Housing insecurity and intersecting social determinants of health among transgender people in the USA: A targeted ethnography

Abstract

Background: Housing is an important social determinant of health (SDOH). Transgender people face a unique blend of discrimination and compromised social services, putting them at risk for housing insecurity and associated public health concerns.

Aims: This targeted ethnography explores housing insecurity as a SDOH among transgender people in the U.S.

Methods: In-depth interviews were conducted with transgender people (n = 41) throughout the U.S.A., identified through purposive sampling. A semi-structured guide was used to elicit personal stories and peer accounts of insecure housing experiences and coping strategies. Interviews were audio recorded and transcribed. Data was coded, sorted, and analyzed for key themes.

Results: Responses revealed pervasive housing insecurity and inter-related challenges. Respondents discussed how intersecting identities create unique constellations of vulnerability, which “intersect like a star.” Financial insecurity and interpersonal rejection were lead housing insecurity causes, often resulting in psychological strain, which was sometimes addressed with substances and sexual risk-taking. These factors were cyclically accompanied by financial and employment insecurity and a cascade of unmet social needs. Social support facilitated coping.

Discussion: Findings support increasing transgender housing security intervention resources that address intersecting and cyclical discrimination, trauma, housing, employment, and health issues.

Introduction

Access to safe, stable, quality housing is a fundamental human need. Housing is a key social determinant of physical and mental health (Flentje et al., 2016). Homelessness and housing insecurity are associated with a range of negative health outcomes, such as barriers to health care, increased utilization of acute-care services, violence victimization, stress, substance use, difficulty securing employment, and food insecurity (Ecker et al., 2019; Flentje et al., 2016; Hafeez et al., 2017; Ma et al., 2008). Transgender¹ people are more likely to experience housing insecurity and discrimination than their cisgender counterparts; thus, their health and well-being are at a greater risk of being compromised (Ecker et al., 2019; Fletcher et al., 2014; Logie et al., 2012).

Stable housing can be difficult for transgender people to secure due to family rejection, poverty and unemployment, and other discrimination related to being transgender (McBride, 2012). Transgender people experience higher rates of long-term housing insecurity and homelessness due to a lack of financial resources, social support, and other risk factors (Grant et al., 2011; James et al., 2016; McBride, 2012). Results of the U.S. Transgender Survey (USTS) the only national transgender survey in the U.S., show that 30% of respondents have experienced homelessness at some point in their lives due to being transgender (12% in year prior to taking survey) (James et al., 2016). At the time of the USTS, 0.53% of transgender people were experiencing homelessness, compared to 0.18% of general U.S. adults (Henry et al., 2016). Further, 9% of USTS respondents were temporarily living with friends or family because they could not afford their own housing. Transgender women of color experienced significantly higher rates of homelessness than their white and transgender male counterparts. In a separate study, 59.1% of transgender people who experience housing-related stress identified as sexual minorities (Henderson et al., 2019). The rate of homelessness nearly doubled for USTS respondents who have engaged in sex work, are living with HIV, have lost their job because of their transgender status, or had been kicked out of their home by their immediate family, as compared to respondents without these life histories (James et al., 2016). Transgender adults who experience homelessness encounter several challenges in the homelessness system, particularly in regard to safety and gender-affirming supports (Ecker et al., 2019).

It is well known that transgender people face exacerbated poverty and pervasive discrimination (Glick, Theall, et al., 2018; Grant et al., 2011; James et al., 2016), which can impact health and economic status. These social determinants of health (SDOH) intersect, and can limit one’s ability to rent or buy housing (Ecker et al., 2019). According to the USTS, unemployment rates among respondents (15%) were three times higher than the national average unemployment rate (5%). Transgender people of color (PoC) experience even higher rates of unemployment; nearly one-third of USTS respondents of color (29%) were living in poverty, more than twice the national average rate (12%). Transgender individuals were nearly four times less likely to own a home (16% compared to 63% of the U.S. population) (James et al., 2016). Other research indicates that in the early stages of the rental search process, housing providers discriminate against transgender people (Levy et al., 2017). Only 21 states and the District of Columbia prohibit housing discrimination based on sexual orientation and gender, while two additional states interpret existing policy to provide protections (Non-discrimination Laws, 2019; State Maps of Laws & Policies, 2019). Twenty-three percent of USTS respondents experienced some form of housing discrimination in the year prior to survey response, such as being evicted from their home or denied a home or apartment due to being transgender (James et al., 2016).

