Multi-level and intersectional stigma experienced by Black transgender women in Chicago: A qualitative study to inform sociostructural interventions for reducing stigma and improving health outcomes

Abstract

Background:

Stigma contributes to health disparities including increased HIV vulnerability among minority communities. Black transgender women experience multiple forms of stigma (e.g., anticipated, experienced), which can result in poor HIV-related outcomes. We utilized an adapted social ecological model (ASEM) to better understand the levels at which stigma is encountered and its impact on lived experience, particularly related to making healthcare decisions.

Methods:

Semi-structured interviews and 2 focus groups (n=38) were conducted with Black transgender women and Black transfeminine individuals in Chicago from 2016–2017. Participants were asked about discrimination in the community, healthcare experiences, and their thoughts and decision-making process with their healthcare provider regarding HIV pre-exposure prophylaxis. We conducted thematic analysis and organized our findings based on the levels of the ASEM: individual, interpersonal, organizational, community, and structural.

Results:

Participants experienced and anticipated stigma at each ASEM level. Stigma was not experienced in isolation: stigma experienced at one level caused anticipated stigma at other levels and internalized stigma leading to negative self-image. In each case, stigma adversely impacted health outcomes (e.g., medication nonadherence, disengagement from care). Stigma within healthcare settings, medication-related stigma, and stigma directed at appearance and identity are particularly detrimental to shared decision making with a healthcare provider.

Conclusions:

Recognizing and valuing Black transgender women’s experience with stigma is essential for developing social and structural interventions that may work collaboratively across multiple levels of lived experience to reduce stigma and healthcare disparities faced by Black transgender women.

INTRODUCTION

Stigma is a threat to public health, particularly for intervention efforts focused on Ending the HIV Epidemic (EHE) in the United States [1]. The disparity in HIV prevalence rates experienced by Black transgender women is partly a consequence of stigma, a multi-dimensional social process by which behavioral or physical traits are identified, disapproved of, and discriminated against [2]. As members of both gender and racial minority groups, Black transgender women experience disproportionately greater HIV vulnerability than their white-identified peers, leading to a significantly higher HIV community prevalence estimate among Black transgender women compared to White transgender women (44.2% vs. 6.7%; 95% CI = 23.2%, 67.5%) [3, 4].

Black transgender women face multiple forms of stigma including racism, transphobia, and misogyny. These forms of stigma may manifest overtly as acts of verbal, emotional, and/or physical violence; or discretely, such as microaggressions [5–7]. Black transgender women may be stigmatized for their identities, personal histories, behaviors, and biology, and these experiences may result in feelings of being unsafe in their bodies (e.g., insecurity about passing/not passing) and may also place them at risk of violence in their environments [8, 9]. As such, stigma is intersectional, with compounded effects on health and well-being [4, 10–12].

The most recognizable form of stigma is “experienced” stigma (also referred to as “enacted” stigma), which describes stigma that is directly faced by an individual (e.g., microaggressions or prejudice from healthcare providers) [13]. Experienced stigma is felt acutely, and repeated exposure to this stigma may cause an individual to “anticipate” experiencing this stigma in future, potentially stigmatizing situations and thus react to this anticipated stigma as if experiencing it directly [14, 15]. Anticipated stigma may also lead to individuals internalizing others’ negative perceptions of them as their own self-perceptions [14, 16].

Frequent stigmatizing experiences directly and indirectly impact the health of Black transgender women as well as their healthcare decision by severely limiting provision, uptake, and access to advantageous community support and HIV prevention services [10]. Stigma remains a widespread concern among persons living with and vulnerable to HIV: 26–40% of persons living with HIV have and continue to experience discrimination from their healthcare providers due to their intersectional identities [21]. Individuals with intersectional minority identities who routinely felt discriminated against by healthcare providers demonstrated chronic stress, avoidance of HIV services, and worse health outcomes [14, 17]. Moreover, persons who anticipate high levels of HIV-related and healthcare stigma in general are more likely to experience negative health outcomes as a result [16].

