Transgender women of color in the U.S. South: A qualitative study of social determinants of health and healthcare perspectives

Abstract

Background: Research has shown that transgender and nonbinary people experience health disparities. However, few studies have explored, in-depth, the health-related experiences, perceptions, needs, and priorities of transgender women of color living in the U.S. South, a region that poses unique challenges to achieving health for transgender people. Aims: This study explored the social determinants of health, healthcare experiences, and health-related priorities of transgender women of color living in the U.S. South. Methods: Using a community-based participatory research approach, we conducted iterative in-depth interviews with 15 African American/Black and Latinx transgender women in North Carolina in May-July 2019 for a total of 30 interviews. We analyzed interview data using constant comparison, an approach to grounded theory. Results: Participants’ mean age was 34 (range 19–56) years. Twenty themes emerged that were categorized into three domains: (1) social determinants of health (family rejection; bullying, discrimination, and violence; isolation; policy barriers; mistrust in systems; employment obstacles; sex work; high cost of care; transportation barriers; church antagonism; and substance misuse), (2) healthcare experiences (emotional burden of healthcare interactions; name and gender misidentification; staff discomfort and insensitivity; sexual risk assumptions; and use of nonmedical or predatory providers), and (3) health-related priorities (understanding healthcare; respect at all levels of healthcare; inclusive gender-affirming care; and comprehensive resources). Discussion: Transgender women of color living in the U.S. South face profound health barriers compounded throughout the life course and have unmet healthcare needs. Participants faced multilayered minority stressors: racial discrimination from society at large and within the LGTBQ community; gender identity discrimination within their regional context and racial/ethnic communities; and exclusion from existing health equity movements for transgender women of color, which often are found in and focus on larger urban communities. Health interventions mindful of this intersection are needed, including antidiscrimination policies and increasing gender-affirming healthcare access.

Policy recommendations to promote health and well‐being in sexual and gender minority populations in the United States

“…Only four studies (Cahill et al., 2020; Fabbre & Gaveras, 2020; Grzanka et al., 2020; Smart et al., 2020) used qualitative methods to examine state‐level policies and one used a mixed‐methods design (Currin et al., 2019). In qualitative interviews, transgender women discussed the importance of private and public insurance coverage of PrEP medications for adherence and acceptance (Cahill et al., 2020).…”

“…In qualitative interviews, transgender women discussed the importance of private and public insurance coverage of PrEP medications for adherence and acceptance (Cahill et al., 2020). Fifteen transgender women in the Southern United States reported that state laws restricting bathroom use based on sex identification led to policing of behavior and stress for TGNC adults (Smart et al., 2020). Moreover, in the LGBTQ+ community, state laws allowing the denial of counseling services to any client on the basis of “sincerely held principles” contribute to feelings of unsafety, the avoidance of help‐seeking behavior, and concerns that other anti‐LGBTQ+ laws would soon follow (Grzanka et al., 2020).…”

“…(2010) and others in the present review (see e.g., Everett et al., 2016), policymakers and stakeholders must also work to abolish existing forms of structural stigma to reduce or eliminate health disparities in LGBTQ+ populations. Research reviewed showed that stigma and discrimination toward LGBTQ+ adults, including those sanctioned by federal, state, and local laws, contribute to poorer physical (Raifman et al., 2018; Solazzo et al., 2018; Titus et al., 2021) and mental health (McDowell et al., 2020; Perez‐Brumer et al., 2015; Smart et al., 2020), a lack of knowledge regarding sexual health and STIs (Currin et al., 2019), avoidance of help‐seeking behavior (Cahill et al., 2020; Grzanka et al., 2020), and feelings of unsafety (Hong et al., 2016). By contrast, findings also suggested that LGB adults living in states with anti‐discrimination policies and laws already in place are more likely to report excellent physical health, access healthcare, and have health insurance (e.g., Solazzo et al., 2018) and are less likely to report mental distress (Raifman et al., 2019).…”

“…Qualitative Perceived Discrimination (Donaldson et al, 2016;Fix et al, 2020;Green et al, 2018;Mann-Jackson et al, 2020;Shattuck et al, 2020); Feelings of safety (Green et al, 2018;Shattuck et al, 2020;Willging et al, 2019); Suicidality (Willging et al, 2019); Depression (Mann-Jackson et al, 2020); Sex Education (Shattuck et al, 2020); STIs and other sexual health diagnoses (Fix et al, 2020); HIV/AIDS (Mann-Jackson et al, 2020); Pregnancy (Fix et al, 2020); Gender dysphoria (Fix et al, 2020); Hormone Therapies (Fix et al, 2020;Mann-Jackson et al, 2020); PrEP Drug use (Mann-Jackson et al, 2020); Abortion and Contraception Services (Fix et al, 2020), Gender-affirming services (Fix et al, 2020); Violence (Shattuck et al, 2020); Social Support (Mann-Jackson et al, 2020) Anti-Bullying or Student Protection Laws/Polices (Green et al, 2018;…”

The Often-Circuitous Path to Affirming Mental Health Care for Transgender and Gender-Diverse Adults

“…It is important to note that these reviews draw from literature ranging from 2008 to 2018. However, the studies on TGD experiences with healthcare or provider knowledge published more recently continue to find similar barriers including mistrust in systems, structural barriers, difficulty finding competent providers, and the importance of gender-affirming environments [ 6 – 9 ]. More empirical research is needed on the specific steps of mental health help-seeking for TGD adults as well as increased attention to barriers and facilitators for a variety of mental health treatment models, such as inpatient settings, and experiences of underserved TGD communities.…”