A narrative exploration of the importance of intersectionality in a Black trans woman’s mental health experiences

Abstract

Background: The current United States presidential administration’s statements and policies have, in a shockingly short time, catastrophically affected people of color and LGBTQIA + communities. And although these numerous discriminatory policies and policy revisions have negatively affected both US people of color and LGBTQIA + people, trans women of color have been disproportionately affected. Even more specifically, when focusing on vulnerability to violence—including murder—it is Black trans women who are most directly affected by the intersections of transphobia and racism in the US. This article explores a Black trans woman’s experiences with mental health professionals across two decades and different regions of the US.

Aims: This article argues for the necessity of understanding trans people’s mental health experiences as necessarily intersectional, in order to more fully appreciate and address the degrees to which factors such as race, socioeconomic class, and geographic context matter in trans people’s efforts to access ethical and effective mental healthcare.

Methods: Using a theoretical framework informed by Kimberlé Crenshaw’s single-axis concept, the authors fully center Aryah’s intersectional experiences and counter a single-axis in exploring trans mental health issues, our article relies on a narrative-based approach. As narrative inquiry is a broad field, we selected Butler-Kisber’s narrative analytic approach, “Starting with the Story” as our method. The narratives are pulled from approximately 10 intensive qualitative interviews over the course of several months.

Discussion: These narratives disrupt the common threads in the literature that ignore the degrees to which race and class matter alongside being a trans woman. In addition, as we noted that nearly all of the mental health literature relied on large-scale survey-based data, this article offers a qualitative narrative exploration of Aryah’s experiences and works to humanize trans mental health challenges and needs, while emphasizing the multilayered oppressions and obstacles that affected Aryah.

The current United States presidential administration’s statements and policies have, in a shockingly short time, catastrophically affected people of color and LGBTQIA+¹ communities. In approximately four years, “Trump has assembled a long record of comment on issues involving African Americans as well as Mexicans, Hispanics more broadly, Native Americans, Muslims, Jews, immigrants” that have worked to villainize people of color, thereby normalizing racialized, particularly anti-Black, violence across the nation (Graham et al., 2019, n.p.). Simultaneously, Trump and staff, including the Department of Justice, the Department of Education, and the Health and Human Services Office for Civil Rights, have actively dismantled numerous protections for LGBTQIA+-identifying individuals—particularly transgender people (Kodjak & Wroth, 2019; National Center for Transgender Equality, 2019a). These rollbacks have eroded or erased equal access to school facilities, affordable housing, and healthcare (Alonso-Zaldivar, 2019; Lovelace, 2019).

And while these numerous discriminatory policies and policy revisions have negatively affected both US people of color and LGBTQIA + people, trans women of color have been disproportionately impacted (GLAAD, 2019; Human Rights Campaign, 2019). Even more specifically, when focusing on vulnerability to violence—including murder—it is Black trans women who are most directly affected by the intersections of transphobia and racism in the US (Carpenter & Marshall, 2017; DC Trans Coalition, 2015; Dunlevy, 2019). These constant life-or-death realities, along with routine denials of basic human rights, take substantial tolls on Black trans women’s mental health (Schreiber, 2016; Steele et al., 2017; Wilson et al., 2016). And as these events and their effects have reverberated across the nation and many trans women’s lives, academic scholarship has worked to catch up with the shifting political, social, and personal landscapes. This special issue is vital to society-at-large and academia specifically, in featuring necessary discussions of these topics. In exploring these topics and reviewing relevant literature, we focused on our guiding research question:

How does a Black trans woman’s experiences with mental health resources relate to the intersections of her trans and racial identities and her socioeconomic status?

This question was formed from the authors’ longstanding friendship, the second author’s personal experiences as a Black trans woman, and our sociopolitical geographic context. Even as a range of shifts have negatively affected trans women across the US, there have been deeper reverberations and dire ramifications in the US Southeast.

We authors have known one another since fifth grade, for over 30 years, and we have written together about topics affecting trans people within this specific US region (Lester, 2018; Shelton & Lester, 2016, 2018). The US’s Southeast—or the “Bible Belt” as it is sometimes called, due to the degrees that socio-politically conservative Judeo-Christian beliefs shape the region—has long been our home. We are well aware of how conservative religious beliefs have historically and currently been associated with racist, sexist, and anti-LGBTQIA + legislation and policies (Garcia, 2016; Polaski, 2019). As a result of this political climate, GLSEN determined in the first and only national survey intersecting LGBTQIA + identities with living in the US South that, though there were nationwide anti-LGBTQIA + sentiments, the consequences of those stances are amplified and typically more severe in the Southeast (GLSEN, 2012). It is in this region that we situate this research.

