Love in a Time of Fear, part 2

Since attachment styles are formed early in childhood and continue to affect how we form relationships throughout our lives, the following writing builds upon a foundation described in Love in a Time of Fear, part 1.

This week I shaved my face. I dressed myself up like a woman, because my hair is long and I live in Arkansas where men ain’t looked upon favorably with long hair. These days I can pass myself off as cisgender better as a woman than as a man. The charade just to keep “Christians” from violently hating me and denying me my basic human rights because they hate me is exhausting. All gussied up and pretty, I went out onto a literal Civil War battlefield to fight for my freedom by asking folks to vote for Josh Moody for Washington County Judge and Chris Jones for Governor this November.

Two days later, I went walking with Josh on the Square of a rural Arkansas town where men sitting around the hardware store literally asked him to instate slavery through the county jail to address the worker shortage, talked about wanting to tie their neighbors up with rope hanging from a tree and torture them for days, and said with unapologetic casualness, “1818 was a good year.”

I knew what was expected of me, and what my safety depended on. I stood there like a good girl and kept my damn mouth shut while the men folk talked about important grown-up business.

Arkansas lately is making me feel like I’m back in my teenage home. Once more, I’m just considered a living, breathing piece of property forced into this world so religious white zealots could control me, not so I could be loved or wanted for real. My heart breaks for all the babies being brought into the world by forced birth now who will grow to feel the same way. I hope God will lead them to the survival guides left behind by the previous generations who know their struggle to be loved all too well. They deserve to be loved and wanted — not for what they can do for white men, but because they are divine beings with inherent, sacred worthiness.

As a white girl-child in the South, I learned that asking for love is an expression of vulnerability to be answered according to the interests of white men. Even in relationships with women, as was the case with my mother and grandmothers, vulnerability was a power lever to advance one’s standing in proximity to white men — fathers, grandfathers, boyfriends, bosses, police officers — who benefit from keeping us divided against one another like crabs in a bucket.

I learned to do mental gymnastics with older men as a child like they were my tumbling instructors, kneeling to offer the assurance that I won’t fall as long as I have the safety of their arms supporting me from behind, while I learned to flip myself upside down and around and ’round at their command. They taught me to be a good girl and keep my damn mouth shut while they talked about important grown-up business like slavery and rape.

In my 20’s, I rejected my role as their trophy, as their woman-prize, as their life raft to be clung to and climbed upon in a sea of responsibility these men had somehow convinced me they were keeping me from drowning in. I decided to become a man and find out what equality with them really felt like. For five years, I had that equality. It was bitter and poisonous, but I had it. It felt good. Like fruit from the tree of knowledge of good and evil, knowing how it felt to walk through the world as a white man’s equal was delicious.

At 30, I retransitioned. I’d made myself sick on the wrong kind of power. I wasn’t who I’d intended to become. I’d become entitled, demanding, and had zero awareness of how much space I took up in conversations with women. I thought if someone just made me President, I’d wave a practical magic wand and fix all the problems that the Democrats ain’t got the guts to do anything about. I needed to lower my testosterone dose, among other things, and come back down to earth. So I did.


At 33, I began dating a white cisgender pansexual man in Arkansas. He’s frequently the only white person in the room, and he keeps getting invited back to the cookout. I could see this from his Facebook photos when I was considering whether or not to date him, and figured if Black folks could stand to be around him, maybe I could too. We’ve now been together for 7 months.

We spend one evening a week together. I yearn for a partner I can share my daily life, meals, and home with — but also a partner who doesn’t frighten or abuse me. There are plenty of available men who think casual rape jokes are cool, who give me no confidence that they respect my bodily autonomy. This one man I’ve found is less available than I’d like, but he doesn’t punch down at me, or at anyone, when he makes jokes. At present, I accept a one-day-a-week relationship as part of the price for being with someone I trust won’t rape me or make me question my sanity. He agrees with me that this is too low a bar, and I deserve better. I’m keeping my eyes open and looking for a better-suited partner, but I’m not going to end a decent relationship with someone I wholeheartedly love while I wait for a better and more consistent relationship to come along.

