HEALTHCARE EXPERIENCES OF TRANSGENDER ADULTS WHO ARE AFRICAN AMERICAN

HEALTHCARE EXPERIENCES OF TRANSGENDER ADULTS WHO ARE AFRICAN

AMERICAN

Chapter 1: Introduction to the Study

Healthcare is an essential resource for all of society, especially its most vulnerable

people. Unfortunately, those vulnerable members often struggle the most to access

healthcare resources (Seelman et al., 2021). Even a single marginalized identity, such as

being African American or transgender, is enough to limit healthcare access (Hall &

Heath, 2021). For those with multiple intersecting marginalizations, such as transgender

African American adults, the barriers they face to obtaining healthcare are multiplied

(Cicero et al., 2019). However, although these intersectional barriers are evident, their

specific nature of how they experience the healthcare system has not yet been adequately

explored for the specific context of transgender African American adults. This gap gave

rise to the need for the present study.

This chapter introduces the study and provides an overview of key components.

The chapter begins with the background of the study, including its research gap. Second,

is the problem statement, which establishes the study's central focus. Third is then the

purpose of the study, which explicitly states the intention of the research. The purpose of

the study then naturally leads to the critical research question guiding the study.

Supporting the research question is a discussion of intersectionality theory, the conceptual

framework for the study. After the framework, the key methodological aspects of the

study are presented in brief, followed by several key definitions. Following the definition

section are the assumptions, delimitations, and limitations. The introduction concludes

with a discussion of the study's significance and a summary.

Background

Racial discrimination and disparity in healthcare are widely researched topics

(e.g., Hall & Heath, 2021; Muvuka et al., 2020). African Americans struggle to access

healthcare because of a combination of overt racism, implicit bias from providers, and the

effects of systemic racism (Parlier-Ahmad et al., 2022). These struggles often include

disrespect everyday racism (Muvuka et al., 2020). In this context, everyday racism

reflects the experience of low-level racism on an everyday basis, such as inconsideration,

stereotyping, and microaggressions, that do not rise to the level of being overtly racist in

the way most would identify as such (Muvuka et al., 2020).

Racism can also prevent individuals from trusting the healthcare system enough to

seek care. For example, because of past healthcare injustices (especially the Tuskegee

syphilis trials), many African Americans are implicitly distrustful of healthcare (Barrett,

2019). In addition, healthcare access is limited by cultural and religious beliefs, bias and

discriminatory practices from providers, socioeconomic status, disparities in healthcare

costs based on race, and a lack of knowledge about healthcare (Chandler et al., 2021;

Muvuka et al., 2020). Some of these issues are specific to African Americans, while

others are shared with other racial minority groups. These factors significantly hinder

equitable healthcare (Muvuka et al., 2020).

Transgender adults of all races also face health disparities; a large body of

research reflects the barriers to healthcare access faced by transgender adults (Kcomt et

al., 2020; Romaneli & Lindsey, 2020; Seelman et al., 2021). For example, healthcare

providers who do not feel favorably about transgender status may deny care, choose not

to prescribe the desired gender-affirming care, or provoke transgender people to feel

unsafe and uncomfortable in receiving care (Sevelius et al., 2021). Although there is

much literature, the topic is quickly evolving, especially with the rise of transgender

issues as a significant political flashpoint (Tishelman et al., 2019). Transgender issues are

also inherently more complicated because they are intrinsically bound up in healthcare,

with gender-affirming care being considered an important or essential part of being

transgender (Reback et al., 2018). At the same time, the medical dimension of

transgender status can complicate other aspects of care, such as fertility treatment (Chen

et al., 2019).

Less well-understood are the barriers facing those who are both African American

and transgender (Howard et al., 2019). These individuals face all the barriers of African

American and transgender people (Kcomt et al., 2020). However, those from such

intersectional marginalized groups experience barriers unique to their intersectionality

(Crenshaw, 1990). There was a significant and relevant research gap in terms of

understanding those intersectional barriers in the healthcare context, specifically, how

healthcare is experienced by transgender people (Cicero et al., 2019; Kcomt et al., 2020)

and transgender people of color, such as African Americans (Howard et al., 2019). This

research gap was vital given the essential nature of healthcare to anyone, especially

vulnerable groups such as African Americans and transgender people.

Problem Statement

The research problem guiding the study was that African American transgender

adults face significant barriers to obtaining desired and necessary healthcare services to

manage optimal health (Howard et al., 2019; Seelman et al., 2021). Healthcare for

marginalized communities is often present with biases and discriminatory practices that

impede high-quality care (Loo et al., 2021). Such barriers take many forms, such as

refusal to prescribe gender-affirming care or everyday racism that is defined as the

experience of a pervasive, low-level form of racism in the medical context (Hobster &

McLuskey, 2020). Because of the importance of healthcare, when barriers prevent access

for an already vulnerable community, such as transgender people, there is a profoundly

detrimental effect on the members of that community (Milner et al., 2019).

Discrimination and refusal to provide care can create significant hardships or even trauma

for transgender and African American people (Hobster & McLuskey, 2020). The

experiences of African American transgender adults needed to be examined and

understood to meet better their underserved medical needs (Cicero et al., 2019).

Many transgender individuals experience inequality in healthcare (Seelman et al.,

2021). The experience of this population is significant in creating increased transgender

affirmative care and inclusive healthcare services (Daly & Champion, 2021). This finding

is true generally but more so for transgender people from racial/ethnic minorities

(Seelman et al., 2021). In particular, Alizaga et al. (2021) found that African American

transgender individuals encounter discrimination based on race, ethnicity, and gender

within the healthcare system. These individuals are at the intersection of multiple

marginalized identities and face intersectional challenges and discrimination (Kattari et

al., 2020). The experience of compounded marginalization for a second characteristic can

cause significant negative effects and cause African American transgender people to

avoid care altogether (Goldenberg et al., 2021). This double discrimination is especially

significant because African American transgender people could benefit in multiple ways

from improved gender-affirming care because of those same intersectionalities (Sevelius

et al., 2021).

Although the research regarding African American transgender adults facing

significant barriers to obtaining desired and necessary healthcare services to manage

optimal health illuminates essential findings, I had found no research that examined the

barriers to obtaining healthcare services to manage optimal health among African

American transgender adults. Given such, further research was warranted that could

examine the barriers to healthcare experiences of African American transgender adults in

an effort to address the documented problem of African American transgender adults

facing significant barriers to obtaining desired and necessary healthcare services to

manage optimal health (Howard et al., 2019).

Purpose of the Study

The purpose of the generic qualitative study was to explore the experiences of

African American transgender adults obtaining necessary healthcare services to manage

optimal health. The central phenomenon of interest for the study was the barriers to

healthcare faced by African American transgender adults. These barriers arise not only

from individual identities but from the intersectionality of two marginalized identities,

transgender identity and African American identity. This study may help healthcare

navigators provide preventative and remedial services to incorporate inclusivity among

transgender adults who are African American with healthcare needs.

Research Question

The research question was: “What are the experiences of African American

transgender adults obtaining necessary healthcare services to manage optimal health?”

Conceptual Framework

The study was guided by the conceptual framework of the intersectionality theory

(Crenshaw, 1990), particularly through a focus on the problems arising from the

intersection of being African American and transgender. Crenshaw introduced

intersectionality in 1989 as a way of understanding situations in which more than one

marginalized identity overlaps (Carastathis, 2016). Crenshaw developed intersectionality

using key concepts from critical race theory (Meer, 2014). The theory's original concept

explored the interaction of gender and African American women and the lack of

understanding of the intersectional marginalized African American women's experiences

(Meer, 2014). In particular, Crenshaw (1990) observed that Black women faced issues

specific to being Black women, not just a combination of issues that arose from being

Black or female. The researcher noted that most feminist groups at the time focused on

the problems experienced by White women while ignoring those of African American

women. These unique issues arising from the intersection of two different marginalized

identities required a new framework; intersectionality theory was that framework and has

since been applied to a much wider group of intersectional identities (Carastathis, 2016).

In this study, intersectionality theory was an appropriate conceptual framework

because of this study's focus on an intersectional population, African American

transgender adults. An intersectionality perspective helped with understanding the dually

marginalized population's barriers to healthcare by exploring how African American

transgender individuals respond to discrimination and how privilege is received. African

American transgender individuals encounter discrimination from healthcare professionals

who have core values and free will to align with social stigmas that discriminate against

race and sexual minorities (Hobster & McLuskey, 2020). Intersectionality theory guided

the research by helping to understand systemic barriers to healthcare at the intersection of

African American transgender individuals and oppression. In addition, prior researchers

have applied intersectionality to transgender people who intersect with other communities

(e.g., Goldenberg et al., 2019; Mog & Swarr, 2008), giving precedent to its use. The study

expanded on intersectionality theory by applying it to a new intersectional population that

had not been adequately researched in the existing literature.

Nature of the Study

The study used a qualitative methodology and a generic research design. The

qualitative methodology is a descriptive and exploratory research type used to research

the subjective human experience (Merriam & Tisdell, 2015). The present study was

focused on the subjective experiences of adult African American transgender people,

aligning with the qualitative method. Qualitative research is also open-ended in nature,

guided by research questions of what, how, or why (Yin, 2017). Such open-endedness

makes qualitative inquiry ideal for exploring new topics (Merriam & Tisdell, 2015). The

intersectionality of African American experiences and adult transgender experiences in

healthcare represents a topic remains underdeveloped in the literature and, therefore,

needs open-ended exploration.

Qualitative descriptive research was well-suited to the study. Descriptive research

is also known as generic qualitative research because a descriptive qualitative design

aligns closely with the general nature of qualitative inquiry (Thorne, 2016). In a

descriptive study, the focus is on describing the central research phenomenon (Percy et

al., 2015). A descriptive study offers greater flexibility than other qualitative research

designs because it does not focus on a single aspect of the phenomenon but rather on the

phenomenon as a whole (Thorne, 2016). This made a descriptive design ideal for looking

at a qualitative phenomenon to which no other specific design applies. As mentioned

above, the study is well-suited to a qualitative methodology. However, the study was

intended to describe the central phenomenon as a whole rather than specific aspects. In

addition, the flexibility of a qualitative descriptive design afforded more latitude to

navigate the complex emotional issues surrounding this study's central phenomenon and

research topic.

Data for the study were collected using qualitative, semi-structured interviews and

open-ended questions. Interviews allow participants to give data that contains extensive

information to express their experiences (Bevan, 2014). An interview guide with the

preliminary questions was prepared and validated to ensure that the appropriate data

points are collected. Each in-depth semi-structured interview (Kallio et al., 2016) was

conducted via Zoom and lasted 60–90 minutes. The results were audio and video

recorded to ensure all data points were captured accurately. Thematic analysis was

utilized in analyzing the participants’ interviews to generate codes, categories, and

themes. Thematic analysis is the process of coding and categorizing raw data (Clarke et

al., 2015). Thematic analysis was appropriate for conducting a generic qualitative study

and firsthand data on the lived experiences of individuals (Clarke et al., 2015).

Qualitative thematic analysis was relevant because it provides ontological and

epistemological features (Ayre & McCaffery, 2022; Sundler et al., 2019). The research

methods for the study are presented in greater detail in the research method chapter.

Definitions

The following key terms are essential for the study:

African American

African Americans are defined as a racial category in alignment with the U.S.

census definition; consequently, African American status is typically self-reported by

members of the group and represents a marginalized social identity (Cicero et al., 2019).

As discussed below under “Black,” the terms African American and Black are used

interchangeable herein.

Barriers

In this study, barriers to healthcare are defined as pervasive factors that act to limit

or remove the ability of individuals to access healthcare, such as discrimination and

racism on the part of healthcare providers (Loo et al., 2021).

Black

Black is a term used to describe race for those who do not identify as being from

Africa but are still a minority (Cicero et al., 2019). The terms Black and African

American are used throughout this study somewhat interchangeably, in part because there

is no clear standard in the existing literature for applying one term or the other, especially

given the changing connotations of the two terms over time and the inherent fluidity of

language.

Intersectionality

Intersectionality, in this study, refers to the intersection of two or more

marginalized identities (Crenshaw, 1990). The present study focused on the intersectional

group of transgender African American adults (Crenshaw, 1990).

Transgender

Transgender people are defined as those whose self-determined gender identity

does not match their biological sex at birth (Hobster & McLuskey, 2020).

Assumptions

Assumptions are foundational aspects of a study that cannot be verified (Merriam

& Tisdell, 2015). Hence, assumptions must be assumed to hold true. Assumptions are

present in all research, including the study. One key assumption for this study was that

the participants would respond accurately, honestly, and completely to the interview

questions. A second related assumption was that members of a twice-marginalized group

would be willing to participate in the research and engage with the researcher on

potentially sensitive topics. This assumption was needed because no other population

could speak to the barriers subjectively experienced by transgender African Americans.

Finally, it was assumed that adult transgender African Americans would have some

insight into the factors that have prevent them from receiving care. This assumption was

grounded in the fact that only they would have experienced any limitation or prevention

of care and was self-evident.

Scope and Delimitations

Delimitations are boundaries in the research (Merriam & Tisdell, 2015).

Delimitations are typically imposed to focus the study and ensure it is feasible (Yin,

2017). There were several delimitations in this study. Firstly, the study was delimited to

the experiences of transgender African Americans in alignment with the identified

research gap. Secondly, the study was delimited to adults, as the existing research has

already focused more on transgender African American children and adolescents. Thirdly,

the study was delimited to specific recruitment sites to help facilitate the researcher's

access to the target population. Lastly, the study was delimited to barriers in alignment

with the practical problem the study addresses. The study was focused only on barriers to

healthcare because of the particular importance of healthcare and because research

indicates the existence of a problem in the healthcare context.