Homeless shelters and other short-term housing solutions can present additional barriers, discrimination, and can be unsafe re-traumatizing environments for transgender people (Grant et al., 2011; Rooney et al., 2016). Seventy percent of USTS respondents who stayed at a homeless shelter in the past year faced some form of mistreatment (James et al., 2016). Transgender people are often turned away from shelters because of their gender, or are required to stay in shelters based on their sex assigned at birth, putting these individuals at further risk of harassment, violence victimization, and prolonged housing insecurity (Grant et al., 2011; Rooney et al., 2016).

Intersectionality is a theoretical framework that attempts to identify how interlocking systems of power impact those who are most marginalized in society (Crenshaw, 1991), positing that multiple social identities (e.g., gender, race) intersect at the individual level to reflect interlocking systems of privilege and oppression (e.g., sexism, racism) at the structural level (Bowleg, 2012; Crenshaw, 1991) and elucidate how SDOH interact. Given the known health disparities among both transgender populations and racial and ethnic minorities (Abedin et al., 2018), it was imperative to utilize an intersectional framework to examine housing as a SDOH in this analysis. Using an intersectional framework illuminates why and how transgender PoC experience greater risks for acute and chronic negative housing outcomes (e.g., eviction, prolonged insecurity) based on their position in multi-axial social hierarchies relative to their white, cisgender counterparts. This qualitative study utilizes an intersectional framework to understand how transgender people experience and cope with housing insecurity, and how these experiences inextricably link to other issues, including health and employment.

Materials and methods

This study utilized targeted ethnography, a rapid ethnographic method used in public health and social science inquiry (Wainberg et al., 2007), consisting of in-depth interviews with transgender people, collected between March and May 2017. The research team consisted of two co-investigators (both white cisgender women, one queer) and two research assistants (a white queer cisgender woman and a latinx queer non-binary individual). The queer researchers were embedded in local and national queer and trans communities and social movement work. The team worked collaboratively throughout the project, including development of the interview guide, informal observation, collecting interviews, and conducting analysis. The two research assistants, who conducted all interviews, received sensitivity training on best practices for conducting qualitative interviews with people from diverse, under-served populations.

A semi-structured interview guide was developed for individual face-to-face interviews, based on pre-determined research questions informed by the literature. The guide consisted of four sections, covering: (1) demographic and socioeconomic information, (2) sexual orientation and gender identities, (3) early and current life stressors, and (4) healthcare-seeking stories. Data related to housing asked about: (1) homelessness and housing insecurity, (2) personal experiences and community accounts, (3) connections between housing insecurity and other life aspects, and (4) coping strategies. Pilot interviews were conducted to refine the guide prior to data collection and were not included in our results.

All transgender individuals 18 and older living in the U.S. were eligible. We conducted 41 semi-structured key-informant interviews; we utilized purposive and snowball sampling, including through collaborating organizations, transgender advocacy and support groups, and personal networks of participants and research staff. In-person interviews with participants in New Orleans, LA, where the study team was based, received a $30 Walgreens gift card and transportation support (parking pass or $5 gift card to cover public transportation costs); participants located elsewhere in the United States received a $30 Amazon gift card, and participated via Skype or Facetime. The research team had local and national resource referral guides available for participants and members of the community at large. Of note, one potential respondent declined participation during the consent process, not wanting to discuss the emotionally charged interview topics. Interviews continued until data saturation was reached.

Interviews, lasting 1-2 hours, were audio recorded and transcribed. Upon completion of data collection, transcripts were coded using NVIVO Version 11. Interviewers completed debrief forms after each interview, which served to ensure quality assurance, provide preliminary analysis of emergent themes, and guide codebook development. The initial codebook was developed a priori based on the research aims and in-vivo, as the analysis process progressed. Memos were written throughout this process to facilitate synthesis of findings. After completion of the initial coding process, secondary codes for the housing-related data were developed in-vivo. Housing data was sorted by respondent gender and race within the secondary coding structure, to allow for an intersectional analysis of the data. Six member checks were conducted, with individuals representing diversity concerning race, gender and geographic location. Results were summarized, and illustrative quotes were selected to underscore key points. The Tulane School of Public Health Institutional Review Board approved this study.

