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Keeping It Real

Transgender inclusion in safe sex education


Notes for Risk Reduction Educators
and Outreach Workers

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this text as pdf

Michelle O’Brien, May 2003

There is a great deal of amazing work being done spreading awareness and knowledge on sexually transmitted diseases (STDs) and safer sexual practices. From volunteer educators in schools to hospital nurses, counselors to street outreach workers, peer educators to prevention case managers, many people here in Philadelphia have dedicated their lives to educating communities on the risks of HIV and other STDs, and providing spaces for people to learn about diverse risk reduction. As one AIDS activist slogan read, "Education is the only cure."

Unfortunately, far too much of this work can be alienating and exclusionary to transgender people. All transgender people are at risk of HIV transmission and other STDs in sex, and some trans communities are at particularly high-risk. Yet very little of the safer sex education work being done includes the wide diverse range of bodies that trans people might have. Overwhelmingly, safe sex education relies on assumptions about bodies, genders and genitals that simply do not speak to the real bodies that some transgender people live with, or the specific ways a transgender person might understand and describe their body.

This pamphlet is designed for non-trans people who are doing safer sex education work. It calls on people to think critically about the ways we discuss bodies and genders, and provides a few tips to developing trans-inclusive safe sex materials and programs. A trans person, particularly someone doing safer sex education, might also find relevant material here. This pamphlet only begins to touch on such a significant topic, and one so desperately in need of more work. But hopefully this text will open a space, get us thinking, and encourage all safe sex educators to develop ways of discussing bodies and sexual practices that are do not alienate or exclude trans people.

This pamphlet does not cover the basics of transgender people, vocabulary, identities or issues. It is meant as a companion to Down to Basics: An Introduction to Transgender Issues, and to complement ongoing research and education on trans issues. This text assumes a certain basic familiarity on trans issues, moving on to the more specific issues concerning safe sex education.

Of course, there other ways besides sex to become HIV+. This pamphlet only talks about safer sex education. For example, it doesn't cover the many issues surrounding trans communities and HIV transmission through needle use. Admirably, groups such as Prevention Point are starting to develop research and outreach addressing needle use among trans people.

This text sometimes refer only to trans people, and other places to trans and intersex people. While this pamphlet is centered around trans people and their bodies, it is clear that many of these statements are equally applicable to intersex bodies and people. I attempted to include intersex people when clearly appropriate. For much better and more substantive information on intersex people, please check out the FAQ available at www.isna.org, the website of the Intersex Society for North America. Regrettably, this pamphlet does not adequately address intersex issues.

A word on tact

Below this pamphlet it going to talk a lot about genitals - about the ways trans and intersex people's bodies might not correspond to narrow, oppressive assumptions. In the spirit of HIV risk reduction education, I try here to be frank and straight forward on a taboo topic. But a word on respect and tact is in order first. Trans and intersex people are commonly asked horribly inappropriate, offensive and extremely personal questions about our genitals. Strangers feel at liberty to approach us, asking random questions about what we were born with, if we've had surgery, what our genitals look like now - all questions that would be clearly and obviously rude if asked to any other person. In some circumstances, like in preparation for a gynecological and prostrate exam, it is clearly necessary to have an understanding of the specifics of someone's genital and reproductive organs. In most circumstances, however, such questions are absolutely not appropriate. While this pamphlet talks frankly about the issue, think carefully about what sort of questions you ask and when.

Instead of advocating education based on specific assumptions or knowledge about people's genitals, this pamphlet is calling for safer sex education that is inclusive of whatever someone might have between their legs.

Some examples

Trans and intersex people have many different kinds of bodies and genitals. Like anyone, when a trans person encounters a safe sex workshop or pamphlet, they might try to figure out if is relevant to them. All too often, a trans person doesn't see themselves, or their specific body and identity, represented. A few hypothetical examples might begin to indicate some of the possible experiences:

Jack is a bisexual trans man (female to male). He passes as male. His has a small penis created from the enlargement of his clit from testosterone use. He calls it his "dicklit." He has had his breasts removed, but no bottom surgery. In sex, he likes to penetrate both men and women using a dildo, and then likes them to give him a hand job, masturbating his dicklit. He doesn't like to be penetrated. At a gay bar outreach workers have set up a small table with condom packets. He takes one, with three condoms and two packets of lube, and instructions on how to put a condom on a man's penis. He knows he can't fit a condom on his dicklit, and that he doesn't like to be penetrated. He throws the condoms away. No gloves or information on sex toys is available at the gay bar.