Based on second author Aryah’s experiences, we center discussions of mental health in relation to trans people, and more specifically, trans women. In addition, given our research question, we wanted to learn how researchers took up these considerations as connected to issues of race and socioeconomics, and their saliency to trans issues and to our geographic context. While the goal was to examine these elements as interconnected in order to contextualize this article’s focus within larger bodies of literature, we found that many scholars’ discussions of trans people’s mental health omitted specific discussions of trans women, or neglected considerations of race or class. In addition to these limitations, we noted that most studies relied on quantitative survey-based research; these approaches were valuable but were not designed to consider mental health resource needs based on individual experiences of what it means to seek mental health support as a Black trans woman in the US.

Literature review

Guided by the research question, we began our literature review by specifically seeking scholarship that considered mental health in relation to trans women of color. There was a substantial body of research exploring trans people’s mental health, with a wide range of foci. Many studies centered trans adolescents’ mental health needs (Baiden et al., 2020; Johnson et al., 2020; Price-Feeney et al., 2020), including ways that contemporary uses of social media negatively and positively shaped mental health (Selkie et al., 2020). Because this article emphasized adult experiences and needs, we shifted our exploration away from these discussions.

Trans adults and mental health

In the substantial discussions of trans adults, there were wide ranges of ways that scholars considered mental health topics. Relative to the opening of this article alluding to the effects of discriminatory national policy shifts, literature included considerations of ways that factors such as barriers to child adoption (Goldberg et al., 2019), religious discrimination (Kim, 2017), and unequal housing access (Beltran et al., 2019) impacted trans individuals’ mental health. Other studies explored how specific experiences or contexts shaped mental health needs. These included working to understand trans military veterans’ treatment needs (Aboussouan et al., 2019), particularly in terms of suicidal ideation; incarcerated adults’ access to mental health resources (Henry, 2020); and degrees of support for asylum-seeking refugees (Byrow et al., 2020). Though race and class were often implicit aspects of some of these studies, given the often-racialized and class-based aspects of incarceration and refugee status, for example, we noted that many of these studies offered little or no explicit discussions of the ways that race and class mattered.

In addition, we noted that many studies focused on trans people as members of a wider LGBTQIA + community. For example, a 2015 examination of mental health services in Ontario, Canada (Simeonov et al., 2015) focused on “lesbian, gay, bisexual, transgender, and transsexual communities” (p. 31). Similarly, while Steele et al. (2017) explored issues of depression in “trans-identified people” (p. 116), the participant sampling included a range of LGBTQIA + individuals and cisgender women. Satuluri and Nadal (2018) examined mental health specifically in relation to people’s perceptions of law enforcement, but again used a “LGBTQ perceptions” umbrella as a means of analysis (p. 43). These studies are valuable in showing the degrees to which mental health is an essential need for many in LGBTQIA + communities, but they do not provide insight into trans individuals’ unique experiences and specific needs. And, as with other bodies of literature, they offered few explicit discussions of race and class—particularly in relation to trans people’s needs.

When studies specifically focused on trans individuals, they usually did so without particular considerations of trans women’s gendered experiences. Rather, these article explored transgender experiences and needs broadly, including mental health needs in relation to “transgender stigma” in society and mental health fields (King & Hughto, 2019, p. 1; see also Bockting et al., 2013; Kattari et al., 2019; Logie et al., 2020; Perez-Brumer et al., 2018). Greater considerations of trans people’s needs are important, and scholarship inclusive of many trans individuals’ experiences provide useful ways to consider ways that realities such as transphobia and cisnormativity shape mental health services. However, trans women are affected by these elements while also facing realities such as misogyny and sexism differently than other trans people (Human Rights Campaign, 2019). Thus, the trend in literature to group trans women with trans people at-large potentially erases some of the ways that their experiences uniquely shape mental health resource needs. In addition, as before, these studies rarely included detailed considerations of race and class as relevant factors; these omissions of gender, race, and class provide incomplete discussions.