Limitations

Limitations are weaknesses of a study (Merriam & Tisdell, 2015). Limitations are

inherent in the research and can only be mitigated in most cases (Yin, 2017). There were

several limitations to this study. First, utilizing qualitative research presents limitations by

yielding no statistical data and hence results that cannot be generalized; instead, it

incorporates realities and subjectivity (Rahman, 2017). The researcher participated in an

external audit to examine the study’s process, interpretations, and findings to help

ameliorate this weakness. The audit involved an external reviewer with accredited

expertise reviewing the study procedures to ensure they were sound and adequate for

addressing the research questions. Additionally, the generic qualitative research design

involves only one source of data. Therefore, the study was limited in that it could not

include multiple sources of data for the purposes of triangulation, offering no way to

verify the results. A final limitation of particular importance was that recruitment could

have been problematic because the study addresses a twice-marginalized population

(Marks et al., 2017). African American transgender people are a twice-marginalized

group who may be distrustful of the research and its intentions, which had the potential to

create a limitation concerning the recruitment of participants. Moreover, the study

addresses potentially sensitive experiences of discrimination. Therefore, measures were

taken to ensure that recruitment was feasible, such as building a rapport with prospective

participants.

Significance

This study is significant because it helped fill the gap in understanding the

experiences of African American transgender adults obtaining necessary healthcare

services to manage optimal health and have faced significant barriers. The study provided

much-needed insight into African American transgender adults’ experiences of healthcare

barriers from the African American transgender adults' viewpoint. The key players that

could benefit from this research are African American transgender adults of Maryland,

healthcare navigators and allies of Chase Brexton Healthcare, Pro Bono Counseling

Project of Maryland, Maryland Health Connection, HealthCare Access Maryland, Johns

Hopkins Hospital, Planned Parenthood of Maryland, and organizations advocating for

racial and gender equality in healthcare such as World Professional Association for

Transgender Health, Rainbow Alliance, and Trans Maryland. Understanding the

phenomenon from African American transgender adults’ perspectives was essential

because the information could impact patient care coordination, referral services, and

treatment plans. The knowledge gained could help inform healthcare professionals and

navigators of the need to advocate for and provide racial and gender equality and make

trans-informed decisions. This study is significant to social change as the study provides

a basis for those wanting to provide assistance to African American transgender adults

and remove barriers that prevent racial and gender equality in healthcare.

The research gap the study addressed is built from three calls for further research

found in the existing literature. Firstly, Cicero et al. (2019) conducted an integrative

literature review on the healthcare barriers faced by transgender people. They concluded

that further research is needed regarding the individual experience of those barriers, a call

for research that this study addressed by exploring the experiences of African American

transgender people with healthcare (Cicero et al., 2019). Secondly, Howard et al. (2019)

conducted a study on the healthcare experiences of transgender people of color. Although

they addressed the issue, they also argued in favor of more research on the topic, which

this study addressed through an in-depth exploration. Finally, Kcomt et al. (2020) studied

healthcare avoidance on the part of transgender people. They called for more in-depth

qualitative research on the experiences of transgender people with healthcare (Howard et

al., 2019), which this study addressed due to its qualitative nature.

In addition, the results of the study could hold practical significance because they

address a timely practical problem. Per Sevelius et al. (2021), transgender African

Americans would significantly benefit from gender-affirming care to help reduce the

burden of marginalization. However, researchers such as Alizaga et al. (2021) and

Seelman et al. (2021) found that these individuals are likely to face more barriers than

other transgender people. Therefore, understanding those barriers so they can be

overcome has significance from both a professional and broader societal standpoint. The

study’s practical significance may lead to insights that can improve the healthcare

provision experienced by transgender African American adults. In this way, the study

contributes to positive social change.

Summary

In summation, the research problem guiding the study was that African American

transgender adults face significant barriers to obtaining desired and necessary healthcare

services to manage optimal health (Howard et al., 2019; Seelman et al., 2021). To address

this problem, the purpose of the generic qualitative study was to explore the experiences

of African American transgender adults obtaining necessary healthcare services to

manage optimal health. This purpose was actualized through a single overarching

qualitative research question: What are the experiences of African American transgender

adults obtaining necessary healthcare services to manage optimal health? The study was

guided by the conceptual framework of the intersectionality theory (Crenshaw, 1990),

particularly through a focus on the problems arising from the intersection of being

African American and transgender. The study has significance in addressing a research

gap and a timely practical problem as identified in the literature (e.g., Cicero et al., 2019;

Kcomt et al., 2020; Seelman et al., 2021). This chapter has provided an introduction and

overview of the study. In the next chapter, the background and theoretical framework

sections of this chapter are further developed into a full review of the relevant literature.

Chapter 2: Literature Review

African American transgender adults face significant barriers to obtaining desired

and necessary healthcare services to manage optimal Health (Howard et al., 2019).

Healthcare professionals who treat marginalized communities present with biases and

discriminatory practices (Loo et al., 2021). Healthcare is a multifaceted, complex human

service profession where barriers create hardship for those who lack access (Milner et al.,

2019). Discrimination and refusal to provide care can create significant hardships or even

trauma for transgender people (Hobster & McLuskey, 2020). Although the research

illuminates important findings regarding African American transgender adults facing

significant barriers to desired and necessary healthcare services to manage optimal health,

I found no research about the barriers to obtaining healthcare services to manage optimal

Health among African American transgender adults. The experiences of African American

transgender adults needed to be examined and understood to meet their underserved

medical needs (Cicero et al., 2019). Therefore, the purpose of this qualitative generic

design study was to explore the lived experiences of African American transgender adults

obtaining necessary healthcare services to manage optimal health.

Current literature has shown the problem of transgender and minority people

facing discrimination and a lack of knowledge when seeking healthcare services (Alizaga

et al., 2021; Cicero et al., 2019; Howard et al., 2019). Some have identified possible ways

to advert such negative outcomes, such as having high levels of resilience due to gender

affirmation and healthcare empowerment (Goldenberg et al., 2021; Sevelius et al., 2021).

Other researchers approached the issue through participants who were care providers to

transgender people, expecting that increased education would enhance providers'

transgender healthcare knowledge. However, Stoumsa et al. (2019) found no correlation

between increased education and enhanced knowledge, meaning that extra education did

not change providers’ practices in the field. These studies' attempts to show the issue as

prevalent, suggest ways to mitigate that issue, and increase education about the same

issues have shown the need for increased research into not only transgender people’s

barriers to healthcare but also people of color’s issues with discrimination and accessing

care.

The first section of this chapter covers the strategy used to find research relevant

to the topic, followed by a discussion of the conceptual framework, such as the

intersectionality theory (Crenshaw, 1990). This literature review shows research on

African Americans and transgender adults seeking and obtaining healthcare. For example,

researchers have discussed the barriers to both minority populations as including

discrimination, cultural characteristics, and lack of knowledge (e.g., Bleich et al., 2019;

Cheatham et al., 2008; Duque, 2021; Harb et al., 2019; Parlier-Ahmad et al., 2022; Rees

et al., 2021; Sacks, 2018; Tishelman et al., 2019; Wheeler et al., 2007; Vermeir et al.,

2018). Thus, the first section of the literature review covers barriers to care faced by

African Americans, followed by the second section's discussion of barriers faced by

transgender adults. Furthermore, some researchers, then the previous topics have studied

transgender ethnic/racial minorities accessing healthcare (e.g., Carter et al., 2020; da

Silva, 2020; Goldenberg et al., 2020; Teti et al., 2021); thus, the third section and

literature review theme concerns transgender ethnic/racial minorities and healthcare.

Research has also shown possible ways to mitigate transgender or racial/ethnic minorities

choosing not to obtain healthcare due to discrimination (e.g., Butkus et al., 2020;

Oliphant et al., 2018; Snow et al., 2022; Strully et al., 2021). The fourth section of the

literature review covers research about preventative and remedial services to barriers to

healthcare. Before continuing to the research method section, the literature review ends

with a summary and conclusions section.

Literature Search Strategy

The literature reviewed for this study was sought through resources found in the

Walden University Library and Google Scholar. The databases that contained the research

included the following: ProQuest databases, EBSCO, ERIC, APA PsycArticles, APA

PsyInfo, PubMed, SAGE Journals, Science Direct, and Google Scholar. The key search

terms and combinations of search terms used to find literature related to the subject

include the following: African American barriers to healthcare, Black adults and

healthcare, healthcare barriers, transgender adult barriers to healthcare, transgender

people and healthcare, minorities and healthcare, racial/ethnic minorities and

healthcare, transgender racial/ethnic minorities and healthcare, preventative services to

barriers in healthcare, and solutions to barriers in healthcare.

Most searches came back with several pages of results, such as searches regarding

African American/Black adults and healthcare barriers. There was a plethora of research

on this subject. There were also several research pages on transgender adults facing

barriers to healthcare. Despite the prevalence of articles about African American adults

facing barriers to healthcare and transgender adults facing barriers to healthcare, the

minority characteristics were mostly discussed separately, with articles focusing on Black

people or transgender adults only without identifying racial characteristics. The

researcher found only nine articles that combined the subjects of transgender adults and

ethnic/racial minorities into a single study focusing on barriers to accessing healthcare.

Of those nine articles, only one discusses Black transgender adults and healthcare. The

low prevalence of research covering both subjects and the issue of accessing healthcare

represents a gap in the literature and shows the need for the current study.

Research in this literature review is mostly from the years 2018 to 2022. Some

seminal research from 1990 to current is presented to support the new research. Over

85% of the research is from the past five years. The following section contains a

discussion of the conceptual framework.

Conceptual Foundation

The theory and concepts that ground this study include the conceptual framework

of the intersectionality theory (Crenshaw, 1990), particularly focusing on problems

arising from the intersection of being African American and transgender. In 1989,

Crenshaw introduced intersectionality developed from the critical race theory

(Carastathis, 2016; Meer, 2014). The theory's concept exhibits the interaction of gender

and African American women and the lack of understanding of the intersectional

marginalized African American women's experiences (Meer, 2014). Initially, Crenshaw

revealed that intersectionality was a concept used to theorize how the law responded to

issues about race and gender discrimination (Meer, 2014), with future research taking the

intersectionality concept further (e.g., Goldenberg et al., 2019).

Crenshaw (1990) created the intersectionality theory to understand how

individuals perceive oppression. Therefore, intersectionality theory is being used to

address the uniquely intersectional needs of African American transgender people. Those

needs and experiences are expected to go beyond the individual issues experienced by

African Americans and those experienced by transgender people. For example, African

Americans are a religious demographic and have cultural opinions about identity (Holt et

al., 2014). However, transgender African American people may experience additional

issues navigating that religious identity under religious conservatism and cultural beliefs.

The logical connections between the framework presented and the nature of my

study include the study's focus on an intersectional population. Crenshaw (1990)

originally developed intersectionality theory to explore the unique barriers experienced

by African American women; however, the theory can be expanded to minorities other

than African Americans and genders other than women. Although the prior approach

explored the obstacles facing African Americans and women separately, Crenshaw (1990)

used the intersectionality theory to show the unique barriers facing African American

women. For example, during the 1990s, most feminist groups focused on problems

experienced by White women, ignoring those of African American women (Mog &

Swarr, 2008), showing the need for the current study to expand the use of

intersectionality in research.

Other researchers have used intersectionality to study issues of transgender rights

and healthcare barriers. For example, Mog and Swarr (2008) conducted a systematic

literature review in seminal research. The researchers used the intersectionality theory to

study common threads of transgender and disability studies, finding that race and gender

bias intersected in commonalities because of social desirability constructs, meaning

societal expectations negatively or positively influences individuals accessing healthcare

if they were transgender as well. The authors also found that bias and discrimination

influenced individuals accessing healthcare, highlighting the intersectionality theory as a

possible lens to view such issues, just as Goldenberg et al. (2019) found in their study of

gender affirmation, healthcare use, and stigma among African American transgender

peoples who were young still. The authors confirmed that gender affirmation would aid

such a population to garner resilience, helping them gain strength to access healthcare

despite discrimination. The authors discovered this finding based on an intersectional

view, just as the current proposal study, confirming the applicability of the

intersectionality theory to populations beyond the original intention of African American

women (Crenshaw, 1990).

Further studies applied intersectionality research and concepts to transgender

health. For instance, Wesp et al. (2019) used the intersectionality theory combined with

social justice constructs to develop a new theoretical framework for future use (similar to

the current study's use of intersectionality) to create Intersectionality Research for

Transgender Health Justice (IRTHJ). The authors found that social constructs intersected

with social marginalization, with transgender people disproportionately influenced by

health issues and inequities while being disproportionately affected by health inequities

for transgender health justice: Wesp et al. encouraged future research, such as the current

study, to use IRTHJ as a tool for future research, suggesting using it to create, implement,

and interpret health research for transgender populations, agreeing with Goldie and

Chatterjee (2021).

Goldie and Chatterjee (2021) also showed the applicability of intersectionality to

transgender populations, expressing that few studies examined intersectionality among

gender identification and race, with none studying power structures, such as the prison

industry (a subject not studied in the current research). Unlike other studies examining

intersectionality, the authors focused on COVID-19 and transgender populations

experiencing oppression when obtaining healthcare. The authors encouraged cisgender

advocates to support the transgender population in dismantling negatively impactful

systems, and they expressed the need for further research, supporting Abreu et al. (2022)

and the need for the current study's use of intersectionality.

