“They feel empowered to discriminate against las chicas”: Latina transgender women’s experiences navigating the healthcare system

Abstract

Background

Transgender Women of Color are more likely to experience oppression at the hands of healthcare providers than their transgender White counterparts. However, there is a paucity of research on the experiences of Latina transgender women in the United States.

Aims

Using an intersectionality theory framework, the present study aimed to investigate the factors that contribute to Latina transgender women’s decision to seek or refuse healthcare services and Latina transgender women’s experiences with healthcare providers in the United States.

Methods

A community sample of 15 Latina transgender women at a large metropolitan city in Florida participated in a focus group to explore their experiences with seeking out and accessing healthcare services.

Results

Thematic analysis revealed five themes: 1) experiences in seeking healthcare, 2) the effects of hormones on mental health, 3) resistance, 4) imparting collective knowledge, and 5) recommendations to healthcare providers.

Conclusions

Through collective dialog these women gave voice to their needs and pains in the context of healthcare while also positioning themselves as agentic, resistant, and aware of the power of collectivism in the process of healing. The current findings support and extend calls for training improvements related to transgender populations, giving voice not only to the need for training but specifying immigrant Latina transgender women’s desire for such training. Also, elements related to Latinx cultural values (e.g., convivencia, familismo) must be considered when working with Latina transgender women.

Introduction

The present study is among the first to consider barriers to accessing healthcare for Latina transgender women who are also immigrants living in the mainland United States. While research that focuses on the discrimination that transgender individuals experience has been plentiful (e.g., Blake, 2018; Glick et al., 2018; James et al., 2016), special attention has yet to be paid to the experiences of Latina transgender women, and how the intersection of their immigration status, gender identity, and ethnic identity uniquely informs their healthcare experiences. The present study extends previous work on healthcare discrimination of transgender individuals and utilizes a critical intersectional qualitative framework to understand the nature and impact that experiencing barriers to healthcare services has on Latina transgender women.

Experiences of transgender women of color

When centering the experiences of transgender Women of Color, it is important to validate multidimensional identities and how these identities are positioned within social institutions and social structures (de Vries, 2015; Hines, 2010). Particularly when considering the intersection of race and ethnicity, gender identity, sexuality, and social class, researchers must use a critical intersectionality framework for considering institutional and structural power and how social identities are interconnected and not additive (de Vries, 2015). The experiences of discrimination for transgender Women of Color are unique when compared to other marginalized groups due to experiences of transphobia, cisgenderism, sexism, and racism simultaneously (Jefferson et al., 2013). For example, transgender Women of Color are more likely to experience higher rates of health disparities (e.g., HIV prevalence), discrimination, and verbal and physical abuse when disclosing their trans identity (Clements-Nolle et al., 2001; James et al., 2016; Koken et al., 2009). These experiences of discrimination and oppression lead to increased rates of stress and depressive symptoms (Jefferson et al., 2013; Reisner et al., 2016), among other health disparities.

Experiences of Latina transgender women

Approximately 21% of the transgender population in the United States is comprised of Latinx transgender people (Hwahng et al., 2019). Latina transgender women who are also immigrants living in the United States are unique with respect to language diversity, immigration status, and socioeconomic status (Hwahng, 2018; Hwahng et al., 2019). Their positionality and experiences of marginalization across ethnicity, gender identity, and immigration status, render Latina transgender women particularly vulnerable to economic stress that impacts their quality of life (Cerezo et al., 2014). Given these intersectional experiences, more research about the experiences of Latina transgender women is needed (Hwahng et al., 2019).

Within the state of Florida, immigrant Latina transgender women face unique challenges. Specifically named as a vulnerable population in this region, Latina transgender women in South Florida may struggle to obtain competent health care services and health care providers as a result of their immigration status (Flechas, 2018; see Sun et al., 2016). Also, immigration status and legal documentation often determines whether Latina transgender women engage in behaviors that put them at risk for HIV exposure (Palazzo et al., 2016). Latina transgender women in the United States experience discrimination based on cisgenderism and nationalism. Given their intersecting identities, immigrant Latina transgender women are often forced to present identification from their country of birth containing their sex assigned at birth, therefore outing them (Quintero et al., 2015). Undocumented Latina transgender women experience more stress related to fear of deportation and work-related discrimination (Yamanis et al., 2018). The impact of this discrimination, whether experienced directly or not, may lead to experiences of increased psychological distress (Cerezo et al., 2014).

Despite experiencing oppression at the intersection of race and ethnicity, gender identity, and immigration status, most of the research conducted with transgender populations has focused on White, middle class, transgender individuals (de Vries, 2012; Jefferson et al., 2013). As of September 2019, to the authors’ knowledge, only five studies exist that have explored the experience of immigrant Latina transgender women in the United States (see Bazargan & Galvan, 2012; Cerezo et al., 2014; Hwahng et al., 2019; Pinto et al., 2008; Rhodes et al., 2013). None of these studies exclusively focus on the healthcare experiences of Latina transgender women. Thus, more research is needed to explore how the positionality of immigrant Latina transgender women in the United States uniquely impacts their access to adequate and appropriate healthcare.

