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. Author manuscript; available in PMC: 2025 Mar 1.
Published in final edited form as: Health Psychol. 2025 Mar;44(3):285–290. doi: 10.1037/hea0001421

Intersectional Structural Oppression as a Fundamental Cause: Reflections on Implementing a Medical-Legal Partnership Project

Kristi E Gamarel 1, Wesley M Correll-King 1, Laura Jadwin-Cakmak 1, Julisa Abad 2, Jay Kaplan 3, Belinda L Needham 4, Arjee J Restar 5
PMCID: PMC11856429  NIHMSID: NIHMS2012878  PMID: 39992774

Abstract

Objective:

Intersectional and structural intervention approaches are critical to addressing health inequities experienced by transgender and gender diverse (trans) populations. In this commentary, we reflect on the implementation of a community-led, medical-legal partnership project designed to address barriers to legal gender affirmation and improve health outcomes for trans women of color with criminal records in Detroit.

Methods:

We initiated a partnership between a community health center and legal advocacy organization to address the health-harming legal needs of five trans women of color with criminal records via attorney support and financial assistance.

Results:

We enrolled four participants, and two received legal name changes. Our low success rate was largely due to legal costs that far exceeded our expectations and resources. These costs stemmed from compounding monetary sanctions participants received for low-level vehicular civil infractions.

Conclusions:

Our implementation of this intervention revealed structural intersectional oppression in action. Monetary sanctions interact with Michigan name change policies requiring court appearances for applicants with criminal records, creating nearly insurmountable barriers to legal gender affirmation for economically vulnerable communities subjected to racism and cissexism. Building intersectional structural competency inclusive of legal literacy via multi-sectoral collaborations between diverse legal and policy experts, community members, and academic researchers is critical to developing interventions to address structural determinants of trans health.

Keywords: transgender health, intersectionality, structural interventions

Medical-legal partnerships embed civil legal aid professionals within healthcare settings to address social oppression contributing to poor health outcomes and population health inequities (Regenstein, Trott, Williamson, & Theiss, 2018). Specifically, medical-legal partnerships are well-positioned to address health-harming legal needs, which are social and structural problems adversely affecting a person’s health or access to health care that can be mitigated through coordinated legal and health care services (Martinez et al., 2017). In response to community-identified needs and with community leadership, our team recently embarked on the development of a medical-legal partnership intended to fulfill legal gender affirmation needs among trans women of color in Detroit, Michigan.

In this commentary, we offer critical reflections and lessons learned while conceptualizing, implementing, and evaluating this intervention that have important implications for researchers and practitioners in health psychology and public health working with transgender and gender diverse (trans) communities. Our experiences highlight the necessity of intersectional structural competency and integrating intersectionality frameworks into applications of fundamental cause theory to identify effective loci for intervening upon complex structural and social determinants of health inequities. Briefly, fundamental cause theory posits that social factors such as socioeconomic status and stigma are fundamental causes of disease because they implicate access to important resources required to prevent and treat multiple disease outcomes (Link & Phelan, 1995). Racism and cissexism have been identified as forms of structural stigma that are fundamental causes of health inequities (Phelan & Link, 2015; Phelan, Link, & Tehranifar, 2010; Zubizarreta, Trinh, & Reisner, 2023). The relationship between fundamental causes and disease persists over time despite changes in intervening mechanisms, making fundamental causes interminable causes of health inequities (Hatzenbuehler, Phelan, & Link, 2013; Phelan & Link, 2015; Phelan et al., 2010). We conclude that medical-legal partnerships require establishing multi-sectoral collaborations with policy and legal experts to address fundamental causes of health inequities at multiple social-ecological levels.

