How Can Harm Reduction Do Better for Transgender People?

July 10, 2019

In 2015 Tori Cooper decided to leave a successful nonprofit career to blaze a trail advocating for the rights of the transgender community. Despite the fact that an estimated 1 million adults in the United States identify as transgender, services and advocacy programs that address the unique needs of this population can be hard to find. Cooper founded Advocates for Better Care Atlanta, an organization that focuses on economic and health equity for trans people.

“I just decided it was time to move things forward,” says Cooper, an African American trans woman from Georgia. “I realized that I might be the person and the agency that would be able to do the things that folks really need and want most.”

Cooper has her work cut out for her. According to a report released by the National Center for Transgender Equality (NCTE) in 2015, the unemployment rate for trans people was 15 percent, triple the national rate, while the unemployment rate for trans people of color was 20 percent. Twenty-nine percent of trans respondents reported living in poverty, with 12 percent reporting an annual household income under $10,000.

Such economic and social stresses contribute to high rates of drug use among transgender people. According to the report, 29 percent of trans survey participants reported illicit drug use or prescription misuse in the past month, a rate nearly triple that of the US population (10 percent). This indicates a need for services, but unfortunately, few harm reduction programs are designed with trans folks in mind.

Robyn Learned, a white trans woman who works with the Gender Health Center in Sacramento, California, says that the Center started distributing syringes to trans folks in 2016 after realizing that many trans or gender non-conforming people did not feel welcome at traditional harm reduction programs.

A trans person of color who uses drugs is targeted by the acute stigmatization of multiple identities, often generating layer upon layer of trauma.

As Learned explains, harm reduction programs are designed to address the needs of people who use drugs, a heavily stigmatized population. Yet drug use is only ever one layer of a person’s identity, and many bear additional burdens of stigma and oppression. People of color who use drugs are further marginalized by racism. A woman of color who uses drugs will additionally experience misogyny. And a trans person of color who uses drugs is targeted by the acute stigmatization of multiple identities, often generating layer upon layer of trauma.

Statistics on HIV and poverty rates illustrate this concept. A 2019 review of transgender women, for example, reported that an estimated 14 percent have HIV. But while white trans women report a 7 percent HIV rate, the rate leaps to 26 percent for Latina trans women and 44 percent for Black trans women.

And while trans people are overall more than twice as likely to be living in poverty as the general US population (12 percent), poverty rates for trans folks who identify as Latinx, American Indian, multiracial or Black hover around 40 percent.


Seeing the Bigger Picture

Shawn Demmons, an African American trans man and former chair of the board of directors at the Transgender Law Center, currently works for the Center of Excellence for Transgender Health in San Francisco. He specializes in training community-based organizations on how to engage people who identify as transgender in health care, with particular emphasis on the marginalizing intersections of social, economic and political factors.

Demmons says that in order for harm reduction organizations to address the needs of the trans population, “you need to think more holistically about what people’s needs are.” He explains, “You are looking at disparities in income, education, access to housing, access to safe spaces, access to health care.”

Demmons recommends that service organizations cultivate relationships with community partners who work on housing, healthcare access, employment, legal aid, political activism and other related issues. Ideally, these linkages should not be mere referrals, but strong partnerships that recognize the critical role of each component in addressing overall wellness.

“Feelings of danger are constantly surrounding people.”

In addition to social, economic and political challenges, trans people who use drugs often face severe trauma and harassment in their daily lives. For example, many trans people who enter facilities that are strictly divided by gender, such as inpatient drug treatment programs, jails and prisons, are misgendered, or placed in a facility that does not correspond to their gender identity. In particular, for trans women placed in a cisgender male facilities, violence, harassment and even rape are common.

“[For] folks of trans experience there can be relentless trauma and microaggressions,” says Tori Cooper. “Feelings of danger [are] constantly surrounding people.”

In fact, 39 percent of NCTE survey respondents reported experiencing serious psychological distress in the past month, compared to 5 percent among the general population. Additionally, 40 percent of trans respondents had attempted suicide—nearly nine times the rate of the general population.

Staff at harm reduction and health-focused organizations should “have some knowledge of trauma-informed care,” says Demmons. For example, if staff is working with a trans woman of color, “you can almost guarantee that she has experienced racism, transphobia [and] violence.” It’s important to ensure that staff “are able to assess for those things and that they are not providing care in a way that could create more harm for that person.”


Barriers and False Assumptions

The trauma resulting from the harassment and violence that many trans women, especially women of color, often experience in their daily lives creates barriers to accessing care. There is an all-too-justified fear of facing discrimination and stigmatization from healthcare providers.

Trans men, though many also face daily harassment and discrimination, often have trouble accessing healthcare or harm reduction services for different reasons. Shawn Demmons explains that while trans women often suffer because they are seen and harassed for their appearance, trans men often suffer because they are not seen at all.

It is common for providers to make presumptions about trans mensuch as assuming that their sexual preference is for heterosexual women.

Trans men “are invisible,” says Demmons. He offers examples of men who are afraid to talk to medical providers about gynecological issues because they don’t want to expose the fact that they are transgender. They therefore lose important opportunities for preventative care.

Demmons also says it is common for providers to make presumptions about trans mensuch as assuming that their sexual preference is for heterosexual women. A study published in AIDS Patient Care and STDs confirms this tendency among providers.