Abreu et al. (2022) used intersectionality to view the findings of Latina

transgender women's experiences in healthcare. The researchers also asked for future

research to explore ways to combat discrimination against transgender people, further

supporting the research above and that of Maroney and Horne (2022). Like the current

study, Maroney and Horne similarly used intersectionality to understand transgender

populations but focused on the intersection of autism with gender identity instead of race.

Despite their study differing slightly from the current study, which focused on the need

for culturally responsive mental health, the authors expressed the need to continue

studying healthcare issues and gender identity. They also showed that culture would

influence decisions to obtain healthcare, aligning with the belief in the current study that

African American cultural and religious beliefs might influence accessing healthcare for

transgender individuals more than transgender people identifying as White.

Based on researchers' requests for further study of intersectionality among

transgender populations (Abreu et al., 2022; Goldie & Chatterjee, 2021; Maroney &

Horne, 2022; Mog & Swarr, 2008), I used intersectionality to understand the dually

marginalized population's barriers to healthcare. I explored how African American

transgender peoples respond to discrimination and how privilege is received. African

American transgender individuals encounter discrimination from healthcare professionals

who have core values and free will to align with social stigmas that discriminate against

race and sexual minorities (Goldenberg et al., 2019). Therefore, the intersectionality

theory guided the research by helping to understand systemic barriers to healthcare at the

intersection of African American transgender individuals and oppression. The following

section presents the literature related to key variables and concepts of the subject studied.

Literature Review

Healthcare should be accessible for all individuals; however, African American

transgender adults face significant barriers to obtaining desired healthcare services to

manage optimal Health (Howard et al., 2019). African Americans alone, without the

added minority status of gender identification, face significant barriers to healthcare that

have continued from the past (Cheatham et al., 2008; Hammond et al., 2010; Wheeler et

al., 2007). These barriers include cultural and religious beliefs among their population,

bias and discriminatory practices, socioeconomic status, disparities in healthcare costs

based on race, and a lack of knowledge (Ali et al., 2018; Chandler et al., 2021;

CharronChénier & Mueller, 2018; Muvuka et al., 2020; Planey et al., 2019; Sacks, 2018).

When racial inequities are combined for an individual with other minority characteristics,

such as variances in gender identity, the problem of barriers to accessing healthcare

increases (Carter et al., 2020; da Silva, 2020; Salerno et al., 2020; Teti et al., 2021).

Healthcare professionals who treat marginalized communities also present with

biases and discriminatory practices, furthering the issue of discriminatory practices in

healthcare (Loo et al., 2021). Healthcare is a multifaceted, complex human service

profession where barriers create hardship for those who lack access (Milner et al., 2019).

Discrimination and refusal to provide care can create significant hardships or even trauma

for transgender people (Hobster & McLuskey, 2020). Therefore, African American

transgender adults' experiences need to be examined and understood to meet better their

underserved medical needs (Cicero et al., 2019).

The current literature review in this section contains the following themes:

barriers faced by African Americans obtaining healthcare, barriers faced by transgender

adults obtaining healthcare, transgender ethnic/racial minorities and healthcare, and

preventative, remedial services to such barriers. African American barriers to healthcare

are first discussed with seminal research (e.g., Cheatham et al., 2008; Wheeler et al.,

2007) to show that the issue has roots in historical and societal issues well before modern

research joined the study of marginalized populations facing barriers to healthcare. The

barriers faced by the African Americans section then continues to newer research from

the past five years to show that the issue remains prevalent and requires further study.

The following section discussing transgender barriers to healthcare contains newer

research than the African American barriers section. Transgender studies have primarily

been developed in recent times with the further acknowledgment of the population

increasing from issues discussed through social media and the Internet (Cicero et al.,

2019). The third section combining the minority characteristics of transgender identity

with racial/ethnic populations presents the newest research, with the oldest dating to 2019

(e.g., Howard et al., 2019), as such research is limited.

This gap in research shows why the current study is necessary, as the issue of

transgender minorities struggling to access healthcare is prevalent in U.S. society but

highly understudied (Teti et al., 2021). To further show the current study's need and some

solutions to the problem, the remedial services section shows possible ways to mitigate

the issue (e.g., Snow et al., 2022). I aim to find that some research may align with the

solutions mentioned by participants in the current study.

Barriers Faced by African Americans Obtaining Healthcare

African American/Black people have experienced marginalization, bias, and

discriminatory practices throughout U.S. history (Hall & Heath, 2021; Wheeler et al.,

2007). Because of the prevalence of this issue, many studies have been conducted to

show the reasons behind such inequalities and find solutions to the problem of racial

stigmatization by enhancing knowledge of the issue while heightening awareness

(Cheatham et al., 2008; Parlier-Ahmad et al., 2022). Although this population has faced

broad inequalities in the United States, the issue of accessing healthcare may be one of

the worst influences, as it affects African Americans' abilities to stay healthy (Hall &

Heath, 2021).

Issues in healthcare that influence an entire population may increase healthcare

costs for healthcare organizations as African Americans may not continue care properly,

such as following medication adherence and attending follow-up appointments (Hall &

Heath, 2021). These issues increase the risk for additional healthcare problems, placing

further strain on an already strained medical system in the United States due to COVID19

and a lack of health insurance or knowledge of ways to receive care despite

socioeconomic issues (e.g., Chandler et al., 2021; Charron-Chénier & Mueller, 2018;

Duque, 2021). Because of the prevalence of research into African Americans facing bias

and discrimination when seeking healthcare, as well as their own population's opinions

based on culture and religion, this section of the study presents seminal research to show

the issue's historical weight that continues into today.

Foundational Research on Issues With Seeking Care

Much seminal research has discussed the issue of African Americans facing

barriers when seeking healthcare. Discriminatory practices developed throughout history,

starting with African Americans facing slavery in the 1800s and continuing beyond the

end of slavery in June 1866 (Wheeler et al., 2007). Because of this negative background,

African American people have developed an overall mistrust of structured systems, and

something later called systemic racism, especially regarding healthcare institutions

(Hammond et al., 2010). This mistrust caused most African Americans to avoid seeking

care altogether or not adhere to medical recommendations when seeking care. The

mistrust also caused them to lack awareness of preventative healthcare services available

to them despite socioeconomic challenges, further exacerbating the issue of high costs in

the healthcare industry and the heightened risk of illness among the population

(Hammond et al., 2010; Wheeler et al., 2007). Foundational research has further shown

that issues of masculinity and cultural perceptions influenced African American

individuals to avoid healthcare (Cheatham et al., 2008). These studies are discussed in

more detail in this subsection.

In a foundational study, Wheeler et al., (2007) focused on diabetes care for

African American patients following up after discharge from an urban hospital. Through

surveys on in-hospital patients that then were discharged, the authors identified several

barriers to this population's continuing care properly: age, gender, race, marital and

employment statuses, level of education in school systems, the status of insured

healthcare, admission, and diagnosis dates, blood sugar level at admission/discharge, and

blood sugar level-raising drug at discharge. Wheeler et al. expressed the need for a future

study to increase the knowledge of the issue and develop more solutions to the problem

than existed in 2007.

Barriers to healthcare for the African American population continued after

Wheeler et al.'s (2007) study. Cheatham et al. (2008) found the same barriers in a similar

study. Although their study researched barriers to African Americans seeking healthcare,

the researchers instead focused on African American men seeking healthcare in general,

without focusing on a specific ailment. Just as Wheeler et al. (2007) identified a barrier

such as sex, Cheatham et al. (2008) found that concepts of masculinity among African

Americans acted as a barrier to seeking care. The researchers also identified religious

beliefs and influences of peers as barriers to seeking healthcare, supporting that the lack

of healthcare among this population may go beyond discrimination, as cultural/religious

beliefs add two-fold issues to an already difficult situation.

Research has shown that peer support can encourage African Americans to obtain

care; thus, it is important to increase the knowledge of family members in the community

to mitigate the opposite (Cheatham et al., 2008). In another foundational study, Hammond

et al. (2010) agreed with Cheatham et al. (2008) that African American beliefs about

masculinity added to the medical mistrust that had developed historically from their

marginalized past. These issues caused African American men to avoid seeking

preventative healthcare, which might have caused increased costs for themselves and

healthcare institutions that must care for patients who lack health insurance and have not

taken measures to avoid getting sicker (Hammond et al., 2010).

Hammond et al. (2010) conducted a cross-sectional analysis of 610 Black men to

develop this conclusion by focusing on their likeliness to obtain blood pressure and

cholesterol screenings. The researchers showed that those with increased medical mistrust

would be more likely to delay care or not obtain care than those with higher selfreliance

characteristics, who were identified as most likely to obtain care from the variables

studied. The variables included advocacy of traditional masculinity norms in relation to

independence, the importance of traditional masculinity norms, and medical mistrust and

self-reported delay in health services considered preventative (Hammond et al., 2010).

The researchers indicated the need to acknowledge masculinity as a barrier to African

American men seeking care, suggesting that healthcare leaders proceed to care for such

patients with this knowledge.

In agreement with prior studies but with a focus on reproductive health services in

African American women (not men), Golden (2014) expressed that low income was a

barrier for African American women seeking healthcare beyond discrimination faced in

the community. The researcher used a specific setting based on ecology to show that

lowincome women in the African American community of a small urban setting struggled

with a lack of income and knowledge, negatively influencing their desire or ability to

obtain health care. Although there may have been provisions to assist low-income people

with obtaining reproductive healthcare, the participants seemed to need to learn how to

access such care. Thus, Golden expressed the need for more research into the issue of

African Americans facing barriers to obtaining proper healthcare, supporting the opinions

of prior researchers discussed in this section (e.g., Cheatham et al., 2008; Hammond et

al., 2010; Wheeler et al., 2007).

Cheatham et al. (2008). Hammond et al. (2010), Wheeler et al. (2007), and

Golden (2014) all suggested and requested future researchers to continue studying the

barriers that African Americans face when obtaining healthcare. The researchers

conducted foundational studies explored in this section to show the historical prevalence

of this racial issue. In answer to such requests and the issue remaining in U.S. society

well into 2022, researchers continued to address this call for future research, as discussed

in the following subsection.

Latest Research on Seeking Care

The issues noted in the foundational research above have continued into modern

times. Research from the past five years shows the issue is prevalent and the need for

future research to continue studying an old problem that has yet to be resolved entirely.

Thus, because foundational research addressed the problem up to the most recent five

years, researchers were able to continue work on the issue by conducting newer and

similar studies to support the findings of seminal research further (e.g., Cheatham et al.,

2008; Hammond et al., 2010; Wheeler et al., 2007). For example, Charron-Chénier and

Mueller (2018) studied racial disparities in medical spending in White and Black

households from 2013 to 2015 through a synthesized literature review study. Their

research supported earlier researchers' assertions in the above subsection concerning the

high costs associated with African Americans avoiding healthcare or not adhering to

medication and follow-up practices (e.g., Golden, 2014). Black households were found to

be less likely to spend money on healthcare costs compared to White households. The

research did not show the reason for such a discrepancy but opined that this issue showed

healthcare inequalities between the two races, indicating the need for more research.

Thus, Sacks (2018) continued such a study into Black Americans facing barriers to

accessing healthcare; however, the researcher focused on a participant sample of

middleclass women who were also Black. The author identified that most research from

the past, such as that of Charron-Chénier and Mueller (2018), focused on comparing

Black and White populations; thus, Sacks (2018) chose to focus on the Black population

only. The author found that discriminatory practices throughout history continued into the

modern era, causing Black people to lack proper medical care. The author found that

race, class, and gender may add increased barriers to healthcare, depending on how much

money an individual can access or if they face cultural assumptions due to being a

different gender, such as masculinity values expressed by prior research as a barrier

(Cheatham et al., 2008; Hammond et al., 2010). The specific issues related to barriers to

healthcare for African American adults are discussed in the following subsections.

Lack of Knowledge and Awareness From Cultural/Religious and Socioeconomic

Differences

Black people from poor socioeconomic conditions may lack awareness of the

need for healthcare or ways to obtain it despite their lack of monetary resources (Sacks,

2018). Black people from middle-class families were more likely to access healthcare

than those of lower-class families who had less money or the ability to obtain information

(Ali et al., 2018; Sacks, 2018). In corroboration of the findings of Sacks (2018), Ali et al.

(2018) conducted a qualitative study (similar to the current proposal) focusing on Black

people from urban areas and the literacy gaps regarding health insurance. Just as

foundational research showed a lack of trust in healthcare practices as a barrier (e.g.,

Cheatham et al., 2008; Hammond et al., 2010; Wheeler et al., 2007), Ali et al. (2018)

showed that this mistrust also aided increased misunderstandings of the need for

preventative care through conducting 12 focus groups on a Black sample of individuals

from Kentucky. The authors noted the need for better information delivery to African

American communities about health insurance options despite their socioeconomic

situations.

The lack of health insurance knowledge negatively influences access to

preventative care and harms advance care planning for African Americans entering older

ages, as suggested by Magwood et al. (2019) and Sanders et al. (2019). They further

supported Ali et al.'s (2018) findings. These findings were corroborated by Campbell and

Egede (2020). They studied 1,183 articles in a systematic literature review to identify

barriers faced by African Americans with Type 2 diabetes residing in an inner-city

environment. The researchers confirmed other findings before them (e.g., Ali et al., 2018;

Sacks, 2018; Wheeler et al., 2007) that the population lacked awareness and knowledge,

causing them to avoid seeking healthcare. Campbell and Egede (2020) suggested that

mistrust might have led to this issue, which had developed from systemic racism faced

when seeking access to healthcare. Muvuka et al. (2020) agreed with Campbell and

Egede (2020) that the Black population lacked awareness about seeking care. Muvuka et

al. (2020) suggested that this issue stemmed from a lack of health literacy or education

among communities in low socioeconomic conditions. Without knowledge, mistrust was

bound to develop among the Black community (Campbell & Egede, 2020; Muvuka et al.,

2020). This concept of mistrust was prevalent in the literature studied; thus, the following

subsection discusses research that has found similar results about mistrust acting as a

barrier to care.

