Learning to endure: A qualitative examination of the protective factors of homeless transgender and gender expansive youth engaged in survival sex

Abstract

Background: Transgender and gender expansive (TGE) youth face a number of adversities that are associated with deleterious consequences, including mental health problems, substance misuse, suicide, and homelessness. However, there is evidence that TGE youth still demonstrate resilience under extraordinary conditions.

Aims: Therefore, this study examined how TGE youth who are homeless and engaging in survival sex describe and understand the protective factors present in their lives.

Methods: In-depth qualitative interviews were conducted with 57 TGE youth living in a large U.S. city. Participants were 17-26 years old (M = 19.88, SD = 1.55), and identified as transgender woman (53%), transgender man (16%), and other (32%; gender-queer, gender-fluid, androgynous, or non-binary). Youth identified as Black (40%), multiracial (35%), Latinx (16%), White (5%), and as another race (3%). Researchers conducted a secondary analysis of qualitative data using thematic analysis.

Results: We identified three themes to capture youth’s understanding of their protective factors: relying on oneself and others to avoid violence, accessing gender-affirming health and mental health care, and proactively maintaining sexual health. Participants described strategies for mitigating risk of harm while attempting to meet their basic needs. Additionally, they discussed the importance of having gender-affirming health and mental health services. Participants also expressed keen awareness of their sexual health risks and making calculated, often proactive decisions about their sexual health.

Conclusion: The protective factors described by TGE youth reflect the unique ways in which hyper-marginalized youth must navigate their own survival and well-being, and align with literature suggesting resilience is not mutually exclusive from risk. By focusing on TGE youth, this research privileges the experiences of individuals historically underrepresented in research and encourages future research to incorporate these perspectives into policies and programs.

Transgender and gender-expansive (TGE) youth (i.e., individuals whose gender identities and expressions differ from those endorsed by cisnormativity), face a number of adversities, including harassment, physical and sexual abuse, and hostile home and school environments (Baams, 2018; Choi et al., 2015; Kosciw et al., 2018; Vigna et al., 2018). Studies have indicated that these adversities are associated with deleterious consequences, including mental health problems and substance abuse (Keuroghlian et al., 2014), suicide (Austin et al., 2020; Haas et al., 2011), and homelessness (Cochran et al., 2002; Durso & Gates, 2012; Shelton, 2016). However, there is evidence that TGE youth still manage to demonstrate resilience in the face of extraordinary adversity (DiFulvio, 2011; Gamarel et al., 2014; Scourfield et al., 2008). Resiliency has, in fact, been shown to exist even among the most hyper-marginalized populations of TGE youth, such as those who are homeless and engaging in survival sex. For example, research has demonstrated that these youths find opportunities to express themselves authentically and to create new communities that support and affirm their identities, while simultaneously navigating the challenges of homelessness and managing the risks of transactional sex (Shelton, 2016). Yet, what remains underexamined is how TGE youth experience the protective factors that contribute to their resilience using in their own words. Thus, the purpose of this qualitative study was to explore how TGE youth who are homeless and engaging in survival sex describe and understand the protective factors contributing to their resilience. Highlighting the lived experiences of TGNE youth using their own words has the potential to inform policies and services for this vulnerable population.

Victimization among transgender and gender-expansive youth

The existing literature on TGE youth has tended to focus primarily on the experiences of victimization perpetrated by family members and peers (Grossman et al., 2006; Toomey et al., 2013). This research has demonstrated that abuse against TGE youth begins early in life and persists across the life course (Stotzer, 2009), and often has consisted of multiple forms of abuse related and unrelated to their gender identities (Atteberry-Ash et al., 2020; Clements-Nolle et al., 2006; Grossman & D'Augelli, 2006). Experiences of childhood sexual abuse have also been shown to be particularly common among TGNE populations (Rimes et al., 2019). Outside of their families of origin, TGE youth frequently report facing violence from their peers in school (Atteberry-Ash et al., 2019; Grossman et al., 2009; Grossman & D'Augelli, 2006; Toomey et al., 2013), and have been shown to experience higher prevalence of dating violence compared to their cisgender peers (Rimes et al., 2019; Walls et al., 2019). While studies have shown that TGE youth are subjected to multiple forms of victimization, evidence suggests they also lack support from law enforcement and other service systems, as these providers may be ill-equipped to respond effectively to their needs (Grossman & D'Augelli, 2006; Stotzer, 2009).