Stigma and discrimination within the healthcare system against transgender people has been widely reported, especially for those who have disclosed their gender identity and have experienced direct discrimination from their providers as a result (e.g., denial of care, abuse, and/or harassment) [18–20]. Surveys have demonstrated that 20 to 41% of transgender people have experienced transgender-related discrimination in healthcare; factors associated with discrimination include being a racial/ethnic minority, gender transition indicators (younger age at first transgender awareness), and history of violence (sexual and physical) [21]. Among transgender women diagnosed with HIV who reported experiencing healthcare-related discrimination, 46% and 51% reported experiencing healthcare discriminated due to their gender and sexual orientation or sexual practices, respectively [22]. Morever, Black transgender women report delaying seeking treatment due to previous experiences of discrimination and victimization when seeking healthcare following a traumatic or violent event, further demonstrating the ripple effects of provider- and healthcare system-driven discrimination [23].

Discrimination and stigma can produce a threatening environment that limits a person’s autonomy [6]; indirectly, stigmatizing experiences may compel one to rely on stigma-avoidance strategies in the future (e.g., choosing to not disclose gender identity to the healthcare team or delaying/avoiding HIV care or prevention services) [8, 13, 17, 24–26]. Downstream, these changes to individual behavior may also exacerbate pre-existing negative social determinants of health such as socioeconomic disadvantage, limited access to healthcare/health knowledge, and involvement with the criminal justice system, which Black transgender women already experience at a disproportionate rate [27]. Black transgender women also experience disparate health outcomes and high incidence of emotional trauma including depression, anxiety, and suicidality as well as physical health issues including substance use, suboptimal antiretroviral therapy (ART) or HIV pre-exposure prophylaxis (PrEP) adherence, and overall greater HIV vulnerability than their peers who identify as non-minorities [13, 19, 24, 25, 28–34]. This has been exacerbated by the COVID-19 pandemic due to factors such as stress, intimate partner violence, loss of insurance, and lack of access to gender-affirming healthcare [35, 36]. There is an abundance of literature establishing stigma as a major barrier to PrEP [25, 29, 37, 38]; additional research emphasizes that transgender women of color experience PrEP-related stigma in the form of stigmatizing perceptions (e.g., all transwomen of color are HIV positive or engage in elevated sexual risk behaviors) [26].

These various forms and levels of stigma impact the lived experiences of Black transgender women. By using a Social Ecological Model (SEM), stigmatizing experiences can be organized within a framework to reveal how multiple facets of an individual’s lived experience may act alone or in conjunction to produce health disparities [9]. We utilized an adapted SEM (ASEM) to better understand stigma described by Black transgender women across five levels (e.g., individual, interpersonal, organizational, community, and structural) [8, 9, 39] to inform potential future interventions for decreasing stigma and improving health outcomes for this vulnerable population.

METHODS

Qualitative data were collected through semi-structured interviews as part of the Your Voice! Your Health! study [17] in Chicago, Illinois, between 2016 and 2017, with the purpose of understanding perspectives of Black transgender women on shared decision making with their healthcare providers, particularly around PrEP. This study analyzed these interviews to understand how Black transgender women conceptualize and describe their personal experiences of stigma. Participants were recruited through multiple means, both online (e.g., Facebook advertisements) and in-person (e.g., recruitment at community-based clinics). Recruitment was conducted with a status-neutral approach, and eligible participants were at least 18 years old, identified as African American/Black and as being on the transfeminine gender spectrum, and reported having sex with men within the past two years [17].

Data Collection

Interviews were conducted by trained community members who identified as transgender women or non-binary persons of color. Interview guides were developed iteratively with feedback incorporated from community members trained in qualitative interviewing methods who assisted with revisions to the interview guides. Semi-structured individual interviews included questions regarding participants’ identities, healthcare experiences, choice to disclose gender identity in healthcare settings, and experience engaging in shared decision making in healthcare settings. Participants gave verbal consent prior to the start of their study visit and completed a self-administered survey following participation in the interviews; survey items included demographics, medical history, and experiences within healthcare. Participants were compensated with $40 USD and were also given information on community resources for LGBTQ persons of color. Interviews and focus groups were audio recorded and professionally transcribed. The Institutional Review Board at the University of Chicago approved the study (IRB15–0811).

