Introduction
Studies show that a substantial proportion of transgender men (i.e., men assigned female at birth [AFAB]) and women (i.e., women assigned male at birth [AMAB]) and gender diverse (e.g., non-binary, genderqueer, gender fluid) individuals—including transmasculine people (i.e., transgender men and gender diverse AFAB people with masculine gender identities)—experience bias, prejudice, and discrimination based on their gender identity (i.e., cissexism) while obtaining health care [
1‐
6]. For example, in the 2015 U.S. Transgender Survey (USTS), a large national survey of transgender and gender diverse individuals, one-third of participants who reported seeing a health care provider in the past year had at least one negative experience related to their gender identity and/or expression—including denial of services; verbal, physical, and sexual abuse; intrusive, non-respectful care; and having to educate their health care provider about transgender health [
2]. Experiences of cissexism in health care settings have notable negative effects on health care access and utilization among transgender and gender diverse individuals [
1,
2,
7,
8]. Indeed, research shows that large numbers of transgender and gender diverse individuals avoid and postpone needed health care, including when sick or injured, as a result of past experiences and fears of cisexism [
1,
2,
7,
8]—which in turn contributes to poor health outcomes in these marginalized and underserved populations [
1,
2,
9].
Intersectionality [
10‐
14], an analytical framework rooted in Black feminist theory and practice [
15‐
18], suggests that multiply marginalized transgender and gender diverse people, such as Black, Native, Latinx/e, Asian, and other transgender and gender diverse people of color, experience—and resist—not only cissexism but also other intersecting forms of discrimination, such as racism. Specifically, intersectionality postulates that multiply marginalized individuals’ lived experiences are shaped by experiences of and resistance to mutually constitutive, unequal power relations (e.g., racism, (cis)sexism, classism, heterosexism)—which are rooted in reciprocal systems of exploitation and oppression (e.g., white supremacy, patriarchy, capitalism, colonialism) and result in experiences of discrimination that are both unique and more than the sum of their parts [
10‐
14]. However, research on discrimination and health care among transgender and gender diverse people has largely focused on cissexism, to the exclusion of other reciprocally constructing forms of discrimination, among samples of predominately white individuals [
1‐
6].
Nonetheless, a small body of research shows that transgender and gender diverse people of color have unique and compounding experiences of multiple forms of discrimination in health care settings [
1,
2,
19]. First, studies indicate that transgender and gender diverse people of color experience higher levels of cissexism in health care settings, including emergency rooms, doctors’ offices, hospitals, and ambulances, compared to their white counterparts [
2,
3]. For example, using data from the 2010 National Transgender Discrimination Survey, Kattari et al. found that 26.1% of transgender and gender diverse people of color experienced cissexism in a doctor’s office or hospital, relative to 18.5% of white participants [
3]. Moreover, 2015 USTS data show that, while 34% of white participants reported at least one negative experience with a health care provider in the past year as a result of their gender identity and/or expression, 50% and 40% of Native and Middle Eastern participants, respectively, reported such an experience [
2]. Second, research indicates that the health care experiences of transgender and gender diverse people of color are simultaneously impacted by not only cissexism but also racism [
3,
19‐
21]. For example, in a qualitative study of transgender people of color in Chicago, IL, Howard et al. found that participants reported negative health care experiences as a result of both cissexist and racist stereotypes among health care providers and difficulty identifying providers who met their needs and preferences related to both gender identity and race/ethnicity [
19]. Compounding experiences of cissexism and racism in health care settings may in turn contribute to the higher levels of avoidance of care due to fear of mistreatment among transgender and gender diverse people of color relative to their white counterparts [
2].
Research indicates that access to and utilization of health care is undermined by not only cissexism and racism but also classism, ableism, xenophobia, and weight-based discrimination, among others [
2,
22‐
26]. However, studies examining the impact of these forms of discrimination on the health care experiences of multiply marginalized transgender and gender diverse people is extremely limited. Indeed, we could not identify any published study on discrimination and health care among transgender and gender diverse individuals explicitly focusing on classism, ableism, or xenophobia. Further, to our knowledge, only one published study has specifically investigated the negative effects of weight-based discrimination on the health care experiences of lesbian, gay, bisexual, transgender, and queer (LGBTQ) people in general [
27]. Thus, we designed a qualitative research study to contribute to the literature on intersectionality, discrimination, and access to and use of health care among multiply marginalized transgender and gender diverse individuals—focusing on how transmasculine people of color, a particularly understudied and underserved subgroup, experience and resist cissexism, racism, and other forms of discrimination in health care settings.
