Thursday, July 15, 2010

Trans People, "MSM" and HIV Study and Outreach

There is a serious problem in HIV study and outreach when it comes to trans people -- and especially transsexuals -- in studies of high-risk populations. Many of late have been doing so by trying to include them under the term "MSM," or, "men who have sex with men." I've heard the creation of this term attributed to the Center for Disease Control, but it's widely used now by United Nations -affiliated organizations and more.

This past Spring, I'd had one such study request forwarded to me by someone who was apparently on one of the mailing lists that I forward communications to. A few days later, he wrote me, irate that I'd not forwarded it to my trans networks. I'd pointed out (feigning ignorance) that while a few trans men might qualify and be interested, much of what was being discussed in his email didn't really fit FTM configuration, especially pre-surgical. This resulted in a missive which started off with "you know what I mean" and launched into an accusation that I'd be "guilty of the murder of" every transsexual woman who perished from HIV who might have benefited from the study. And yet, the survey was written so thoroughly to exclude those of female gender identity, I can't see any way that any self-respecting trans woman would be able to sit through the whole thing without becoming thoroughly incensed at the obvious refusal to dignify her as who she is.

I get it that effective terminology must be given to identify target high-risk groups for the sake of study. I get it that the terminology needs to be both simple and encompassing. I get it that HIV is a serious issue and relevant to the trans community, though not all trans sub-groups are high-risk. I get it that penile-anal intercourse (PAI) risk groups can include trans women (indeed, we're upset when we're not). What I don't and will not get is the gay community's insistence that transsexual women are "really men" and how it's such a bother having to state otherwise in order to be inclusive. To be fair, there are many folks in HIV study and advocacy who don't feel or act that way, but the prevalence of MSM-exclusive study sure reinforces this impression.

MSM reportedly came to be because of a need to include males who identify as straight rather than gay or bi, but by circumstance still had or have sex with other males. It also takes out of the equation people who identify as gay or bi, but who aren't currently sexually active with men. What's interesting is that even though MSM terminology was apparently devised in order to respect various mens' identities and transcend the cultural and historical contextual constructions built around terms like "gay," often no such accommodation or respect is given to trans female communities. To justify this, sometimes people will point to other cultures where trans women are more inclined to identify themselves as "really male" so that we Westerners seem the odd ones out and explainable by cultural context -- a situation that exists mainly because outside Western societies, trans people in most cultures have not yet had the freedom to develop a language with which to self-identify, and therefore accept whatever language is available to them.

Admittedly, it doesn't help that "trans" covers such a widely diverse set of people, including male-bodied people in a stage of bodily transition to female, female-bodied people in a stage of bodily transition to male, male-bodied people who view themselves as both genders / neither gender / somewhere in between, female-bodied people who view themselves as both genders / neither gender / somewhere in between, people who identify as the same gender of their birth assignment but who sometimes crossdress for a variety of reasons, people who don't like or fit social rules of gender, and although trans doesn't encompass them, sometimes people who are physically intersex are relevant to trans-related medical study. Notice that I didn't address operative status -- post-operative transsexuals no longer need to identify as trans in any way, and for the sake of HIV research should only be classified as men and women. It also doesn't help that there is little consensus within trans communities on what the various labels mean, and that many people affected by trans issues do not identify as trans. However, when it comes right down to it, the issue looks a lot more complicated than it really is.

MSM terminology actually does include some of those trans identities when male-identified, though they're sometimes dismissed from studies as not the intended target trans group (it's interesting, for example, that people will sometimes be familiar with lesbian- or bi-identified trans women, but not grasp that there can be gay- or bi-identified trans men). Where MSM fails spectacularly is specifically with female-identified, male-bodied persons (usually transsexual), by insistently identifying them as male.

As simple as this fact is, it seems to get dismissed because of cisgender (that is, non-transgender people) failure to recognize how much of a barrier and how disrespectful this is, feeling that it's simply easier and more expedient for us to "just get over it." Those folks, of course, can be classified as ignorant @$$es -- not because they identify as such, but just because it's more convenient for me to do so.

This is one of those things that it would seem to me to be obvious, but frankly, transsexual women are typically not going to participate in a study that willfully disrespects them as women, or is phrased in ways that would not even seem to be applicable to them. Those kinds of things generate a barrier not only to the studies in progress but willingness to consider future studies, regardless of inclusion. Add this to a medical framework where distrust and an expectation of prejudice and inconsistency from medical professionals abounds, and the reluctance rises exponentially.

Recognizing that that the terminology needs to be simple and encompassing, it seems to me a small thing to expect a "& TFSM" ("and trans female-identified people who have sex with men") acronym added where MSM appears.

That's a first step. And it means nothing if it's accompanied by inconsistent gender acknowledgment throughout. Because as much as I want to do what I can to address HIV issues among trans people, increasingly the tools to do so are being branded with a moniker that at best says "this isn't for you," and at worst is completely insulting.

(Crossposted to DentedBlueMercedes)


Unknown said...

I participated in one of these studies a few years ago in San Francisco. I was approached by the study-taker who asked me if I'd like to take the study; when I saw it was for people who had sex with men I told him I was a lesbian. He said that was fine as long as I had been born male (which I was).
The study was exactly as you describe; it completely de-gendered me, assuming everyone taking it was male-identified and in possession of a penis (of which I was neither). The study also assumed that the only way a person could have sex would be to stick a penis into some orifice, which made questions like "Have you had vaginal sex?" very difficult for me, as a lesbian, to answer.
In the end I persisted in taking it because I was financially hurting and needed the money the study was offering. During the last followup test the person taking my cheek swab was surprised there were trans women in the study, so even all the staff were of mixed ideas of who should be included in the study.

Mercedes said...

Thanks for this. I hope you don't mind if I quote this in the comments where this article was posted elsewhere, because one of your points addresses something that was brought up there.

Meanwhile, on that other comment thread, one HIV advocate points out that part of the reason MSM developed in this way was because:

"... In years past donors simply refused to fund TG services directly but would “allow” HIV service providers to provide these services under the “MSM” target (and some would encourage this)"

Which doesn't change any of what I'd said here, but does signal that there is an additional barrier in the form of prejudice from funders.

Also, TFSM has been demonstrated to have some flaws as a term, so has been withdrawn.

Joseph Charles (J.C.) said...

Very informative blog. THANKS!