Analysis

A standard code book was developed apriori following the Peek Model of Shared Decision Making [30] and updated during the coding process, as previously described [17]. The code book was used by the research team to identify common themes that emerged during interviews, and supplemental notes were added by the research team for organization and legibility. Interview transcripts were assessed for themes and subsequently coded by at least two members of the research team using iterative qualitative thematic analysis. Discrepancies were discussed until agreement. Upon completion of coding, transcripts were entered into qualitative data analysis software (NVivo, Version 11.4.1, QSR International, 2017) [40].

Each interview transcript and transcript-segments associated with each code were reviewed to develop a preliminary understanding of how Black transgender women conceptualized and reported their personal experiences of stigma. Transcripts were re-read, the codebook was updated with sub-codes relevant to the emergent theme of stigma following Kemnitz [41], and salient quotes were organized into the ASEM to reflect the lived experiences of Black transgender women (Figure 1). The ASEM was influenced by Baral et al.’s modified SEM for HIV risk in vulnerable populations [8] as well as White Hughto et al.’s modified SEM for transgender stigma and interventions [42]. Illustrative quotes were identified, and participants were assigned pseudonyms to protect anonymity.

Fig. 1.

Adapted Social Ecological Model (ASEM) for Experienced and Anticipated Stigma Faced by Black Transgender Women (BTW)

RESULTS

We conducted 24 semi-structured interviews and 2 focus groups with Black transgender women in Chicago, Illinois between 2016–2017 (n=38). Table 1 describes the sociodemographic characteristics of participants based on survey completion. Thirty-seven (97.4%) participants identified as transgender women, while one (2.6%) participant identified as genderqueer. Twenty-five (65.8%) of participants were 30 years old or younger, eight participants (21.1%) were between the ages of 31–50, and three participants (7.9%) were older than 50. We organized the experienced and anticipated stigma reported by participants into five different levels: 1) Individual; 2) Interpersonal; 3) Organizational; 4) Community; and 5) Structural. For each relevant quotation, we indicated the type of stigma (i.e., experienced, anticipated, or experienced and anticipated) and the other ASEM level(s) described by the participant when applicable (i.e., if the quotation illustrated multi-level stigma).

Table 1.

Sociodemographic and Health Characteristics of Participants (n=38) 2016–17, Chicago

Characteristic	N (%)
Self-identified Gender
Transgender female	37 (97.4)
Genderqueer	1 (2.6)
Sexual Orientation
Bisexual, pansexual, or queer	9 (23.7)
Straight/heterosexual	13 (34.2)
Gay or same gender loving	13 (34.2)
Other	3 (7.9)
Age Group
18 – 30 years	25 (65.8)
31 – 50 years	8 (21.1)
> 50 years	3 (7.9)
Unknown	2 (5.3)
Race/Ethnicitya
Black/African American	36 (94.7)
Multiracial	6 (15.8)
Hispanic/Latina/x	4 (10.5)
Asian/Asian-American/Pacific Islander	1 (2.6)
Unknown	1 (2.6)
Highest Level of Education
8th grade or less	1 (2.6)
Some high school (did not graduate)	11 (28.9)
High school	9 (23.7)
Some college or 2-year degree	15 (39.5)
4-year college graduate	0
> 4-year college degree	2 (5.3)
Annual Income
< $20,000	15 (39.5)
$20,000 – 59,000	9 (23.7)
$60,000 – 149,000	0
$150,000 – 199,000	1 (2.6)
Not employed	11 (28.9)
Unknown	2 (5.3)
Type of Insurance
Private	6 (15.8)
Medicaid/Medicare	22 (57.9)
Free clinic	4 (10.5)
Other	2 (5.3)
No insurance	3 (7.9)
Unknown	1 (2.6)
Ever Tested for HIV
Yes	36 (94.7)
No	2 (5.3)
Self-Reported HIV Status
HIV+	12 (31.6)
HIV–	22 (57.9)
Unknown	4 (10.5)

^aParticipants were permitted to select multiple options

1). Individual Level

At the individual level, stigma that Black transgender women experience towards multiple aspects of their intersectional identities at other levels (e.g., the interpersonal and community levels) was internalized such that their attitudes towards their own identities reflected others’ perceptions [8, 10]. When participants voiced thoughts or feelings about their own selves, these perspectives were often entangled with the opinions of other individuals in their social network and more broadly as well.

