What is it about the subject of AIDS which compels readers to turn the page? How come people become uncomfortable when they hear that someone is HIV-virus infected? In my experience it is because nobody wants to think about illness and dying. None the less HIV and AIDS still very seriously effects the transgender and non-transgender communities. And, the character of the epidemic has changed in ways that are worthy of thought and discussion.

Dear Gianna:

I am very worried about my husband. He crossdresses and claims he is not gay, yet I suspect he has secretly experimented. I believe he had sex with strangers while attending a party down in New Orleans. I tried talking with him about this, but he denied having had sex while dressed as a woman. I am not so sure he understands how worried I am. He could infect me with AIDS. We haven't had sex for months because I don't want him touching me. How can I find out the truth if he wont talk to me?

A Concerned Wife, Baton Rouge, Louisiana

Ms. Gianna responds:

Your fear as a spouse of a crossdresser is not unique. Chances are your husband is not gay, however I cannot say whether he is experimenting with sex outside or your marriage. In many instances people crossdress for emotional relief, because they need to do so as part of their self-identity. Other times people crossdress as part of a very discreet sexual turn on or part of role play games.

I am very glad that you took it upon yourself to ask someone for help and information about your situation. Sometimes wives of crossdressers do not, and then never learn the basic information needed to understand a husband who crossdresses. For instance, you obviously are aware that your husband crossdresses, however you did not say whether you and your husband feel comfortable discussing the topic of crossdressing.

It is common that crossdressers frequently do not feel comfortable talking about the content of their sexual fantasies while they are crossdressed. This is particularly so because they do not wish to jeopardize their relationships. In your situation, if you are fearful your husband is having unprotected sex, you need to find out more about his practices and experiences. I would suggest stating that you would like to hear more about why he enjoys crossdressing. Ask him why he finds crossdressing satisfying. I believe if you make it safe for him to talk about his crossdressing, you will gain a better understanding what it is he actually does.

In your discussion you also need to directly ask if he has had unprotected sex without condoms. If he has, he is at risk of contracting the HIV virus and passing it to you through unprotected sex. Should he have had sex outside your marriage, I would suggest you both get tested either through your physician or at an anonymous clinic sponsored by your local public health department. Finally, if he refuses to talk about the HIV issue, refuse to have sex with him until this issue is resolved. Also, always insist he uses a condom for your protection until he presents HIV-negative test results.

In all situations, if you have trouble communicating with your husband, I would strongly advise marriage counseling. A family therapist with sex education training would be your best bet. However, almost any good relationship therapist would be able to teach the both of you how to increase your communication skills within the relationship. Both of you could then discuss the crossdressing and HIV issues together privately, doing so with more ease with your new communication skills.

Dear Gianna:

I am 18 and transgendered. This is supposed to be a time of being a happy young adult for me. I got a big problem to do with dating. I found out I am HIV-positive. This happened last year. I still have men who are interested in me. I also like being a woman. But I don't know how to do something. When do I tell men about my having HIV?

Mavis in Baltimore

Dear Mavis:

Unfortunately your experience of having contracted the HIV virus at a young age is becoming more and more common. So, too, it is common for people to believe HIV/AIDS does not affect them, or that discussing safe sex precautions is necessary. Young people often believe they will live forever, and other adults often say, It wont happen to me. However, the very best prevention for any person, regardless of age, is to use precautions. I am glad you are choosing to ask questions, rather than further complicate your situation. In addition to protecting others, you also want to protect yourself.

Most people are not aware that the HIV virus mutates into different strains. This means there are numerous combinations of HIV out in the world, some strains are more deadly than others. If someone is a long-term survivor and infected with one type of HIV, reinfection with a different strain can be deadly. Moreover, in addition to HIV/AIDS, over the past several years a new disease has emerged which is equally as deadly as AIDS. This is Hepatitis-C which has no cure or treatment. Like other forms of Hepatitis, C attacks the liver and the body's immune system, however, unlike AIDS most people are not aware of its silent presence and it can remain quiet for up to 20 years before becoming symptomatic.

Illness and death certainly are subjects people like to avoid, particularly during sex or lovemaking. After all, lovemaking is a celebration of life and each other. However, before engaging in intimacy in todays world of deadly infections it is crucial Safe Sex precautions be discussed and used. Although it is everybody's responsibility to protect themselves, in some locations having protected sex may be legally required of infected persons to protect others.

As a rule of thumb it is best to introduce the subject of condoms and dental dams before taking ones clothes off. I advise clients to do so at the same time that they discuss their transgender status with a potential sex partner. This is particularly so for pre-operative transsexual and transgenderist individuals. Some individuals feel comfortable enough to state they are HIV-positive. Other persons introduce the subject by stating since I come from a high risk group, there is a strong possibility I may be HIV- positive. Rather than discussing their medical histories some individuals just hand their partner a protective device and state, You must wear this if you are going to have sex with me.

One of the reasons HIV-positive people feel uncomfortable discussing their HIV status, is they are afraid of being treated badly once a partner finds out. Chance are if you handle the situation like a fact of life, and don't allow people to abuse you, nobody is going to make a big issue of it. I have provided telephone consultation to clients throughout the United Sates, and the vast majority of those who are HIV-positive report being able to find sexual partners as well as meaningful relationships despite their medical condition.

Dear Gianna:

I live in rural Tennessee. I also am HIV-positive. This presents several problems. My doctor has been very supportive of my being my true self. I'm FTM. She prescribes my hormones. She and I are wondering if I am allowed to have my breast removal surgery. I am in good health even though I have been infected for over seven years. My doctor said she sees no reason why I cant have surgery, but we haven't been able to locate any clinical literature regarding HIV transgender surgical issues. Could you please provide a reference?