Healthcare experiences of transgender women

Given that transgender Women of Color face significant health disparities, victimization, and discrimination (Clements-Nolle et al., 2001; Sevelius, 2013), one important avenue to explore is how transgender Women of Color experience access to the healthcare system including healthcare providers. Transgender women in particular may experience apprehension in seeking out medical care and health services. Research with this population is highly medicalized, and focuses on negative outcomes such as HIV rates and risky behaviors (Baral et al., 2013; James et al., 2016; Sevelius, 2013), or groups transgender women in with cisgender men who have sex with men (Garnett et al., 2018; Hojilla et al., 2018; Logie et al., 2017). Many transgender women will delay seeking out healthcare due to experiences of harassment or discrimination from healthcare providers, as well as a lack of sensitive or competent providers who understand their needs (Socías et al., 2014; Thomas & Safer, 2015; Wagner et al., 2016). Other doctors may attempt to hold transgender women to their own personal standards of femininity and womanhood, devaluing their decisions or questioning identities that fall outside of this norm (Sallans, 2016).

Healthcare experiences of transgender Women of Color

Research suggests that transgender Women of Color disproportionately struggle with adequate access to health care because of interlocking systems of oppression (see Hudson, 2019). Transgender Women of Color may experience racism and cisgenderism due to the stigma of violating specific gendered cultural norms (Nemoto et al., 2004). Transgender Women of Color often have no choice but to pursue care from non-healthcare related people (Sevelius, 2013). For example, transgender Women of Color are often forced to use hormones purchased on the street as a result of medical providers and systems that stigmatize their intersecting identities (Sevelius, 2013). Additionally, transgender Women of Color may experience gendered racism from their healthcare providers (Lewis et al., 2016), impacting their comfort with seeking out healthcare. With that said, much heterogeneity exists within transgender Women of Color communities. More focused attention and critical scholarship focused on Latina transgender women is needed (see Hwahng et al., 2019).

Healthcare experiences of Latina transgender women

For Latina transgender women, having access to culturally competent healthcare providers who are experienced with working with transgender patients would provide a much needed next step to reducing the barriers to healthcare access for this community (Nemoto et al., 2004). Given that clinicians and healthcare providers make up two crucial roles in the health and wellness of transgender people and the documented complicated relationship that transgender individuals have with healthcare providers, research must establish how providers understand their role and choices concerning their work with immigrant Latina transgender women (see Richards et al., 2014). This complicated relationship is rooted in a historical sense of discrimination and prejudice from the medical system, in which doctors functioned as gatekeepers to decide who had access to medical transition, a model that still continues to this day (Alpert et al., 2017).

Theoretical framework

The present study uses the theoretical framework of intersectionality (Crenshaw, 1989) to examine the experiences of Latina transgender women as they navigate the healthcare system. Intersectionality was developed to critically understand the multidimensional ways in which Women of Color, and others living at the intersection of multiple marginalized identities are impacted by the interaction of multiple systems of oppression (Collins, 2015; Combahee River Collective, 1995/1977; Crenshaw, 1991). Previously, antiracist and feminist analyses used single-identity frameworks that failed to capture the ways in which racism, patriarchy, heterosexism, and other power structures act collaboratively to create structural and political forms of violence against Women of Color (Crenshaw, 1989). As an analytic tool, intersectionality facilitates the interrogation of these “-isms” as they operate simultaneously (Collins, 2015; Combahee River Collective, 1995/1977; Crenshaw, 1991), and provides a critical analysis of the experiences of Latina transgender women who are impacted by interlocking systems of oppression.

Studies show that transgender individuals face multiple barriers to healthcare such as discrimination, lack of cultural competence by providers, health system barriers, and socioeconomic barriers (Safer et al., 2016). Further research indicates that Black and Latina transgender women are at especially high risk of HIV/AIDS and health-related concerns (Denson et al., 2017). For the current study, we utilized intersectionality theory as it requires that systems (e.g., racism, cisgenderism, classism, immigration status, healthcare), social relations (e.g., patient doctor), and the related biopsychosocial processes individuals experience (e.g., isolation, the side effects of hormone therapy) are explored in tandem. While Latina transgender women share overall experiences of oppression with other transgender Women of Color, given the added layers of oppression faced by this community (e.g., immigration status, language barriers; Cerezo et al., 2014; Quintero et al., 2015) it is important to explore Latina transgender women experiences within the healthcare system.

The use of intersectionality in the current study allows for the authors to center their analysis on how power functions and contributes to specific health- and wellness-related inequities, providing critical and holistic insight into Latina transgender women’s experiences. Thus, the authors of this study invite and encourage readers to hold an intersectional frame as they read and interpret the following sections.

Current study

The aim of the current study was to engage a community sample of immigrant Latina transgender women to explore their experiences with accessing healthcare in the United States to better understand their unique healthcare needs and experiences. The following research questions guided the focus of the study: 1) What are the factors that contribute to Latina transgender women’s decision to seek or refuse health care services? and 2) What are Latina transgender women’s experiences with healthcare providers in the United States?

Method

The current study utilized a focus group interview with a group of 15 immigrant Latina transgender women living in Florida. The research team was particularly interested in making meaning out of the participants’ experiences with accessing healthcare in the United States (see Schutt, 2014). Given that Latina transgender women and their experiences with accessing healthcare have not been studied to date, a qualitative approach was used (Morrow, 2007). Specifically, the data was analyzed using thematic analysis (Braun & Clarke, 2006) to uncover themes within the participants’ narratives about their healthcare experiences.

