Transsexuals and transgendered people in prison, including those with HIV/AIDS, share the needs of all prisoners for HIV/AIDS care and prevention services, but also have needs that are unique to that population. In this article, Ann V Scott and Rick Lines of the Prisoners' HIV/AIDS Support Action Network (PASAN) provide an overview of the major issues and recommendations contained in HIV/AIDS in the Male-to-Female Transsexual and Transgendered Prison Population: A Comprehensive Strategy, a brief prepared by PASAN. (1) The article first describes the research undertaken to produce the brief. It then provides some background information on transsexual and transgendered people in general and transsexual and transgendered youth and sex-trade workers in particular. The article discusses the risk of HIV infection for transsexual and transgendered prisoners. Finally, it summarizes the major issues confronting male-to-female transsexual and transgendered prisoners and makes recommendations for action in the following areas: prevention of HIV transmission; injection drug use and HIV; medical and support services; human rights and confidentiality; and aftercare.
PASAN first began research into the HIV/AIDS service needs of male-to-female transsexual and transgendered prisoners in 1996. Since 1993, PASAN has been working with over 200 HIV-positive prisoners from across Canada. Approximately 10 percent of PASAN's HIV-positive clients identify as transsexual or transgendered. This number greatly overrepresents the proportion of transsexual and transgendered prisoners in any given prison population. PASAN believes that this overrepresentation of HIV infection in the male-to-female transsexual and transgendered prison population, combined with the unique needs of this population, demand attention from both the provincial and federal levels of correctional services.
PASAN's experience working with male-to-female transsexual and transgendered prisoners has led us to document many specific barriers faced by transsexual and transgendered prisoners with HIV/AIDS in trying to access proper health care and other support services. To document the issues and to identify solutions, PASAN prepared HIV/AIDS in the Male-to-Female Transsexual and Transgendered Prison Population: A Comprehensive Strategy. The document details 44 recommendations in the areas of prevention, injection drug use, medical and support services for people with HIV/AIDS, human rights, compassionate release, and confidentiality, testing, and aftercare.
Fifteen male-to-female transsexual and transgendered prisoners and ex-prisoners living with HIV/AIDS were interviewed and used as consultants in preparing the document. Their experiences were expressed both through anonymous written questionnaires and through personal interviews.
The recommendations are based primarily on the experiences of male-to-female transsexual and transgendered people in federal and provincial prisons and jails in Ontario. Nevertheless, we believe the recommendations are relevant for the Canadian prison system as a whole (particularly in the case of federal institutions), although we are also aware that differing correctional, health-care, and human rights legislation from province to province may affect whether and how specific recommendations need to be implemented in provincial institutions.
Who are transsexual and transgendered persons?
"Transgender" is an umbrella term used to describe those who live outside of normative sex and gender relations. (2) These are people who identify with a core gender identity that society believes is not congruent with their external genitalia. Six of the groups within the transgendered community are transsexuals, transgendered people, intersexed people, cross-dressers, drag kings and queens, and transvestites.
Transsexual and transgendered youth, prostitution, and HIV/AIDS
The transsexual and transgendered street youth community is a closely knit circle, where young prostitutes are often supported in the sex trade by older, more experienced prostitutes, who refer to the youth as their "daughters." These older sex-trade workers not only provide support and protection to these youth, but also help them learn their way around an often dangerous profession. Many of the transsexual and transgendered youth working on the streets are youth of colour who have faced further disenfranchisement and societal barriers resulting from institutionalized racism. (3)
The youth working the streets are often at great risk of violence, and they often live in a street subculture marked by drug use (both injection and non-injection) and unsafe sex. This living environment often places the youth at increased risk of HIV infection. Sex-trade workers have revealed that unsafe sex practices occur frequently, particularly among individuals working the streets. The use of alcohol or drugs, as well as financial incentives (more money for unsafe sex), leads to a high risk of HIV/AIDS infection in the transsexual and transgendered sex-trade community. (4)
Of 43 transsexual and transgendered youth surveyed by the Toronto-based Street Outreach Services, 35 were living with HIV/AIDS. Of these, 19 believed they were infected by a husband (a consistent partner in their life, and their protector) or boyfriend. (5) While this rate of seroprevalence should in no way be extrapolated to apply to transsexual and transgendered sex-trade workers as a whole, it is nevertheless indicative of the conditions of vulnerability in which many transsexual and transgendered prostitutes live and work.