“I feel different about myself. Because I have struggled in the past of how I felt I should feel. I guess that sound crazy, what people tell you or what society tell you…But I never felt completely comfortable. And even at my age, I feel maybe I don’t know if I’m doing the right thing. But it feels right.”

(Ashton, anticipated stigma; other ASEM levels: interpersonal; community; structural)

Similarly, Crystal reported that her transition was defined by others’ opinions of her, but also expressed relief that the discrimination she faces now is gender-appropriate: “[My transition] made me believe I’m a better person. Even though I’m misjudged or given the wrong pronoun, I like it because at least I’m not being called gay or a Geechee” (Crystal, experienced stigma; other ASEM levels: community; interpersonal).

The theme of one’s transition feeling “right” was echoed by multiple participants. Yet even when participants spoke proudly of their identity, they also shared that they need to be conscious of how they will be received by others: “I’m very proud of my transness, but I’m very perceptive of how people are going to handle my sexuality” (Sherrell, anticipated stigma; other ASEM level: community).

Repeated exposure to experienced stigma and the internalization of this stigma were also reported. Shante described how she is continuously impacted by the stigmatization of her intersectional identity as a Black transgender women:

“It does affect me. It makes me think that, ‘Oh, everything can’t work in my life.’ Like there’s no prosper and stuff like that. So yes, I am affected, every day. I mean, I just walk around here trying to smile about it, because … you can’t just let that affect your day of where are you trying to go. So I try to put on a front and a façade, just like it’s nothing. But it does hurt.”

(experienced and anticipated stigma)

In her statement, Shante also emphasized the mechanism by which stigma grows: slowly, and built through repeated stigmatizing experiences.

2). Interpersonal Level

At the interpersonal level, stigma is anticipated and experienced from individuals within one’s social network including peers, sexual partners, family members, and fellow racial and/or gender minority-group members [8, 9, 42]. Some participants reflected on the positive aspects of their interpersonal relationships facilitated by shared identities. For Crystal, forming a relationship with other trans individuals was a meaningful experience: “I actually got to connect and meet African American transgender [individuals] and get advice from them and hang with them, because we’re…the same color, going through the same situation.” Participants also described forming positive social relationships with fellow trans-women as a “sisterhood;” yet, they also described how these relationships can produce negative experiences:

“They [other transgender women] make me feel so good on a daily basis. Everybody always [asks] ‘you OK? We’re just checking up on you to make sure you’re all right.’ The love just be overwhelming sometime. I’ve got a big smile on my face now because it’s a wonderful feeling … But sometimes when you’re trying to transition to being a female figure, a lot of girls become cattiness. I just couldn’t deal with that because I felt like we should be helping each other, instead of being catty to each other.”

(Jaylow, experienced stigma; other ASEM level: individual)

In addition to peers, Black transgender women may also experience stigma from their biological family due to familial and cultural factors. As Zella explained:

“I feel like everyone that’s of color gets shit from their family for being different. But I feel like Black African American girls get it worse than everybody … I feel like there’s so much pressure for males to be masculine, or not to be different or change their gender. There’s a lot of pressure to be a man and stay a man.”

(experienced and anticipated stigma; other ASEM levels: individual; community)

Experienced stigma at the network level may cause Black transgender women to anticipate stigma during future interactions with their networks. In particular, anticipated stigma from one’s peers and/or romantic or sexual partners may prohibit Black transgender women from seeking sexual health services, including HIV prevention and PrEP. Jaylow felt she would be judged for lifestyle choices, making her “feel less so,” stating “if I do got something [i.e., a sexually transmitted infection], I’ll just keep it to myself. And don’t even tell nobody” (anticipated stigma; other ASEM level: individual). Brooklyn echoed this sentiment: “You got some people out here that’s messy … People be like, ‘Oh she just wanna get on PrEP because she out there having unprotected sex,’ or whatever the case may be” (anticipated stigma; other ASEM level: individual).

