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 Trans Group Blog)

    • Paul C
    • July 16th, 2010

    Interesting and timely. I have been involved in advocacy for HIV services for transgender people (female and male) for over 12 years. I would like to clarify that the idea to have the the broad term “MSM” encompass TG people was a very practical matter intended to be sure that TG people were included in the funding streams for services. 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). Largely because of these early advocacy efforts, you and I both can now proudly refer to transgender people (who are at high risk) when soliciting funds for HIV services.

    While your “TFSM” (“trans female-identified people who have sex with men”) is interesting it is awkward at best and leaves out, as you point out earlier, trans male-identified (but still female-bodied) people who have sex with men. I, and I dare say them as well, do not agree that they would be covered under the umbrella term “gay”.

    We are now using, in Asia Pacific, “men who have sex with men (MSM) and transgender (TG) populations” when referencing high-risk groups. This has been requested by and seems to be accepted by “most” transgender people, even those who do not identify directly as TG themselves (including those in the Pacific Islands and in South Asia such as hijras and female-identified kothis).

      • Just Some Trans Guy
      • July 21st, 2010

      “I, and I dare say them as well, do not agree that they would be covered under the umbrella term ‘gay’. ”

      Thanks for speaking for me, but I am in fact capable of speaking for myself. The only reason I would think that MSM wouldn’t cover me (a queer, though not gay, man) is because of the possible transphobia of the researchers, not because I don’t consider myself as falling within the “MSM” category.

      And I have nothing but a big, hearty “fuck you” to anyone who doesn’t consider me a queer man.

        • chartreuseflamethrower
        • July 22nd, 2010

        I haven’t met a single man who’s only interested in other men who didn’t call himself gay (same for men only attracted to women considering themselves straight). I know a woman who’s pre-op and only attracted to cis men, and she considers herself straight and a woman who’s non-op/non-hormone and only attracted to women who considers herself a lesbian.

        I also know a few trans people who have a few issues with the “identified” terminology.

    • dentedbluemercedes
    • July 16th, 2010

    TFSM doesn’t need to encompass male-identified trans folk: they’re male-identified, so MSM does include them. But looking further, there may be a concern in it not including bi-gendered or gender-neutral folks.

    Consequently, MSM & TG is probably better. What’s crucial is inclusive and respecting language.

  1. “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.”

    I just… I don’t know where to begin with this statement. The thrust of this taxonomy is that post-operative women are classed as woman, no longer needing to be separated from the rest of the women, while we non-or-pre-operative folk are classed as ‘sorta-woman…ish, at the moment,’ with all that implies as to the point where bottom surgery becomes a legal requirement for basic human rights.

      • dentedbluemercedes
      • July 16th, 2010

      That’s not my intent. Sorry if I phrased it poorly, but in this case, I’m speaking strictly from the medical standpoint where it becomes necessary to have some form of taxonomy specific to women with male parts i.e. for HIV study and outreach.

      Outside that context, then yes, it would be purely other-ing. Outside that context, I’ve always seen trans as an elective designation per each individual, but one that can still convey a generalized sense of community.

      • dentedbluemercedes
      • July 16th, 2010

      Ria commented on Trans Group Blog’s posting of this article:

      “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.

      This brings up several points, but one demonstrates why I felt it was necessary to make the statement that you raise a concern about.

      • Indeed, it’s just a common thread I see running through some more, well, middle-class narratives to be honest: the idea that penis = man/male/boy and that how dare one degender the post-operative women, as opposed to the not-currently-operative. I just sort of feel the need to come back to this theme now and again, that transition is mainly centred on two goals: Getting others to see a person as their identified gender, and getting themselves to see a person of their identified gender that they are comfortable seeing when they look in the mirror.

        SRS is *way* more about the latter, and it bothers me to see the tendency of people to use it as a signifier when they are out about their transness. The implication that those who are further along, or more complex in their transition are more women than those who are not is, well, kind of insulting to the first twenty-six years of my life. I wasn’t a boy then, no matter how hard I tried to be one to please others and in the hope that it would make me stop feeling awful about myself.

        The study is problematic generally because it assumes male-assigned-at-birth is the same as man, but that’s not the point I’m replying to. SRS does not eliminate all the other ideosyncracies that most trans women have (like prostates for example) and does not eliminate sexual histories. The problem is one of not respecting one’s gender identity, which is not helped by creating a path of enfranchisement whereby one becomes a woman by medical procedure, be it anything from bottom surgery to… say… hair removal, we then have our lack of transition used as justification for withholding the resources necessary for transition.

        Sorry if this seems a large reaction, I just find it an important point to raise. It’s my wheelhouse as far as trans rights go.

    • Grant
    • July 16th, 2010

    I disagree Paul. A good portion of trans men identify as gay, regardless of surgical status. Most trans men have top surgery and stop there. There are very few trans men that have genital reconstruction surgery, but they still see themselves as men and hence use their bodies like a man would. This is especially true for gay trans men. We have anal sex, and yet it is not seen the same as someone who was assigned male at birth, despite the fact that we have anal sex with gay men. Due to this fact, gay trans men should be included as a high risk population. Determining risk factors should rest more on behavior (what kind of sex and who the sex is with) than on genital status.

      • Big Kate
      • August 6th, 2010

      Grant, I agree about f2M describing them self as GAY, and i agree they may have anal sex, but sexuality is not defined by what orifice you use. So I know quite a few Gay me who use any orifice available that gives them pleasure including their vagina

        • Grant
        • August 6th, 2010

        Point taken. I guess I was trying to emphasize the fact that gay trans men consider themselves gay and therefore use their bodies a lot like cis gay men. I wish there were actually statistics on how many trans men use their original plumbing, because I hate to make generalizations on what trans men do with their bodies. Personally, I go through phases during which I don’t let anyone near my vagina and other times when I don’t care. But I never have a problem with men going near my butt, so that was the point I was trying to make.

    • chartreuseflamethrower
    • July 16th, 2010

    This is another problem in trying to find statistics on trans people- it’s so hard for the people doing the studies to use some basic common sense and courtesy when doing it.

    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.

    I really can’t believe “professionals” are allowed to use these kind of tactics to try and basically force someone to take part in a study. That really loses credibility for me.

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