Transgender Sex Work and Society


Edited By
Larry Nuttbrock

416 pages
Hardcover, $75.00 / £62.95 ISBN: 9781939594228
E-book, $45.99 / £38.95 ISBN: 9781939594235

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This is the only book that systematically examines transgender sex work in the United States and globally. Bringing together perspectives from a rich range of disciplines and experiences, it is an invaluable resource on issues related to commercial sex in the transgender community and in the lives of trans sex workers, including mental health, substance use, relationship dynamics, encounters with
the criminal justice system, and opportunities and challenges in the realm of public health.

The volume covers trans sex workers’ interactions with health, social service, and mental-health agencies, featuring more than forty contributors from across the globe. Synthesizing introductions by the editor help organize and put into context a vast and scattered research and empirical literature. The book is essential for researchers, health practitioners, and policy analysts in the areas of sex-work research, HIV/AIDS, and LGBTQ/gender studies.

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FOREWORDFree Chapter
Walter Bockting
(since 1/28/18)

Larry A. Nuttbrock
(since 1/28/18)

SECTION I: Empirical Descriptions and a Conceptual Formulation For Sex Work Among Transwomen in the United States

1. Qualitative Description of Sex Work among Transwomen in New York City
Sel J. Hwahng

This chapter provides a qualitative description of transwomen sex workers in New York City. Sex work occurs largely in “ethnocultural communities” that are distinct with regard to ethnicity and other variables. These include African American or black and Latina(o) and transgender people involved in the House Ball community, Asian sex workers, and white cross-dressers. Variation across these communities in the frequency and motivations for sex work, working conditions, typical clients, and power dynamics with clients were examined. The communities have little in common with one another and are economically and culturally structured along a hierarchy of power and privilege.

2. Quantitative Description of Sex Work among Transwomen in New York City
Larry A. Nuttbrock

This chapter provides of quantitative analysis of sex work among transwomen in New York City. Levels of sex work were shown to range from low (fewer than 5 partners a month) to moderate (5–49 partners a month) to high (50–400 partners a month); different demographic and lifestyle factors were associated with these different levels. This analysis, following Hwahng, highlights nonwhite ethnicity and its association with an early entry into the sex trade as strong predictors of moderate and high levels of sex work. Early entry into the sex trade, in turn, reduces the odds of completing high school and of being employed during early adulthood, which further increase the odds of later life involvement in sex work.

3. Why Are So Many Transwomen in the Sex Trade, and Why Are So Many of Them Ethnic Minorities?
Larry A. Nuttbrock and Sel Hwahng

Building on the qualitative and quantitative descriptions of sex work in Chapters 1 and 2, the two of us (LN and SH) collaborate here in a further analysis of two fundamental issues: the high proportion of transwomen who engage in sex work and the high proportion of transwomen sex workers who are ethnic minorities.

SECTION II: Survival Sex Among Young Transgender Persons in the United States and the United Kingdom

4. Compound Harms: What the Literature Says about Survival among Young Trans People in the United Kingdom and the United States
Lorna C. Barton

Survival sex is defned as the exchange of sex for food, shelter, drugs, money, or other items. Young trans people engaging in survival sex in the United States and the United Kingdom constitute a major research gap, and this literature review focuses on a selection of compound harms gleaned from an interdisciplinary literature review. It highlights, frst, young trans people and homelessness; second, access to services for the homeless; third, young trans people’s recruitment into the street economy and survival sex; and last, young trans people’s public visibility to law enforcement.

SECTION III: Personal Relationships and Health Risk Behavior

5. Relationship Dynamics and Health Risk Behavior among Transwomen and Their Cisgender Male Partners
Tiffany R. Glynn and Don Operario

This chapter looks into the relationships between transwomen and their cisgender male partners, with a focus on sex work as a specifc variable that shapes these relationships. This chapter examines health risk behaviors within these relationships and how sexual behaviors vary in the context of primary (i.e., emotionally committed) partnerships versus commercial exchange partnerships between transwomen and cisgender men. The aims of this chapter are threefold. First, we will review research on the complexity related to identities and sexual dynamics within these dyads, with specifc focus on cisgender men. Second, we will explore health risk behaviors within this relationship context, including the role of sex work and psychological motives that might contribute to partners’ health behaviors. Third, we will examine implications of this research for guiding health-promotion interventions for these populations.

