Don’t Try to Play Me, Boy

Arkansas has never been an ideal place for a Queer to find dates. Southerners are, however, a very “Hold my beer!” kind of people. In down-home fashion, therefore, I’m the sort of Queer who moved back to Arkansas after many years away, said “Hold my beer!”, and went looking for a date anyway.

I’m 33. I don’t feel old. Old enough to be among a tragically small minority of folks who remember Gullah Gullah Island. But not old. Isn’t this the prime of my life? I got over the hurdles of my teens, coming out as queer in Arkansas during an era when getting married would not have been legal even if I’d been 18. Then I trampled through my 20’s, thought I knew everything, somehow convinced a lot of people I knew more than I really did, and fell predictably flat on my face in a fit of cosmically intense reckoning with reality before my 30th birthday. Now I’m 33 and the one real thing I know for certain is that I don’t know much.

Also I know that key lime pie is tasty. If you disagree, I’ll eat yours for you. Then I’ll calculate the points into my Weight Watchers app, because at 33, the other thing I really know about this season of my life is that key lime pie does not magically fall off my body like it used to.

So I get this email today from a prospective suitor. I’ve gotten dozens of emails from men who do not seem to understand what “demisexual” means, even though I clearly define the word in my personals ad: I’m not interested in sex with anyone I don’t have a strong emotional connection with. They can blame me for ending a sentence with a preposition, but not for being unclear about what I’m looking for.

The email that arrived today stood out for this reason alone: He lives less than a mile from me. Way out in the country. Do you know how convenient it would be to date someone within walking distance? I want to say yes on this basis alone. I haven’t been on a date since 2015. I haven’t had sex since 2016.

Whoa. Really? Isn’t winter of 2021 happening, like, next month? Yes. Yes it is. Funny you noticed that, too.

I’ve begun to wonder if I’m asexual. Then I remember how much I really, intensely, eagerly, whole-heartedly love sucking cock. I am not asexual. There is no way I could be asexual. I just, you know, haven’t had sex. In five years.

Part of this dry spell happened because of genital surgery. In May 2016, I went under the knife for the simplest of all possible gender-affirming surgical procedures. In August 2016, I went back under the knife to remove massive wads of scar tissue that had kept me nearly immobilized in pain all summer, caused me to lose my job and health insurance, and traumatized me so sufficiently that I had a psychotic break not long thereafter. But I’ve not been psychotic in at least three years? I’ve been sober for that long, at least, and I think those occurrences happened together.

The rest of the dry spell happened because, after I’d gone through all that, I no longer had an appetite for consumptive sex. It was like I’d had 300 McDonald’s burgers a year for two years, and eating burgers in Steamworks bathhouse had made me so nauseated I just couldn’t eat another one again when it was offered to me. That was in 2018. Then I turned down another, and another. 2019 happened. The offers started getting better ⁠— but they were better than the lowest possible standard of what constitutes a date, so I still said “no, thank you.”

2020 happened. I blamed covid for my continued celibacy, but really I don’t think I’d have gotten laid even if we’d had a real President who valued 700,000 people’s lives more than his own angry insurrectionist fan base’s egos.

In 2021, I got vaccinated, quit my job as a trucker, and started looking around Arkansas for dates with thoughtful, considerate, fully vaccinated, anti-racist, pro-feminist, pro-choice, pro-science people who could perhaps satisfy my deep enjoyment of sucking cock. That’s how this guy up the road found my personals ad.

Here’s the thing though: Dude can’t even tell me what interests him. He’s 26. I remember being a 26 year old man and thinking that the whole world revolved around me because I was the coolest thing on the planet since key lime pie. But I’m not 26 anymore. I’m 33. This means I need any man’s petition for my interest to be at least as interesting to me as this key lime pie I cannot stop thinking about. This is what “demisexual” means. If he does not present himself in a way that can compete with the sense of comfort, peace, calm, and reliability a key lime pie gives me, he is not going in my mouth.

Am I being unreasonable? Have I gotten so old that even polite-but-insubstantial offers of sex make me throw down curmudgeonly missives for the darn kids to get off my lawn?

I asked him why I should take interest in him. What are his favorite books? What inspires him? What is he passionate about? What is he doing with his life, and how does he feel about it? I asked how he thought he’d respond if he were in my shoes, being propositioned by someone who has offered no substance or insight into himself as a human being worthy of my attention.

He said, “If I were you I’d think I’d need to meet him and really see for myself,” with a great big smiley face. Bless his little heart.