The discrimination and violence experienced by transsexual and transgendered sex-trade workers are related to the denigration of prostitutes in Canadian society. Because of criminal prohibitions against soliciting, many sex-trade workers (male, female, and transsexual and transgendered) are forced to take their business practices underground. They work in dark parking lots, stairwells, and other remote areas where they can stay away from the eyes of police. Unfortunately, these types of work environments also make prostitutes physically vulnerable, placing them at increased risk of violence and death. Discriminatory attitudes and legislation against sex-trade work are at the root of this problem; they contribute not only to producing unsafe working conditions for transsexual and transgendered prostitutes, but also to creating social conditions where the risks of HIV infection are increased.
Because both drug use and communicating for the purposes of prostitution are penalized under the Criminal Code, many of the transsexual and transgendered youth will come into conflict with the law and may end up spending time in prison. Inequitable treatment of transsexual and transgendered sex-trade workers before the courts may come into play, thereby increasing their likelihood of incarceration. Anecdotal testimony received in preparation of the brief - from both transsexual and transgendered sex-trade workers and agencies serving the transsexual and transgendered community - suggests a pattern of differential, more punitive, responses to transsexual and transgendered individuals at trial. A 1998 study in Québec revealed that 50 percent of the transsexual and transgendered sex-trade workers interviewed had done time in jail. (6)
Risk for HIV/AIDS among transsexual and transgendered prisoners
The discrimination, inequality, health and safety issues faced by transsexual and transgendered prisoners are proportionate to the issues faced by transsexual and transgendered people in the community. Canadian prisons incarcerate both gay men and men who identify as "straight" but who engage in same-sex activities while inside. Male-to-female transsexual and transgendered prisoners who have not undergone sex-reassignment surgery and had their gender change legally registered are housed in male prisons, and are among the most marginalized and disadvantaged in the prison community. They are often used as sex objects and are therefore at increased risk of violence within the institution. Many transsexual and transgendered prisoners find it necessary to trade sex for protection. Their very survival, therefore, hinges on their willingness to provide sex for their partners, who are often very abusive to them.
Issues and Recommendations
Prevention of HIV transmission
HIV is transmitted in prisons through unsafe needle use (sharing needles for injection drug use, tattooing, or body piecing) and unsafe sex. Male-to-female transsexual and transgendered prisoners are engaging in these activities and putting themselves at risk for HIV infection because they do not know that these activities are unsafe, do not know how to engage in them safely, or are denied access to the materials necessary to prevent HIV transmission.
Comprehensive education and responsive, gender-positive programs are the first steps in preventing HIV infection in the male-to-female transsexual and transgendered prison population. Comprehensive educational sessions for medical staff should be implemented that address the unique medical issues of male-to-female transsexual and transgendered prisoners. They should address issues such as hormones and their effect on overall health; the regular monitoring of hormones; and drug interactions between hormones, street drugs, and HIV/AIDS medications.
Educational services must also be provided to prison social workers and case management officers to assist them in developing skills to serve the unique needs of male-to-female transsexual and transgendered prisoners while incarcerated, for example, helping to ensure that all requirements and documentation necessary for sex-reassignment surgery are being met in the prison system.
To address these issues, we recommend:
1. External, community-based AIDS and health organizations should lead educational sessions. Peer education should also be promoted. Federal and provincial correctional services should recognize and utilize the expertise of community-based gender-positive agencies when planning any male-to-female transsexual and transgendered HIV/AIDS programs
2. Condoms, dental dams, latex gloves, appropriate lubricants, and other safer-sex materials must be made available to male-to-female transsexual and transgendered prisoners in a discreet, non-identifying manner. Condoms prevent the sexual transmission of HIV/AIDS. Lubrication is essential for male-to-female transsexual and transgendered prisoners due to their risk of tissue damage during intercourse, which may cause bleeding and place male-to-female transsexual and transgendered individuals at increased risk for HIV/AIDS transmission. Condoms and other safer-sex materials must be distributed in such a way as not to stigmatize those individuals seeking access to them.
