social support

Psychology of Sexual Orientation and Gender Diversity Coping, Resilience, and Social Support Among Transgender and Gender Diverse Individuals Experiencing Gender-Related Stress Kaitlyn R. Gorman, Jillian C. Shipherd, Kathleen M. Collins, Hamish A. Gunn, Rachel O. Rubin, Brian A. Rood, and David W. Pantalone Online First Publication, November 19, 2020. http://dx.doi.org/10.1037/sgd0000455

CITATION Gorman, K. R., Shipherd, J. C., Collins, K. M., Gunn, H. A., Rubin, R. O., Rood, B. A., & Pantalone, D. W. (2020, November 19). Coping, Resilience, and Social Support Among Transgender and Gender Diverse Individuals Experiencing Gender- Related Stress. Psychology of Sexual Orientation and Gender Diversity. Advance online publication. http://dx.doi.org/10.1037/sgd0000455

Coping, Resilience, and Social Support Among Transgender and Gender Diverse Individuals Experiencing Gender-Related Stress

Kaitlyn R. Gorman University of Massachusetts Boston

Jillian C. Shipherd VA Boston Healthcare System, Boston, Massachusetts

Kathleen M. Collins, Hamish A. Gunn, and Rachel O. Rubin

University of Massachusetts Boston

Brian A. Rood UnitedHealth Group, Minneapolis, Minnesota

David W. Pantalone University of Massachusetts Boston, and The Fenway Health, Boston, Massachusetts

Transgender and gender diverse (TGD) individuals experience stigma related to their gender identity. However, little research has been conducted exploring how TGD individuals cope with, build resilience from, or obtain support concerning gender-related stress. In this study, we recruited TGD individuals (n � 30) to elucidate the coping strategies used in response to gender-related stress; to explore how they developed and maintained resilience; and to understand the impact of social support from others in navigating gender-related stressors. Participants completed individual, semistructured, qualitative interviews, which we coded using consensual qualitative research methods. Many participants underscored the strain of having to educate cisgender friends, family, and health care providers about TGD experiences. Participants endorsed using strategic avoidance or modulating their gender presentation to manage gender-related stress. Additionally, participants discussed various intragroup prosocial behaviors (i.e., developing TGD spaces) to sustain resilience and increase or maintain social support. Despite the expansive literature focused on TGD risk, most participants reported significant self-compassion and effective coping strategies for managing gender-related stress throughout their lives. Unique techniques described by our participants that are infrequently discussed in the coping literature on cisgender individuals (i.e., strategic avoidance and intragroup prosocial behaviors) echo those reported by other marginalized group members.

Public Significance Statement The present study used consensual qualitative research methods to investigate coping and resilience in a sample of transgender and gender diverse (TGD) individuals. We advanced the understanding of how TGD individuals cope, and even thrive, despite the ubiquitous experience of gender-related stress. Possible implications emerged about ways to better support TGD individuals, both clinically and socially.

Keywords: transgender, gender-diverse, coping, resilience, support

Transgender and gender diverse (TGD) individuals are those whose affirmed gender (i.e., the way they identify) is inconsistent with

their sex assigned at birth (Maroney et al., 2019). An expanding literature has demonstrated that, because of their gender identities, TGD individuals are at high risk for experiencing hostility and other forms of discrimination (James et al., 2016) and assault (Stotzer, 2009). Published prevalence estimates of exposure to assault among TGD adults are up to 38% for physical assault (Testa et al., 2012) and up to 47% for sexual assault (James et al., 2016). Given these high rates of victimization, it is unsurprising that TGD individuals are at high risk of traumatic exposure (Shipherd, Maguen, Skidmore, & Abramovitz, 2011) and experiencing psychological distress, such as anxiety (Valentine & Shipherd, 2018) and depression (Rotondi, 2012), as well as suicidal ideation and attempts (Rood, Puckett, Pantalone, & Bradford, 2015). Notably, the literature continues to identify associations between psychological distress and identity- related stressors, including discrimination and violence (e.g., Rood et al., 2015).

X Kaitlyn R. Gorman, Department of Psychology, University of Mas- sachusetts Boston; Jillian C. Shipherd, VA Boston Healthcare System, Boston, Massachusetts; X Kathleen M. Collins, Hamish A. Gunn, and Rachel O. Rubin, Department of Psychology, University of Massachusetts Boston; Brian A. Rood, UnitedHealth Group, Minneapolis, Minnesota; X David W. Pantalone, Department of Psychology, University of Massa- chusetts Boston, and The Fenway Institute, Fenway Health, Boston, Mas- sachusetts.

Correspondence concerning this article should be addressed to Kaitlyn R. Gorman, Department of Psychology, University of Massachusetts Bos- ton, 100 William T. Morrisey Boulevard, Boston, MA 02125. E-mail: [email protected]

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Psychology of Sexual Orientation and Gender Diversity © 2020 American Psychological Association 2020, Vol. 2, No. 999, 000 ISSN: 2329-0382 http://dx.doi.org/10.1037/sgd0000455

1

Despite the unfortunately common discrimination and victim- ization experienced by TGD individuals, it is important to recog- nize that the modal response to traumatic events is recovery. Overcoming life challenges is the foundation of the development of resilience (e.g., Masten, 2001). An understanding of resilience factors (i.e., resilience promoting experiences), particularly mod- ifiable elements that can be fostered and supported to change, is essential to inform the development of behavioral interventions targeting TGD individuals (Matsuno & Israel, 2018). Resilience to adversity, and the process(es) that underlie it, may moderate the associations between identity-related stressors and the mental health of TGD people.

Resilience: A Developmental Process

Currently, there is no universal definition of resilience. One common conceptualization, emerging from a developmental per- spective, defines resilience as the ability to maintain relatively stable, healthy levels of psychological and physical functioning in the face of singular stressful events (Bonanno, 2004). A drawback of this theory is its poor match for individuals with marginalized identities, such as TGD individuals, who experience prolonged and repeated identity-related stress—not just a singular event, as the- orized in Bonanno’s model of resilience. In a recent systematic review (N � 20) about resilience in sexual minority men, the authors defined resilience as a developmental process that occurs in response to adversity, wherein an individual’s use of resources available, (i.e., socioeconomic, behavioral coping strategies, cog- nitions or emotions, and relationships), during periods of stress, protects them from potential negative outcomes (Woodward, Banks, Marks, & Pantalone, 2016). They defined resilience as dynamic over time and consisting of unique factors that vary across populations, that is, building on Bonanno’s framework to better tailor the construct of resilience to members of vulnerable populations who experience numerous, ongoing stressors. Al- though the populations are different, this framework appears to be a good analogue, as sexual minority men and TGD individuals both experience identity-related minority stress. Woodward and colleagues’ (2016) definition of resilience proposes the existence of unique factors across populations that impact resilience devel- opment, and the definition is potentially more applicable to TGD individuals given its focus on incorporating the experiences of multiple stressors and the dynamic response over time.