So I wrote him back. I kept it light-hearted. As light-hearted as “Well I think I’m 33 years old and done been fooled enough times to know when someone wants in my pants, OR is covering up a lack of substance in his own life by skirting my questions about what makes him substantial” can be, anyway. I added, “Doesn’t mean I won’t ever meet up with you. But it does mean this: Don’t try to play me, boy.”

The 26 year old who was eagerly double-messaging me earlier has not yet responded.

The 76 year old who prompted yesterday’s dissociative episode has me wondering if men in Arkansas ever actually grow up at all? A friend whose husband just left her reminds me the answer might very well be “no”. A lifetime of seeing men around here behave as overgrown, emotionally-stunted 12 year olds whose wives are expected to clean up their messes, pay for their occupational whimsies, and cater to an emotional fragility that makes thin ice look inviting to walk on, suggests to me that perhaps they just don’t ever grow up. Maybe it’s only men in other places who grow up, because their environment requires them to? Arkansas does not require maturity, conflict resolution, or collaboration skills of white men, ever.

This, I fear, might leave me hungry for a dick to suck for as long as I live here.

But at least I’m not hungry for self-respect anymore. Walking distance or not, if the dude can’t name one book he loves and tell me why that story is important to him, I can’t give him a blow job. I just cannot.

So I wait.

Service Made Visible: My Dog is a Radical Revolutionary

This is Max. Max is a Service Dog. He’s still in training, and I’m responsible for training him. He’s learning quicker than I expected. He’s been “at work” two days now. He was originally rescued in March, after his abusers decided he was a “bad dog” who wouldn’t listen or behave. He was afraid of everything. Max has come a long way in a short time.

We’ve been training together since the day Max found me and asked what was for lunch in the parking lot of a Love’s truck stop. I fell in love the moment I saw him. I didn’t know then that I needed an actual, legal service dog. I did know I was having mental health struggles and needed a friend who would love me real good while I kept working on remembering how to love myself.

I’ve had to learn a lot about pit bulls in that time, because pit bulls are not terriers. I am myself a Britney Spaniel/Australian Shepherd mix, who just happens to look like a human to the unsuspecting onlooker. I know what to do with an overly eager-to-please dog who loves to be rewarded for jumping hoops correctly. I know what to do with performance-oriented reward-seeking. Max ain’t that kind of dog.

Today, someone I love yelled at me. He said some real hurtful things. Things that have me realizing I’m not welcome in my home. Things that make me wonder why I ever thought I was. He said the hurtful words about ten minutes before I had to be at an evening workshop on Contemplative Writing hosted by the local public library. That was inconvenient timing.

As I exited the scene of explosive familial dysfunction splattered across the living room like a crime scene waiting to be secured and photographed, Max accompanied me to my office. I opened up the laptop. I clicked the Zoom link. I joined the writing workshop. It was 6:00 pm. I was on time. I’d jumped the hoop correctly. Now, for my reward!

Max put his paw on my leg like he needed to go out. I knew he didn’t need to go out, because I’d just taken him outside right before I got yelled at. I pushed his paw away and told him I was working. Another paw. Two paws. In my lap, all at once. 65 pounds of pit bull climbed onto me, as serious as a dragonfly in mating season. I was going to pay attention to him, dang it. He wanted to play. That silly computer I was looking at? Not as important as he was. This was the first time he has ever climbed onto my desk. While I was fighting him off, at that.

Shoot, I thought. Is he ever going to cut it as a service dog? Am I fooling myself? Sometimes he behaves so well. Then sometimes, he’s just such a handful. He won’t listen. He won’t stop. He does not care that I’m in a situation where my presence and attention is required in this very moment. He does not care that the people on this Zoom screen have PhDs and I need to hear what they’re teaching me. There’s no way I can train him to be a service dog, I think in frustration. This is too much, I would sigh, if I were breathing. He licks my face.

Max’s head pops through a magic virtual rainbow and onto the Zoom screen with all the other attendees. I think he’s trying to sniff them? He wants to know who these creatures are inside the computer demanding my energy right now when — don’t they see? — what Max wants here is more important than any of them. He is going to have my full attention whether any of us likes it or not.

I imagine this happening at the job I’m currently interviewing for. What if I were sitting at a meeting with the lead researchers, whose time is precious, carrying on our professional business? Then boom! There’s Max! Right in my face. Just like he’s doing now. This is unacceptable. I push him down off me repeatedly, but he’s only more insistent. God, if only I could afford a real trainer! Then I remember that a real trainer told me I have what it takes to train dogs for a living. I don’t know what that trainer was smoking when he said that, but apparently I need some of it. My dog is physically on top of me during class where I’m supposed to be paying attention. I don’t have what it takes for anything right now.