The implication of these exclusions is that they sometimes presented limited, and even problematic, discussions of trans people and mental health. For example, numerous researchers considered the implications of mental health services in addressing substance abuse (Holt et al., 2018; Swann et al., 2020; Valentine & Shipherd, 2018), without necessarily examining the ways that gender-, class-, and/or race-based realities might have played roles both in participants’ addictions and in difficulties accessing interventions. Others explored mental health in relation to sexually transmitted infections, including HIV (Hines et al., 2017; Logie et al., 2018; Munro et al., 2017), with attention to the quality of the mental health services, but with no considerations of the multidimensional factors contributing to patients’ health or healthcare access, in terms of healthcare cost concerns, or of gendered and racialized barriers in mental health. To be clear, it was not that these studies were not valuable; it was that they were incomplete. Trans women, and more specifically trans women of color, were either absent from this literature, or their unique experiences were elided by broader discussions of trans people’s mental health topics.

Trans women of color and mental health

Given our research question’s specific emphases, we worked to refine our literature review so that we might situate this article within scholarship that moved beyond the more generalized discussions of trans people that we had found. When we narrowed our search, however, there was far less literature explicitly exploring trans women’s of color mental health access, experiences, and needs. A substantial portion of this literature was large-scale quantitative research, and while many of these studies did include gender identity and racial identity in the data collection, the research methods did not necessarily extend to discussions on trans women of color. Instead, trans populations were regularly, and often necessarily, designated statistical minorities (e.g., Brennan et al., 2017; Lefevor et al., 2019; Swann et al., 2020), which regularly meant that researchers omitted trans people’s racial identities from their findings, in order to prevent making even smaller respondent groups within the study.

When literature did factor in race, much like the ways that trans people are subsumed under the LGBTQIA + umbrella, participants’ trans identities were often absorbed into examinations of race and mental health (e.g., Cokley et al., 2013; Lazarevic et al., 2018). The effect was that, rather than considering what it means to be, for example, Black and trans, studies’ foci regularly became how being Black mattered, with trans identity in the margins, or vice versa. Almost no studies explored what mental health might mean to someone who was Black and trans and a woman. Those intersections of identities were generally excluded, despite constant reminders in media news cycles that those elements matter collectively (Carpenter & Marshall, 2017; DC Trans Coalition, 2015; Dunlevy, 2019).

There were few but highly valuable discussions of mental health specifically in relation to trans women of color. Budge et al. (2016) offered a rare and necessary perspective in their examination of a range of factors, including socioeconomics, race, and sexual orientation, influencing trans people’s access to mental health—including organizing their findings to focus specifically on trans women. They noted in their discussion, as we also found, that “trans populations [are] often treated as one homogenous group” (p. 1036), making it near-impossible to actually ascertain how mental health might matter across trans subgroups, including trans women of color. When researchers focused specifically on trans women of color, what they learned was that the links between gender and race mattered substantially in mental health needs and access. Unsurprisingly but importantly, “the dual impact of gender and racial minority marginalization” directly shaped what these women needed, sought, and were able to access in relation to mental health (Restar et al., 2019, p. 164). In addition, emphasis on gender and race demonstrated that the combination of both heightened women’s experiences with and self-internalization of transmisogyny, thereby limiting the degrees to which mental health services addressed their needs (Hudson, 2019; Matsuzaka & Koch, 2019). These studies emphasized the substantial effects of acknowledging and including multifaceted identities in discussions of mental health services. However, even most of this literature omitted the socioeconomic realities that affect trans women’s of color efforts to navigate mental health resources. Bolivar (2017) alone explicitly engaged with the “triple threat of sexism, racism, and classism” that affects trans women of color (p. 323); however, this paper was not specifically focused on mental health topics. Bolivar’s discussion of police brutalization of trans Latina sex workers unquestionably relates to mental health needs, but the paper was an indictment of law enforcement’s transphobic, racist, and classist violence rather than a paper on mental or emotional resources.

