Gender Minority Persons’ Perceptions of Peer-Led Support Groups: A Roy Adaptation Model Interpretation

INTRODUCTION

Literature addressing the health of persons identifying as gender minority (henceforth, gender minority persons) has frequently documented issues related to adverse behavioral health outcomes for this population.^1–5 The term “gender minority” recognizes identities that include, but are not limited to transgender, gender non-conforming, non-binary, genderqueer, gender fluid, or intersex.¹

Specific adverse behavioral health outcomes experienced by gender minority persons include much higher levels of psychological distress (including anxiety, depression, associated substance abuse, suicidal ideation, and suicide attempts) when compared with cisgender, heterosexual populations (that is, those persons whose gender identity corresponds to their sex assigned at birth). ^2,3,4 For example, findings from the 2015 US Transgender Survey revealed a 39% rate of psychological distress among gender minority persons, compared with 5% among cisgender heterosexual persons. In addition, 40% of gender minority persons reported having attempted suicide in their lifetime, compared with 4.6% of their cisgender heterosexual counterparts. ⁵

Gender affirmative approaches to care are those that center transgender and gender diverse experiences, with the understanding and assertion that being transgender is an identity and not a disorder.⁶ Although affirmative counseling approaches exist for gender minority persons, most counseling methods continue to focus on pathology and diagnosis.⁷ Collectively, this focus has led people in the gender minority community to mistrust healthcare personnel, services, and institutions.^{5, 7–9} It is noteworthy that advocates for gender minority persons continue to argue against the diagnosis of “gender dysphoria” listed in the fifth and earlier editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM),¹⁰ arguing that the term pathologizes gender minority persons in much the same way as ‘homosexuality’ pathologized sexual minority persons prior to removal of this word from the DSM in 1973.^1,11 Despite these troubling considerations, what is known from the literature is that gender minority persons can develop resilience to mitigate psychological distress. For example, diverse sources of social support, such as peer support, family support, and identifying pride initiatives, have been shown to ameliorate psychological distress among gender minority persons by providing a social environment that affirms rather than stigmatizes various gender identities.^2,7,12,13

However, there is a gap in the related literature in investigating the outcomes of peer-led support groups from the perspectives of gender minority persons receiving this gender affirming service. Addressing this gap might be useful in determining positive changes that gender minority individuals prioritize for their own health and well-being, rather than selectively choosing the desired outcomes to be achieved from the limited available literature and standard instruments. Thus far, the predominance of literature related to peer support for gender minorities (online or in-person) focuses on suicidal ideation and associated mental health diagnoses and/or symptomology.¹⁴ This is important because the use of standardized behavioral health symptomology scales used by researchers can be experienced as distressing or stigmatizing by research participants identifying as gender minority persons. Many existing instruments have been developed with a dominant cultural group, typically cisgender heterosexual persons, as reference. This can contribute to the existing mistrust of both the medical establishment and academic investigators and a consequent reluctance to participate in research. Such reluctance has contributed to gender minority persons often being referred to as a ‘hard-to-reach’ population for researchers to access, engage, or retain for health-related research.^15–17

The purpose of the descriptive qualitative study reported in this paper was, therefore, to identify gender minority persons’ perceptions of their experiences in a peer-led support group organized specifically for gender minority identifying persons. Of particular interest were each person’s priorities for their well-being. The paper also includes an interpretation of the study data and themes within the context of Roy’s Adaptation Model (RAM).¹⁸ RAM is a nursology conceptual model that addresses individual and group responses to environmental stimuli that are observed as physiological and psychosocial behaviors. Adaptation is reflected in behaviors that are more or less integrated. Nursing practice actions occur as management of the environmental stimulus most responsible for adaptation and those environmental stimuli that contribute to adaptation. The interpretation of the data for the themes was done to identify stimuli associated with adaptation and management of stimuli as ways to inform nursology practice, research, and advocacy related specifically to care of gender minority persons.¹⁸

METHODS

Design

In a way that would engage community members in the research process, the study was conducted in collaboration with community partners from a resource center that sponsored the peer-led support groups provided to local gender minority persons. In brief, this study involved community partners in dialogue with the research team across all phases of the study, including data analysis and findings.¹⁹ Community partners included both co-founders and co-directors of the resource center providing the peer-led support groups, as well as the facilitators for the peer-led support groups. The interdisciplinary research team included a nursologist researcher and clinician (the first author of this paper), a medical and cultural anthropologist, and a trans-identified family studies and human development scholar. The second author of this paper was not involved in the design or identification of the themes discovered in the study data.