Discussion
Using thematic analysis, we found that transmasculine people of color experience pronounced barriers to accessing physical and mental health care, all of which can be linked to structural cissexism, structural racism, and capitalism. Specifically, the participants in our study reported having trouble identifying health care providers, including obstetrician/gynecologists, with expertise in transgender health, which is linked to pervasive structural and institutional cissexism in society in general and the health care system in particular [
50‐
54]; challenges obtaining care from providers who shared their gender identity, race/ethnicity, and/or other marginalized social positions, which is linked to structural and institutional cissexism, racism, and other forms of discrimination [
55,
56]; and difficulty meeting the high financial costs of health services, which is linked to the market-based nature of health care in the U.S [
57‐
59]. Additionally, study participants reported anticipating and experiencing multiple, intersecting forms of interpersonal discrimination—including cissexism, racism, weight-based discrimination, and ableism—in various health care settings. While most participants discussed these fears and experiences of discrimination separately, many also described how they simultaneously impacted their health care experiences in compounding ways, in line with intersectionality [
10‐
14]. Our findings align with and build on those of Howard et al., who found that transmasculine people of color experienced discrimination in relation to both gender identity and race/ethnicity in health care settings [
19]. Similarly, the authors also found that, although participants tended to describe these two forms of discrimination separately and mentioned that their dominance varied across clinical encounters, the health care experiences of transmasculine people of color were simultaneously and uniquely impacted by both cissexism and racism, among other forms of discrimination, as shown in our study [
19].
Of note, our study elucidates the unique and specific impact of anti-Black racism on the health care experiences of Black transmasculine people in particular, as well as the mutually constitutive and compounding ways in which anti-Black racism intersects with cissexism and weight-based discrimination in the health care system. Specifically, we found that all Black participants experienced racism during clinical encounters, which underscores the persistent and pervasive nature of anti-Blackness in U.S. society in general and in the health care system in particular. Indeed, critical race theorists explain that racism, especially anti-Black racism, underpins all U.S. systems and institutions, including but not limited to the education, employment, housing, criminal legal, and health care systems [
60,
61]. Moreover, Washington, Roberts, and others have demonstrated how U.S. medicine, which espoused and propagated eugenics, was developed through the exploitation of and experimentation on Black individuals, from slavery to the present [
62‐
64]. Lastly, scholars have also shown the mutually constitutive nature of anti-Black racism and other forms of oppression, including transphobia, anti-fatness, and ableism, among others, which subjugate and disproportionately harm those who experience them simultaneously [
65,
66]. Thus, our study provides an empirical illustration of how these historical and contemporary processes undermine the health care—and in turn, the health—of Black transmasculine people in particular, whose experiences in the health care system are shaped by intersections of anti-Black racism, cissexism, weight-based discrimination, and ableism.
Similarly to other quantitative [
8,
67] and qualitative [
19,
68] research studies, we also found that experiences of discrimination in health care settings were linked to the denial of, delays in, or avoidance of care and the receipt of low-quality care among transmasculine people of color. Further, in line with other research conducted among predominately cisgender populations, we also identified negative effects of health care discrimination on participants’ mental and physical health [
9,
69,
70]. Lastly, in line with other studies conducted among predominately white transmasculine individuals [
50,
71], our findings indicate that transmasculine people of color actively use a range of strategies to challenge and resist the multiple forms of discrimination they face in health care settings. Specifically, study participants reported establishing boundaries with health care providers, seeking care from providers with expertise in transgender health and who share at least one of their social marginalized positions, self-advocacy during clinical encounters (including asking questions and requiring documentation of the visit), ensuring peer support during health care visits, and obtaining health information through social networks of transgender and gender diverse peers [
71].Additionally, participants recommended that health care providers receive critical, historically-informed training in recognizing and addressing cissexism, racism, and other forms of discrimination in health care settings.
Our findings should be interpreted in the context of several limitations. First, our sample primarily consisted of individuals who had received at least some college education and were enrolled in a private health plan; thus, findings may not reflect the experiences of transgender and non-binary AFAB people with less than a college-level education or those enrolled in a public health plan or lacking health insurance. Second, our study was limited to young adults aged 18–25 years; as such, our findings may not be applicable to younger or older transmasculine people of color. Third, focus groups took place in the greater Boston area, thus findings may be less applicable or transferable to those who live in geographic areas with other social (e.g., more conservative gender norms and sexual attitudes), economic (e.g., lower levels of educational attainment), political (e.g., no legal prohibition of gender identity-related discrimination), and health policy (e.g., located in a state with no Medicaid expansion) climates. Fourth, focus groups were not stratified by race/ethnicity or gender identity, so findings may have masked differences among racial/ethnic and gender identity subgroups of transmasculine young adults of color. Fifth, our findings pertain to experiences of interpersonal discrimination in health care settings and do not examine the influence of institutional discrimination in the health care system or of structural discrimination in society more broadly, which shapes individuals’ health care experiences as well as the nature, occurrence, and impact of interpersonal health care discrimination. Lastly, we were not able to examine transmasculine people of color’s experiences of heterosexism, xenophobia, and other forms of discrimination in our study. Thus, future quantitative, qualitative, and mixed-methods research studies that investigate how various multiple and intersectional forms of discrimination at multiple levels and in multiple settings differentially and simultaneously affect the health care experiences of specific subgroups of transmasculine people of color from diverse gender identity and racial/ethnic as well as socioeconomic, age, geographic sexual orientation, and nativity backgrounds, among others, are needed.