Issues of Mistrust and Medication Adherence

Among issues identified as barriers not discussed in research thus far (e.g.,

negative or positive moods about illness), the other findings showed a direct correlation

with prior studies showing barriers due to a lack of medication adherence or issues with

obtaining medication in general, resources being unobtainable or low, cultural beliefs, and

religious expectations (Ali et al., 2018; Hall & Heath, 2021; Parlier-Ahmad et al., 2022;

Sacks, 2018). In support of issues with medication adherence among African American

U.S. adults (Ali et al., 2018), Hall and Heath (2021) and Parlier-Ahmad et al.

(2022) studied medication adherence or issues among Black adults. Hall and Heath

(2021) explored medication adherence to show misconceptions about care for

hypertension and diabetes and misconceptions and an increased interest in natural

remedies. After finding 58 papers that matched the search criteria, Hall and Heath found

that mistrust in healthcare providers might have led to misconceptions and an

overreliance on home remedies to avoid going to the doctor. Parlier-Ahmad et al. (2022)

found an issue with White and Black individuals opioid use individuals and how White

adults had better outcomes than Black adults with the same issues. The systemic issues in

the healthcare environment caused Black adults to struggle with seeking out help for

addiction to opioids. Thus, the researchers conducted secondary data analysis using a

cross-sectional survey and a review of medical records. Ninety-eight Black participants

provided a urine test, most being treated for over one year. There were no differences

among the gender of the participants, but the researchers showed that older age and

whether they had used pills through injection correlated to improved outcomes. The

researchers found that if the participants could access high-quality treatments, they had

better outcomes for recovery; however, they faced stigma and discrimination when

accessing care, so those barriers must be addressed to improve outcomes further. The

researchers suggested the need to develop care that would be culturally informed to help

with lowering mistrust in the community.

Parlier-Ahmad et al. and Hall and Heath (2021) identified medication adherence

as an issue regarding mistrust among Black American adults. Participants in

ParlierAhmad et al. (2022) did not always obtain quality care. Such patients had relapses

if they could not follow their medications prescribed to handle the symptoms of their

addiction to opioids. At the same time, participants in Hall and Heath (2021) avoided

medication adherence as well. Parlier-Ahmad et al. (2022) and Hall and Heath (2021)

identified mistrust as the possible cause of a lack of medication adherence. This barrier

extended beyond the racism or discrimination faced, although the lack of mistrust might

have stemmed from such issues in the first place.

Sanders et al. (2019) similarly identified that barriers to healthcare extend beyond

simple discrimination, influencing African Americans beyond their youth and well into

their older ages. The authors conducted a qualitative study on five experts of health

disparities experts, nine members of the community members, and 11 dangerously sick

Black patients and those who provide them care (Sanders et al., 2019). These participants

identified a pattern of discriminatory practices as extending throughout their lives. This

issue caused them to avoid necessary healthcare during the healthy part of their lives as

they did not obtain preventative services that might have supported better health later in

their lives. Medical issues faced by the older adults in the African American population

might have been avoided, reduced, or mitigated altogether if they had trust in medical

providers and willingly sought care (Magwood et al., 2019; Sanders et al., 2019). The

discrimination faced in healthcare caused them to avoid attending healthcare visits and to

have insufficient medical knowledge of the need for preventative care (Sanders et al.,

2019). Bleich et al. (2019) further acknowledged the issue of historical discrimination

causing Black people to avoid preventative healthcare services. Thirty-two percent of

Black participants admitted to facing discrimination when attempting to get clinical aid.

Another 22% avoided healthcare altogether for the same reason, as shown through the

logistic regression of 802 Black people (Bleich et al., 2019). Although the study was

quantitative, Bleich et al. (2019) were essential to research to show the issue's prevalence

in current times, making the current study important to the field of healthcare and Black

populations. Systemic racism added to the issue of discrimination, with Black people

avoiding more than just the police, as they ignored healthcare issues to stay away from

any possible discrimination also faced in healthcare institutions (Bleich et al., 2019).

Not only have researchers studied the issue of barriers to healthcare in adult

African Americans, but some researchers have also identified Black youth facing

significant barriers to care (Planey et al., 2019). Barriers to care faced in youth may make

it more difficult for Black people to trust medical professionals after they have grown up.

These barriers are particularly prevalent for Black youth seeking mental health care; thus,

Planey et al. (2019) used a systematic review of this issue to show the barriers and

possible facilitators to seeking care. The youths faced barriers from being young, factors

associated with the therapy itself or the clinician, stigma and discrimination, spirituality

and religion, and cost and availability of treatments. Despite the barriers, some

facilitators have also identified: practitioners in child mental health as having a high level

of care for young people, caregivers having experience with the youths, and the youths

having support through good social networks, spirituality, and or religion (which was also

a barrier), parents or caregivers offering mandated referrals, and geography. The

facilitator of spirituality or religion was also a barrier, showing the need to understand

how such factors may act as both hindering and helping Black individuals who wish to

seek mental healthcare. The findings showed that there still existed a need to reduce

barriers for this population to care for as mental health is vital to a functioning society.

Alang (2019) corroborated Planey et al.'s (2019) findings; however, Alang did not focus

on Black youths' mental health and used a mixed-method study. Instead, Alang studied

mental Health among U.S. Black adults. Like Planey et al. (2019), Alang (2019) found

that racism hindered access to care. From a survey on drug use and health, 1,237 Black

adults reported unmet needs regarding their mental health care.

Alang (2019) found that Black people who had higher educations or were

currently enrolled in college had more fear of healthcare practitioners, with many

reporting high levels of mistrust, a theme supported by much of the research reviewed

(Magwood et al., 2019; Sanders et al., 2019). Alang (2019) expressed the difficulties

Black adults have because of systemic racism, which has limited their desires or abilities

to access care. The study was important to show the overwhelming data indicating that

racism and discrimination have caused mistrust in healthcare practitioners, all acting as

barriers to care for Black individuals.

Issues Influencing Long-Term Care

Because of systemic racism, most Black adults have faced discriminatory

practices related to their healthcare throughout the entirety of their lives. Magwood et al.

(2019), Rositch et al. (2019), and Mathews et al. (2020) all studied chronic conditions

that Black adults had to face throughout their lives, such as HIV, stroke issues in older

age, and cancer. The lack of health insurance mentioned by Ali et al. (2018) was found by

Magwood et al. (2019) also to harm advance care planning for African Americans

entering older ages, as suggested by Sanders et al. (2019). They further supported Ali et

al.'s (2018) findings. Magwood et al. (2019) suggested that increased stroke risk was

prevalent for African Americans who faced discriminatory practices when seeking

healthcare. The authors studied whistleblower interviews with ten healthcare providers,

20 focus groups of stroke patients, and 19 of their families or caregivers (Magwood et al.,

2019). The study differed slightly from past studies as Magwood et al. (2019) included

healthcare practitioners' opinions to show barriers to care, which still showed issues with

a lack of awareness and knowledge. In corroboration of Magwood et al. (2019), Rositch

et al. (2019) found that long-term care suffered for Black individuals with cancer, as they

faced concepts of fear in their communities and the double issue of bias toward the illness

and their minority race. The family could encourage patients to seek care; however, the

families had preconditioned opinions about healthcare stemming from cultural and

religious differences. Fear was one of the seven identified psychosocial factors that

influenced Black participants to continue care properly throughout their lives for cancer,

as identified through a thematic analysis of four focus groups with 40 participants and

interviews with nine others. The other factors included "pride/dignity,

selflessness/selfsacrifice, cancer fatalism, and distrust/skepticism of medical care"

(Rositch et al., 2019,

p. 1192). Because of familial mistrust and experience in the past with a history of family

cancer, the participants reported low communication behaviors among family members

who could have offered better guidance if they had not also developed a fear of the

system.

Continuing to express the need to combat issues that would cause long-term care

in chronically ill Black adults, Rositch et al. (2019) identified the need for increased

communication to encourage members of this community to get cancer screenings to

avoid increased costs later in life. This finding supported other researchers who had

requested better information dissemination to Black communities about long-term

illnesses and preventative healthcare services (e.g., Magwood et al., 2019; Mathews et al.,

2020). Mathews et al. (2020) studied barriers to care for Black people with HIV,

identifying the same factors as Rositch et al. (2019) and others (e.g., Bleich et al., 2019;

Sanders et al., 2019). These factors that supported prior research in the above subsections

stated that a lack of knowledge and trust in healthcare systems caused Black people with

HIV to delay care, potentially causing the illness to spread to others or to evolve into a

worse situation like AIDs. This mistrust also led Black American adults not to seek

preventative testing services. Without preventative services, healthcare institutions face

an influx of HIV-infected Black people in the future who may require long-term care, as

Magwood et al. (2019) regarding stroke victims and Rositch et al. (2019) regarding

patients with cancer. Beyond long-term care illnesses, there is one virus that has

influenced all communities, but especially Black ones, COVID-19; thus, the following

subsection contains some articles that focus on barriers to care for Black seeking help

when infected with COVID-19.

COVID-19 and Black Individuals’ Barriers to Care

Although COVID-19 influenced all populations in the United States, many fell ill

during the outbreak. The virus negatively influenced Black individuals more than White

individuals (Duque, 2021). For example, Chandler et al. (2021) studied the impact of

COVID-19 on Black women. The findings developed from interviews with 15 Black

women participants. The goal was also to show the participants' knowledge rates about

the virus, as public data had shown low rates of understanding among this population and

about this subject. Interviews occurred with 15 African American women. These women

were patients at a family-based center that served the community in which they lived.

Most participants cited social media and online news platforms as sources of COVID-19

information. These findings were shown through a thematic analysis with MaxQDA

software, with deductive/inductive coding. Seventy-nine percent of the women

interviewed did not trust the information they had found on the virus; this same amount

felt confused about the information they had received. These findings confirmed findings

from other researchers regarding mistrust (e.g., Bleich et al., 2019; Sanders et al., 2019),

but this mistrust could have longer-reaching consequences as COVID-19 remained in

society. Duque (2021) agreed that Black people were more adversely affected by COVID-

19 than other populations as Black people continued to face systemic racism in poverty

and an inability to obtain quality homes in safe environments. The researcher used an

action-oriented approach to study nonprofits using a mixed-method approach. The

findings indicated that intergenerational poverty, possibly derived from systemic racism,

was a barrier to COVID-19-related care. The study was essential to confirm that such

racism had caused long-reaching consequences for this minority population, further

confirming research by Wakeel and Njoku (2021). These researchers showed that issues

of racism and stigma intersected with COVID-19 for Black Americans using the

Weathering Framework. This framework showed the ability of a particular community to

weather issues placed in front of them despite racial obstacles. The researchers agreed

with prior research (e.g., Bleich et al., 2019; Sanders et al., 2019) that mistrust was

prevalent in the community, possibly leading to more infections than in other

communities and higher mortality rates. In further agreement, prior research (e.g.,

Chandler et al., 2021; Duque, 2021), Wakeel and Njoku (2021) stressed the importance of

further research into systemic barriers faced by Black people, as well as the need for

interventions to combat misinformation found online and increase awareness in an

untrusting African American population. Similar barriers are shown for transgender

adults, as discussed in the following section.

Barriers Faced by Transgender Adults Obtaining Healthcare

Many transgender individuals experience inequality in healthcare (Seelman et al.,

2021). The experience of this population is significant in creating increased transgender

affirmative care and inclusive healthcare services (Daly & Champion, 2021). For this

reason, several researchers have studied transgender people's experiences with barriers to

healthcare (e.g., Cicero et al., 2019; Kcomt et al., 2020; Romaneli & Lindsey, 2020;

Seelman et al., 2021; Vermeir et al., 2018). Because research has shown that some

awareness may have increased with time, this section is divided by years to show a

possible change in outcomes over time. However, some changes seem minimal and

further show the need for more research like the current study.

Studies in 2018

Recent research from 2018 showed that the problem existed five years ago and

persists today (Hussaini & Nilsen, 2018; Lee et al., 2018; Reback et al., 2018; Vermeir et

al., 2018). Houssayni and Nilsen (2018), Reback et al. (2018), and Vermeir et al. (2018)

studied barriers to care for transgender people who identified as American, while Lee et

al. (2018) showed similar issues in accessing care in Korean transgender participants.

Unlike Americans, who had acknowledged that transgender beliefs did not constitute a

disorder, Korean transgender people still faced the issue of practitioners believing they

might be mentally ill, further hindering care (Lee et al., 2018). Some participants decided

on different therapies over others; thus, the researchers included this question in the

nationwide cross-sectional survey of 278 transgender Korean people (Lee et al., 2018).

Most participants (91%) were diagnosed with the disorder just mentioned, with 88%

choosing hormone therapies and about 42% getting sex change operations. The

participants showed the following barriers: experiences with negative implications in

healthcare settings, few specialized and knowledgeable practitioners available to the

Rainbow Connection population, and social stigma. Most had reported going to the street

for their hormone medications. The findings showed a lack of safe access to care for these

individuals.