Additionally, there are within-group differences among TGE youth that may potentiate risk (Rimes et al., 2019). For example, research indicates there are differences in stress levels and life satisfaction for transgender youth compared to non-binary youth (Rimes et al., 2019; Todd et al., 2019). Further, the challenges faced by TGE youth may be complicated by other marginalized aspects of their identities, such as race and/or ethnicity (Atteberry-Ash et al., 2019; Birkett et al., 2015; James et al., 2016; Kosciw et al., 2018). For example, previous research has indicated that TGE women of color may be more prone to drop out of school due to bias-based (e.g., racist and transphobic) bullying in high school as well as the lack of self-compassion and social support that tends to result from this bullying (Eisenberg et al., 2017; Kim, 2009; Nemoto et al., 2004; Vigna et al., 2018). School dropout in turn has been related to other adverse consequences, such as homelessness (Kennedy, 2007), reinforcing how risks are exacerbated for certain subgroups of TGE youth.

Transgender and gender-expansive youth homelessness and its consequences

Homelessness among TGE youth has been considered a serious social problem, with research demonstrating higher prevalence of homelessness among TGE youth compared to cisgender youth (Choi et al., 2015; Durso & Gates, 2012). TGE youth often become homeless after being kicked out of their homes because of their TGE identities, or because they lack sufficient safety and protection from primary caregivers (Alessi et al., 2020; Shelton, 2016). While this experience is similar to sexual minority youth (Alessi et al., 2020), research suggests that the experience of TGE youth homelessness may be qualitatively different than heterosexual and sexual minority youth due to a lack of gender-affirming shelters and increased barriers to securing permanent housing (Shelton, 2015).

The overrepresentation of TGE youth in the homeless population subjects them to a number of additional hazards. For example, homeless TGE youth are at increased risk for engaging in survival sex (i.e., exchanging sex to meet one’s basic needs such as shelter, food, drugs, and/or money; Atteberry-Ash et al., 2020; Greene et al., 1999; Grossman & D'Augelli, 2006; Belzer & Radzik, 1997), since homelessness often contributes to engagement in survival sex (Keuroghlian et al., 2014; Nemoto et al., 2004; Rice et al., 2013; Tyler, 2008). Living on the street and engaging in survival sex may be complicated by a lack of available alternative housing and employment opportunities for TGE youth due to stigma and discrimination (Alessi et al., 2020). As a result, TGE youth may remain on the street for long periods of time, with engagement in transactional sex being one of the only ways to survive (Dank et al., 2015). Additionally, they may face challenges with maintaining their sexual health (Garofalo et al., 2006; Santa Maria et al., 2019), as has been evidenced by elevated prevalence of HIV and other sexually transmitted infections (STIs) among populations of TGE youth who are homeless and engaged in survival sex (Bith-Melander et al., 2010). The ability for TGE youth to care for their own sexual health has, in part, been affected by external factors such as the availability of gender-affirming and culturally sensitive services (Garofalo et al., 2006; Santa Maria et al., 2019).

Beyond a lack of sexual health resources, research has indicated that TGE youth generally experience inadequate access to comprehensive physical and mental health services (Mizock & Mueser, 2014). This has frequently been a problem for homeless youth (Hudson et al., 2010), but the difficulties for TGE youth may be compounded by stigma and discrimination and a lack of gender-affirming healthcare providers (Grossman & D'Augelli, 2006; Todd et al., 2019; Vance et al., 2015). The lack of appropriate care afforded to TGE youth, especially those who are homeless, has been associated with difficulties maintaining overall physical and mental well-being (Vance et al., 2015). Given that TGE youth tend to have greater mental health challenges (e.g., depression and anxiety) than their cisgender peers (Reisner et al., 2015; Walls et al. 2019), the lack of trained providers continues to be a particular concern. Studies have shown that timely access to providers trained in administering gender-specific care can have a variety health benefits for TGE youth (Olson et al., 2011), and that finding a health care provider to administer gender-affirming hormones can also facilitate other forms of health-care such as preventative care or treatment of STIs (Stieglitz, 2010).

