When identity claims: Risky processes of body modification among transgender women of Lima, Peru

1. When identity claims: Risky processes of body modification among transgender women of Lima, Peru Alfonso Silva-Santisteban, Ximena Salazar, Lealah Pollock, Jana Villayzán and Carlos F. Cáceres.

2. Opening Remarks • The transgender population is the group most affected by the HIV/AIDS epidemic in Peru (30% vs 12-18% in gay men, 0.4% general population) (Silva-Santisteban 2010) • Globally, transgender women have a unique context of risk, and traditional HIV prevention efforts might not be suited to their needs (Kosenko 2010). • For many years trangender women have been conflated (hidden) within the category MSM. • In the past years motivated by the demands of transgender activists, research efforts have focused to study this population independently from MSM (information is still scarce)

3. Genderenhancement and transgenderwomen • An important part of identity affirmation . • Described in several parts of the world where hormone use is the most common practice. • Beliefthat intramuscular hormone injectionresults in “more powerful” effects (Bockting 1998, Nemoto 1999). • In the US: weightedaverage of 27% for hormone injection (Herbst 2008). • In Thailand: 50 to 74% for hormone use (Wimonsante 2005, Nemoto 2008). • Siliconeinjectionisanothercommonpractice: it has beendescribed in the US (25% Herbst 2008), and South America.

4. Genderenhancement and transgenderwomen • Risk practices regarding hormone and silicone injections are not described in depth. • Practices may go from obtaining hormones, silicones and supplies from nonmedical sources (34% in Herbst 2008), to sharing needles for injection (6% in Herbst). • In Peru, this topic has been described in qualitative studies. Hormone use, cosmetic surgery, industrial silicone injection or airplane oil (Salazar 2010).

5. Methods • Using respondent driven sampling (RDS), 8 initial participants (seeds) generated a sample of 450 TGP from Lima between April and July 2009. • RDS?

7. Methods • Formative phase 2 months, direct collaboration with TW organization. • Socio-demographic characteristics, body modification procedures, among others were explored through an interview plus testing for HIV and other STI´s.

9. Objetivos

10. Results

13. Results • No association was found between having engaged in any gender enhancement/transition procedure and HIV (p=0.48) nor with hormone injection (p=0.76) or industrial silicone injection (p=0.58).

14. Discussion Main Finding: In Lima, gender enhancement occurs outside the health system. This reflects the desire to create a body that conforms to identity in a context of extreme exclusion which needs to be further explored. There is an extended use of industrial silicone, in spite of health consequences.

15. Discussion From an statistical petrspective there was no association between gender enhancemt (or hormone/silicon injection) and HIV infection, concurring with other studies (Schulden 2008, Nuttbrock 2009). What does these mean? Should we not “worry” about this issue?

17. From a publichealthperspective Studies in the USA have shown that hormone therapy provision may stimulate transwomen access to health programs (including HIV prevention programs), and improve their quality of life (Sevelius 2009). Notthe case forourreality. Other countries like Brazil have established harm reduction programs to provide clean needles to transwomen for hormone and silicone injection (Gagizi 2006).

18. From a publichealthperspective • However: there is no conclusive evidence on the association of hormone and silicone injection and HIV infection. • Silicone injection is an irreversible and harmful process, and other alternatives should be preferred. • Gender enhancement should be included as part of integral health services offered to this population in health facilities.

19. Froman integral pespective • Gender enhancement is not a matter of HIV transmission or disease control. • It is a right of transgender people that has to be granted by the health system and society. • We need to adress social inclusion as our main strategy.

20. Froman integral pespective • We need to work from the transgender community, with the transgender community.

22. “Activism without theory could be reckless, theory without activism, is useless” Paul Glover

23. References • Bockting WO, Robinson BE, Rosser BR. Transgender HIV prevention: a qualitative needs assessment. AIDS Care. Aug 1998;10(4):505-525. • Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav. Jan 2008;12(1):1-17. • Kosenko KA. Contextual Influences on Sexual Risk-Taking in the Transgender Community. Journal of Sex Research [serial on the Internet]. 2010: Available from: http://informaworld.com/10.1080/00224491003721686 • Nemoto T, Luke D, Mamo L, Ching A, Patria J. HIV risk behaviours among male-to-female transgenders in comparison with homosexual or bisexual males and heterosexual females. AIDS Care. Jun 1999;11(3):297-312. • Nemoto T, Iwamoto M, Perngparn U, Areesantichai C. HIV risk behaviors among transgender (Kathoey) sex workers in Bangkok, Thailand. Oral Abstract Session: AIDS 2008 - XVII International AIDS Conference: Abstract no. MOAD0302 • Salazar X, Villayzán J. (2010). La situación de la población Trans en el Perú en el contexto del acceso universal a tratamiento, atención y apoyo en VIH/SIDA. Lima: IESSDEH, ONUSIDA. • Silva-Santisteban A, Salazar X, Pollock L, Villayzan J, Caceres CF. When identity claims: Risky processes of body modification among the male to female transgender persons of Lima, Peru. Oral Abstract Session. AIDS 2010 – The XVIII AIDS Conference.Abstract No. MOAD030. • Schulden JD, Song B, Barros A, et al. Rapid HIV testing in transgender communities by community-based organizations in three cities. Public Health Rep. Nov-Dec 2008;123 Suppl 3:101-114.

24. Thank You