SECTION IV: Mental Health and Substance Use Issues Among Transwomen in the Sex Trade

6. Mental Health and Transphobia among Transwomen Sex Workers: Application and Extension of Minority Stress Models
Don Operario, Tiffany R. Glynn, and Tooru Nemoto

The aims of this chapter are to (1) describe the literature on mental health problems and their social determinants among transwomen sex workers, including fndings from a study of 573 transgender women from San Francisco with a history of sex work, and (2) examine the Gender Minority Stress Model and its applicability to transgender female sex workers. On the basis of this analysis, we suggest implications for research and for social and health service providers working with transgender female sex workers.

7. Sex Work and Major Depression among Transwomen in New York City: Mediating Effects of Gender Abuse and Substance Use
Larry A. Nuttbrock

This chapter provides rare longitudinal data about the association between sex work among transwomen and serious depressive symptomatology in the form of DSM major depression. After the strength of this association was evaluated, the extent to which it is mediated by gender-related abuse and substance use was systematically examined. The results suggest that sex work among transwomen is strongly associated with clinical depression in large part because of increased levels of gender abuse and substance use.

8. Substance Use among Transgender Sex Workers
Beth R. Hoffman

The last chapter showed that sex work among transwomen is strongly associated with measurements of substance use; however, systematic reviews of these associations have not been provided in the literature. This chapter presents a review of this literature.

SECTION V: HIV Among Transwomen in the Sex Trade

9. The Prevalence of HIV among Transwomen Sex Workers: A Review of Current Literature
Ayden I. Scheim, Laura Winters, Zack Marshall, Daze Jefferies, and Stefan D. Baral

Transgender (trans) women and women who engage in sex work are groups that face a higher burden of HIV relative to other populations. Women at the intersection of these identities and occupations experience compounded vulnerabilities to the acquisition and transmission of HIV. In this chapter we provide an overview of recent research on HIV prevalence and incidence among transwomen who engage in sex work globally, and the multiple factors contributing to their HIV-related risk and resilience.

10. HIV and Substance Use among Transwomen Sex Workers: A Vicious Cycle of Socioeconomic Hardship, Unmet Service Needs, and Health Risk
Tiffany Glynn, Don Operario, and Tooru Nemoto

In this chapter we focus on two health issues commonly examined in research on transwomen who engage in sex work: HIV risk and substance use. Our goal is to provide a contextualized understanding of the association between sex work and health risks in this population by characterizing the socioeconomic and ecological factors that may motivate transwomen to engage in sex work and that, in turn, determine health challenges among transwomen sex workers.

11. Sex Work, High-Risk Sexual Behavior, and Incident HIV/STI among Transwomen in New York City: A Study of Mediating Factors
Larry A. Nuttbrock

This chapter provides rare longitudinal data on the magnitude of the association between sex work and incident HIV/STI among transwomen in New York City; additional analyses examine the extent to which this association is mediated by gender abuse, depression, and substance use.

12. Sex Work and Antiretroviral Therapy among Transwomen of Color Living with HIV in New York City
Larry A. Nuttbrock

Using data from the baseline component of the New York Transgender Project, this chapter presents fndings regarding the prevalence and correlates of antiretroviral therapy (ART) among transwomen of color living with HIV in New York City. A signifcant minority (12.7%) were not receiving ART, and over one-third (37.5%) of those receiving ART self-reported a detectable viral load. Compared to those reporting no sex work, those who were highly involved were 70% less likely to report an undetectable viral load (OR = .30). This likelihood may reflect a lifestyle that is not conducive to adhering to treatment protocols. Better ways of engaging and promoting ART among HIV-positive transgender women highly involved in the sex trade are clearly needed.

SECTION VI: Transgender Sex Work in Different Cultural Settings

13. Sex Work in Turkey: Experiences of Transwomen
Ceylan Engin

Most research that is available on transgender sex workers focuses on Western nations, and research on the status of transgender sex workers in non-Western societies remains limited. This chapter focuses on transwomen who participate in sex work in Turkish society. Turkey presents a unique example as a predominantly Muslim society where prostitution is legal in the form of state-run brothels, also known as genelevler. I posit that the current genelev system marginalizes transgender sex workers by allowing only biological women to work as registered sex workers. I then perform a content analysis of the experiences of transwomen, drawing from 53 previously collected interviews and testimonials. I argue that indoor prostitution in the form of genelevler would provide a superior working environment for transgender sex workers and could alleviate some of the hazards associated with street prostitution.

