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Transcript: Empowering the Transgender Community: The San Diego Experience

In May 2005 HIV InSite recorded the proceedings of several sessions at Equality and Parity: A Statewide Action for Transgender HIV Prevention and Care. Following is a partial transcript of presentations on Empowering the Transgender Community: The San Diego Experience.

Participants: Tracie Jada O'Brien, Transgender Health Project, Family Health Centers of San Diego; and Jim Zians, Principal Investigator, San Diego County Transgender Needs Assessment Report.

Tracie O'Brien

Good afternoon, everyone. My name is Tracie O'Brien, and I'm the coordinator of the Transgender Health Project at Family Health Centers of San Diego. It's an honor to be here today to share the experience that we had in San Diego in empowering the transgender community of San Diego County. It is really important to say that the California Endowment graciously funded the Transgender Health Project, and it was really a great undertaking to empower and assess the comprehensive needs of the San Diego transgender community, and I would just like to share with you some really important information about the organization in which I work, about the California Endowment, about San Diego County's transgender community and how we all step forth as a collective group of people of transgender advocates, consumers, and allies, along with Family Health Centers to make a definite change of healthcare, medical care, and social services care service in San Diego County.

That was a lot, huh?

Okay, and this is my first PowerPoint, by the way; I'm so excited. I would also like to welcome my partner in crime, Dr. Jim Zians. We've worked really, really hard this last almost year and a half in completing the Transgender Healtcare Needs Report 2004, and it's almost in completion stage. It's going to the printers, and the report will be available via e-mail - electronic copy - and there will be very minimal hard copy but it will be available electronically, so just take down my information and I will more than happy to pass it along to you.

But getting back to the presentation, Family Health Centers of San Diego County provides comprehensive accessible quality health care services to residents and business of San Diego and surrounding regions. We offer affordable services to all income levels, with a special commitment to low income medically underserved individuals. The services offered at Family Health Centers of San Diego are as follows.

Family Health Centers of San Diego is the second largest community clinic network in California. We have thirteen clinic sites throughout California, in this entire county, I mean, El Cajon, Jamul, and South Bay closer to the Tijuana border. We have multiple sites providing a vast array of services. Those services include women's health services, pediatrics, adult medicine, health care for the homeless, laboratory care, pharmacy care, drop-in centers, mental health services, dental care, vision care, specialty clinics, health education, and outreach services. I just want to add the Family Health Centers has been in existence for over 35 years. Family Health Centers came to be in a part of town very much like the Mission area here used to be some time ago. A little old lady would walk through the community - it was like the Barrio Logan community, Latina community of San Diego, and she would walk around caring for people, and she would continue to walk, and as she began to walk and start caring for people, to make a long story short, this small clinic evolved. It evolved from a drop-in center to almost thirteen locations providing an array of services for medically underserved and underprivileged and low income and marginalized communities, so I'm really proud to be the only open and out transgender person working there so far, but there is always room for more people.

Family Health Centers of San Diego has always also been on the forefront of HIV services, and I would like to share a little bit of that history with you now. In 1987, Pacific Outreach Services began at Family Health Centers of San Diego. In February of 1990, an acquisition of a beach area clinic and a Ciaccio Memorial Clinic was dedicated to HIV services specifically for the community, and Ciaccio Memorial Clinic opened up for services at its own site. Now these two clinics were mixed together providing like prevention -- probably like condom services -- the minimum of services that was available back in 1990. If any of you services providers and consumers can remember the pandemic back in 1990, how devastating it was and how the services were or were not appropriate for that specific point in time, but at that point in time, Family Health Centers of San Diego had these two clinics dedicated to providing services, and at that time these two clinics kind of separated from each other, so we had this clinic out towards the beach and we had this other Ciaccio Memorial Clinic at its own site, and that site -- in 1995, that site, which is the Ciaccio Memorial Clinic, moved to North Park. I would also like to add that North Park is the epicenter of the LGBT community in San Diego, so North Park Clinic is right at the epicenter of the AIDS pandemic ever since the early 90s.

HIV/AIDS specific care, support, and prevention programs continue to be added to this day. We do have a gay men's health program, we have a young men of color program, we have Latino programs, and now we have the first ever transgender health project in San Diego County, which is a coup in itself. I mean, you guys have been to the big ol' boy city of San Diego County, just the mere fact that we're acknowledged in San Diego County is really a wonderful thing, a wonderful, wonderful thing. Because we have a tendency to be more open to gay and lesbian issues, and when you are gender variant, you can't help but present your differences to people, because, unlike being gay or lesbian, not to speak down anyone in this room, but unlike being gay or lesbian where you may have the tendency or the ability to cover that identity, well, you know, being transgender is not an identity, it's a presentation; it's who we are, so it's really difficult to camouflage that, so to have a program such as ours going strong in San Diego county is a really wonderful thing.

So Family Health Centers of San Diego and our 13 clinic sites, mainly our North Park Area site, which is really dedicated to fight HIV prevention services and ADAP services and HIV testing, is located in North Park in San Diego County, and we are currently the largest comprehensive provider of HIV-related services in San Diego County, and I'm so proud to be a part of that whole program.

And now I want to share with you how myself and my community came to be a part of this wonderful, wonderful medical provider organization. And I like to call it the emergence process. The transgender emergence process is really a wonderful thing to be a coup within a "heterosexual mainstream medical clinic," so I'm really, really proud of that. And how this started was that, you know, historically since the AIDS pandemic, we have the historical MSM program, you know, and like was mentioned earlier in one of the rooms inside, the transgender community had this really small box within MSM program. And also just to speak realistically, since the pandemic of AIDS, it really empowered a lot of people, and mainly it empowered the white gay male, and a lot of these programs, the MSM programs, they were white gay male driven, white gay male directed, and white gay male supportive. And once again this disclaimer not to speak down on anyone in this room, but I'm just speaking the facts as which I see it.

And the MSM programs from my experience in the past that many directors of MSM programs would not even entertain the thought of extending service to a transgender person. Because I've in social service for quite some time now, and the first program that sought out to fund HIV prevention services was a young men of color group, and they wanted me to be their token transgender person, because, you know, there is like this little molecule of money provided for our community underneath MSM programs, and I said no because I did not want to be a part. I wanted to provide services for the community so I said no. But, you know, Family Health Centers is really different, because, in this MSM program there was a clinic called the Gay Men's Health Clinic, and this clinic provided comprehensive services, HIV testing, STD and STI screenings, vaccinations for hep A and hep B, a three-series shot of vaccination, and also anal warts -- just comprehensive preventive care, you know, for gay men. Given the part of town that it was in, which is heavily populated with the transgender community, some of the girls started going there as well.

