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Transgender Health logoLink to Transgender Health
. 2022 Oct 7;7(5):385–396. doi: 10.1089/trgh.2021.0011

A Scoping Review of Health Outcomes Among Transgender Migrants

Vanessa A Castro 1, Wesley M King 1, Laima Augustaitis 2, Kate Saylor 3, Kristi E Gamarel 1,*
PMCID: PMC9829141  PMID: 36644484

Abstract

Purpose:

Transgender people constitute diverse populations who experience a range of adverse health outcomes. Despite increasing awareness of adverse health outcomes among migrant populations, there has been a dearth of studies focused on the health of transgender migrants. The goal of this scoping review was to describe common themes and empirical trends in research on the health of transgender migrants and identify gaps for future research and programming.

Methods:

Using a systematic review protocol, we searched PubMed, Embase, Scopus, PsycINFO, CINAHL, and Web of Science with a combination of terms to identify empirical articles that examined health outcomes among transgender migrants. The search included studies published as of May 2019.

Results:

Twenty of 1666 identified records met inclusion criteria. All studies were cross-sectional, and 50% were quantitative designs, 45% were qualitative designs, and 5% were mixed-methods designs. The majority reported on sexually transmitted infections (55%), violence (40%), and mental health (35%). Qualitative studies were generally high quality, while many quantitative studies had high risk of bias. While some adverse health outcomes may abate, stigmatizing social conditions continue to impact transgender migrant's health postmigration.

Conclusions:

Anti-transgender and anti-immigrant stigma may contribute to adverse health outcomes for transgender migrants. Additional research using rigorous inclusive methods to survey a broader range of health domains is needed. The lives of transgender migrants are continuously upended by oppressive policies; therefore, it is vital to continue to expand the breadth of transgender health research.

Keywords: health, immigration, migration, transgender


Correction added on October 6, 2022 after first online publication of August 11, 2021: In the Results section of the abstract, the second sentence was updated from stating “there were an equal proportion of quantitative and qualitative designs” to “50% were quantitative designs, 45% were qualitative designs, and 5% were mixed-methods designs.

Introduction

Transgender is an umbrella term referring to individuals whose gender identity or expression is inconsistent with that typically associated with their sex assigned at birth.1 Across the globe, transgender populations face multidimensional forms of stigma and violence, which drive mental and physical health inequities in conditions, including depression, victimization, HIV and other sexually transmitted infections (STIs), and substance use.2,3 Many transgender people migrate to the United States and other countries in search of legal protections, economic opportunities, access to medical gender affirmation, and safety from anti-transgender stigma and violence in their countries of origin.4–9 In this article, the term migrant is used to refer to any individual intending long-term relocation in a different geographic area, including refugees, internationally displaced persons, asylum seekers, and immigrants. Evidence suggests that transgender migrants may bring with them histories of violence and trauma as they resettle, and anti-transgender and anti-immigrant stigma may continue to shape their health status during and after migration.6

Over the past 20 years, the number of migrants around the globe has increased, with most migration occurring between countries that rely on or supply migrant labor (e.g., Mexico and the United States; the United Arab Emirates and India), as well as from politically unstable countries to more stable neighbors (e.g., from Syria to Turkey and Lebanon).10 Populist political discourse has used this trend to garner support for xenophobic policies that endanger migrants’ health.11 In the United States, the Trump administration made sweeping reforms to immigration policy, including broadening deportation criteria, reducing refugee admissions, narrowing asylum eligibility criteria, and ending temporary protections of work eligibility.12 Furthermore, the revival of racist and xenophobic movements in Western European countries underlies widespread hostility and violent reactions to asylum seekers and immigrants.13,14

Simultaneously, stigma and violence against transgender people, especially transgender women, have risen in Latin American and Caribbean countries.1 This region accounts for 78.8% of murders of transgender people worldwide, and human rights advances protecting transgender and gender expansive people are being reversed.1 Transgender activists and sex workers are particularly at risk of experiencing stigma and violence from family members, intimate partners, health care workers, and law enforcement.15,16 Consequently, many transgender people from this region have migrated to the United States seeking escape from victimization.5 Media has reported that transgender migrants experience extreme discrimination in deportation centers in the United States, including poor quarantine procedures and inadequate health care.17