Collectively, the research team has done extensive work addressing various healthcare needs of transgender populations. The research team sought to encourage an empowering and power-sharing process attending to social inequities by centering gender minority people’s experiences and perspectives of changes or outcomes (which are usually defined independently by ‘experts’) related to participation in the peer-led support group. The theories of minority stress and intersectionality influenced the initial thinking about the study (see Box 1 for Minority Stress and Intersectionality Theories).^20–24 This influence is important as it is among suggested best practices in developing a gender affirmative research approach that acknowledges vulnerabilities in marginalized populations and how race, class, sexual orientation, and other important identities are essential to, and inseparable from, a person’s experiences.^6,25 However, the theories admittedly did not dictate or serve as a formal framework for the actual design of the study or the data analysis. Instead, the study proceeded with its basis in community engagement. Hence, the design was based on a need for a descriptive qualitative study evident both in the literature review and in discussions with the community partners. The data analysis proceeded as a simple content analysis without an explicit theoretical base.²⁶ The extent to which any implicit theory or theories influenced the data analysis is not known.

Box 1. Minority Stress and Intersectionality.

Minority stress theory is based on the premise that sociocultural prejudice and discrimination cause minority stressors that can have negative mental health implications for members of minority populations.²⁰ These can be described as either distal stressors (those that involve direct experience of discrimination related to one’s identity) or proximal stressors (those negative beliefs about one’s identity and the associated stress of concealing that identity).²⁰ Specifically, minority stress theory has focused on stigma faced by sexual minorities and has been more recently been used to focus on gender minority populations.¹¹

Intersectionality theory considers the meaning and consequences of belonging to multiple stigmatized and oppressed social groups. It was initially developed by African American feminist legal scholar Kimberle Crenshaw²¹ to describe oppression experienced by African American women, who had been overlooked by research that traditionally studied gender and race separately. More recently, intersectionality theory has been applied to understand resiliency²² in the context of multiple minority stressors. Intersectionality scholars have argued for more systematic inclusion of gender minorities in research.^23,24

Sample

Recruitment flyers were placed at the resource center where the support groups took place and on the resource center website. Snowball sampling was also used to recruit people, wherein people who had already participated in the study used their social networks to encourage other potential participants to contact the researcher to take part in the study. This study was limited to people participating in, or having participated within the past year, in a peer-led support group. This was in an effort to capture those for whom recollection might be more reliable and reflective of the current support groups. Participants were required to be18 years of age or older; self-identified as a gender minority person; comfortable participating in the interview in English; and consenting to audio recording of the interview. Although the resource center had recently begun a support group for parents of transgender and gender nonbinary youth, inclusion of parents and those under the age of 18 years was beyond the scope of resources for this study. A total of 24 participants met the inclusion criteria and participated in the study.

Instruments

A demographic form developed by the first author in collaboration with community partners, was used to learn of people’s characteristics, such as length of attendance at support groups, age, sexual orientation and gender identity, area of residence, and participation in any individual counseling sessions. Sexual orientation and gender identity questions were written referencing best practices recommended by the Williams Institute.²⁷ Race and ethnicity questions were developed following guidelines from the US Census bureau, and areas of residence as rural, suburban, or urban were described by average population size as defined by the US Census Bureau.

The semi-structured interview guide, which was informed by topics identified in the literature and developed by the research team, included open-ended questions related to participation in a peer-led support group (see Box 2 for Interview Questions). Furthermore, the interview questions were based on discussions with the community partners. The questions were designed to yield descriptions of the peer-led support group structure and organization, as well as to obtain the perspectives of the people who participated. For example, people were asked what they would tell a friend who was interested in coming to the support group, but who wanted to know more about what the support group was like. People also were asked what changes they already had experienced happening in themselves or in their life as a result of their participation in the support group, as well as what changes they hoped would happen if they continued to participate in the support group. These questions were designed to elicit responses from people that might speak to experiences that were for them important to their participation in the peer-led support groups. In addition, each person was asked about their specific gender identity and the unique causes of stress for others sharing that identity.

Box 2. Interview Questions.

• Since you have participated in the peer-led support groups here in [city] if one of your friends was interested in coming to the support group but wanted to know more about what the support group is like, what all would you tell them?

• Are there any other aspects of the support group that you think are important to mention?

• Your mentioned identifying as [gender identity]. We want to understand the unique causes of stress for people who identify as [gender identity]. What experiences in your life have sometimes made it feel stressful to be [gender identity]?

• In addition to identifying as [gender identity], you also mentioned identities like race, ethnicity, sexual orientation, rural or urban location. Are there other important identities that also make up who you are?