With my microphone muted, I take Max by the collar and escort him out of my office. I close the door behind me. He has to learn boundaries.

I walk back to my desk and sit down just long enough to feel the weight of my mistake sear into me like the seat I’m in is on fire. I stand back up. I open the door, pet him behind the ear, and go to Max’s backpack. I pull out an esophagus — his favoritest favorite treat in all of the treat kingdom.

“Okay, let’s go to work.” I put his service vest on him and take him back into the office. Then I apologize to my workshop crew that it took ten minutes to get present with them, after I’d just been yelled at and made to question whether I need to find a new place to live because I’m not wanted in the house I pay the mortgage on. I didn’t tell them that part.

“I’m sorry,” I typed. “My dog is trained to disrupt me when I’m dissociating. He’s making it really hard for me to pay attention to the workshop because he’s doing his job a little too well right now.”

I gave Max the esophagus. He had performed his duties admirably.

All my life, I’ve hidden dissociation. The first time I can identify having done it, I was three years old. It’s easy to sweep dissociation aside and pretend it’s not happening, just like whatever is causing it. I can tune in so attentively to one thing, one important thing, or one thing I convince myself is important, that I don’t notice the whole world burning down. Or the blood spatter of harsh words on the wall of my living room. I once gave a Trans 101 presentation to a packed audience at the 2016 Philly Trans Health Conference less than four hours after a surgeon drained my literally-exploded, three-week-old priapism into a plastic bag on the bed of his hotel room. I took the stage that day with hydrocodone rollin’ through my veins. My presentation was received with five-star reviews, a job offer, and extensive commendation. Y’all, I can dissociate like Vincent Van Gogh could paint.

Year after year, no one knew. No one knew the pain I was hiding all those times I stood center stage in the advocacy arena fighting for healthcare and social justice. No one knew I wasn’t feeling my own feelings, or that I was losing my ability to feel empathy for theirs. No one knew the slippery slope I was sliding down toward anger, frustration, rage, and despair. They just saw my career soaring. They saw the acceptance letter into the UW Masters of Public Health program. They saw measurable progress that was happening wherever I got involved. I guess they thought I was happy. I had certainly fooled myself. I thought being in a state of constant dissociation was as “happy” as I could get. I didn’t know any of the people around me were, you know, actually happy with their lives. I wasn’t trying to lie to them. I was just lying to myself so good, I couldn’t tell the truth if I’d wanted to.

Until one day, the truth caught up with me, and I lost everything. The grad school, the limelight, the gigs, the tenuous grip on reality I’d been clinging to. All of it. I lost it all. The people who’d been actually happy moved on with their lives, while I sat in a puddle of my own failure wondering where I’d gone wrong. Each time I tried to repeat the old patterns, or perform like everything was okay, the words that came out of my mouth were all wrong. I had no charisma to hide behind anymore. I’d lost that, too.

Max ain’t that kind of dog.

Now that he’s in my life, I’m incapable of hiding dissociation. He does not care if I’m in an interview on live television with Oprah. If I go all Shonda-Rhimes-before-she-loved-herself and dissociate during that interview, Max will be on top of me like a clown on a unicycle. Ain’t nobody gonna stop that dog from doing the only important thing in this world: Getting me to be present with myself, feel what I’m feeling, and not let the pressures of “work” or social expectations get in the way of that goal.

Max embodies what tens of thousands of people throughout the United States are striking for in their workplaces right now. He puts the brakes on expectations to leave our feelings at the door and show up as half-humans, like the Borg, to serve a force of assimilative destruction that cares only about its own self-promotion at the expense of any and all human lives. He’s not a bad dog. He’s a good dog guiding me through a bad situation. He’s a loyal friend who interrupts whatever is going on, to ask: But it can wait until you’re breathing real slow and deep again, and until you can name your feelings, right? We can play until you can do that. You can’t work until you do that. Come on, now. Be real.

You really can’t work if you can’t feel. Stop pretending you can. Breathe. Play. Now.

Like thousands of out-of-touch employers who dislike being exposed by their workers for treating the backbone of their organizations like worthless, disposable objects instead of real people with a full range of human emotions, I dislike that Max exposes my dissociation. I dislike that what was previously invisible, except insofar as the fruits of my labor eventually demonstrated themselves, I can no longer hide. Now my dissociation is as obvious as a 65-pound pit bull on top of my face.

I guess I’ll have to get with listening to what my heart has been demanding from the picket line.