3). Organizational Level

The organizational level refers to how Black transgender women, their identities, and the healthcare services they may wish to receive are stigmatized and discriminated against within healthcare settings through assumptions and stereotypes by healthcare providers or others (e.g., Black transgender women are sex workers/sexually promiscuous) as well as lack of knowledge about the trans community [16]. Stigma experienced and anticipated at this level may be particularly detrimental as it may cause Black transgender women to delay or avoid accessing healthcare services such as HIV treatment or prevention services. Shante reported that her prior experiences made her feel so uncomfortable that she “actually stopped going to the doctor and taking my meds for about two years” (experienced stigma). According to Keke: “A lot of girls don’t trust healthcare systems, and so they don’t know how to navigate them, or don’t want to anymore” (experienced and anticipated stigma; other ASEM level: organizational). This distrust of the healthcare system is in large part a response to the discrimination and stigma that Black transgender women experience in healthcare settings on a routine basis from staff at all levels. Penny expressed this plainly: “Stereotypes can definitely have an influence on whether a person feels comfortable with disclosing information to their provider, even information that they have to know or they should know” (anticipated stigma; other ASEM levels: individual; organizational).

Ty said she and her trans peers have experienced stigma and discrimination in healthcare settings “from facility managers to healthcare assistants to providers to… everyone” (experienced stigma). In healthcare settings, Black transgender women experience and anticipate stigma that targets their individual and intersectional identities, including gender, sexual, and racial identities. Many participants reported experiencing stigma for their Black racial identities:

“Black people are often stigmatized as unclean people who are just gross and disgusting … really it’s a conversation of a lack of access to good healthcare and like the right forms of protection and things like that … There is [also] this idea that I as a Black person don’t know what I am talking about … Even if I have done the research, even if I have done the homework, I show up and a doctor is like, ‘Oh, okay, here comes that dumb Black person again who is going to think they know everything about everything.’”

(Keyonna, experienced and anticipated stigma; other ASEM levels: individual; structural)

Moreover, Shante reported receiving stigmatizing treatment due to racial differences between her and her majority group-identified transgender women peers:

“The other doctor [advised] one of my other girlfriends of another nationality … ‘Take this hormone to soften your voice, to soften your skin, to grow your hair.’ That type of advice was never even given to me. Thank God for the internet and having friends or other people to talk to, to advise you. But yeah, they will give girls of other nationalities a little bit more support.”

(experienced and anticipated Stigma; other ASEM levels: individual; structural)

Many participants voiced facing stigma and discrimination targeted at their queer or transgender identities. Jaylow recalled the stereotype that “people that are openly gay or in the LGBTQ community, that we all have HIV” (experienced and anticipated stigma; other ASEM levels: individual; community); Ciara expressed feeling inundated with HIV tests and like she could not discuss her transgender identity with her physician without being offered a test––“why, because I’m like this [a transgender woman]?” (experienced stigma; other ASEM level: individual) Reecey also shared feeling like people think “all [transgender individuals] do is drugs and prostitute” (anticipated stigma; other ASEM levels: individual; community). Participants also reported feeling depersonalized and objectified due to their identity within medical settings; in her interview, Keyonna shared a stigmatizing healthcare experience where her provider exoticized her identity:

“It was really uncomfortable. The provider kept telling me about how intriguing it was and how he had always wanted to have a transgender patient. It was like an exciting moment for him, like some kind of achievement that he was able to finally meet a trans woman in person and prescribe her medication. It was really frustrating. It didn’t seem like he was in it to help me. It seemed like he was in it to have something to boast about as a mental health professional.”

(experienced stigma; other ASEM level: individual)

Participants expressed that their needs were often inadequately met by healthcare providers and staff. Participants did not receive gender-affirming information “that [they] need to continue to transition or…lead healthy lives” (Shante, experienced stigma; other ASEM level: individual), their opinions or personal healthcare understandings were dismissed, and their lived experiences were not properly considered or understood. Additionally, many participants described anticipating stigma at the organizational level due to prior stigmatizing encounters experienced at that level; however, stigma at other levels also worked to fracture the relationship between Black transgender women and their providers. Jaylow discussed how stigma she experienced and anticipated at the community level caused her to raise her defenses against potential stigma in healthcare settings at the organizational level as well:

“We [Black transgender women] definitely have it hard … When you come into the clinic, like, is you judging me too? I’m already getting judged in the streets, and now I got to come and sit in my care provider, and you going to judge me as well? He should definitely know that certain situations, that we go through, that we already have our guards up, for a lot of individuals, overall.”