Marissa is a trans woman (male to female) who sleeps with men. She occasionally passes as female, but not always. She identifies herself as heterosexual. A number of factors contribute to particularly discomfort to being identified as a gay man: her strong sense of being female, her own homophobia and a particular experience of being violently attacked by strangers yelling homophobic comments. She has a penis, which she calls 'that thing', which she doesn't like to use in sex. Having anal sex with men as a bottom is important to her self-esteem, and sometimes she allows her partners to use no condom if she thinks they will like her more. Three times street outreach workers, possibly identifying her as a drag queen, have given her safe sex materials targeting men who have sex with men. Consistently, she felt alienated and angry at having been identified as a gay man, and tries to avoid such outreach workers.

Casey identifies himself as a gentleman. He sleeps with women, using both bondage and hand-genital sex as both a top and bottom. He was assigned female at birth, but has always known himself clearly to be a man. He has not modified his body, and rarely passes. He has never had contact with any transgender-identified people, resources or communities. He is not comfortable talking about his genitals in any terms, and is rarely willing to discuss his body, gender identity or sexual practices with anyone. At his coed Narcotics Anonymous meeting, a HIV/AIDS educator came from a local agency and gives a presentation on safe sex. All the way through the presentation, the educator constantly uses gender and genital specific phrases. She describes the use of gloves and dental dams in lesbian sex, the need for condoms by men in heterosexual and gay sex. She asks the audience many questions, including Casey, who she refers to as "the woman in the back." Casey says nothing the whole time, finding the presentation irrelevant and offensive.

The rest of this pamphlet will attempt to identify some of the underlying inaccurate assumptions by safe sex materials and educators in these examples. From there, it will outline a few possibilities of rethinking safe sex curriculum.

Laying it out

In our transphobic society, most people have rigid and specific ideas about the kinds of genitals people have. These assumptions are shared by nearly all safe sex curriculum and outreach materials. Even the most basic sentences from safe sex materials might rely on a whole set of presumptions, like 'Men should use a condom in sex, by putting it in on their penis.' Such statements rest on ideas are so widespread to be virtually unconscious: You can tell someone's gender and sex by looking at them, and from that you can easily tell their genitals. Men have a penis, scrotum, and testicles. Women have a vulva, clitoris and vagina. No one has both, or anything else. Everyone uses these words to describe their bodies. One can tell what sort of sex someone is having with their genitals. None of these things are necessarily true. Let's go through them one at a time. Here are few basic facts that correct some of the above assumptions:

False assumption: You can tell someone's gender and sex by look at them.

  • Guessing someone's gender or sex based on their appearance can be inaccurate and disrespectful. Many people do not conform to narrow definitions and social expectations of male or female. People can dress and present themselves in countless differently gendered ways. Some people might 'pass' - be quickly identified with one gender or another. In some cases this might be their gender identity, in other cases it might be a drag performance; in some cases it might be their assigned gender, in others it might be self-identified gender that doctor's don't readily recognize. We can never be certain of someone's gender identity without their own self-definition. In the above examples, the mis-identification of both Casey and Marissa contributed to their frustration and detachment from safe sex materials.

    • False assumption: And from their gender you can easily tell their genitals.

  • Knowing someone's gender doesn't tell you anything about what their genitals look like. Some people are born intersex, with bodies that are not completely, easily classifiable as narrowly male or female. Many trans people might present or even pass with a self-identified gender that doesn't correspond to how many might assume their genitals to look like. As you can't tell someone is trans by looking at them, you can never tell what their genitals might look like.

    This is a really crucial point. Not all men have penises, not all women have vaginas. Put differently, not everyone with a penis is a man, not everyone with a vagina is a woman. Realizing and taking seriously this simple fact would be a tremendous step forward in making safe-sex materials trans-inclusive. Any man you are outreaching to with might, possibly, have a vulva. And any woman you are speaking with might, possibly, have a penis. In the examples, the outreach workers made false assumptions about Jack's genitals based on how they read his gender.

    • False assumption: Men have a penis, scrotum, and testicles. Women have a vulva, clitoris and vagina. No one has both, or anything else.