The intersectionality framework provides a useful perspective to understand the experiences of transgender migrants worldwide. Unlike cultural explanations for immigrant health outcomes which emphasize individuals’ assimilation or acculturation to their place of destination, an intersectionality framework allows for a structural analysis of how occupying multiple disadvantaged or stigmatized social categories influences immigrant health.18–21 The intersectionality framework holds that interlocking systems of oppression based on race, ethnicity, gender, class, and other social categories create inequities that uniquely affect individuals with multiple marginalized identities.19,20,22 When applied to migration and health, this framework suggests that analyses must account for how migrants’ intersecting identities may shape their experiences.18

Research has explored the complex social structures in which transgender migrants exist and reveals the unique needs of communities managing multiple and intersecting forms of marginalization related to their immigration status, gender, race, ethnicity, and class.4–10 For example, lesbian, gay, bisexual, transgender, and queer (LGBTQ) adults who have migrated to the United States have reported concerns about fear of deportation and access to health care.7 For transgender migrants, identification requirements for employment or health insurance may further exacerbate these concerns as those who are undocumented or who have been unable to legally change their name or gender marker may be further deterred from accessing these resources.4 This example illustrates how anti-transgender stigma and anti-immigrant stigma occur simultaneously and reinforce each other to limit transgender migrants’ economic opportunities and access to health care.4–6

In addition, transgender migrants who are racial or ethnic minorities in their new destinations experience racialization and racism.4,18 In countries where white Europeans are the dominant ethnic group, migrants with other ethnic identities experience racialization when sociopolitical norms and structures visibilize, otherize, and commodify their ethnic minority status.18,23,24 Transgender migrants may also have limited access to social networks or services available to other migrant groups who may provide emotional or instrumental support during the migration and protect against the impacts of racism because of anti-transgender stigma operating within migrant communities.25,26 That is, transgender migrants experience prolonged exposure to multiple forms of stigma in their countries of origin and new destinations.25,27,28 Taken together, this burgeoning body of literature highlights the importance of understanding how intersecting marginalized social identities may fuel health inequities among transgender migrants.25

There has been a growing body of literature documenting health inequities among transgender populations worldwide2,29; however, the health status of transgender migrants is not well understood. As such, we conducted a scoping review of the literature to better understand findings across geographic settings, identify gaps and methodological limitations, and provide guidance for future research.30 Scoping reviews are suggested when a body of literature is yet to be reviewed or is heterogeneous in nature, making it challenging to conduct a precise systematic review.30 Given the exploratory nature of our topic, this scoping review sought to describe common themes and empirical trends in research on the health of transgender migrants and identify gaps for future programming and research using rigorous methodologies.

Methods

Inclusion criteria

We included English language empirical studies that examined health outcomes in a sample of transgender participants who permanently migrated at some point in their lives. We operationalized “migration” broadly to encompass all experiences of long-term relocation, including displacement, voluntary migration, intranational migration, and international migration. We included empirical articles that used a range of methodological approaches to capture the breadth of existing research on transgender migrants. Studies that also included cisgender participants needed to present disaggregated data on health outcomes among the transgender subsample or, if qualitative, clearly indicate whether illustrative quotes came from transgender participants or whether themes applied to transgender participants. Consistent with the World Health Organization's definition of health, we included any primary empirical article that described a health outcome related to physical, mental, and social well-being.31 We did not place restrictions on publication date, study design, country of origin, or destination to avoid reducing specificity.

Literature search

We conducted a database search of PubMed, Embase, Scopus, PsycINFO, CINAHL, and Web of Science using a combination of two search strings developed through collaboration with a health sciences librarian (Supplementary Table S1). The first search string consisted of terms and medical subject headings (MeSH) related to transgender identities such as “Transgender Persons [MeSH]” and “gender minority.” The second search string retrieved records related to migration with vocabulary such as “refugee,” “Emigrants and Immigrants [MeSH],” and “undocumented.” The final search was completed on May 17, 2019.

After retrieving all records and removing duplicate citations, two authors independently reviewed each abstract. Records were discarded at this stage if both reviewers agreed that the titles and abstracts clearly indicated that the study did not meet inclusion criteria. Following this stage, the two authors independently assessed adherence to inclusion criteria in full-text versions of the remaining articles; when discrepancies arose, two additional authors served as tiebreakers. The tiebreakers read the full-text articles under question and justified inclusion or exclusion of each article to the rest of the study team based on evidence taken directly from the text. At this stage, the most common reason for exclusion was due to population criteria. This study was exempt from the University of Michigan Institutional Review Board review as all data came from extant peer-reviewed literature.