• It could be that you’ve already experienced some changes in yourself or in your life because you’ve been in the support group. What things have you already seen happening in yourself or in your life because you’ve been in the support group?

• What things do you hope will happen in yourself or in your life as you continue to participate in the support group?

Data Collection

All data were collected by the first author, who has extensive experience in interviewing gender minority persons in both clinical practice and research settings. Prior to beginning the interview, the people were asked to complete the demographic form. They retained the form throughout the interview for their use as a potential reference to reflect on their peer-led support group involvement. This encouraged each person to reflect on the potential influence of peer-led support group participation related not only to gender identity, but also to other aspects of their identity or individuality. Interviews took place at locations suggested by the people participating. Chosen locations helped to ensure that the people participating felt safe and relaxed, and could therefore talk openly. Interviews were audio recorded with each person providing a single interview that lasted an average of 60 minutes.

Ethical Considerations

The study was approved by a university institutional review board. The study was also reviewed, discussed, and accepted by the cofounders and peer-support leaders of the gender minority resource center. Each person gave oral informed consent to be interviewed and have the interview audio recorded. It was understood by the researchers and community partners that some participants in this project might not be publicly open (‘closeted’) in certain respects or in certain settings with their gender identity. For some or many, this protection from self-exposure might involve concerns for personal safety. Given this consideration, the researchers requested and obtained a waiver of consent, as a signed consent form would be the only record linking the participant to the data. At the time of consent all inclusion criteria were orally verified, with the participant attesting to meeting all inclusion criteria by oral agreement prior to participation in the interview. All interviews were recorded on a password protected recording device and placed in a securely locked briefcase. Password encrypted recordings were then sent to a transcription service with a history of successful protection of research data for prior studies.

Data Analysis

Individual interviews were transcribed verbatim. Content analysis,^26,28 which is used to organize descriptions of perceptions of feelings, behaviors, and experiences into meaningful distinct categories or themes, was used to code the answers to the interview questions. The unit of analysis was each person’s words, phrases, sentences, or paragraphs that expressed answers to the interview questions. Trustworthiness of the data was estimated by first comparing themes concurrently and independently identified by two members of the researcher team, each of whom is experienced in qualitative data analysis and in working with gender minority persons. They iteratively reviewed and modified themes until consensus was reached. Subsequently, the third member of the research team conducted an audit trail that supported the themes identified by the first two researchers. The themes were further compared with field notes from a journal written by the researcher (the first author of this paper) who had collected the data, and were used in reflexive analysis.

The themes emerged seemingly de novo from the people’s answers. It is, however, recognized that the data analysts may have had implicit perspectives in mind as they coded the answers and as they developed the themes.

Roy’s Adaptation Model

The second author, who is widely recognized for expertise in use of nursology conceptual models and has conducted several studies guided by RAM²⁹, reviewed all interview data and the themes that emerged from these data and then interpreted these data within the context of a nursology conceptual model (RAM for this paper), as had been done in two other publications.^30,31 As the interpretation proceeded, both authors engaged in extensive dialogue to determine which RAM concepts reflected which themes, avoiding a “forced fit” between RAM concept and themes. The interpretation of the data for the themes involved comparison of the data for each theme with RAM concepts, including focal and contextual stimuli; coping processes; physiological, self-concept, role function, and interdependence adaptive modes; management of stimuli; and adaptation level. The focal stimulus is the stimulus most responsible for adaptation, and the contextual stimuli are those stimuli that contribute to adaptation. Responses to stimuli are mediated by innate and acquired cognator and regulator coping processes.¹⁸ Cognator coping processes encompass perceptions, processing of information, learning, making judgments, and expressing emotions. Regulator coping processes, which were not relevant for this study, deal with autonomic nervous system activity.

Physiologic mode responses to stimuli address the interaction between the person and environment in terms of all bodily functions, including oxygenation; nutrition; elimination; activity and rest; protection; the senses; fluid, electrolyte, and acid-base balance; neurological function; and endocrine function.¹⁸ Self-concept mode responses are behaviors that pertain to the physical and personal aspects of self. The physical self includes body sensations (feelings, attitudes, and sense of symptoms about one’s physical body) and body image (how people perceive their appearance). The personal self encompasses self-consistency (maintenance of a consistent way of being), the self-ideal (what each person would like to be or can be), and the moral-ethical-spiritual self (one’s personal beliefs and understanding of one’s place in the universe).¹⁸