Within this extensive, disparate, and at times limited body of literature, this article works to continue to center trans people’s experiences with mental health access, while simultaneously incorporating discussions of race and class as salient, and focusing on the implications of living in a specific sociopolitical context. We focus on Aryah, this article’s second author and a Black trans woman of color. Her narratives disrupt the common threads in the literature that ignore the degrees to which race and class matter alongside being a trans woman. In addition, as we noted that nearly all of the mental health literature relied on large-scale survey-based data, this article offers a qualitative narrative exploration of Aryah’s experiences. This approach works to humanize trans mental health challenges and needs, while emphasizing the multilayered oppressions and obstacles that affected Aryah.

Theoretical framework

Because one focus of this article is to explore the ways that race and class intersect with being a trans woman, our perspective is informed by Crenshaw’s concept of “intersectionality” (Crenshaw, 1989). Briefly, intersectionality examines the interconnectedness of people’s multifaceted identities within systems of privilege and oppression. Crenshaw argued that it was impossible to discuss sexism without simultaneously acknowledging the ways that “[r]ace, gender, and other identity categories” matter, too (Crenshaw, 1991, p. 1242). As part of her discussion of intersectionality, Crenshaw (1989) introduced the concept of a “single-axis framework” (p. 139), which we adopt as our theoretical lens.

The single-axis framework considers the implications of many well-meaning and social justice-minded individuals ignoring the multidimensional natures of individuals’ experiences and identities and reducing those experiences and identities to “a single categorical axis” that unintentionally but undeniably erases other equally salient identity elements (Crenshaw, 2004, p. 140). For example, Valentine and Shipherd (2018) in-depth review of mental health “among transgender and gender non-conforming people” focused on the single-axis of “gender identity” (p. 24). Though well-intentioned research, this approach ignored the ways that factors such as poverty and racism might affect individuals’ needs for and access to mental health services, and ultimately excluded the unique and intersectional needs that someone like Aryah might need as a Black trans woman.

Method: collaborative narratives

To fully center Aryah’s intersectional experiences and counter a single-axis in exploring trans mental health issues, our article relies on a narrative-based approach. Narrative offers a “distinctive way of thinking and understanding that is unique and embodied” and situates individual experiences within wider cultural contexts (Butler-Kisber, 2018, p. 73; see also Bruner, 1986). The focus on individual experiences aligns well with the theoretical framework’s social justice orientation, as narratives “bring the previously silenced stories of women […] from the margins to the centre” while shifting “voice, power, interpretation, and representation” in ways that empower participants (p. 73).

Narrative analysis: starting with the story

As narrative inquiry is a broad field, we selected Butler-Kisber’s narrative analytic approach, “Starting with the Story” as our method (Butler-Kisber, 2018, p. 81), because it aligned well with our collaborative research approach. This method began with “intensive interviewing to examine how interviewees use language to construct meaning and make sense of their personal lives” (p. 75). As we mentioned earlier, we have known one another for decades, so the interviews began broadly, with Stephanie asking Aryah about her experiences as a Black trans woman over various years. Over the course of months of interviews, approximately ten total with each an hour or longer, we mutually agreed that Aryah’s narratives concerning mental health needs and resources were particularly important, both to her personally and to discussions of Black trans women more generally.

With this narrowed focus, we constructed the aforementioned research question, and Stephanie interviewed Aryah specifically in relation to Aryah’s mental health experiences as a Black trans woman living in the Southeastern US. Stephanie used phenomenological narrative interviewing (deMarrais, 2004; Shelton, 2014). This interviewing technique is specifically designed to encourage detailed narrative responses and to make the participant’s experiences the basis of the interview itself. The interview protocol had a single question, “Think of an experience that you have had, as a Black trans woman, that related to mental health needs. Could you describe that experience in as much detail as possible?,” which Stephanie asked multiple times, to provide Aryah opportunities to apply the question to various moments of her life. The majority of the interview used Aryah’s responses as the basis of extensive follow-up questions. Importantly, due to our longstanding friendship, the interviews were relaxed and friendly, though we had a co-determined research purpose for them.

Following these interviews, Stephanie transcribed Aryah’s narratives and then reconvened with Aryah to collaboratively analyze them. Butler-Kisber (2018) notes that the narrative analytic approach of “Starting with the Story” is “highly dependent on trusting relationships developed between the researcher and participant(s)” (p. 81). These relationships are essential because this approach necessarily disrupts the researcher’s autonomy and control over the data analysis process. Regularly, researchers describe member checking processes following interviews and transcriptions, but this approach actively integrates the participant throughout as a fellow researcher—not as simply a source of research data. “Starting with the Story” meant not just starting with Aryah’s narratives, but involving Aryah directly in considerations “of how each [narrative] pertained to” the research question (p. 83).

