Experiences of Trans Women and Two-Spirit Persons Accessing Women-Specific Health and Housing Services in a Downtown Neighborhood of Vancouver, Canada

Abstract

Purpose: Little is known about trans womens' experiences accessing gender-segregated health and housing services, particularly services for marginalized individuals living in poverty. As such, we conducted a qualitative investigation into experiences of accessing women-specific health and housing services among trans women and two-spirit persons in a downtown neighborhood of Vancouver, Canada.

Methods: Between June 2012 and May 2013 interviews were conducted with 32 trans women and two-spirit individuals who had accessed women-specific health and/or housing services. Participants were recruited from four open prospective cohorts of sex workers and individuals who use drugs. Interview data were analyzed using a participatory analysis approach with two participants who were hired as research assistants.

Results: Participants were generally able to access women-specific services in the neighborhood. However, there were reports of discrimination related to gender identity, discrimination based on gender expression (e.g., requirement of a feminine gender expression), and lack of staff intervention in harassment from other service users.

Conclusion: Trans women and two-spirit persons in our study relied upon services for their health and safety and, therefore, exclusion from women-specific services had potentially severe adverse consequences such as homelessness and sexual violence. Recommendations to improve accessibility, including policy development and procedural recommendations, are put forth.

Introduction

Health inequities, such as depression and violence, have been recorded among certain trans persons, and these negative health outcomes have been linked to transphobia and stigma.¹ For example, due to fear of discrimination, trans individuals have reported avoiding healthcare or not disclosing their gender to healthcare providers.² Similarly, trans persons are often vulnerable to poverty and are overrepresented among those who experience homelessness.³ In a national survey, 19% of trans persons surveyed reported ever being homeless because they experienced gender discrimination.⁴ Because discrimination in housing is prevalent, housing is a primary concern for marginalized trans groups.⁵

In addition, trans and two-spirit persons frequently face barriers to economic opportunities,⁶ which affect health outcomes.^4,7 For instance, lower income has been linked to stigma and suicide among trans populations.⁵ Sex work has been noted as a more accessible economic option for trans persons due to severe economic barriers.⁸ The discrimination and stigma that many trans individuals encounter shape HIV vulnerability.⁹ For example, condomless sex has been found to be associated with unstable housing¹⁰ and experiences of transphobia among trans women.¹¹ Certain groups of trans sex workers face an increased burden of HIV¹² and there is evidence that the greatest burden of HIV vulnerability may be upon trans women,¹³ two-spirit persons,¹⁴ and trans sex workers of color.¹⁵ Therefore, trans persons, particularly trans women and two-spirit persons, may have heightened health inequities due to racism and employment, housing, and gender discrimination.

Despite the evidence of the importance of accessible health and housing services, trans persons continue to face obstacles in these settings.^16,17 For example, trans persons are often refused medical care¹⁸ and are turned away from both men's and women's housing shelters.¹⁹ Thus, the literature indicates that there is work to be done in health and housing settings to improve trans persons' experiences, particularly socially and economically marginalized trans women and two-spirit people. As such, the objective of this exploratory study was to investigate the experiences of trans women and two-spirit persons when accessing women-specific services in Vancouver's Downtown Eastside.

Methods

As part of a larger qualitative project examining the experiences of trans and two-spirit persons engaged in drug use and sex work, the first author conducted in-depth semi-structured interviews with 34 trans and two-spirit individuals between June 2012 and May 2013 in Vancouver, Canada. Participants were recruited from three open prospective cohorts of individuals who use drugs (The At-Risk Youth Study, Vancouver Injection Drug Users Study, and AIDS Care Cohort to Evaluate Access to Survival Services) and an open prospective cohort of sex workers (An Evaluation of Sex Workers Health Access). The cohort methods have been described elsewhere.^20–23 Eligibility included (1) identifying as a person whose gender identity/expression differed from assigned birth sex, (2) having engaged in sex work or illicit drug use, (3) ever accessing women-specific health or housing services, (4) residing in Greater Vancouver, and (5) being 14 years of age or older. All participants provided written consent and were paid CDN $20. This study holds ethical approval through Providence Health Care/University of British Columbia Research Ethics Board and pseudonyms are used to protect participant's identity.