Given that gender socialization begins at birth, and gender identity development begins around age three (Weinraub et al., 1984), TGD individuals spend much of their lives managing gender-related stress. Up to 75% of TGD youth report feeling unsafe in school (GLSEN, 2019). Despite these stressors, many TGD youth thrive in adulthood, developing resilience to gender- related stress as they age— given that the stressors are likely to arise continually throughout adulthood (Valentine & Shipherd, 2018). Key to the definition of resilience is the experience of overcoming adversity to return to a healthy baseline despite stres- sors (Matsuno & Israel, 2018; Puckett, Matsuno, Dyar, Mustanski, & Newcomb, 2019), and thus, coping—the actions taken to man- age stress in the moment—may be a part of the process of building resilience. Previous conceptualizations of resilience for TGD in- dividuals have centered on coping with, understanding, and valu- ing their gender identity in the face of societal discrimination (e.g.,

Matsuno & Israel, 2018; Meyer, 2015; Singh, Hays, & Watson, 2011). Under the umbrella of resilience, coping skills are one factor that might buffer the effects of gender-related stress on negative mental or physical health.

Coping: A Potential key to Resilience

Coping is an active response to a stressor (e.g., Lazarus, 1985), and there are a variety of potential coping strategies that could be useful over time and across contexts. Lazarus (1985) defined coping as a person’s evolving cognitive and behavioral efforts to manage specific stressors. From this perspective, coping strategies can be considered to fall into two categories: emotion-focused coping, which is used to regulate negative emotions caused by stress, and problem-focused coping, which entails altering the individuals’ engagement with the stressful part of their environ- ment (Lazarus, 1991). Lazarus’s definition of coping is founda- tional in the coping literature. However, the construct of coping is continually evolving, and researchers exploring TGD coping have developed community-specific theories of coping.

Budge, Adelson, and Howard (2013) conducted a cross- sectional quantitative study to explore emotion-focused and problem-focused coping with stressful encounters in TGD individ- uals. They used exploratory factor analysis to evaluate a standard measure of coping and surmised that two clusters, facilitative coping and avoidant coping, may be indicative of the true latent constructs describing coping in their TGD sample—versus Lazar- us’s original model that included eight problem- and emotion- focused coping clusters. Published results from a qualitative study described a range of facilitative coping strategies for stressful encounters described by TGD adults, specifically cognitive (i.e., positive reframing or letting go) and behavioral (i.e., seeking social support or activism) approaches (Budge, Katz-Wise et al., 2013). The utilization of social support appears to be vital in the experi- ence of coping for TGD individuals both as a way to handle stress related to identity (Budge, Katz-Wise et al., 2013) and as a precursor to utilizing other facilitative coping skills (Budge, Adel- son, & Howard, 2013).

Social Support: A Potential Key Coping Strategy

Under the umbrella of facilitative coping, seeking and utilizing social support (e.g., from a significant other, friends, or family) might be uniquely beneficial to TGD individuals, who face sig- nificant societal and interpersonal rejection (Budge, Rossman, & Howard, 2014). Research has demonstrated that the extent to which TGD individuals are interpersonally connected to other TGD individuals is associated with positive mental health (Gon- zalez, Bockting, Beckman, & Durán, 2012; Matsuno & Israel, 2018; Testa, Habarth, Peta, Balsam, & Bockting, 2015). Recent literature suggests that the psychological and social benefits gained from being part of a community may be particularly important for sexual and gender minority (SGM) individuals when experiencing minority stress (Matsuno & Israel, 2018; McConnell, Janulis, Phillips, Truong, & Birkett, 2018). Literature enumerating the need for social support, including community support, is vast (see, e.g., Cohen & Syme, 1985). In addition to social support, facili- tative coping strategies, such as engaging in activism and educat- ing others, were reported to be beneficial for some transgender

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2 GORMAN ET AL.

individuals, as they were associated with both increased affirma- tive emotions and feelings of well-being (Budge, Katz-Wise et al., 2013).

Interpersonal interactions have the potential to help and also to harm, through rejection, discrimination, or victimization. With roots in childhood, TGD individuals are more likely to report social obstacles and lack of available social support than cisgender peers (Stieglitz, 2010). For example, TGD individuals report feel- ing less support from their family of origin than their cisgender siblings (Factor & Rothblum, 2007). In one large, national study, 53% of the sample reported experiencing significant family rejec- tion (James et al., 2016). This finding is particularly alarming, as the experience of the converse, family support— compared to both support from friends and support from TGD communities— has been found to predict fewer symptoms of anxiety and depression and greater resilience in TGD individuals (Puckett, Cleary, Ross- man, Newcomb, & Mustanski, 2018). Furthermore, when compar- ing across family support, friendship support, and support from TGD communities, high family support predicted the same level of resilience, regardless of support from friends or TGD communities (Puckett et al., 2018). In one study, perceived social support from family was significantly and negatively associated with partici- pants’ suicidal behavior (Moody & Smith, 2013). Taken together, the research paints a bleak picture of many TGD individuals’ experiences of support and interpersonal relationships throughout their lives, and the deleterious impact limited support can have on TGD individuals. Many resources that are available theoretically to support TGD individuals are simultaneously sources of discrim- ination risk, making it reasonable for there to be a decreased interest in engaging with these resources despite potential benefits.

Current Study

The overall goal of our qualitative study was to learn about how TGD individuals utilized coping resources in response to the gender-related stress they experienced. Most previous work in this area has been quantitative, using measures that were developed on primarily cisgender populations. We chose a qualitative study design to center the voices of these highly marginalized individ- uals and to learn about their coping, social support, and resilience experiences in their own words. Specifically, we aim to (a) under- stand elements that TGD individuals identify as critical to the development and maintenance of their resilience in the face of gender-related stress. Within the context of resilience, we aim to (b) elucidate the coping strategies used by TGD individuals to manage their responses to gender-related stress. Finally, we aim to (c) explore the role of social support, specifically, as it serves as a barrier or facilitator of coping with gender-related stress. Taken together, the current study aims to increase our understanding of how TGD individuals manage and thrive despite the experience of gender-related stress.