  • All people's genitals are not the same, or fit into one of two boxes. Intersex people might have genitals that are complex, in some cases having both a vulva and a penis. Trans people might modify their bodies in a vast range of ways, including many alterations to one's genitals. Testosterone can have cause a clit to grow significantly. There are many surgeries available, some of which create genitals that are passable as a particular sex, while others create less easily definable genitals. These different types of surgeries are nearly as numerous as the surgeons performing them, and can have many different results. Some trans people choose to not go through any surgeries, or cannot access them.

    • False assumption: Everyone uses these words to describe their bodies.

  • People use all sorts of different languages to describe their bodies. Some trans people might not be comfortable talking about their genitals at all. Others might be able to listen to people use traditional language to describe their genitals, but only if not prefaced with the word 'your', as in 'the penis' instead of 'your penis.' Some trans and intersex people have developed our own creative languages, words in use among a particular community or even by a single individual to refer to their bodies in ways that feel more respectful and make more sense. Some trans people simply refer to their genitals with the words associated with our self-identified gender. While a doctor might call a trans woman's genitals a penis, she might simply call it her vagina. In these examples, Jack has a word he uses for his genitals, and Casey is just not willing to talk about his body.

    • False assumption: One can tell what sort of sex someone is having with their genitals.

  • Knowing someone's gender, even their genitals, tells you nothing about what kind of sex they like to have, or with who. There is no necessary relationship between sexuality and gender identity. Trans people and intersex people can identify around any sexuality, prefer having sex with any type of person, and prefer any particular type of sex. Just like with everyone, such things can only be figured and out and defined by the person themselves. A trans woman might like to have sex with only non-trans women, or only trans men, or only people with penises, or with anyone who knows how to use a whip - there are countless possibilities. In some cases, a trans person might not readily admit to the kind of sex they like to have, possibly because of homophobia, or if that sex runs counter to assumptions about their gender identity - like a trans man enjoying being vaginally penetrated. He might not feel comfortable admitting that in some circumstances. Some trans people prefer sex that involves no genitals, such as fisting or some BDSM practices.

  • These five points are the all key. Intersex and trans people might be visibly or invisibility present in any outreach and education setting. If educators are to include their experiences and bodies, it is crucial to not make assumptions about people's gender, genitals, sexual practices or languages to describe bodies. Even in particular sex minority communities, like a gay bar, such assumptions can be dangerously alienating to people at risk for HIV transmission.

    Avoiding such assumptions completely is, admittedly, difficult. This pamphlet doesn't have any easy answers or quick fixes. There are clearly many issues to balance, including continuing to offer direct and accessible information to non-trans people. So little real work has been done around this subject, and very little is available on trans-inclusive safe sex education.

    Doing the work right

    While there are no easy answers, there are few tips. Each is a tool available to safe sex education workers.

    • Don't make assumptions about the bodies or genders of people you're talking with. Even in a gender-segregated facility, there might be people present that don't feel comfortable with the gender they are being categorized as. Through language, comments, and content keep in mind that someone's gender is not always immediately apparent by the way they look or the way someone else labels them. Equally, just by knowing someone's gender you don't know their genitals. It's worth saying again - not all men have penises, not all women have vaginas, and not all people with penises are men, and not all with vaginas are women.

    • Try to refer to safer sex practices more generally than specific kinds of sex. This is something many safe sex educators are already taking seriously. Many educators talk about the key body fluids that can transmit HIV, the mucous membranes and body openings that could be site of transmission, and finally the forms of barriers that could be used. Such presentations address the overall concept of safe sex, and describe real strategies for protection, without needing to narrowly categorize precise kinds of sex. This can be much more inclusive of trans and intersex people.

    • Refer to sex acts in terms of specific body parts, not genders and sex. In some cases it is necessary to talk about very specific sex acts, and not just generally about openings and fluids. When doing so, however, it's important to not assume the gender of anyone involved. Instructions on how to put a condom on a penis can be useful to many people, including two women having sex who both have penises. Comments like, "When a man and a woman have sex, they should use a condom," automatically makes a whole set of assumptions about the body parts, genitals and sex acts involved that might not be true.