Interview data were analyzed using an inductive theory- and data-driven approach²⁴ guided by a framework that positions health as an outcome of social-structural contexts.²⁵ Data were analyzed by the first author and by two participants who were hired as research assistants in a process they developed called participatory analysis, which has been described in depth elsewhere.²⁶ This approach was initiated to ensure that the data were analyzed by trans participants and not solely the cisgender (nontrans) first author. Using a participatory analysis approach enriched and contextualized the research findings, provided an opportunity to engage with research participants in the co-construction of knowledge,²⁷ and is guided by current guidelines on ethical research with trans people.²⁸

Two participants were excluded from the analysis because they reported never accessing women-specific housing (e.g., shelters) or health services (e.g., detoxification, drop-in centers). All 32 participants had been assigned male sex at birth; however, not all identified as women and many used more than one category to describe their gender. Sixteen participants identified as transgender, eight as women, seven as transsexual, and six as two-spirit. Two-spirit is a fluid concept that sits outside of Western concepts of gender and sexuality and is used to describe Indigenous persons who have feminine and masculine spirits.⁷ Participants ranged in age from 23 to 52 years of age, with an average age of 40.3 years. Twenty-two (68.8%) participants identified as being of Indigenous ancestry (First Nations or Métis), seven (21.9%) identified as White and three identified as Filipino, Asian, and “other” visible minority respectively. Fifteen participants (47.9%) identified as heterosexual, seven (21.9%) as gay, five (15.6%) as bisexual, two (6.3%) as two-spirit, two (6.3%) as asexual, and five (15.6%) did not report their sexual orientation. Some participants used more than one identifier. See Table 1 for additional participant demographics.

Table 1.

Trans Women and Two-Spirit Persons Participant Demographics N = 32

	Yes (%)	No (%)
Indigenous ancestrya	22 (68.8)	10 (31.2)
Living with HIV	17 (53.1)	15 (46.9)
Current sex work activityb	25 (78.1)	7 (21.9)
Current drug use activityb	17 (53.1)	15 (46.9)
Ever incarcerated	25 (78.1)	7 (21.9)

^aIndigenous ancestry includes First Nations, Inuit, and Métis peoples in Canada. No participants identified as Inuit in our study.

^bWithin the last 30 days.

Study setting

This study was undertaken on unceded Coast Salish Territories¹ in the Downtown Eastside neighborhood (DTES) of Vancouver. The DTES has a service-based character, which arose in response to soaring HIV rates and overdose related deaths in the 1990s²⁰ and the continued violence against sex workers.³⁰ There are services that are exclusively for women, including housing shelters, supported housing buildings, and drop-in centers that offer low threshold, minimal barrier services, and harm reduction programs. Women-only services in the DTES generally have informal trans-inclusive practices. Thus, the study is uniquely situated to investigate trans womens' and two-spirit persons' experiences accessing women-specific services.

Results

Discrimination based on gender identity: Exclusion

The majority of participants accessed women-specific services regularly, particularly drop-in centers; however, some participants reported being denied access to detoxification centers. When attempting to access detox, Daphne (Indigenous, trans woman) was told “We can't have you here. We don't have housing for you.” Alex (Indigenous, transsexual) also described being denied access to detox:

I was trying to get into detox a couple weeks ago … and I was so happy they accepted me. Anyway, they phoned me back and they said it was a religious organization. They couldn't allow transsexuals in there.

Participants also described encountering barriers to women-specific housing shelters, as described by Mae (Indigenous, trans, two-spirit):

At first I had problems [accessing women's shelters]. They asked me why don't I go to men's. I was like I did go to men's before and I was getting sexually harassed all the time. I remember one time waking up at [a men's shelter] and there was like five guys standing around my bed in the dark and they were all naked from the waist down. [After the sexual assault] I left the building. I never went back. … And then, just this past year, they start letting me go into the women's shelters.