And there was a point in time when I was working at a recovery program in San Diego County and I realized that a lot of the girls were going to Tijuana, a lot of girls were sharing needles, a lot of girls were going to parties and they were being infected with HIV and STDs just by sharing needles. So we at that point in time, first we went to the Lesbian Health Project in San Diego County and shared our plight with them, and they were like, "Oh, okay, well, sorry, we'll get back with you," which they never did, you know. So we felt hurt, we stepped back and healed ourselves, because I'm from the streets so it would take more than that to get me down, you know. So from that point in time we then went to Family Health Centers, the then Gay Men's Health Project and told the then-doctor, Dr. Joseph Brown, about the comprehensive emergency needs of the transgender community, mainly HIV services that are appropriate for the transgender community, that target the transgender community, and also monitor hormone therapy and transition-related care. And God, they were open to the whole idea, they were open to the whole idea, and it was really a wonderful thing, and in doing so we decided, they said, "Let's get the transgender community together and start an advisor group and where we can go with this."

In doing so we got people together, and we started the Transgender Community Coalition. The Transgender Community Coalition kind of gave education to the Gay Men's Health Clinic. It gave them education about the needs of the transgender community, and they were open, you know, because this is mainly a clinic of providers who provide services and, you know, have you guys been around medical nurses or PSR, the providers, you know? The mundane work of doing charts and stuff like that can get really tedious, so it was really difficult to get a lot of people to understand. We were forthright and we kept right on going, so what we did was we created the first-ever -- of Southern California, that is -- Transgender-specific HIV prevention brochure, which we have some in the back for you if you'd like, because we have over 10,000 of them. They're on the back table, and they're also available in the AIDS Clearinghouse catalog, and I'm really proud to do that because what that did, that gave the girls and the guys in our community something to do. Because it's really important as providers to understand that when you try to reach out to a community who has no history of being reached out to, to have the expectation that everyone would come to the table full of thought and ready to put in work, that is not the case. There is a healing process that needs to happen within the transgender community, and I will speak more to that as I go on.

I also want to give kudos and much gratitude to the California Endowment. The California Endowment Committee's first grant, like it was said earlier, funded this parity and equality conference. It also funded the Transgender Health Project of Family Health Centers. But also what you guys might not know is they also fund the FTM Alliance in Los Angeles, they also fund the National Center for Lesbian Rights here in San Francisco, and the University of California, Davis, just to name a few. So the California Endowment is a really, really wonderful organization. I'm so happy to be a part of that.

With the money that was allocated from the California Endowment, the Transgender Health Project came into being, and the project goals were two-fold. Number one: to increase awareness regarding unsafe sexual practices and needle use behaviors among transgender persons at high risk to HIV infection, improving health-care seeking behaviors. Decrease barriers to health and social services by building a network of TG-friendly providers, and that's what I hope we're doing in this breakout session, is building the capacity to be good supportive providers that have the capacity to serve and understand the transgender community. And number three: to build the capacity of the transgender community coalition members of San Diego, establishing a self-regulating, effective, grass-roots forum to address a spectrum of TG-related issues.

Now if you guys could just imagine our first meeting, we had all these people who are trans-experienced in this room, and every trans person had an agenda. Every trans person had a need -- which was wonderful, but it was kind of difficult to keep everybody in check, you know, but it was a wonderful undertaking because I come from the mainstream social service, so I told myself some time ago if I was going to spend this much energy in making a change, I would rather do it within my own community, so that's why I came home.

So the project has its strategies, and those strategies was phase 1, the assessment, which I'll speak to much later and Dr. Jim Zians will speak to some of the analysis from, do a comprehensive needs assessment of the transgender community, because we first approached the California Endowment with the request to create a project. The California Endowment said, okay, well, we can't really give you money to create a project without knowing what the needs of the community are. And they said we need to do this comprehensive need assessment. So once again all the girls and guys got together once again -- can you imagine -- all these people creating these questions, you know, little did we know, then we found out much, much later these tools were already created by one of the people like JoAnne Keatley and the Van Ness Recovery House in Los Angeles, but we didn't know. I'm really happy that we were able to create a comprehensive tool. And a part of the phase one was to do a community outreach and education to TG persons and service providers, which also was a wonderful undertaking, and once again advocacy among community organizations and service providers, building the capacity to advocacy and the collaborative efforts between agencies to work together to provide good services.

And phase two is implementation. We just completed the needs assessment sometime back at the end of last year that will culminate into the Transgender Healthcare Needs Assessment Report 2004, which will be going to the printers very, very shortly. And I'm very happy to say that we met with the California Endowment and we sent off a proposal, a three-year proposal for phase two about two weeks ago, and we'll probably hear back from them stating that, oh, we'd love to give you the money, probably in October, and I'm choosing to think that way, because I don't have the luxury to think any other way than that. I refuse to think any other way than that. And phase two will happen when the funding is forthcoming in October, and I'll probably be here next year telling you what phase two as all about.

So a part of the strategy, like I said earlier, was to build the capacity of the San Diego transgender community. That culminated into the Transgender Community Coalition. And I have this here because this is our coalition little logo here, and this was created by one of our own trans women in our community. We all work together, and she created that, and a part of bringing the community together was the membership drive. Now looking around this room I see different cultures, I see different ethnics, I see different values, you know, and I'm going to say this: you know, the transgender community is not unlike any other community. What separates us most is race, classism, ageism, sexism, culture, and norms, and, you know, we have a tendency to have, this group of girls and guys over here -- this group of girls over here, the guys completely over here, and the black girls here, Latin girls here, the API girls here, which really does a disservice to our community. So I was given the task to try to bring all the girls and guys together, and you know, it was a wonderful undertaking because we did the best that we could.