Resilience and transgender and gender-expansive youth

Due to the number of adversities facing TGE youth, researchers have increasingly sought to examine the resilience of these youth to better understand how they endure difficult life circumstances. Definitions of resilience tend to vary across studies, but it is generally understood to be “a dynamic process encompassing positive adaptation within the context of significant adversity” (Luthar et al., 2000, p. 543). Therefore, resiliency theory attempts to understand why certain people exposed to negative or traumatic events are able to persevere, despite their experiences (Fergus & Zimmerman, 2005). One of the distinguishing qualities of resilience is that it occurs amid an environment of persistent fundamental risk (Brodsky & Cattaneo, 2013). Therefore, previous literature on resilience has tended to focus on the qualities and characteristics of individuals or on the resources available to help individuals overcome the deleterious effects of high-risk situations and environments (Brodsky & Cattaneo, 2013). These characteristics are often referred as protective factors, or external stimuli that promote the well-being of an individual (Zimmerman et al., 2013). Much of the literature on resilience has been based on discussion of cisgender, heterosexual samples; thus, the common protective factors identified have included those that reinforce a strong sense of self within a supportive social context (e.g., family connection, social support, prosocial behavior, ethnic identity, and self-confidence; Eisenberg et al., 2017; Fergus & Zimmerman, 2005; Zimmerman et al., 2013). However, these protective factors may not be readily available to TGE youth (Shelton, 2016; Todd et al., 2019). Many TGE youth experience transphobia in a variety of social contexts (e.g., the family, school, and/or community), thereby reducing their ability to develop or reinforce the protective factors that are inherent through these social connections (Grossman & D'Augelli, 2006; Nemoto et al., 2004).

Despite being less likely to experience what are commonly understood to be protective factors, TGE youth may still benefit when such factors, such as social support and positive school climates are present (Hatzenbuehler et al., 2014). Yet, because of the disparate experiences between TGE and cisgender youth, TGE youth are more likely to need to highlight opportunities for resilience found in situations or environments that are traditionally thought of as leaving them vulnerable to negative health and mental health outcomes (Shelton, 2016). For example, although homelessness is still considered a risk factor, the freedom from oppressive living environments has been considered a protective factor for TGE youth (Shelton, 2016). Other research on TGE youth of color has shown that resilience for this group develops through accepting an evolving sense of self, advocating for self and others, gaining awareness of societal oppression, and finding a community within the broader sexual and gender minority population (Singh, 2013; Singh et al., 2011). Still, the distinct experiences of TGE youth have precipitated the need for more research to examine resilience among this group (Shelton, 2016). It is not only important to examine the protective factors among TGE youth populations (DiFulvio, 2011; Eisenberg et al., 2017), but also to allow these youth to describe in their own words what factors in their lives function protectively

Methods

The current study, which involved secondary analysis of qualitative data, was guided by the following research question: How do TGE youth who are homeless and engaging in survival sex describe and understand the protective factors contributing to their resilience? This study extends from a larger one that was conducted in a large Northeastern city in the United States in 2011 and 2012. The initial study examined the personal characteristics of 283 sexual and gender minority homeless youth engaging in survival sex and their interactions with police as well as health and social service providers (Dank et al., 2015).

Participants and procedure

As the goal of the current study was to examine the experiences of TGE youth specifically, youth who identified as cisgender were excluded from the analysis. Participants from the larger study were included in the current study based on the following criteria: identification as transgender, non-binary, or gender expansive (e.g., genderqueer, androgynous) and reported active engagement in survival sex. The study employed an inclusive definition of youth (i.e., 15-24; United Nations Department of Economic & Social Affairs, 2018), but also included participants up to age 26. These youth became homeless and engaged in survival sex during their youth. The sample was comprised of 57 participants, who were between the ages of 17 and 26 years old (M = 19.88; SD = 1.55). They identified as transgender woman (53%), transgender man (16%), and other (32%; gender-queer, gender-fluid, androgynous, or non-binary). Participants identified their sexual orientation as heterosexual (33%), bisexual (16%), gay (12%), lesbian (11%), and queer, questioning, or other (28%). The majority of youth in this study identified as racial or ethnic minorities, with 40% identifying as Black, 16% as Latino/a, and 35% as multiracial. The remainder identified as White (5%) or another race (3%). Participants had varying levels of education: approximately 47% did not complete high school, 26.5% only obtained a high school diploma, GED, or equivalent, 23% attended at least some college, and the remainder did not provide their level of education (3.5%).