*Correction added: The number of qualitative studies originally read 47% and cited references “4,5,10,33–35,36.” The number of quantitative studies originally read 47%. The percentage of studies conducted in the U.S. originally read 63.2%. These statistics have been updated in the text. Additionally, the percentage of studies on HIV/STIs (k = 11, 57.9%), violence (k = 8, 42.1%), mental health (k = 6, 31.6%), accessing health care (k = 4, 21.1%), substance use (k = 4, 21.1%), and tuberculosis (k = 1, 5.3%) have been updated above.

Data extraction

Two authors independently recorded the following characteristics of each included study: study design, sample characteristics, sampling methods, theory or conceptual framework, research question, participant eligibility criteria, relevant findings, limitations, health outcome(s), and participants’ countries of origin. Although not required for a scoping review,30 we chose to assess study quality using the 2018 version of the Mixed Methods Appraisal Tool (MMAT).32 The MMAT allows for efficient assessment of qualitative, mixed-methods, and survey-based quantitative research and focuses on studies’ overall quality of evidence rather than on adherence to specific protocols. Two authors independently appraised each study. Discrepancies between authors regarding interpretation of study characteristics or quality metrics were resolved through discussion with the complete study team. The reported results reflect consensus agreements. The subsequent sections of this review summarize the findings regarding the health needs and outcomes of transgender migrants and evaluate the methodology of the 20 included studies (Fig. 1).

FIG. 1.

FIG. 1.

Flow diagram of search procedures.

Results

A total of 20 articles remained after 61 articles were further excluded [wrong population (k=26), not empirical (k=16), poster/abstract (k=9), no health outcome mentioned (k=6), not available in English (k=2), no access (k=2)].

Of the 20 reviewed studies, 45% were qualitative studies,4,5,9,33–36,48,49 50% were quantitative studies,37–46 and one used mixed methods47 (Table 1). The majority of the studies were conducted in the United States (65.0%). The remaining was conducted in Canada, Austria, the Netherlands, Italy, and Colombia. The majority of reviewed studies described HIV/STIs (k=11, 55.0%), violence (k=8, 40.0%), and mental health (k=7, 35.0%). The remaining focused on accessing health care (k=4, 20.0%), substance use (k=4, 20.0%), and tuberculosis (k=1, 5.0%). Table 2 presents the methods, relevant findings, and health outcomes of each of the studies.*

Table 1.

Characteristics of Studies

Characteristic Studies (n=20)
n (%)
Publication year
 Before 2000 1 (5.0)
 2001–2010 4 (20.0)*
 2011–2015 5 (25.0)
 2016–2019 10 (50.0)*
Location (not mutually exclusive)
 United States 13 (65.0)*
 Italy 5 (25.0)*
 Canada (Ontario) 1 (5.0)
 Austria (Vienna) 1 (5.0)
 Netherlands (Amsterdam) 1 (5.0)
 Colombia (Bogota) 1 (5.0)
Methods
 Qualitative  
  Interviews 4 (20.0)
  Focus groups 2 (10.0)
  Photo voice 1 (5.0)
  Document analysis 2 (10.0)
 Quantitative  
  Survey 6 (30.0)
  Medical chart review 4 (20.0)
 Mixed-methods 1 (5.0)
Health outcome (not mutually exclusive)
 Violence 8 (40.0)
 Mental health 7 (35.0)
 HIV/STI 11 (55.0)
 Access to health care 4 (20.0)
 Substance use 4 (20.0)
 Tuberculosis 1 (5.0)

STI, sexually transmitted infection.

Table 2.