Role function mode responses focus on the roles each person takes on throughout life, based on age, gender, developmental state (primary role), occupation and relationships with family members, such as child, parent, relative (secondary roles), and organizational memberships that typically are associated with secondary roles.(tertiary roles).¹⁸ Interdependence mode responses deal with the person’s feelings of adequacy of relationships with significant others and feelings about giving and receiving love, respect, and support.¹⁶

Management of stimuli is directed to maintenance or modifications of focal and/or contextual stimuli by means of nursology interventions The four adaptive modes are interrelated and are manifested as an overall adaptation level, which may be compromised (an adaptation problem stemming from inadequate integration or compensation in life processes), compensatory (manifested as challenges to integrated life processes), or integrated (life processes work holistically to meet the person’s needs).¹⁸

FINDINGS

Initial Findings

In terms of demographics, most participants were white, resided in an urban area, had attended the peer-led support group twice each month for 1 to 2 years, and had received private counseling within the past year. Participant demographics were aggregated and not assigned to individual quotes in an effort to protect confidentiality (See Table 1 for Complete Demographics). Briefly, peer-led support groups met twice per month with separate groups for persons identifying as transmale, transfemale, and/or non-binary. All groups were described as loosely structured with an average attendance from five to fifteen people. Topics or conversations were often described as developing organically and without agenda. Occasionally however, groups might request a guest speaker to address specific topics of interest such as gender affirmative hormone therapies, or legal information and documentation related to changes to birth certificates, or state identifications. All groups reviewed rules prior to the start of every meeting including the maintaining of confidentiality as well as respect for names and pronouns.

Table 1.

Demographics N=24

	Categories	N
Length Attending	Greater than 5 years	2
	3–4 years	4
	2–3 years	5
	1–2 years	10
	Less than one year	3
Attendance within past year	Monthly	3
	Twice Monthly	12
	Four to six times a year	5
	Once or twice a year	4
Private Counseling	Yes	18
	No	6
Age	Less than 25 years	5
	26–35	6
	36–45	5
	46–55	5
	56–65	2
	66 years and older	1
Sexual Orientation	Gay	2
	Lesbian	7
	Bisexual	5
	Heterosexual/Straight	1
	Additional Identity	9
Gender Identity	Transgender man/Transman/Trans masculine	6
	Transgender woman/Transwoman/ Trans feminine	11
	Genderqueer/Gender nonconforming/gender nonbinary	5
	Additional Identity	2
Race/Ethnicity	White	15
	Hispanic, Latino, or Spanish Origin	5
	Black or African American	0
	Asian	0
	American Indian or Alaska Native	3
	Native Hawaiian or Other Pacific Islander	0
	Multiple races	1
Current Residence Description	Rural (no more than 2,500 people)	1
	Micropolitan (more than 2,500 but not more than 50,000)	2
	Metropolitan (large central population of 50,000 or more)	21
Total Household Income	Less than $25,000	16
	$25,000 to $34,999	1
	$35,000 to $49,999	1
	$50,000 to $74,999	5
	$75,000 to $99,999	0
	$100,000 to $149,999	1
	$150,000 or more	0

Seven initial themes that captured the people’s experiences and outcomes of the peer-led support groups emerged from the content analysis of the study data. The themes were: 1) Exploration, 2) Self-Acceptance/Self-Determination, 3) Identity, 4) Safety, 5) Stressors (with sub-themes of Internal Stressors, External Stressors, and Intersectional Stressors), 6) Community Engagement, and 7) Improved/Positive Outlook. A brief description of each theme is given in table 2. (See Table 2 Themes and Descriptions)

Table 2.