Results

Respondents utilized a wide range of labels to identify their genders, including transfeminine, transmasculine and non-binary or non-conforming language, as seen in Table 1. Respondents also reported a range of racial identifications (Table 1). Respondents ranged from 18 to 70 years old, with a mean age of 31 years. Respondents reported an array of sexual orientations including: queer (n = 16), straight (n = 6), pansexual (n = 5), bisexual (n = 3), no term (n = 3), gay (n = 2), asexual (n = 2), translesbian (n = 2), and heteroflexible/mostly hetero (n = 2). Participants were currently residing in the Gulf South (n = 17), Mid-West (n = 18), West Coast (n = 4), and Northeast regions (n = 2). One-third of respondents self-reported as lower or working class, and 2/3 as middle class. Sixty-three percent had completed some college or trade school, 20% some graduate education, and 12% some high school. Participants’ jobs/occupations varied widely from construction worker to medical doctor.

Table 1.

Genders and races of respondents.

Gender	n	Race	n
Transwoman	4	White	17
Male	4	Caucasian	4
Male, transmale	3	White, Caucasian	4
Genderqueer	3	Black	2
Gender non-conforming	3	African American	2
Female	2	Latina, Puerto Rican, white	1
Female, transfemale, transwoman	1	White, non-hispanic	1
Female, transgender female	1	Hispanic	1
Bigender	1	African American: black & Creole	1
Man, transman	1	“I don’t really like to subscribe to that”, Mixed- African, Indian, Asian, and British	1
Genderqueer man	1	African Indigenous, mixed ancestry Black, Native	1
Agender, bigender	1	White, Hispanic, Latinx	1
Transman, transmasculine, non-binary	1	Black, African American	1
Non-binary	1	White, Lebanese, Middle Eastern	1
Woman, femme woman	1	Unavailable- (not asked)	1
Child of God, trans- if forced to use a word	1	White, Latino	1
Transsexual	1	Mexican	1
Woman, lady	1
Transmasculine, transmale	1
Woman	1
Male, transgender male	1
Female to male, transgender man, transman	1
Transmasculine, non-binary	1
Transfeminine, transfemme, trans goddess	1
Non-binary, genderqueer, transman, transmasculine	1
Gender non-conforming, non-binary	1
Transwoman, woman	1
Transmasculine., genderqueer	1
Total	41	Total	41

Results are presented by theme, including: (1) housing, intersectionality and the social determinants of health, (2) pervasiveness of housing insecurity, (3) housing insecurity causes and buffers, (4) implications of housing insecurity, and (5) potential solutions. Themes are narratively summarized and illustrative quotes are offered where the respondent’s gender and race are presented in their own words.

Housing, intersectionality and the social determinants of health

Overwhelmingly, respondents discussed a wide range of struggles and obstacles in their lives, of which housing was just one.

My issue is housing. And my issue is also health care. And transportation. And money is an issue. So those are my issues…

Trans woman; African American: Black & Creole; 39

Respondents talked about the ways in which all of their struggles are interrelated.

Educational opportunities are a very big thing. If people haven’t had as many educational opportunities, that makes it harder to get anything beyond minimum wage. I know that’s a problem for a lot of people. A lot of people, including myself, during housing insecurity, have been dealing with the aftereffects of abuse, too. That’s a very big thing because it’s very hard to work if you’re having flashbacks or anxiety attacks all day long.

Trans woman; Racial identity unavailable²; 31

Participants also discussed the ways their identities intersect to create unique constellations of risk and challenge.

(Trans people) are so ostracized and demonized, they end up in these risk minority groups, you know - HIV positive, poor, homeless, ill, sex worker. All of those categories exist to other people - cis, older, white… they’re just not as implicated ‘cause it’s not intersecting like a star - you know, from all these directions.

Transsexual individual; African Indigenous-mixed ancestry, Black, Native; 23

Pervasiveness of housing insecurity

Housing insecurity is pervasive in transgender communities.

Pretty much everyone that I know - the majority of my friends are trans or gender nonconforming - and right now everyone’s rushing to find housing, and a lot of the stress is due to financial problems and trying to find places that we can afford. So, yeah, pretty much everyone is stressed out right now.