Such findings led to recommendations agreed with by other researchers. For

example, Lee et al. (2018) suggested the need to improve such healthcare through

intervention programs, agreeing with other researchers in 2018, such as Houssayni and

Nilsen (2018), Reback et al. (2018), and Vermeir et al. (2018). All of these researchers

agreed that barriers included low access to health insurance and health disparities that

negatively impacted transgender people's abilities to obtain primary care or access

medications related to gender confirmation, such as hormone therapy. Barriers negatively

influenced access to emergency healthcare (e.g., Vermeir et al., 2018). Reback et al.

(2018) focused on transgender women, unlike the other studies that had included both

gender identities (e.g., Lee et al., 2018; Vermeir et al., 2018). This focus helped to

identify issues commonly faced with infertility developed from taking hormone therapies.

Because of bias and preconditioned beliefs, transgender women were too scared to access

care. Reback et al. (2018) suggested that heightened education about gender minorities

might increase practitioners' cultural sensitivity when dealing with this population.

Houssayni and Nilsen (2018), Reback et al. (2018), and Vermeir et al. (2018) suggested

further research into the issue to heighten awareness of the need for more education and

culturally-sensitive knowledge.

Studies From 2019

In 2019, research into transgender people attempting to access healthcare and

barriers to seeking care continued in response to requests from prior research (Chen et al.,

2019; Cicero et al., 2019). For example, Cicero et al. (2019) conducted an integrative

literature review on transgender adults' healthcare experiences that included 23 studies

selected for their relevance to contextualizing the experiences of transgender adults

interfacing with healthcare, especially concerning the Healthy People 2020 report. Cicero

et al. found that transgender adults experienced many issues, including barriers to access

to health care, discrimination by health care professionals and clinicians, limitations on

health insurance benefits for essential care, and barriers to essential care, including

crosssex hormones and primary care and preventive medicine. These perceived barriers

matched those found by Chen et al. (2019), who also studied practitioners with

transgender patients and their ability to access healthcare, precisely fertility issues.

Gender-hormone medications can influence fertility, which helps transgender

individuals transition to a gender-affirming aspect of their care (Chen et al., 2019;

Reback et al., 2018; Tishelman et al., 2019). For example, because of discrimination,

Tishelman et al. (2019) found that fertility care was complex for transgender individuals

to access. Through a nationally-distributed survey, 110 participants expressed difficulties

obtaining care from admission and expense problems; the necessity for gender-affirming

therapy; patient ages or lack of knowledge to choose future goals; and provider-related

issues regarding a lack of education and their roles as clinicians (Tishelman et al., 2019).

Chen et al. (2019) continued such research and distributed a 46-item survey to 200

providers at conferences or listservs. The quantitative study showed a mean of 3.64 and a

standard deviation of 1.61 for overall knowledge among the participants, indicating that a

high amount of knowledge existed. Despite participants stating that they had patients who

had no desire to delay care or treatment, the participants indicated they witnessed

provider-related barriers to healthcare, with p < .001. These barriers also included bias

and a lack of knowledge of culturally-sensitive care among providers, supporting other

research (e.g., Lee et al., 2018; Vermeir et al., 2018). Cicero et al. (2019) conducted an

integrated literature review of mixed methods to support such findings further to show

that such themes were prevalent in past research. These themes included transgender

people facing bias, discrimination, and a lack of knowledge/culturally-sensitive care;

moreover, the researchers identified a lack of a clear definition of transgender people as

confusing practitioners and further harming the transgender community who face

misconceptions about their characters.

These issues continued in schools in 2019, as well. For example, Goldberg et al.

(2019) studied transgender students and their healthcare experiences. These students were

younger than other populations studied, indicating they might not have as much resilience

as older transgender individuals who have faced discriminatory practices for much longer.

Goldberg et al.'s participants feared violence and negative interactions when seeking

mental or physical healthcare. The participants expressed frustration with constantly

facing misgendering by practitioners, which caused the participants to avoid care.

Misgendering is when a person refuses to acknowledge the gender an individual identifies

with in favor of the biological gender listed on their birth certificates (Harb et al., 2019).

Misgendering was also expressed by Harb et al. (2019) and Kcomt (2019) as an issue

causing transgender people to avoid seeking care. Participants reported that misgendering

was offensive to them, and they would rather avoid experiencing it altogether by not

accessing care (Harb et al., 2019). The researchers studied transgender individuals

assigned to the female sex when born and how they feared accessing sexual health

services because of misgendering. The study mainly included White transgender people

(N = 17). Most were unaware of HPV indicators and had not obtained Pap tests because

of a lack of competent care, as supported by Kcomt (2019), who conducted a systematic

review on the issue of healthcare discrimination. Other sexual minorities did not seem as

compromised when accessing care as transgender individuals, with a significant

prevalence of discrimination cited in most reviewed studies (n = 8).

Harb et al. (2019) requested awareness of structural inequities among healthcare

practitioners to increase culturally-sensitive care among this population, also confirming

the findings of Macdonald et al. (2019) and Tishelman et al. (2019). Macdonald et al.

(2019) studied barriers to oral health care for transgender youth, including young adults.

The participants reported wanting to be treated like an average person, feeling exhausted

from constantly reminding practitioners of their identified gender, thus expressing

misgendering as a barrier like other researchers (e.g., Chen et al., 2019; Cicero et al.,

2019). The 36 participants were interviewed using a semi-structured guide, and they

reported primarily positive results, with negative results occurring from misgendering

that was corrected immediately by the oral practitioners. This improvement in knowledge

compared to other studies (e.g., Chen et al., 2019; Cicero et al., 2019) may indicate

awareness has increased among practitioners, or dentists may have better

culturallysensitive training, being more removed from the sphere of mental health where

bias first developed, than other healthcare industries (Macdonald et al., 2019).

Studies From 2020 to 2022

Because these researchers called for more research, researchers from 2020 to

today have continued to study the issue of barriers to care for transgender individuals

(e.g., Bakko et al., 2021; Johnson et al., 2020; Kattari et al., 2020; Kcomt et al., 2020;

Meyer et al., 2020; Rees et al., 2021). For example, Kcomt et al. (2020) continued the

study of healthcare avoidance from anticipated discrimination among transgender people.

In particular, the researchers aimed to understand the factors that predicted transgender

people's healthcare avoidance from a nationally representative sample of 19,157

transgender people ages 25 and older. The study found that nearly 25% of the sample had

avoided healthcare. Transgender men were significantly more likely to avoid healthcare,

especially if they were visually non-conforming. Health insurance status was also

significant and interacted with gender identity. They argued for the importance of

providers offering better trans-friendly care, supporting Cicero et al.'s (2019) assertion for

better care for this community and Romaneli and Lindsey (2020). Romaneli and Lindsey

studied multiple healthcare discrimination indicators to identify response patterns with

transgender help-seekers. The researchers found patterns of health service discrimination

among transgender individuals requesting healthcare. Specific subpopulations were at

greater risk of experiencing various types of healthcare discrimination and receiving care

from providers with little transgender competence. These results corroborated Seelman et

al. (2021), who studied healthcare mistreatment among transgender individuals to

understand if race or ethnicity played a role in the mistreatment of patients. Their

quantitative study used data from a 2015 nationally representative transgender study.

Seelman et al. (2021) found that (c) among transgender clients of minority statuses

beyond gender choices, the psychosocial risk was consistently more important than

characteristics based on socioeconomic issues in predicting abuse. In addition, however,

gender identity incongruity with identifying documents was a major predictor of

mistreatment, as supported by others (Johnson et al., 2020; Kattari et al., 2020; Kcomt et

al., 2020; Meyer et al., 2020; Rees et al., 2021).

The lack of health insurance, persistent discrimination faced when obtaining care,

high costs to care, and lack of sensitive care and knowledge among practitioners was

consistently reported in research (e.g., Bakko et al., 2021; Johnson et al., 2020; Kattari et

al., 2020; Kcomt et al., 2020; Meyer et al., 2020; Rees et al., 2021). For instance, Johnson

et al. (2020) conducted a study due to the gap in research for transgender people in the

Southeast United States. The researchers claimed that most research on transgender

people and their access to healthcare is affected by barriers focused on those in northern

U.S. cities; thus, the researchers aimed to show healthcare barriers for this population in

that location, avoiding the most used locations, to gather data. Four focus groups were

conducted that lasted 120 min to explore experiences of accessing healthcare with their

identified genders. The researchers conducted a qualitative study that showed the

following barriers to accessing healthcare: having fear or mistrust in the system,

experiencing inconsistencies when seeking care, facing providers' disrespect, and

experiencing mistreatment. These findings were also supported by Kattari et al. (2020)

when studying healthcare denials among transgender populations. The barriers mirrored

others, such as discrimination, lack of knowledge, and lower income, as found through a

multivariate logistic regression (Kattari et al., 2020). Again, Kattari et al. (2020)

suggested more education for practitioners, supporting assertions by Houssayni and

Nilsen (2018), Reback et al. (2018), and Vermeir et al. (2018) and others (e.g., Bakko et

al., 2021; Johnson et al., 2020; Kcomt et al., 2020; Meyer et al., 2020; Rees et al., 2021).

Access to care poses an issue for transgender individuals. However, when combined with

the individual being from an ethnic/racial minority, barriers to care increase. As discussed

in the following section, the combination of issues may cause heightened discriminatory

practices.

Transgender Ethnic/Racial Minorities and Healthcare

Because the current study was concerned with the intersection of race and gender

identity and the effects of both on barriers to care, this section discusses the few studies

found that included both minority statuses. Not many studies included ethnic/racial

minorities and transgender people, showing the need for further research. Even fewer

studies focused on African American transgender adults than the current study. One study

was Alizaga et al. (2022), which studied the experiences of healthcare discrimination

among transgender and gender non-conforming people of color. The researchers used a

quantitative research methodology and conducted a latent class analysis to understand

better the types of discrimination faced by transgender people of color. Many transgender

people of color either experienced or anticipated discrimination and those who

experienced it perceived worse or no healthcare service (Alizaga et al., 2022; Goldenberg

et al., 2020, 2021). Salerno et al. (2020) also specifically studied Black transgender

people, showing the discriminatory practices that influenced their access to quality care.

Another such study by Goldenberg et al. (2020, 2021), included transgender youths of

color and gender affirmation as a potential source of resilience for transgender youth of

color. The researchers found that the youth reported more stigmatization associated with

healthcare than anything, even when they had received affirming care. Those receiving

gender-affirming care could still face stigmatization during the process of accessing that

care, confirming the findings of Howard et al. (2019), who studied the healthcare

experiences of transgender people of color using a qualitative study with data from

interviews with 22 participants and focus groups with 17 of those participants. The

researchers found that all participants described negative experiences with healthcare

providers because of biases against their race or gender identity.

Howard et al.'s (2019) participants who sought out expressly LBGTQ-friendly

care still worried about experiencing racism there, confirming findings by Carter et al.

(2020) and da Silva (2020), who both found fear of healthcare because of experiences

with a lack of awareness and racism. Similarly, Kattari et al. (2020) confirmed the

possibility of such continued bias when studying the intersecting experiences of

healthcare denials among transgender and nonbinary patients. The researchers conducted

a quantitative study with data from a nationally representative 2015 trans study with

27,715 participants. Around 8% had been denied trans-specific healthcare, while over 3%

had been denied general healthcare (Kattari et al., 2020). Healthcare denial was most

strongly predicted by older age, biracial or multiracial status, and lower-income status.

Teti et al. (2021) found corroboration for Kattari et al.'s (2020) findings through a

qualitative study. Thirty-five qualitative studies were included after a systematic search

that included 1,607 participants. Most conducted focus groups and or interviews of their

participants. The findings were mostly aligned with one another, with most research

discussing the barriers and challenges faced by this population when seeking care for

their gender-affirming or basic healthcare needs. The findings showed that most other

research discussed the patients' needs and the strengths within the patients that helped

them combat the barriers faced and seek care. The researchers encouraged more research

into this subject, especially racial/ethnic minorities, and possibly included methods to

assess this issue. These results are relevant to informing the social problem that the study

addresses while showing the gap in the research about African American transgender

people and their barriers to care. Although few studies existed that combined both

minority characteristics, some still were able to suggest possible solutions, which also

mirrors the goal of the current study; thus, the following sections include some

preventative and remedial services suggested by transgender researchers to increase

access to care and lower discriminatory practices.

Preventative and Remedial Services to Barriers in Healthcare

Most studies reviewed suggested the same possible solutions to decreasing

barriers to care for sexual and racial/ethnic minorities. These solutions include the need

for increased education among providers (Ali et al., 2018; Stoumsa et al., 2019),

increased resources and healthcare empowerment provided to low socioeconomic

communities (Sevelius et al., 2021), and the need for gender affirmation (possibly leading

to heightened resilience levels; Butkus et al., 2020; Moseson et al., 2020; Oliphant et al.,

2018; Snow et al., 2022). Some researchers even showed the need for more outreach

work, specifically in minority communities, to increase awareness of healthcare needs for

certain illnesses, such as hypertension in African Americans (Ferdinand et al., 2020) and

COVID-19 for minority populations (Strully et al., 2021).