Themes and Descriptions

Theme	Definition
Exploration	Defined as ‘figuring it out’ as related to transitioning, names, and pronouns; exploration of how to access information and services, considerations of presentation, as well as exploration of existing or developing relationships/attractions related to the process of transitioning.
Self-Acceptance/Self-Determination	Self-Acceptance is defined as comfort in disclosing gender identity to others, with their sexual attractions, presentation and appearance, such that physical appearance matches their desired or ideal gender expression. Self-Determination is defined as discussions related to autonomous decision making related to gender expression, having influence on others’ views of gender, and a positive sense of one’s future.
Identity	Defined as multiple aspects of self, including but not limited to gender identity, as well as identities related to shared interests or hobbies. Includes larger conceptual acknowledgement of identity beyond a categorical measure and the relation of identity and language, particularly familial and kinship language expressed by identifying as non-binary.
Safety	Defined as safety in ‘being out’, ‘passing’, the immediate nature and unpredictability of being unsafe, as well as safety in multiple contexts such as with family members, ‘being clocked’ or being seen as trans, and histories of personal and/or collective trauma, vulnerability to violence, and underground economies.
Stressors  • Internal Stressor  • External Stressors  • Intersectional Stressors	Internal Stressors are defined as the personal/interpersonal stressors that refer to past experiences not aligning with current gender identity, feeling that something is wrong with self or feeling at fault, a sense that one’s gender makes others (including friends, family, partners) uncomfortable. External stressors are defined as the structural aspects of healthcare, knowledgeable personnel, the general public, required evaluations for gender affirmative hormone therapies and/or surgeries, navigating legal requirements in name, gender documentation, and acknowledging the challenges/dangers posed by a prescriptively binary social and legal order. Intersectional Stressors are defined as discussions related to navigating/disclosing/withholding aspects of identity within varied contexts, including but not limited to gender identity, ethnic and tribal identities, and sexual identity.
Community Engagement	Defined as having the opportunity to share personal experiences as gender minority, sharing of resources and information, and importance of giving back to the larger gender minority community, and the opportunity to role model.
Improved/Positive Outlook	Defined as most often expressing feeling confident, happy, and excited about the future, as well as feeling that self matters as well as acceptance of uncertainty.

Initial Findings Interpreted within the Context of RAM

The themes identified in the initial content analysis were later interpreted within the context of RAM.¹⁸ The interpretation includes a link between each theme and one or more concepts of RAM, along with quotations found in the study data. Some themes included content that is consistent with more than one adaptive mode, which supports the interrelations of modes.

Self-Acceptance/Self-Determination (2) and Stressors (5) as Focal and Contextual Stimuli

The theme of Self-Acceptance/Self-Determination is reflected in the RAM concept of stimuli. The decision to ‘come out’ or disclose ones’ gender minority identity to self, to family members, friends, and/or partners reflects elements from Self-Acceptance/Self-Determination, which may be considered the focal stimulus. Examples of Self-Acceptance/Self-Determination as the focal stimulus are evident in these comments:

“I came out when I was in my 60s. …I learned a lot about what it meant to be transgender…everything…pointed to me being a transgender woman. When I realized that, I came out. The male persona faded away…and it was amazing. It was all over.”

“I like to be out in general because for me, visibility is important. …to me…being out as a trans person who is pretty happy and pretty…stable in their life and has a passion for something. I think that it’s important to show to the world that you can be trans and not be suffering all the time or have to be traumatized.”

Self-Acceptance/Self-Determination elements reflective of contextual stimuli often pertain to when and where the person identified as a gender minority came out. Examples from the data are:

“My sort of coming out story is that as a child, I didn’t really understand ‘gender’. I just knew who I was and who I was is quite feminine…I finally reached the point where I knew what I needed to do and went through with it.”

“And then once I came to [city], I was like, I don’t know anybody. I can be me…I don’t have all the people with expectations of who I was.”

Elements of the Stressor sub-theme of Internal Stressors reflective of contextual stimuli pertain to responses to one’s coming out or being out by family members, partners, and friends, or others to whom participants described as being particularly close. This closeness was demonstrated or stated as being central to the core of participants’ affective lives and identities, often manifesting in observed sadness, frustration, or uncertainty among participants.

Examples are:

“My wife and kids…are the biggest issue. Because my wife, when I came out to her, she told me in no uncertain words that no, I will not be a lesbian. So, I’m not going to be married to a woman. So, you can forget that. You better not be bringing this up around our kids.”

“A lot of preconceived notions and assumptions about behavior and interests [are] really weird. Like when I came out to my first boyfriend, he was just like oh so, you want to be the girl? So, does that mean you want to be submissive? I was just like no, that’s not what that means.”

Elements of the Stressor sub-theme of External Stressors reflective of contextual stimuli pertain to healthcare personnel’s and the general public’s responses to one’s coming out or being out. An example is:

“I haven’t had any nasty, nasty experiences seeking medical care outside of home, but I’m still cautious. You know, if I’m not on home turf then that’s always a big stressor. I think every trans person I’ve talked to that we’ve had that conversation, it’s a big stressor.”

Elements of the Stressor sub-theme of Intersectional Stressors reflective of contextual stimuli are related to experiences of coming out or being out in consideration of ethnic and tribal identity, and identity related to emotional, romantic, or sexual attraction.

“I don’t like people assuming that I’m a cisgender male because they are assuming this about me that are not true about myself. Like you know, I’ve had people think that because I’m Mexican and I look like this gender guy, that I must be a macho guy. That I must carry that Mexican machismo with me and that’s not who I am at all…So, I like to be out as trans to people whenever I can.”