Man, trans man; white, Caucasian; 18

Experiences of housing insecurity ranged among respondents. Some people discussed moving frequently, staying with friends or relatives for short periods of time, living in hotels, sleeping in cars, squatting in abandoned buildings, and sleeping outside. For some people who had leased homes, the financial pressure of covering bills was continually weighing on them.

Being able to find work, and paying for a house, or even being able to go to a landlord and get a house on their own. A lot of people live with their boyfriends or girlfriends. If something goes wrong, they need to move out at a moment’s notice, and they’re on somebody’s couch.

Woman, lady; white; 32

Discrimination was discussed frequently, and often correlated with traumatic experiences. People shared stories of discrimination from current and potential landlords.

Two successive apartments that I lived in, I was kicked out for being transgender.

Trans woman, woman; white, Latino; 33

With housing, being trans is always a thing you have to worry about - it’s your home space and you want to be yourself. Housing is expensive pretty much everywhere. You have to think about roommates and, “Am I going to have to out myself?” Finding housing or applying for official housing applications as a trans person sucks because they pull up your official name change history, so that can lead to a lot of rejections. It just adds another layer with housing already being such a challenge for everybody.

Trans man, transmasculine, non-binary; white; 21

People also shared stories of discrimination from roommates.

We’re moving, definitely for sexuality-related reasons, and racist. Our roommate’s racist and a little bit homophobic and definitely classist.

Genderqueer individual; Latina, Puerto Rican, white; 25

Respondents discussed housing insecurity and living with partners; if relationships dissolve, that can lead to unexpected housing shifts. Many mentioned not being financially or emotionally prepared to live independently. Living with unstable friends and unsupportive family can also lead to precarious housing situations and a sense of insecurity.

Housing insecurity: causes and buffers

Intersecting challenges

The intersections of housing insecurity and various axes of identity emerge as uniquely salient and influential in different matters. Respondents most commonly articulated dynamics around gender identity, gender expression, “passing” (having others correctly perceive your gender), race, and class. Respondents discussed gender and how transfeminine and non-binary folks experienced disparate amounts of challenges compared to trans masculine people.

Every transfeminine person that I know has been homeless, is currently homeless, or in between… Most trans people I know have been homeless in some way, shape, or another. But the trans masc people have more stable housing…I think it’s because of transmisogyny, I guess it’s also maybe a class thing. I think also my transfeminine friends have to rely on each other more, and they’re heavily marginalized; it’s a community of people who have less access to resources.

Agender or bigender individual; Black; 26

My friends that are trans women have more struggle. Transmasculine friends definitely struggle but the world is less kind to trans women. Women in general already have to try harder to get well-paying work, and then if you are a trans woman, it makes it harder. Friends that are transfeminine tend to have less stable income and therefore less stable housing, unless they are in a relationship with someone who has stable housing.

Transmasculine, non-binary individual; white; 34

Respondents also discussed how gender expression and binary-gender “passing” relate to experiences procuring housing and accessing resources; for trans folks with binary gender identities, the ability to be read as their gender facilitates access.

Pretty privilege - like if you’re at least pleasing to the eye, if what you look like matches up with expectations of what you should look like, it’s just easier to get the shit you need.

Genderqueer individual; Latina, Puerto Rican, white; 25

For gender nonconforming people, “passing” is also a challenge.

When you are gender nonconforming, that makes it even much harder for you to find secure housing.

Transsexual individual; African Indigenous, mixed ancestry, Black, Native; 23

Some respondents discussed differing experiences by race and class.

It seems like my landlord and the people involved in property management are nicer to my neighbors who are all white people. And I do feel like they’re particularly rude and dismissive of me. Part of that may be because I have not gone through the world as a white person and so don’t tap into the power that maybe I do have…

Agender or bigender individual; Black; 26

Especially for trans women of color, that’s the population that I see with the biggest likelihood of housing insecurity … I think I have, to some degree, the economic privilege and race privilege and passing privilege that is an insulation against that personally.

Genderqueer individual, white; 28

Financial insecurity

Respondents discussed the interplay between financial security, housing, discrimination, and disparate access to resources. Many respondents cited educational limitations and their impact on financial literacy and employment opportunities.

