to trans-sensitive services and providers, it is essential to note that health care requirements will vary depending on context and individual attributes of service users. Bockting and Kirk’s anthology addresses this diversity in part by including articles which situate the concerns of the communities they serve in their geographical and social location: Brazil, New York City, San Francisco, Quebec. While the book remains fairly North-American-centric, it is clear that most of the contributors support a community-based model of treatment and care which necessitates an approach that is sensitive to the needs of the people served. This avoids the error of “one size fits all” HIV care and education, and of trying to stuff trans people into a mold that doesn’t fit them. Yes, there are some common themes in HIV prevention, such as safer sex and needle use education, but this anthology eloquently addresses the role of trans- and context-specific experiences.

For example, the chapter on the travesti of Brazil combines an intriguing discussion of the gender identities of this community, along with their work in the sex trade, and their position in the social hierarchy, to show how education about HIV prevention must intervene at various levels. As a means of inexpensive body modification, the women self-inject with silicone, and share needles among one another. In addition, the social stigma against condom use in Brazil, and the difficulty of negotiating its use by clients, is significant.

Safer sex as a difficult negotiation for many trans people is a recurrent theme. Difficulties may emerge because the trans person is a sex worker for whom a deal may be financially essential, or because trans people may feel so negatively about themselves that they are willing to take the risk in order to have a sexual partner. This hesitancy, in turn, may be exploited by the partners who take advantage of economic and emotional vulnerability to have sex without a condom. As Kammerer et al note in the chapter, “Transgender, HIV/AIDS, and Substance Abuse,” “Safer-sex negotiations are complicated, whether inside or outside a commercial context, because the time that might be devoted to these negotiations is simply taken up by other issues, whether spoken or unspoken.” Since sex work is a common source of money for low-income trans women, and since many studies have indicated a high rate of HIV infection, it is crucial that service providers address the needs of this group. However, it is also important not to exclude non-sex-workers in HIV outreach for safer sex and safe injection.

At the moment, trans concerns are sometimes only a “T” tacked on to the familiar “LGB” acronym. It is incorrectly assumed that queer services will happily serve trans folks and be aware of their specific needs. Street-based trans sex workers may be geographically separated from queer and straight sex workers. Their issues around gender may take primacy over other health-related concerns. Most importantly, plenty of trans people do not identify as gay or lesbian, and so do not feel at home in many of the queer service environments. It was with this perspective in mind that I turned to Counseling Lesbian, Gay, Bisexual, and Transgender Substance Abusers. I was gratified to find at least one chapter devoted specifically to trans issues. This chapter highlighted issues of diversity, transphobia, sexual orientation, self-affirmation of identity as key for therapists dealing with substance abuse in a trans population.

The chapter also suggests a four-stage model for progressing towards a positive trans identity which, it is felt, is essential for successful substance abuse treatment (though the authors also note that it is also difficult to move through these stages when in the throes of substance abuse. This presents somewhat of a catch-22 for the therapist as well as the patient). First, self-recognition of oneself as trans, second, self-acceptance, self-integration, and finally self-transcendence. Each of these stages requires looking within the self, making connections with others, and finally finding a larger purpose or meaning for one’s existence. This is a simple but practically challenging method of working through the diverse concerns that trans clients might present with.

The rest of the book is dedicated to information for service providers on such topics as definitions and terminology, institutionalized social oppression (a critical subject for clinicians who have often been trained to view clients as individuals in isolation from their larger context), and various practical treatment issues such as where to house clients in a live-in facility. Substance abuse, the book notes, is a serious problem for trans people; indeed, “Substance abuse problems are rampant in the transgender population.” However, rather than also identifying trans people as inherently pathological, the authors go on to note that it is the loss of social coherence, sometimes part of experiences of being trans, which usually undergirds substance abuse. Drugs and alcohol represent a coping mechanism by trans people.

This work is particularly refreshing in that it addresses the role of the therapist in not replicating relations of prejudice and oppression. It indicates the responsibility of the therapist to provide a safe, respectful environment for trans clients. Too often, service providers simply reproduce and promote the same oppressive conditions which led trans people to them in the first place.

The themes to be derived from these two works include the importance of treating each trans person as both an individual, and as someone located in a social context where transphobia is significant and trans identities are not allowed full expression. Additionally, both highlight the importance of a multifaceted strategy which is realistic, situated in the concerns of daily life, and oriented primarily towards a community outreach-public health model.

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