And in doing so I was here in San Francisco area staying with my older sister, and then I went to Los Angeles and I had the wonderful opportunity to be at Los Angeles' Transgender Day of Remembrance about two years ago, and thereafter I went back to San Diego and got this job, and so I was given the undertaking of how can I bring the community together to start this whole kickoff session for the report and get everybody involved and get everybody excited about this whole thing. So I was just sitting there and I was, okay, thinking about Rita Hester you know, who was killed, I was thinking about Gwen Araujo, I was thinking about people in my own community that passed away, and I thought okay, what is the total opposite of the Day of Remembrance -- the Transgender Day of Empowerment. And so we said, okay, we planned the first ever Transgender Day of Empowerment in San Diego County, and so we had like Rosalyne Blumenstein from Los Angeles County came and spoke, and we had wonderful entertainment. And I was so nervous because we had put out flyers, I went to the bars, I went to the street and told everybody to please come, please come. We reached out to the API community, African-American transgender community -- all the communities, and with great gratitude and much chutzpah I say that we had over 200 people at our first-ever Transgender Day of Empowerment, so that's really a wonderful undertaking.

And in doing so that was the kickoff of our needs assessment -- get everybody interested in the needs assessment, get everybody interested in saying, this is our empowering moment, let's empower ourselves, empower the community to come together as one. Instead of having these subgroups all around San Diego County, let's try to come together and be this one united front. But then in doing the assessment we needed to get volunteer surveyors, so we did; we got volunteers called gatekeepers from different parts of the community. To make this real, we had a girl who was African-American, we had a guy who was Caucasian, we had a girl who was API; this was an effort to reach as many people as possible, so we looked for gatekeepers, we found these gatekeepers, and the volunteers were given like three four-hour trainings by myself and Dr. Zuans on confidentiality, on record keeping, on getting information, so that they were very well versed, and also to guiding the community through some of the questions. Because, you know, once again, to ask a disenfranchised community to sit down and ask these questions about their history, their childhood, their education, their frustrations, their mental illnesses, their lack of surgery, or they're having surgery, can be somewhat overwhelming for the average person, let along a transgender person, who has never had this type of undertaking at all in their life. It's also that debriefing aspect of the whole component -- it's like a 24-page assessment.

And we had incentives, you know, we had incentives for the community, and we also had our volunteers, and then we had volunteer outreach workers once again to go to our internet sites, to go to our sex worker street corners, and to go to the bars where the transgender community hang out. And it's really important to be visible in the transgender community and it is really important to have this work done by people who are trans-experienced, because once again, to see one's self reflected back in a positive light may actually light some type of inspiration in that person to make a life change. And then last year at San Diego Pride, the Pride Committee of San Diego County gave us a booth, and we were like number two in the parade, and one of our community members won the Community Service Award, so we were right up front in the parade and we had a really wonderful time. I put that in there because, you know, I think since we are a part of LGBTQ&I that we decided to start with the Gay and Lesbian organizations first, because we are a part of the LGBT component, so we started there working within that whole context because these guys are familiar with LGBT-run organizations, you know that they are not all T-friendly all the time. So the work began right there.

This would be a really important part of pride. But I also want to say so people understand that at our booth we had people who started from the front, got to our booth, and by the time they got to our booth they were in tears because people of LGBT and allies and supporters were taunting them, and they were wondering why this happened at a gay pride event? You know, and I was just dumbfounded. And I said, well, you know, it happened because they need to be educated. But they were confronted, the whole issue was confronted, so I just said that because it's something we need to deal with and make sure it doesn't happen again, because if we do stay invisible, if we do not show up, then nothing will every change.

And we also had the TCC, which is the Transgender Community Coalition Speakers Bureau. Now anyone with trans experience who is sitting in this room, who ever went to the doctor, who ever went to any type of legal services, you know you're done some educating, you know. So we all have the capacity to educate, you know, because we have girls and guys in our community -- like, say, for instance one of our trans guys goes to the doctor for like a Pap smear or a breast exam, well, you know, and presenting male, because you all know how terrifically the testosterone works on our brothers, you know. This is really heartfelt to have these guys turned away because the provider cannot understand why this man standing before them is asking for a Pap smear or a breast exam, and so what had happened was that the person began to educate the providers, so we had the compacity within ourselves to be very wonderful educators. And so we began our speaker's bureau, where they go to schools, they go to social service providers, and we go to the legal providers as well.

And we also have fund raising; we all love a good drag show. So, you know, money was needed to help support the community so we had, you know, wonderful fund raisers, we had bake sales, we had, like, three or four shows, and we raised over like $1,000 each time, so that was a really wonderful thing. Once again, this was about the activities, this was about bringing the community together, bringing the community out of their homes, away from the internet, away from the bar, away from the street, to a whole different environment. I remember pride. We had a Saturday before pride and we were all making signs for pride. I mean, we had Latin girls, we had African-American girls, we had trans guys, and we had a good ol' time. And that wouldn't have happened had we not had the TC in place, had not California Endowment funded this process, had not we began this whole empowerment process.

And also, after that we had the transgender community first-ever summer picnic, which drew over 70 people, and there's only one thing I can say about that picnic. We met two wonderful families, and I'm going to share this with you. A 15-year-old trans guy and his mom and his dad, a nine-year-old trans guy and his mom and his dad saw our web site and brought their sons to our picnic. And for their sons to see our guys barbecuing and playing football, they got a chance to see themselves. Now I don't know about you, but when I was nine year old I didn't see myself nowhere. I was so afraid, I was so, like, out there, but you know. I just sat there, and, you know, I think someone also said that we're contract and objective driven, but, see, I had this whole little mind thing about the measure of success -- I always tell my program manager, this is what I call the measure of success. How it affects the community, how it empowered the community. And it is a wonderful thing and to have those parents tell us we had no place to go, we found your web site, and we come to this picnic and my son can see his future. And it was really wonderful for the guys that are already transitioning to see little guys living their truth.That was a really wonderful thing and I'm really proud of that accomplishment as well.

And then of course, you know, there's the Transgender Day of Remembrance, where we honor our fallen brothers and sisters by violence, and I'm also proud to say that we also have the Transgender Youth Support Group. It's a weekly group, and there are a lot of transgender youth in San Diego, a lot of them are homeless, a lot of them are doing survival sex, a lot of them are doing unprotected survival sex. So we have a big brother and big sister program where we have a group at the Hillcrest Youth Center, which is like a component of the San Diego LGBT Community Center, and it's a youth program. We have some of our transgender girls and guys doing support groups and guiding our transgender youth toward being part of tomorrow.