Thanks, Max. You did good work today.

Happy Indigenous Peoples’ Day, National Coming Out Day, and Shiny New Certificate Day.

Both Indigenous Peoples’ Day and National Coming Out Day are dear to my heart.

At 14, I first “came out” in Arkansas where my self-extraction from the closet of Evanglical authoritarianism was not welcome. I called myself a lesbian, because I knew I wasn’t straight. Then I kept dating boys in high school who usually figured out they were gay around the time we broke up. I did not know how to be a gay man in my own body yet, but I spent more than a decade, years of hormone therapy, and a few surgeries trying to figure it out.

By 29, I’d learned being a gay man was not all it was cracked up to be. The gay part, yes. The man part? With cisnormative assumptions about how I was allowed to feel, and be, and express my rage and sadness about the harms of colonization and patriarchy? I couldn’t do it.

At 30, I retransitioned. Shedding the old, tired suit of manhood, I embraced the gown of Queerness. Changed hormone regimens again, which started a third puberty. I shifted to they/them pronouns, which I’d tried to do with the first transition but had been socially and medically pressured to “just choose one” cisnormative gender from the binary system despite my ineffective protests. I’d thought I was settling for “the lesser of two evils”. Now I understand what happens when I allow any evil to dwell in my heart. Never again.

I have since grown to understand that the binary system of gender exists to maintain white men’s illusory power over people of color and over non-men.

I wish a blessed Indigenous Peoples’ Day and — God willing — Indigenous Peoples’ Century to all the brilliant Two-Spirit folks whose names for your own gender, whose names in your own mother tongue, whose names for the world you love, deserve to be spoken fearlessly. As Dr. Mikaila Brown suggested during last week’s symposium at Cornell, may we forever more bring ourselves to meet you at the level of your power, and not reduce ourselves to the level of your pain. You are what makes this world worth living in and living for.

With deep, profound gratitude, I am happy to build upon these life experiences with a new, shiny Executive Leadership Certificate from Cornell University in #Diversity and #Inclusion, received yesterday. This certificate confers not only an accomplishment, but a sacred duty to honor those who’ve made this moment possible. I intend to serve you well, dear loves.

Redneck Solidarity

Redneck Solidarity: Black lives matter!

1999: I was 11 years old, and the Dixie Chicks‘ opening act was Ricky Skaggs. I already owned his album ‘Soldier of the Cross’, but apparently the rest of my generation didn’t know him so well. The Chicks came out on stage while everyone was bustling about for t-shirts and snacks, and commanded our attention. As they introduced their own opening act performers, Natalie explained:

We asked Ricky to share the stage with us for this tour because the music industry has for so long stripped us of our historic roots in the name of profit. We are Bluegrass artists who happen to have a hit-selling Country album. To appreciate our music, you have to understand where we come from. We want our younger generation of fans to learn where you come from, too, and what role this music and its history have played in shaping who you are and the media you’re buying.

They gave us ten minutes to find our seats and asked us to give Ricky Skaggs and Kentucky Thunder the same courteous attention we intended to give The Chicks.

The following year, their careers were effectively destroyed over speaking out against George Bush, and they sealed that coffin further by denouncing the Iraq war.

Tonight though, they took the stage with Queen Bey in perhaps the boldest statement of their careers: Redneck Solidarity with Black Feminist empowerment.

Daddy Lessons couldn’t have been more perfect an anthem for that solidarity.  It is the story of every poor Southern girl clawing her way toward Liberation from within the gun-totin’ Patriarchy. Ain’t make no difference her skin color — though let’s not get twisted thinkin’ everyone’s experience is the same across race. May be all women need empowerment. May also be white women and trans folks have more opportunities to share liberation with women and trans folks of color. May be that’s what Redneck solidarity really means.

My Daddy said shoot.

Praise the Lord and pass the ammunition,

Because Earl had to die. 

At a point in our country’s history, before the Plantation Owners frightened us into hating one another’s voices of freedom and silencing one another’s songs of liberation, we sang them together.

When I read that white country music fans were rebuking the CMA awards show because it was “Diluting its country brand by allowing a pop star to take the stage…”, my first thought was “WHERE WERE THESE PEOPLE WHEN I WAS CRYING ABOUT KIDD ROCK STEALING AIRTIME ON MY COUNTRY MUSIC CHANNEL???”

For real though, where where they? What was their complaint about Beyonce rooted in, if they were content to let Kidd Rock take over not only their stage for one night but also their Country music radio stations without complaint? What is the difference between Kidd Rock and Beyonce? We’re Southern, not stupid. Let’s stop pretending we don’t see this.