Research on the Health of Transgender Migrants by Region and Country

Author (year) Location Study design Sampling method Sample Relevant findings Health outcome
Alessi et al. (2017) USA and Canada Cross-sectional qualitative interviews Purposive sample 26 LGBT adults; 2 transgender men and 2 transgender women Most participants migrated due to discrimination experienced because of their gender and/or sexual identity. Upon migration, participants experienced violence due to their immigration status, religion, and sexual and/or gender identity. Violence
Alessi et al. (2018) Vienna, Austria and Amsterdam, Netherlands Mixed-methods; quantitative survey and qualitative interviews Purposive sample 38 LGBT participants; 5 transgender women; 2 gender nonconforming; 1 transgender man 89.2% reported PTSD symptoms before migration. Most participants fled violence, abuse, family, war, government instability, and political persecution. Many participants described experiencing targeted violence from officials and other refugees during their migration journey. Violence; mental health
Bianchi et al. (2014) Bogota, Colombia Cross-sectional; qualitative interviews Convenience sample 26 migrants; 12 transgender women Transgender women experienced employment discrimination, which necessitated engaging in survival sex. Transgender women often experienced violence from clients and reported inconsistent condom use and low HIV testing rates. Violence; sexual risk; HIV testing
Cerezo et al. (2014) California, USA Cross-sectional; qualitative interviews Convenience sample 10 Latina transgender women Participants migrated due to discrimination; however, participants also experienced psychological distress due to a lack of emotional support, violence, and discrimination. In the USA, participants faced employment discrimination, which led to engaging in survival sex. Violence; mental health
Cheney et al. (2017) California, USA Document analysis Convenience sample 45 documents from transgender women asylum seekers from Mexico Participants had a poor quality of life in Mexico which included experiencing assaults and psychological distress Violence; mental health
Crepet et al. (2016) Italy Cross-sectional; quantitative survey Clinic based 3588 migrants; 194 identified as transgender 2.4% screened positive for at least 1 TB symptom. Trans patients had the highest probability of screening positive for TB TB
Gowin et al. (2017) USA Document analysis Convenience sample 45 redacted declaration documents and psychological evaluations from transgender women asylum seekers from Mexico Transgender women experienced a wide range of stressors, including verbal, sexual, and physical assault. All participants were diagnosed with PTSD. Although migration to the USA reduced stress, many continued to experience stress related to documentation status, income, and racism Violence; mental health
Hwahng et al. (2019) New York City, USA Cross-sectional; Qualitative focus groups Convenience sample 13 Latina transgender women Participants reported that support groups helped them form new support systems, access health care, build capacity, access educational and gender affirmation resources, and decreased alcohol use. Access to Health care, including gender affirming care; Alcohol Use
Leyva-Flores et al. (2016) USA Cross-sectional; quantitative survey Convenience sample 4075 Central American migrants; 0.71% identified as transgender Transgender participants had the highest HIV prevalence HIV prevalence
Nemoto et al. (2011) California, USA Cross-sectional; quantitative survey Convenience sample 573 transgender women with a history of sex work; n=200 migrants Not specified Migration status did not significantly predict depression
Nuttbrock and Hwahng (2017) New York City, USA Cross-sectional; Quantitative survey Convenience sample 199 transgender women Those who were foreign born had an increased odds of engaging in sex work and condomless sex. There were no differences by country of origin and HIV/STI incidence. HIV risk
Palazzolo et al. (2016) Washington, DC, USA Cross-sectional; qualitative interviews Convenience sample 8 Latina transgender women Most participants immigrated after experiencing violence in their country of origin. Participants who gained legal asylum reported greater control over their sexual relationships, improved access to services, and safer employment options. Legal name change was described as an important aspect of gender affirmation. Participants reported using nonprescribed hormone use and accessing HIV testing at Emergency Rooms. Violence; HIV risk; HIV testing; access to health care
Rhodes et al. (2013) North Carolina, USA Cross-sectional; quantitative survey Respondent Driven Sampling 190 MSM and transgender women; 31 transgender women Social support, sexual compulsivity, and self-esteem were associated with depressive symptoms. There were no differences between MSM and transgender women. Mental health
Rhodes et al. (2015) North Carolina, USA Cross-sectional; photo voice Convenience sample 9 Latina transgender women Transgender women experienced daily challenges, reported low accessing to gender affirming medical care, and engaged in unsafe coping strategies (i.e., alcohol, substance use, and condomless sex) due to stress Access to health care, including medical gender affirmation; substance use; HIV Risk
Sausa et al. (2007) California, USA Cross-sectional; qualitative focus groups Convenience sample 48 transgender women of color Sex work initiation often occurred through peers. Sex work was associated with violence, drug use, and STIs. Participants migrated to USA for a liberal and affirming society Violence; substance use; STIs
Spizzichino et al. (1998) Rome, Italy Cross-sectional; medical chart review Clinic based 528 patients at Drug Treatment/AIDS Unit; 167 identified as transgender One-third of transgender patients were engaging in sex work. HIV prevalence among transgender patients was 45.5%. Transgender patients reported lower heroin use but higher cocaine use than cisgender patients. Transgender patients living with HIV had greater retention in care and condom use than their cisgender counterparts. HIV risk; access to health care
Spizzichino et al. (2001) Rome, Italy Cross-sectional, medical chart review Clinic based 353 transgender patients HIV prevalence was 38.2%; patients from Brazil and those reporting a higher number of sexual partners had a greater odds of living with HIV HIV prevalence
Yamanis et al. (2018) Washington, DC, USA Cross-sectional; quantitative survey Convenience sample 38 transgender women Participants had a high prevalence of depressive symptoms (35%), lifetime suicide ideation (47%) and attempts (32%), and HIV prevalence (32%). Mental health; HIV prevalence
Zaccarelli et al. (2004) Rome, Italy Cross-sectional; medical chart review Clinic based 437 transgender individuals Approximately 31% were living with HIV and 15% reported injection drug use. Those who were living with HIV were more likely to not use condoms regularly HIV incidence; drug use; HIV risk
Zehender et al. (2004) Italy Cross-sectional; quantitative case–control; medical chart review Clinic based 393 immigrants; 31.1% transgender women All patients living with HIV and HTLV-1 were transgender women who engaged in sex work. Transgender women who engaged in sex work also had the highest prevalence of HTLV-2. HTLV-1 and HTLV-2 prevalence

