11th Harm Reduction Conference in the United States

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North America and Caribbean Regional Correspondent
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The 11th Harm Reduction Conference took place in San Diego, California from 3-6 November. It included workshops, talks, and panels with American sex work organisations such as HIPS, SWOP-USA and independent sex work activists like Emi Koyama, who works out of Portland and Seattle. Koyama is active in American sex work advocacy. She presents workshops and speaking on panels at conferences such as the Desiree Alliance and The Seattle Annual Sex Work Symposium hosted by SWOP Seattle.

For the Harm Reduction Conference, Koyama presented a workshop called “Stop Throwing Condoms at Us!: Survival, Risk Management, and Lived Realities of Trans Women of Colour and Others in the Sex Trade.” Drawing from the Center for Transgender Equality's 2011 report, “Injustice at Every Turn,” Koyama aimed to “bring attention to the struggles trans people face in every aspect of life, from family acceptance to poverty/jobs, violence to criminalisation, especially trans people who are Black, indigenous, or people of colour.” She stated that, “all of those factors lead to a disproportionate number of trans women of colour engaging in sex trade in order to survive.” As she notes, social service providers and public health officials target trans women of colour “as a ‘high risk’ group in terms of HIV and other sexually transmitted diseases, but their interventions often fail because they are not based on the lived realities of trans women of colour in the sex trade.” She calls attention “to a finding by UCSF Center of Excellence for Transgender Health that the provision of PrEP, which has been shown to be an effective way to reduce HIV infections among cis men who are MSM” is ineffective for trans women. Often, transgender women are often included in the category 'MSM'. 

Her key message is that, “society must meet the basic needs of trans women of colour such as housing, income, and community instead of focusing on reducing HIV risks among trans women, both for practical as well as for ethical reasons." She says she was interested in doing a workshop that was not about the “‘cultural competency’ that trans trainers are often asked to do” because “cultural competency trainings assume that social service providers or public health officials know what is best for trans women and provide tools so that they can do their work more efficiently.” She notes that, “the failure of the PrEP distribution programme exemplifies the need for something different.” 

Koyama believes “that we need to understand why PrEP distribution, or condom distribution for that matter, that is known to be effective among MSMs was not so among trans women.”

Koyama points to the fact that, “one thing that public health people need to understand is that the threat of HIV does not carry the same weight in the lives of many trans women of colour who are struggling to meet basic needs. When one does not foresee surviving next seven or ten years into the future, or being healthy otherwise and having a future worth living in, HIV is nothing more than an abstract threat in the distant future that she may not even live into. No amount of public campaigns ‘educating’ them about the risk of HIV, no matter how ‘culturally appropriate’ they are, can make them care about the risk of HIV infection enough to turn down the extra cash they might make today for not using condoms.”

Elaborating on the findings of the PrEP study, Koyama says that though MSMs were willing to take PrEP, the same response did not exist for trans women. “In other words, trans women who regularly take more behavioural risks are not any more likely than those who are not to take PrEP as prescribed.” Koyama points out that the “behavioral risks” trans women take are different from those MSMs tend to take: “MSMs are typically engaging in risky behaviors for personal relationships and pleasure,” she says, “while trans women are more likely to be engaging in risky behaviors for survival (i.e. sex work). When one's survival depends on regularly engaging in risky behaviors, it becomes necessary to develop a coping mechanism to ignore or push out of our consciousness how risky these behaviors are, otherwise the awareness of the enormity of the risk can paralyze us and keep us from doing what we need to do in order to survive. When viewed from this perspective, indeed, public health campaigns warning trans women about the risks of HIV infection sabotages trans women's survival.”

She believes, “we need to first address basic survival needs. Condoms are pretty cheap, but PrEP actually costs about $1000 per person per month: imagine what trans women could do if each trans woman had access to $1000 per month to spend in however way they saw fit rather than having PrEP thrown at them: perhaps that would actually allow trans women to reduce the amount of behavioral risks they take.”

Koyama says the workshop was well received but also admits that there, “there aren't easy things people can do to fix things on individual levels.” She hopes that, “it would at least motivate the participants to engage with local trans community and have trans women of colour participate not just as low level ‘peer outreach’ workers but in designing and directing researches as well as service provisions.”