Expecting a partner to respect me as a full human with equal rights is really the bare minimum. It’s just a bare minimum most men in the United States don’t live up to.

The men when I was a teen were cops, lawyers, and rednecks who took advantage of my desperate yearning for someone, anyone, to please just love me. I was 12, 13, 14. They were 28, 44, 50. But thanks to this recent Evangelical power-grab across the whole damn government, I feel 12 again. I’m 34 years old, and I feel like a trapped child among merciless “Christian” savages in their quest for control over my body. I am the 10 year old girl in Ohio who had to go to Illinois for an abortion. I am the 11 year old child whose body can’t take the physical demands of pregnancy. I am a survivor of Focus on the Family which taught me in childhood to be a “good girl” for white men who don’t respect me as a human being. If I had never become a man myself, I don’t know that I would have gained enough perspective to hold real boundaries today against the white men who have always felt entitled to control my body.

Recently I talked with my partner about this. It’s a power dynamic threatening to knock our relationship out of sustainable balance. It’s a power dynamic knocking me out of sustainable balance. He didn’t understand, at first. He sees me as his equal. So when I described myself as “property,” and remarked how I appreciate that he “grants” me my full humanity in our relationship, he was appalled. He found it gross to think of my rights as his to grant or deny to me. As far as he’s concerned, he doesn’t have that kind of power over me.

He does have that kind of power though, and he can choose to wield it over me if ever he wants to. As much as I trust he won’t abuse that power, I cannot pretend he doesn’t have that power, any more than I can pretend a lion doesn’t have large teeth when I’m in his habitat. The lion and I may have an established, loving relationship that would make the cutest viral TikTok video ever — but if he ever has a Really Bad Day and decides to turn on me, I know who would win and who would lose that fight. I cannot pretend homicide isn’t the number one cause of death for pregnant people. I cannot pretend cops and judges don’t consistently side with abusive white men who argue in court that “she had it comin’.” I cannot pretend the law protects me as a transgender person even half as well as it fails to protect the cisgender women who still get killed, stalked, and discriminated against in this country every day. I cannot pretend I wasn’t raped just one year ago, by a man who used the Trans Panic Defense to (easily) convince management at our workplace that he was the one who’d been wronged because he’d allegedly thought I was a woman, and this alleged deception was a worse offense than the fact that I’d told him “no” more than a dozen times and repeatedly pushed him off me before he forced himself into my body. The patriarchal landscape in which my relationship with my partner exists puts a weight in my knapsack that I’m constantly carrying around. His participation in the oppression isn’t required for me to experience the weight of that oppression.

If you want me by your side in a relationship, I need you to acknowledge I’m carrying around the weight of how society gives you the option to abuse me, regardless of what you choose to do or not do with that power. If you want me to be your equal in a partnership, I need you to understand how unequal we are in the scope of social power systems. If you’re legally and socially empowered to harm me without consequence, what’s to keep you from abusing me and simply calling it by another name?

Since the government considers me less than a full human, to be owned or controlled by white men, what does it take to make me an equal in a relationship with a white cisgender man? Is equality in our current society even possible? What changes would that require? What Constitutional amendments would that require? What changes in manhood and the standards men set for themselves would our equality require?

Love in a time of fear is soul-crushing, like the full weight of unrelenting gravity trying to squash stars out of existence. I hear persistent messages from the government, from neighbors, from media, all basically saying I should just count my blessings every day I’m not beaten or shot to death. I should just be grateful I have a relationship with a man at all. I should be glad that when unwelcome men hit on me I can say, “I have a boyfriend,” persuading them to leave another man’s already-claimed property alone in peace. I should be grateful for that “protection” having a boyfriend adds to my life, as if simply saying “Please leave me alone” isn’t reason enough to respect my boundaries.