    • Whenever possible, ask people what kind of words they use to refer to bodies. While referring to penises or vaginas is better than 'boy parts' or 'girl parts', it can still be alienating. Many trans people aren't comfortable with people using certain words to describe their genitals, and don't identify with such words at all. Each person figures them out for themselves or in particular communities, and there is no simple way to know beforehand what words feel right to people and which don't. In one-on-one or small group interactions, ask what words people are comfortable with. You don't have to ask about their genitals - which is often rude and inappropriate - but you can check in about language. In a condom demonstration, for example, it's not hard to ask, "When the penis is hard - is it cool to call it a penis? Is there a word you prefer? No? - okay. When the penis is hard…"

    • Include materials on diverse sexual practices in all outreach settings. As the example with Jack above illustrates, having materials that are too specialized to particular sex acts can exclude some trans people. Always have a variety of safe sex materials on hand, and always include at least some information about other sorts of sex acts, even when you don't expect its practice to be widespread in a particular setting. This, of course, has to be balanced with developing specialized materials for particular communities. A gay man you're talking with might like to be vaginally penetrated, or a lesbian might use her penis in sex. Recognizing the diversity of trans bodies means understanding that there are many, many kinds of sex two people might choose to have.

    • Include some materials on trans and intersex bodies and issues in presentations. From a few sentences to a whose section, including material covering trans and intersex issues can mean a great deal to challenging transphobia and creating a more respectful space for trans and intersex people that might be present. Developing such a section requires accurate knowledge, and is often best done by trans or intersex people themselves, or in close consultation.

    • Develop trans-specific outreach and education strategies. Many trans communities are at particularly high risk of HIV. These communities are frequently grossly under-served by risk reduction strategies and programs. A number of groups in Philadelphia and nationally have begun recognizing the need for outreach and education specifically designed for trans people. Again, this work is often best done by a trans person well connected to the particular communities being targeted. What works among a particular trans community, might not work in another - trans people are as diverse as everyone else. Developing an effective program is a serious task, and not possible to cover here.

    Given these suggestions, what might have happened in our examples? In Jack's case, the outreach workers could have more materials on hand. They could have brought along some gloves and a few pamphlets on using condoms on dildos or means of cleaning sex toys. If these materials had been on the table, he might have grabbed them. Marissa might have listened to another trans woman, and been open to safe sex information that targeted trans people. With some support and time from a trans support group or trans aware counselors, she might develop the self esteem and confidence to insist on her partners using condoms, or learned of her ability to use a Reality condom. And finally Casey might have listened if the presenter had just been more careful and trans-inclusive in her language and identification of people.

    Resources

    Unfortunately, very little is out there on trans-inclusive safe sex education strategies. A few groups, however, stand out:

    The Positive Health Project of New York City does street outreach and education with trans people. Far more than most organizations, they have managed to incorporate trans-inclusion into most of their work. The can be called at 212.465.8304.

    Here in Philadelphia, several groups have done trans-specific street outreach or trans-inclusive community HIV/AIDS education. No one, however, has developed a decent body of trans-inclusive safe sex education material. ActionAIDS, Prevention Point and PCHA have all done street outreach to trans communities. ActionAIDS and PCHA have both done trans-inclusive safer sex public presentations and workshops.

    At ActionAIDS, call the Transgender Outreach Specialist at 215.981.3351. The Philadelphia Community Health Alternatives (PCHA) can be reached at 215.563.0663. As well as trans-aware outreach speakers, occasional street outreach, they also offer a health clinic that works with trans people. Prevention Point's number is 215.787.0112, and GALAEI's is 215.985.3382.

    There are a number of people around Philadelphia researching this topic. If you have further suggestions, resources, contacts or materials, please call the Transgender Specialist at ActionAIDS at 215.981.3351.

    Closing words

    Thinking about sex and bodies in ways that recognize the reality of trans people is not simple. Trans and intersex bodies are often outside the narrow, rigid categories that too often inform and structure how we speak and think about people. This is the source of a great deal of discrimination, hostility, pain and exclusion for many trans and intersex people. The consequences of inadequate, exclusionary language are real and severe - high rates of cancer mortality, transmission of HIV and sexually transmitted diseases, and chronically inadequate health care.

    Safe sex educators can be a part of changing the ways people think about bodies and gender. By listening to trans people's experiences, thinking critically about the work, and being open to change and learning, safe-sex educators can begin to develop means of actively including and respecting trans people.