Respondent-driven sampling (RDS) was used to recruit participants in the larger study. Thirteen participants, identified by service providers and youth leaders, were selected as initial seeds in order to facilitate the recruitment process. Prior to engaging in the study interview, all participants, including the initial seeds, were screened for eligibility and provided with referrals to social and community organizations as needed. Those meeting eligibility criteria were interviewed after they gave informed assent. Potential participants were not included in the study if it was determined that participation would create psychological distress. In such instances, appropriate referrals to mental health services were provided to these individuals.

Participants received $20 cash at the end of the interview as well as three unique, coded coupons. Following a brief discussion of the recruitment process, participants were instructed to hand the coupons to other sexual and gender minority youth they knew who were engaging in transactional sex. For each successful referral, participants received an additional $10. The coupons had unique numeric codes on the front of them to prevent duplication and identify the youth who initiated the referral. Wave 1 consisted of those participants referred by initial seeds. To ensure that sample and social network attributes reached equilibrium, at least four waves of chain referral sampling were achieved (Heckathorn, 1997), leading to the recruitment of a diverse sample of sexual and gender minority youth engaging in transactional sex in a large Northeastern city in the United States. It took approximately nine months to recruit the sample used in the larger study. The goal of the recruitment process was to obtain the largest, most representative sample possible, rather than to estimate the number of sexual and gender minority youth engaged in survival sex.

The initial study was approved by the IRB of the Urban Institute, while procedures for the secondary analysis of qualitative data were approved by the IRB of Rutgers University. A detailed description of the methodology used in the initial study can be found in Dank et al. (2015).

Measures

A semi-structured interview guide was used to gather data. Seven youth were trained to conduct the interviews, but most interviews were conducted by one youth interviewer. Interviews ranged from 20 to 120 minutes and elicited information about participants’ experiences on the streets and their use of survival sex to meet basic needs. The interview also covered their entry points into survival sex and experiences with police, social service providers, and organizations. Audio-recordings were collected and transcribed by a professional transcription company. A data collection instrument was used to organize the coded data, to allow for “yes/no” responses to certain questions, to record demographic information, and to accurately capture longer explanations to interview questions.

Data analysis

Thematic analysis was used to identify patterns in the data and also to elucidate the lived experiences of participants beyond that of surface level description (Braun & Clarke, 2006). The first and third authors (BG & DM) began the data analytic process by engaging in open coding. This led to the identification of initial codes and categories, which were combined to avoid redundancy and then organized to prepare for the development of preliminary theme development. As themes were identified, the first and second authors (BG & EA) held weekly debriefings to review and refine codes until agreement was eventually reached. During these debriefings, biases and assumptions were discussed to avoid constraining the analysis (e.g., the assumption that misusing substances would automatically prevent youth from fostering various protective factors). Peer debriefings were also used to ensure that researchers’ preserved the integrity of the data. The researchers explored their positionalities (e.g. race, gender, socio-economic backgrounds) to minimize their influence on the analysis and theme development. The first two authors continually returned to the data to ensure that themes reflected the experiences of participants and that this was communicated through a cohesive story (Braun & Clarke, 2006). Once themes were finalized, the third author (DM) reviewed themes to ensure that they were consistent and precise and that there was no overlap between them (Nowell et al., 2017). The fifth author (MD), who was a member of the original data collection team, also provided feedback to ensure that themes reflected participants’ experiences. To enhance rigor, the research team considered negative cases, which illuminated experiences differing from the common experiences of participants. Additionally, researchers maintained an audit trail to document coding procedures and decision-making processes to increase trustworthiness (Padgett, 2017).

Results

Evident from the data was participants’ acknowledgement of the risks of engaging in survival sex. For example, they reported experiencing physical violence while exchanging sex for money or material goods, health and mental health problems stemming from being unable to take care of themselves on the street, and being concerned about contracting sexually transmitted infections or HIV through survival sex. However, they also discussed various ways to take care of themselves despite these risks. We identified three themes that highlighted these protective factors: (a) relying on oneself and others to avoid violence, (b) accessing gender-affirming health and mental health care, and (c) proactively maintaining sexual health. Participants were all assigned unique participant ID codes that would be used in place of their names throughout all reporting of the research to ensure maximum confidentiality.