In general, ignorance of the complexity and variety of sexual experience among trans people can lead to inaccurate risk assessment and lack of access to appropriate preventative services. For example, studies on clinical health and sexual orientation of trans men undergoing masculinizing hormone therapy have indicated that testosterone can play a significant role in shifting trans men’s sexual partners from women to men who have sex with men, with important implications for preventative sexual health. (The studies acknowledge that it is unclear whether testosterone facilitates this shift, or if trans men become more willing to explore existing sexual preferences as a result of increased comfort with their bodies and identities as they transition.)

Demmons emphasizes that harm reduction and other health providers should always ask, rather than assume, a person’s sexual behaviorand continue to ask throughout the person’s engagement in the program.


Stimulants and Safe Sex

“There is the potential for an emerging epidemic of HIV if you are having sexual partners in a population we know has high prevalence of HIV,” Demmons says. Risks associated with sexual behaviors around drug use, especially stimulants, should be factored in with increased libido reported by trans men on hormone therapy and with new sexual behaviors experienced by trans people in transition.

From a harm reduction perspective, says Tori Cooper, if a person is taking one or more substances that increase sexual arousal or behaviors, “that will put them at increased risk for HIV and STDs.”

 Data from the 2015 National Survey on Drug User Health indicates higher use of stimulants among sexual minority and transgender adults. That year cocaine use was 183 percent higher among sexual minority adults than among their sexual majority counterparts, while methamphetamine use was 283 percent higher. A Canadian study, which measured cocaine and amphetamine use among transgender people in Ontario, found rates of use 325 percent and 550 percent higher, respectively, than for the general population.

Another Canadian study published in 2011 demonstrated a link between methamphetamine use and unprotected sex among gay, bisexual and transgender individuals. Methamphetamine use during sex can increase the risk of HIV and other STDs by delaying orgasm and drying the mucous membranes, which can cause tearing and infection.


Trans Leadership and Good Practice

Transgender people, especially those who use drugs, face a variety of risks in all spheres of life. But by adopting a holistic and inclusive approach to wellness, harm reduction and health-focused organizations can create programs that engage and empower them.

Trans folks are the experts on their life.

The process starts by hiring trans folks in program management and organizational leadership. Trans people in leadership positions, and particularly trans people of color who use drugs, will help ensure that those who experience multiple layers of marginalized identity have opportunities to engage in harm reduction services and advocacy around issues that affect them.

Trans folks “are the experts on their life,” says Learned. “If you give them the freedom and the space and the support to be able to express that to you, they will be much more able to have agency to help themselves with any decision they need to make.”

Cooper adds, “If the folks who are most affected are not making the policies, then they are not going to create the policies that are most effective.”

Cisgender staff should be trained on how to appropriately engage with transgender individuals, which can include everything from gender affirmation and proper pronoun use to trauma-informed care and the knowledge to discuss hormone therapy with clients and make appropriate referrals.

For Tori Cooper, engagement starts the moment a person walks in the door. “Number one is affirm people’s gender or their gender presentation or their gender identity,” she says. “If someone tells you they are a woman, then you respond to them accordingly,” because that “automatically adds a layer of respect to the situation.”

Demmons recommends that staff ask all participants about gender identity and pronouns. Including all participants would help avoid situations in which only people perceived as trans are asked about their gender identity and would also facilitate a cultural shift towards recognizing the fluid nature of gender. He also adds that intake forms should include non-binary options, and that program locations should offer gender-neutral restrooms.

Other examples of trans-specific harm reduction include education and resources on silicon injections, hormone therapy and stimulant use. According to a 2015 report on amphetamine use by Harm Reduction International, recommendations include providing safe smoking materials such as pipes, lip balm and burn salve, teaching and encouraging alternative use methods such as smoking (as opposed to injection), and offering water, juice, healthy food, toothpaste and toothbrushes to protect against dehydration and poor nutrition and to promote dental hygiene.

Staff should also work with transgender clients who use stimulants and engage in sex work—work undertaken by 10.8 percent of respondents to the 2015 National Transgender Discrimination Survey, with rates twice as high among trans women than trans men, and much higher among trans people of color than white trans people—to create plans to manage use, avoid binging and promote safer sexual behavior. These discussions should include information on the use of condoms and lubrication, and how to confront real-world challenges associated with sex work, lack of housing and domestic violence.

Although there are many specific ways in which harm reduction organizations can offer help, resources and information for transgender people, simply creating spaces where trans people feel acknowledged and comfortable is a vital first step.

Effective engagement is “not necessarily [about] building anything specific for trans [people],” says Robyn Learned. “It’s more [about] building a place that is known to be inclusive and open to them and they will find you.”

Harm reduction programs are designed to reach vulnerable populations, but many do not yet sufficiently break down barriers to care for people who are marginalized not only by drug use, but by multiple identities and other factors. Robyn Learned challenges harm reduction programs to measure success particularly through their ability to engage trans women of color who are homeless or participate in sex work.

“If you can serve them well, then you can serve everyone well,” she says.

 It’s a challenge to which harm reductionists need to rise.

Photo of transmasculine person vaping by Zackary Drucker via the Gender Spectrum Collection at Broadly

Tessie Castillo

Tessie is an international journalist and author from Raleigh, North Carolina, whose writing explores criminal justice, drug policy and harm reduction. Her first book, Crimson Letters: Voices from Death Row, offers a searing portrait of men on North Carolina's Death Row and the broken systems that put them there. Sign up for her newsletter to receive her latest articles.

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