Method

Procedure

Participants. Participants were recruited as part of a study exploring TGD individuals’ experiences of gender-related minor- ity stress. We interviewed 30 TGD adults in 2014 –15. All partic-

ipants reported their sex assigned at birth and self-identified a gender identity label in an open-ended question. Eligible partici- pants (1) currently lived in the U.S., (2) identified as “transgender” or “non-cisgender,” (3) were age 25– 40, and (4) had begun the gender affirmation process by dressing most of the time as their identified gender for at least the past six months. Although gender identity and gender expression (i.e., the ways in which an individ- ual preforms a gender identity) are independent constructs, gender affirmation criteria allowed assessment of the interaction of the TGD person’s gender expression and the environment. Given the aims of some of the other planned analyses (Rood, 2016), TGD individuals who were not outwardly affirming their gender identity were not eligible, as they were less likely to have experienced the same discrimination as those expressing their gender identity more overtly. The criterion does not assume that a person who does not express their gender identity through their dress does not experi- ence gender-related stress; however, we did use it to attempt to set bounds on the experience with the assumption that outward gender expression increases the likelihood of gender-related discrimina- tion. Finally, geographic region and ages of participants were restricted to minimize age cohort effects and other life stressors that are unique to age, generation, or nationality. See Table 1 for detailed sample demographics.

Recruitment. We recruited participants via online message boards, listservs, and social networking sites for TGD individual. Online recruitment was crucial because research suggests that the Internet is a particularly viable source of networking and informa- tion gathering for transgender individuals (Horvath, Iantaffi, Gray, & Bockting, 2014). We electronically sent recruitment letters and flyers to websites with predominantly TGD audiences. Study con- sultants, including prominent TGD health researchers, also posted a link to the online study through private social networking groups (e.g., in Yahoo! and Facebook).

Procedures. After reviewing the recruitment materials, poten- tial participants were directed to a secure area of SurveyMonkey to complete an eligibility screener. Eligible participants who pro- vided consent were invited to schedule a semistructured qualitative interview. Interviews were conducted online via Skype, which is considered among the most secure Voice over Internet Protocol providers and offers encryption for voice conversations. At the start of each semistructured interview, to assure comprehension, the interviewer reviewed the purpose and voluntary nature of the study, as well as the informed consent document that the partici- pant had previously signed electronically.

We took several steps to maximize confidentiality. First, we provided participants with a participant-only Skype account and a unique password (i.e., no participant used a personal account). Furthermore, the video on the interviewer’s Skype account was switched off, so that we received no video feed of the participant. The audio, however, was recorded using a digital audio recorder placed next to the speaker of the computer. Interviews lasted 37–94 min in length (M � 62.2, SD � 11.9). Participants com- pleting interviews received a $30 gift card.

Interviews were transcribed by undergraduate research assis- tants and checked for accuracy by two independent reviewers. All identifying information was removed, and identification numbers were assigned to ensure confidentiality.

Research team. The study was conceptualized by four re- searchers, three of whom had considerable experience in SGM

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3COPING, RESILIENCE, AND SUPPORT AMONG TGD ADULTS

health research (one queer transgender man, two queer cisgender men, one heterosexual cisgender women). The coding team in- cluded five members, all of whom were current clinical psychol- ogy doctoral students. Four coding team members identified as cisgender female and one identified as cisgender male. One mem- ber of the research team identified as queer, two identified as lesbian/gay, one identified as bisexual, and one identified as het- erosexual. The team was supervised by a clinical psychologist and university professor (queer, cisgender man) with expertise in SGM

health research. Although the majority of the coding team identi- fied as part of the broader SGM community, no coders identified as TGD, which serves as a potential limitation to our findings. Furthermore, we aim to position ourselves not as experts on TGD resilience, but as coconspirators attempting to elevate the TGD voices of our participants (Patterson, 2018).

Ethical considerations. All participants provided informed consent prior to beginning study procedures. The Suffolk Univer- sity IRB continuously approved the study during data collection and transcription. Interviews were transcribed verbatim with proper nouns redacted, and the audio recordings were subsequently deleted.

Measures

Demographics. Participants were asked to provide their U.S. zip code, sex assigned at birth, gender identity, sexual orientation, age, relationship status, education level, race/ethnicity, and expe- rience with different gender affirmation processes.

Interview protocol. The interview protocol included ques- tions about resilience strategies, comprising methods of coping and sources of support, used to manage responses to gender-related stress. Discussion of each content area began with an open-ended question, that is, “In thinking about a stressful experience related to your gender, what stands out to you the most, how did you cope/deal with it?” All participants were asked the same root questions. Follow-up questions were not scripted; the interviewer had a list of general probes that were individually tailored to the participant’s responses. For example, for resilience, all participants were asked “When you hear the word ‘resilience,’ what comes to mind about your life experiences as a [GENDER IDENTITY LABEL] person?” and “What, in general, has contributed to your resilience even when faced with difficulties related to your gen- der?”

Data Analysis

Data analysis was guided by consensual qualitative research (CQR) methodology (Hill, 2012), an inductive method that holds the importance of words over numbers and allows for an integra- tion of multiple viewpoints by ensuring that the research team reaches consensus during coding. CQR entails a deliberate itera- tive process with extensive debate and group communication (Hill, 2012). It has been a useful strategy in research that requires rich descriptions of inner experiences in members of marginalized populations, such as TGD individuals (e.g., Rood et al., 2016).

The data were analyzed through a constructivist-interpretive lens, in effort to report on lived experiences of TGD individual and their understanding of resilience guidelines (Levitt, Motul- sky, Wertz, Morrow, & Ponterotto, 2017). We made consistent efforts to maintain fidelity per APA’s qualitative data analysis guidelines (Levitt et al., 2017). With CQR, it is understood that each member of the research team came to the data with unique expectation and biases, and the research team discussed how their own perspectives may shape their understanding of the data (Hill, 2012). Furthermore, in an effort to limit the effect of prior knowledge on the data analyses and increase fidelity of the results, the research team worked to discuss and challenge prior conceptions held before analyzing the data (Hill, 2012; Levitt et al., 2017).