Participants

Participants in the study (N = 15) were self-identified transgender Latina women. The age range for participants was 22–61 years-old with an average age of 42.8-years-old (SD = 13.47). At the time of data collection, all participants resided in the state of Florida. Eight (53.33%) of the participants were U.S. citizens, three (20%) of the participants were permanent residents of the United States, and four (26.67%) of the participants did not disclose a documentation status. Participants represented heritage from six different Latin American countries, including Cuba (n = 7, 46.67%), Puerto Rico (n = 3, 20%), Nicaragua (n = 2, 13.33%), Colombia (n = 1, 6.67%), El Salvador (n = 1, 6.67%), and Venezuela (n = 1, 6.67%). Of those participants, most (n = 13) were born outside of the mainland United States. Participants identified their race/ethnicity as Latina (n = 4, 20.00%), Hispanic (n = 3, 20.00%), White Latina/Hispanic (n = 3, 26.67%), Indigenous Native Latina (n = 1, 6.67%), Mulata (n = 1, 6.67%), Mestiza (n = 1, 6.67%), White (n = 1, 6.67%), or did not disclose a racial or ethnic identity (n = 1, 6.67%). Most participants (n = 13, 86.67%) were first generation migrants (i.e., born outside of the United States) while some participants were second generation (n = 1, 6.67%) or third generation (n = 1, 6.67%) migrants. See Table 1 for a detailed breakdown of the participants’ documentation status, generational status, sexual orientation, relationship status, level of education, and religious identity.

Table 1.

Participant demographics.

Documentation Status	n	%
United States citizens	8	53.33
Permanent residents of the U.S.	3	20.00
No Answer	4	26.67
Latin American Heritage
Cuba	7	46.67
Colombia	1	6.67
El Salvador	1	6.67
Nicaragua	2	13.33
Puerto Rico	3	20.00
Venezuela	1	6.67
Race/Ethnic Identity
Hispanic	3	20.00
Latina	4	26.67
White Latina/Hispanic	3	20.00
Indigenous Native Latina	1	6.67
Mulata Latina	1	6.67
Mestiza	1	6.67
White	1	6.67
No Answer	1	6.67
Generation Status
First Generation Migrants	13	86.67
Second Generation Migrants	1	6.67
Third Generation Migrants	1	6.67
Sexual Orientation*
Transsexual/Trans/Tranny/Travesti	6	40.00
Heterosexual/Straight	4	26.67
Female	2	13.33
Pansexual	1	6.67
Feminine	1	6.67
Lesbian	1	6.67
Relationship Status
Single	9	60.00
Married	3	20.00
Engaged	2	13.33
Divorced	1	6.67
Level of Education
Some College or Technical School	7	46.67
Attended High School	4	26.67
High School Degree	2	13.33
College Degree	1	6.67
No Answer	1	6.67
Religious Identity
Catholic	9	60.00
Christian	1	6.67
Santera	1	6.67
Witch	1	6.67
No Answer	3	20.00
Frequency of Attendance at Religious Services
Every Week	2	13.33
Nearly Every Week	2	13.33
About Once a Month	1	6.67
Several Times a Year	2	13.33
Less than Once a Year	4	26.67
Never	3	20.00
No Answer	1	6.67

*Note We intentionally use the labels verbatim that participants use.

Recruitment

Participants who self-identified as having Latin American heritage, were transgender, lived in the United States, and were at least 18-years-old were eligible to participate in the study. Participants were all recruited from a local, not for profit organization in a large city in Florida that provides services to sexual and gender diverse individuals who are victims of domestic violence, sexual assault, human trafficking and other types of victimization.

Focus groups and data collection

After receiving institutional review board approval by the University of Tennessee, Knoxville (UTK), data were collected using one focus group led by the first author. At the start of the focus group, participants completed a demographic questionnaire then participated in a 90-minute focus group where they were asked open-ended questions about their experiences regarding accessing healthcare in the United States. Participants were given the option of completing the demographic survey and participating in the focus group interview in English, Spanish, or English and Spanish. All participants completed the surveys and participated in the focus group in Spanish.

Consistent with recommendations by Stewart and Shamdasani (2014) for running focus groups, the first author created a safe environment where participants shared ideas and engaged in a discussion in an organic manner. That is, the first author’s main goal was to get participants talking by posing questions while allowing participants to connect with the question and each other in order to provide a genuine response. At times, the author interjected to ask appropriate follow-up questions to seek clarification and/or raise a new question for consideration (Braun & Clarke, 2013; Stewart & Shamdasani, 2014). Given the first author’s previously established professional relationship with the organization and involvement in previous initiatives by the organization, rapport was easily established. Specific to the study at hand, and consistent with the framework of intersectionality, all questions were designed to prime participants to think about their intersecting identities as Latina transgender women. Responses to the following interview questions were analyzed: 1) What are your experiences with accessing health services/doctors (e.g., mental health services, physical health services)?; 2) What factors contributed to your decision to seek out or refuse health care?; 3) How do your health care experiences impact your mental health as a Latina transgender woman?; 4) Do you feel that there are enough providers who are competent to provide appropriate care to Latina transgender women? Why or why? Please provide some examples; 5) What recommendations would you give a healthcare provider regarding your needs as a Latina transgender woman?; and 6) What do healthcare providers need to know in order to provide you with services that will improve your experiences as a Latina transgender woman?