Relying on oneself and others to avoid violence

Participants described their ability to mitigate risk of violence while attempting to meet their basic needs (e.g., making money and securing a place to stay) through their reliance on both themselves and others to avoid violence. Avoiding violence was not only essential for personal safety, but also to be able to continue generating income from survival sex. This meant that the need for self-protection was often calculated based on participants’ perceived level of danger. For example, participant P68102, a 20-year-old white gender-queer youth reported: “It depends on the context, you got two feet to run with, pepper spray, and determination.” Others described a willingness to use physical violence to protect themselves, especially when assessing a situation and realizing they had no choice but to use such methods. In such cases, three participants expressed:

P68826 (18-year-old Black transgender woman): If somebody tried to hurt me, I would just try to like fight it out, like get the hell off me.

P68892 (21-year-old Hispanic non-cisgender youth): My hands and feet are lethal…I am a cool person, a relaxed person, but if I feel threatened, that my life is at risk, then I’m going to beat the shit out of you and ask questions after.

P66145 (19-year-old multiracial transgender man): If they have a knife, I will fight.

Some took additional steps to protect themselves by carrying weapons. For instance, one participant, a 20-year-old Black transgender woman, carried multiple weapons for protection, stating:

P68943: I told you I keep my blade in my hand and my mace. I would blind their ass and cut the shit out of them. Just keeping it real…Because I hurt them before they hurt me. That’s the motto.

While many relied on weapons to protect themselves, some also depended on the assistance of others to stay safe. Such was the case for a 20-year-old multiracial transgender woman, who described her reliance on a friend whom she hired for protection:

P66292: Usually I have my security guard go with me like who usually wait in the lobby or something like that.

Interviewer: This is the person who’ll get half of the money?

P: Yeah, but … he doesn’t ask for much. Like, he doesn’t like me giving the money and stuff like that, but you know I give it to him because I know he has kids…

I: He just wants really to protect you?

P: Yeah, he's all protective on me like he always tells me, ‘I'm here for an hour if you don’t call me in an hour I'm coming up stairs.’

Most participants who reported relying on others had less formal arrangements than what participant 66292 described. Such cases included a 21-year-old multiracial transgender woman, a 19-year-old Black transgender non-binary youth, and a 21-year-old transgender woman, who reported:

P68945: I remember this one time my best friend came with me, he waited outside for me, outside the door.

P65891: I tell my oldest cousin, and I make sure he's always outside waiting for me in his car.

P63463: I do have a friend with me, or I make friends with somebody on the street.

Similarly, participant 63516, a (19-year old multiracial androgynous youth), reiterated the importance of participants having the protection of others while engaging in survival sex, commenting: “A friend of mine, we kind of, like, helped each other out.”

Relying on others also meant that participants counted on other sex workers, usually friends or acquaintances, for assistance when in acute need. One participant, a 19-year-old Black transgender man, said:

P69312: Just in case something happen…if I know somebody, I’ll tell them, ‘Oh go stand over there just in case I need you.’ Like, just in case I’m hurt, like I was to get into a fight and I try to run away and they see me running, they’ll know something up. So I’ll have a backup person or something like that.

For others, their sense of self-protection stemmed from their ability to access support from police if they were in danger. Participant 68941, a 24-year-old multiracial transgender woman, expressed: “Yeah, call the cops immediately” when discussing how to mitigate risk of violence. A similar sentiment was expressed by participant 64149, a 19-year-old multiracial non-cisgender youth, who talked about how they would respond in an unsafe situation:

Interviewer: Do you have a safety plan in case someone tries to hurt you?

P64149: Yes, 911.

As P64149 and others mentioned, finding ways of avoiding violence was a prominent protective factor, one that enabled them to survive on the streets by ensuring their physical safety.

Accessing gender-affirming support for physical and mental health

Amidst the challenges of being homeless and engaging in survival sex, participants still had to care for their physical and mental health. This was not always an easy task, as participants had to find care that was able to address their needs and concerns. In particular, they described the importance of having gender-affirming health and mental health services; these services supported their ability to live authentically and manage the stress of the living on the street. For one participant, a 21-year-old multiracial transgender woman, accessing gender-affirming health care was essential to her well-being and she relied on support from service providers to receive this type of care:

Interviewer: Do you buy hormones off the street?

P68945: Oh no, I’m going to [agency name].

I: So you are getting it free?