A Medical-Legal Partnership to Address Legal Gender Affirmation Needs

Founded in 2018, the Love Her Collective is a community-academic partnership that seeks to identify and address the needs of trans women of color in Detroit, Michigan. The core research team consists of academic researchers at the University of Michigan and community members from the Trans Sistas of Color Project, which is a non-profit organization led by trans women of color. The Love Collective’s projects have focused on examining and developing programming to address community-identified issues including trauma, economic precarity, interpersonal violence, and HIV (Gamarel, Jadwin-Cakmak, King, Hughes, et al., 2023; Gamarel et al., 2022; Gamarel, Jadwin-Cakmak, King, Reyes, et al., 2023; King, Jadwin-Cakmak, Trammell, & Gamarel, 2023). One of the Love Her Collective community members also serves as the Director of the Transgender Outreach and Advocacy Program at the Fair Michigan Justice Project. She drew the team’s attention to how many of the clients she serves through the Trans Renaming Program are unable to change their legal names because they have a criminal record. The team initially assembled to address this issue consisted of the community partner who is a Latina trans woman and directs the Trans Renaming Program and two of the academic researchers who are White, cisgender women.

Lack of access to legal name change has important consequences for health equity and human rights. For trans people, having legal gender affirmation needs met (i.e., legal name and gender marker changes) may reduce the risk of experiencing structural stigma and discrimination in administrative settings, thus affording greater access to resources necessary for wellbeing such as housing, employment, and healthcare (Cicero, Reisner, Silva, Merwin, & Humphreys, 2019; Puckett et al., 2024; Spade, 2015). For example, trans women have described how having legal gender affirmation may reduce the likelihood of hiring discrimination and misgendering or harassment in the workplace (Jennings Mayo-Wilson et al., 2020). Furthermore, legal gender affirmation has been associated with decreased mental health symptoms, fewer behavioral health conditions, and better physical health in diverse samples of trans adults (King & Gamarel, 2020; Puckett et al., 2024; Yee, Lind, & Downing, 2022). With increasing recognition of legal gender affirmation’s importance to trans populations, legal names have shifted from being understood solely as government-controlled markers of citizenship towards amendable markers of personhood based in human rights to expression and equal recognition before the law (Obasi & Nick, 2024; Wentling, 2020).

Currently, Michigan’s name change process involves many arduous steps, including filing a petition, paying fees, getting a criminal background check at a police station, publishing a notice of the hearing, and attending the hearing in a court. Michigan law states that anyone with a criminal record requesting a name change is “presumed to be seeking a name change with a fraudulent intent” and must provide proof to rebut that assumption during an in-person court appearance (MI Act 288, 2024). This law differentially impacts trans women of color because they are overrepresented in the criminal-legal system due to intersectional oppression that drives economic vulnerability, engagement in criminalized economies, and contact with police and the courts (Daum, 2015; Ezie, 2023; Gamarel, Jadwin-Cakmak, King, Hughes, et al., 2023). Based in Black feminist conceptualizations of intersectionality (Crenshaw, 1991), we define intersectional oppression as the social, economic, and political marginalization that groups positioned at the nexus of multiple systems of power experience due to the synergistic and compounding relationships between those systems—in this case, racism and cissexism (Bowleg, Malekzadeh, AuBuchon, Ghabrial, & Bauer, 2023).

The Love Her Collective secured funding to develop a partnership between Corktown Health Center, a medical home focused on serving sexual and gender minority (SGM) people in Detroit, and the Fair Michigan Justice Project, an existing partnership between the Wayne County Prosecutor’s Office and a nonprofit focused on ending discrimination impacting SGM people in Michigan. Through this partnership, we intended to provide legal assistance to trans women of color with non-assaultive criminal records to legally change their names and to evaluate the effects of this process. The core research team consulted extensively with the National Center for Medical-Legal Partnership, the American Civil Liberties Union (ACLU) of Michigan, and the Michigan Advocacy Program as well as with lawyers, researchers, and service providers who currently lead medical-legal partnerships in and beyond Michigan to develop programming.

In this intervention, the community member who directs the Trans Renaming Program conducted an initial health-harming legal needs screener with participants and facilitated linkage to social, medical, and behavioral health services at Corktown Health Center. She also linked participants to a partnering attorney referred to us by Fair Michigan who provided services throughout the project at a flat rate of $5500. The attorney then conducted legal intake, investigated outstanding legal charges accrued across all Michigan judicial jurisdictions, and represented participants in court appearances. Once legal issues were resolved, participants then completed the Trans Renaming Program. Participants received $500 in unconditional emergency assistance for court fines and fees, food, housing, and transportation.