“Probably just a platform that I can build up on…Because I am Navajo…just recognition for myself and telling the world…who I am. Not through First Nations…but through the peer-led group of me just going in one day and really finding out who I am and knowing where I stand independently and not as a group.”

“I also identify as a lesbian, which makes things somewhat more difficult for me…Identifying as a lesbian when I’m a non-binary assigned male at birth person always feels like a minefield just because of the attitude that if you transwomen don’t exist, then these ‘men’ cannot be lesbians.”

Exploration (1) as Cognator Coping Processes

The theme, Exploration, reflects RAM cognator coping processes.¹⁶ The cognator coping process is especially evident in the “figuring it out” aspect of Exploration. The person identifying as a gender minority engages in learning about their body and presentation in relation to gender expression and affirmation; how to enhance or de-emphasize certain parts of the body, how to tie a tie, and/or discussing surgical options and considerations.

When asked about their experiences in the peer-led support group, everyone indicated that the discussions provided information about practicalities of coming out (such as obtaining a new birth certificate or a new driver’s license) and acknowledged the affective aspect of living as a person identifying as a gender minority. Other comments found in the data emphasized the information gained from members of the support group was the need to learn or navigate the process of transitioning, and beginning to perceive themselves within a particular sexual orientation. As one person stated,

“I put asexual or demisexual because I’m not really sure. Who knows with changed dosages or changed meds and changed administration of estradiol, it could change again. But I put lesbian because I’m strictly esthetically atttracted to women and asexual or demisexual because I’m not sure if maybe when I have that connection with a person, that I will be sexually attracted to them, but maybe not. I don’t know.”

The cognator coping process also is evident in the emotionality underlying some comments about how people have navigated various processes in affirming their gender identity. An examples of one such comment is:

“I just get such energy from it. I can’t see myself stopping. It’s not like a drug. It’s not like I’m hooked on it, but I just get a wonderful sense of well-being from being around others who are going through what I went through.”

Exploration (1), Identity (3), and Improved/Positive Outlook (7) as Self-Concept Mode of Adaptation

The theme of Exploration is reflected in the physical self aspect of the self-concept mode. An example of a comment about the physical self is:

“I’m 60 percent sure about T[estosterone] but…I just have some sensory issues and I’m not looking forward to having a beard and being all hairy”

“With hormones…loss of muscle strength was difficult getting used to…I started to need help opening a salsa jar.”

Exploration also reflects the personal self aspect of the self-concept mode. An example of a comment about the personal self – self consistency is:

“The best thing is that we don’t judge one another for who we are...so you can be yourself. You can tell people the truth and how you really feel. That really helps you come to terms with who you are in your own mind. Which is the most important thing for somebody who is transgender.”

The themes of Identity and Improved Positive Outlook reflect the self-ideal aspect of the self-concept mode. An example of a comment about the personal self – self ideal is:

“Well, it would be nice to get to a point where I don’t need [the support group]. Although, then I would do it just to help somebody that is starting or has problems. My life is much better now since when I first started coming there…basically, I’ll end up helping other people.”

Noteworthy is that none of the initially identified themes reflect the moral-ethical-spriritual self aspect of the self-concept mode.

Community Engagement (6) and Safety (4) as Interdependence Mode of Adaptation

Much of the content reflecting the interdependence mode was evident in the theme of Community Engagement related to ‘giving back’ to the peer-led support group after having achieved at least some improvement in their unique experience as a gender minority person. As one person stated,

“What’s next for me is to teach these girls and to help them educate themselves that sex work isn’t all that it’s glamorized to be in their head. Because a lot of girls see that…as a quick buck. But then it leads to drugs and alcohol and all of these other things that surround the sex work arena. So, what my personal goal is out of this peer support group would be to educate the girls more on the things that they really desired when they were kids…and teaching them not to let go of their dreams.”

Other content reflecting the interdependence mode was evident in the theme of Safety. A typical comment is:

“I like to be out as trans in my life as much as I can. But also, to be mindful of is it safe to do so? Safe anywhere from just being subject to invasive questions all the way to am I going to be physically harmed in this space?”

Self-Acceptance/Self-Determination (2) as Role Function Mode of Adaptation

The theme of Self Acceptance/Self Determination contains some content that is consistent with the role function mode. Examples of comments found in the data are:

“Even though I’ve got friends and I’ve got social connections, it still helps me on some level really getting that mirroring. You know, I see the magic of a transgender person too….that’s a person that’s really seen both the male and female worlds from the inside out.”