My partner doesn’t like that I see myself as property. I don’t know how to explain to him with words what it feels like to go from being a white woman, to being a white man, to not being a white man anymore. I don’t know how to say, “I believe that you see me as a full human, but I also know most people don’t see me that way, and it’s dangerous for me to pretend they do,” in a way he’ll fully comprehend.

This week I shaved my face. When date night rolled around, he looked at me and scrunched his nose with disapproval. I don’t look right without my beard, he says. I’m not “me”. He’s not wrong. But I survived the Old Boys’ banter in the hardware store about bringing back slavery and lynchings without being followed home or hurt, and I lived to show up for date night this week. If I’d been visibly transgender in that hardware store…. Well, being able to blend in as if I were cisgender helps keep me alive and safe around here. It’s humiliating and infuriating, but at least I’m alive to be mad about the injustice.

Love in a time of fear is also brilliant. We’re stars committed to shining amidst profoundly frigid darkness, resisting the gravity trying to squash us out of existence. I hear persistent messages from my lover, from friends, from Mother Earth, all basically saying they count their blessings every day I’m not beaten or shot to death. I am glad we create warmth for one another. I am grateful for our commitment to nurturing one another’s invaluable lives. I am delighted to cultivate a brighter future together than the darkness into which we’ve been delivered.

My partner holds space for me to breathe when we’re together. The nausea and headaches ease up in the wondrous force-field of his embrace. I do not pretend his individual white-cis-man-ness can singularly protect me from the big bad world, but he digs deep enough within himself and takes care not to replicate the cruelty most men casually take for granted as their right to inflict. He figures out how to make me laugh in spite of the fear. Those moments of laughter and joy, of warmth and embrace, of care and growth, of passion and devotion, are worth living for. Even in a world filled with hate, love is worth living for.

Even in a time of fear, love is worth living for.

“We’ve Invited the People of Color. Where Are They?”

I believe that transparency is fundamental to Democracy, and fundamental to healthy community building. I hope the organizations who’ve inspired this post will share this belief, as it forms the basis upon which I write the following in a spirit of goodwill and community healing:

Last night I attended my first-ever local Democrats meeting. I’d been asked by half a dozen people to show up and get involved.

“We need you,” they said. I’m allergic to being needed, after 5 years of living as a white man and developing a disastrous savior complex in my 20’s. Highly allergic. You don’t need me. You need to look within yourself and be honest about what you see.

“We lack organization since the old guard has phased out,” one told me. “That generation of Democrat didn’t listen, but they were organized. The newer folks care enough to listen, but we aren’t as organized.”

“Our Black caucus and Hispanic caucus have already peaced out,” a couple of them shared. “How can we be a Democratic group without a Black caucus and Hispanic caucus? They won’t even show up anymore! How can we live up to our values with just white people at the table?”

So I showed up. I listened. I learned. I ate lemon cake.

I noticed there was one visibly Native American person in the room, and everyone else was white. I was the only transgender person in the room; everyone else was cisgender. There was one Black woman on the zoom call, who also happens to be the only Black Justice of the Peace for the whole county; everyone else on zoom appeared to be white or had their cameras turned off.

I asked the leadership about this lack of diversity after the meeting concluded. The white woman in command began naming a list of BIPOC community organizers she knows, none of whom want to be involved with the county Democrats. I asked her why they don’t get involved (as if people she named hadn’t already told me themselves.)

“Well I’ve invited Irvin, but he doesn’t want to get involved until he sees us in Springdale doing the work in the community,” she answered. She looked resigned, like there was simply nothing more the Democrats could do to persuade the magical and illustrious Irvin Camacho to give a flying flip about the Democrats who want his communities’ votes so desperately for their many candidates.

“Great!” I said. I mean, really, this was wonderful news for the Democratic Party in Arkansas! Apparently Irvin’s still open to them earning his presence at their table. He hasn’t slammed the door in their face and told them to go masturbate with sandpaper. There is opportunity here! All the Democrats have to do is show up for grassroots community engagement and help out in the ways that are needed by the people they’re supposed to serve.