Intersectional Structural Oppression in Action

Although we planned to enroll five participants, we were ultimately able to enroll only four participants and secure legal name change for two. Despite our team’s lived and professional experience with trans women of color in Detroit and our consultations with experts in medical-legal partnerships, SGM law, and legal issues impacting low-income residents of Detroit, the average cost of legal fees each participant incurred far exceeded our expectations and resources. More specifically, we initiated this project ignorant to how policies regarding monetary sanctions interfere with the legal name change process to functionally bar many trans women of color in Detroit from obtaining legal name change and reaping the resultant social and health benefits. Monetary sanctions refer to the fiscal penalties judiciaries levy against individuals as a consequence for offenses or violations and include fines, court costs, restitution, forfeitures, and civil penalties (Harris & Smith, 2022).

All participants had at least one unpaid monetary sanction, most of which were vehicular including outstanding parking tickets and driving with an expired license plate. Our participants were unable to pay the original cost of these sanctions yet continued to need to drive to meet essential needs due to the lack of safe public transit in Detroit, resulting in additional traffic violations. Unpaid monetary sanctions then compounded into higher values and, eventually, misdemeanor charges with arrest warrants. Appearing in court for a name change to rebut fraudulent intent would therefore put participants at risk of arrest with no guarantee that the name change would be granted. Because of this dynamic, we amended our project to increase the funds participants could use towards monetary sanctions from $500 to $1500. Still, this increase was not enough to cover most participants’ costs.

Emerging research has characterized monetary sanctions as manifestations of colorblind racism (Bonilla-Silva, 2015; Harris, Pattillo, & Sykes, 2022). Though the policies governing monetary sanctions do not mention race, these policies disproportionately ensnare poor people of color in cycles of debt, law enforcement surveillance, and punishment (Friedman et al., 2022). Carrying monetary sanctions leads to fear, frustration, anxiety, and despair that may cause or exacerbate existing physical and mental health problems for individuals, families, and communities as they grapple with intensifying financial strain while balancing expenses for competing necessities such as healthcare, food, and housing (Friedman et al., 2022; Harris & Smith, 2022).

Our experience thus reveals structural intersectional oppression in action. We use this term to refer to how social, political, and economic systems differentially distribute tangible and intangible resources that promote wellbeing along multiple axes of social power simultaneously. In this case, the policies and practices governing monetary sanctions in Detroit and surrounding areas severely compromised our ability to fulfill trans women of color’s legal gender affirmation needs, exemplifying how structural racism and cissexism intersect to perpetuate socioeconomic and health inequities and threaten trans women of color’s human rights.

Implications for Applications of Fundamental Cause Theory

Despite calls to address social determinants in health behavior change interventions (Alcántara et al., 2020), existing interventions designed to address SGM population health have continued to focus primarily on individual-level mechanisms of change (Chang et al., 2024; Kent, Wheldon, Smith, Srinivasan, & Geiger, 2019; Kidd et al., 2022). Although we intended to address social determinants of health, our medical-legal partnership intervention served as a “band-aid solution” to an intersectional fundamental cause problem. Our experience sheds light on the importance of intersectional structural competency inclusive of legal literacy in interventions focused on addressing the health of trans communities (Bowleg, 2023; Yassine, Menon, Ramanathan Holiday, & Penn, 2022). More specifically, we learned the very real consequences of failing to conceptualize and interrogate multiple fundamental causes simultaneously using intersectionality frameworks, which may have revealed connections between how poverty and SGM policies and laws collide and contribute to health inequities.