Table 1 Sample Characteristics

n % of sample

Age (M, SD) 30 30.4 years (6.1) Sex assigned at birth

Female 15 50.0 Male 15 50.0

Race/ethnicity White 12 40.0 Biracial/multiracial 10 33.3 Asian/Asian American 3 10.0 Black/African American 3 10.0 Latino/Hispanic 2 6.7

Gender identity Female/woman 8 26.7 Trans-male/trans-man (FTM) 7 23.3 Trans-female/trans-woman (MTF) 4 13.3 Gender queer 3 10.0 Male/man 3 10.0 Gender fluid 1 3.3 Masculine of center 1 3.3 Transboi 1 3.3 Yin male 1 3.3 Transsexual 1 3.3

Sexual orientation Queer 13 43.3 Lesbian/gay 5 16.7 Heterosexual/straight 4 13.3 Pansexual 4 13.3 Bisexual 3 10.0 Asexual 1 3.3

Relationship status Single 9 30.0 Partnered 7 23.3 Married 7 23.3 In an open relationship 3 10.0 Engaged 2 6.7 In many open relationships 1 3.3 Non-romantic co-parent

relationship 1 3.3

Level of education College graduate 13 43.3 Some college 8 26.7 Graduate level education 5 16.7 High school graduate/GED 4 13.3

Have participated in the following gender affirmation processes

Hormone therapy 23 76.7 Considered some form of SRS 24 80.0 Completed some form of SRS 10 33.3 Told friends or family about

affirmed gender 30 100.0 Told people at work or school

about affirmed gender 26 86.7

Note. FTM � female-to-male; MTF � male-to-female; SRS � sex reassignment surgery.

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4 GORMAN ET AL.

In following the CQR coding steps, our research team first developed a tentative list of domains, based on a review of the literature and the primary questions in the interview protocol. The domains represent general topic areas that were covered in the interview guide. Our team took the initial domain list and independently coded the same four transcripts. In this process, we tested the domain list by applying it to the transcripts to determine how well the domains “fit” the data. We indepen- dently modified the domain list (e.g., adding, removing, or combining domains) based on the topic areas that emerge from the data. After this process, we met as a team to compare notes and discuss changes to the domains until a stable list emerged, which was used to code the remaining transcripts (Hill, 2012).

After coding all 30 transcripts, the team worked together to formulate core ideas. Core ideas represent clear and concise summaries of each piece of data (i.e., the participant’s narra- tive). The function of constructing core ideas is to concisely label each piece of data, which enables more effective compar- isons across participants in the later cross-analysis. The team examined the core ideas represented within each of the domains across all participants. Finally, since the core ideas each reflect one piece of data, cross-participant comparisons of data re-

quired grouping core ideas into construct categories and sub- categories. Categories and subcategories were labeled as “gen- eral” if they applied to 29 –30 participants, “typical” if they applied to 16 –28 participants, and “variant” if they applied to 2–15 participants, per CQR methods (Hill, 2012).

To assess for completeness of the data, we conducted stability checks. After domains and categories were created, raters used unanalyzed cases to test the fit of growing themes (Hill, 2012). The frequency of data categories and subcategories across participants provides evidence of data saturation and the comprehension and completeness of our data (e.g., Yeh & Inman, 2007). Additional cases did not produce new domains or categories (Hill, 2012).

Results

Throughout the interviews, three distinct categories emerged: (1) coping with gender-related stress (with five subcategories); (2) resilience from gender-related stress (with five subcategories); and (3) social relationship strain and support with dealing with gender- related stress (with six subcategories). See Table 2. Consistent with CQR methodology, we do not report categories and subcat- egories that applied only to a single participant. We enumerate categories and elaborate with illustrative quotes, below.

Table 2 Categories, Subcategories, Illustrative Core Ideas, and Frequencies

Domain/category/subcategory Illustrative core idea Frequency

1. Coping with gender-related stress General (30) a) Evaluate context before revealing identity There are safe and unsafe spaces to share your gender; It is easier in

some context to pass than to be open Typical (28)

a) Avoidance of gendered contexts Highlighting gender can be stressful; gendered spaces can be dangerous Typical (17) b) Downplay gender identity It is sometimes better to hide gender identity and allow outside factors

define us Variant (14)

c) Disengage from hurtful experiences Just put it out of my mind; continue on with what I was doing Variant (14) d) Engage in gender stereotyped behavior Leaning into gender stereotypes can help with passing; behaving more

feminine/masculine can help you blend in Variant (11)

e) Supporting others with similar identities I feel better when I help others in the community; I create spaces for myself and others to feel safe

Variant (8)

2. Resilience from gender-related stress Typical (28) a) Grit or tenacity Surviving discrimination and negativity gave me strength; I am stronger

than others because of what I’ve gone through Typical (19)

b) Not internalizing others’ judgments I have learned to be OK despite what others say; other people’s opinions do not matter as much

Typical (17)

c) Incorporating gender identity into a sense of self

My gender is only a part of me, not all of me; I have learned to embrace my gender-identity

Variant (12)

d) Developing resilience from other marginalized identities and generalizing to TGD identity.

Racism taught me how to deal with gender discrimination; stress in other areas of my life taught me to be strong

Variant (10)

e) Social comparison (upward and downward)

I feel hopeful when I see TGD individuals succeeding in life; I get strength from helping TGD people navigate difficult situations I’ve gotten through

Variant (8)

3. Social relationship strain and support with dealing with gender-related stress

General (30)

a) Pros and cons of healthcare professionals A supportive therapist has been important to my well-being; I avoid going to the doctor because they do not understand TGD health

Typical (25)

b) Protection by supportive friends and family

Effort from family and friends is important; my family accepting me makes me feel lucky

Typical (19)

c) Support from cisgender people It is validating to be accepted by my cisgender friends Typical (18) d) Strain or stress from well-meaning

cisgender individuals Cisgender individuals can increase gender-related stress unintentionally Typical (18)

e) Support by other TGD individuals TGD individuals understand me at a different level; I can be more authentic with TGD individuals

Variant (15)

f) Impact of positive gestures Small gestures can make a big impact in feeling supported Variant (13)

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5COPING, RESILIENCE, AND SUPPORT AMONG TGD ADULTS

Coping With Gender-Related Stress

Evaluate context before revealing identity. Gender-related stress is a point of psychological pain for many TGD individuals. When coping with gender-related stress, one method that partici- pants reported was deciding selectively if, how, and when to disclose their TGD identity in a given context (n � 28). Many participants discussed disclosure versus concealment as a tenuous balance between intimacy and safety. Participants reported reluc- tance about disclosure, expressing concerns ranging from emo- tional discomfort to fears about physical safety. Multiple aspects of the TGD experience and identity may be deliberated with respect to disclosure. Each aspect of their TGD identity can be experi- enced as a separate coming out process.