Working together, we “selected portions of the transcribed texts” that seemed to both of us and especially Aryah, particularly salient to both her life experiences and the research purpose. With those participant-directed decisions, we recognized that space limitations would “not permit a full recounting” of the narratives (p. 84), so worked to edit the narratives to preserve Aryah’s intentions, the narratives’ coherence, a connection to the single-axis theoretical framework, and an overall response to the guiding research question. Ultimately, we chose three that best fit these aims. These narratives were written in first-person, not only because that approach “adher[ed] as closely as possible to the words and sense expressed by the participant,” but also because first-person “foreground[ed Aryah’s] voice and perspectives” as the point of the research (p. 83). The entirety of this manuscript, including the section Findings, was co-written, with Aryah not just reviewing ways that her narratives were presented but being actively involved in how they would be constructed, ordered, and discussed. The goal was to shift Aryah from being researched to being a collaborating researcher.

Research identities and subjectivities

As already noted, Aryah identifies as a Black trans woman. She currently works with a national trans advocacy organization in the Southeast. Stephanie identifies as a White cisgender lesbian, and is a university researcher living in Alabama, often considered one of, if not the, most racist and anti-LGBTQIA + state in the region. We both regularly—and often, such as here, collaboratively—conduct research, share findings, and educate others on LGBTQIA + issues, including emphases on trans people, and particularly trans people of color. Our multiple identities—as LGBTQIA + people, as US Southerners, as friends, and as collaborative educators, researchers, and writers shaped the entirety of this project, from inception to this article.

Trustworthiness

We recognize that while subjectivity is a standard element of qualitative research, projects such as ours, which rely on memory work and collective writing, are “intersubjective” (Onyx & Small, 2001, p. 781). Intersubjectivity is a concept that acknowledges collectively constructed scholarship such as ours, and the complexities that arise through our collaboration, due to our relationship, individual and shared perspectives, and biases. To strengthen our work, we drew on sections of Kornbluh’s (2015) discussion of trustworthiness in qualitative research throughout our writing process. First, Kornbluh emphasizes transparency, both in the research/writing process and in sharing the research (p. 397). We worked diligently to openly share with one another throughout our work, and, with the previous section, to make our research process clear to others. Second, Kornbluh notes the importance of “being open to change” as a part of collaboration and member checking (p. 397), which we took seriously in our many months of discussions and sharing, as we made edits to various sections based on our feedback to one another. As part of those efforts, when possible, we corroborated Aryah’s narratives with various documents and memories that we shared, both to include specific details in the narratives and to provide additional accountability, separately and collectively. The overall effort was to acknowledge that our approach is steeped in personal experiences, while offering transparency to increase trustworthiness.

Findings

As we considered how to organize the narratives, we selected a chronological approach. We begin with an experience Aryah had in high school, then move to two key points in adulthood, all relative to mental health. This approach allowed us to show the intersections between her identities and her experiences as a Black trans woman, as well as the ways that these needs remained relevant over time.

High school and sugar intake

I (Aryah) felt trapped. For years, I had been admonished on playgrounds and in church to “act like a boy.” Beginning in middle school, I had begun to quietly pack feminine clothing into my bookbag, so that I might unpack my authentic self for the school day, and then stuff remnants of myself back into the satchel before climbing on the school bus each afternoon. For a time, school had been a relatively safe place for me, made all the more so by an ardently religious homelife that offered no understanding for who I knew I was. However, even at school there was no full recognition of my authentic self, as teachers and peers, including Stephanie, merely attributed my clothing, mannerisms, and painted nails—which had to be scrubbed clean each afternoon—to my personality. Multiple years of packing and unpacking pieces of myself Monday through Friday, while keeping other portions completely hidden, took its toll.

Severely depressed, I confided in a school counselor, desperate for words and understandings to help me articulate who I was and what was wrong. Slumped in an uncomfortable, creaking plastic chair, teenage me quietly asked, “Can you help me with my struggles to understand myself?” Retrospectively, I recognize the moment was a brave one: a teenager independently asking for help, knowing the likelihood of family and peer rejection. However, despite my desperation, the counselor actively avoided discussing gender identity and expression. Instead, she asked, “How is your diet? What do you eat on a normal day?” The remainder of the session turned into a lecture about how my daily intake of various nutrients was creating “bipolar tendencies.” The session ended with me being assured that my self-reproach, depression, and desperate efforts to understand myself were simply “a matter of eating too much or little sugar.”