“When I started coming to the support groups here, I had no idea what it meant to be a trangender woman. I didn’t have a clue. I mean, that stuff I read online was one thing. But actually living it, I had no reference points. So I learned how to be myself coming to the support group because I really had no idea.”

Exploration (1) as Management of Stimuli

The theme, Exploration, contains some content that reflects the intervention component of RAM, that is, management of stimuli. Specifically, several people described ways in which the support groups provided practical information related to services throughout the local area that provide gender affirmative and/or knowledgable care, as well as useful and varied information related to exploration. Others discussed the importance of providing a validating space for one’s gender identity as essential to their emotional well being. Examples of comments that underscored the effectiveness of this type of support and recognized it as a valuable service are:

“To have that resource where I can just walk in and have just this instant group of people know what you are going through and who you can get advice from and who actually know about resources…whether its medical or hair removal or just even mentally like where to go for a haircut and places to avoid.”

“One member of our group had some problems with their doctor [who] had started them on hormones and then hadn’t check their levels in over 6 months. You are supposed to check your hormone levels every three months…so, it was a real concern. So, they are changing doctors now.”

A New Theme: Authenticity as Physiological Mode and Self-Concept Mode of Adaptation

A new theme, Authenticity, was uncovered in the data as the interpretation of themes proceeded. Given that authenticity as a moral ideal has been discussed at length within various philosophical schools of thought,³² the two authors of this paper agreed to define this theme as the principle of being true to oneself, that is, living authentically. Most importantly is that the theme, Authenticity, emerged from the data of the people’s experiences, rather than from a sociological, biological, or other externally applied construct.

This theme was found to reflect the physiological mode and the moral-ethical-spiritual self component of the self-concept mode. The data indicated that living authentically presented challenges to the people who attended a peer-led support group.

Authenticity as the Physiologic Mode of Adaptation

The newly identified theme, Authenticity, is consistent with the the physiologic adaptive mode. Some, but not all people, mentioned gender affirmative hormone treatment as important to their gender affirmation, which reflects endocrine function. For example, one person mentioned the difference beween a current specific estrogen level (suggested by medical guidelines) and an ideal level (or the level at which the person feels their gender is affirmed, albeit at a lower level than the suggested guidelines). Others mentioned the physiological effects of testosterone and estradiol.

Authenticity as the Moral-Ethical-Spiritual Self Component of the Self-Concept Mode of Adaptation

The new theme, Authenticity, also is consistent with the moral-ethical-spiritual self aspect of the self-concept mode. Most if not all of the challenges of living authentically relate to gender identity, expression, and lived experience, which were weighed against a sense of security in being out in particular contexts or situations. Examples of the importance of living authentically are evident in these comments:

“The best thing in the world is coming to the group and everybody knows that I’m a woman and they know my name and they care about how they address me…and so you can be yourself.”

“They can come here no matter who they are. They identify as someone different than what society sees them as and they are accepted here…I’ve seen a lot of the girls come to acceptance with themselves. Because they don’t want to hurt themselves anymore because they don’t feel like they are different. They feel at home.”

“I like to say that passing is a privilege but visibility is an even greater privilege. I know that passing has helped me in a lot of different areas of my life…But I think the places that I feel healthiest and sort of happiest are around people who know that I’m trans.”

Adaptation Level

Taken as a whole, our interpretation of themes within the context of RAM indicate that some people had progressed from compromised adaptation to at least compensatory adaptation. Many, however were experiencing integrated adaptation.

DISCUSSION

The themes discovered in the study data were developed from participants’ experiences of attending a peer-led support group. The RAM interpretation revealed that the themes were consistent with the concepts of RAM, and that the RAM provided guidance for identification of a theme that had not been identified in the original study data. Of note is that no data reflected the regulator coping process, which is not surprising as data for the autonomic nervous system were not thought to be relevant for this study. Placing the themes within the context of RAM provided a distinctive nursology perspective that includes potential implications for explicit nursology based assessment of, and interventions for, gender minority identifying persons who are attending, or wish to attend a peer-led support group.

Assessments based on identified focal and contextual stimuli from this study might be useful in both behavioral health and healthcare assessments that attend to gender minority persons’ health related needs. In terms of behavioral health, preparing for and providing a welcoming and affirming space for gender minority persons that asks for and is respectful of a person’s gender identity (including use of correct name and pronouns) might be a reasonable consideration among nursologists in addressing the contextual stimuli of negative experiences with healthcare personnel, particularly as they relate to the gender minority person’s being ‘out’. In addition, understanding the complexities of being out for gender minority persons might help to identify individual needs and areas for further exploration, discussion, and planning that might potentially move beyond singular considerations of gender identity.