14. Hijras/Transwomen and Sex Work in India: From Marginalization to Social Protection
Venkatesan Chakrapani, Peter A, Newman, and Ernest Noronha

Transgender people have been evident in India for centuries, a fact reflected in descriptions in the Kama Sutra, an ancient Sanskrit text more than 1,500 years year old. Descriptions of transgender men and women are also found in major Sanskrit epics of India (Pattanaik, 2014), among the oldest surviving epic poems on earth, and images of transgender people are depicted in many ancient Indian temple carvings. In the sixteenth and seventeenth centuries, when the Mughal Empire controlled most of the Indian subcontinent, trans people attained special status in the king’s court as political advisers, administrators, and generals; they also served as guardians of women in harems (Reddy, 2005). Thus, the concepts of a third gender, that some male-born and female-born individuals desire to identify with a gender different from that assigned at birth, and that transwomen may engage in sex work, have been relatively well known in India for centuries. From this perspective, transgender people in India have a longer documented history than they do in most other nations on earth.

15. Transgender Sex Work in Brazil: Historico-Cultural Perspectives
Don Kulick

This is a new introduction to Harrington Park Press’s reprint of “The Gender of Brazilian Transgendered Prostitutes” (article originally published in American Anthropologist 99 (3), 574 –585, September 1997).

16. The Changing Landscape of Transgender Sex Work, Pimping, and Trafficking in Brazil
Barry M. Wolfe

This chapter presents an international legal framework for transgender traffcking and sexual exploitation. Particular aspects of the social and cultural environment typically associated with transgender sex work in Brazil will be depicted; transgender pimping structures and processes will be mapped; factors that lead transgender sex workers to accept exploitation will be explored; human traffcking structures and processes will be described; and conclusions about the limits of law enforcement will be presented. The chapter is based on more than ten years of experience interacting and working with Brazilian transgender sex workers. I also founded SOS Dignity, a nongovernmental project that is part of an established AIDS NGO. This organization has defended numerous transgender sex workers in civil and criminal cases ranging from improper arrests to charges of homicide. My conclusions are based on academic qualifcations in the felds of international law and criminology; ten years of experience as a specialist in international immigration law; assistance with cases involving human traffcking; and personal involvement.

17. Sociocultural Context of Sex Work among Mak Nyah (Transwomen) in Kuala Lumpur, Malaysia
Tooru Nemoto, Rebecca de Guzman, Yik Koon Teh, Mariko Iwamoto, and Karen Trocki

In Malaysia, transgender women (mak nyah) are a highly stigmatized and persecuted group. Mak nyah have little to no access to gender-affrming healthcare and are exposed to widespread societal stigma, employment discrimination, persecution by Islamic religious authorities, and police harassment. Violence, HIV risk, and criminalization are further compounded for mak nyah who engage in sex work. This study aimed to explore and describe the health and social needs of mak nyah on the basis of in-depth qualitative interviews with 18 mak nyah sex workers in Kuala Lumpur. We adapted grounded theory and qualitative descriptive methods to analyze the themes that emerged. Narratives of mak nyah illustrated a complex web of mutually reinforcing vulnerabilities. Mak nyah faced hypervisibility in public settings, where they endured routine intimidation and harassment, and near invisibility when seeking access to and information about hormone use and other health needs. Faced with these and other injustices, many mak nyah engaged in a benefcial informal network of support with peers and allies, though the mak nyah’s needs extended well beyond the resources available. Study results suggest that public health and advocacy efforts to improve mak nyah’s safety and well-being will require the commitment of a broader human rights agenda.

18. Sociocultural Context of Health among Kathoey (Transwomen) and Female Sex Workers in Bangkok, Thailand
Tooru Nemoto, Usaneya Perngparn, Chitlada Areesantichai, Mariko Iwamoto, Charlene Bumanglag, and Julia Moore

Although prostitution is illegal in Thailand, a number of kathoey (male-tofemale transgender women) and women engage in sex work mainly for economic reasons. Both kathoey sex workers (KSW) and female sex workers (FSWs) face health risks, such as sexually transmitted infections (STIs), substance abuse, and violence; however, risk behaviors and surrounding environmental and sociocultural contexts signifcantly differ. This study revealed that KSWs were younger and better educated, worked shorter hours, and had a smaller number of customers than FSWs. Only one KSW reported having seen a healthcare provider in the previous 12 months, and only half of KSWs had ever been tested for HIV, whereas almost all FSWs had been tested. Both KSWs (75%) and FSWs (87%) sent money home to support their families, but a higher number of FSWs expressed their willingness to engage in unsafe sex with customers for extra money than did KSWs. KSWs were more likely to use illicit drugs and have sex with customers under the influence of substances than were FSWs. The study clearly indicates that comprehensive HIV/STI prevention and health promotion programs must be implemented that are specifc to KSWs (e.g., reducing substance abuse) and FSWs (e.g., addressing economic pressure).