Single-axis analysis

When we revisited this moment, one that we have discussed numerous times, the theoretical emphasis on single-axis understandings gave us new insight. Certainly, this was an instance when a youth’s plea for help not only went unanswered but was trivialized. Many mental health professionals continue to avoid or pathologize gender identity (Haynes, 2019; Lewis, 2019), just this one did by shifting emphasis from gender to the presumably neutral topic of dietary habits. However, even we, when revisiting this moment had not fully taken into account ways that race and class mattered.

Both of us grew up in low-income families, and we met in gifted education classes. These two factors mattered relative to Aryah, simply because they were additional ways that she was isolated and stripped of resources. Though our school system was majority Black students, there were few students of color in the gifted program; additionally, there were few low-income students in the program. Aryah was isolated because of all that was happening internally and externally, but her class status and racial identity further separated her from peers. She had felt alone, and in looking back, we realize that when taking into account the myriad, intersecting elements of her identity, she truly was alone. She was wholly unique and isolated, in a classroom full of peers. That social separation as a teenager, coupled with reductive mental health resources that deemed her issue a matter of sugar levels, left her trapped in a socially mandated performance of masculinity, as she continued to “act like a boy” at the behest of others.

Early twenties and an “unsafe” work environment

After a similar experience with a college psychologist, I moved out of the Southeast to New York and began working for a nonprofit that served workers displaced by the 9-11 terrorist attacks. I was in a state with substantially more protections for trans and gender nonconforming people, and for the first time, my driver’s license read “female.” Because my identification reflected that I was a woman, I did not have to apply for my position as a trans person; I earned it as a woman who was qualified, and it was one that I enjoyed and performed well. After such negative experiences as a teenager, my life was wonderful—I was my authentic self, living in a region that offered substantially greater protections and resources, and I had a rewarding career.

Then my grandfather died. Because he was not considered immediate family and I would need to travel back to the South for the funeral, I talked with Human Resources (HR) about bereavement leave. While I met with an HR Officer, I mentioned being trans—after all, that part of me was no longer secret or confusing. The Officer assured me that taking time off to attend the funeral “wouldn’t be a problem.” I left to grieve my grandfather, anticipating no issues. However, when I returned, the manager told me, “You can’t return again until after you’ve had a psych [psychiatric] review. Until then, your presence makes this an unsafe workplace.” No one ever said that being trans was the “danger,” but it was the only new detail in my employment. Baffled and hurt, I prepared to go through the necessary steps to keep my job.

I learned, though, that while mandated, the mental evaluation was not covered by my insurance and would have to be paid for fully out-of-pocket; additionally, the screening had to be done by a psychiatrist, not a more-affordable community health center counselor. The cost would have been prohibitive anyway, but I was simultaneously banned from working while ordered to pay for the review. Before this moment, I had been earning roughly minimum wage while living in one of the most expensive states in the US, and now I was suddenly on the verge of destitution. After only a short time, though I was trying to scrape together the means of fulfilling the mental review requirement and accessing basic necessities, I received a letter from the nonprofit: “You’ve been terminated for not coming to work.” In an instant, I had gone from optimistic and successful to underemployed and crushed. Because being trans was apparently deemed “unsafe” for others.

Single-axis analysis

The catalyst for Aryah’s firing was the HR Officer learning, and then communicating with others, that she was trans. It was not a subversive secret that she had withheld; it simply was irrelevant to her job qualifications. And, the workplace’s immediate dictate that she have a psych exam linked trans identity to mental illness. However, as we prepared the narratives for this article and discussed this moment, we both returned over and over to the fact that it was ultimately the intersections of transphobia and socioeconomics that had cost her the job. Lack of mental health insurance and inadequate funds had meant she was unable to satisfy the requirement for the exam that her employers had mandated. And, while we both acknowledge that some might wonder, “Who would want to continue to work for a place like that?,” such a position is inherently classist. It assumes that Aryah would have had sufficient employment alternatives, which her experiences demonstrated she did not, to simply reject the position and move on.