HTLV, human T-lymphotropic virus; LGBT, lesbian, gay, bisexual, and transgender; MSM, men who have sex with men; PTSD, post-traumatic stress disorder; TB, tuberculosis.

*Correction added: Under the “Studies (n=20) n (%)” column, several rows have been corrected. In the “Publication year” section, the row “2001–2010” originally read 3 (15.5) and the row “2016–2019” originally read 11 (55.0). In the “Location (not mutually exclusive)” section, the row “United States” originally read 12 (60.0) and the row “Italy” originally read 6 (30.0).

HIV and other STIs

The majority of studies focused on HIV34,35,40–42,44–46,48* and other sexually transmitted diseases (e.g., human T-lymphotropic virus [HTLV]).33,43 Quantitative cross-sectional studies, which used survey methods and medical chart abstraction, showed a high prevalence of HIV ranging from 33–45.5% among transgender migrants in the United States44,46 and Italy.41,42,45 Nuttbrock and Hwahng found that transgender women living in New York City who were foreign born had increased odds of engaging in sex work and condomless sex compared to those born in the United States.40 There were inconsistent findings in two clinic-based studies regarding HIV risk behaviors in Italy. Spizzichino et al. found that transgender migrant patients living with HIV reported greater consistent condom use compared to their cisgender migrant counterparts.41 On the contrary, Zaccarelli et al. found that transgender migrant patients living with HIV were less likely to engage in consistent condom use.45

*Correction added: The studies cited here originally read “32,33,34,40,41,43–45” and have been corrected as above.

Qualitative studies of trans migrants illustrated that violence, discrimination, and stress were linked to HIV risk behavior, such as survival sex work, inconsistent condom use, and low HIV testing rates.35,48 For example, Bianchi et al. found that transgender migrant women reported employment discrimination which necessitated engaging in survival sex.48 Palazzolo et al. found that Latina transgender migrants living in Washington, DC, reported greater control over their sexual relationships and improved access to HIV prevention services after being granted asylum.34

Two studies focused on other sexually transmitted diseases. Zehender et al. found that transgender migrants in Italy had increased odds of being coinfected with HIV and HTLV-1 and had a higher prevalence of HTLV-2 compared to a control group of pregnant cisgender women.43 Using focus group methodologies, Sausa et al. found that sex work was associated with STIs among transgender women of color in United States; however, the authors did not specify the STIs.33

Violence

A substantial number (40.0%*) of studies found that transgender migrants experienced violence in their countries of origin, as well as upon migration. The majority of the qualitative studies conducted in the United States demonstrated that transgender participants migrated from their country of origin due to violence and discrimination attributed to their gender identity and/or expression.5,33,34 Sausa et al. found that safety motivated migration for many transgender women in the United States.33 Gowin et al. found that transgender women seeking asylum from Mexico experienced less violence once arriving in California; however, they continued to experience stress related to documentation status, income, and racism.49 However, there were divergent findings regarding experiences of employment discrimination upon relocating. One qualitative study found that some transgender women reported less employment discrimination upon migration.34 However, another qualitative study found that transgender migrants continued to face significant employment discrimination upon migration.5

*Correction added: the percentage originally read (42.1%).

Mental health

Studies that reported on the mental health of transgender migrants included post-traumatic stress disorder (PTSD) symptoms,49 psychological distress,4,5 depressive symptoms,39,44 and suicide ideation and attempts.44* The cross-sectional quantitative studies found a high prevalence of mental health symptoms. For example, Gowin et al. found that all transgender women migrating from Mexico to the United States in the sample were diagnosed with PTSD.49 Yamanis et al. found a high prevalence of depressive symptoms (35%), lifetime suicide ideation (47%), and suicide attempts (32%) in a sample of transgender women in the United States.44

*Correction added: The references cited originally appeared as depressive symptoms,35,41 and suicide ideation and attempts.41 These have been corrected as above.

