Table 3.
Qualitative themes organized by domain with select quotations from in-depth interviews.
| Social determinants of health |
| 1. Family rejection |
| “(My family) bullied me… The only one that never told me anything was my great-grandmother. She would defend me a little bit. But yeah, I mean, everyone.” (Latinx) “I knew I could walk the streets freely and dress how I wanted to dress and that if anybody messes with me, my family’s gonna get you, whereas these girls don’t have that family or that backbone or that structure. And so it’s like they’re alone, and they’re, you know, scared to walk anywhere, scared to go anywhere.” (African American/Black) |
| 2. Bullying, discrimination, and violence |
| “[School was] very difficult. I got called names. I had zero friends from kindergarten through twelfth grade.” (African American/Black) “I was kicked out of school for fighting. I fought a lot in school. I felt like I had to protect myself… I ended up getting into a really bad fight. It’s also like when I was working at this store, and this lady paid this guy $20 to beat me up.” (African American/Black) “I think each transwoman’s experience is different. We grow up in a society where, a lot of us, our parents don’t take to their son acting effeminate, or their son expressing that they’re not a boy, they’re actually a girl. In the Black community it’s very shunned and a lot of the time you’re excommunicated or cast out. A lot of us already feel like pariahs in our own way.” (African American/Black) |
| 3. Isolation |
| “I usually don’t open up to people, because I don’t like to be rejected and, so that I won’t have to experience rejection from anyone, I prefer to be alone.” (Latinx) “I was brought up by older queens… The purpose of your having a [gay] family is for when your biological family ditches you and kicks you to the curb because you are who you are, you have a family.” (African American/Black) |
| 4. Policy barriers |
| “I think as a transwoman, when you get your name changed officially, there’s like a whole new life, whole new persona… For any transwoman, I think I can speak for a lot of them, once you get that name changed, officially and documented, it’s something that I can freely show you, my ID. I don’t have to be shy or explain myself.” (Latinx) “It’s hard for me, difficult to find a job… First of all because they ask me for documentation, and a valid Social Security, and later ‘cause I’m a transwoman. So it’s kind of more complicated twice.” (Latinx) |
| 5. Mistrust in systems |
| “[Being transgender] played a big role in the way [the police] were treating me. They didn’t treat me nice. They were not nice at all. I hadn’t been in trouble with the law or nothing.” (African American/Black) |
| 6. Lack of safe and steady employment options |
| “I had a job offer at a group home that was paying like $14.00 or $15.00 an hour and the only thing that I would have to do was I would have to go get a new ID made with male on it and I would have to dress as a male, and I’m not doing that.” (African American/Black) “It was a problem at my old job… They wrote me up because I went to the girl’s bathroom… and fired me.” (African American/Black) |
| 7. Sex work |
| “It was hard for me to find a job. I did some sex work to be honest. How else am I going to pay my bills?” (Latinx) |
| 8. High cost of care |
| “As far as going to the clinic and stuff, I haven’t been in so long because I don’t have any insurance. So I know if I go it will be expensive, so I haven’t really been.” (African American/Black) |
| 9. Transportation barriers |
| “The bus driver knew me before my transition. Just, ‘Oh, so you’re a girl now? Wow. How does it feel to be a tranny?’… Guess what I was doing now? Taking another extra hour to get to, or walking more, so I don’t get on this bus. So, it was more – that really traumatized me for a long time because of what he did.” (Latinx) |
| 10. Antagonism by church |
| “They pulled me in front of the church and they put this oil stuff on my forehead… Doesn’t this sound crazy? But I guess they call it ‘speaking in tongues.’ They were praying the gay or something out. I played along with them just so they would leave me alone… It’s so embarrassing.” (African American/Black) |
| 11. Substance misuse |
| “I’ve cut back a lot now, thank God. But before, whenever I would get discriminated against or down, I would drink.” (African American/Black) |
| Healthcare experiences |
| 12. Burden of emotional preparation to interact with health care |
| “[Like that song,] Eye of the Tiger. You’re going to get looks, you’re going to get comments, so just toughen up, toughen up. You always have to be aware that something bad could happen.” (African American/Black) |
| 13. Name and gender misidentification |
| “I was in emergency care. And they say you’re – they told me at the front desk, ‘You’re a man. We can’t treat you as a woman because you’re a man. Your identification says that you’re a man.’” (Latinx) |
| 14. Perceived staff discomfort and insensitivity |
| “[A primary care doctor said], ‘Why do you do this, why do you look like this?’ And that’s his question. And that was – made me uncomfortable.” (African American/Black) |
| 15. Assumed to be at sexual risk |
| “Every time I went, they also gave me a HIV test. Like, I know I’m not positive, so why every time I come in here? I could say I have a headache or toothache or something and the person will do a blood test and see if you have HIV or any kind of disease. I know I don’t have these things so why do you all keep… Is this like a routine thing for them?… They just do it. It’s like, okay, now I feel like that’s discrimination. I don’t feel like it’s because I’m Black, I feel like it’s because I’m trans.” (African American/Black) |
| 16. Non-medical and predatory sources of care |
| “But the red flag for me is you can’t even ask for [the] name [of the person giving silicone injections]. I ask, ‘What's her name? What's her number?’ ‘Oh, I can’t tell you her name. Nobody knows her name.’ That, for me, was the red flag. How am I not going to ask for your name? You’re about to inject something in me, but I can’t even know your name? No, no, no.” (Latinx) |
| Health-related priorities |
| 17. Understanding healthcare |
| “I relied so much on Google, too much on Google. When I was first transitioning, I saw a lot of transwomen around me. They already had surgeries. I think that pressure when you’re so young and so vulnerable, you want to do it like this. So, I think that was my mistake.” (Latinx) |
| 18. Respect at all levels |
| “I love [my provider] to death. He really, really helped me out a lot, versus everybody else before him [who] just brushed it off to the side and not seeing that I really needed help and stuff. He wrote a note telling people how to treat me and stuff like that. I’ll never forget him. He went above and beyond. And he listened to me. He was really concerned about my health. When I came to him, he was concerned. It was never nothing different. He never questioned who I was or anything like that.” (African American/Black) “Most importantly, [that doctors] care for us as the people we are, and that they respect us.” (Latinx) |
| 19. Inclusive gender-affirming care and services |
| “It costs money to get laser hair removal… Honestly, as far as laser hair removal, I’ve spent – I could’ve bought a car, seriously. That was mainly going to different ones… until the last one I went to, who had a great machine that worked on Black skin. And if I would’ve known that, I could’ve saved probably about $5,000. ‘Cause I was going to one girl, her machine wasn’t even appropriate for Black skin.” (African American/Black) |
| 20. Comprehensive health resources |
| “I just think they need to give the trans community their own clinic, that’s just what I believe, and that's just because I've experienced a trans clinic, and it was just awesome.” (African American/Black) “Because I don’t understand why they got it in New York and San Francisco and they don’t have it here, you know? That makes me feel like, well, North Carolina just don’t give a damn about the transgender girls, you know what I’m saying?” (African American/Black) |