3. Known sexual offenders and sexual predators must not be segregated in the same protective custody units where male-to-female transsexual and transgendered prisoners are housed. Male-to-female transsexual and transgendered prisoners are vulnerable to sexual assault. Sexual predators should be identified and segregated from the general population, but not placed in the same protective custody units where male-to-female transsexual and transgendered prisoners are located.
Injection drug use and HIV
The link between drug use and transmission of HIV can be direct (through injecting with contaminated needles) or indirect (when impaired judgment leads to unplanned or unprotected sexual intercourse). PASAN has therefore advocated a multifaceted approach to dealing with drug use and the risk of HIV infection. This approach should include a needle exchange program, bleach-kit distribution, education on safer injection drug use and hormone injection, and drug treatment options - including methadone maintenance - for prisoners wishing to access them
Among male-to-female transsexual and transgendered prisoners, syringes are shared not only for injecting narcotics but also for injecting hormones, thus placing these individuals at additional risk of HIV infection. (7)
To address the issue, we recommend
1. A confidential needle exchange program should be implemented. Because the syringes needed for the proper injection of hormones are intramuscular, corrections services must also ensure access to intramuscular syringes
Medical and support services
While incarcerated, transsexual and transgendered prisoners have access to a health-care system that many of them described as indifferent, or sometimes even hostile, to their unique needs. To provide this population with appropriate health care, it is necessary to consider and address the specific barriers transsexual and transgendered prisoners face when trying to access optimal health care. Correctional health-care providers must be given the resources and training to enable them to support the unique medical, hormonal, and psychosocial needs of transsexual and transgendered prisoners
Universal access to health care is a fundamental right of all Canadians. Corrections services, at both federal and provincial levels, are mandated to provide a quality of care comparable to that available in the community. Given the unique medical needs of transsexual and transgendered prisoners with HIV/AIDS - whether in terms of HIV treatments or hormone therapy - it is very important that medical staff be knowledgeable in these areas
To address these issues, we recommend
1. Hormones should be given to all male-to-female transsexual and transgendered prisoners who have used them in the community, regardless of HIV status. Hormone access should not be contingent solely upon the approval of gender-identity clinics (such as the one at the Clarke Institute of Psychiatry in Ontario) or specific doctors approved by these clinics. Hormone usage should be monitored closely by health professionals who understand the effects of hormones on the endocrinological system.
2. All transsexual and transgendered prisoners with HIV/AIDS should have access to alternative therapies and non-approved treatments. Careful attention must be given to evaluating the degree to which the clinical drugs (for HIV/AIDS) and biochemical drugs (for hormone replacement therapy) interact and affect the progression of HIV/AIDS
3. Transsexual and transgendered prisoners living with HIV/AIDS must be guaranteed access to medical and dental workers of their choice. In particular, they must have access to experienced and expert HIV primary-care physicians and endocrinologists who are gender-positive and aware of the health-care needs of transsexuals and transgendered people. They should also be able to access the psychiatric or psychological services of a clinician who is an expert in dealing with the transsexual and transgendered experience
4. The services of community-based workers serving the transsexual and transgendered community or people with HIV/AIDS must be made available to all male-to-female transsexual and transgendered prisoners who desire them.