Right now, I hide the fact that I’m gender queer because now my ID . . . says that I’m female, and I do not really feel completely female either. But, now that I work as a manager, I have to hide the fact that I’m trans, or that I’m not a cis woman, because I’m afraid that that’s going to affect the way my employees do their job.. . . I do not publicize that at work, for sure, ‘cause I do not want to be discrimi- nated against either. Even if I know I will not lose my job, I do not want to have to deal with jerks, you know? (age 31, Multiracial, identifies as genderqueer)

Engage in gender stereotyped behavior. Similarly, many participants reported modulating the presentation of their gender identity across settings. Participants discussed different situations in which they would perform gender in a stereotyped manner, instead of their typical gender expression (n � 11). Purposefully modulating gender expression could occur in response to feeling unsafe or afraid of drawing attention.

[At a wedding last year,] I did my best to put on my best “guy mask”. . .my voice got lower, and I didn’t gesticulate, and I was very vigilant about what I talked about as well, because, if I talked about anything I was too interested in, the pitch of my voice gets higher, when I get excited about things.. . . I tried to talk about things that I was not interested in.. . . I would pretty much let everyone else lead the conversation, essentially, and sort of just smile and nod.. . . (age 25, Black, identifies as FtM)

Downplay gender identity. In contrast, several participants discussed downplaying their authentic self in an effort to draw less attention in situations that have the potential to result in gender- related stress or discrimination (n � 14).

Since I still have the passport of a female and the female first name . . . with the airports, I try to look more feminine. . . . I would make sure that I shaved in the morning. And, going to the doctor’s office, I will also try to wear the stuff that I had that I thought looked more feminine, just to avoid confusion with my paperwork and myself. (age 32, White, identifies as FtM)

Disengage from hurtful experiences. Several participants described actively trying to ignore or forget hurtful gender-related comments or hateful encounters they experienced (n � 14). When the situation felt unsafe, some participants reported fleeing the situation in an effort to find safety and mental well-being.

I was riding the bus . . . and there was a guy on the bus who started verbally harassing me . . . he was calling me a “man” and calling me a “tranny,” and saying really insulting things. And I was really, really

uncomfortable, and I didn’t know what to do . . . and the bus driver, I know he heard him . . . saying these things, and he didn’t do anything. . . . I just pushed the button to get off the bus, even though I was not anywhere near where I was going.. . . (age 31, Multiracial, identifies as MtF)

Avoidance of gendered contexts. A common technique de- scribed by the participants to mitigate gender-related stress was to avoid situations likely to highlight gender (n � 17). Frequently, participants discussed avoiding health care visits due to the antic- ipated stress the visits would elicit. Similarly, participants dis- cussed avoiding certain aspects of their lives to avoid gender- related stress, such as using public restrooms and going to class, work, or social events.

If [my parents are] there, I will not use the bathroom in public ‘cause I feel like it will make them uncomfortable, and I do not want to deal with it. I do not want to deal with them acting weird about it . . . yesterday, my mom and I went to Ikea, and I was able to go to the bathroom because we loaded up the car and then I was like, “Oh hey, I have to go to the bathroom”—while she was already in the car.. . . Techniques like that are how I actually manage going to the bathroom when I’m around them, but it’s really annoying to have to navigate that. (age 30, Multiracial, identifies as MtF)

Supporting others with similar identities. Although many participants endorsed the use of strategic avoidance to mitigate gender-related stress and prioritize their own safety, they also reported using their identity experiences to support other TGD individuals. Participants discussed the process of using their own experiences of support and discrimination in an effort to help support other TGD individuals who may have had similar experi- ences (n � 8). They reported creating spaces for individuals with similar identities, seeing strength in other TGD individuals, and seeking out people with shared experiences. Participants were able to take their experiences with gender discrimination and create a space to help them heal.

While I was in school, one thing that helped me cope with stress—I started an initiative for queer and trans people of color.. . . And it was a good space . . . it was a predominantly White institution, so it was a space where, for a moment, we could all just not have to worry about managing the feelings of other people who identified as allies because I am very antially (clarifying). I’m anti-self-identified allies. So . . . I put my energy into that space, and making a difference on my campus, and that helped me deal with stress a lot. (age 28, Black, identifies as trans boi)

Resilience From Gender-Related Stress

Grit or tenacity. Participants were asked to describe what “resilience” means to them, and what elements of their lives contributed to any resilience they have developed. We asked participants to consider both internal qualities as well as external experiences that contributed to their resilience development. Many participants reported gaining strength from the challenges they faced due to their TGD identity. Participants reported feeling that the stress they encountered earlier in life made them emotionally stronger and more mentally flexible. The mechanism that brought about resilience was not always clear to participants. However, a few repeating ideas emerged, such as a decision to prove them-

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selves despite the odds, or a learning process that develops along- side the experience of adversity (n � 19).

I’m typically looking on the bright side and I help friends out with things a lot. I serve as emotional support for a lot of people I know.. . . I guess I’m one of those strong-willed individuals that’s just able to keep going no matter what happens.. . . Probably the negativity from my dad has contributed to most of that . . . growing up with him telling me I’d never amount to anything and things of that nature has just pushed me more and more to want to prove him wrong, and show that he’s always been wrong about me.. . . I just strive to be a better person. (age 30, White, identifies as female)

Not internalizing others’ judgments. Several participants discussed working to let go of feeling shame and the judgment placed on them by others, in an effort to build up their internal reserves and buffer the impact of gender-related stress (n � 17).

I think that people who think [I’m not a real man] are going to think that way no matter what, and I’ve finally come to a point where I’m OK with being me or talking about what I want to talk about, and listening to the music I wanna listen to, and all of that stuff. Because I’ve realized that . . . I cannot control someone else’s reaction, I cannot control anyone else’s judgments or thoughts about who I am. All I can do is make sure that I’m as happy and living as authentically as possible. (age 35, Black, identifies as FtM)

Developing resilience from other marginalized identities and generalizing to TGD identity. Importantly, a few participants discussed the importance of the intersection of their TGD identity and other marginalized identities, including race, mental health, and spirituality, in their resilience development (n � 10). Some individuals expressed early experiences of assimilating or hiding aspects of themselves for preservation being a skill that served them as they began to understand their gender later in life,

I think [my Latin identity is] probably one of the ways that I learned to hide parts of my identity. When I was growing up . . . teachers would kind of encourage . . . hiding your cultural heritage and being able to speak English better and to really assimilate—that was kind of framed as being very successful. So, I think that’s probably where I learned a lot of that, and how it can become second nature to hide certain things for people to view you as successful or sort of like a “worthy” person. (age 26, Latino, identifies as masculine)

Similarly, others expressed sublimating the pain of prejudice from race and gender into a freedom of self-expression and ac- ceptance.

