Harm reduction for transgender and non-binary communities

By Kai Proschan

Harm reduction is a critical public health strategy when it comes to ensuring healthier and longer lives for transgender and non-binary people. Most times, the concept of harm reduction is reduced to Narcan and overdose training or syringe access and safer use sites. Both are essential components of this health care practice; however, harm reduction applies to practically every part of our daily lives regardless of gender identity: housing, food, transportation, employment, and mental health.

When supporting transgender and non-binary people in particular, it’s important to know that these communities may be at higher risk of harm due to social stigma and discrimination.

“It’s about mental health. It’s talking about sex work and queer healthcare. It’s making all these spaces more accessible,” said Seth Katz, Community Programs Coordinator at San Francisco AIDS Foundation. 

Accessibility is the key word here. Studies show that transgender and non-binary people who utilized harm reduction strategies were better able to manage their emotional and physical well-being and reduce the risks associated with certain behaviors. These strategies can involve providing access to safe and accessible health care with trained providers offering gender-affirming and culturally appropriate services. Other strategies may include needle exchange programs, peer support groups, access to safe housing and employment resources, and creating affirming and safe spaces where transgender and non-binary people can discuss their health without stigma.

Drug use is more common in the transgender and non-binary communities because of social stigma. Many individuals self-medicate with drugs because they do not have access to appropriate healthcare or mental health services. 

When caring for people who use drugs (PWUD), it is essential to focus on harm reduction strategies instead of abstinence-only approaches. Providing access to safe and sterile needles and other injection supplies is one way to maintain an individual’s autonomy while reducing harm.

In recent years, the need for increased access to harm reduction services for transgender and non-binary people has become more urgent. Transgender and non-binary people are at significantly higher risk of health risks than their cisgender peers. This includes physical health risks, such as higher rates of HIV, STIs, substance use, and mental health risks, such as higher rates of depression and suicide. These risks are compounded by the discrimination and stigma faced by transgender and non-binary people when accessing health care, which can lead to delayed or foregone care. Additionally, studies have shown that transgender and non-binary people are more likely to engage in sex work and use drugs, increasing their risk of HIV, STIs, and substance use. Increasing access to harm reduction services is essential to address these risks. 

When we look at harm reduction as preventative medicine, it becomes apparent that harm can occur anywhere, anytime, especially for transgender and non-binary individuals. More so when they are also a person of color. 

“When you go to a clinic or harm reduction center, more harm is committed if they’re not trans competent or there’s additional judgment, stigma, transphobia,” Katz said. “You have to be linguistically and culturally competent, and we’re speaking as queer as a culture.”

As poet and writer Audre Lorde once said, “​​Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare.” Somewhere in the history of healthcare, systems started to preferentially treat certain groups of people and leave other communities with little to no support. Something like the correct gender marker for a transgender person can be the difference between getting arrested or let go with a simple warning. 

“Applying for jobs, loans, or buying a car or home is easier when your documents match up with the person. Harm reduction goes beyond the medical space,” said Bella Jackson, TransHealth Services Manager at SFAF. She and Joaquin Meza, the TransCare Coordinator and Benefits Navigator at SFAF, are part of a two-person team that helps transgender and non-binary individuals petition for name and gender marker changes.

“They’ll turn you away if the papers aren’t printed correctly or sized a certain way. If you’re in a particular city with a very busy courtroom, you might not even be able to submit after waiting for hours,” Jackson said in regards to the application process for changing gender and name markers.  

The provision of harm reduction services is an essential part of providing comprehensive care to transgender and non-binary people. By acknowledging these communities’ unique challenges and incorporating a harm reduction approach into their care, healthcare providers can create an inclusive and safe space for transgender and non-binary people. This can build trust and help transgender and non-binary people develop positive relationships with their providers and have access to the health services they need.

Ivana Staiti, ASW, is a counselor at SFAF’s Stonewall Project, a California state-certified drug and alcohol treatment program providing harm reduction services through counseling, education, and support groups. Behavioral change can be  critical in ensuring that individuals from trans and non-binary communities are equipped with life-long tools to help them live healthier and fuller lives. 

“I don’t approach this work as just me helping them. I also want to build on how we are engaged with systems. What wounds do people have from institutions? Family? A lot of that work is trauma work and addressing underlying needs that haven’t been met for a person,” she said. 

In addition, a harm reduction approach can be more inclusive and affirming for transgender and non-binary people, as it recognizes and respects the right to make decisions about your own lives and bodies rather than trying to impose a one-size-fits-all solution.

When it comes to mental health, harm reduction strategies can effectively protect transgender and non-binary people from facing mental health issues alone or not addressing them at all. Some strategies can include mental health counseling, social support programs like group therapy that provide safe and empowering spaces for people to meet and socialize, and educational resources. Knowledge is power, and providing more resources to empower individuals allows them to take better care of their health. This can range from HIV and AIDS care, gender-affirming care, or broad mental and behavioral health support. 

“For many institutions, peer support is huge in the form of groups. It’s about honoring lived experiences and people being the experts of their own experiences and what they need,” said Staiti. 

However, there is a common issue that arises in these peer-led groups. Aerin Riegelsberger, MSW, ASW, is a counselor with the Stonewall Project and calls out how these groups can easily take on a power hierarchy similar to that of a doctor and patient, teacher and student, or leader and follower.  

“Efforts are being made to decolonize how we think about mental health and the power dynamics between expert clinicians and the learning client,” he said, “but it’s a slow process.” Most often, a licensed clinician or staff member leads these peer groups. Yet, more often than not, these group leaders don’t have any personal experiences living through situations that require harm reduction. It’s like a victim of abuse speaking to someone with no experience with abuse whatsoever except textbooks. Or a male doctor consoling a woman who had a traumatic abortion experience. Riegelsberger wants to see more peer groups with individuals with lived experiences similar to the clients. 

Ultimately, harm reduction for the transgender and non-binary community is about speaking the language, providing access, and creating systems that build up these resources for current and future generations. 

Clinicians and health professionals can better educate themselves about gender-affirming health care and the ways in which it differs from person to person. Understanding how hormone replacement therapy can be essential to an individual’s overall health is a critical step in reducing any future harm.

Then comes access. More programs dedicated to the community is necessary to ensure that the most number of people are supported in their health–a key tenet of public health and medicine in general. And finally, the future-facing work of hiring people from the community to build up these programs and provide insights from their own lived experiences is critical. A social worker degree or counseling certificate can only go so far, and having the individuals who know how to support each other will not only lead to increased harm reduction, but also provide employment opportunities for these individuals. 

In the short-term, harm reduction can improve the quality of life for transgender and non-binary people. Harm reduction strategies can provide individuals with access to medical services, including hormone therapy and gender-affirming surgeries, which can be a crucial part of this community’s health care. 

Long-term, these strategies can help reduce the stigma and discrimination faced by this community and ultimately create a more inclusive society. Furthermore, creating a safe space for transgender and nonbinary people can encourage them to seek help and support for issues such as substance abuse, mental health, and homelessness.

Kai Proschan (she/they) is a nonbinary, trans-femme, Japanese-American writer and creative based in Los Angeles. Her work centers around queer and trans health and wellness, identity politics, and beauty. She has been previously published in Cosmopolitan, Dazed, and Parents, and is currently working at FOLX Health as the Senior Director of Audience Development.