The exclusion that trans women and two-spirit persons' experienced increased vulnerability to negative health outcomes, including sexual assault and avoidance of services as demonstrated by these examples.

Discrimination based on gender expression: Gender policing

Participants reported that their experiences were affected by how staff and cisgender service users interpreted their gender expression. Lilly (Indigenous, transgender) explained, “I find that if you look more femme and look more real, you get less harassed than if you look more boyish.” Similarly, Abigail (White, trans woman) noted that certain trans women and two-spirit individuals had difficulty accessing women-specific services “ ‘Cause they don't wear any makeup. … They're looking very masculine.” For Jarrah to be allowed to stay at a women's shelter she had to have her gender expression approved by staff.

I was talking to [a staff member on the phone] and she goes, “Do you at least look like a girl?” So I said yes [and when I went there] she looked at me, she's like you're in, you're accepted. … She was more worried about me being a man trying to get in there so I can get at the girls. (White, woman)

Participants attributed the ability to access and be accepted in women-specific services to feminine gender expression. As Becka (Indigenous, transgender) explained, “I'm a lot more accepted [at a drop-in] than some of the other [trans people] that do come through those doors … because I seem to be trying to be more female. Likewise, Brigitte (Asian, transsexual) reported positive experiences and commented on why some had negative encounters:

I guess it depends on how you represent yourself in public. And then they treat you with respect. … Because some of them look like they think they're feminine, meanwhile they got a full beard and you know, acting like a man.

These examples highlight a tension between permitting trans women to access women-specific services and requiring feminine gender expressions for meaningful inclusion.

This tension also played out between participants. For example, Natalie explained her perspective:

There are some transsexuals or transvestites that go in there who don't go in dressed as women and they still allow them to access the services. … I think if you're gonna access girls' facilities that you should at least make the effort to dress like one ‘cause it does bother some of the women. (Indigenous, transgender)

Amelia (White, transsexual women) had concerns around trans women with less feminine gender expressions accessing housing shelters and she noted that the concerns were rooted in not wanting to upset cisgender women. In fact, shelter staff asked Amelia to talk to a trans woman living at the shelter about how to present as less masculine: “I just told them if you think you're a woman shouldn't you be trying to look like a woman? You can't walk around looking like a guy.” Therefore, trans service users also engaged in gender policing, sometimes at the request of staff.

These examples illustrate how participants' experiences at women-specific services were dependent upon binary conceptions of gender. Those who were perceived to be “trying” to be feminine were treated with respect and had greater inclusion than those with a different gender expression, or those who were unable to have a feminine gender expression because of poverty, medical status, or physiology. Alex (Indigenous, transsexual) summed up these tensions and pointed to the danger in service providers subjectively determining whether trans women and two-spirit people are “trans” or “woman” enough. Alex proposed the implementation of a self-identified gender policy at women-specific services to prevent discrimination:

It's basically you're just gonna have to take their word for it and just accept anybody that says they're transsexual even if they're not. It's all you can do, otherwise we're gonna be picking and choosing … Who's gonna be judge and jury? … You don't want to do that either.

Discrimination from cisgender women and lack of staff intervention

Participants in our study also reported discrimination from other service users. Thea (Indigenous, transgender) reported using women-specific services, but not fully engaging due to this discrimination:

A lot of other women will have issues with transgendered people and they'll say stupid things like oh you're a man. Why are you here? Or they'll say, you don't have to act like a fag just to get women's services. … So I don't really stay long. I usually only access them if I need it.

