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.

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)

Gender enhancement and transgender women An important part of identity affirmation . Described in several parts of the world where hormone use

is the most common practice. Belief that intramuscular hormone injection results in

“more powerful” effects (Bockting 1998, Nemoto 1999). In the US: weighted average of 27% for hormone injection

(Herbst 2008). In Thailand: 50 to 74% for hormone use (Wimonsante 2005,

Nemoto 2008). Silicone injection is another common practice: it has been

described in the US (25% Herbst 2008), and South America.

Gender enhancement and transgender women 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).

Methods

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

RDS?

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.

ObjetivosVariable Crude % (N) Adjusted % (95% CI)

Has been subject to any change in order to make her body more femenine 76.0 (335) 69.8 (61.4 - 76.2)

Where (what part of body)         Nose 17.9 (62) 22.6 (17.1 - 32.7) Hips 33.4 (112) 33.7 (26.6 - 42.8) Butt 44.8 (150) 44.6 (37.7 - 53.4) Thighs 20.3 (68) 17.1 (11.2 - 23.9) Breast 37.9 (127) 36.7 (30.2 - 45.7) Forehead 25.7 (86) 25.6 (18.1 - 32.6) Cheek bones 21.5 (72) 21.8 (15.1 - 29.8) Lips 9.0 (30) 14.0 (7.3 - 20.9) Chin 13.7 (46) 15.1 (8.8 - 22.9)Type of procedure         Implants 21.5 (72) 24.0 (17.8 - 32.4)

Other surgical procedures 10.1 (34) 10.0 (5.1 - 18.1) Biopolimeros/colageno 4.8 (16) 4.4 (1.9 - 6.7) Industrial silicone injection 42.7 (147) 39.6 (31.9 - 44.7) Sex reasiggment 0.9 (3) 1.6 (0 - 3.4)

Where was the procedure carried out        

Private health establishment 21.2 (71) 26.9 (20.4 - 37.1) Public health establishment 1.2 (4) 0.5 (0.1 - 0.9) My house/aqcuaintance 53.8 (180) 50.7 (43.3 - 59.0)

       

ResultsVariable Crude % (N) Adjusted % (95% CI)

Has been subject to any change in order to make her body more femenine

76.0 (335) 69.8 (61.4 - 76.2)

Where (what part of body)         Nose 17.9 (62) 22.6 (17.1 - 32.7) Hips 33.4 (112) 33.7 (26.6 - 42.8) Butt 44.8 (150) 44.6 (37.7 - 53.4) Thighs 20.3 (68) 17.1 (11.2 - 23.9) Breast 37.9 (127) 36.7 (30.2 - 45.7) Forehead 25.7 (86) 25.6 (18.1 - 32.6) Cheek bones 21.5 (72) 21.8 (15.1 - 29.8) Lips 9.0 (30) 14.0 (7.3 - 20.9) Chin 13.7 (46) 15.1 (8.8 - 22.9)Type of procedure         Implants 21.5 (72) 24.0 (17.8 - 32.4)

Other surgical procedures 10.1 (34) 10.0 (5.1 - 18.1) Biopolimeros/colageno 4.8 (16) 4.4 (1.9 - 6.7) Industrial silicone injection 42.7 (147) 39.6 (31.9 - 44.7) Sex reasiggment 0.9 (3) 1.6 (0 - 3.4)

Where was the procedure carried out        

Private health establishment 21.2 (71) 26.9 (20.4 - 37.1) Public health establishment 1.2 (4) 0.5 (0.1 - 0.9) My house/aqcuaintance 53.8 (180) 50.7 (43.3 - 59.0)

       

Variable Crude % (N) Adjusted % (95% CI)

Hormones use 86.6 (290) 82.7 (76.9 - 87.3)

Type of hormones

Contraceptive pills 56.9 (165) 54.7 (45.5 - 63.6)

Contraceptive injection 68.6 (199) 65.9 (57.3 - 74.0)

gel 1.4 (4) 0.7 (0.1 - 1.3)

patches 1.7 (5) 1.4 (0.3 - 2.8)

Who indicated hormones

Nobody (myself) 13.1 (37) 8.5 (4.4 - 12.8)

Friend/acquaintance 65.7 (186) 66.7 (60.0 - 79.1)

Health personnel 20.2 (57) 21.1 (10.9 - 28.7)

Other 0.7 (2) 0.1 (0 - 1.7)

Health control for hormones usage

No 92.8. (270) 95.2 (91.2. – 96.4)

Variable Crude % (N) Adjusted % (95% CI)

Hormones use 86.6 (290) 82.7 (76.9 - 87.3)

Type of hormones

Contraceptive pills 56.9 (165) 54.7 (45.5 - 63.6)

Contraceptive injection 68.6 (199) 65.9 (57.3 - 74.0)

gel 1.4 (4) 0.7 (0.1 - 1.3)

patches 1.7 (5) 1.4 (0.3 - 2.8)

Who indicated hormones

Nobody (myself) 13.1 (37) 8.5 (4.4 - 12.8)

Friend/acquaintance 65.7 (186) 66.7 (60.0 - 79.1)

Health personnel 20.2 (57) 21.1 (10.9 - 28.7)

Other 0.7 (2) 0.1 (0 - 1.7)

Health control for hormones usage

No 92.8. (270) 95.2 (91.2. – 96.4)

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).

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.

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?

From a public health perspective

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).

Not the case for our reality.

Other countries like Brazil have established harm reduction programs to provide clean needles to transwomen for hormone and silicone injection (Gagizi 2006).

From a public health perspective 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.

From an 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.

From an integral pespective We need to work from the transgender

community, with the transgender community.

“Activism without theory could be reckless, theory without activism, is useless”

Paul Glover

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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.

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