Some studies focused on minority populations, their barriers to seeking

healthcare, and ways to mitigate these issues. Although not focusing on transgender

people, these studies remain useful because they still reflect the issue of race (Ferdinand

et al., 2020; Strully et al., 2020), an intersecting issue discussed in conjunction with

transgender populations that was studied within the current paper. Strully et al. (2020)

indicated that outreach efforts were required regarding COVID-19 vaccination for

minority populations because of misinformation and cultural beliefs concerning

healthcare. Because of these issues, minority populations (i.e., specifically persons of

color discussed by the author) were less likely to have heightened awareness of vaccines

or to volunteer to be vaccinated; thus, Strully et al. suggested launching campaigns in low

socioeconomic areas or where higher populations of minorities live to try and spread

accurate information to those communities and combat the old belief system stemming

from these populations being used to facing racial inequities and common misconceptions

about their communities. The authors suggested creating selfreflective/adaptive

campaigns while reassessing old strategies to empower these minority populations

regarding seeking healthcare. Also specifically focusing on populations of persons of

color regarding healthcare access, Ferdinand et al. (2020) studied why African Americans

faced such high rights of cardiovascular diseases. The findings mirrored Strully et al.'s

(2020) findings that suggested issues seeking healthcare stemmed from

diagnosis/treatment racial inequities and few practitioners in these communities having

the proper knowledge to apply care that was competent culturally. Ferdinand et al. (2020)

also made similar suggestions to Strully et al.'s (2020) suggestions to help alleviate this

global healthcare issue regarding minorities feeling safe enough to seek healthcare, no

matter what they might face regarding illness. These suggestions included raising

community awareness through outreach programs to educate patients in the community

while employing informed practitioners in these areas to ease the burden of

discrimination. Unlike Strully et al. (2020), Ferdinand et al. (2020) went further in their

findings to suggest that information technology might be a better way to reach younger

generations of minorities to increase community engagement about the way to raise

disease resistance.

Out of all the suggestions for ways to mitigate barriers for transgender people, the

most prevalent involved practitioners using proper gender affirmation and patients being

able to obtain treatments that suited the gender with which they identified. For example,

Sevelius et al. (2021) studied the importance of gender affirmation in other healthcare

outcomes. Their quantitative study included a sample of 858 transgender women of color.

Their results yielded that affirming a person's gender and empowering healthcare choices

significantly influenced the overall impact of sexual orientation-related intolerance on

viral inhibition (Sevelius et al., 2021), meaning that these factors could reduce the harm

caused by discrimination to general healthcare issues. Stoumsa et al. (2019) also

conducted a quantitative study to determine whether formal education on transgender

health forecasts knowledge about the care for transgender patients. The researchers found

no correlation between increased hours of education and enhancement of the healthcare

provider's knowledge of transgender healthcare, which was surprising as most researchers

have insisted that increased education on the issue would allow practitioners to provide

better quality care (Butkus et al., 2020; Moseson et al., 2020; Oliphant et al., 2018).

Beyond solely educating practitioners of minority issues about accessing healthcare,

researchers also mentioned the need to improve the overall quality of care by raising

social awareness and ending discrimination (Butkus et al., 2020). Butkus et al. (2020)

specifically mentioned the lack of universal access to healthcare of high quality for the

general population and the minority population, stating that ensuring coverage is not

enough for minority populations. Minority populations still deserve high-quality

healthcare when seeking help, not just lowered or free prices to access it (Butkus et al.,

2020). Butkus et al. (2020) suggested lowering workforce shortages so that burnout does

not influence practitioners to not take the time to understand minority issues, which

would help them approach these vulnerable populations more gently than if practitioners

were too overburdened with patients to provide personalized care. This research is

relevant as the researchers have called for further investigation of interventions beneficial

to providers' knowledge while improving transgender healthcare.

Some researchers focused on the idea of transgender people seeking healthcare for

pregnancies, providing some methods to alleviate any issues with this vulnerable,

minority population from seeking very basic medical needs for pregnancies and

reproductive healthcare issues. Moseson et al. (2020) stated that most studies focused on

heterosexual issues with reproductive health, mostly ignoring the population of

transgender people who remain capable of carrying a full-term baby. Such people face a

large amount of discrimination when presenting as a different gender, such as a man who

is now pregnant, from what a practitioner expects. Much discrimination occurs in this

situation, possibly causing the patient to avoid seeking help when their babies and own

bodies require specific care. Thus, Moseson et al. suggested the need for inclusive

healthcare practices, specifying that practitioners must learn to remain respectful, and

they should have enough knowledge about this population to avoid showing surprise and

making the patient potentially uncomfortable enough to avoid coming back for necessary

care. These populations still require care, and causing more discrimination regarding

healthcare access may harm these patients mentally and physically.

Although most research expressed the need for gender affirmation to increase

resilience among transgender people, only a few showed ways to mitigate issues with

individuals who were both transgender and from an ethnic/racial minority. This lack of

suggestions shows the need for current research, as the aim was to find more solutions to

the problem by continuing the calls for research made by other researchers (e.g., Butkus

et al., 2020; Moseson et al., 2020; Oliphant et al., 2018). The final section of the literature

review follows and contains a summary and conclusions developed from the reviewed

literature.

Summary and Conclusions

The current literature review contained the following themes: barriers faced by

African Americans obtaining healthcare, barriers faced by transgender adults obtaining

healthcare, transgender ethnic/racial minorities and healthcare, and preventative, remedial

services to such barriers. These themes led to the conclusion that healthcare should be

accessible to all individuals despite perceived barriers. However, the research showed that

African American transgender adults faced significant barriers to obtaining desired

healthcare services to manage optimal health (Howard et al., 2019). African Americans

alone, without the added minority status of gender identification, face significant barriers

to healthcare that have continued from the past (Cheatham et al., 2008; Hammond et al.,

2010; Wheeler et al., 2007). These barriers include cultural and religious beliefs among

their population, bias and discriminatory practices, socioeconomic status, disparities in

healthcare costs based on race, and a lack of knowledge (Ali et al., 2018; Chandler et al.,

2021; Charron-Chénier & Mueller, 2018; Muvuka et al., 2020; Planey et al., 2019; Sacks,

2018). When racial inequities are combined for an individual with other minority

characteristics, such as variances in gender identity, the problem of barriers to accessing

healthcare increases (Carter et al., 2020; da Silva, 2020; Salerno et al., 2020; Teti et al.,

2021).

Because this study studied participants' sexual and racial minority characteristics,

the intersectionality framework was used to view the results—this framework in the

literature review was developed by Crenshaw (1990). The logical connections between

the framework presented and the nature of this study include the study's focus on an

intersectional population. Crenshaw originally developed intersectionality theory to

explore the unique barriers experienced by African American women; however, the

theory could be expanded to minorities other than African Americans and genders other

than women.

The following chapter reviews the methods used to collect and analyze data. The

next chapter, research method, also contains information about the participants, including

the population, sample size, and ethical considerations when conducting the study. The

methodology includes the study’s results, followed by the results chapter, which

disseminates the results with the research from the current chapter.

Chapter 3: Research Method

The purpose of the generic qualitative study was to explore the experiences of

African American transgender adults obtaining necessary healthcare services to manage

optimal health. The previous chapter developed the theoretical foundations of the study

and its background. This chapter addresses the research methods laid out in the nature of

the study in the introduction, which is discussed in full. First, the research methodology

and research design are more fully discussed and justified. Second, the role of the

researcher in the research process is discussed. Third, the methodology is laid out,

including the participants, the instrumentation, the data collection procedures, and the

data analysis. Next are issues of trustworthiness, discussed in terms of its four

dimensions. Finally, this chapter ends with research ethics and a summary.

Research Design and Rationale

The research problem guiding the study was that African American transgender

adults face significant barriers to obtaining desired and necessary healthcare services to

manage optimal health, and only limited research has examined (e.g., Salerno et al.,

2020) the barriers to obtaining healthcare services to manage optimal health among

African American transgender adults (Howard et al., 2019). This problem was addressed

through a single, overarching research question: “What are the experiences of African

American transgender adults obtaining necessary healthcare services to manage optimal

health?”

Underlying this research question, the central phenomenon of interest for the

study was the barriers to healthcare that are faced by African American transgender

adults. These barriers arise not only from individual identities but from the

intersectionality of two marginalized identities, that of transgender identity and that of

African American identity. To address this phenomenon, a qualitative approach and a

generic qualitative research design were adopted for the study.

The qualitative methodology was a descriptive and exploratory research type used

to research the subjective human experience (Merriam & Tisdell, 2015). Qualitative

research is descriptive in that it seeks to document the human experience using longform,

in-depth data collected from those who have firsthand experience with the central

research phenomenon (Moen & Middelthon, 2015). Qualitative research is also

openended in nature, guided by research questions of what, how, or why (Yin, 2017). The

open-endedness of qualitative inquiry is not only expressed in the type of research

questions it is used to answer but also in the way in which a qualitative researcher must

seek to elicit all perspectives on the phenomenon, with a focus on documenting each

perspective at least once rather than on analyzing the frequency of repetition (Moen &

Middelthon, 2015). Such open-endedness makes qualitative inquiry ideal for exploring

new topics (Merriam & Tisdell, 2015). Qualitative research is also contextual, capturing

much of the context around the research topic through its open-ended exploration (Moen

& Middelthon, 2015).

Qualitative research was appropriate for several reasons. The present study was

focused on the subjective experiences of adult African American transgender people. This

study's focus on subjective experiences aligned closely with a qualitative method. In

addition, the intersectionality of African American experiences and adult transgender

experiences in healthcare represented a topic that was not yet well developed in the

literature and, therefore, was in need of open-ended exploration. Furthermore, issues of

intersectional discrimination are inherently contextual, as the nature of the intersectional

effects depends upon the context in which they occur. Therefore, the main aspects of the

study strongly aligned with qualitative research.

By contrast, quantitative research is closed-ended (Park & Park, 2016).

Quantitative studies are used to examine the relationships between closed-ended variables

rather than open-endedly explore phenomena (Apuke, 2017). In addition, quantitative

research’s greatest strength is in large sample sizes (Park & Park, 2016). Large sample

sizes are made feasible through the collection of closed-ended, short-form data. These

data, however, cannot enable exploration of new ideas because of this closed-ended

nature (Apuke, 2017). In addition, quantitative research is a poor choice for exploring

new topics or ideas, as quantitative studies require a strong theoretical grounding (Park &

Park, 2016).

A quantitative methodology would have been poorly aligned with the significant

characteristics of the study. The study was intended to explore a broad phenomenon

rather than focusing on specific variables or their relationships. Moreover, the population

of interest for this study was difficult to access, which would have greatly hindered

attempts to gather large-scale quantitative data. Additionally, the study addressed a new

and poorly understood topic upon which the prevailing theory offered no clear

hypotheses. Therefore, a quantitative research methodology would have been a poor

choice.

Within the qualitative paradigm exist a multitude of research designs. For this

study, the specific research design was a generic qualitative design, also known as

interpretive description. Generic qualitative research is a descriptive qualitative design

aligns closely with the general nature of the qualitative inquiry and lacks the more

specific focus of other qualitative research designs (Thorne, 2016). Generic qualitative

research focuses on describing the study's central phenomenon (Percy et al., 2015). The

interpretive component is that such description must then be interpreted to derive

meaning within the context of the research problem and corresponding societal problem

(Thorne, 2016). A descriptive study offers greater flexibility than other qualitative

research designs because it does not focus on a single aspect of the phenomenon but

rather on the phenomenon as a whole (Percy et al., 2015). Hence, it is possible to adjust

the research approach when necessary.

A descriptive research design was well-aligned with this study. As established

previously, the study strongly aligned with an overall qualitative methodology. However,

the study was intended to describe the central phenomenon of the barriers to healthcare

faced by African American transgender adults as a whole rather than specific aspects,

making it align with a generic qualitative design more than other, more specific

qualitative designs. This phenomenon was expansive and in need of full exploration,

given that the type and nature of these barriers was unknown. In addition, the study was

descriptive and intended to describe the intersectional experiences of African American

transgender adults in the healthcare system. In addition, the flexibility of a qualitative

descriptive design afforded more latitude to navigate the complex emotional issues

surrounding this study's central phenomenon and research topic.

Other qualitative research designs would have been less appropriate. A case study

(Yin, 2017) design focuses deeply on context. While context was an aspect of this

research, it was not the central focus. A narrative approach to research focuses on

understanding the narratives or stories of the participants (Murray, 2009). However, this

study was focused on discrete experiences, not holistic narratives. A phenomenological

design is used to study lived experiences in-depth (Moustakas, 1994). While this study

was intended to study experiences, the depth of phenomenological description was more

than was needed to obtain a general understanding of the phenomenon. A

phenomenological design is also descriptive in nature, but it is more focused on the lived

experiences of the participants in their own right. This study, by contrast, was intended to

use the experiences of the participants in a more instrumental fashion. This use required

less depth and the smaller sample sizes in phenomenological research even vis-à-vis other

qualitative designs would not have suited this study’s purpose given the desire to explore

the phenomenon as fully as possible. Hence, interpretive description was appropriate

because of the inappropriateness of alternate qualitative research designs.

Role of the Researcher

In qualitative research, the role of the researcher is that of primary data collection

instrument (Merriam & Tisdell, 2015). In this study, the researcher was positioned as an

impartial observer. An impartial observer means that the researcher would not include any

individuals who have a preexisting relationship with the researcher, with the advantage

being that the researcher could avoid power dynamics or conflicts of interest power

dynamics or conflicts of interest.

However, a disadvantage was that the researcher had a stake in the research topic

as a scholar of that topic with both personal and professional feelings regarding it; such a

stake could lead to the introduction of bias without due care (Holmes, 2020). In

particular, as the researcher, I care strongly about justice regarding both racial and

transgender issues. These key issues that are reflected in my worldview were both present

in this study and, indeed, were the main foci of the research. Additionally, I am a mental

health counselor who specializes in services for the LGBTQ+ community. I have worked

in various capacities in the Department of Social Services. I am aware that healthcare can

be difficult to obtain for members of this community. Given the nature of my experience

with the phenomenon, the study could have been subject to bias without care taken to

prevent my experiences from compromising the integrity of the findings. Therefore,

reflexivity was employed. Reflexivity entails identifying preconceptions due to a

researcher’s experiences and continuing to do so throughout the research, out of an

awareness that positionality changes during a study (Holmes, 2020). I took care to remain

aware of my biases, preconceptions, and expectations before and while conducting the

research. These factors were set aside to the extent possible in order to minimize bias. No

other ethical issues arose because of the researcher's positionality.