Upon learning Beyonce’s performance allegedly diluted “the value” of Country music, then I understood:

The Evangelical whiners are not upset about compromising the integrity of Country music. They are upset about compromising the country music brand. Their White Supremacy exists to reinforce Capitalism. White Supremacy and the Country music industry are so engrained, people have forgotten where the indious business ends and our Southern heritage and roots begin.

Real Country came from making the best we could with both poor immigrants from Europe and their trafficked, enslaved neighbors from Africa singing together by the fire on Sunday evenings. Real Country is not about making money for multi-millionaires, especially by throwing a brilliant Black woman under the CMA bus. Real Country music “ain’t gonna work on Maggie’s Farm no more” and never gives up on the power of love to shoot straight from the hip without missing, especially to when aimed take down the Patriarchy. Real Country music honors women.

Real Country music is the Dixie Chicks and Beyoncé singin’ about their daddies teachin’ ’em to shoot in self-defense.

Together.

🦄💕

Transcending Barriers for Safer Pleasure: A Publication for Transgender Women

This booklet was authored by Brandyn Gallagher in collaboration with Project Inform to provide the most up-to-date, science-based information available for transfeminine people at the time of publication in March 2016.

To learn more about PrEP, advancements in HIV prevention, and options for protecting your health and wellness, please ask your physician or visit https://www.facebook.com/groups/PrEPFacts/ for direction toward more current information.

Is Taking PrEP the Right Choice for You?

Brandyn Gallagher edited this booklet in collaboration with David Evans of Project Inform, updating an older version written for MSM so the writing is trans-inclusive as of January 2016. The scientific evidence upon which this writing is based was the most up-to-date available at the time of publication.

To learn more about PrEP, advancements in HIV prevention, and options for protecting your health and wellness, please ask your physician or visit https://www.facebook.com/groups/PrEPFacts/ for direction toward more current information.

Will the AMP Study Set the Standard for Transgender Inclusion in HIV Prevention Research?

This November, the AMP Study (also known as HVTN 703/HPTN 081) will bring a fresh approach to HIV prevention research. The Phase 2B study is inspired by vaccine research, which seeks to arm the immune system to resist HIV infection — but it skips a step by directly giving HIV-negative people antibodies rather than using a vaccine to trigger the desired antibody response. However, the AMP study is notable for more than this new approach to HIV prevention. It’s also engaging transgender people and people of color at every step of the process, and is the first HIV prevention clinical efficacy trial to explicitly name transgender men as an eligible population to be included in the study.

As explained by HIV Vaccine Trials Network (HVTN)’s lead behavioral scientist, Michele Andrasik, Ph.D., the AMP Study is taking “a true community-based participatory approach.” Trans people and people of color have been involved in writing the protocol, crafting language on enrollment forms and reviewing informed consent and educational materials. Trans people have been employed to fill clinic staff openings, and professional consultants with lived trans experience have been hired to train cisgender (non-transgender) clinicians and staff.

Even as clinic staff have been learning about the concept of AMP in preparation for trial launch, they’ve also been adjusting to the idea of working with transgender people — a minority population that has been widely excluded from HIV research despite a 1993 federal law prohibiting such exclusions.

As a transgender advocate, I’ve been working with the staff of the AMP Study as a member of their community advisory board. A month before the trial’s launch, I sat down with Andrasik and the AMP Study’s community engagement project manager, Gail Broder to hear more about their experiences in this process.

“It’s been interesting, because we usually hear that studies move too slow, but we’re not hearing that,” Andrasik noted. “There’s a balance between moving forward … and ensuring that all the appropriate community stakeholders have a say.”

“Some staff want more time to learn because AMP is a new concept, and because working with trans people also seems new to them,” Broder said. “Once we start explaining, it’s really pretty simple for people to understand.”

“Are they really so ‘hard to reach’? Or have we just not figured out how to reach them?” Andrasik asked rhetorically about minority populations, while emphasizing the importance of positively engaging those populations financially whenever possible. She notes that community participation means more than merely soliciting feedback from members of minority communities — who may or may not get paid — to inform work being controlled by white cisgender people receiving a salary. Moreover, she stresses that including minorities in research is imperative for good data, and if researchers want minority participation in their research, they must begin by hiring staff and leadership from those minority groups.

That can be an intimidating shift for professionals who aspire to work as allies to transgender people, especially once they’re confronted by the rest of society and its attachment to unexamined attitudes and practices on gender and whiteness. But no one said being an ally was easy.