I want to say, just to go back to -- I know you guys can remember when we started off the slides with the Gay Men's Health Project? But this is the name now, and I'm proud of that. They decided to change it to the Tuesday Night Clinic, and this is one of our advertising, and of course we have monitoring hormone therapy, free HIV testing, STD screenings and testing, hepatitis B vaccinations, supportive medical staff, and services in Spanish. Also at this point, this is the cover of our report, and this is us at pride last year, and this is me right here. That's at pride last year, and this is the young lady that won the Community Service Award. I say this with pride because I left home at 1970 at 19, and I went to the streets. You know, I'll be 54 in a couple of months, and I -- to still be here, to still be able to give back, because, you know, when I left home in 1970, all I wanted was a fine home. Like someone said in there, it was here all the time, and it's my hope to give that to each and every one of you today and my trans brothers and sisters. I would now like to turn it over to our illustrious project evaluator to give you some analysis of the report that we did. Thank you.

Jim Zians

It's really an honor to be here. I do have one correction to make because, it's interesting, I go by Jim all the time and I've been in graduate school forever, but somewhere along the line I'm defending my dissertation hopefully at the end of July, so everybody's calling me Dr. Zions, and I've always been Jim, and I don't know where this has come from. I guess it's hopeful feeling, hopeful -- you know -- and it's so funny because I noticed that it says, Ph.D. on the handout, so I said something to Tracie just ten minutes before we spoke and I thought I had explained it. I've had this happen before, too, and I even said something to Tom, who gave a nice introduction earlier and it was -- right over the head, so just call me Jim, and keep your fingers crossed.

Also, I started in this field in outreach at the AIDS Foundation which unfortunately closed in San Diego, gosh, over a decade ago, and somewhere along the line I was always kind of, like, on my way to graduate school. I probably had the first laptop before they had -- Sanyo I think came out with like a primitive laptop, I had the first one, and I was always very interested in -- like, I was the outreach person who wanted to write new curriculum for the groups and things like that, so I really think that one of the contributions that's been really helpful to me and will keep me Jim all the time is that I really kind of see myself as that outreach person who accesses target populations, and I think Tracie underestimated, even though she told a great story about how this developed in San Diego County, but to watch the emergence of the transgender community in San Diego County. San Diego County is not San Francisco by any means, and they talk about starting from practically nowhere and then having a few of, as Tracie said, the girls sitting in what was called the Gay Men's Clinic. I was working at the Gay Center at the time and I used to go over there -- we collaborated -- and I remember going to the -- at the Tuesday Night Clinic was the Gay Men's Clinic and seeing some of the transgender clients sitting there and working there with a wonderful guy named Dr. Brown, who I guess is here in San Francisco now, you're lucky enough to have him. And some of the doctors at Family Health Centers really took it upon themselves to learn some of the things that doctors don't necessarily get trained to learn. And it's really exciting to watch this emergence and to have wonderful friends like the California Endowment. And it's really changing San Diego County turning from an LGB community, or really an LG community, to an LGBT community and educating within the lesbian and gay community. And we have some data that show this. Let's jump to the data. I want to make sure we have time.

First of all, I'm going to be -- even though this is a wonderful story, the needs assessment is data, and we have some parts of the story that shows we have our work cut out for ourselves. First of all, I'm going to be talking about some of the key findings that aren't always exciting to talk about but it's nothing that we didn't know going in. Emergence means you're emerging from somewhere and the emergence is from a lot of enormous disenfranchisement and lots of barriers. And I'll be talking how the data show problems with education, skyrocketing unemployment, mental health problems on a composite scale with 13 items that we did factor analysis. We have a really nice measure of mental health and the scores can go from 0 to 13 how half of the respondents scored a 6 and under on the mental health problems issues. High rates of disability among the respondent sample. A life focused on transgender issues where you have late in life, in the late 30s and 40s, still dealing with major issues around gender identity. The issues of passing privilege. I'll show some data that's very interesting and somewhat controversial around passing privilege, given the more open transgender persons are, the more wonderful it is for the community and how the data will show that those who pass are fine perhaps not being as open about their transgender identity. And then some unique needs and some safety issues that came up in the assessment.

And then of course the important relationship with health care providers, which is important for both the transgender community, the LGBT community, working with the providers, and it's important for the provider community to take a part in developing this very important reciprocal relationship. Because the transgender community as it emerges, other than it's the right thing to go and it's fair and it's nice that people should have all sorts of altruistic values, in terms of the outside world of transgender community, my wish for the transgender community and any community is they're a group of consumers and they're going to -- consumers are consumers, they're a market economy and they're going to join forces with the rest of the world, so it is in everyone's best interest that this happens.

In terms of the age, the average age was 38.5, the median age was 39. We had a nice representation. Standard deviation was about 13.1, which shows a nice spread across the ages; we didn't have just one age group represented, and as Tracie stated it's very exciting. We had a nine year old take the survey with his family supervising and we had two sixteen year olds and a fourteen year old. The fourteen year old is now fifteen, and so we have four individuals under age 18. We have two respondents age 65 and older. The age range was from nine to 79, which is a really nice thing to say about a study like this.

In terms of ethnicity, they did a very good job. In San Diego County it's really tough to find, in terms of the LGBT community, Latinos and Latinas are very invisible and often not accessible. We have about a 25% of the population of San Diego County are Latinos and Latinas, and they did manage 16.2%, which is better than we've done in some other work in the LGBT community. And less than half the sample was Caucasian. San Diego County only has five -- a little less than 5-1/2% -- African Americans and they did a wonderful job with accessing African American to be in the study. Asian/Pacific Islanders make up about 10% of the population in San Diego County, and again, they're tough to find in the LGBT community. We were pleased, and there was a lot of effort to try to have this to be as representative a sample as possible. In terms of where they live, we have 38 zip codes within a 60-mile radius, and it's interesting. I think one of the first findings that we had was that a fourth of the sample refused to give their zip code, although they did tell us that they lived in San Diego County, how many years they lived in San Diego County. More than half the sample lived in San Diego County for eleven years or longer. But how do you account for people saying that they live in San Diego County eleven years, six years, or five years, and then they won't give their zip code? And that is interesting because of the correlations between those who not feel safe and those who did not give their zip code kind of tell the story.