Human rights and confidentiality
Unfortunately, discrimination against people with HIV/AIDS is a fact of life in Canada. This is true in our society and it is true in the prison system. In Canadian prisons, societal AIDSphobia is often exacerbated by anti-prisoner and anti-drug user prejudices, as well as racism, sexism, transphobia, and homophobia. Transsexual or transgendered prisoners with HIV/AIDS often find themselves even further marginalized by virtue of their gender. In this atmosphere, anti-discrimination laws and human rights protections become even more crucial
Transsexual and transgendered prisoners are subjected to unwarranted isolation and segregation. The reasons given for the punishment of isolation vary, but they share a common theme: the prisoner somehow jeopardizes the "good order of the institution," either because of HIV infection or because assumptions about the transsexual and transgendered prisoner's behaviour (when coupled with the knowledge that s/he is HIV-positive) is deemed to be a threat to either staff or other prisoners
To address these issues, we recommend
1. The confidentiality of male-to-female transsexual and transgendered prisoners' HIV status must be respected. Staff members who break the confidentiality of male-to-female transsexual and transgendered prisoners should be disciplined and/or dismissed. The distribution of medications, special diets, and nutrient drinks should not require a breach of confidentiality of transsexual and transgendered prisoners with HIV/AIDS. Transsexual and transgendered prisoners who want access to supportive counseling, medical treatment, and hormones must be guaranteed that their confidentiality will be respected
2. No male staff should have the right to search female transsexual and transgendered prisoners; only female staff should be allowed to do searches.
3. Male-to-female transsexual and transgendered prisoners living with HIV/AIDS should not be involuntarily isolated or segregated. Clear policies should be implemented to eliminate unwarranted isolation or segregation of transsexual and transgendered prisoners.
Many prisoners with HIV/AIDS first seek medical and community supports for their illness during incarceration. Therefore, transsexual and transgendered prisoners with HIV/AIDS who receive health care during their incarceration should be supported in continuing to access appropriate care after their release. Correctional services, both federal and provincial, need to provide the links necessary to facilitate a continuation of care and support. These links should not be limited solely to gender identity clinics, or professionals approved by such clinics, but should also include community-based agencies that have credibility and experience working with street-involved transsexual and transgendered people, with sex-trade workers, and with ex-prisoners. Currently, many gender-positive services, supports, and treatments for the transsexual and transgendered prison population are available only outside of correctional services facilities. Mechanisms need to be put in place to ensure that these programs are available to transsexual and transgendered prisoners upon their release from prison
To address these issues, we recommend
1. Exit kits containing HIV/AIDS information, contacts with gender-positive community-based organizations, condoms and bleach must be made available to prisoners when they are released from custody facilities.
2. The federal and provincial correctional services should work with community-based gender-positive HIV/AIDS housing programs and service organizations to ensure that they meet the needs of transsexual and transgendered ex-prisoners. Community-based housing programs and service organizations should be supported in adapting their services to the needs of recently released transsexual and transgendered ex-prisoners with HIV/AIDS. Discharge planners, correctional social workers, and case management officers must be educated on the availability of, and programs offered by, HIV/AIDS supportive housing in their regions. The National Parole Board must be similarly educated on the benefits offered by community-based HIV/AIDS supportive housing so that they can fairly and accurately assess the parole plans of transsexual and transgendered prisoners with HIV/AIDS.
1. PASAN. HIV/AIDS in the Male-to-Female Transsexual and Transgendered Prison Population: A Comprehensive Strategy. Toronto: PASAN, 1998. Copies of the document are available from PASAN at 489 College Street, Suite 405, Toronto, Ontario M6G 1A5 or telephone (416) 920-9567.
2. . K Namaste. Access Denied: A Report on the Experiences of Transsexuals and Transgenderists with Health Care and Social Services in Ontario. Toronto: Project Affirmation, 1995. Although "transgender" is considered the umbrella term, the term "transsexual and transgendered" is used throughout this article in an effort to be as inclusive as possible. Some transsexuals do not consider themselves transgendered, and vice-versa.
5. As cited by W Travers, at the Transgendered Youth Workshop in Toronto in 1996.
6. K Namaste. Évaluation des besoins: Les travesti(e)s et transsexuel(le)s à l'égard du VIH/sida. May 1998. Unpublished.
7. R Jürgens. Update on Needle and Syringe Exchange in Swiss Prisons. Canadian HIV/AIDS Policy & Law Newsletter 1996: 1(4): 2-3; J Jacob. Germany - Needle Exchange in Prisons in Lower Saxony: Preliminary Review. Canadian HIV/AIDS Policy & Law Newsletter 1997: 3(2/3): 30.