I feel that part of being Black and transgender is that . . . I’ve finally realized that I do not have anything to lose. So, that’s kind of empowering in a way . . . you know, in that, no matter what I do, I’m not what anyone expects me to be—so I might as well be me. And I think that that has . . . been liberating. (age 35, Black, identifies as FtM)

Incorporating gender identity into a sense of self. One unique source of resilience that a few participants endorsed was engaging in the process of incorporating their TGD identity into a fuller understanding of themselves (n � 12). For some individuals, this meant understanding their TGD experience through a medical model after affirmation. For others, it meant creating a new label that fit their understanding of their gender identity.

Basically, I’m a trans man, but I kind of invented the title of “yin male” as my personal label, because I present as a person that’s not very masculine so I . . . present more on the feminine side. (age 26, Multiracial, identifies as yin male)

Similarly, although some individuals see their TGD identity as central in their lives, others see it as a small piece of their identity.

Like anybody else, we come in all shapes and sizes.. . . For most trans people, it’s one factor of who they are. I’m left-handed, but it’s not the most important thing about me. I was born a male, but that’s not the most important part of my story.. . . It’s part of my own identity as, again, a fairly plain-Jane female, but there’s so much more. (age 39, White, identifies as MtF)

Social comparison (upward and downward). Several par- ticipants expressed that TGD communities were a primary foun- dation that helped bolster their own resilience. This resilience comes from hearing about both pains and successes (n � 8).

Knowing other trans people has really helped me. Knowing how much worse it could be from their stories and also wanting to just, you know, have that next step in the transition process, almost that jealously, that—“this person has top surgery, I want to be there!”—to keep going. . .[and] have that life. (age 28, Multiracial, identifies as FtM)

Social Relationship Strain and Support With Dealing With Gender-Related Stress

Protection by supportive friends and family. Throughout the interview, participants highlighted the psychological impact on them of the people who surrounded them. Depending on the context and type, relationships might increase or decrease gender- related stress—including friends, family, mentors, and health care providers. Many participants reported that having supportive friends or family protected them from the potential for more discrimination or pain (n � 19).

I have really pretty solid friendships and relationships in my life that I feel like are incredibly valuable to me. And, in that sense, my partner . . . she’s really great, and is one of the only people in my life who I can count on to just never mess up on pronouns, and is really good at just letting me talk about a thing without feeling like she has to fix it—and that feels really important. My sister is amazing. She doesn’t always get the pronouns but she really wants to. We’re incredibly close. . . . [S]he always understands when I tell her about a situation that’s frustrating . . . she just always gets it. And I have friends who I am really close with here, so that feels really important. (age 32, White, identifies as female)

Support by other TGD individuals. Many participants spoke about the importance of having other TGD individuals in their lives (n � 15). Having access to someone with similar lived experiences helped them process the challenges that arose. Al- though participants discussed positive elements of engaging with TGD communities, they also reported stress in navigating barriers to these communities (e.g., physical distance) given their vital importance. Notably, several participants underscored the differ- ence between TGD communities and sexual minority communities, with some participants highlighting the prevalence of transphobia they experienced in sexual minority-dominated communities. Oth-

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7COPING, RESILIENCE, AND SUPPORT AMONG TGD ADULTS

ers described positive experiences and social support in both spaces.

I: How about dating or romantic partners? Have they been helpful at all when it comes to dealing with the stress associated with being trans?

P: Yes. For a while, I was with another trans guy and it was a breath of fresh air. There was certain things that I didn’t have to explain, and certain ways that we feel, that other people do not understand. (age 40, Black, identifies as FtM)

Support from cisgender people. Participants identified the substantial role played by cisgender individuals in their lives to support their well-being. Specifically, some participants experi- enced it as validating when cisgender individuals made efforts to support, validate, and work to understand the TGD experience (n � 18).

My fiancé. . .it’s impossible about talking about . . . my story without talking about my fiancé. The first time I was out at night dressed as a woman was a first date with him. The support that he’s given me. . . . I still lean on him heavily. That’s probably how I deal with it the most. You know, waking up every morning and having someone tell you that you’re beautiful: That goes a long way to kind of even things out. (age 31, White, identifies as MtF)

Strain or stress from well-meaning cisgender individuals. Conversely, several participants underscored the strain of educat- ing cisgender friends, family, and partners (n � 18). Participants described a variety of experiences of friends supporting them through their affirmation processes. Participants described feeling validated and supported by friends who “taught them” how to perform their gender. However, other participants felt discrimi- nated and insulted by friends with rigid and narrow perceptions of how to enact gender.

Most of my friends have been really helpful, in that they’ve been really supportive, and they’ve all been as kind as they know how to be. What has not been helpful, however, is that lots of my friends feel like they need to help me be better at being “a man.”. . . But, obviously, that’s not actually helpful, but they do not recognize it, and I do not tell them they’re being shitty . . . because I know they’re not coming from place of malice. And I recognize that they just want me to be happy and comfortable, and so it’s really hard for me to say, “you’re actually kind of being a dick.” (age 35, Black, identifies as FtM)

Impact of positive gestures. Several participants shared that specific positive gestures from family members were very mean- ingful to them in feeling accepted and loved, even if the support had been uneven overall (n � 13).

I think, back in the day, there was no support [from my family]. But they’ve come a long way, and I think they’re helpful, by affirming me as myself and calling me my name and the pronouns. Just asking questions and being curious when they do not know . . . and I think part of it, for them too, is I know it’s really stressful on them to have to come out for me, you know, tell other people that I’m different, so I appreciate [them] just being there for me. (age 35, Multiracial, identifies as transsexual)

Pros and cons of health care professionals. Beyond support from family or friends, both validation and invalidation from

health care providers has had a profound impact on many partic- ipants (n � 25).

