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Transgendered Youth at Risk for Exploitation, HIV, Hate Crimes (2003)

Transgendered Youth at Risk for Exploitation, HIV, Hate Crimes (2003)

©2003, 2013 by Dallas Denny

Source: Dallas Denny. (2003). Transgendered youth at risk for exploitation, HIV, hate crimes. In Burnaby-New Westminster task Force on the Sexual Exploitation of Children and Youth, Working with sexually exploited youth and youth at risk of sexual exploitation: A handbook, 3-34-36. Burnaby, BC. This paper has been widely reproduced on the internet.

Transgendered young people are at high risk for exploitation and violence. All to often, they are rejected by their families and find themselves on the street. Unable to find work, they sometimes turn to sex work, which puts them at risk for HIV/AIDS and sexually-transmitted diseases, drug use, and assault from pimps and customers. At bottom, the problem is not with them, but with a society that offers them no other options.


Transgendered Youth at Risk for Exploitation, HIV, Hate Crimes

 by Dallas Denny, M.A.


 Transsexualism has long been defined as a condition in which the individual wishes to manifest the primary and secondary sex characteristics of the non-natal sex and live as a member of that sex (DSM III-R). However, there is an increasing awareness among researchers and clinicians that genital surgery is not uniformly desired or sought by all persons who dress and behave as members of the other sex on a full-time basis (DSM IV). Some individuals who live as members of the non-natal sex identify not as transsexual, but as transgenderists, and have no desire for genital surgery (Boswell, 1991). The term transgender(ed) is increasingly being used to describe people who transgress gender for whatever reason, and is considered to include transsexual people, transgenderists, crossdressers, and drag queens (Bornstein, 1994). However, some transsexuals do not identify as transgendered, and resent being categorized with non-transsexual transgendered people.

Most transgendered and transsexual persons are invisible in society, leading unexceptional middle-class lives, but a highly visible minority function as exotic dancers, female impersonators, and sex workers. Because this is a youth-oriented subculture; because the sub-culture is associated with violence, substance abuse, and HIV transmission during unprotected sex and via shared needles; and because it offers a source of easy cash when discrimination closes other avenues of employment, transgendered and transsexual adolescents and young adults are often drawn to it. [1] Many transgendered and transsexual persons are rejected by their families (Denny, 1995; Walworth, unpublished), or are victims of hate crimes, rape, persecution, discrimination in employment and housing, and denial of social services based either on their appearance or because others possess knowledge that they are transgendered (cf San Francisco Human Rights Commission, 1994). Abrupt and total ostracism, and especially loss of income can put transgendered persons quite literally on the street, with sex work as the only immediately available vocational option. Transgendered youth, who are likely to be lacking in marketable job skills, are especially at risk. Although the remainder of this discussion is specifically written about transgendered youth, it is applicable to all transgendered persons; young people are not the only victims—merely the most frequent.


Some Areas of Risk



Although the rate of suicide and suicide attempts in transgendered youth is unknown, it can be supposed to be quite high. Suicides of gay and lesbian teens, who share similar characteristics of guilt and shame, are known to be quite frequent. A retrospective study of mortality and morbidity in a cohort of 425 transsexual patients given hormonal therapy, (Asscheman, Gooren, & Eklund, 1989) found five times more deaths in male-to-female persons than expected. In another retrospective study, Walworth (unpublished), found that 50% of her sample of 52 post-operative transsexual women [2] reported having considered suicide, and 7.7% had actually attempted it.

Mutilation of the genitalia also occurs with some frequency in transgendered persons (Haberman & Michael, 1979). This can consist of self-castration, penectomy, or both. In some cases, the individual prepares carefully. Lowy & Kolivakis (1971). reported that one individual, after repeated refusals for hormonal treatment from the medical community, became a nurse and took a course in urological nursing so that he could do a more competent job (and did, when he eventually autocastrated). However, self-mutilation is most likely to occur during times of extreme frustration and in association with substance abuse. Recently, Tayleur (unpublished), has reported instances of transsexual individuals amputating one or more fingers while high on PCP.