(experienced and anticipated stigma; other ASEM levels: individual; community)

Keyonna also identified how the experienced and anticipated stigma she faced in other levels at different times of her life played a significant role in her health problems; moreover, she explained how critical it can be for Black transgender women to have a provider to whom they can safely disclose their identity to, and who is empathetic to their lived experiences:

“I was in the hospital…for psychological help. I had failed a suicide attempt. And so when I stopped me and checked myself into the hospital that day, I let them know, ‘Part of why I am here is because people…mis-gender me and I can’t have that happen here if you all want me to get any better.’”

(experienced and anticipated stigma; other ASEM levels: individual; community; structural)

4). Community Level

At the community level, Black transgender women experience and anticipate stigmatization regarding their appearance and identity from the community in general––not by individuals known to Black transgender women within their social network but rather by strangers [9]. Participants aligned themselves with multiple communities including sexual identities (e.g., straight, LGBQ), gender identity (i.e., transgender), and social, cultural, or ethnic communities including church/religion and the African American community. Stigma at this level is felt not only from proximal sources as in the prior three levels but also from distal, impersonal forces:“[My identities] greatly affect how I am treated. Society doesn’t have an acceptance of Black folks as of yet, and … there is not much acceptance of transgender folks, either” (Mesha, experienced and anticipated stigma; other ASEM levels: individual; structural). This feeling of being stigmatized by a community at large emerges as a direct result of stigma and discrimination that Black transgender women face in their everyday lives. Keyonna elaborated on her experience:

“I’m fortunate that there hasn’t been as much physical violence in my life. But definitely verbal violence…the usual slurs like tranny, faggot. People looking at me and just being obviously disgusted, shaking their head because ‘Why am I walking around like that?’ and ‘Why am I acting like that?’ People trying to convince me to admit that I am a man.”

(experienced stigma; other ASEM level: individual)

Participants noted experiencing and anticipating stigma related to their physical appearance across a range of situations: Keyonna expressed being repeatedly misgendered because of her hobbies (e.g., lifting weights, riding a bike), while Ashton explained that Black transgender women are often accused of “trying to … trick someone” (experienced stigma). Black transgender women may internalize this fear of verbal, emotional, and physical violence as anticipated stigma and may attempt to modify their behavior and their patterns of interaction to avoid potentially stigmatizing or discriminatory experiences in the future. Ciara described how this stigma impacts her day-to-day life:

“Just to walk down these streets and someone calls you a sissy or a faggot or a geechee, or something like that. That’s what we really go through. Getting beat up, killed. Like I know a lot of girls who’s dying. Who just got killed… I always have my guards up, because I always think that people trying to use you or like abuse you or trying to fulfill this fantasy of having the best of both worlds, per se.”

(experienced and anticipated stigma; other ASEM level: individual)

Participants often described feeling community-level stigma from communities with whom they share aspects of their intersectional identities. Many interviewees shared reports of experienced and anticipated stigma from the Black/African American community in particular, with Jazz stating“the Black community discriminates against us” (experienced stigma; other ASEM levels: individual; interpersonal). As Jaylow elaborated:

“My own color, they’re always trying to fight me and be so disowning me … I can’t walk the street sometimes, because I feel like if I’m on the street with one of my fellow Black community people that I’m around, I can’t even be around them that much, because I feel like I’m going to get a bottle thrown at me.”

(experienced and anticipated stigma; other ASEM level: interpersonal)

Stigma is also experienced and anticipated from cisgender individuals who may or may not share aspects of Black transfeminine intersectional identity. Ciara discussed the types of stigma she perceives from cisgender women:

“Women look at us like, ‘Oh, that’s so disgusting, and how could she go this far?’ ‘Oh, we can accept a gay man, but we can’t, this is too much…These freaks are taking over.’”

(experienced and anticipated stigma; other ASEM levels: individual; interpersonal)

Chay also described experiencing and anticipating stigma from cisgender women both in the form of direct confrontations and microaggressions:

“Cisgender females, the ones that are insecure with theyself already, have the tendency to look at transgenders and think that we’re a threat. They have a very verbal, boisterous, way of saying things. Or doing subliminal indirect comments, gestures, body language wise. Letting you know that they doing it towards you.”