Transcription and translation of data

Focus groups were digitally audio-recorded, identifying information of participants were removed, and the focus groups interview was transcribed by a transcriber fluent in Spanish and who has over five years of experience with translations work, including translation work with LGBTQ-related studies. The transcription of the focus group was then translated by the same transcriber from Spanish to English and then translated back to Spanish to ensure accuracy of the translation (Ozolins, 2009). Once translations were finished, the first author reviewed the original transcription and translation to ensure that the final translated transcription was accurately captured. The first author is fluent in Spanish (i.e., native language) and has experience collecting, translating, and transcribing data through focus groups.

Research team and researchers’ positionality

The authors of the current study had a range of identities across race and ethnicity, gender identity, generational status, and sexual orientation. The research team included an assistant professor of psychology who identifies as a first-generation Cuban, gay cisgender man (first author). The research team also included an assistant professor of psychology who identifies as a third generation Latina, heterosexual cisgender woman (second author) and an assistant professor of psychology who identifies as a Black, queer cisgender woman (third author). The research team also included a doctoral student in counseling psychology who identifies as a White transmasculine non-binary queer person (fourth author) and a doctoral student in counseling psychology who identifies as a transgender non-binary Afro-Latinx first generation immigrant (fifth author). Finally, the research team included an LGBTQ community leader and organizer who identifies as a first-generation Latinx, gay cisgender man (sixth author).

The first and second author coded the data and kept a research journal to reflect on their reactions to the data through the coding process (see Gilbert, 2001). The third, fourth, and fifth authors served as auditors and engaged in discussions with the first and second authors throughout the coding process in order to provide a peer examination of the data analytic process (see LeCompte & Goetz, 1982). As a non-POC individual, the fourth author was crucial in maximizing objectivity in the coding and writing process of the manuscript by providing feedback about conclusions drawn by the rest of the team, who identify as POC. In addition, given the sixth author’s extensive community and advocacy work with transgender individuals in Florida, this author was crucial in helping the rest of the research team in the creation of the interview questions in order to use language that honored the lived experiences of our sample.

Data analysis

All of the data were entered into a qualitative web-based program used to organize qualitative data (i.e., Dedoose) and a thematic analysis approach was used to analyze the data (Braun & Clarke, 2006, 2013). Data analysis began with the first and second authors independently reading the transcription of the focus group interview. All responses were placed in categories based on similar expressions of ideas, or meaning units (Giorgi, 1985) and initial themes were developed. Both coders then met to discuss and agree upon an initial set of themes. Then, the third and fifth authors, who served as auditors, reviewed the sets of themes and provided feedback to the first and second authors. The third and fifth authors met with the first and second authors to provide feedback, come to a consensus, and revise the thematic structure for the project.

Results

Results from the semi-structured interviews yielded five major themes and five subthemes illustrating Latina transgender women’s decision for seeking health care services and participants’ experiences with healthcare providers, including: 1) experiences in seeking healthcare, 2) the effects of hormones on mental health, 3) resistance, 4) imparting collective knowledge, and 5) recommendations to healthcare providers (see Table 2). All participant responses can be categorized in at least one of the themes/subthemes and many of the participant narratives reflect multiple themes.

Table 2.

Thematic structure and percentage of individuals acknowledging each theme.

Theme	Subtheme	% of Sample
Experiences in Seeking Healthcare	Barriers to Healthcare Access Inappropriate and Inadequate Treatment by Healthcare Providers Providers’ Lack of Training Ridiculed and Mistreated by Healthcare Providers’ Staff Positive Experiences	93.00 % (n = 14)
The Effects of Hormones on Mental Health		47.00 % (n = 7)
Resistance		27.00 % (n = 4)
Imparting Collective Knowledge		67.00 % (n = 10)
Recommendations to Healthcare Providers		33.00 % (n = 5)

Experiences in seeking healthcare

Fourteen participants (93%) in the sample shared rich experiences about difficulties accessing health care services and receiving inappropriate and inadequate treatment in healthcare providers’ offices, both by medical providers and their staff. For participants, the lack of competence and appropriate services created feelings of distrust, distress, and led them to not seek services. This theme is illustrated by one participant’s narrative when she shared about being denied treatment for cancer due to the lack of transgender-specific training by her doctor,

I went to the hospital but they didn’t give me chemotherapy when I left, and I left worse than I was when I went in. I had chills, vomiting, dizziness, it was unbearable (40-year-old, first generation, Puerto Rican).

On the other hand, some participants shared positive experiences as they navigated the healthcare system. Five subthemes emerged that represented experiences in seeking healthcare, including: 1) barriers to healthcare access, and 2) inappropriate and inadequate treatment by healthcare providers, 3) providers’ lack of training, 4) ridiculed and mistreated by healthcare providers’ staff, and 5) positive experiences.

Barriers to healthcare access

Some participants stated that they encountered a number of barriers to accessing healthcare, including lack of insurance and financial difficulties. For example, one participant shared,

The majority of us girls don’t have access to health care. The large majority has a small income, so they aren’t able. Trans people … they won’t give you anything (45-year-old, second generation, Nicaraguan).