So you’re never really offered this ability to grow. You’re kept out of higher education. You’re never taught how to make a resume, or how to fill out a housing application, how to build credit, how to open a bank account.

Woman, lady; white; 32

Passing, social rejection, mental health, and economic pressures were also discussed as factors that impact the type of employment attainable. Respondents discussed being limited to socially isolated jobs, the service industry and sex work.

I do feel like my employment options are limited. Either based on discrimination on the part of the person hiring or just my own anxiety about passing or not passing at work, makes it hard for me to keep a job.

Woman, femme woman; white; 28

It’s a bad cycle and you don’t really know where to step in. If you don’t have nice clothes, you can’t get a nice job, which means you can’t afford housing, which means you can’t afford nice clothes or food… I think the biggest thing in terms of housing is just getting people jobs. It’s really hard to find trans-affirmative employers. … And I think lots of people in the community have such bad mental health issues that having a stable job is hard.

Male, white; 25

Respondents across multiple urban areas (e.g., Pittsburgh, New Orleans, San Francisco) discussed how the economic ramifications of gentrification impact housing.

Social rejection and support

Gender-related rejection from social support networks, especially from family, lead to insecure housing and financial issues for respondents from youth to adulthood. Respondents also reported rejection from roommates and neighbors.

People who have access to wealth, white people, don’t have those issues … when my parents found out I was trans, my mom was like “That’s your decision but I don’t agree with it” and then my dad was like “You’re having an identity crisis” and they cut my phone off… versus my white trans-female roommate who’s parents still pay her phone bill, are paying for her surgery this summer, she stays there all the time, she still talks to them, her parents dole out money to her all the time. They’re helping me pay her rent when she leaves so I’m secure.

Transsexual individual; African Indigenous, mixed ancestry, Black, Native; 23

Social support systems, including intimate relationships, friendships, family—both birth family and chosen family—and community connections were all discussed. Access to these social resources varied widely.

Some people have family they can rely on. I don’t, and some of the trans people I know don’t and some do. Some get lucky and their families are super supportive and others are like disowned by their family completely.

Transmasculine, non-binary individual; white; 34

As many people reported stories of rejection from families of origin, the role of queer and chosen family becomes important.

I had my trans women who were friends of mine and also coworkers in the sex industry. We kind of had each other, that’s the only ones we had, you know, mainly my trans mom, she was my support system.

Trans woman; African American: Black & Creole; 39

I met an older trans woman who also was homeless who kind of took me in, took me under her wing, and built an alternative family structure with other homeless and queer teenagers and punk kids.

Woman, lady; white; 32

Sharing financial resources was facilitated in a variety of ways. Friends and families reportedly subsidized housing and life expenses as short- and long-term solutions. Some helped gather enough money for a security deposit or down payment to establish a lease or buy a home.

The Internet and social media play a facilitating role in resource sharing and community support; Facebook groups for queer-identified individuals connect people with resources.

A friend set up a system, people were donating $20, $30 to me a month and it was helping me augment rent. That has been the most actually helpful thing I’ve ever had, it’s just money, not having to worry about rent.

Transsexual individual; African Indigenous, mixed ancestry, Black, Native; 23

Respondents discussed the financial burden and pressure of supporting their friends and peers. Such interdependent dynamics can put pressure on existing relationships.

I think those of us who do have the means to put people up-are. Friends of mine who don’t have an income, who don’t have a place to stay on their own, are staying with people who do… I know two trans girls living together right now and one is just completely financially supporting the other because she doesn’t have any way to do that right now, and that’s a huge stress.

Woman, femme woman; white; 28

Shelters and housing support services

Many respondents discussed the limited capacity of shelters to meet the needs of transgender community members. A primary critique was that shelters often assign placement based on sex assigned at birth versus gender. For many, the ability to pass as their gender was significant. Non-binary individuals were ostracized from the often gender segregated shelter services. Respondents noted that such policies were particularly detrimental to trans women.

In St. Louis, we’ve had a lot of the shelters shut down by the city, and the shelters that are remaining - there’s still a lot of prejudice, especially against trans women, in terms of getting into those shelters. So definitely having more options would be helpful.