P68945: I want to do it the legal way. I love [agency name] actually, [Agency name] is wonderful. They helped me out with a lot of stuff, they have great resources

Others reported similar experiences of being able to access and receive gender-affirming health services from agencies; access to this care was commonly framed as an asset. As P67767, a 19-year-old Black transgender woman) expressed: [name of agency] is great, hormone injection to me, it’s real good. Transition is a good thing.” Participants often asserted that the benefits of gender-affirming care were about more than the specific services received. When describing positive service experiences, participants repeatedly discussed the importance of receiving care from gender-affirming providers. This was the case for multiple participants:

P67528 (20-year-old Hispanic transgender man): It's awesome, I love it, I feel free. I feel like I can be me, like I don’t have to fake I’m something I’m not. They respect my PGP, my Preferred Gender Pronoun, everything, and they are helping me a lot.

P68102 (20-year-old white gender-queer youth): [The provider] was great, and she was just like the…sassy dyke….and yeah has been doing AIDS activism for like 40 years, so she's totally in the loop of just things. It just, it was easy.

Participants also described the importance of receiving gender-affirming mental health care, or at least mental health care where they felt comfortable as transgender individuals. As one participants expressed:

P69005 (20-year-old Native American transgender woman): At [name of agency] I went in looking for like counseling or something…and they provide like medication like for my depression and anxiety and stuff. And so that’s what I get from there.

For some participants, gender-affirming online and in-person support groups were pointed to as alternative resources that they could utilize for their mental health. Two participants described their experiences with these groups:

P68762 (20-year-old white transgender man): There’s a place online called [name of place]…they are for [transgender people]. To just sit there and chat to them, they got their own therapists over there or whatever.

P66218 (21-year-old Black transgender woman): I just go over there for [support group name]…which is like great because they help…I didn't know too much about [transgender people], and myself, and it helped me learn more about myself and other transgender people. And people of color.

Participants’ descriptions highlighted that leveraging support for their physical and mental health was essential to their well-being. Maintaining other aspects of well-being required different approaches, especially when it came to sexual health.

Proactively maintaining sexual health

Participants expressed keen awareness of the elevated risk of contracting HIV and other STIs through engagement in survival sex. Despite knowingly engaging in risky sexual behaviors, TGE youth were still able to find ways of dealing with associated concerns. TGE youth described making calculated decisions about their sexual health. This often involved a strong commitment to using condoms while trading sex, especially when they were so readily available. Participant 68703, a 20-year-old Black transgender woman mentioned this as: “They give them out like candy, like they always give it to you. You never have to worry about a condom in New York.” This access provided participants a basic mechanism for managing sexual health. As participant 68826, a 18-year-old Black transgender woman, expressed: “I'm really scared to catch AIDS so I get…I don’t know what it is but it’s like plastic and it’s really thin, and I just, and just do what you got to do.” Others who were fervent about using condoms also took the initiative to consistently get tested for diseases, such as participant 66462, a 20-year-old Hispanic transgender woman: “I use condoms, I get tested every three months and I’m always keeping up. I'm pretty much always keep up like I wouldn’t get anything.”

Although protection against disease was often in mind, participants also discussed the reality of being confronted with the potential to make more money if they engaged in risker sexual behaviors (e.g., not using condoms). However, the decision to engage in such behaviors did not mean that participants were not still proactive about their sexual health. Participant 63774, a 19-year-old Black transgender woman, expressed:

Interviewer: So, in the cases that you don’t [use a condom], is it with clients that are willing to pay more, or clients you feel comfortable with?

P63774: There’re some clients that be willing to pay like a nice lump sum of money, you know what I’m saying? Like $500 and just to do it raw.

I: Without the condom?

P63774: Yeah. And even like I would say like 25% of the time I have let somebody else do me but…I don’t let them come in me. You need to pull it out or your balls are going to get kicked.

Participants also managed to maintain their sexual health by utilizing sexual health services, which sometimes came in the form of information. For instance, participant 68943, a 20-year-old Black transgender woman, learned about the additional health risk of meningitis from an agency and took steps to protect themselves from this risk:

I go get tested and make sure I’m always updated on my HIV, always get my shots and make sure that’s good, and especially with meningitis… it’s meningitis that people need to get checked…and six months ago when I came and they said people was getting it, it was offered free at the clinic for LGBTQ people.

With other participants, remaining proactive about sexual health was a necessary for obtaining other health services. Participant 66378, a 20-year-old Black transgender woman described such engagement: “I tested for everything…you have to for hormones, you have to get tested.”