Nemoto et al. found no association between migration status and depression in a sample of trans women; however, the overall prevalence of depression in this sample was high (48.7%).37

Studies also described the context of mental health. Cheney et al. found that transgender women who were seeking asylum from Mexico in the United States experienced violence in their country of origin, which resulted in psychological distress.4 Similarly, Cerezo et al. found that many of the participants experienced psychological distress due to a lack of emotional support, violence, and discrimination in their country of origin.5 Using cross-sectional quantitative survey methodology, Rhodes et al. found that low levels of social support, high levels of sexual compulsivity, and high levels of self-esteem were associated with greater depressive symptoms in a sample of migrant men who have sex with men (MSM) and transgender women. Although the authors did not conduct formal moderation analyses, they found that there were no significant differences between MSM and transgender women in their reports of depressive symptoms.39

Access to health care

Twenty percent of the studies reported on access to health care. Health care was defined as access to gender affirming medical care,9,35* retention in HIV care,42 and general health care access.34 Rhodes et al. found that Latina transgender women who had migrated to the United States had difficulty accessing gender affirming medical care.35 Other studies in the United States and Italy showed that transgender migrants had greater health care access upon migration. For example, Spizzichino et al. found that transgender migrants living with HIV in Italy reported greater retention in HIV care compared to their cisgender migrants.42 Two studies described potential ways of enhancing access to health care. Hwahng et al. found that support groups helped transgender women who migrated to the United States form new social networks, access general health care, and obtain educational and gender affirmation resources.9 Palazzolo et al. found that participants who had gained legal asylum had improved access to health care services; however, many of the participants were using nonprescribed hormones for medical gender affirmation.34

*Correction added: The reference cited originally appeared Health care was defined as access to gender affirming medical care,10,35 and has been updated as above.

Substance use

Three of the qualitative studies reported on substance use among transgender women who migrated to the United States. Rhodes et al. found that transgender women reported engaging in alcohol and substance use to cope with postmigration stress.35 Similarly, Sausa et al. found that transgender women of color often engaged in sex work and that sex work was often linked with substance use.33 Hwahng et al. found that participating in support groups decreased Latina transgender women's alcohol use.9 Finally, one quantitative study reported on substance use among transgender patients in Italy. Specifically, Zaccarelli et al. found that 15% of transgender women who had migrated to Italy reported injection drug use.45

Tuberculosis

Only one study focused on tuberculosis. Specifically, Crepet et al. found that transgender migrants living in Italy had a higher probability of screening positive for tuberculosis symptoms compared to their cisgender counterparts.38

Discussion

Out of the 20 articles documenting health outcomes of transgender migrants reviewed, 75% were published in the past 10 years. Consistent with the general state of transgender health literature, HIV and other STIs comprised the majority of the health domains.2 Several studies focused on violence and mental health. While some studies found that violence and adverse mental health outcomes were reduced upon migration, others found that transgender migrants continued to experience violence and adverse health outcomes in their destinations.

Consistent with the intersectionality framework,19–21 study findings suggest that transgender migrants experience unique stressors due to overlapping anti-trans stigma, anti-immigrant stigma, and racism.50 In several qualitative studies, participants described emigrating to escape physical violence, sexual violence, discrimination, and lack of economic opportunity due to their gender identities.4,5,33,49 However, transgender migrants also reported experiencing targeted racism and violence from immigration officials during their journeys and engaging in sex work in their destinations in response to employment discrimination related to their immigration status, race, ethnicity, and gender identity.5,33,48 Although migration is oftentimes a necessary safety measure, it also exposes transgender migrants to additional intersectional forms of stigma and structural vulnerabilities.

While no studies tested interventions designed to improve health outcomes among transgender migrants, some provided guidance for promising areas of future interventions. Several studies highlighted how participants benefited from connections with other transgender migrants either through formal support groups run by community-based organizations or through informal peer networks.5,9,33,44 Furthermore, being undocumented was associated with increased risk of depressive symptoms and increased HIV risk in this population, suggesting that policies and practices that broaden access to legal services for transgender migrants may be health promotive.34,44 However, these studies were all conducted with transgender women and primarily Latina/x transgender women who migrated to the United States, limiting their generalizability to transgender migrants with other gender identities or who have migrated to other countries.