Similarly, another participant shared,

[We] don’t have access to a doctor because it costs two hundred and fifty dollars. Depending on the doctor you see. Right here in Miami, if you aren’t mister moneybags, they won’t see you, they just won’t (25-year-old, first generation, Cuban).

Some participants specifically discussed documentation as a barrier to receiving appropriate healthcare access. For example, one participant stated,

Many people are undocumented. They’re also not going to provide them with medical assistance and they have to resort to purchasing hormones under the table (49-year-old, first generation, Cuban).

Inappropriate and inadequate treatment by healthcare providers

Participants named specific interactions with healthcare providers who flat out did not address their medical needs. One participant explained,

They see you, but if you go with an operation or something, they won’t see you, they’ll send you to [another] doctor to receive service (40-year-old, first generation, Venezuelan).

Other participants discussed how medical providers refused to provide minimal services at the expense of the person’s further physical complications. One participant shared:

She got silicone implants and it went to her feet. She was really sick, in the hospital, she had a fever for 15 days and they finally gave her an injection. They gave her an injection in her leg and she asked the doctors to just remove the bandages and they said no. She’s still there, fighting for her life (25-year-old, first generation, Cuban).

Similarly, another participant shared being between life and death before any medical doctor would provide services:

When I had my silicone put in, my body started to reject it. And I was here five years with this silicon in my body until they could operate on me because the doctors didn’t take responsibility for the problem. And I was practically between life and death when they were finally able to operate on me (30-year-old, first generation, Colombian).

Other participants specifically shared frustration about their doctors’ tendency to attribute their presenting concerns to hormone treatment. For example, one participant shared,

And oftentimes they blame all of your problems on hormones. If you come to them with like a sprained ankle or a migraine, ‘oh it could be because of the hormones’ (45-year-old, second generation, Nicaraguan).

Similarly, another participant stated,

They always blame everything on the hormones because they don’t know how to treat [the problem] itself. I mean, it’s nothing new, but it’s still not part of medical language (24-year-old, third generation, Cuban).

Providers’ lack of training

Participants discussed being aware of their medical provider’s lack of training, which prevented them from providing appropriate services. This included lack of professional training and using inappropriate pronouns. For example, one participant reported being aware of the lack of training medical doctors receive in graduate school:

I was going to say [that] doctors are overall illiterate when it comes to transgender health. So, medical schools, they don’t teach transgender health to doctors so doctors don’t know how hormones operate in your body, how to properly assign you the dosage that you need… and, like, they don’t understand the process of surgery (22-year-old, first generation, Salvadorian).

Similarly, another participant shared the lack of training by medical doctors at different levels of training,

Because the interns arrive completely ignorant. Compared to all the professionals [they graduate], completely ignorant in terms of how to work with the trans community (58-year-old, first generation, Cuban).

In addition, some participants discussed frustration about the medical field’s lack of awareness and training about proper use of pronouns. This is highlighted by one participant who shared,

A year ago I went to the emergency room and they had an argument about [my pronouns] and they just called me my last name (49-year-old, first generation, Nicaraguan).

Other participants expressed frustration with the lack of knowledge from providers and support regarding the mental health consequences for taking hormones. One participant stated,

the hormones cause mental instability. And there’s no specialist who understands why that happens. So, you’re practically on your own with maybe some mental assistance, and maybe that’s not the best (58-year-old, first generation, Cuban).

Ridiculed and mistreated by healthcare providers’ staff

Participants discussed being ridiculed and mistreated by health care providers’ staff during medical visits. One participant stated,

They act as though they don’t know you. How can I explain this? They know you’re a woman, but they treat you like a man (58-year-old, first generation, Cuban).

Similarly, another participant shared,

Instead of calling you [name], they call you “bro” or [say] “look at that guy or little boy” (54-year-old, first generation, Venezuelan).

Some participants highlighted the importance of not only receiving competent services by medical providers but also their staff. One participant shared,

It depends on the level of knowledge, not just of the doctor, but also their staff. In this respect, it’s important to be responsible with how patients are treated [at all times] (30-year-old, first generation, Colombian).

Furthermore, some participants made a distinction about services provided at each specific type of medical establishment. One participant shared,

If you go to a private clinic, they feel as though it’s something private, you understand? They feel empowered to discriminate against las chicas. It’s very sad (35-year-old, first generation, Cuban).

Positive experiences

Some participants reported positive experiences with healthcare providers including receiving the appropriate medical procedures and using gender-affirming names and pronouns. For example, one participant shared her positive experience when receiving hormone treatment:

I’ve been going to a doctor for a while who specializes exclusively in hormones. And she’s not some kid that was born yesterday, she studied medicine. The doctor, who’s a female doctor explained to me that injectable hormones cause more damage than pills because the injectable hormones are absorbed very quickly into the blood stream while the pills allow your body’s metabolism to adjust. Your liver is most vulnerable to everything (45-year-old, second generation, Nicaraguan).