Policy and Practice Implications

First, our experiences suggest that structural problems such as barriers to legal gender affirmation for people with criminal records require complex solutions that may be best identified through multi-sectoral collaborations. We had anticipated that expunging criminal records rather than negotiating monetary sanctions payment would comprise the bulk of the necessary legal work based on our team’s experience and the extant literature on the health-harming legal needs of trans women of color in the U.S., which focuses somewhat narrowly on discriminatory law enforcement practices and criminalization of sex work (Carpenter & Marshall, 2017; Rosentel, López-Martínez, Crosby, Salazar, & Hill, 2020; Yarbrough, 2021). Ultimately, our team’s lived and professional experience did not grant complete or inherent understanding of the interwoven systems through which structural intersectional oppression operates. Reaching beyond our networks to partner with individuals or organizations who work in poverty law more broadly (e.g., public defenders) rather than SGM law specifically (e.g., Fair Michigan and several of the medical-legal partnerships we consulted with) may have helped us realize the full extent of the monetary barriers to legal name change for the community we sought to serve. In this vein, we are currently beginning a partnership with a street outreach court program, which provides more specialized legal services for individuals experiencing housing deprivation who are contending with civil infractions and misdemeanors.

Furthermore, despite positive impacts on the four participants we reached, we ultimately conclude that our medical-legal partnerships must be accompanied by policy change efforts to be most effective and efficient. Intervening downstream of multiple fundamental causes cannot interrupt their relationship with health outcomes on a population level (Link & Phelan, 1995; Phelan et al., 2010). Previous research has characterized state policy changes that reduce the scope of monetary sanctions as necessary to reduce health inequities impacting economically marginalized communities of color. These include decriminalizing traffic offenses, prohibiting monetary sanctions from accompanying custodial or supervisory sentences, revising government budgets to fund judiciaries via streams other than monetary sanctions, ending government contracts with private debt collection agencies, and mandating evaluations of ability to pay for all defendants (Friedman et al., 2022). Our experience suggests that these policy changes would make legal gender affirmation more financially accessible for trans women of color in Michigan by preventing the likelihood of carrying monetary sanctions in this community.

In addition to policies focused on monetary sanctions, Michigan’s legal name change process could be amended to allow people with a criminal record to change their names for gender affirmation purposes without having to rebut a presumption of fraudulent intent. Recently, a coalition led by the ACLU of Michigan has successfully advocated for many changes to make Michigan’s court systems and name change process more accessible to trans communities (ACLU, 2024). Despite this work, policy changes that would eliminate criminal background checks and court hearing requirements for legal name changes are not included in current proposed legislation. If such changes go into effect in the future, we believe our medical-legal partnership will be able to meet the legal gender affirmation needs of trans women of color with a criminal record more efficiently and successfully.

Conclusion

We invite health psychologists and public health researchers to learn from our experiences and leverage the expertise of policy and legal experts who focus on trans populations as well as other social and structural determinants of health and human rights (e.g., poverty law, immigration law). While medical-legal partnerships are vital to addressing systemic barriers to health equity, our commentary highlights the need for intersectional structural competency and legal literacy in all intervention efforts focused on trans health (Metzl & Hansen, 2014; Metzl, Petty, & Olowojoba, 2018; Yassine et al., 2022). Designing interventions to prevent and mitigate structural oppression as a driver of trans health inequities requires multi-sectoral collaborations between policy and legal professionals with diverse areas of expertise to analyze the intersection of multiple fundamental causes (Moradi & Grzanka, 2017; Weber & Parra-Medina, 2003). Though “intersectionality” and “multilevel” have become buzzwords within the field, our experience reflects a concrete, urgent need for community-led, multilevel, and multi-sectoral interventions that that prioritize structural change while supporting organizations, communities, and individuals (Grzanka & Cole, 2022; McCormick-Huhn, Warner, Settles, & Shields, 2019).

Public Significance.

  • Intersectional structural competency inclusive of legal literacy is important for all intervention efforts focused on transgender health.

  • Including intersectionality frameworks into applications of fundamental cause theory can help identify effective loci for intervening upon complex structural and social determinants of health inequities among transgender and gender diverse populations.

Acknowledgements:

The authors would like to thank the transgender women of color, partnering attorney, and the community health center who participated in this project. This project was supported by an Antiracism Pilot Grant from the University of Michigan Office of the Vice President for Research and the authors were also supported in part by National Institutes of Health grants (T32HD007339; P2CHD041028; R25MH067127; UM2HD111102). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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