In terms of healthcare assessments, it is helpful for nursologists to understand the needs of gender minority persons as they relate to the level of desired medical interventions, or lack thereof. In cases where medical intervention is desired, it is important (as an example) for nursologists to understand how people feel as a guide toward effective affirmative hormone therapy rather than merely referencing recommended laboratory levels. It is also helpful for nursologists to understand the limitations to informed consent models in terms of what is known/might be expected from gender affirmative hormone therapies. Referral to peer support, however, might provide valuable personal insights for those gender minority persons considering such therapies as an opportunity to further assist in their decision-making process.

Noteworthy was that many persons who participated in the study experienced integrated adaptation, which is of clinical value to nursologists providing care for gender minority identifying persons and moves away from gender minority identity as pathological. Both the initially identified themes and RAM interpretation of themes provide insight for the type of support a peer-led support group located in the Southwestern United States provides to others who identify as gender minority persons. In various community healthcare environments, knowing available community resources available to clients is considered vital among nursologists. This is particularly the same in areas with limited resources or access to behavioral health services and/or gender affirmative medical care. Although this is not to suggest that peer-support is to replace or make up for professional behavioral health services or other specific healthcare, understanding the potential usefulness of peer support is imperative. Nor is this to suggest that results from this peer-led support group are necessarily the same as for other support groups. However, our results do suggest ways in which nursologists might follow through with persons who have been referred to similar support groups in their community. Of particular importance, follow through might initiate a dialogue to determine possible limits of community support and elucidate specific needs of the individual that might not be supported or provided by peers. Conversely (and if applicable), follow through might also suggest limitations to professional counseling and to help determine the intersection of community support and clinical practice that complement one another and help inform professional behavioral health strategies in working with gender minority identifying persons. In short, the shared experiences of the peer support participants were an essential supplement to a cisgender biomedical paradigm.

Given the pervasive mistrust toward healthcare environments among gender minority identifying persons, knowing how to actively follow through with community level referrals might provide an opportunity to foster trust. ^5,7–9 This might be of particular value should the person require more professional behavioral health interventions. In addition, referral to community level support might be a reasonable suggestion for those considering seeking gender affirmative medical therapies. Although informed consent models cover most of what one might expect from gender affirmative medical therapies, discussions among peers might prove helpful in an individual’s decision-making process.

This study findings and RAM interpretation also provide insight for nursologists to better understand the ways in which the dynamics of socially prescribed expectations related to gender have potential to adversely affect the lives of gender minority clients to the extent of having to navigate spaces in a way that necessarily must consider ones’ immediate safety, as well as potential stressors. This insight might offer an opportunity for educating colleagues who are not knowledgeable or supportive of gender minority identities or healthcare needs as to what is at stake in their reticence related to professional inclusive patient-centered healthcare.

Lastly, the overall study results support findings from similar research with gender minority communities as they relate to the moderating effects of peer-support on stigma and discrimination ^2,12,33 The findings of this study also present the unique perspective of gender minority persons participating in peer-support services provided in one of the least densely populated states in the US, with substantial Hispanic, Latinx, and American Indian populations. This in contrast to the bulk of research with gender minority communities from large coastal urban locations.³⁴ In addition, findings reported from this study are currently being used to develop an outcomes measurement tool that is affirming to gender minorities and used as part of a community engaged evaluation of our community partner’s gender minority peer-led support groups as well as the potential to evaluate similar peer-support programs in the future.

Limitations

The study was limited to a small sample of English speakers and all participants were from the Southwestern United States. A small sample size might be viewed as a limitation to this study, although it is recognized that qualitative studies often have small sample sizes to describe the experiences of individual participants, rather than larger samples that might be representative of a population.

In addition, transmale and nonbinary persons were underrepresented compared with transfemale persons in this study. Transferability of the themes discovered in the study, as well as the new theme discovered in the RAM interpretation is limited as recruitment information about the study was distributed through the resource center and its associated website. Future research is needed to determine the extent to which the themes reported in this paper and RAM interpretation are applicable to other gender minority persons.

Although qualitative studies may have limited transferability due to comparatively small samples, we maintain that they are valuable indicators of a range of views within a given population and how these views may be influenced. It is also worth noting that inasmuch as the people in this study often reflected on experiences of many years prior to their support group participation, recall bias may have distorted recollections of their experiences. To minimize recall bias, the first author/interviewer attempted to establish a climate that would enable the participants to recall experiences and events that occurred many years before as they related to their participation in the peer-led support group.