Making Change: The Cost of Being Transgender

May 10, 2007 — -- Kenyatta can't talk long; she has a date.

"We call them dates," she said of the men with whom she has sex for money.

Anxiously, she brushes her long dark hair off her slight shoulders and out of her smoky eyes.

Once you know that Kenyatta, 22, was born a male, her large hands and Adam's apple seem obvious. But at first -- and even second -- glance, there is little to suggest that she wasn't a girl her entire life.

She prostitutes herself "about twice a month" in order to buy the black market hormones that enlarge her breasts, raise the pitch of her voice and keep hair from growing on her face.

"Honestly," she said, "I have to pull a trick to pay for hormones."

Kenyatta is one of 25 young people spending the night at Sylvia's Place, an emergency homeless shelter for New York City's gay, lesbian, bisexual and transgender youth.

A third of the people here this Tuesday night, like most nights, are low-income transgender women who were born male.

Kicked out of their homes and ostracized by their peers, they look to each other for solace and to the streets to make a living.

In an effort to make their bodies more feminine, some "trans women" take unregulated doses of hormones bought on the black market and pump industrial silicone -- the same stuff used in brake fluid -- into their breasts. Many have hurt themselves or attempted suicide.

Being transgender is costly. It costs people their families, homes, health, educations and jobs.

It also costs a lot of money.

To pay for their transitions, many of these young women have not only lived on the streets but worked there as well. They sell their bodies to afford the treatments and trappings necessary to make those bodies look to the world as they do in their heads.

Wealthier parents with a child who begins to present as transgender, sometimes as early as 5 years old, will seek information on the Internet, with a family physician, or through a community organization. But many low-income parents can't afford access to those resources.

Children from poorer families are more likely to be thrown out of their homes and end up on the streets.

Though the transgender community in the United States is small, roughly estimated at between 1 and 3 million people, it represents a broad diversity of people.

"Transgender can be anything from feeling internal body dysmorphia [an altered body image] to acting on it, as with cross-dressing, to actually changing your body through hormones, silicone injections and surgery," said Cris Beam, a journalist who spent seven years following a group of transgender youths on the streets of Los Angeles for her book "Transparent."

Those who want surgery and can afford it can spend $10,000 to $20,000 for a sex-change operation.

But for most transgender people, surgery is not an option. Their primary concern is simply making ends meet.

"The vast majority of [transgender] people are poor," said Chris Daley, director of the Transgender Law Center. "Being trans affects their economic health and means unemployment and underemployment. There is a real material cost in transitioning."

In San Francisco -- arguably the most transgender friendly city in the country and home to the minority's largest population -- 60 percent of transgender people make less than $15,300.

Experts and advocates say that people obviously in the middle of transition are often discriminated against when looking for work. Those with jobs often cannot get their health insurance to cover the cost of hormone therapy.

"They're often turned away from places like McDonald's if they're visibly trans -- the most basic workplaces and most basic jobs," said Ray Carannante, associate director of the Gender Identity Project at the Lesbian, Gay, Bisexual and Transgender Community Center in New York. "They're out there and they often have to rely on sex work. Very often, trans young people have to rely on sex work regardless of what other skills they have."

Britney Spears, who took her new name from the pop singer she loves, was born 22 years ago in Queens, N.Y. Then named Nick, she began wearing her younger sister's clothing when she was 5 years old -- at home and even at school.

When her mother died a few years ago, Britney went to live with a grandmother in Baltimore who later kicked her out.

Now unemployed and living at Sylvia's Place, she tried working at McDonald's and "even [has] the scars to prove it."

"I worked at McDonald's, but it was horrible," she said. "They made me dress as a boy. When I went to the interview, I was all dressed up and I looked beautiful, but the manager said, 'Don't do it around the other workers cause it makes them uncomfortable.'"

Black Market Hormones and Silicone Injections

Many transgender people use hormones to alter their sex characteristics. Estrogen adds breasts to men, stops facial hair from growing and raises the voice.

Costs for hormones vary from place to place and depend upon a person's needs. Medicaid will not pay for most hormone treatments because it considers the therapies optional.

Most transgender people cannot afford to see doctors and get the necessary tests. Instead, they buy hormones on the black market -- usually hormone replacement therapies for menopausal women smuggled into the United States from Mexico.

"The costs vary," said Carannante. "I might be able to get hormones on the street for $20, but someone else might pay $100 dollars for the same thing. The majority of trans youth of color are not getting hormones by prescription."

Janet, 25, hasn't uttered her birth name in almost a decade. She began her transition to become a woman at 14. At about the same time, she began robbing houses to afford black market hormones.

She has criss-crossed the country and bought illegal hormones in California, New York and Texas.

"Just go into any transsexual bar and someone there will be selling," she said.

The only time she ever received hormones by prescription and at regulated doses was at a county jail in San Francisco. After being raped in another prison, she contracted HIV.

On the black market, she said, 1 cc of estrogen costs around $15. A physician might charge more than five times that amount.

She has also spent $800 on laser hair removal and at one time considered pumping industrial silicone into her breasts.

Dr. Ward Carpenter, a physician at the Callen-Lorde Community Health Center who works with transgender patients, said there were numerous risks associated with both silicone injections and unregulated hormone use.

"Silicone is a huge health problem … One patient has had 20 surgeries to remove all the silicone injected into her hips 30 years ago. It solidifies, becomes very hard, and clumps into rocks," he said.

"Silicone has a tendency to migrate in the body," he added. "It can be injected in the hips and then you end up in the emergency room with silicone in the lungs."

There are also health risks associated with illegal hormones. Progesterone has been linked to breast cancer and estrogen can cause deadly blood clots in the "lungs, legs, heart and brain."

Class Matters

Low income "trans men" also face challenges in their transition from females to men.

Born Raquel Samantha Hall, 20-year-old Kels never felt comfortable in his body.

"My body never felt right to me," he said. "I always wanted to dress boyish and do boyish things. The body I'm in, I hate. I don't like my breasts or my voice.

"I want to chop off my breasts, but that will cost $8,000. I don't even have good enough credit to get $8,000. I don't even have good enough credit to get a credit card."

Affording their transition is not all low-income transgender people have to worry about.

Young transgender children in wealthier families often receive the benefit of their parents' education and access to information.

Children attending smaller schools in wealthier districts are more likely to have adults advocating for them than those in poor areas where funding is spread thin, said Daley.

Transgender people also must regularly contend with acts of violence. The young people interviewed by ABCNEWS.com all said they had been verbally harassed and some had been physically assaulted.

"For the last decade or two, about one trans person is murdered every month," said Mara Keisling, the executive director of the National Center for Transgender Equality. "We know that number is actually higher because a lot of trans people's murders go unreported either because the police are confused or are trying to help victim's family by masking the person's identity."

"It's very class related," she added. "When we look at who murder victims are, they're generally young low-income trans women of color and very often immigrants. If you're any of those things you are more susceptible to violence and disrespect. If you're all of those things, you probably feel like you have a bull's-eye on your back."