Another way to manage sexual health risks was to know their clients well and limit risker behaviors to regular clients. Participant 67767, a 19-year-old Black transgender woman, reported: “Sometimes out of three of the clients that I know, that I know…they are clean, I would not use a condom.” For others, focusing on clients who were only interested in lower-risk sexual behaviors was a way to be proactive about their sexual health while they engaged in survival sex. Participant 65959, a 19-year-old Black transgender woman, explained:

Those fetish guys…you don't have to really sexually interact with them they just want you to do certain things, you know, whatever they find fetish…I feel like if you find all those you should make them your regulars and keep them that way. Because you don't have to be in jeopardy of catching an STD or anything like that, it's nothing bodily fluids no, nothing, you're good.

As demonstrated by this statement, participants emphasized that the myriad ways they demonstrated agency in managing their own sexual health was critical to their overall well-being.

Discussion

In an effort to understand the experiences of TGE youth who were homeless and engaged in survival sex beyond the risks present in their lives, this study explored how TGE youth described and understood the protective factors contributing to their resilience. The three themes identified reflect strategies that participants learned to be able to endure difficult life circumstances. The first, relying on oneself and others to avoid violence, involved reports of willingness to fight or carry a weapon as well as descriptions of asking for protection from a friend, others engaging in survival sex, or the police. The underlying sentiment of participants’ narratives was that they could rely on themselves or others to effectively protect themselves from violence. Behaviors used for protecting themselves were beneficial even for participants who depended on their willingness to use violence, an option that is not considered the most pro-social. Given the level of risks to personal safety experienced by TGE youth who are homeless (Reck, 2009), just the presence of a sense of self-preservation and the ability to achieve it demonstrated the resilience of this group, regardless of the specific ways in which participants chose to act to avoid general violence. Further, it is important to consider the findings of previous research, which has suggested that even when resilience is demonstrated in ways that are not pro-social (Alessi et al., 2020), among vulnerable groups these qualities, characteristics, and resources should still be considered protective because they function in the place of pro-social protective factors that are not available. Findings on participants’ reliance on others for safety align with previous research on transgender populations, which has indicated that support from others can mitigate environmental risks (Bockting et al., 2013).

Participants also described access to gender-affirming health and mental health care as essential to their well-being while living and working on the streets. Participants suggested that the availability of gender-affirming health services, particularly hormone therapy, was a significant protective factor. Previous research has shown that living on the street can afford TGE youth opportunities to live as their authentic selves; opportunities that were unavailable while they were living with their families of origin (Alessi et al., 2020). The availability of and access to gender-affirming health care is an additional and significant asset for youth seeking to live authentically. In addition to describing the benefits of particular gender-affirming services (e.g., hormones) participants also highlighted the qualities of gender-affirming care providers that they perceived as essential to positive health and mental health care service experiences. This included providers who were TGE themselves or were knowledgeable allies. Finally, participants also mentioned the value of having access to group mental health services that were gender-affirming. Generally speaking, the positive appraisals of health and mental health services found in this study stand in contrast to TGE individuals’ appraisals of other types of services, which have tended to be negative (e.g., housing, employment; Grossman & D'Augelli, 2006). This contrast made the role of gender-affirming health and mental health care as a protective factor particularly apparent.

It was not surprising that sexual health would be an active issue among a sample of TGE youth who were homeless and engaged in survival sex. However, apparent from TGE youths’ own descriptions and understanding was that the proactivity toward caring for their sexual health extended far beyond simply contending with risks. For many participants, proactivity about their sexual health was demonstrated through condom use. This protective factor was supported by the widespread availability of condoms, a basic facilitator of sexual health, often accessible through various service providers. Even when participants described scenarios in which they did not use condoms, typically because they were able to make more money while trading sex, they still calculated the additional risks and tended to take steps to mitigate these risks. As many participants discussed concerns or fears about contracting HIV, it is important to contextualize these concerns and fears. The interviews in this study were conducted prior to the widespread availability of pre-exposure prophylaxis (PrEP), a daily oral medication used to prevent transmission of HIV, as well as before this drug was approved for adolescent use (Machado et al., 2017). Future studies should examine whether TGE youth engaged in survival sex now use PrEP as an additional method of proactively managing sexual health, as well as whether and how it is able to prevent HIV for this population. In addition to condom use, participants also described their diligence in getting tested for HIV and other STIs, and treating these conditions as necessary. Another way in which participants were proactive about their sexual health was to cultivate relationships with specific clients or specific types of clients. Considering social relationships with clients, which are inherently part of the risks posed to individuals engaged in survival sex, as protective certainly runs contrary to the ways in which protective factors are typically conceptualized (Werner, 1990), but it was apparent from participant responses that these social relationships could sometimes be beneficial.