“So what are you doing to help get Alice Gachuzo elected to city council in Springdale right now?” I asked. I was on the edge of my seat, ready to hear about the door-knocking, the phone calling, the texting, the donation drives, the events these experienced, political-savvy people were helping Alice with for her campaign as a first-time candidate with a solid history of non-political leadership in the community.

“Oh, I know Alice!” the leader said excitedly.

“Yes, but what are you doing to help her get elected?” I asked again. “What are all the people who were in this room tonight doing to help her get elected?”

Another leader of the group spoke up. “City Council is a non-partisan race,” he said. “We don’t usually get involved in those.”

White Democrats, this is where the fork in the road requires us to choose between white colonization practices, or community, and walk the path we choose. What we “usually get involved in” and what we need to get involved in if we care to repair our communities are not the same path. Let me explain:

City Council may be a non-partisan race, but the impact of the first-ever Black woman being elected to office in Springdale, a predominantly non-white city run by wildly non-representative, white council members, is immeasurable. The impact of her representing the people of Springdale instead of the special interests of the political and financial elite, is immeasurable. Her potential impact on our communities as minoritized humans is immeasurable. I don’t even live in Springdale anymore, and I’m working to help Alice get elected because I know she will make the world a better place. That’s all the reason I need to show up and help.

The old ways of the Democratic Party were about playing by a two-party rule book of numbers and cunning out-maneuvering. The Democrats approached politics like a chess game with Republican opponents, instead of a life-or-death struggle that transcends party lines. That old style and approach gave rise to Hillary Clinton. The United States had already made very clear when we voted for Obama that we wanted Change. We wanted freedom and justice for all. We wanted hope. We wanted to stop playing old political games of oppression olympics, and start investing in our children, in our well-being, in our planet, and in our future. But then the Democratic Party in 2015, turning to its old, familiar, abusive patterns under the arrogant assumption that Donald Trump couldn’t possibly get elected, tried to force-feed us one of the most repugnant candidates it could: Hillary Clinton. The Democratic Party tried to make us accept as our leader a woman who talked about Black children as if “they must be brought to heel”, a woman who verbally eviscerated a 12 year old rape victim on the witness stand in Arkansas to advance her career as an attorney, a woman who deliberately aligned herself with the man responsible for “three strikes and you’re out” executive legislation — as well as the soaring stock prices of Corrections Corporations of America, a for-profit prison system continuing to this day to profit on the enslaved labor of primarily Black and brown bodied people. The national Democratic Party chose the white colonization practices path instead of the community path, and walked the path they chose, and got Donald Trump as a result.

When you tell God you want white colonization practices, God will give you what you ask for.
When you tell God you want anti-racism, God will give you what you ask for.
When you’re lukewarm, God will spit you out like Hillary Clinton’s hot sauce.

When Irvin tells the leader of the local Democrats he’ll show up for us when he sees us showing up for his communities, he’s offering us a way out of that predicament. The price his presence will cost us is a simple, sincere commitment to prioritizing the needs of the people, and doing what’s right, over the “usual” procedural vestiges of a crumbling Party.

That’s probably what the Black caucus’s presence will cost us. That’s probably what the Hispanic caucus’s presence will cost us. That’s what the privilege of enjoying Indigenous people at our decision-making tables will cost us. White Democrats like me must pay the price of humility and committed action to earn their presence at our table. Nothing is free.

This is like any other relationship, y’all. You can’t just offer a half-assed contribution to an unhealthy relationship and expect the best-ever partners to stick around for that relationship. You get what you give. People who know their worth will go where they are appreciated.

White Democrats have been showing up with pretty-worded apologies, and maybe occasionally a dozen roses, asking minoritized people for yet another chance to hold an abusive relationship together. Then when they get another chance, they crack open another cold one in front of the TV and sit down to relax like they’ve done a gazillion times before. Meanwhile, people of color have been asking Democrats to be full-fledged partners in their lives — doing our part for laundry day, doing the dishes, and treating the children like they’re our responsibility to show up for.