In terms of -- this was very educational for me. How do you -- all of the sudden you've got this enormity of identities to try to figure out. How do you ask questions and how do you create a graph when you're going to ask different kinds of information? The advisory committee at the time was helping to create the survey and decided on the identities within the transgender community that we would use, and some of them it varies for each group and in the literature in terms of cross dressers and transvestites. But we did ask the respondents to self identify, and here we have the representative sample, and more than 50% of the group identified as pre-operative. And in terms of their gender identity by gender assigned at birth, we have this data, and we have mostly assigned male at birth and a gender identity of female, and you can see that in the first column. And when the report comes out, if you wanted to leave your e-mails, we'll certainly send the report, hopefully in about three weeks, and it can go into detail.

And here we have gender at birth by how you identify within the transgender community, and then after that we have -- I couldn't even get this on two slides -- we have 27 different combinations if you add sexual orientation to the group, and you can see how difficult it is to try to make sense of this data, and how complicated it is, and this is for the within group like me trying to -- you know, there's nothing to win me over in terms of trying to understand, but as this emergence occurs, we have a lot of educating to do.

Also, the committee, we had a decision to make around sexual orientation. A lot of transgender persons, as you know here in the room, don't like the term sexual orientation; it is meaningless because it's so tied to biological anatomy. But we did decide to ask that question. In terms of their education of the sample, we had another finding. We have data on the LGBT community in San Diego County from 1998 and then the LGBT senior data on education. And in San Diego County of the LGB community is very, very educated. More than half the sample of LGBT seniors have bachelor's degrees; it was almost 70% and in the LGB community in 1998 more than half had advanced education. In the transgender community here, we have 17% of people with bachelor's degrees and fortunately the assessment did ask a lot of questions around barriers to education, and we found some very interesting data in terms of discrimination, not feeling comfortable while they're in school, family problems, violence at school, money being saved instead of for education for TG issues, poor mental health, poor concentration problems around education.

And we found that barriers to education predicted some other things later on in life. Those who showed greater barriers to education had low annual income, and of course we left out those younger respondents who are still in school. This was looking at older adults. Greater barriers to education were related to lower scores on the life satisfaction composite in the survey, and greater barriers to education were related to lower scores on good mental health. So from a needs assessment point of view we certainly have some ideas of how this program that Tracie's going to be developing in the community can certainly start working toward lowering these barriers to education and trying to help people meet their education goals.

In terms of annual income, this group is pretty disenfranchised. We have, gosh, almost 38% of the sample making less than $10,000 a year, and a little over 20% making less than $20,000 a year. Now, in San Diego County that is not very good, to say the least, in terms of financial resources. We have a few respondents who have done well and we actually found them toward the end of recruitment for the survey, and we have this enormous group with less than $10,000 in resources. Remember the average age of the study was almost 39 years old, so we're talking about the 40-somethings here.

In terms of employment, skyrocketing unemployment. I think one of the, probably a, most important finding if we want to narrow the findings down to the three. No population accepts unemployment rates almost approaching 40%; that's just unheard of, and yet we have 37.3% unemployment. We did ask quite a few questions about trying to explain barriers to employment. Their own lack of work history, feeling uncomfortable in the work environment in San Diego County, inability to focus while at work, having discrimination issues either from the past, the present, or just fearing discrimination. And then we have findings here looking at relationships between preparedness for employment -- we actually had some questions and created a composite score -- and good mental health, and those who scored low on prepared for employment also had low scores in good mental health, and there were relationships also between life satisfaction and barriers to those who were least prepared for employment also showed high barriers in education.

In terms of openness about being transgender we asked when were you open, and gosh, we have over 10% of the sample who has never been open, and if you look at -- these are the ages at which they're open -- we have a third open in their teens, and another 21.8% open in their 20s, but gosh, if you add up never been open with open in your 50s and open in your 60s, we're talking about a quarter of the sample not open until much later. Yes? (Question from audience) Oh I'm sorry. We have a sample of 136.

Now if you look at the next couple slides in a row, here we asked them how open they are if they hide from their family, and even though its very nice to see that more than half the sample never hides from their family and then rarely hides from their family, from a needs assessment, you know, you find about 4% of something in a needs assessment like nutrition and not having enough money for food, you end up with a meals on wheels program for various groups. So if you look at often and always, well over 10% if you combine the two, you still have a group hiding from their own families, and again very similar hiding from neighbors and your community. Here the jump from the way the graphs are. In the one before it went to 50. Here from 0 to 30 you see never and rarely; just a little over 50%. But watch this next slide. This is hiding from your neighbors and coworkers. We have a very different story. We have basically the reverse of what is occurring, which also helps explain the low income and the high rates of unemployment.

And then we of course looked at openness with health care providers. We found some interesting findings. Those respondents who were more open with their health care providers were related to higher ratings on surveys that stated you had a sense that you health care provider knew you well and made decisions in your best interest, and of course that's very exciting. If you were those respondents who are more open with their health care provider, this was related to feeling like your doctors and providers were competent in transgender issues. Those respondents who were more open with their healthcare provider on TG issues had lower ratings on the question, "I avoid going to the doctor due to negative experiences of hostility, discrimination, and prejudice." And here, of course, is the slide that I should have shown you first in terms of how open they are with their health care providers, and we have again a quarter of the sample not very open with health care providers. In talking to some of the respondents in focus group and meetings, hearing how they actually go to the doctor as a different person than they live in the community, it's tragic.

We asked some other questions. This gives you an idea. Most of my needs as a transgender person are met by a health care provider and we have, gosh, here we have strongly disagreeing 14.1% and disagreeing 21.1%, so we certainly have another finding in the needs assessment where Tracie's group will be working to help create a better continuum of care in terms of educating health care providers and there's a reciprocal relationship here, educating transgender persons on helping to educate their providers and taking risks and being more open, and as difficult as it is to walk into the dentist's office and not want that look from a receptionist that doesn't understand. The more you can get a community to kind of engage in this kind of process together and be empowered, the more progress can be made, so we have our work cut out for us in San Diego County.