Steve in Tennessee

Dear Steve:

If you are interested in having a bilateral mastectomy and chest reconstruction, your being infected with the HIV virus should not effect either your ability to have surgery or its outcome. At the end of this article I have included a copy of clinical literature from the book Transgender Care, co-authored by myself and Donald Tarver, M.D.. You may order it through the IFGE bookstore or from the publisher, Temple University Press (1997). If either you or your physician have access to Medline, a computerized medical search service, you would want to utilize the keywords transsexualism, HIV, and surgery in order to locate any papers or transcripts on the subject.

RECOMMENDED GUIDELINES FOR HORMONE ADMINISTRATION, AESTHETIC SURGERY, AND GENITAL REASSIGNMENT SURGERY IN HIV-POSITIVE AND IMMUNOCOMPROMISED INDIVIDUALS

1. Hormone administration for HIV-positive individuals should follow the guidelines at the end of Chapter 3.

(Authors note: Hormone administration is in essence the same as it is for HIV-negative persons, except in cases of severe liver failure or other medical conditions which recommend against hormone usage.)

2. Individuals utilizing physician-prescribed self-injected hormones should follow the physicians advice in the handling, cleaning, and disposal of syringes. Needle sharing is strongly discouraged.

3. HIV-positive and immunocompromised individuals are commonly prescribed prophylactic treatments or medicinal, antidepressive, dietary, and other regimens that may impair liver functioning. Physicians should be especially mindful of the monitoring of liver function.

4. Physicians (as well as both MTF and FTM consumers) are advised to review gonad-removal options because such procedures require individuals to utilize lower postsurgical dosages of hormones, thus placing less stress on long-term liver functioning. Intravaginal removal of organs in FTM surgical patients is advised over other procedures that might involve increased surgical invasiveness.

5. Evaluations regarding surgical appropriateness for aesthetic and Genital Reassignment Surgeries should follow the guidelines found at the ends of Chapter 4 and 5.

5a. To date, numerous HIV-positive individuals having a stable fair or better health condition have undergone aesthetic surgical procedures with no known untoward effects. Such procedures include mastectomy, breast augmentation mammoplasty, facial cosmetic surgery, and other minor elective procedures.

5b. A handful of HIV-positive individuals have undergone Genital Reassignment Surgery performed by reputable surgeons. The surgical recommendations herein are the first ever proposed for these individuals because, at present, no case studies document how Genital Reassignment Surgery affects the immune system postsurgically. However, extensive studies have been done on general, cardiac, orthopedic, and other medically necessary surgical procedures. These operations have not adversely effected immune systems of stable HIV-positive patients. Furthermore, the ethical guidelines of the American Medical Association state that physicians may not withhold medically necessary therapy because of the physicians fear of contracting the patients diseases.

6. Surgeons are advised to consult with a surgical candidates primary physician to verify the individuals current health status and the medical appropriateness for any surgical procedure. Candidates having fair or better health conditions may be considered medically appropriate, particularly when an aesthetic surgery or genital-reassignment procedure is deemed psychologically beneficial to the individuals quality of life.

7. Fair health or better shall be inclusive of the individuals being free of associated diseases and major opportunistic infections for three months with regard to aesthetic surgeries and for six months with regard to Genital Reassignment Surgery. Such diseases would include Kaposis sarcoma and Pneumocystis carinii pneumonia. Examples of major opportunistic infections would include systemic candidiasis, systemic or chronic mucocutaneous herpes simplex, aspergillosis, cryptococcal diseases, cytomegalovirus infection, nocardiosis, strongyloidiasis, toxoplasmosis, zygomycosis, and tuberculosis.

8. Surgeons are advised to evaluate the appropriateness and role of individualized pre- and postsurgical prophylaxis. This may help prevent the development of hospital-acquired illness or the reactivation of a latent disease.

9. Surgeons unwilling to perform surgical procedures on individuals designated as medically appropriate by the candidates primary physician are advised to refer such individuals to reputable surgeons familiar with operating on HIV-positive individuals.

10. Surgeons and primary physicians who view an individual as medically inappropriate for the extensive invasiveness of Genital Reassignment Surgery yet recognize the individual as appropriate for the lesser invasiveness of gonad-removal surgery are advised to inform the individual that such procedures are available. MTF gonad removal (orchidectomy) and FTM gonad removal (oophorectomy, via intravaginal methods) do not have the extreme invasiveness or graft complications associated with more complex genital-reassignment procedures.

Numerous orchidectomies have been performed on MTF transgender individuals who are HIV-positive, with no known contraindications for those established as being in a stable fair or better health condition. Little information available regarding HIV-positive FTM response to gonad removal. Gonad removal is reported to provide individuals with some psychological sense of completion, whereas not having any procedure leaves the individual in the limbo of transition and may contribute to gender dysphoria. Pharmacologically, gonad removal enables the administration of lower dosages of hormones, thus lowering long-term risks of liver damage and other side effects.

11. Being deemed medically inappropriate for any one or all surgical procedures carries a heavy psychological burden for transgender individuals. Surgeons declining to perform surgical procedures as well as primary physicians discouraging individuals from seeking these surgeries are advised to refer or provide psychological support when turning an individual away.

12. Being crossdressed or living in role provides no one protection from the HIV virus. Individuals who anticipate having sex or having a fantasy fulfilled are strongly advised to carry prophylactic protection.