Implications

This study yields several implications for research, policy, and practice. There continues to be a dearth in research concerning TGE populations. By focusing on a sample of TGE youth, the majority of whom were also racial or ethnic minorities, this study aimed to encourage future research to expand on its findings by continuing to study diverse TGE populations. Because few studies have examined the protective factors present in the lives of TGE youth living in vulnerable circumstances, future research should examine how such protective factors are related to health and mental health outcomes for TGE youth. Additionally, the growing recognition that functional protective factors for populations such as TGE youth may not always be considered pro-social should be accounted for in future research concerning the vulnerabilities and resilience of this population.

This research aimed to offer insights into the experiences of TGE youth who are homeless and engaged in survival sex beyond their vulnerabilities. However, it is essential to consider that youth develop protective factors, such as those found in this study, in the context of the many vulnerabilities they experience. There are a multitude of policies that should be examined to address these vulnerabilities. For example, findings demonstrated how access to gender-affirming health and mental health care contribute to TGE youths’ overall resilience, so an expansion of free and low-cost health and mental health services designed to meet the needs of diverse populations of vulnerable youth could serve to benefit TGE youth. As this research demonstrates, youth access such services when they are available. Additionally, the lack of legal protections for TGE youth, especially those who are homeless and engaged in survival sex is a notably absent protective factor. Policies such as those aimed at decriminalizing survival sex would allow TGE youth to rely on systems to protect them from violence instead of having to rely primarily on themselves or others to meet this need.

Previous research using the same sample of TGE homeless youth showed that they had difficulties with service systems, particularly housing and employment, due to barriers such discrimination and lack of appropriate resources (Alessi et al., 2020); however, this study’s finding that TGE youth tend to have positive appraisals of health and mental health care services when those services are gender-affirming suggests that models of care may contribute to these disparate relationships. It would be beneficial for service providers in other domains to examine what contributes to gender-affirming health and mental health service environments and attempt to employ appropriate strategies to ensure that a full range of services are available and accessible for TGE youth in need. Indicated from this research is that both free or affordable access to desired services (e.g., hormones, support groups), and the presence of gender-affirming providers are major contributors to the success of services in this domain.

Limitations

This study does have several limitations. The use of respondent-driven sampling is appropriate for hard-to-reach populations, such as TGE youth who are homeless and engaged in survival sex, but also limits the representativeness of the sample. In this study, the sample was specifically comprised of TGE youth who were located in a large, densely populated city in the northeastern United States. Future studies should explore whether findings about protective factors of TGE youth are transferable to other vulnerable populations in similar contexts or even TGE youth in other parts of the US. Another limitation is that data used in this study were collected between 2011-2012 and therefore the presence of certain protective factors may have changed over time. Continued research should explore whether and how these protective factors evolve. Finally, the majority of this sample identified as transgender women, and may have been less representative of the experiences of individuals with other TGE identities. Future research should aim to also include a more representative sample of transgender men, as well as TGE individuals with identities falling across the spectrum of non-cisgender identities.

Conclusion

This study offers preliminary insight into the protective factors that homeless TGE youth who are engaged in survival sex may have available to them, as described in their own words. Despite the presence of ongoing risks from their environments, the TGE youth in this study were still able to mitigate the effects of the risks that they faced using these self-described protective factors. Through their own behaviors and reliance on supportive peers and service providers, they were able to address major risks to their physical and mental well-being. Although few studies have considered the benefits of protective strategies that are not pro-social or are intertwined with risk, findings from this study emphasize that individuals in acutely vulnerable circumstances may need to rely on these types of protective factors and other nontraditional sources of strength.

Funding Statement

This manuscript was supported by Award No. 2016-MU-CX-K011, awarded by the National Institute of Justice, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this article are those of the authors and do not necessarily reflect those of the Department of Justice. Data collection was funded by a grant from the Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs, US Department of Justice, awarded to the Urban Institute in Washington, DC (2011-JF-FX-0001).

Declaration of conflict of interest

There were no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.