Substance Abuse

Because they are often desperate to change their bodies, transgendered youth are easy victims to unscrupulous “practitioners” who perform quasi-medical services in exchange for money. In addition to all of the substances which are traditionally considered when one thinks of substance abuse (alcohol, tobacco, marijuana, cocaine, heroin, amphetamines, barbiturates), transgendered youth seek to feminize or masculinize their bodies by injection of hormones and liquid silicone.

Hormones are obtained from other transgendered persons (or from nontransgendered persons) or by forging prescriptions, or are purchased inMexico. They are injected, often without proper regard for safety precautions, often in large quantities, and in unorthodox areas of the bodies like the breasts and genitals, using the street logic that “more is better” and that they will somehow be more effective if used in the genital and breast areas. Pills are abused, as well.

Hormones are potent substance, and their administration is associated with a variety of risks, including thromboembolic events and elevation of liver enzymes for estrogens (the female hormones), and liver damage for androgens (the male hormones). Their use requires periodic medical monitoring which includes blood tests. Transgendered youth, by using hormones procured on the street, circumvent this monitoring, as well as other procedural safeguards such as counseling (Walker, et al., 1984).

Medical-grade silicone was once available by cannibalizing breast implant sacs, but this source (which was probably rarely used, anyway) has dried up due to the FDA’s ban (San Francisco Chronicle, 1992, 8 January). The most commonly-used silicone, both before and after the FDA ban, is of industrial grade, purchased in hardware stores or automotive supply houses (Oakland Tribune, 1993, 18 February). It is injected subcutaneously into cheeks, lips, chins, foreheads, breasts, thighs, hips, and thighs, and almost any other imaginable part of the body by non-trained, unlicensed lay “practitioners” who travel across the country, charging large sums for this “treatment.” Eventually, the bodies of the “patients” can contain large quantities (up to 3 liters) of liquid silicone. Once injected, it is impossible to remove without extensive plastic surgery, and scarring is almost inevitable (Ohtake, Itoh, & Shioya, 1992).

The use of liquid silicone for injection has long been condemned by the FDA, even by physicians (Sadusk, 1966). Long-term effects include systemic illness, disfiguration due to hardening and migration of the silicone; short-term effects include respiratory distress and even death (Greer, 1993; Vilde, et al., 1983). The “benefit” is an immediate alteration of the shape of the body: instant cheekbones, breasts, hips, thighs. The contours created are often more exaggeratedly feminine than those found in nature. The individual feels more attractive and may experience a short-term gain in business, especially if she is a prostitute.


Because transgendered youth on the streets are likely to engage in prostitution or consensual sex with a variety of partners without using safe sex techniques, and because substance abuse and use of shared needles (for injection of hormones as well as illicit drugs) is endemic in this population, transmission of the HIV virus is a prime consideration (Alan, et al., 1992). Transsexual persons often have disregard or disgust of their genitals, and usually prefer that they not be touched by their partners; consequently, many transsexual prostitutes prefer to take the passive role in anal intercourse and/or the receptive role in oral intercourse. Unprotected anal intercourse is, of course, a known high-risk sexual activity. This is not mere idle speculation; a recent survey of transgendered sex workers in San Francisco showed a 70% incidence of HIV infection.

Transgendered persons often feel shame, disgust, and guilt because of their desire to function as members of the other sex. This can undermine decision-making, and thus be a significant factor in transmission of the HIV virus. The individual who prefers to think of her anus as a vagina, and the individual who does not carry protection because she believes that it will prevent her from succumbing to temptation, as well as the sexually naive crossdressed individual who is aggressively approached and seduced may find themselves engaging in high-risk sexual activities without protection. Without a source for support and education, the behavior may occur throughout a long period of time, increasing the risk of infection.


Transgendered individuals can enrage others by their mere existence. If appearance is androgynous or gives mixed gender signals, they become likely targets for gay-bashing. Many individuals have secondary sex characteristics (male pattern baldness, facial and body hair, deep voices, adam’s apples) which are difficult or impossible to hide, making them easy to spot. Additionally, sometimes sexual partners do not know that the woman they picked up is has a male anatomy, and can become violent when they do discover it. For whatever reason, there is an astounding amount of violence done to transgendered persons, much of which is not reported because of shame or internalized transphobia. That which is reported is often either not listed as a hate crime, or, if it is, is listed as violence against a gay male rather than to a transgendered person.