19. Transgender Sex Work in the Andean Region: Between Vulnerability and Resilience
Ximena Salazar, Aron Núnez-Curto, Angélica Motta, and Carlos F. Cáceres

This chapter describes transgender sex work in the Andean region in South America (formed by Peru, Ecuador, Colombia, and Bolivia). The history and current situation of transgender sex work in this region are presented in conjunction with the workers’ legal status, HIV risks, and other characteristics. Some unique features of conducting transgender sex work in this area are summarized briefly.

20. Transgender Sex Work in Spain: Psychosocial Profile and Mental Health
Rafael Ballester-Arnal, Maria Dolores Gil-Llario, Jesús Castro-Calvo, Trinidad Bergero-Miguel, and José Guzmán-Parra

This study compared sex workers and non–sex workers among transwomen seeking services at the Transsexual and Gender Identity Clinic in Málaga, Spain. Compared to those with no history of sex work, those with such a history reported more family issues (e.g., having a mother with psychological problems and having been thrown out of the house), a history of having been arrested, sexual abuse, and substance use. The sex workers were also more likely to report behavior consistent with an antisocial personality disorder based on SCID-II. These findings are consistent with studies from other parts of the world and point to transwomen sex workers as a population with distinctive issues and concerns.

21. Prevalence and Associated Factors of Condomless Receptive Anal Intercourse with Male Clients among Transwomen Sex Workers in Shenyang, China
Zixin Wang, Joseph T.F. Lau, Yong Cai, Jinghua Li, Tiecheng Ma, and Yan Liu

Globally, transwomen sex workers have high prevalence of HIV and condomless receptive anal intercourse with male clients (CRAIMC). We investigated the prevalence of CRAIMC and factors associated with CRAIMC among transwomen sex workers in China. HIV prevalence among transwomen sex workers was high but probably underestimated. The high prevalence of condomless anal intercourse with male nonclients and high mobility in sex work among this population in China are causes for concern. Risk factors for CRAIMC were multidimensional and should be considered when designing interventions targeting transwomen sex workers. Such interventions are urgently needed.

SECTION VII: Care and Treatment of Transgender Sex Workers

22. Issues in the Care and Treatment of Transwomen Sex Workers
Asa Radix and Zil Goldstein

In this article, we present and discuss basic principles for the care and treatment of transgender sex workers. These individuals have typically experienced an array of diffculties and life challenges, including different forms of abuse, aspects of discrimination, and family problems, and caring for them requires a holistic understanding of these issues as they may relate to substance use and mental health issues. Better care and treatment of transgender sex workers are sorely needed, and we hope this chapter will assist practitioners in better serving this population.

SECTION VIII: Criminal Justice Versus Public Health Perspectives on Transgender Sex Work

23. Police Abuse, Depressive Symptoms, and High-Risk Sexual Behavior for HIV among Transwomen
Larry A. Nuttbrock

Building on a previous longitudinal study describing the effects of broad measures of gender abuse on depressive symptomatology and high-risk sexual behavior for HIV among transgender women, the current analysis examined longitudinal associations of perceived psychological abuse by the police with depressive symptoms and high-risk sexual behavior for HIV in this population. The analysis suggests that psychological abuse by the police elevates depressive symptoms, which then reduce the odds of using condoms with different types of partners. These findings suggest that aggressive policing in urban areas such as New York City may be counterproductive from a public health perspective.

24. Criminal Justice versus Health and Human Rights Perspectives on Transgender Sex Work
Tara Lyons, Leslie Pierre, Andrea Krüsi, and Kate Shannon

In this chapter we systematically present the array of factors and issues associated with a criminal justice as compared to a public health perspective on sex work. Focusing on transgender sex workers, we discuss and summarize the different perspectives and controversies involved in this ongoing debate.

SECTION IX: Analytic Summary and Directions for Further Study

25. Analytic Summary and Directions for Further Study
Walter Bockting and Larry A. Nuttbrock
(since 1/28/18)

(since 1/28/18)

(since 1/28/18)


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