Trans woman; Racial identity unavailable; 31

Respondents noted that other factors, like race and age, correspond with increased housing access or barriers depending on the relative social privilege or marginalization of the identities.

Implications of housing insecurity

Insecure housing impacts ranged among participants and involved intersecting concerns.

When you don’t have the stability of a home you just feel lost. And trying to get your life together sometimes just is not that easy.

Genderqueer individual; Hispanic; 36

(Housing insecurity) makes hygiene a lot more difficult. It makes finding and maintaining work a lot more difficult. It’s a lot of stress. It’s a lot of interactions with police. It disrupts your ability to sleep well and soundly, which has a lot more deleterious effects on your health than people think. … it’s not like you can just relax if you’re homeless. You never really get to do that. After months of never really getting to relax, never really getting to take your time having a hot shower or bath, never having a constant place to go home to, it’s a lot of stress. Not knowing where your next meal is coming from, or if you’re going to get another one or trying to ration what you have – especially considering without a refrigerator – it really limits your food choices…

Trans woman, woman; white, Latino; 33

Many participants discussed the psycho-emotional toll of housing stress.

I’ve always been grateful when I’ve been in a tight spot if anybody’s been like here, you can have my couch, or you can sleep with me in my bed. But it’s just not stable. In order to stay centered and calm, there are certain things that I need, housing is definitely one of them. If I can’t go home and feel safe, then I’m just wandering around and become super erratic and much more anxious.

Genderqueer individual; Latina, Puerto Rican, white; 25

It was rough because you didn’t know what the next step was. But also you didn’t get no rest because you was always stressed just trying to figure out where you were gonna get this money from.

Child of God or trans, if forced to use a word; African American; 35

Respondents discussed the health and lifestyle impacts of their housing situations and solutions. Living with family members often came with more rules and less privacy. Some respondents noted difficulty cultivating sexual and intimate relationships from lack of privacy. Others discussed not feeling free to express their full-selves. An HIV-positive woman discussed adherence interruptions due to hiding medication from family.

Respondents highlighted intersecting social determinants of health and noted how insecure housing leads to insecure employment and finances, plus an array of access barriers and a cascade of unmet social needs.

Unstable housing makes a big difference in people’s ability to hold a job, to do what they need to do, to have healthcare, to keep healthcare, to keep appointments, to be able to even stay in the same city.

Genderqueer individual; white; 37

Respondents discussed how the pressures to make rent lead to non-ideal employment situations.

I had instead gotten a job that I didn’t like to pay rent at a place that I felt unwanted, to make sure that I was not homeless.

Female to male, transgender man, trans man; Black, African American; 24

Coping via substances and sex

Many respondents discussed using substances including alcohol, marijuana, and other drugs to cope with the stress of insecure housing.

I’m surprised sometimes about my friends’ abilities to party super hard while not having a place to live - but I guess it makes it easier - you don’t have to think as much. You’re just crashing from house to house.

Agender or bigender individual; Black; 26

One respondent highlighted that in certain cities with 24-hour establishments, drinking also provided shelter.

Being in New Orleans or New York, and you don’t have a place to stay and it’s raining or cold, so you stay in a 24-hour bar, and drink all night because that’s preferable to sleeping in the rain, or in the subway or something

Woman, lady; white; 32

Respondents also discussed the role of sex in coping with housing insecurity. Some people are seeking solace and stress release through sexual encounters, while others are depending on survival sex work to make extra income.

Girls are jumping in the car (sex work) so they can make money… Now you’re gonna go look for drugs so you don’t feel bad, you gonna search for love. Probably gonna have sex with someone who’s not taking care of themselves, and then you’re not taking care of yourself, and everybody’s just kinda - you know - spreading this shit around.

Trans woman; African American: Black & Creole; 39

Solutions

Respondents raised the importance of transgender inclusive or specific housing in addressing housing insecurity, sharing stories of collectively established homes and shelter projects.

A trans and gender nonconforming house. A big halfway house for the dolls and kids, so they can be comfortable. Run by us, so that they can see people who are just like them, that we have some of the same struggles, but some of us have it more together. If we can get into a space that really allows us to take care of one another it would be much easier.… the trans community don’t really trust the people running things, the mainstream gay men that are over these CBOs. Something for us, by us.