Data collection and presentation

This scoping review also highlighted important methodological shortcomings that are critical to advance our understanding of the health of transgender migrants. First, the methods used to identify transgender participants varied considerably among studies. None of the studies reported using validated methods to assess gender identity, and several did not adequately explain how they categorized participants by gender identity.51 For example, in a study examining HIV prevalence study among Central American migrants transiting through Mexico, Leyva-Flores reported that “0.71% [of the sample] identified themselves as TTTs” referring to transvestite, transgender, and transsexual people; however, it was not clear how data regarding gender identity were obtained or whether the TTT category was mutually exclusive from the male and female categories. Future studies examining migration and health should use the two-step method to collect data related to gender identity.52,53 While this method has not been formally validated outside of North American and European contexts, preliminary studies using Spanish and Portuguese translations of this method in Latin America and the Caribbean suggest that the two-step method can be successfully used cross-culturally.54

Second, all of the studies relied on convenience or clinic-based samples and utilized cross-sectional study designs, which limit our ability to draw conclusions on the effects of migration on the health of transgender populations. Although the current political context may evoke mistrust of research, future studies using longitudinal designs are warranted to better understand the health of transgender migrants. In addition, many studies relied on small samples of transgender women primarily using convenience sampling, which further limits the representativeness of these findings. Quantitative studies often relied on cisgender comparison groups.38,39,41,42,45,46 Future research studying the impact of migration on the health of transgender migrants would benefit from selecting transgender individuals who have not experienced migration as the control group.

Apart from study quality metrics, another challenge resulted from articles inadequately labeling their data. Often, transgender women are incorrectly lumped in with MSM, which obstructs understanding the health of transgender communities. For example, articles that initially met the criteria were excluded at full text screening because they did not desegregate transgender women in the sample. In addition, only two qualitative studies explicitly mentioned the inclusion of transgender women, transgender men, and nonbinary participants; all others did not provide details on the gender identity of participants or included only transgender women. Regardless of the number of transgender participants in a study, it is imperative that researchers appropriately describe their data (including in the title of the study) and not misrepresent participants’ gender identities.

Overall study quality

As shown in Table 3, six of the nine included qualitative studies met all of the MMAT appraisal criteria,5,9,33–35,48 as did the single included mixed-methods study.47 Two of the qualitative studies which did not meet all MMAT criteria analyzed the asylum applications of transgender migrants from Mexico to the United States.4,49 These two studies were secondary analyses of translated legal documents whose intended audience was immigration judges rather than data collected for medical or public health purposes; therefore, we did not find these sources and methods appropriate to answer research questions regarding the impact of migration on health. However, the methodological strengths of the other qualitative studies suggest that this methodology may be especially appropriate for collecting original data intended to answer research questions related to the health and life experiences of transgender migrants.

Table 3.

Study adherence to Mixed Method Appraisal Tool criteria

Qualitative studies Research question is clear Data address research question Qualitative methods are appropriate Methods adequately answer research question Findings are adequately derived from data Interpretation is sufficiently substantiated by data Coherence between data sources, methods, analysis, and interpretation
Alessi et al. (2017)
Bianchi et al. (2014)
Cerezo et al. (2014)
Cheney et al. (2017)
Gowin et al. (2017)
Hwahng et al. (2019)
Palazzolo et al. (2016)
Rhodes et al. (2015)
Sausa et al. (2007)
Quantitative studies     Relevant sampling strategy Sample represents target population Appropriate measurement Low risk of nonresponse bias Appropriate statistical analysis
Crepet et al. (2016)
Leyva-Flores et al. (2016)
Nemoto et al. (2011)
Nuttbrock and Hwahng (2017)
Rhodes et al. (2013)
Spizzichino et al. (1998)
Spizzichino et al. (2001)
Yamanis et al. (2018)
Zaccarelli et al. (2004)
Zehender et al. (2004)
Mixed methods studies     Adequate rationale for mixed methods Effective integration of study components Results adequately brought together in interpretation Divergences and inconsistencies adequately addressed Each component meets quality criteria for method
Alessi et al. (2018)

• indicates that a study met the MMAT appraisal criteria in the checklist.

○ indicates that a study did not meet the MMAT appraisal criteria in the checklist.