I do not see a doctor regularly. The only health care professional that I have any regular contact with is my therapist. She’s been excep- tional. She’s someone who works specifically with the trans commu- nity and nonbinary genders so she seems to have a really good handle on a lot of what’s going through my head and that’s been . . . a lifeline. For everything else, I just typically go to a clinic and . . . if I have to go there, I make sure I’m as butch as possible. . . . (age 40, White, identifies as gender-fluid)

Discussion

In recent years, there has been a growing body of literature focusing on the strengths that allow TGD individuals to maintain resilience and cope with the numerous stressors (e.g., Matsuno & Israel, 2018; Singh, Meng, & Hansen, 2014), including the process of building resilience and fostering supportive communities (e.g., Puckett et al., 2019). The present study provided an opportunity for TGD individuals to describe—in their own words— how they have coped with gender-related stress, the factors that have fostered and maintained their resilience, and how social relationships have impacted their lives, in both positive and negative ways.

To date, a large portion of research focusing on TGD experi- ences has been anchored in a cisgenderist framework, often pathologizing TGD identities or dichotomizing the experience of gender into cisgender versus transgender (Ansara & Hegarty, 2014). This study aimed to counter cisgenderism by centering a diverse spectrum of TGD voices regarding their own definitions of resilience to gender-related stress, along with the coping strategies they identify as helping to manage their response to gender-related stress—as well as the role of interpersonal relationships. Partici- pants thoughtfully described effective ways of dealing with painful experiences unique to TGD communities. Given how pervasive these stressful experiences are, flexible and context-sensitive cop- ing strategies may be most adaptive. Participants elaborated on how they have continued to build strength and resilience after negative experiences related to their gender identities. Finally, participants shared the ways in which social relationships, and the accompanying social support or social strain, impact their experi- ence of gender-related stress.

Although our data analysis methods were inductive, interest- ingly, participants ended up describing coping experiences that fit closely with the facilitative versus avoidant coping strategies cat- egorization introduced into the TGD coping literature by Budge, Katz-Wise et al. (2013). Strategic avoidance was a strategy de- scribed as being used frequently by the participants. Although avoidance is frequently labeled as problematic in the psychology literature, strategic avoidance may be an effective way to maintain safety in times when an individual with a stigmatized identity feels threatened emotionally or physically (e.g., Bogart et al., 2018). TGD people report having learned that they can find themselves in dangerous situations in places that cisgender individuals find in- nocuous. To mitigate that risk and navigate the world successfully, many TGD individuals reported struggling to balance gender iden- tity concealment and expression (e.g., Rood et al., 2017). Given the potential harms resulting from gender identity disclosure in nonaffirming settings, the use of strategic avoidance is adaptive. This strategic avoidance seems warranted especially given that

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lifetime rates of trauma exposure are nearly 100% among TGD individuals (Shipherd, Berke, & Livingston, 2019; Shipherd et al., 2011). Given these alarming rates of violence toward TGD indi- viduals, making deliberate decisions about when to disclose or conceal may be paramount to maximizing safety.

Previously published literature suggests that lower visual con- formity is associated with greater victimization risks for TGD individuals (i.e., Begun & Kattari, 2016). In an effort to feel safe in uncomfortable environments, some individuals described efforts to decrease or increase gendered behaviors—so as to limit drawing attention to themselves in terms of their gender identity or presen- tation. These behaviors varied, including both exaggerating a gender expression in line with their gender identity, or presenting in a way that aligns with gender expectations for their sex assigned at birth (i.e., due to identification or name) despite their gender presentation being different than the typical gender expression associated with their gender identity. Regardless of direction, this experience was often described as stressful, and participants de- scribed modulating gender presentation to facilitate reducing dis- comfort or avoiding harm.

At the times when they felt safe from the risk of victimization, many participants found the confidence to push back on the urge to avoid, and reported practicing facilitative coping by looking for ways to use their identity to find strength. Some participants reported creating community spaces to support other TGD indi- viduals. This pro-social behavior, of developing TGD spaces, appears particularly important—as it not only demonstrates the development of resilience, but the resulting experience of these communities was linked to fostering resilience in others and cre- ating a positive, symbiotic network within TGD communities. Although there is limited research on prosocial behaviors and resilience or coping, some research suggests that there may be an association between empathy or helping and resilience (e.g., Grot- berg, 1997).

Although many participants described a narrative of struggling with self-worth and self-love in the past, most reported more compassion for themselves, and the simultaneous rejection of judgment from others, at the time of their interviews. The perspec- tive they gained from their struggles and skills they accumulated over time helped several participants feel inspired to “give back” to other TGD individuals when possible. Participants described TGD spaces as opportunities for both upward and downward social comparison. When looking upward, participants reported feeling hopeful or even inspired; when looking downward, partic- ipants described finding a purpose that allowed them to give back to their communities. Sometimes, participants reported, the act of giving back helped them cope with day-to-day stressors, and at other times, they conceptualized it as part of their own resilience, regardless of what they may or may not be experiencing in a given moment. Many participants discussed wanting to give back to TGD communities in various ways, from structured programs with volunteering or mentorship, to unstructured methods, such as using their own experiences to support other TGD people who are struggling. This community-bolstering cycle of channeling adver- sity into communal support is underresearched in general, and is primarily absent from the TGD literature. Although the research is limited, similar experiences have been reported by individuals residing in urban communities of color (Payne & Hamdi, 2008).

The intersections of race and resilience were particularly salient to some participants, especially TDG participants of color. Previ- ous research suggests a cumulative negative impact of intersecting minority stressors on mental and physical health experiences (e.g., Balsam, Molina, Beadnell, Simoni, & Walters, 2011). Individuals who believed that their community could not accept the intersec- tion of their TGD identity and their race often lacked the support that seemed to help bolster others with different constellations of identities. Dealing with race-related stressors alongside gender- related stressors seemed to help some individuals feel more pre- pared for potential hardships. This result is unsurprising, given that individuals who identify as both a racial minority and TGD are at greater risk of violence than those who possess either identity separately, with predicted probabilities of sexual assault up to 58% (Coulter, & Rankin, 2020). As of July 2020, there have been 25 murders of TGD individuals during the 2020 calendar year alone, 14 of whom identified as a TGD person of color (Human Rights Campaign, 2020). Given that our participants indicated a distinc- tion between the experiences of non-White and White TGD indi- viduals, further research is needed to elaborate on these distinc- tions and determine the best ways to support TGD individuals of color.

Previous literature suggests that having a self-generated defini- tion of self may be a component of resilience in TGD individuals (Singh et al., 2011). Participants described the process of integrat- ing gender into a self-concept, where the role of gender varied from person to person. For some, their gender identity was a clear source of strength and pride. For others, gender identity was a small aspect of how they experienced themselves. Regardless of the salience of their gender identity, the experience of incorporat- ing it into a self-concept was reported as beneficial. A sense of self was also associated with the experience of social relationships, as the people surrounding the TGD individual can either bolster that sense of self or challenge it.