“We booked reservations for community stakeholders to meet at a hotel, but the reservation system required us to enter ‘Mr.’, ‘Mrs.’, or ‘Ms.’ for each attendee. We were baffled,” said Broder, sharing her growing appreciation for the difficulties trans people face while trying to do basic things she takes for granted every day. “We said: ‘We don’t know if this person is a ‘Mr.’ or a ‘Ms.’. They’re just a human being trying to attend this meeting. Just leave it blank and enter their name.’ But the hotel staff couldn’t do that. It’s a hotel room! Why does it matter whether they’re a ‘Mr.’ or a ‘Ms.’ or neither? We’re paying the same for everyone, but no one can opt out of being non-consensually gendered.”

“Ultimately we called the hotel specifically to discuss the problem with their reservation system and to explain why they need to not call people ‘Mr.’ when they show up to check in,” Broder said. “We’re trying to be as proactively educational as we can be and help all the cisgender people we work with along the way to understand that we [cisgender people] aren’t the only people who exist, and good customer service means respecting everyone.”

Broder added that “stock photo sites did not have appropriate images,” and that the HVTN chose to deliberately recruit — and monetarily compensate — trans people and people of color for photo shoots to appropriately reach the minority populations most impacted by HIV.

Despite often-heard fears expressed by the research community about the “hard to reach” transgender population, early findings reveal that HVTN’s choice to genuinely engage minorities is paying off, with the communities it needs to reach taking notice after decades of being turned away as research participants.

“Transgender people can be a part of our research studies, and they’re great participants, and we need to be including them in all of our trials because they’re part of the population relying on these data, too,” Andrasik expressed emphatically. “We’ve found, in our limited sample size in phase I studies, that transgender participants appear to have no greater chance of HIV outcome than their cisgender counterparts, and they have the same rate of showing up to clinic appointments.”

Sites have begun actively recruiting trans people not just for the AMP study, but also for many clinical trials across all levels of risk. The impact on enrollment, though anecdotal and unpublished for now, has been positive across the board.

“Did visibly including trans people in our recruitment efforts improve overall recruitment and ability to reach enrollment goals? It appears that the answer may be ‘yes’,” Andrasik stated.

“People keep saying ‘we don’t have the epidemiology data to include trans people in this study’, but then they don’t do the research needed to correct the exclusion,” Broder stated. “You just have to start including minorities. Start where you can. Don’t wait for someone else to do it. Just start.”

Where do I fit in? PrEP and Transgender Men

View original publication on BetaBlog.org

When I read results from clinical trials about PrEP—or other HIV prevention tools or strategies for that matter—I’m often left wondering: Where do I fit in?

There aren’t guidelines about Truvada-based PrEP use for transgender men who have sex with men because there haven’t been any studies specifically looking at how the drug works in our bodies. In fact, major PrEP clinical efficacy trials have not included transgender men in any of their study populations to date. Robert Grant, MD, MPH, the principal investigator of the first successful randomized controlled PrEP trial with human subjects, iPrEx, confirmed this, saying, “to my knowledge, no trans men have been included in PrEP research.”

Grant says that it’s challenging to get study protocols that include transgender men approved. “The study sponsors will often ask that trans women and men be excluded if there will not be sufficient recruitment for a separate analysis. We had to argue to include trans women in iPrEx. We wanted to include trans men too, but we did not have estimates of HIV incidence among trans men that were required for inclusion in an efficacy trial.”

Because the majority of transgender men have reported condomless anal or vaginal sex with cisgender (non-transgender) men, it makes sense from a public health standpoint to include us in studies in order to capture the role we play in HIV prevention and transmission as a part of the MSM population.

Studies that present their findings as applicable to all MSM but do not include transgender MSM in their data fall short of having representative samples. This gap in our research agenda, evidence-based recommendations, and knowledge of PrEP has important clinical, ethical, and practical implications. Not knowing how PrEP can, and will, work for transgender bodies means that we’re left to wonder—are we truly protected?

“The lack of information about PrEP in trans men is a real problem,” said Grant.

The PrEP CDC guidelines tell us that it may take different amounts of time for people to achieve full protection based on whether they’re exposed to HIV rectally or vaginally. Many PrEP providers tell male patients that they will be adequately protected against HIV after seven consecutive days of adherence, with the assumption that their patients will be exposed to HIV only during anal sex.

Providers may fail to note, however, that Truvada takes longer to accumulate in vaginal tissue—and that transgender men often do not engage exclusively in anal intercourse. The best available information suggests that transgender men who have receptive vaginal intercourse will be protected after 20 consecutive days of dosing, when Truvada reaches its maximum concentration in the body.