The extent of this violence should not be underestimated. In my five years in Atlanta, there have been no fewer than 10 violent deaths of transgendered persons reported in the press. Six of these were the apparent work of a serial killer (victims were shot and dumped in various locations; most were sex workers). The deaths were reported on the news, but little else was heard about them. The extent to which transgendered persons are devalued by our society becomes apparent when one considers that the last time such a large number of persons were serially murdered in Atlanta, the entire nation was in an uproar about the Atlanta child killings.

Violence against transgendered persons is not anAtlantaproblem, however, nor even a national problem; it is an international one. Death squads in South American countries have executed transsexual persons and crossdressers in large numbers, and police in other countries (especially in the Mid-East) harrass, torture, and murder transgendered persons with little fear of reprisal.




Education is a partial remedy for much of the violence done to transgendered persons. It is important that educational efforts be made to all segments of the treatment community, to government agencies, to private service providers, to the general public, and to transgendered persons themselves, who often have no clear knowledge of their options, for with education comes the realization that many stereotypes about transgendered persons (i.e., they are all prostitutes; that they are caricatures of men and women) are just not true (for instance, this article was written by a transsexual woman). Local, regional, national, and international conferences, books, pamphlets, instructional videos, speakers, peer counselors, telephone help lines, computer bulletin boards, Standards of Care, and other resources are available through The American Educational Gender Information Service and other non-profit agencies.


[1] For a graphic portrayal of this subculture, see the 1985 HBO release, “What Sex am I?” narrated by Lee Grant.

[2] Transsexual women—that is, natal males who have or are having sex reassignment, have previously and quite unreasonably been called and continue to be called “male transsexuals” in the literature. Because this usage is offensive to transgendered women, we do not use it.


Alan, D., Alexander, R., & Monroe, J. (1992, July). Transsexuals: Don’t think about them and they go away… and die! International Conference on AIDS, 19-24 July, 1992, 8(2).

Asscheman, H., Gooren, L.J., & Eklund, P.L. (1989). Mortality and morbidity in transsexual patients with cross-gender hormone treatment. Metabolism: Clinical and Experimental, 38(9), 869-873. Also presented as a paper at the 11th Harry Benjamin International Gender Dysphoria Association Symposium,Cleveland,Ohio, 20-23 September.

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American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, 4th. ed. Washington, D.C.: American Psychiatric Association.

Anonymous. (1992, 8 January). Big award in S.F. lawsuit led to breast implant moratorium. San Francisco Chronicle, A4.

Anonymous. (1993, 18 February). Auto-shop silicone used for injection. Oakland (CA) Tribune, A-8.

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Denny, D. (1995). Prodigal son: A tale of noncommunication and rejection. Chrysalis: The Journal of Transgender Issues 2(1), 23-27.

Greer, R. (1993, 17 February). Silicone injection killed man, police say. Atlanta Journal-Constitution, B6.

Haberman, M.A., & Michael, R.P. (1979). Autocastration in transsexualism. American Journal of Psychiatry, 136(3), 347-348.

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Lowy, F.H., & Kolivakis, T.L. (1971). Autocastration by a male transsexual. Canadian Psychiatric Association Journal, 16(5), 399-405.

Ohtake, N., Itoh, M., & Shioya, N. (1992). Postoperative disorders of augmentation mammaplasty by the injection method in Japan. In U.T. Hinderer (Ed.), Plastic surgery 1992, Vol. 2, pp. 677-678.New York: Elsevier.

Sadusk, J.F. (1966). Letter to the editor: FDA’s position on injected silicones. Plastic and Reconstructive Surgery, 37(3), 251.

Vilde, F., Arkwright, S., Galliott, M., Galle, P., Labrousse, J., & Lissac, J. (1983). (Fatal pneumopathy linked to subcutaneous injections of liquid silicone into soft tissue). Annales de Pathologie, 3(4), 307-312.

Walker, P.A., Berger, J.C., Green, R., Laub, D., Reynolds, C., & Wollman, L. (1984). Standards of care: The hormonal and surgical sex reassignment of gender dysphoric persons. Annals of Plastic Surgery, 13(6), 476-481.

Walworth, J. (unpublished). Sex reassignment surgery in male-to-female transsexuals: Client satisfaction in relation to selection criteria.