In terms of disability, we have 38 respondents out of the 136 who were on disability. And most of the disabilities were tied to mental health issues. I think we only had six respondents who were on disability -- seven respondents on disability because of HIV and AIDS. So it was 28.6% of the sample that was disabled, and of course, being disabled related to not being employed and lower income and lower financial resources. So, like I said, in a needs assessment, once you reach 4% you can get a meals on wheels program. Gosh, we have more than a quarter of the sample disabled, and half of the disabled persons stated that they have trouble walking. And then of course, most of them being mental health disorders, I'll talk about that in a moment.

Also note, within the disabled group we had another scary finding where a large percentage of those who were disabled reported some suicide ideation. 44% of the disabled respondents said that they experienced suicide ideation. I ran some analysis to see if being disabled predicted how suicidal people were, and there was even a more scary finding in that it actually didn't predict it because in the entire sample we had 43 of the 136 respondents stating that they commonly experience suicide ideation. So as we are excited about the emergence of a community, the scary part of a needs assessment is it comes to light some of the real difficult issues and challenges that we have in this community and having a suicide hotline and starting work in mental health is clearly the top of the agenda for Tracie and her coworkers and for her agency and funders to work together.

In terms of drugs and alcohol, we're a little bit surprised. We're not sure why we had low rates of some drug use when we thought that they would be higher, although we did have some difficulty getting some of the sex workers -- the transgender sex workers -- to feel safe enough to take the survey. But we do have some sense in our community that this is an underestimate. But we didn't find high rates of substance abuse in the respondent sample.

(Question from audience)

Sure, yeah. We have surveys among MSNs in San Diego County that shows methamphetamine use. If you were stand outside certain bars from 10 o'clock in the evening to 2 in the morning among gay and bisexual men in San Diego County, we have rates of methamphetamine use at about 14-15% and club drug use just a little bit under that in general. So we have high rates of substance use in the LGBT community. We actually just did a -- I was involved in a risk survey for lesbian and bisexual women, and we found 5% meth use but high rates of alcohol use and high rates of women who were really concerned that they had a drug or alcohol problem. And then we also found among lesbian and bisexual women, women who had been in treatment for substance use before with a group having the most difficulty, so we had about 70% recidivism among some women in San Diego County. So there's no reason to think that the transgender community is not exposed and does not have these problems. In talking to some of the respondents and in talking during some of the meetings that we had, there was a sense that some people taking the survey, especially the enfranchised group, were having some difficulty reporting perhaps some things that put some of their behaviors in a bad light, so we may have had some underreporting.

Tracie: What was going on, I was looking at you and I was thinking about those of you going forth on assessing your own community's needs. Well, you must understand that for those people with trans experience who are doing methamphetamines, who are doing sex work, taking an assessment is not a priority, so in trying to outreach to that part of the community it was extremely difficult. There was a high level of distrust, there was a high level of just flat-out refusal, and we looked at incentives, we had movie tickets, we had Starbuck's, but a sex worker or a substance user had no need for a movie ticket or a Starbuck's card. For those of you looking forward to assessing your community. Looking back at hindsight, how they could have done better was like to really put ourselves in that provincial place, out on a corner with the population, but see I was doing that kind of by myself, and I'm in recovery, so there's certain -- I'm not willing to do is put myself out there like that, you know. And I think that spoke to the inability to get the sex workers and those who are currently abusing substances.

(Question from audience)

We didn't ask that specific question. It was some question pertaining to recovery. We had a couple respondents that were currently in recovery, and I think looking back at hindsight now, there's probably a lot of things we would have done different in the form of actually asking questions. And this was a grassroots effort, and this was an assessment created by the community and Family Health Centers of San Diego. So I think it was unfortunate that we were unable to get that part of the community, but it is a huge estimate about the community because the community is definitely suffering.

Jim: Really good questions.

In terms of the passing privilege, really educational for me in trying to understand what I was seeing in the data, and some of you, I'll look for some head nods, I'm sure a lot of you already know all about this, but we did ask whether or not the respondents felt that they had attained a passing privilege, and a third said that they had -- passing, meaning that no one would know whether or not they were -- I'm sorry -- yeah, got it. Okay. In some analysis around the passing privilege though, it was very interesting, because those who attained the passing privilege were less likely to be open about their transgender status. But there was also a relationship between scores on life satisfaction and having a passive privilege with those who rating themselves higher on having a passive privilege were more likely to have higher scores on life satisfaction. Now, politically, from a civil rights point of view this may not be good news, but data is data, and you put it out there and it's something for the community to struggle with in terms of this important issue.

We asked respondents whether or not they wanted to have sexual reconstruction surgery someday, and almost half the sample said yes, 44.4%. 41.3% said no. 12.7% had already had surgery. Now we had -- I don't know if I put this slide in here or not -- no, I didn't. I did run an analysis. We did not get significance, but I was interested in seeing whether or not those who had SRS already, how they did compared to those who either did not or those who wanted it, and I did find something approaching -- 136 is a pretty small sample size for some analyses, and I did find something approaching significance that had what we call a medium effect size, which means that if we were to run the surveys with another 50-75 people perhaps we would find significance. And what I did is I re-coded the data comparing those who already had the SRS surgery, comparing them to those who said they wanted to someday, and guess who scored higher on life satisfaction? Those tho had already had SRS surgery. And of course I have to state that this is not significant yet, so we can't actually make a statement, and you're not to report data about nonsignificant data, but it is common to report effect sizes, and of course, given the data it looks like it's due to a small sample. So I believe we can start thinking down the line that those who want SRS surgery are not scoring as high in life satisfaction, and once they do have the surgery they start doing a lot better. And that's important news as the communities try to plan how to eliminate barriers, particularly financial barriers for those who want SRS.

(Question from audience)

Yes. And when we have enough we can actually co-vary for that and actually look for that. A statistician in the group, that's very good.

(Question from audience)

Yeah. These are simple cross-sectional main effects, just looking for relationships among.... If it comes time to write a paper we may try to snoop through the data and find a little bit more about what that means. What's interesting, though, it's a simple relationship, is that those who have already had SRS, on this composite measure I think there are seven questions that show high reliability, internal consistency, and on the factor analysis show that they only represent one factor, and we use that as a composite score for life satisfaction. The relationship is that the means of the scores, even though it's not significant, they score higher on that, and that's all we can say about the data at this time, although we would run other analyses to find more about it, sure. I'm hoping that with this data we'll have some papers.