Everything known about how PrEP works during vaginal sexual exposure is based on studies of cisgender women—but transgender men have different biological and physiological considerations than cisgender women. Transgender men oftentimes experience vaginal atrophy as a result of testosterone use. Might this condition significantly change the effectiveness of Truvada as PrEP?

Many men are unable or unwilling to use condoms for receptive vaginal intercourse because of the tearing and bleeding that often occurs during sex with vaginal atrophy. Does PrEP provide better HIV protection in combination with condoms despite the damage caused, or counterintuitively, does PrEP provide better protection without condoms since they may exacerbate tissue damage?

PrEP providers may reassure male patients that it’s not a big deal to miss a single dose once in a rare while1, based on the iPrEx OLE study which found no seroconversions among MSM who took Truvada at least 4 times per week. Because no transgender men were included in the iPrEx study, however, we can’t say for sure if this also holds true for transgender men. Cisgender women need to have nearly perfect adherence in order for PrEP to provide full protection against HIV. Is this the case for transgender men who engage in receptive vaginal intercourse, too?

It will be some time before PrEP research is able to fill in the missing data for trans men and answer these questions, but it is critical that efforts begin immediately. Transgender men are currently experiencing a watershed moment of visibility in the larger gay community. Casual bath house sex, cruising, and hooking up using phone apps are increasingly commonplace.

“The field desperately needs HIV and STD prevalence and incidence data, as well as information on demographics, comorbidities, and risk behaviors. In concert with epidemiologic characterization, at-risk trans men should be included in HIV prevention studies based on the type of exposure being investigated—that is, trans men who engage in receptive rectal intercourse should be included with other populations who have receptive rectal intercourse, and trans men who engage in receptive vaginal intercourse should be included in studies of others who have the same sexual practices,” said Raphael J. Landovitz, Associate Professor of Medicine in the Division of Infectious Diseases at UCLA.

Despite the gaps in clinical knowledge of how PrEP works for transgender men, all evidence supports the idea that Truvada provides a high degree of protection in people who take the pill consistently as prescribed—with no reason to believe that it is ineffective for transgender people. Even if there is a slight reduction in effectiveness, which has not yet been tested and is thus unknown, PrEP isrecommended for anyone HIV-negative at substantial risk for HIV infection.

PrEP may well be a life saver for transgender people who are disproportionately affected by HIV risk factors like poverty, unstable housing, discrimination, survival sex work, and disconnection from health care. We can’t give up on including transgender people in medical research. The urgency with which this minority population needs evidence-based guidance on sexual health care recommendations is an opportunity to improve the humanity of science moving forward.

OP-ED: WHY I IDENTIFY AS A FAGGOT

View original publication on HIV Equal

In my younger years, I was called a faggot. I did not consent to this. A kid in gym class swung a three-foot metal pole at my head, and the teacher didn’t care when I reported being bullied. I grew older and connected with mentors who’ve since passed on their own lessons to me about moving through the world being irremediably and obviously gay. Being a faggot is not synonymous with being a gay man, however. Many gay men do not identify as faggots – and some faggots do not identify as men. We’re a diverse bunch like that. But regardless of our internal identities, it’s a word we’ve all heard.

“I was called faggot growing up. I hated it because I knew those jocks were right. I hated they could see the thing I was trying so hard to hide,” a friend shared with me early in my transition. “Calling someone faggot, for me, is basically saying, ‘I can see what you really are. The thing you’re trying to hide.’”

Isn’t that why we hate the word? Because people see us, and sometimes they hate what they see, so we try harder than anything not to be seen at all? Because being called “faggot” means we’re failing to convince our oppressors that we’re their equal? Because invisibility feels safer, and we’re exhausted from living in constant fear?

There are certain images the word “faggot” evokes – images of brutality, of discrimination, of vitriol; images of disease, of stigma, of suffering; images of loneliness, of brokenness, of heartbreak.

In those same images though, I see something more.

Survival. Perseverance. Strength. Determination. Triumph. Authenticity. People who call ourselves faggots exhibit courage beyond measure. We have stared Death in the eyes and refused to blink. We are more than deviant sex behind closed doors. We are a tribe in which membership has nothing to do with our genital configurations or our blood, and everything to do with the capacity of our ever-expansive hearts to love one another in the face of great and divisive adversity.

In embracing my faggotry, I embrace my resilience. Owning this aspect of my identity is an expression of gratitude – both toward my former self for making my way through Hell alive, and toward those strong-willed fighters who came before me for the contributions they’ve made to the world I live in today.