Overall, the strength of evidence presented in the quantitative studies included in this review was poor. In particular, 6 of the 10 studies did not recruit participants that matched their target populations. For instance, the target population identified in Rhodes et al. was sexual minority immigrants in North Carolina; however, their sample included transgender women without reporting their sexual minority status and did not include cisgender sexual minority women.39 Nonresponse bias was an issue in six of the nine studies as well. In a 3-year cohort study, 56/74 (76.1%) of participants eligible for the final assessment were actually interviewed, representing 28% of the original 199 participants in the first wave.40 Issues of nonresponse bias were also present in cross-sectional studies, although these were mostly due to challenges inherent in recruiting from small populations historically stigmatized through research such as undocumented Latina transgender women in the United States.44

Limitations

There are important limitations to our review. There is the potential for source bias in the scoping review process. We searched six different databases to identify studies; however, the search was limited to studies published in English. These criteria may have resulted in a loss of studies and affected the findings from this review. For example, performing the searches in English may have overrepresented the proportion of articles published in the United States and other countries where English is spoken. Due to ever changing linguistic norms across cultures surrounding gender and sexual minority identities, keywords may have been missing from the MESH terms resulting in loss of articles.

We did not include search terms related to sexual behavior such as “MSM.” This may have resulted in the erroneous exclusion of studies with participants classified as MSM but who are not cisgender men. The findings of this review support previous calls to identify participants’ gender identities consistently and correctly in global health research involving transgender people; doing so may serve to combat stigma and make findings regarding the experiences of transgender migrants more discernable.2,55–57 Finally, although two reviewers completed study identification, it is plausible that studies that met inclusion were not included in the review due to reviewer bias.

Conclusion

The lives of transgender migrants are continuously upended by oppressive policies; therefore, it is vital to continue to expand the breadth of transgender health research to challenge transphobic, anti-immigrant, and racist policies. In particular, findings from this scoping review highlight how intersectional stigma and violence characterize the lives of many transgender migrants. However, our findings also highlight significant gaps and methodological limitations in the published literature on transgender migrants’ health.

Specifically, there is a need for future research using longitudinal designs, appropriate comparison groups (e.g., transgender migrants compared to nonmigrants), and validated methods for ascertaining gender identity and migration status. Some of the articles we reviewed conflated transgender women with MSM, which undermines self-determined identities and limits the ability to reach meaningful conclusions on the unique needs of transgender people. By disaggregating data, researchers can challenge the erasure of transgender people and advance efforts to improve inclusivity in health research and practice for transgender populations.

Both quantitative and qualitative studies that examine a greater variety of health outcomes and that recruit participants outside of the United States and Western Europe are needed to draw meaningful conclusions about the health needs of transgender migrants across the globe. For example, no studies included in this review focused on general health outcomes such as cancer or metabolic syndromes. These outcomes are understudied in transgender health research, and we urge researchers filling this gap to consider the role of migration in their work.2

Research is needed to examine migration motives and experiences of resettlement across racially, ethnically, and socioeconomically diverse transgender communities. Future research must incorporate an intersectionality lens and specifically examine how LGBTQ and migration policies shape the health and well-being of transgender migrants.58 Our findings support previous calls for a human rights approach to public health research and practice with transgender migrants through the provision of basic safety, freedom from violence, and access to legal protections.6 Research and practice conducted in partnership with communities of transgender migrants have the potential to lend support for inclusive comprehensive immigration reform proposals and programs that can positively transform the health and well-being of transgender migrants.

Supplementary Material

Supplemental data
Supp_TableS1.docx (13.1KB, docx)

Acknowledgment

The authors thank Don Operario, PhD at the Brown University School of Public Health for his input on this project.

Abbreviations Used

HTLV

human T-lymphotropic virus

LGBT

lesbian, gay, bisexual, and transgender

LGBTQ

lesbian, gay, bisexual, transgender, and queer

MeSH

medical subject headings

MMAT

Mixed Methods Appraisal Tool

MSM

men who have sex with men

PTSD

post-traumatic stress disorder

STI

sexually transmitted infection

TB

tuberculosis

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent official views of the National Institutes of Health.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This research is supported by National Institutes of Mental Health (R25MH067127, PI: Neilands), in which Dr. Kristi Gamarel participated as Visiting Scholar.

Supplementary Material

Supplementary Table S1

Cite this article as: Castro VA, King WM, Augustaitis L, Saylor K, Gamarel KE (2022) A scoping review of health outcomes among transgender migrants, Transgender Health 7:5, 385–396, DOI: 10.1089/trgh.2021.0011.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental data
Supp_TableS1.docx (13.1KB, docx)

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