Other participants specifically recalled feeling affirmed by specific providers, at specific hospitals because they did not make participants wait and used the participants’ appropriate pronouns. One participant stated:

And a really good hospital is [name of hospital]. They treat you well, they treat you almost immediately, in about five to ten seconds. The first thing that the doctor says when they come in is, “And what’s your name as a woman? What do you prefer to be called?” (51-year-old, first generation, Puerto Rican).

Similarly, another participant explained,

I have an open-heart pacemaker and they gave me the pacemaker … [name of hospital] for me are great. I am thankful and thank God and thanks to everyone that I have [come in contact with at the hospital] (22-year-old, first generation, Salvadorian).

Furthermore, some participants appreciated that some hospitals provided them with the appropriate care they needed while respecting their identity and their bodies. One participant stated:

In the [name of hospital], the education is a bit advanced. I would say extremely advanced when it comes to trans [people]. The first thing they say is, “Can we touch you?” and you say “of course”. And they asked me, “Can we check you?” They weren’t over touchy either (35-year-old, first generation, Cuban).

Some participants shared having positive experiences with mental health providers who affirmed their identity. One participant stated,

I went to a psychologist, they interviewed me and they said to me, “you know what you want. You don’t have a psychiatric problem (58-year-old, first generation, Cuban).

The effects of hormone on mental health

Seven participants (47%) in the sample spoke directly about the effects of hormone treatment on the overall psychological well-being in the transgender community. Some participants openly discussed mental health concerns as a direct result of taking hormones. This theme was illustrated by one participant’s narrative regarding her emotional reactions after taking hormones,

When you take hormones, the whole world is different. I’ve never suffered depression and I started to cry whenever I saw a butterfly. I became so sensitive that I just couldn’t control it and that’s some type of imbalance (40-year-old, first generation, Venezuelan).

Similarly, another participant shared:

The worst damage from the hormones is mental health. Because it causes really strong emotional imbalance and the more hormones you take, the stronger the emotional relapses you have. But your character becomes stronger. It has happened to me. The hormones, in my conceptualization, damage your emotional stability and health (34-year-old, first generation, Cuban).

Resistance

Four participants (27%) shared instances where they asserted their identity during interactions where they were discriminated. That is, these participants did not simply take a passive stance toward their oppressor, but they actively claimed their identity and their right to be in different spaces. For example, one participant shared:

As a person, you just have to make the space for yourself. Because they’ve tried to say to me, “Hey man”. And you’ve got to say, “Excuse me, but no! You’ll either call me lady or don’t call me at all.” I mean, if you hold your ground and specify how you want them to treat you, they’ll respect you” (58-year-old, first generation, Cuban).

Similarly, another participant stated,

If you tell me ‘reject yourself,’ well, let me tell you something. Where I’m at, I’m direct and [I know who I am] (49-year-old, first generation, Nicaraguan).

Similarly, other participants asserted their right to be seen and heard and for others to acknowledge their presence. One participant said:

Now, if you’re gonna touch me as I am, I am a woman. Like it or not, you’re gonna have to call me lady or man. Don’t call me bro, nobody’s gonna call me that… I think I’m great as a woman, I feel confident in myself. I feel pride. I can walk in front of anyone [as I am] (51-year-old, first generation, Puerto Rican).

Imparting collective knowledge

Ten participants (67%) engaged in a process of sharing knowledge about specific events they encountered on their journey toward affirming their gender. That is, these participants not only wanted to share their experiences but it was evident that they wanted others in the group who were earlier on their journey, or who had questions about specific procedures to be well-informed. A sense of cohesion and collective wisdom was formed among group members. Specifically, these participants provided advice to the other group members on hormones. For example, one participant shared:

They should inject the hormones when the doctor is present, and these were the consequences. I’m telling this to you so that when they inject the hormone, you go to the doctor and let the doctor [do] everything. They tested my leg first, this one and then this one afterward (30-year-old, first generation, Colombian).

Another participant stated:

That’s important because what they’re saying is that each body is different and doesn’t have the same metabolism and everybody reacts completely differently to hormones. That’s why it’s so cool to see that everyone’s experiences are different. Because when I started to take the hormones, people told me, ‘it’s not that’, [and] it was completely different [for me] (24-year-old, third generation, Cuban).

Recommendations to healthcare providers

Five participants (33%) recommended that healthcare providers seek transgender-specific information before meeting with the transgender person rather than relying on the client to educate them. For example, one participant shared:

Like when they know a transgender person is coming, to be prepared, just like a professor when they teach a class. You understand? It can’t be the first appointment but if they know that, for example the doctor, that they have to be on top of stuff and that they’re going to follow [your progress] well, then they have to get everything together for the second visit and the third visit, etc. (34-year-old, first generation, Cuban).

Similarly, another participant specifically shared that healthcare providers need to be aware of the physical needs of transgender clients before they come into their office:

And something that’s really delicate to doctors too and that I’ve found out, and that’s an important point, that when transgender people go to the hospital, or exams. We have [previous surgeries] in our bodies that they aren’t aware of when they see you (49-year-old, first generation, Nicaraguan).