Our study on the experiences of multiple, intersecting forms of discrimination in health care settings has important implications for practice and policy. First, as underscored by many participants in our study, there is a pressing need for health care facilities to hire, promote, and retain transgender and gender diverse health care providers and health care providers of color, including providers with both marginalized gender identity and racial/ethnic positions, at all levels of the institution. Indeed, research shows that receiving care from a provider who shares one or more marginalized social positions with multiply marginalized patients can promote patient comfort during clinical encounters, as well as the delivery of high-quality care [
21,
72‐
75]. However, health care institutions should ensure that marginalized health care providers and leaders are supported in their work and that robust mechanisms are in place to identify and meaningfully address bias, prejudice, and discrimination directed toward them when they occur. Second, some participants called for health care providers to receive critical, historically-grounded training on the impact of cissexism, racism, and other intersecting forms of discrimination on health care. It is possible that these trainings may decrease the burden transmasculine people of color face in having to educate providers about their gender-specific health concerns and health care needs [
2]. However, research shows that provider training has limited and mixed results on improving provider knowledge and delivery of clinical services to marginalized populations, including transgender and gender diverse individuals [
76]. For example, in a 2019 study, Stroumsa et al. found that providers’ knowledge of transgender health was associated with transphobia but not with formal or informal education on the topic [
77].
Thus, efforts are needed to address cissexism, racism, weight-based discrimination, ableism, and other intersecting forms of discrimination in clinical encounters, health care institutions and systems, and society in general. At the interpersonal level, research suggests that using a shared-decision making approach rooted in the provision of person-centered [
78], structurally competent [
79], and culturally humble [
80] care may be beneficial to improving the health care experiences and promoting the health of transmasculine individuals of color [
81]. Such an approach would ensure that providers listen to and center transmasculine patients of color’s health and health care concerns, needs, and experiences at the intersection of multiple dimensions of discrimination and in the context of other societal factors that shape their health and lives, including housing, employment, and food security [
81]. Moreover, this approach would also involve providers avoiding making assumptions about transmasculine people of color’s behaviors, concerns, and needs, using accurate language to refer to patients and their bodies, ensuring that only information that participants would like to document is included in the visit notes, and that supportive individuals of patients’ choice are allowed to attend clinical visits [
50,
71,
81‐
83].
At the institutional level, efforts are needed to dismantle practices, rules, regulations, systems, and norms that perpetuate and reinforce cissexism, racism, weight-based discrimination, ableism, and other forms of discrimination and implement systems that promote equity and respect towards transmasculine individuals of color and other multiply marginalized populations [
84]. Of note, research suggests that applying a shared decision-making framework that centers the lived experiences and health care experiences of transmasculine people of color to the organizational context of health care institutions, including their workflows, health information technology, organizational structure and culture, resources and clinic environment, training and education, and incentives and disincentives, may help improve health care experiences and health outcomes in this and other marginalized populations [
84]. Further, health care institutions can create searchable directories of health care providers with lived experiences of and competence in providing care at the intersections of gender identity and expression, race/ethnicity, and other dimensions of social position and ensuring the inclusion of transmasculine people of color and other marginalized groups in health education and other materials [
73]. Moreover, health care institutions can partner with community-based organizations that serve transmasculine individuals of color to deliver health services in trusted community-based settings, which may facilitate access to and utilization of high-quality health care in these communities [
21,
71].
Even still, addressing multiple, intersecting forms of discrimination in health care settings will require the creation of new health care institutions and community-based organizations that center the lived experiences of transmasculine people of color from the beginning and provide tailored, person-centered, and structurally competent care that challenges structural and interpersonal cissexism, racism, and other forms of discrimination as well as capitalism in health care [
85]. Lastly, ensuring access to high-quality health care among transmasculine people of color will necessitate repealing discriminatory laws, policies, and regulations and challenging social norms that promote and reinforce cissexism, racism, weight-based discrimination, ableism, and other social inequities at all levels of society [
86‐
88]. Further, efforts to establish and promote structures, systems, practices, and norms that foster equity and social justice at the intersection of multiple dimensions of social inequality in all sectors of society through advocacy, community organizing, and participatory social movements that center the most marginalized are urgently needed to ensure access to high-quality care and foster health and well-being among transmasculine people of color and other multiply marginalized populations [
86,
88].