(Question from audience)

Yeah. It's actually questions derived from a standard measure that's the life satisfaction measure. So I think we stuck with this composite measure that we use, but these are really good issues, and it's always important that data is just interpreted, and different interpretations vary, and perhaps -- I would love to come back if we ever write a paper for the discussion section and get your input because that's certainly -- research always has the results section followed by discussion, where you have these varying points of view of what the interpretations may mean. And clearly a gay male researcher who is learning as he goes like I am does not understand the issue as well as many of you, and it's important to have a lot of input as we try to make sense of what the data mean. So these are really good points.

Tracie: I think it's important to understand that the transgender community is the only community that one graduates from, and that's usually those who have SRS. However, in that same context there are still a lot of us who did not get SRS and stay in the community and live our lives under the transgender continuum. And with those questions like, are you feeling good today? Are you not feeling good today? Has your life been okay? And these are some of the kind of questions they were asked -- for me being a lay person, not being an analysis person like Jim here, what I got from that is that the daily experiences, their livelihood, their yearly income, their shelter, their living in fear constituted a low life satisfaction as I saw it in the whole context.

(Question from audience)

Jim: Oh sure, remember in this analysis I left the people out who said they didn't want- I left them out of the analysis. I was comparing only those who had, and the samples sizes are very different, so you have different tests. You can't assume what's called homogeneity of variance, you violate all these things and you have to account for that.

(Question from audience)

This is so interesting, and I'm so glad that we're talking about this because this is so true when you start bringing data into social issues, too, because you have a relationship like this. Did I not do this in the meetings with all you folks because you want it, and then you don't want it. Because -- and if you can -- I've been doing this for a while now. It took me forever to get through school and I've been kind of the data person in a lot of these things in San Diego County, so I've been through it -- now I get excited when I hear it because it means everyone is thinking outside the box and thinking about all the different possibilities and all the different ramifications and how it's so important to be responsible when we're dealing with data. But there is this relationship of wanting, but go away also, because it's -- data is to be interpreted, and some interpretations can point in different directions than others, and it's so important to have an open community process when the next step -- hopefully they'll be funded -- and the next step will be to take this report, which will be open to everyone, and to have community groups and hold open forums and to have a lot of people look at the data and do community planning so we don't end up with a group think, or you don't end up with just a few people making interpretations. So now when I see this I find it exciting because we wouldn't have done a needs assessment if we didn't feel that we would find something that was frightening or scary or confusing. And to make sense of that does not need to necessarily be a negative experience but it can be a challenging experience just to try to make sense of what it all means.

(Question from audience)

This is an exciting discussion, and -- you want to hear the rest, okay -- I think that's a very good idea. I'll try to zip through and leave some time. But also, just remember, too, that when you add those in the sample who said that they didn't want surgery, the little over 40%, I get miss-mash in the data, meaning that it cannot be true. Now if it's marketed in such as way that there's a perception that you have to want it or you're not -- for right now in the part that I'm involved in it's important to interpret just the interpretation of the data. But I can certainly see where you can start going down a road that could feel like it could be harmful. In terms of HIV status, we had about 18.9, almost 19% who were HIV positive and we had a small group that didn't know their HIV status. In terms of their risk of contracting a new STD we certainly had some risk variables that are creating a finding for us and certainly a goal of the needs assessment, that we do need specialized HIV prevention and STD treatment for transgender persons, and Tracie and her basically -- started out as a one-person show -- has really had leadership in this area and we already are providing some of these important services in the community and we need to expand them. In terms of sexual intercourse, we asked about their partners and we believe here we also have an underestimate just like we did with the drug behavior. In terms of casual and anonymous partners we did expect higher rates, and we believe that people were underreporting. We also did not get -- it was estimated that we would have anywhere from 25-30 sex workers take the survey, of which I think only one or two took the survey because of the issue of distrust in San Diego County. The transgender sex workers in a focus group stated that they have a very difficult relationship with both the LGBT community in San Diego and the legal system and the police in San Diego County, so we have a lot of work to do trying to enfranchise that group and engage them into services.

Let me kind of zip through to mental health. The mental health composite was a strong finding. As I already stated at the beginning; on our composite scale you could score from 0 to 13, and more than half the sample scored a 6 or below on this issue. So we found high rates of mental health symptoms in the 136 respondents who took the survey. And here's just a graph of some of the things we found: family problems, depression (more than half the sample reporting this), dwelling on problems, some isolation almost approaching 25% of the sample, feeling that they have few friends, avoiding people. So one of the findings here is to really expand specialized services in terms of mental health and to work with the agencies that specialize in mental health like the gay center in San Diego County. Low self esteem approaching 50% of the sample.

Here I already stated suicidal ideation. Of the 136, only 125 responded to this question, and we had over a third of the sample stating that they experienced suicidal ideation. If you look at the disabled group it goes to almost 45% of those who were disabled. And then just one of the questions asking are these the best years of my life, we only had 40% of the respondents agreeing that these are the best years of my life. And again, the issue of mental health -- this part of the presentation was to help us get funding for some of the things, and so we're kind of milking it a little bit here, but I think we've made the point.

In terms of feeling that the LGB community supports transgender persons, we only had 20% of the sample really strongly agree. Half the sample did feel somewhat supported, and we feel this is probably the half of the group that was enfranchised. Part of the recruiting process was to find the enfranchised group and then to have gatekeepers try to find people who weren't hooked up into programs and find those who -- and we did have half the sample more neutral or not feeling supported by the LGB community.

In terms of feeling safe where they live, we had 13% of the sample that didn't feel safe where they live. I have a few notes on this, too. If you didn't feel safe where you live, you also were more likely to be in the low economic group and you scored lower on social support measures and you also scored lower on life satisfaction measures. I can't think of another community within the LGB community that you have 13% of the sample that they don't feel safe at home, and that's an unacceptable experience within the community, and certainly we need to work toward that. In terms of services for hate crime, we had almost 10%, 8.7% saying they needed and had no access. That's huge in the needs assessment, again, where you're kind of putting in some litmus paper and trying to make some sense of things.