(experienced and anticipated stigma; other ASEM level: individual)

Although less violent, anticipated stigma may still produce reactionary behaviors such as seeking out others who share most aspects of their intersectional identity: “I’m very much not attached to people who I don’t share this whole identity with, because they tend to have very terrible ways of interacting with people who don’t look like them” (Keke, anticipated stigma; other ASEM level: interpersonal).

5). Structural Level

The structural level describes institutionally embedded stigma – in the form of social and cultural norms, as well as societal factors (e.g., health, economic, educational, and social policies) – that maintains inequalities, prompts structural violence, and negatively impacts Black transgender womens’ lived experiences [9, 39]. These norms and policies contribute to harmful social determinants of health and lead to disparate allocation of resources, housing instability, lack of capital, poor access to medical services, and criminal legal involvement [39, 43, 44]. Multiple participants noted how societal policies contributed to stigmatization of Black transgender women. Jaylow reports being almost denied access to a women’s shelter after being released from prison because her parole officer doubted her identity:

“My parole officer…he didn’t ever get the chance to meet me. But I’m trans…they [female facility] are now accepting transwomen that identify as a female figure. So, he [saw] the jail picture of me, and…[he said], ‘Well she look like a…male. So, I don’t think she should be in that facility.’ So that was stereotypes. So, I know how it feel, and I’m like, ‘Well, he don’t even know me’”

(experienced stigma; other ASEM level: individual).

Several participants also described routine errands during which they were required to present identification as stigmatizing encounters due to not having their legal gender changed. This participant described being “outed” as transgender:

“The first time I was going to cash my check, the lady didn’t know I was trans. And most times when I go to cash my check or to get a license or service period, they don’t know that I’m trans until they read my ID, and then they out me as trans”

(Participant, Focus Group 2, experienced stigma; other ASEM level: individual).

Multiple participants reported how employment opportunities, or lack thereof, result from structural stigma and also contribute to experiences of community and organizational stigma. One participant stated, “Most people know that most transgender women can’t — especially Black transgender women — it’s hard for us to find jobs. It’s not impossible, but it really is hard” (experienced stigma; other ASEM levels: individual; community). This participant expanded that this stereotype can lead healthcare providers to “always ask us, have we had sex for money?” or “automatically think they were a sex worker” (Participant, Focus Group 2, experienced and anticipated stigma; other ASEM levels: individual; organizational).

Finally, one participant explained how the compounding nature of experiencing intersectional stigma repeatedly at different ASEM levels can lead to anticipated stigma that impacts the healthcare experiences of Black transgender women:

“I think that they [healthcare providers] need to understand that they’re [Black transgender women] a little bit more sensitive to a lot of situations, because they’ve experienced more bad experiences than a lot of other people. By being Black, it’s already a strike against you, a lot of time, in the world and in the community. And then gay don’t help either…There’s more stereotypical things. So, it’s a lot still to be done. We’ve come a long ways, but we still have a long ways to go.”

(Jasmine, experienced and anticipated stigma; other ASEM levels: individual; organizational; community)

DISCUSSION

Although there have been studies utilizing a socioecological model among Black transgender women to specifically describe PrEP-related stigma [45], this study uses the five-level ASEM to describe experienced and anticipated stigma faced by Black transgender women and how those levels interact to impact health. We found that Black transgender women experience and anticipate multiple types of previously documented stigma related to several aspects of their intersectional identities, and this stigma is faced at multiple levels of interaction: the individual, interpersonal, organizational, community, and structural levels. The application of a five-leveled ASEM helped characterize and understand what forms of stigma Black transgender women experience and how they conceptualize these experiences. By using the ASEM, we see how stigma faced at one level may lead to downstream effects including internalization and anticipation of stigma as well as the emergence of self-injurious behaviors at another level. Additionally, by highlighting experienced and anticipated stigma at the healthcare organizational level, we emphasized the need for those working to mitigate trans health disparities to understand how stigma experienced at multiple different settings may produce long-lasting emotional, mental, and physical harm. Thus, a solution to the negative health effects of stigma must adequately address each level of stigma rather than the organizational level alone. These findings may be of particular use to those working in healthcare to understand how stigma impacts HIV treatment and prevention decisions of Black transgender women.

