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going to the Jackson Clinic? I hate it there. People are always staring.” As she said this, she herself was staring down at her own cleavage.

“Sure! Let’s get the ball rolling. Start by talking to one of the social workers. We’ll get you in a drug program and follow your HIV infections here. You’re in luck. Someone actually donated some Premarin to our pharmacy. Who knew? I never thought we’d use it, but why not use it for you?”

I had taken a basic negotiating skill we teach our students—establishing a therapeutic contract—and applied it to a homeless, black, HIV-positive, prostituting transsexual. It worked. She came every month. I knew that in the beginning she came for the estrogen alone, but slowly, surely, she started to take her health seriously. Curiously, her blood counts did not deteriorate appreciably from month to month. It was almost as if she had partial immunity to the effects of the virus. “You’d better watch your blood pressure,” I told her during one visit in which she confessed she had been lax about taking her medicine. “Mark my words. Something other than the AIDS virus is going to do you in if you don’t take care of yourself.”

For every temporary gain or spiritual healing, however, there seemed to be 10 medical and spiritual failures. For example, I had to find a way to tell Charisse she would die soon. She and her two children had been living on the streets. Her family threw them out when they found out she had AIDS. She felt well, but her T cell count was down to 30. At that level, death is usually just a short time away. “Have you made plans for your children?” I asked when the medical student assigned to her faltered. One of them was with her, a waif under 2, playing obliviously with her shoes. He most likely had AIDS also. “You’re at a stage of your illness where you will become ill soon. It’s time to think about these things.” Charisse burst into tears. The student looked as if she might cry also. “No, I haven’t made any plans. I’m just going to Hell. I guess HRS [Health and Rehabilitative Services, Florida’s welfare program] will take my children.”

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