Methodology

Participant Selection Logic

The population of interest for the study was all African American transgender

adults in the United States. Within this overall population, the target population was

African American transgender adults in the Mid-Atlantic region of the United States.

Localizing the population by the state is important because states have different cultures.

In addition, many laws and healthcare practices are determined at the state level, meaning

that African American transgender adults in the Mid-Atlantic region of the United States

likely face different issues than those in other states. The inclusion criteria for the study

was: (a) be African American, (b) identify as transgender, (c) have lived in the

MidAtlantic region of the United States for at least one year, and (d) have accessed

healthcare or attempted to access healthcare in the Mid-Atlantic region to ensure relevant

experiences, and (e) be at least 18 years of age.

Sampling within this population was conducted through a combination of

purposive sampling and snowball sampling. Purposive sampling involves approaching

prospective participants specifically for their ability to answer the research questions

(Etikan et al., 2016). Snowball sampling involves asking the first round of participants to

suggest other potential participants (Parker et al., 2019). Snowball sampling is useful

when the population of interest is difficult to access, which was expected to be the case in

this study as African American transgender adults are a twice-marginalized population.

Purposive sampling was conducted through social media platforms of Facebook, Twitter,

Discord, and LinkedIn. A preliminary sample size of 8–10 participants was targeted. The final

sample size was determined by saturation or the point at which new participants no longer add new

data (Hennink & Kaiser, 2021).

Instrumentation

The primary instrument of data collection for the study consisted of qualitative,

semi-structured interviews conducted by the researcher. The qualitative interview is the

standard means of collecting qualitative data because interviews offer an in-depth

understanding of participants’ opinions and perceptions (Kallio et al., 2016). The

interviews in this study were semi-structured. Semi-structured interviews offer a special

combination of structure and adaptability (Adeoye‐Olatunde et al., 2021). Semistructured

interviews are structured in that they are conducted with the use of an interview guide.

This guide includes a list of the key topics the interview must address and a list of

preliminary questions to guide the interview. However, the researcher is not constrained

by these preliminary questions and may opt to ask probing, follow-up, and clarifying

questions as long as all the topics in the guide are adequately addressed as well (Kallio et

al., 2016).

The interview guide was key to the interviews. I developed the interview guide in

advance with careful reference to the underlying literature reviewed in the literature

review. A panel of three experts from the university was recruited to review the interview

guide after it was developed (Appendix B). In addition to offering direct feedback on the

validity and appropriateness of the guide, the experts each completed a mock interview

using the guide. In this fashion, it was possible to ensure that the interview guide was

adequate and appropriate for collecting the specific data necessary to answer the central

research question. Each interview was conducted virtually through Zoom and both audio

and video recorded. Interviews were then transcribed to yield the final data necessary for

the study. In addition, research notes were taken during the interviews to help recall any

non-verbal data that would contribute significantly to meaning, such as body language or

expressions.

Procedures for Recruitment, Participation, and Data Collection

Prior to any data collection or recruiting any participants, the first step in the study

was to secure Walden University’s Institutional Review Board (IRB) approval to conduct

the research. Any changes requested by the IRB were made to secure approval.

In addition, the policies of the social media sites Facebook, Twitter, Discord and LinkedIn

were reviewed, and site authorization were sought and obtained prior to recruiting

participants via that platform as needed.

Prior to IRB approval, as part of the IRB application, a recruitment post was

drafted (Appendix A). This post consisted of a description of the study, its purpose, and

what would be required of participants. Prospective participants interested in the study

were able to contact me by e-mail. The recruitment post was posted to a series of relevant

social media groups identified through a careful review of the indicated social media

platforms to find groups for transgender African American adults or groups for

transgender people in general.

Prospective participants who contacted the researcher were asked to briefly verify

that they met the inclusion criteria, namely that they (a) be African American, (b) identify

as transgender, (c) have lived in the Mid-Atlantic region of the United States for at least 1

year, (d) have accessed healthcare or attempted to access healthcare in the Mid-Atlantic

region to ensure relevant experiences, and (e) be at least 18 years of age. Then, if they

met the criteria, they were sent a copy of the informed consent form. This form more

thoroughly detailed the study, how the participants would be protected, how they could

withdraw, and similar topics. Participants who accepted the informed consent were asked

to sign the form using DocuSign. Once a participant agreed to informed consent, an

interview was scheduled at a time of mutual convenience.

Interviews were carried out using a semi-structured interview protocol (Appendix

B) and in a secure digital setting through password-protected Zoom calls. Each interview

lasted 60-90 minutes. Interviews were audio- and video-recorded using the functionality

of Zoom software. The researcher transcribed each interview within 1 week. A copy of

the transcript was emailed to each participant to review. Each participant was also asked

to provide a copy of the recruitment post to any friends or other contacts they felt might

be interested in participating in the study. Recruitment continued until the point of

saturation was reached.

Once collected, data were stored securely. All digital data are kept on an

encrypted and password-protected external drive when not in use. This drive are stored in

a locked drawer when not in use, along with any physical data. Data will be maintained

for 5 years after publication, then destroyed through deletion and the burning of the drive

along with any physical documents.

Data Analysis Plan

The data from the interviews were analyzed to answer the single, overarching

research question. To this end, the qualitative thematic analysis was applied to the data.

The data analysis was carried out with the assistance of NVivo qualitative data analysis

software. Qualitative thematic analysis is a six-phase process as follows.

Phase one is to build a strong familiarity with the dataset (Clarke et al., 2015).

This phase involves repeatedly reviewing the transcripts until a sense of familiarity arises.

This familiarity with the data serves to ground the analysis in the dataset more fully. The

second phase is to conduct open coding on the data (Clarke et al., 2015). Open coding is

the process of labeling all potentially relevant ideas in the dataset with the same label or

code each time they appear. The open coding process drew upon an initial codebook

developed from the literature. However, coding was not limited to the codes in the

codebook; emergent codes could also be used. Then, the third phase is to use the codes to

develop key themes (Clarke et al., 2015). Themes represent larger ideas in the data that

may be relevant in answering the research questions. Themes can be identified by

observing the occurrence of codes and how those codes occur in relation to one another in

multiple places throughout the dataset.

In the fourth phase of thematic analysis, the themes must be validated (Clarke et

al., 2015). Validation requires that each theme be carefully cross-checked against the

underlying data to ensure it is actually reflective of ideas in the data. Once each theme is

individually validated, the fifth phase is to cross-validate the themes (Clarke et al., 2015).

Cross-validation involves comparing the themes to each other. In this phase, each theme

must be given a name once it has been confirmed to both represent a complete idea and to

be meaningfully distinct from the other themes. The final phase of thematic analysis is to

compile and discuss the resulting themes (Clarke et al., 2015). The results and discussion,

conclusion, and recommendation sections of the study include the realization of Phase 6.

Issues of Trustworthiness

Trustworthiness is the qualitative version of validity and reliability (Moen &

Middelthon, 2015). Therefore, trustworthiness was critical to the study. All four major

dimensions of the trustworthiness construct were addressed as follows.

Credibility

Credibility is the equivalent of internal validity. Hence, credibility involves a

sound research process (Merriam & Tisdell, 2015). Credibility was achieved in two main

ways for this study. First, the important components of the study were carefully aligned.

The research purpose was a direct extension of the research problem, and, in turn, the

research question operationalized the research purpose. The interview guide was

developed in such a way as to ensure that the research question could be answered using

the data it elicited. In this way, the study was internally coherent. Additionally, transcript

review was used to ensure that the interview transcripts captured what participants

actually meant to convey.

Transferability

Transferability is the equivalent of external validity. Hence, transferability refers

to how well the results apply in other contexts (Moen & Middelthon, 2015). However, a

qualitative study is not generalizable in the same way as a quantitative study. Instead, the

task of qualitative research is to document the research process sufficiently so that future

readers can assess whether they should apply the results (Merriam & Tisdell, 2015). To

this end, data collection was carefully discussed herein. In addition, the results contain a

full description of the final sample.

Dependability

Dependability is the equivalent of reliability. Since qualitative studies are

expected to yield the same precise results on being repeated, dependability applies better

to the analysis (Merriam & Tisdell, 2015). In particular, the key to dependability is a

robust and well-designed analysis that any other research could repeat to obtain the same

results. Hence, the analysis in this study carefully followed the steps laid out in the prior

section, and evidence for the analysis are provided in the form of the codebook and

quotes.

Confirmability

Confirmability is the equivalent of objectivity. Therefore, confirmability refers to

demonstrating that the study was conducted impartially (Moen & Middelthon, 2015). The

first strategy for achieving confirmability included discussing the researcher's potential

biases and preconceptions regarding the limitations. Additionally, member checking, the

repeated validation steps in the data analysis, and the liberal use of quotations from the

participants serve to bolster confirmability.

Ethical Procedures

Ethical research practices were adhered to at every stage of the research. Prior to

collecting any data, IRB approval was sought and obtained. Where appropriate, site

authorization was obtained from social media platforms. If it seemed prudent, approval to

recruit in groups was sought from group leaders/administrators. All participants were

provided with informed consent documentation. These documents were reviewed,

esigned, and returned for a participant to participate. All participants were assigned code

names to protect their confidentiality. Only the researcher and approved university

personnel had or will have access to the original data containing the participants'

identities.

All data are stored securely. Data are kept on an encrypted and passwordprotected

external drive when not in use. This drive is stored in a locked drawer when not in use,

along with any printouts or other physical data that arise. Data will be maintained for 5

years after publication, then destroyed through deletion and the burning of the drive along

with any physical documents.

Participants could contact me by email to withdraw their data from the study at

any point prior to the publication of the study. Any identifying information was cleaned

from the data prior to analysis through redaction. No coercion was involved in the

recruitment of participants. As the study addressed a sensitive topic, participants were

provided with the contact information for a low- or no-cost mental health hotline.

Participants could also ask to pause or terminate their interviews at any point or decline to

address a particular topic. In this way, the risk to the participants, who are a

twicevulnerable population, was minimized as much as possible.

Summary

In summary, the research problem guiding the study was that African American

transgender adults face significant barriers to obtaining desired and necessary healthcare

services to manage optimal health, and no research had examined the barriers to obtaining

healthcare services to manage optimal health among African American transgender adults

(Howard et al., 2019). The purpose of this generic qualitative study was to explore the

experiences of African American transgender adults obtaining necessary healthcare

services to manage optimal health. This purpose was addressed through a single,

overarching research question: “What are the experiences of African American

transgender adults obtaining necessary healthcare services to manage optimal health?”

This chapter addressed the research methods.

The central phenomenon of interest for the study was the barriers to healthcare

faced by African American transgender adults. To address this phenomenon, a qualitative

approach and a generic qualitative research design were adopted for the study. In this

study, I was positioned as an impartial observer. The population of interest for the study

was all African American transgender adults in the United States. Within this overall

population, the target population was African American transgender adults in the

MidAtlantic region of the United States. Sampling within this population was conducted

through a combination of purposive sampling and snowball sampling. A sample of 8–10

participants, adjusted for saturation, was sought. The primary instrument of data

collection for the study was qualitative, semi-structured interviews conducted by me.

Purposive sampling was conducted through social media platforms. Qualitative thematic

analysis was applied to the data with the assistance of NVivo qualitative data analysis

software to answer the research question. The next chapter contains the results of the data

analysis.

Chapter 4: Results

The purpose of this generic qualitative study was to explore the experiences of

African American transgender adults obtaining necessary healthcare services to manage

optimal health. The phenomenon investigated in this study was the barriers to healthcare

faced by African American transgender adults, as this population continue to experience

obstacles in obtaining desired and necessary healthcare services to manage optimal health

(Howard et al., 2019; Seelman et al., 2021). The generic qualitative research design

allowed for a descriptive and exploratory inquiry on the subjective experiences of adult

African American transgender adults on accessing healthcare services. Based on the

research purpose, problem, and design, the research question developed to guide this

study was, “What are the experiences of African American transgender adults obtaining

necessary healthcare services to manage optimal health?”

This chapter contains the results that answered the research question. To

contextualize the results, the setting and demographics are reported in this chapter. The

data collection, data analysis, and trustworthiness techniques applied to the methodology

are also described in this chapter. The themes that emerged from the analysis are then

presented along with narratives and excerpts from the data.

Setting

This study was conducted with a target population of African American

transgender adults in the Mid-Atlantic region of the United States. As of 2022, an

estimate of 1.3 million adults identify as transgender in the United Stated (Herman et al.,

2022). The Mid-Atlantic region has an approximate transgender adult population of

253,000 (Herman et al., 2022). Approximately 0.6% of transgender adults in the United

States are African American (Herman et al., 2022). This percentage is similar to the racial

distribution of the general population in the United States (Herman et al., 2022).

Demographics

The sample of this study was eight African American transgender adults living in

the Mid-Atlantic region of the United States. Specifically, the participants of this study

were: (a) African American, (b) identify as transgender, (c) living in the Mid-Atlantic

region of the United States for at least one year, (d) at least 18 years of age, and (e) have

accessed healthcare or attempted to access healthcare in the Mid-Atlantic region to ensure

relevant experiences. These eligibility criteria were indicated in the participant

recruitment letter. The participants underwent a screening interview for their eligibility

prior to data collection. The information were verified during the interview proper.