And, as we talked about this experience and worked to fill in various details in the narrative, we both wondered at the ways that race might have mattered. We both acknowledged that there was no blatant racism, but Aryah is a Black woman. And, there is substantial evidence of the substantial pay gap and underemployment that affects Black women across the US. On average, Black women earn 38% less than White men and 21% less than White women (AAUW, 2018; National Partnership for Women & Families, 2019). This stark reality, coupled with the transphobia that designated Aryah “unsafe” and the monetary hardship that prevented her from complying with her workplace’s directive, placed her in an incredibly vulnerable situation, which ultimately led to joblessness and homelessness. Race and racism do not need to be explicit to have real consequences.

Late twenties and sleeping on the beach

I felt adrift. Disillusioned with New York, I headed Southward again, and found myself in Florida. I had lost a good job and, once again, moved away from those unprepared to support my efforts to be myself. I had left colleagues, friends, and families, and in doing so, I had also lost basic necessities. Over and over again in my new location, despite indefatigable efforts, I found myself unemployed and homeless. Finally, one day offered a glimmer of hope: the city’s homeless shelter had no housing for trans people, but officials would work to help me access transitional housing. I had applied for and been granted food stamps, so I had some food security, and now I would have shelter, too. There was only one catch: I had to undergo a mental health check first. It was as if the previous years had come back to haunt me.

My meeting with the city-mandated psychiatrist was strange. He explained to me, “Human bodies house spiritual forces, male and female,” and diagnosed that I was “a male body housing a female spirit.” Even more bizarrely, the psychiatrist insisted that being trans “isn’t a ‘thing,’” but instead “a female spirit has possessed you.” The diagnosis, aside from apparent possession, was, “You are schizophrenic and psychopathic.” And though I had no access to the mental health paperwork—while the city did, as part of my housing application—he wrote me several prescriptions, including Zoloft, an antidepressant, and Geodon, an antipsychotic. Aware that I needed this doctor’s support, but also concerned with the medications, I asked, “What are these for? What do they do?” He explained that the Zoloft would “lift your mood,” and that the Geodon, a medication typically prescribed for schizophrenia and bipolar disorder, “should help you sleep.”

In an effort to cooperate, I took all pills as directed, but because I did not need them, they immediately wreaked havoc on my body. The Geodon was the worst, causing a strange combination of lockjaw symptoms. I would involuntarily clench my teeth painfully, and then my mouth muscles would open so wide that I feared the skin around my mouth would tear. Meanwhile, I was expected to continue returning to this “doctor.” I arrived at my next appointment furious, but my anger had no outlet. I was completely dependent on this person’s recommendation, while it was obvious that his treatment was not only detrimental but dangerous. Faced with my impotent fury, this city-sanctioned doctor’s emphatic insistence that I had been “possessed,” and the horrific side effects of the mandated drugs, I chose to protect myself and stopped seeing him. The effect, though, was that I was no longer enrolled in the housing program. Homeless again, I slept on the beach for months, still looking a job.

Single-axis analysis

As with the previous narrative, this was an instance when Aryah’s trans identity and socioeconomic situation were the most obvious factors. The city’s unpreparedness to support a trans person’s needs, and their mandate that Aryah see a psychiatrist who was literally endangering her health and well-being, forced her to comply with unnecessary medications and alarming psychiatric sessions. But, in returning to Crenshaw’s emphasis on intersectionality, we would point out that this experience was inextricably connected to the preceding one in New York.

The lower pay and socioeconomic vulnerability, exacerbated by imbalanced and racist pay scales, led to all that Aryah recounts. A first-of-its-kind study found that Black people are a disproportionate percentage of the homeless population, with some cities having a Black population of less than 10%, but the demographic making up ∼ 1/3 of those homeless (LAHSA, 2019). Simultaneously, 20% of trans people are homeless (National Center for Transgender Equality, 2019b), and women are the fastest-growing homeless population in the US (Welch-Lazoritz et al., 2015). From a single-axis perspective, any of these findings taken independently would be alarming; intersectionally, Aryah’s individual narratives serve to represent a nationwide pandemic. Black trans women experience homelessness at approximately five times the rate of the general population, and experience extreme poverty at approximately twice the rate of all other trans people (National LGBTQ Task Force, 2019). And when resource-holding agencies irresponsibly mandate mental health examinations, either at the already-impoverished individuals’ expense or at the hands of mental healthcare providers unqualified to evaluate and support trans people, the effect is catastrophic. For Aryah, it meant that a bright, motivated woman found shelter on a beach each night. For her and many others it sometimes means suicidal ideations; for some, it means death. The importance of considering the intersections of race and class with trans identities, particularly when exploring topics such as mental health, is sometimes a literal life-or-death matter.

