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Multi-Level and Intersectional Stigma Experienced by Black Transgender Women in Chicago: a Qualitative Study to Inform Sociostructural Interventions for Reducing Stigma and Improving Health Outcomes

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Abstract

Background

Stigma contributes to health disparities including increased HIV vulnerability among minority communities. Black transgender women experience multiple forms of stigma (e.g., anticipated, experienced), which can result in poor HIV-related outcomes. We utilized an adapted social ecological model (ASEM) to better understand the levels at which stigma is encountered and its impact on lived experience, particularly related to making healthcare decisions.

Methods

Semi-structured interviews and two focus groups (n = 38) were conducted with Black transgender women and Black transfeminine individuals in Chicago from 2016 to 2017. Participants were asked about discrimination in the community, healthcare experiences, and their thoughts and decision-making process with their healthcare provider regarding HIV pre-exposure prophylaxis. We conducted thematic analysis and organized our findings based on the levels of the ASEM: individual, interpersonal, organizational, community, and structural.

Results

Participants experienced and anticipated stigma at each ASEM level. Stigma was not experienced in isolation: stigma experienced at one level caused anticipated stigma at other levels and internalized stigma leading to negative self-image. In each case, stigma adversely impacted health outcomes (e.g., medication nonadherence, disengagement from care). Stigma within healthcare settings, medication-related stigma, and stigma directed at appearance and identity are particularly detrimental to shared decision-making with a healthcare provider.

Conclusions

Recognizing and valuing Black transgender women’s experience with stigma are essential for developing social and structural interventions that may work collaboratively across multiple levels of lived experience to reduce stigma and healthcare disparities faced by Black transgender women.

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Data Availability

The data that support the findings of this study are not publicly available due to the sensitive nature of the data and the possibility that the data contain identifiable information that may compromise the privacy of research participants.

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Acknowledgements

We thank Your Voice! Your Health! participants for their contribution to this study. Morten Group recruited and interviewed participants.

Funding

This work was supported by the US Agency for Healthcare Research and Quality (U18 HS023050). John Schneider was supported by the US National Institutes of Health (R01 DA039934). Moira McNulty was supported by the Third Coast Center for AIDS Research (P30 AI 117943), the Center for Prevention Implementation Methodology (P30 DA027828), and the National Institute of Mental Health (K23 MH118969).

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Authors and Affiliations

  1. Chicago Center for HIV Elimination, Chicago, IL, USA

    Jared Kerman, Russell Brewer, Anna Hotton, Rey Flores, Samantha A. Devlin, Eleanor E. Friedman, John A. Schneider & Moira C. McNulty

  2. Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA

    Jared Kerman, Russell Brewer, Anna Hotton, Rey Flores, Samantha A. Devlin, Eleanor E. Friedman, John A. Schneider & Moira C. McNulty

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  1. Jared Kerman
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Contributions

MCM, RB, AH, and JS contributed to the study conception and design. Material preparation, data collection, and data analysis were performed by JK and MM. The first draft of the manuscript was written by JK, and all authors commented on and edited previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Moira C. McNulty.

Ethics declarations

Ethics Approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board of the University of Chicago (7/2/2015/No. IRB15-0811).

Consent to Participate

Informed consent was obtained from all participants in the study.

Consent for Publication

N/A (no personally identifiable information was included in the manuscript)

Competing Interests

Non-financial interests: Moira McNulty has served on an advisory board for Gilead Sciences, Inc.

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Kerman, J., Brewer, R., Hotton, A. et al. Multi-Level and Intersectional Stigma Experienced by Black Transgender Women in Chicago: a Qualitative Study to Inform Sociostructural Interventions for Reducing Stigma and Improving Health Outcomes. J. Racial and Ethnic Health Disparities (2023). https://doi.org/10.1007/s40615-023-01853-6

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