Participants also reported harassment from cisgender women in supported housing buildings. Skye (Indigenous, trans women, two-spirit) said “There's other women in there that call me a man and tell me that I shouldn't be there. … I feel out of place there, I really do.” Ophelia (Indigenous, transgender) reported parallel experiences:

When I first lived at [supported housing] there was some woman that disrespected me in every way, [saying] I shouldn't be there, I have no right being there and they were gonna sign a petition for us trans people not to live there.

Similar experiences were reported at housing shelters. Jarrah (White, woman) described physical violence in the shelter: “I was laying in bed, trying to go to sleep. [A resident] boosts the door open and says my husband's outside ready to beat your head in.” She noted that staff did not intervene, “Staff doesn't really step in. They have that rule where you do not step in and take care of business, which to me is totally wrong.” Likewise, Thea (Indigenous, transgender) found staff did not intervene:

I feel unsafe in a lot of those spaces ‘cause I feel that they don't protect people's rights enough. … At [a drop-in] there's one woman in particular who always yells stuff, “Oh you're not a woman.” … I always think that they're not kicking her out because she's a woman and I'm trans. … I have to be extra polite, extra nice, extra personable just to be in a lot of the services.

Both Thea and Jarrah discussed how lack of staff intervention made them feel unsafe. Thea also noted that she had to be “extra polite, extra nice” to access women-specific services, and as discussed earlier in the article participants were also required to embody a stereotypical feminine gender expression to access services and to minimize discrimination. These examples of cisgender women comfortably engaging in discrimination, and not being held accountable by staff, illustrate the power imbalances between cisgender women and trans women and two-spirit persons in the services. Thus, negotiating women-specific services was complicated for participants who had a more fluid gender expression and for those whose gender expression was deemed not “feminine” enough by staff and other service users.

Discussion

Some participants reported that they were denied access to services because of gender identity or because they were not performing their gender in ways deemed appropriate. These exclusions increased vulnerability to negative health outcomes, including sexual assault and avoidance of services. As Sakamoto et al.³¹ found, participants in our study were also told in different ways that they were unwelcome or did not belong in women-specific services and this contributed to further social exclusion. Participants also reported that staff did not intervene when they experienced discrimination from cisgender service users. Perhaps this was due to policies around staff safety, which Jarrah mentioned, or perhaps it was related to a lack of staff training and knowledge of trans-related issues as described in other settings.³² Our findings add to the evidence on the prevalence of transmisogyny whereby trans women, particularly trans women of color and those who are marginalized, experience high rates of violence and exclusion.³³ The findings illustrate how transmisogyny functions, along with interlocking discriminations related to gender, sex work, class, and racism. Within this context trans women and transfeminine persons are perceived to violate gender norms and are subject to continual gender policing. Trans women are considered to be deceivers (not “real” women) and this is used to justify violence and exclusion.^34,35

There was a requirement for participants to embody a particular kind of binary feminine gender expression to be welcomed within these services. For those interested in presenting in a feminine manner, poverty and economic barriers make this requirement highly unattainable given the costs of make-up, electrolysis, hormones, and so on. Trans women and two-spirit persons often lost the ability to self-identify their gender because their identity was defined by staff who determined whether they could access the service. In other settings trans women also reported that they were denied access to women's homeless shelters if they were not taking hormones, or if they did not have a feminine gender expression.³²

Gender policing was justified in our study by staff concerns that cisgender men would pretend to be trans to get access to cisgender women. This is an unverified claim that is used to justify the exclusion and marginalization of trans women from services more broadly³⁶ and to prioritize the safety and health of cisgender women over trans persons^33,37 as demonstrated by the Bill C-279. Bill C-279 sought to add gender identity to the Canadian Human Rights Act and the Criminal Code. The Conservative-led Senate recently amended the bill to prevent it from applying to public spaces, including bathrooms, in the name of protecting cisgender women; a move that effectively destroyed the bill.