The importance of social relationships emerged as crucial in nearly every interview. When positive social support was reported by the participant, they also reported feeling better able to manage gender-related stress and were more resilient against potential harms. Support could be communicated through more minor ac- tions, like using accurate pronouns, to more substantial actions, like intentionally validating the TGD individuals’ gender identity. Our findings aligned closely with others reported in the literature in recent years (e.g., Matsuno & Israel, 2018; Puckett et al., 2019), underscoring the importance of validating social support in TGD communities, as many participants discussed positive repercus- sions of having social support. However, given the broad range of experiences that TGD individuals identified as being supportive, future research is needed to continue to expand knowledge on the ways TGD individuals may feel supported by others, both in and outside the TGD communities.

In contrast to the benefits afforded by a supportive environment, many individuals had experiences in which support was lacking, or they felt injured by individuals whom they anticipated would have been supportive. For example, participants reported that health care providers frequently caused them harm by misgendering them or being dismissive of their needs. Another problem that partici- pants identified was health care providers asking to be educated about transgender health by the patient, a practice that is itself a minority stressor (Shipherd & Sloan, 2019). Furthermore, lack of

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9COPING, RESILIENCE, AND SUPPORT AMONG TGD ADULTS

experience and training on TGD health may increase discrimina- tion and mistreatment of TGD individuals (Matsuno, 2019). These experiences frequently left TGD individuals reluctant or unwilling to seek medical attention altogether, even when it was clear that they needed care. In devastating instances, health care professional negligence of TGD patients has led to avoidable death (Robinson, 2010). Beyond health care providers, many participants reported feeling strained or removed from their family of origin. Even well-intentioned friends may precipitate gender-related strain, as demonstrated by participants describing friends who attempted to “help” the participant express their gender identity in scripted ways that increased pressure or did not align with the participant’s gender expression. These negative experiences aligned closely with others described in the literature (e.g., James et al., 2016), and further underscores the importance of helping TGD individuals engage with supportive communities.

Limitations

Given that research on TGD individuals is positioned as non- normative, it is important to acknowledge that our cisgender iden- tities created a distance between the coding team and the content of this research that allows for bias to interfere (Galupo, 2017). Importantly, we must acknowledge the privilege that comes with our cisgender identities and not conflate the research team’s affil- iation with sexual minority communities as being comparable or equivalent to TGD communities, especially because TGD individ- uals often report being marginalized within broader sexual minor- ity communities (Patterson, 2018). Given the qualitative design of the study, we must acknowledge the potential influence of biases on the part of both the participants (e.g., recall, social desirability) and the investigators (e.g., a priori-determined research concerns, trans-affirmative), as well as the limitations related to insight. Furthermore, as this study was conducted in connection with a larger research project, we must note that the exclusion of indi- viduals that had not affirmed their gender via their appearance and clothing may have removed an important perspective from our findings. Additionally, participants volunteered to be part of the research study, which likely contributed to selection biases (i.e., volunteerism, comfort discussing the topics under study). Partici- pants were recruited from the Internet, which can also present unique challenges in terms of recruitment and selection bias, including a greater likelihood of participants being White, younger, and relatively well-educated (Ross, Mansson, Daneback, Cooper, & Tikkanen, 2005). We made great efforts to recruit and collect data through a rigorous methodology informed by previ- ously published research (see Miner, Bockting, Romine, & Raman, 2012). Despite these efforts, Internet-based studies yield conve- nience samples that can exclude certain subpopulations from par- ticipating (e.g., individuals who do not have access to a computer).

Conclusions

Although some findings align with elements of the previous coping, resilience, and support literature, some important novel elements emerged as well. Specifically, strategic avoidance in this population may be an adaptive and useful tool for coping in certain situations. Although research has begun to explore both positive and negative implications for TGD individuals’ experiences with

identity concealment (Rood et al., 2017), future research should aim to explore both the utility and the costs of avoidance behavior across situations. The impact of social relationships on TGD individuals’ experience was notable throughout many interviews. More research is needed to explore clear methods for cisgender friends, family members, and allies to best support TGD individ- uals, given that well-meaning interactions, such as advice-giving or “teaching,” can be burdensome or invalidating. Conversely, the burden on TGD individuals having to “teach” cisgender individ- uals about the TGD experience may also interfere with overall support and well-being. Although the results of the current study underscored that support can be experienced in a number of ways, further research is needed to explore the best ways to support TGD individuals, from the perspective of health care provider, or cis- gender family member or friend.

The vital importance of TGD communities arose frequently in interviews, across the domains of coping, resilience, and social support. This idea aligns closely with previous literature that underscores the importance of TGD communities in fostering resilience by buffering the negative impact of minority stress (Matsuno & Israel, 2018). Although many individuals described positive experiences they accrued from participating in TGD com- munities, some also discussed barriers that prevent them from engaging fully with TGD communities (i.e., physical distance from in-person TGD support groups). Given the impact that these com- munities have on TDG individuals’ well-being, more research and advocacy is needed in effort to develop, bolster, and support greater visibility of and participation in these communities. How- ever, it is important to note that not every participant with access to TGD support groups experienced them as supportive, due to a variety of reasons (e.g., groups holding a standard of a gender- binary for the whole group), and thus, more work needs to be done to amplify these TDG voices to bridge potential gaps left by standard care from support groups. Finally, clinical research is needed to best address how clinicians can work to highlight the strength and resilience that many TGD individuals possess, and how to bring that resilience to the attention of their client.

References

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Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT people of color micro- aggressions scale. Cultural Diversity and Ethnic Minority Psychology, 17, 163–174. http://dx.doi.org/10.1037/a0023244

Bogart, L. M., Dale, S. K., Daffin, G. K., Patel, K. N., Klein, D. J., Mayer, K. H., & Pantalone, D. W. (2018). Pilot intervention for discrimination- related coping among HIV-positive Black sexual minority men. Cultural Diversity and Ethnic Minority Psychology, 24, 541–551.

Begun, S., & Kattari, S. K. (2016). Conforming for survival: Associations between transgender visual conformity/passing and homelessness expe- riences. Journal of Gay & Lesbian Social Services, 28, 54 – 66. http:// dx.doi.org/10.1080/10538720.2016.1125821

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Received March 6, 2020 Revision received August 14, 2020

Accepted September 20, 2020 �

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