On Being Transnational and Transgender: Human Rights and Public Health Considerations

There has been a notable increase in attention to the lives and health needs of transgender people.^1,2 The growing burden of HIV among transgender communities during the 1990s brought visibility to this population, spurring two decades of research on individual-level health behaviors, mental health, substance use, and sex work as drivers of transgender women’s HIV risk.³ The Institute of Medicine called for a broader research agenda on transgender-specific health needs in 2011—the same year that the National Transgender Discrimination Survey highlighted systematic antitransgender bias and structural violence as enduring challenges for transgender people.⁴ The human rights of transgender people have more recently been garnering attention as a legitimate public health issue, demonstrated by the study by Cheney et al. (p. 1646), in this issue of AJPH, on transgender women from Mexico seeking asylum in the United States. This work demonstrates how the arc of research on transgender health has evolved from initially focusing on individual-level behaviors to considering transnational and legal issues that affect health outcomes.

The study analyzed asylum declarations filed through a legal service organization in California by transgender women immigrating from Mexico. Although Mexico has instituted national policies that acknowledge the rights of sexual minority populations, such as the legalization of same-sex marriage, there remains resistance to progress among religious institutions and local communities that acknowledge only heterosexual lifestyles and that discriminate against nontraditional forms of gender identity and expression. According to their document analysis, systemic community violence was a key impetus for transgender women’s immigration from Mexico.

Forms of violence included childhood insults by family members, intimidation in school settings, and more extreme acts of physical victimization, sexual assault, and murder of transgender adults. Transgender women reported a lack of support from police and the legal system in Mexico; some officers were perpetrators of transgender violence. The authors noted limitations of their research, including a nonrepresentative sample of transgender women from Mexico who had access and comfort using legal services in the United States, which might not be the case for many transgender immigrants.

Violence and other human rights violations among transgender people are not geographically unique. Findings reported in the National Transgender Discrimination Survey revealed the “banality” of violence in transgender communities in the United States,⁴ and our research findings have documented the prevalence and health correlates of antitransgender violence in the United States⁵ and throughout the Global South.³ For example, research with transgender women in Thailand (known locally as kathoey) reported violence inflicted by family members (generally fathers and brothers) while participants were questioning their gender and expressing nonnormative gender traits.⁶ In Malaysia, transgender women (known locally as mak nyah) are frequently exposed to physical violence and harassment from police and religious authorities, and the systematic employment discrimination of mak nyah can lead to survival sex and an elevated risk of trauma, exposure to violence, HIV, sexually transmitted infections, and substance abuse.⁷

Many transgender women immigrants and asylum seekers bring a history of violence and trauma with them as they resettle in the United States. Consequently, they may avoid institutions that require disclosure of their gender history, such as health care and legal support agencies, to protect themselves against the antitransgender stigma that has been well documented in the United States. Unhealthy trajectories may continue in the United States for transgender immigrants because of the intersection of antitransgender bias, anti-immigrant bias, and racism and because of health systems that traditionally have a myopic view on individual-level determinants of health.

We urge public health researchers and providers to contextualize the health needs of transgender immigrants within a transnational and human rights backdrop. Individual-focused health interventions, guided by individual-level theories and frameworks, may have limited success without recognition of the structural and life course challenges that transgender immigrants experienced before, during, and after their migration to the United States. Future study must address transgender immigrants’ and asylum seekers’ access to and utilization of health and social service in the United States in relation to their cumulative exposure to antitransgender discrimination, violence, and trauma. Transnational public health and policy efforts are necessary to advance the human rights of transgender people globally and must promote basic safety, freedom of expression, freedom from violence, and access to legal protections as foundations for public health for transgender people.