Trans people, like cisgender people, have a wide range of gender expression; however, cisgender women are not required to have a feminine gender expression to access women's services. In addition, the notion of gender transition as a linear process from one sex to another is rooted in rigid understandings of two mutually exclusive sexes that have polarized characteristics.³⁵ Transition is not a linear process, and many trans persons are not interested or are unable to transition for a variety of reasons,³⁸ including financial barriers.³⁶ Less than half of trans youth in Canada reported living full-time in their felt gender¹ and Scheim and Bauer³⁹ found that only 30% of trans Ontarians lived in their felt gender full time. Thus, it is vital that services implement policies of respecting self-identified gender.³⁶

Policy and legal implications

Most women-specific health and housing services in the area have adopted formal or informal “trans inclusive” policies; however, the policies are not put into practice consistently as our findings illustrate. Thus, it is imperative that trans-inclusive policies that respect trans and two-spirit persons' self-identified gender are established and enforced in women-specific services.⁴ These services could possibly work together with gender diverse service users to craft and implement trans-inclusive and anti-discrimination policies and procedural recommendations.⁴⁰ Structural barriers, such as employment discrimination, need to be addressed by hiring trans persons as staff⁴¹ and environmental changes, such as gender neutral bathrooms and updating materials to include trans-specific content, are recommended.⁴² In addition, it is imperative that staff in women-specific services address and stop the harassment of trans women and two-spirit persons using their service. Also including a gender-inclusive policy on intake forms would signal to all service users that trans and two-spirit persons are welcome and that staff will intervene in any harassment.³⁶ Given the concerns from staff regarding cisgender men accessing women-specific services it is also recommended that trauma-related education and policies for staff and service users are put in place.

All of the exclusions that trans participants described are illegal under the BC Human Rights Code⁴³ with a narrow possible exception for women-only services, which have sought and obtained exclusions from section 8 of the code.⁴⁴ Section 8 prohibits discrimination in the provision of a service (e.g., access to emergency shelters or drop-in spaces). However, section 41 of the Code contains an exemption that permits not-for-profit organizations to grant preference to members of identifiable vulnerable groups in the provision of services under certain circumstances. Organizations seeking to exclude trans women must apply for and be granted an exemption from the operation of the Code. As such, services and organizations should be made aware that excluding trans persons, for any reason, and allowing discrimination to occur in their spaces is illegal.

Limitations

The study findings may not be generalizable to other settings given the great heterogeneity of trans women and two-spirit peoples. In addition, the unique experiences of two-spirit individuals may have been overlooked and as such future research would benefit from two-spirit specific research conducted by indigenous peoples and/or in accordance with indigenous research methods. Future research would also do well to incorporate the experiences of staff and cisgender service users in women-specific services to contribute to a more comprehensive examination of how gender-inclusive policies play out for trans and two-spirit persons. Lastly, data were based on self-report and may be susceptible to response biases.

Conclusion

Participants in our study relied upon services for their health and safety and, therefore, exclusion from women-specific services had potentially severe adverse consequences such as homelessness and sexual violence. The potential costs of excluding trans women and two-spirit peoples from health and housing services include increased HIV vulnerability through reduced access to HIV prevention services, and through homelessness and social exclusion that are structural risk factors for HIV.⁴⁵ Making access to services dependent on stereotypical feminine gender performance excludes those who are unwilling or unable to successfully perform “the feminine.” Thus, it is imperative that trans women and two-spirit persons, regardless of gender expression, are able to access health and housing services.

Acknowledgments

We thank all those who contributed their time and expertise to this project, particularly the participants, research assistants, community advisory board members, and partner agencies. We would also like to thank the two anonymous reviewers for their helpful comments and engagement with our work. This research was supported by operating grants from the U.S National Institutes of Health (R01DA033147). At the time of the research T.L. and A.K. were supported through the Canadian Institutes of Health Research. W.S. was supported by the Michael Smith Foundation for Health Research. K.S. was partially supported by a Canada Research Chair in Global Sexual Health and HIV/AIDS and Michael Smith Foundation for Health Research Scholar Award.

Author Disclosure Statement

No competing financial interests exist.