Trans woman; African American: Black & Creole; 39

They’re not an official organization, but an entity of trans guys bought a house and they rent it out for super cheap to other trans and gender non-conforming adults. If someone needs emergency housing, it’s there. If they need a place for longer while they look for a job or build up income, it’s there.

Male, trans male; white, Caucasian; 32

Respondents offered many solution ideas, critiqued the ways services are currently provided, and discussed that even temporary housing solutions won’t address the underlying problem of living in a transphobic world.

We’re gonna need a radical breakdown of all this…we have to just strip transphobia from life because it’s like here’s your food stamps, housing voucher, bus tokens and the outcomes of their lives are still similar to people living under the bridge, who might actually have a much wider social net from being able to congregate together and share experience.

Male, transgender male; white, Hispanic, Latinx; 33

Respondents shared additional ideas about structural level solutions, including universal livable minimum wages and societal prioritization of housing and well-being over profit. Many respondents discussed the pervasive trauma and discrimination faced by the community and the importance of utilizing trauma- informed care models across services.

Discussion

This study examined housing insecurity among transgender individuals through an intersectional, SDOH lens. Housing insecurity was a pervasive issue for respondents and their peers, among many inter-related challenges. The interconnectedness of these issues was a clear finding, and one that warrants more consideration in determining how to approach housing, public health, and overall well-being interventions for this population. Respondents discussed the ways their diverse identities intersect to create unique constellations of risk and challenge. Common factors were identified and can be targeted in programing and policy aimed at improving housing among this population.

While research exploring this topic has historically been limited, our study corroborates emerging literature demonstrating the pervasiveness of homelessness and housing insecurity among this population (Anderson-Carpenter et al., 2017; Bradford et al., 2013; Fletcher et al., 2014; James et al., 2016; Schick et al., 2019). Similarly, these findings support other work demonstrating the intersecting relationship between housing and other SDOH (Wahowiak, 2016), although this relationship has been less explored among transgender populations. Further, the multiplicative nature of intersectional adversity is well established (Bowleg, 2012; Sun et al., 2018) and therefore intersectional-systems thinking approaches can be useful in designing interventions to address homelessness in LGBTIQ + communities (Fraser et al., 2019). There are numerous examples of promising housing programs and policies (Dickson-Gomez et al., 2011; Sanbonmatsu et al., 2011; Wolitski et al., 2010) that may also be employed and tested in this population.

Discrimination and interpersonal rejection, were overwhelmingly cited as lead causes of housing insecurity. The overall pervasiveness of discrimination and its tolls on transgender populations is well established (Glick, Andrinopoulos, et al., 2018; Glick, Theall, et al., 2018; Grant et al., 2011; James et al., 2016). Transgender people face higher rates of childhood trauma, PSTD, and other mental health issues than the general population, seemingly due to living in a transphobic world (Gehring & Knudson, 2005; Reisner et al., 2016). Interpersonal and family rejection is also high in this population and associated with negative health outcomes (Klein & Golub, 2016). Transgender youth make up a disproportionate amount of the clients served by youth homeless programs compared to their cisgender counterparts (Choi et al., 2015; Durso & Gates, 2012). Any interventions aiming to address the many lifetime obstacles this population faces in securing a stable healthy life should utilize a trauma-informed approach (Hall & DeLaney, 2019). Emerging intervention research with transgender individuals involves trauma-informed psychotherapy (Bess & Stabb, 2009), dialectical behavior therapy (Sloan et al., 2017), embracing self-worth (Singh et al., 2011), and can include work with psychedelic therapy (Scheer & Poteat, 2018; Sevelius, 2019). Further, targeted approaches may include not only enactment of anti-discrimination or human rights laws, but support for putting them into practice. For example, having websites or social media that provide a toll-free telephone number, offer services, or provides public education and materials to affected individuals but also to others who may be discriminating, in an effort to educate them about what actions constitute unlawful discrimination.

Financial limitations, frequently tied to discrimination, were also frequently discussed by participants. The disproportionate poverty faced by this population (James et al., 2016) exacerbates housing insecurity. Compared with their white and cisgender counterparts, Transgender PoC face greater risks, compounded by both race and gender oppression, for systemic disenfranchisement from financial opportunities (e.g. employment) as well as health and social services where permanent housing is a prerequisite to access, which can further obstruct future access to stable housing(Glick et al., 2019; Hudson, 2019; Wesp et al., 2019). Housing instability may be addressed, in part, through employment and financial support programs, tailored to the needs of the transgender population.