Since we're out of time and I want to make sure we have time for questions, I'm going to zip to the recommendations that we found, and the recommendations include: education, decreasing barriers, working with school systems, local universities, and advocacy to TG students to try to reduce barriers. In terms of employment, with a skyrocket unemployment we have our work cut out to try to decrease barriers and target job training for LGBT needs in the culture. In terms of mental health, we need full capacity building, city and county-wide, and within the LGB community and a suicide hotline and community awareness around the suicide issue. Sexual risk behaviors and specific needs of enfranchising the TG sex workers. We have a lot of work to do to engage them. In terms of depletion of personal resources, we have a group here that spends most of their adult life -- the first half of their adult life -- dealing with these issues, and that is an enormous drain on personal resources, and I can't think of another community that needs to do that. And clearly we need to work toward increased access and see what we can do to help with those issues. In terms of unique needs, prioritizing public policy and civil rights, and working with the LGB community in particular, increasing capacity for LGB organizations to improve overall services for transgender persons and certainly working on the reciprocal relationship between TG patients and clients and the health care providers overall. And then, Tracie and I will take your questions.

Audience Questions

(Question from audience)

I remember running the analysis, and since it's not in the report and I would have to look at it again, but I'm believing that I didn't find age differences, and there's probably a reason for that, meaning that there are groups of younger persons who are doing -- and I think one of the reasons why age may not have been significant is that the cohort groups are so different. That those who lived in a different age bracket are -- some people are doing better and some people are still struggling with their interpretation as opposed to youth, some are struggling, but in a lot of ways things are better for youth. I mean, we have a nine year old and a fifteen year old taking the sample, so when you find no differences of age you would then maybe try to co-vary for other things to see what may be getting -- why you wouldn't see that, but basically at this time we would say that age wasn't significant -- there were no differences. They were both -- older people had lower life satisfaction and high scores on life satisfaction as did some young people.

(Question from audience)

Yeah, we had three homeless respondents in the study, which I'm sure is an underestimate. We also had a lot of people living -- they weren't homeless but they didn't -- we had a few people not paying rent, and not paying a mortgage, so you assume that they're somehow having some sort of a living arrangement. And in terms of home ownership, San Diego County is a very expensive -- I have some data here on home ownership. In San Diego County, home ownership is lower than the rest of the country, it's 15.1 to 67% of those in San Diego County actually own their own home, and in the study we only had 17.6% of the sample owned their own home, which is really a handful of individuals.

(Question from audience)

Challenge in a good way -- no, actually you were looking at concerns around political and social issues around the data around the issue of "first, do no harm." So that is, so I say challenge, no challenging me, like, you're wrong, whatever. Challenge means, what do we make of this? If we interpret this one way this could happen versus another -- we need to be careful about this -- or before we publicly say that we need to be clear about this, this, and this. That's challenging the data and it's responsible to do that and irresponsible not to do it, so it's welcoming.

(Question from audience)

Let me tell a quick anecdote. We have a methamphetamine problem in the gay community as we do many in San Diego County and we recently had -- this kind of came to a head for a reason and the news media was involved and the health department. The research I do at UCSF, we work with methamphetamine abuse in gay men and I was ready to give a talk to the community presenting data. I run a research study. To be in the research study you have to be HIV positive, gay, bisexual, MSM, and to be in the study it means that you have a history of having unprotected sex with individuals who are either HIV-negative or you don't know the HIV status of the sex partners. So these are men who are positive, who are on meth, and infecting others. Well, when I came down to give the talk I saw that the TV news media was there covering parts of the talk and I got on my cell phone, I called my boss, and I'm like, this might not be sound-bite appropriate. This is a federal study and what are they going to -- how are they going to take any of this data and -- this is the.... I changed my slides -- luckily I had my laptop -- and I threw in -- and it was not appropriate to talk about that because you can't have a full discussion. Meaning that this data -- this is an audience where we just kind of put it out there, but we need to be very careful in terms of the messages and the sound bites and the perceptions both from the outside and in terms of trying to create a plan, the community plan for what we want to happen as health care providers. I think it's okay for us to then have an agenda, an open agenda, to make sure that no harm is done.

Yes.... (question from audience).

It was a very detailed checklist of the different procedures that they wanted to have done, either they already had them done or they're hoping to have them done, and there were two sections. One involved actual medical surgery, the other were medical procedures like hormone procedures and things like that.

(Question from audience)

Right, I think there were 40 some items...

(Question from audience)

Or you need to work on the norms within the community because what the data show that people who say they want it and don't have it yet are showing some symptoms, they're scoring in a certain way. So who's to say that part of the community process would be to kind of change the expectations of the norms? It wouldn't necessarily go in the direction of trying to figure out how people should have surgery. Maybe part of the issue is the broader issue. But all we know is those who say they want it (and there are barriers to having it) are scoring in certain directions differently than those who have already had surgery and those who say they don't want it. And that's where we are so far and I think you're absolutely right, though. You have to be careful how it's interpreted.

Yes.... (question from audience).

I think as a community, as the transgender community emerges, and educates, and is educated, it's going to be like -- you know, think about the churches in America. There's going to be things that are agreed upon, there's going to be divisions, there's going to be confusion, there's going to be excitement when there is a rite of passage and there's different milestones that are attained both politically and legally. And there's going to be messes, and I think that it's just, it's the way -- it's going to be like every other community and it's going to be both frustrating and exciting all at the same time with very, very unique and challenging questions.

Tracie: What's important is that we are creating the road maps. And that's why this is so important. The dialog we have with each other is important. The philosophies and discussions about this data, because we are the generation that's creating the road map, the passages for those who come after us. Because I remember when I was first coming out there was this thing that you had to obtain surgery to be OK with yourself. That was the whole thing, like she mentioned. It took me almost 40 years to realize I was okay just as I was. Because there was no system of care, no road map for transgender people to realize, from the womb we're okay -- from the womb we're okay. (Audience member: Absolutely. Celebrate all of you who are.) Exactly, exactly. We don't realize that; we don't know that because society doesn't tell us that, the books don't tell us that.

Audience member: There are really people that I feel, transgendered women, who really do have a very good reason for having surgery. And it works for them.

Tracie: Exactly.

Audience member: But there are a lot of us that have the surgery for different reasons, but your life does not change after that. As a matter of fact it may make things worse.


Audience member: If you're looking to validate your womanhood by having surgery, then you're making a great mistake. You need to be that woman before the surgery.

Tracie: Exactly, exactly. But, see, there's no system in place to allow that to be. That's why it's so important for those teens and those youth at that picnic to see the emergence process. This is a decision that we all make, not just something we need to do. Thank you.