Discussion

What is perhaps most fascinating about Aryah’s narratives is that though she described access to mental health professionals, including one whom she chose herself, she never actually received useful mental health services. Over decades, despite three mandatory evaluations and two times when those services were tied to her livelihood, not one instance helped her. Instead, they presented obstacles to her safety and access to basic necessities, while endangering her mental and physical health. There are unquestionably mental health providers who offer trans-positive care, but access to those resources—both socioeconomically and geographically—are often limited. We outlined the ways that being in the Southern US shapes trans individuals’ experiences and access (see also Bradford et al., 2013; Perez-Brumer et al., 2018). Two of Aryah’s narratives take place in this region, and the lack of access has not shifted substantially in the years since those experiences (GLSEN, 2012; Shelton & Lester, 2016). The other narrative, however, which took place in a different region of the US, emphasizes that other regions are not automatically different or better. The fact is that transphobia and cisnormativity continue to dominate healthcare services and communities throughout the US (e.g., Bockting et al., 2013; King & Hughto, 2019; Logie et al., 2019) and even the world (e.g., Birch et al., 2019). Trans stigma coupled with pervasive shame when accessing healthcare (King & Hughto, 2019) creates conditions in which trans people are discouraged and prevented from accessing effective care.

Aryah’s experiences accentuate the degrees to which trans-positive policies must be intersectional if they are to be effective. Research that includes trans people without considerations of the ways that racism, classism, and other realities severely limit mental health care research and practice are insufficient and problematic. Research that employs a single-axis approach, even if inadvertently or due to statistical limitations, omits critical ways that cultural and political realities inform mental health scholarship, application, and access. We would assert that there is a demonstrated need in mental health literature to more explicitly explore the ways in which and degrees to which multifaceted identities and experiences shape mental health needs and availability.

In addition, given the trans stigma noted in much of the mental health literature (e.g., Bockting et al., 2013; King & Hughto, 2019; Logie et al., 2019), there is a need to ensure that mental health education and training include trans people in a range of capacities, including as faculty, medical experts, and potential patients. Aryah’s experiences communicate the very real consequences of care providers lacking information or empathy for trans people—even to the point of dismissing trans identities and inappropriately prescribing medications. Trans people deserve access to quality mental health care, and those providers need resources to prepare them to be trans-positive and welcoming.

In addition, Aryah’s narratives emphasize the necessity of researchers more fully acknowledging and addressing the systemic inequalities that lead to these particular issues in the first place. These narratives, taken together, illuminate the degrees to which a range of societal factors intersect with transphobia, racism, and classism to exacerbate or even create the very issues that mental health research seeks to address. Literatures exploring the quality of mental health care are valuable, but they are incomplete if they do not consider how socio-political and cultural factors shape those individuals receiving and giving care.

Limitations

We recognize that Aryah’s narratives are unique to her. In being a qualitative study, the goal was not to present reproducible or immediately generalizable findings; instead, the goal here is to offer individual narratives both to humanize the consequences of inadequate and/or harmful mental health resources and to ask that these and others’ experiences shape discussions of trans mental health services moving forward. Unfortunately, while having Aryah’s narratives present rare or unusual circumstances would be preferable, the fact is that this research alongside the related literature suggests otherwise. Her experiences are representative of the challenges that numerous trans people experience in their daily efforts to access basic necessities and good mental health services. We opened with an overview of the degrees to which the US has become a hostile place for trans people, for people of color, and particularly for trans people of color. Never have the stakes been higher or the needs greater. The current national climate only intensifies the myriad of factors that Aryah faced, and scholarship that aims to support and celebrate trans people must more fully examine trans people as multidimensional individuals acting within a range of socio-political factors, and train mental health care professionals to not only support but value trans people and their experiences. People’s lives depend on them doing so.

Conflict of interest

The authors have no conflict of interest to report.