An expansive approach is necessary to identify and respond to experiences of stigma, especially those that occur in healthcare settings. The National Academies Press’s 2021 consensus study report “Sexually Transmitted Infections: Adopting a Sexual Health Paradigm,” offers robust recommendations for structural interventions for STI prevention at the individual-, interpersonal-, institutional-, community-, and structural-levels [4]. The multitude of interventions suggested in this report demonstrates that there is no “silver bullet”-type intervention that can alleviate stigma at each level; however, there are many existing strategies that can be simultaneously deployed as components of a multi-level intervention. Clinicians and other healthcare employees must value the lived experience of their patients and understand the social burdens and healthcare disparities that Black transgender women may face due to their intersectional identities. Further qualitative research as well as cultural sensitivity and competency trainings have the potential to educate clinicians on the importance of providing trauma-informed care that considers the lived experience of Black transgender women alongside the historical, social, and structural factors that contribute to cultural and gendered gaps in current HIV prevention techniques [46].

We previously reported that a shared decision-making model might relieve stigma felt within healthcare settings at the organizational level [17]; moreover, adoption of anti-stigma practices into routine quality improvement (QI) efforts may facilitate more thorough and effective interventions within healthcare settings. Existing models for transgender-specific QI models are few [47, 48]. Key insights include implementing anti-stigma training for all staff ––including for non-HIV-related specialists who often have difficulty accessing such trainings [25] –– as well as developing robust collaborative networks with transgender health-focused organizations. Our findings demonstrated that some HIV-related healthcare stigma experienced or anticipated at the organizational level may in fact originate at the interpersonal level; as such, these interventions would be best paired with another––e.g., the employment of Black transgender women as peer health navigators, which operates at the interpersonal level and has demonstrated success at increasing uptake of HIV treatment services among Black transgender women, as well as the structural level by increasing employment opportunities [17, 49].

Developing tools to measure the type of stigma experienced by Black transgender women can help further understand the discrimination-based barriers to healthcare encountered at multiple levels [50]. Patient-facing assessment instruments such as the Multiple Discrimination Scale (MDS) have demonstrated effectiveness at measuring levels and types of stigmas endured by Black/African American and Latino men who have sex with men [14]; nevertheless, it has yet to be validated in versatile populations including Black transgender women. In addition to enduring race/ethnicity- and sexual identity-based stigma, Black transgender women also experience severe stigma and discriminatory violence targeting their gender identity; yet, the MDS does not include gender-based stigma, and thus is not inclusive or descriptive of Black transgender women’s intersectional identity [30]. Our findings can inform the development of discrimination scales specific to Black transgender women’s lived experiences.

A principal limitation in our findings is that the goal of the larger research study was not to delineate experiences of stigma, and so data collection was not directly focused on stigma faced by Black transgender women. Another limitation is that the study utilized a status neutral approach and recruited people who were living with HIV and those without HIV; as such, participants were not asked directly about their HIV status and related stigma, but participants were free to share this information if comfortable. Lastly, although transgender and gender diverse individuals collected qualitative data for this study, the coding team consisted of cisgender, white-identified research staff, thus may not have captured all nuances of the Black transgender female experience.

CONCLUSION

Black transgender women endure chronic exposure to multiple forms of stigma and discrimination. Multi-level discriminatory experiences result in internalization and anticipation of experiencing further stigmatization and discrimination in the future. Recognizing and valuing Black transgender women’s lived experience with stigma is essential for understanding factors that contribute to decision-making about health, including for reducing PrEP and HIV-related healthcare disparities. Using an ASEM is an effective way to organize with nuance the intersectional stigma experienced by Black transgender women. Deeper consideration of how Black transgender women experience intersectional stigma may inform collaborative and multi-leveled interventions that target stigma within healthcare systems as well as at other levels of lived experience. The stigma that is experienced in one level may come to be anticipated at another, and so collaboration between agencies with interventions focused at multiple different levels will be key to ameliorating Black transgender women’s disproportionately high rate of experiencing stigma as well as improving overall health outcomes.