Being a faggot means living in a way that feels right to me as a priority over what’s expected. It means being seen for the rawness of my humanity rather than the mask I so often wear. It means taking struggles and obstacles by the horns and hacking my way through them without reservation. It means surviving a part of my identity I once believed could only result in my death. It means being a whole human being whose sexuality, whose existence, requires no apology.

This word holds the same meaning regardless of who is saying it. It is the intent that changes. The intent is what we respond to. The intent is where its power comes from.

Jocks in high school: “I see what you really are. I hate you. I don’t want you to live, faggot.”

My partners: “I see what you really are. I want you. Don’t hide from your authenticity, faggot.”

Myself: “I see what you really are. I love you. There is nothing shameful about being a faggot.”

TRANS MEN: THE INVISIBLE BATTLE WITH HIV

View at HIV Equal

So there I was, sitting in a room full of the world’s top HIV researchers, uncomfortably under-dressed in my Mr. Friendly t-shirt but not letting that stop me from asking the question I need answered.

“Dr. Molina, in your study on intermittent PrEP dosing among men who have sex with men (MSM), did you see or anticipate any differences in efficacy between the transgender gay men in your study versus the cisgender men? What have we learned about the 2+1+1 dosing for men who engage in receptive vaginal intercourse?”

I desperately need this information, you see, because every day I log into Facebook and respond to yet another question about HIV prevention from yet another trans guy who wants to protect himself from HIV and whose doctors won’t help him. I am a moderator of the PrEP Facts: Rethinking HIV Prevention and Sex discussion group where people from all over the world – research scientists, doctors, community organizers, and lay people alike – come to learn and digest the latest information about HIV prevention and safer sex strategies. There are a lot of trans folks and a myriad of gender identities present there. Many of us use this Facebook group as our primary source for medical information concerning HIV prevention because we cannot get adequate care from our doctors.

But then I ask the doctors why they’re failing us, and they say to me that they don’t have any data. They don’t know the answer. They can’t answer these questions without studies to back them up.

So I asked Dr. Jean-Michel Molina about the trans men in his study, with the naïve and unwarranted optimism that he would tell me something useful, something I could relay to the droves of trans men seeking me out as their last glimmer of hope for sexual health. He responded by telling me about the one trans woman in the study, with no mention of trans men at all. Another researcher in the room explained to me afterward that trans men were not included in this study. Dr. Sheena McCormack would later apologize to me that her PROUD study in the UK, about which I’d been on the edge of my seat for months to see results, also failed to include trans men.

I have been a participant in a PrEP research study at the University of Washington, as have many of my trans brothers in Seattle, so I know we’re showing up to do our part for medical science. Yet, even though we’re presenting ourselves, able and willing to offer our researchers abundant data about our bodies, at best these studies have not been designed to track the information we’re providing. Or, at worst, as was the case in both the IPERGAY and PROUD studies, the criteria for entry into the studies are designed in such a way that explicitly makes trans men ineligible altogether.

I want to let you in on a little secret: Transgender gay men are not heterosexual women. We do not have sex like women do. Our behavioral risk factors are the same as the behavioral risk factors of gay men, because – big surprise – we are gay men. Sometimes we have anal sex. Sometimes we have vaginal sex. We have sex in bathhouses, perhaps with 20 or more guys in one evening. Not all of us, but some. We cruise for hookups in the twilight hours at Volunteer Park. We meet guys on Scruff, Grindr, and Craigslist for casual one-offs. Some of us use poppers, crystal, and other drugs associated with the gay party-and-play scene. We are at high risk of HIV just like cisgender MSMs are, and we’re being ignored.

This cannot continue. We already have a 41 percent or greater rate of suicide attempts. For trans folks who survive society at large, we are then faced with incompetent medical professionals who use the wrong pronouns, who refuse to listen to us and who cannot or will not give us answers about how our bodies work. We have to fight for basic healthcare, fight for HIV prevention, and then ultimately fight for HIV treatment after we’ve been cast aside until it’s too late to prevent infection. Still, no matter how hard we fight, we cannot bypass our doctors to independently investigate research about the HIV prevention strategies that are optimal for us ourselves – because no such research exists. We are an invisible, dying group of gay men being left to face the threat of HIV with no one hearing our cries, no researchers taking notice and no public health officials acknowledging our plight.

The HIV epidemic of the 80s and 90s does not have to repeat itself. We have the tools and the knowledge to prevent HIV. We just need medical professionals, researchers and advocates to step up and make it happen now. Please, help us.