You don’t get people of color at a table built by white supremacy simply by asking them to show up. You get people of color at the table by scrapping the bullshit and building a new table they feel comfortable at. You get people of color at the table by acknowledging openly and honestly where the harms have been your own fault, and not repeating the mistakes again. They don’t want roses and chocolate. They want you to not sit back down in that old chair while asking them to bring you another beer — or get out and take your roses with you. I feel like they’ve been really clear about this.

By the end of the night, one of the leaders casually offered to me, “You can be in charge of our diversity!”

Oh, what I would have given last night to still feel even an ounce of the honor, the excitement, and the pleasure I used to feel when people invited me to be a First, Only, and Different participant in a game they had already fully constructed around and without me. But I see the F.O.D.s who’ve already told the Democratic Party what kind of community participation they need in order to feel invested in in this relationship, and I’ll be honest: I don’t want to be the next in line for the kind of relationship they got served.

In the interest of not picking on just one organization, it’s not like the Democrats are alone with the White Blinders problem. I saw a similar mess this week where a local, white-led LGB(T) organization responded to Black and Indigenous queer community organizers who’d identified a specific white supremacist threat against the Pride parade, by issuing a statement that they’d enlisted extra help from the police department, denied any known specific threats existed, and low-key urged queers of color not to arm themselves for self-defense and just trust the police to handle it — all while choosing not to engage any of the queers of color in meaningful conversation.

I didn’t have to know their organization is entirely white, to know their organization is entirely white. I didn’t have to know the only trans person on their board of directors left earlier this year, to conclude they are entirely cisgender-led. Their statements this week made the evidence abundantly clear. We can hear whose voices are missing from organizations’ decision-making tables as clearly as we can hear the voices missing from the San Francisco Gay Men’s Choir of 1992.

White supremacy is a retropsychopathology affecting us no less intensely than the unchecked retroviral epidemic of the 1980’s. What will it take for us to look within our hearts and choose the path of our loving, friendship-focused, generous, inner child rather than the policies and systems of white entitlement we’ve been trained into as adults?

Having diverse voices in your ranks is how you avoid these fiascos when unexpected or urgent situations arise. You build the relationships when times are good, so you have diverse people to collaborate with when times are hard. And you don’t get those relationships by setting the terms of the relationship and then inviting others in. You get those relationships by co-creating and sharing in the work as much as in the fruits of the labor.

White people, we can do this. Just take a deep breath, and choose what you’ll invest your energy in today.

On Democracy and Our Humanity

For the first time, I’ve gotten involved in a political campaign. Two of them. I’m learning things about the way our “democracy” is systematically structured against democracy though. Can we talk about what I’m seeing?

Observation #1: Non-profits are not allowed to support any political candidate.

Observation #2: Many cities and towns prohibit political candidates from gathering on public property.

Observation #3: People with lots of money host fundraisers and events on private property for the candidate of their choice.

Stir them all together, and what do we have? Vote-buying power for the financially wealthy. Cities and towns with uneducated voters. And a real struggle for average, non-politician, service-oriented people who care enough to take on the establishment and represent our communities appropriately in the government.

I’m working on a small, local campaign for Josh Moody for Washington County Judge. I feel strongly about Josh’s efforts because he will work to reduce incarceration of Washington County citizens, push back against $100 million in taxpayer funds being spent to build a new jail that we don’t need, and redirect existing funds toward providing mental health and housing stability services. He will nurture and heal Washington County residents. He’s committed to investing in our strengths, not our weaknesses.

My job is to schedule “Think Out Loud” community listening sessions where he goes around Washington County and listens to what you care to say. He wants to know your needs, your ambitions, your hopes, and your requests. This is what every prospective government official should be doing.