Discussion

The Latina transgender women in this focus group articulated their experiences with the healthcare system in the United States, including their challenges as well as their resilience. The five themes regarding navigating healthcare included: 1) experiences in seeking healthcare, 2) the effects of hormones on mental health, 3) resistance, 4) imparting collective knowledge, and 5) recommendations to healthcare providers. Through collective dialog these women gave voice to their needs and pains in the context of healthcare while also positioning themselves as agentic, resistant, and aware of the power of collectivism in the process of healing. This discussion includes a synthesis of the findings alongside extant scholarship on Latina transgender women, a review of the implications for clinicians and researchers, and limitations and future directions.

Lack of quality and abusive healthcare services toward Latina transgender women

The Latina transgender women in this study provided rich narratives about receiving less than ideal, and often intentionally inappropriate services by healthcare providers and their staff. These participants discussed systemic barriers that prevented them from even accessing healthcare providers, such as lack of insurance, financial means, and documentation. Although other studies have also documented the lack of healthcare access and exposure to incompetent providers (Thomas & Safer, 2015), the intersection of racism, cisgenderism, and nationalism significantly impacted our participant’s ability to access the financial resources and documentation needed to seek healthcare. Therefore, the Latina transgender women in this study were exposed to added layers of oppression that arguably make their experiences with the healthcare system and health providers less accessible when compared to their White transgender counterparts. These findings add to the existing literature with predominantly White transgender individuals and make a significant contribution to research.

At the hands of medical and other healthcare providers, these participants either were denied medical services or received minimal services that did not accurately address their presenting concerns. As found in the existing literature, these participants shared frustration when interacting with healthcare providers due to the assumptions made by providers that all of their presenting health concerns were related to their transgender identity (James et al., 2016; Safer et al., 2016) while questioning the legitimacy of their identities (Sallans, 2016). Adding to the current literature, our participants provided specific examples where healthcare providers waited until participants were between life and death before they intervened and provided them appropriate care.

An important contribution of this study is the narratives about positive experiences with a select group of doctors. These participants were able to reflect and share with the other group members specific interactions with providers where they felt affirmed and seen (e.g., providers using appropriate pronouns) and felt that these providers were invested in providing them the best possible medical services. This finding is important because it offers hope that medical professionals might be becoming more knowledgeable about appropriate practices with transgender women, which might reduce the real and valid fears transgender women have that prevent them from seeking services (Grant et al., 2010; James et al., 2016).

Addressing transgender training issues in healthcare

The current findings support and extend calls for training improvements related to transgender populations, giving voice not only to the need for training but specifying immigrant Latina transgender women’s desire for such training. For example, the present study amplifies previous findings where transgender participants describe a lack of provider training (Loza et al., 2017) and bearing the burden of having to educate their providers (Grant et al., 2010). The current participants, however, add weight to these findings by specifying that providers need to engage in self-study prior to treating transgender clients, specifically as it relates to their physical health care needs. These data also coalesce with the findings from Tanner and colleagues (Tanner et al., 2014) that discrimination experienced at the intersection of racism and cisgenderism was associated with the participants perceiving urgent care as inaccessible to them. We call for providers and their staff members to be adequately trained on healthcare access issues related to the transgender community, with special attention to issues that affect the Latinx transgender community (i.e., immigration status; Cerezo et al., 2014; Quintero et al., 2015; Tanner et al., 2014).

The need for training improvements is not limited to physical health care providers, as the current participants reported psychological concerns as a result of hormones that could be addressed by culturally mindful mental health providers (Cahill et al., 2018; Jaiswal, 2019). Mental health clinicians seeking to improve care provided to Latina transgender immigrants may consider receiving training that will help them to: (a) learn the concepts and key health concerns faced by this community, (b) navigate client conversations regarding the use of interpreters, (c) assess and modify forms and office spaces, and (d) provide trauma-informed care (Keuroghlian et al., 2018). Chavez-Dueñas et al. (2019) Healing Ethno and Racial Trauma (HEART) framework is an example of a trauma-informed model attuned to intersectionality that may be particularly helpful, as it was developed specifically for Latinx immigrant communities. The aforementioned barriers to Latina transgender health are addressable if health care systems prioritize these critical training needs and utilize intersectional tools and strategies in the process.

Resistance and healing

In the absence of adequate health care and as a result of facing discrimination by providers, our participants shared narratives about practicing resistance in order to facilitate their wellness. By advocating for themselves with their providers, as well as advocating through collective knowledge sharing, they provide practical examples of health autonomy, a set of resistance mechanisms identified even among LGBTQ + Latinx youth (Schmitz et al., 2019; Schmitz et al., 2019). Yet the current findings are novel in that they provide examples of what the process of resistance looks like for Latina transgender women both retrospectively (as they reflected on comments made to their providers) and in the moment (as participants took advantage of opportunities to share their embodied knowledge with other Latina transgender women in the focus group setting). This process coalesces with and bolsters findings from Loza and colleagues (Loza et al., 2017) wherein Latina transgender women took medical advice, particularly around hormone use, from women they knew who shared their identities.