Another approach to addressing housing insecurity is to bolster the buffers that reduce the psychological toll of housing stress, additional burdens to economic and employment security, and a cascade of unmet social needs. Social support was commonly cited as a coping strategy by study respondents, therefore strategies to ensure and strengthen social support should be considered (Hogan et al., 2002). Resilience in the face of great adversity is a documented attribute of transgender populations (Bockting et al., 2013), was evident in our study sample, and should be incorporated into all housing and well-being support programs for transgender populations. This could include enhancing resilience skills and incorporating transgender people who already exhibit such proficiencies, into program development, service provision, and funding opportunities.

Existing housing services (e.g., shelters) are intended to alleviate some of the crisis burden, however, study participants shared stories to the contrary. It is known that shelters are common sites of discrimination and failed service provision. Transgender people avoid staying in shelters for fear of gender-related discrimination and mistreatment (James et al., 2016). Previous data shows that those who do access shelter services report high rates of mistreatment (70%) including verbal harassment and physical and sexual assault (52%), rejection because of their gender (9%), or being forced to present as the wrong gender to access services (14%) (James et al., 2016). Policy level change is necessary to expand protections for transgender people accessing housing. Such change can include passing the American Housing and Economic Mobility Act (“American Housing and Economic Mobility Act – 116th Congress”), Equality Act, and/or comprehensive nondiscrimination legislation to ensure that transgender people are protected from discrimination in housing, public accommodations, employment, education, etc. (Rooney et al., 2016). Further, amendments to the U.S. Department of Housing and Urban Development’s equal access rule which ensure that individuals have the right to be housed according to their gender (HUD, 2016) must be enforced and protected, as they are currently under attack (Hananel, 2019).

Respondents offered solutions ranging from individual to structural level changes, and all levels of intervention warrant further consideration and resources. Sustainable solutions require multi-level interventions, providing resilience-promoting support to transgender individuals, delivering transgender-competent emergency services, supporting existing community-developed resources, and working to address societal level transphobia via policy interventions. Grassroots-level responses to these issues exist throughout the country, including transgender cooperative led housing, social media housing forums (Fitzpatrick, 2017), and crowdfunding efforts for gender-affirming medical care (Barcelos & Budge, 2019). Public health professionals should be supporting the sustainability of these projects.

The current study has several strengths. First, research related to transgender populations and housing is limited, and this article helps to fill that gap. Second, the sample includes diversity of gender experiences, including trans-feminine, trans-masculine, and non-binary people. Last, the qualitative approach offers nuanced understandings and may be useful in exploring housing insecurity in transgender sub-populations and other groups facing rampant discrimination. One limitation was the relatively small proportion of PoC in the sample. While we acknowledge the exponential disparities at the intersections of race and gender, we were not able to systematically explore it within this sample. While there was diversity in gender, age, class, and education, limited racial diversity may have concealed further findings. Future research should oversample PoC. Second, the qualitative nature of the analysis did not allow us to look for trends across multiple demographic factors, which may have masked diversity, for example we did not analyze based on age, which may have masked a cohort effect. Further, the geographic diversity in the sample was mostly urban, and rural experiences may differ.

Conclusion

This study examined housing insecurity through an intersectional SDOH lens among transgender adults in the U.S. Gender and racially diverse respondents discussed the ways their unique identities intersect to create unique constellations of risk and obstacles in accessing stable housing and employment. Findings support a need for increased research on this topic; multi-level programmatic responses to transgender housing insecurity; trauma-informed interventions that address the interconnected and cyclical discrimination, trauma, housing, employment, and health issues faced by this population; and societal transformations to remove the systemic transphobia and racism negatively impacting the daily lives of transgender people.

Funding Statement

This study was supported by grants from the National Institutes on Alcohol Abuse and Alcoholism (NIAAA) (P60AA009803), and the Drug Dependence Epidemiology Training Program, NIH/NIDA (T32DA007292).

Declaration of conflict of interest

The authors state that they have no conflicts of interest to declare.