I keep running into roadblocks though. “No political campaigning on city property” and “We would love to host you, but as a non-profit organization we cannot let you use our space or be affiliated with us in any way.” This keeps Josh from getting to listen to the most marginalized people — especially people who rely on non-profit services to stay alive. This keeps him out of homeless shelters, out of churches, out of community groups, out of public libraries, and out of city parks. This system of government interference in political campaigns keeps him from having access to Washington County residents, and keeps Washington County residents from having access to him.

Meanwhile, Republican candidates seem to have plenty of for-profit business owners ready, willing, and legally allowed to host their events for community outreach. With promises of jail expansion, using covid relief funds to expand imprisonment instead of honoring Washington County residents with rent stability, and sometimes even a blatant indecency to kindly say hello to certain minoritized constituents, Republican candidates in local races are buying votes through a crony system that only allows gathering in for-profit spaces.

I’m watching a parallel tragedy unfold in my volunteer work on the Chris Jones for Governor campaign. For so many decades of Arkansas history, the Democratic Party has played by an oppressive two-party rule book; few people — particularly people of minoritized race, gender, and class — feel heard or cared about by the Democratic Party. Arkansas is not a red state. Arkansas is a non-voting state. Arkansas is a state that asks, “What’s the point?” when I plead for their vote this November in support of candidates who want to invest in our children, in our economy, and in our future.

The alternative to Chris Jones for Governor is Sarah Huckabee Sanders, who has repeatedly shown up in photos with, allied herself with, and chosen not to denounce white supremacist insurrectionists. She’s proposing tax cuts to benefit the wealthy (think Walton- and Tyson-wealthy) that will negatively affect already underfunded social services. Her father was the same terrible governor who took me out of class in high school so I could be weighed and have my BMI printed on my report card, because he believed having our parents shame us for being fat would leave a better impact on Arkansas’ youth than making healthier school lunches more affordable than a dollar menu McDonald’s burger. She responded to the Uvalde shooting by saying that very evening, “We will make sure that when a kid is in the womb, they’re as safe as they are in the classroom” — completely missing the reality that people who are not white and financially wealthy, like her, are not safe in Arkansas. Also missing the reality that Arkansans will die from ectopic pregnancies under her plans for anti-abortion laws. Or maybe she just doesn’t care if poor Arkansans die, since rich Arkansans will always have access to abortions whether it’s legal or not. She has spent her life preparing herself as a political pawn for a group of anti-Democratic, anti-American goons who want to take the government my uncle gave his life in the US Army to protect, and replace it with an authoritarian regime. This terrifies me.

Sanders’ campaign has raised over $13 million to Chris Jones’ $2 million at this point. She is buying her way into the governor’s seat, while Jones is out walking all over the state to meet with communities, truly listen, and consider the feedback and solutions that real Arkansans are now proposing to him. He is not a politician. He is a minister who sees a need for Arkansas to be represented and cared for in a spirit of faith, hope, and hard work. Chris Jones is currently doing what I was taught in high school American Government that our elected officials exist to do. He doesn’t have as much money, but he does have the power of people who know Arkansas needs relief and empowerment.

If people vote. If he can reach them. If he’s allowed to gather with them. If local anti-political ordinances don’t keep Chris Jones from being allowed hear to all voters, like they have been keeping Josh Moody from hearing all voters.

I’m sitting with the weight of this truth and trying to explain it to my inner 16 year old who once sat in Bob McKee’s American Government class at Fayetteville High School, bright-eyed and trusting about the promise of freedom and justice for all.

Can you explain any of this to my inner 16 year old? Can you say anything that will make the pain of betrayal by my own country, my own state, my own city goverment sting less? Can you do anything to change the system so it serves the people affected by it? Even just one small thing? Even just show up to vote for candidates who care about living up to the values of liberty and equality which America purports to uphold, rather than sustaining the values of division, hatred, violence, and heartlessness we’ve been suffering from for too long? Maybe putting up yard signs and talking with your neighbors? Something? Anything?

There’s a 16 year old in Arkansas who needs you to leave them a better reality than what’s been handed down to me. Please show up for them?

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.

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.