This practice of coming together to share knowledge and otherwise collectively navigate local and broader sociopolitical issues, also termed convivencia, has been critical to Latina women in pursuit of liberation (Delgado Bernal et al., 2008; Galvan, 2001; Pérez Huber, 2017). Previously identified in the context of rural Central Mexico (Galvan, 2001), the education of Latinx Kindergarteners (Delgado Bernal et al., 2008), and undocumented Chicana/Latina immigrant advocates (Pérez Huber, 2017), the current study illuminates the utility of convivencia with respect to immigrant Latina transgender women’s healthcare. In addition, the practice of coming together by the participants to help each other heal in our study also highlights the key Latinx cultural value of familismo, or the importance placed on the family unit (Arredondo et al., 2014). Unlike the definition of family in mainstream American culture, for Latinx individuals friends and acquaintances are often regarded as family members (Falicov, 2014). In our participants narratives’ we saw key elements of familismo such as emphasis on affiliation (acceptance and solidarity) and cooperation (reliance on others from the group for support; Adames & Chavez-Dueñas, 2017). Based on the current research on the experiences of transgender women within the healthcare system, these findings are unique to this population and have implications for future research and interventions.

Implications, future directions, and limitations

There are several interrelated implications, future directions, and limitations based on the current study. Individuals providing health-related services to Latina transgender immigrants may assess their capacity to provide culturally mindful care to this community. This assessment may illuminate: (a) areas of strength that can be advertised to the community, (b) areas of growth that can be addressed through structural or personal change, and (c) gaps in training that can be systemically addressed in formal and informal ways (e.g., dialog with transgender health experts, webinar attendance, hiring Latina transgender women as consultants, independent study, and coursework). Regarding the latter point, researchers may conduct intervention studies to explore the impact of different training modalities on immigrant Latina transgender women’s perceptions and utilizations of certain providers or settings. Other intervention studies could use specific Latinx cultural values (e.g., convivencia, familismo) to increase resilience among immigrant Latina transgender women.

Given the intersectional frame of this study, it is important to consider the implications, future directions, and limitations that attend to power, privilege, and oppression with respect to what was stated by our participants, as well as what may not have been stated as result of power dynamics (e.g., unrepresented Latinx transgender identities, silenced voices, and time constraints; Grzanka et al., 2017). For example, one limitation of the study is that there were no Afro-Latina participants included. Yet, ethno-racial discrimination disproportionately impacts darker skinned and African diasporic peoples (Adames & Chavez-Dueñas, 2017), including Afro-Latina transgender immigrants. The intersection between immigration status, gender, and race is critical, and researchers should consider explicating the experiences of those existing at the bottom of the different social identity-based hierarchies (e.g., undocumented, Black, and poor people).

Several points should be made about the researchers’ positionality in the context of oppression, power, and privilege. First, it should be noted that five of the researchers identify as scholars of Color, including four Latinxs. This positionality allowed for a rich and nuanced discussion about the participants’ experiences of immigration as a barrier to accessing services. Second, given the participants’ preference for speaking Spanish, the first author’s bilingualism (with Spanish being his native language) facilitated rapport-building with participants. On the other hand, four of the researchers identify as cisgender including the first author (who conducted the focus groups and lead the data analysis). It is important to recognize the overrepresentation of cisgender researchers in transgender studies, the impact that this overrepresentation has on the way stories about transgender people are told, and how cisgender allies often profit from the experiences of transgender individuals (Galupo, 2017; Patterson, 2018). To this end, we acknowledge that the first author’s identity as a cisgender man might have influenced the level of disclosures by participants during the focus group. Keeping in mind that five of the researchers in this study identify as cisgender, we followed Galupo (2017) and Patterson’s (2018) recommendations and included a statement about how the identities of the research team may impact the research process, were intentional about citing transgender scholars, and collaborated with gender diverse researchers.

Another study limitation that relates to power dynamics but is also a function of focus group methodology involves the elevation of certain narratives, potentially reducing space for alternative narratives to enter and be considered. For example, in this study, the health needs and struggles related to hormones and transitioning were centered. Because attaining these physical health services is a central issue for the participants and key to holistic wellness of many transgender Latinas, it is possible that there was silencing related to the challenges that present themselves after attaining said services. Providers striving to be culturally mindful may benefit from not only enhancing the quality of care Latina transgender women receive in pursuit of these services but by normalizing and creating space for them to discuss challenges that present after transitioning. The authors encourage future studies exploring the impact of being transgender on mental health and doing so at all points in the journey (before, during, and after) for those who transition.

In the same vein of being mindful about how power dynamics play out in a study’s methodology, future research should involve participants in the coding process. While the diverse identities of our research team (including two transgender and gender non-conforming researchers) allowed for a rich and objective analysis of the data, future research should involve participants past the data collection stage. For example, researchers could solicit feedback and input from participants once data is transcribed and before coding and/or after the research team has reached a consensus about the final thematic structure and before engaging in the writing process (see Creswell, 2013; Flores et al., 2018). Furthermore, although focus groups containing participants who share similar identities and life experiences were important to use in this study to ensure cohesion of the group (Krueger & Casey, 2008), the geographic location from where these participants were recruited presents a limitation. For example, none of our participants mentioned language as a barrier to access healthcare services. Given that participants resided at the time of the study in a large metropolitan city in Florida where Spanish is widely spoken, it is plausible to believe that if this focus group was conducted in another state, or across multiple states, participants might have identified language barriers as an added barrier to accessing healthcare providers (Pabon & Wisotzkey, 2013).

Declaration of interest

The authors declare that they have no conflict of interest. The authors received funding from the Society for the Psychological Study of Social Issues (SPSSI), Grants-in-Aid (GIA) for this project.