Seven participants reported seeking the services of a primary care doctor, while

five participants stated additionally seeing sexual-health doctors. One participant sought

the services of a dermatologist. Six participants sought healthcare services for hormone

therapy, routine check-ups, general health concerns, and other illnesses. The descriptive

information of the participants’ healthcare-seeking behaviors is presented in Table 1.

Table 1

Descriptive Information

Participant

Type of Doctor Seen

Purpose for Seeing Doctor

Alex

Primary care doctor

Hormone injections and general health

concerns

Jordan

Primary care doctor

Hormone injections and family history of

heart disease

Blake

Dermatologist

Hormone injections and allergies

Casey

Primary care doctor, sexual health doctor,

gender-affirming care doctor

Hormone therapy, gender dysphoria and

routine physical health check-up

Riley

Primary care doctor, sexual health doctor

Hormone injections, gender dysphoria and

routine physical health check-up

Jamie

Primary care doctor, sexual health doctor

Hormone therapy and routine physical

health check-up

Ariel

Primary care doctor, gynecologist

Routine physical health check-up

Robin

Primary care doctor, gynecologist

Routine physical health check-up

Data Collection

The data collection method in this study was individual interviews. The interviews

were semi-structured in nature. Data collection occurred from July to November of 2023.

Prior to the interviews, necessary approvals and consent were obtained from the Walden

University Institutional Review Board (IRB) and the participants. The IRB application

included the proposal for this study and the draft of the participant recruitment letter. The

recruitment letter contained a brief introduction of the researcher, the nature and purpose

of the study, and the eligibility criteria for participation. The researcher’s e-mail address

was also indicated in the recruitment letter which the prospective participants used to

contact the researcher regarding inquiries and interest in the study. No permissions were

needed for the recruitment of potential participants from social media platforms Facebook

and LinkedIn.

Potential participants who expressed their interest in joining the study were

scheduled for a brief screening interview via Zoom online conferencing platform. The

screening questions were about the participants’ ethnicity, age, area of residence, and if

they accessed or attempted to access healthcare in the Mid-Atlantic region to check if

they met the eligibility criteria. The participants who met the eligibility criteria were

asked for their preferred interview schedule via Zoom online conferencing software.

During the initial screening interview, the contents of the informed consent form were

also discussed to the eligible participants. The informed consent form contained

information about the protection of the participants’ rights and the terms and conditions

of participation. The stipulations included the voluntary nature of participation,

transparency in potential risks in participation, and agreement for the audio and video

recording of the interview for data collection and analysis purposes. Zoom has a

recording functionality which was utilized in the transcription process. A digital copy of

the informed consent form was sent to each participant via e-mail with the instructions of

returning a signed copy prior to the interview schedule. All eight participants complied

and expressed their understanding and agreement to the stipulations of participation.

During the interview, the contents of the informed consent form were reviewed

and the eligibility of the participants were validated. The participants were informed that

the maximum duration of the interview session was 90 minutes. An interview protocol

was used as a guide to maintain the alignment of the data collection to the research

question of this study, while the semi-structured nature allowed for the collection of more

in-depth information through asking probing and follow-up questions. All five interview

questions were asked to all the participants. Apart from the interviews with Alex and

Ariel during which minor connectivity issues occurred, all the interviews did not have

any problems. The connectivity issues with Alex and Ariel did not seem to have a

significant impact on data collection as the interview duration for both interviews were

similar to that of the other six interviews averaging at approximately 60 minutes.

At the end of each interview, the participants were informed of the member

checking process. The member checking process entailed the participants’ review of the

interview transcript and the summary of the information they shared based on the

researcher’s understanding. The purpose of the member checking process was to establish

the accuracy of the data and the researcher’s interpretation of the data (Merriam &

Tisdell, 2015). Thus, immediately after each interview, the recordings were transcribed, a

summary was produced, and the transcripts and summary were sent to the participants via

e-mail to allow them to review whether the researcher accurately encapsulated their

insights.. The participants were asked to return their validated transcripts within 14 days,

after which, the transcript was considered approved and ready for data analysis. All of the

raw and processed information collected from the participants were kept in the

researcher’s personal password-protected computer and encrypted cloud storage. These

data will be permanently deleted 5 years after the conclusion of this study.

Data Analysis

The data analysis procedures for this study were based on the six-step thematic

analysis framework developed by Clarke et al. (2015). The six steps were: building

familiarity with the dataset, open coding, developing categories, validating themes,

crossvalidating themes, and compiling and discussing the themes (Clarke et al., 2015).

The qualitative data analysis software NVivo version 14 was utilized as a tool for

managing and organizing the data during the analysis.

Building familiarity with the dataset involved multiple immersions in the data.

The researcher became exposed to the data starting from the individual interviews with

the participants followed by listening to the interview recordings and transcribing the

interviews. After the participants’ transcript validation and member checking process, the

researcher imported the eight final transcripts to NVivo and read them three times as a

whole to acquire a holistic understanding of the data. Next, the open coding process was

conducted. The transcripts were read line-by-line in search of ideas that were relevant to

this study. The ideas within the lines of texts were summarized into concise descriptions

to form codes. Lines of texts with similar ideas were assigned to the same code. Table 2

shows examples of lines from the transcripts and the codes assigned to them.

Table 2

Sample Codes

Sample codes

Quotes

Experienced double discrimination

“So it's a double discrimination. face discrimination related to my

race and gender simultaneously.” “Casey”

Difficulties with name change

“Plus it goes back to the insurance company tells them that I

haven't had my name changed, then I have to pay, I literally have

to pay the state to have them change my name.” “Alex”

Difficulties accessing some

treatment plans

“it's sometimes difficult, like finding treatment plans, um,

medication. Healthcare in general sometimes can be, um, tricky

because you have to find providers and, you know, like when

you're filling out your forms, you know, everything is not covered,

like everything is not specifically labeled, like that type of thing.”

“Blake”

Speaking up

“I definitely try to fix it. I try to face it head on. Try to speak to the

issue, the root.” “Casey”

Seeking referrals for a suitable

doctor

“I've called my health insurance before and they've directed me to

the appropriate healthcare professional that could assist and

referrals from other providers as well.” “Casey”

Receiving support from

community

“And my intersectional identity connects me to communities of

both African American and LGBT individuals. And so these

networks offer a source of understanding the advocacy, and I want

to say resilience.” “Casey”

The third step was to develop categories which refer to larger and more abstract

ideas than codes (Clarke et al., 2015). Categories were developed from codes with similar

patterns within the ideas and were relevant to the research question of this study. The

transcripts were treated as a whole dataset from which the codes and categories emerged

instead of breaking down the analysis per interview question. The codes and categories

are presented in Table 3.

Table 3

Codes to Categories

Codes

Categories

HCWs' assumptions against them

Experienced double discrimination

Misgendered and feeling looked down on

Systemic issue

Being true to who they are

Advocating for themselves

Representing transgender women in the local

community Speaking up

Avoiding conflicts

Avoiding encounters with discriminatory doctors

Willing to drive elsewhere

Telemedicine

Receiving support from community

Need for cultural competency training among HCWs

Need for respect

Need more effort to help transgender woman,

specifically praying for change

Seeing a transgender doctor

Recommendations for change

Seeking open-minded and accepting doctors

Seeing an African American doctor

Seeking referrals for a suitable doctor

Not given the help needed

Denied help by HCWs

Hinders transition

Not taken seriously by HCWs

Don't know how to help

Perceived lack of knowledge of HCWs about

transgender individuals

Unwilling to help

Perceived unwillingness of HCWs to help

transgender individuals

Difficulties accessing some treatment plans

Difficulties with insurance

No clear protocols for transgender patients

Difficulties with name change

No options for non-binary gender in forms

Difficulties with paperwork for health insurance

The fourth step was to validate the categories. Theme validation involved

reviewing the coded texts in each theme to verify that the themes were sufficiently

supported by the data and that they emerged from the data instead of the researcher’s

interpretation or bias. During this step, the categories with incomplete narratives were

compared and contrasted against each other to identify whether a broader theme would

emerge. From 12 categories, four final themes were developed as seen in Table 4. The

final themes were further reviewed through cross-validation in the fifth step of the

analysis. During this step, the themes were given their final names that describe the idea

they conveyed in a way that answered the research question. Cross-validation also

entailed contrasting the themes against each other to ensure that no themes overlapped.

Table 4

Categories to Themes

Preliminary Themes

Themes

Experienced double discrimination

Experiences of gender- and race-based

inequalities in healthcare settings

Advocating for themselves

Avoiding encounters with doctors’ discrimination

Receiving support from community

Recommendations for change

S eeking open-minded and accepting doctors

African-American transgender adults' practices

of overcoming the barriers to accessing

healthcare services

Denied help by HCWs

Not taken seriously by HCWs

Perceived lack of knowledge of HCWs about

transgender Individuals

Perceived unwillingness of HCWs to help transgender

individuals

Healthcare needs of African-American

transgender adults are unheard and not

addressed by healthcare workers

Difficulties with insurance

Difficulties with paperwork for health insurance

Difficulties with paperwork and health

insurance claims

The final step was to report the results. The report of the themes was organized

logically through the number of occurrences in the data. The report includes narratives

and excerpts from the data to support the findings.

Evidence of Trustworthiness

Trustworthiness is a vital to the demonstration of a rigorous qualitative study

(Moen & Middelthon, 2015). Chapter 3 included a presentation of the issues of

trustworthiness based on the criteria of credibility, transferability, dependability, and

confirmability. The following sub-sections contain the techniques applied to the

methodology to address the issues and establish the trustworthiness of this study.

Credibility

Credibility refers to the extent to which the data can be assured as accurate

representation of the participants’ actual experiences (Merriam & Tisdell, 2015).

Credibility was established through the alignment of the components of the study and

through member checking. The components of the study that were aligned were the

research problem, purpose, question, and methods. The phenomenon of the African

American transgender adults’ experience of barriers to obtaining healthcare services is not

widely researched. Thus, a descriptive and exploratory approach such as a generic

qualitative design was appropriate for this study. This design entailed the use of

openended questions to elicit in-depth and detailed responses from a sample of eligible

participants which was achieved in this study through the use of semi-structured

interviews and purposive sampling. The participants contributed to the member checking

process though transcript reviews and validation of the researcher’s summary of the

interview data.

Transferability

Transferability refers to the extent to which the results can be applicable to similar

contexts (Moen & Middelthon, 2015). Readers can validate the applicability of the results

of this study through the detailed descriptions of the data collection and data analysis

processes. The setting and demographics of this study were also reported. Furthermore,

the assumption that the sample of this study were members of a twice-marginalized

group, which is being African American and transgender, was also disclosed.

Dependability

Dependability refers to the extent to which the results remain consistent despite

replication of the methodology (Merriam & Tisdell, 2015). Obtaining similar results

through repetition of the study depends on the richness and thickness of the descriptions

of the study materials and procedures. The development and validation of the interview

protocol were included in Chapter 3. The interview protocol is presented in Appendix B.

The utilization of the interview protocol as a data collection tool was reported in this

chapter. In the analysis of the data, the steps of thematic analysis and the use of NVivo

data analysis software were described. The development of the data into codes and then

codes into themes are shown in the codebook (see Appendix C).

Confirmability

Confirmability refers to the extent to which the results are objective and replicable

(Moen & Middelthon, 2015). The researcher’s potential biases as a mental health

counselor with specialization in working with the LGBTQ+ community were divulged

and described in the previous chapter. The methodological limitations and the procedures

to address them were also detailed in the previous chapter. To remain objective in the

analysis of subjective interview data, a systematic coding schema was followed based on

the data analysis procedures recommended by Clarke et al. (2015).

Results

This section contains the results of the analysis of the experiences of African

American transgender adults in obtaining or attempting to obtain healthcare services in

the Mid-Atlantic region of the United States. This section contains the results of the

analysis of the experiences of African American transgender adults in obtaining or

attempting to obtain healthcare services in the Mid-Atlantic region of the United States.

The results answered the research question, “What are the experiences of African

American transgender adults obtaining necessary healthcare services to manage optimal

health?” Four themes emerged from the analysis. The themes were: (a) experiences of

gender- and race-based inequalities in healthcare settings, (b) African American

transgender adults' practices of overcoming the barriers to accessing healthcare services,

addressed by healthcare workers, and (d) difficulties with paperwork and health insurance

claims. The presentation of the themes is organized from the most highly recurring to the

least recurring idea within the dataset. The number of times the themes recurred along

with the number of contributing participants is presented in Table 5.

Table 5

Theme Occurrences

Theme

No. of Contributing

Participants

No. of Occurrences in

the Data

Experiences of gender- and race-based inequalities

in healthcare settings

African American transgender adults' practices of

overcoming the barriers to accessing healthcare

services

Healthcare needs of African American transgender

adults are unheard and not addressed by healthcare

workers

Difficulties with paperwork and health insurance

claims

Experiences of Gender- and Race-Based Inequalities in Healthcare Settings

All eight participants reported experiences of gender- and/or race-based

inequalities in their access or attempt to access healthcare services. The inequalities were

experienced from HCWs such as doctors, nurses, and health insurance staff. Seven

participants shared their perceptions that they experienced, the word of Casey, “double

discrimination” for being both African American and transgender. Casey elaborated: I

would say it's a double discrimination … it's created a unique form of bias that affects

my quality of care received … So there's already challenges in being African American

alone, and then there's separate challenges for being transgender alone. But the

differences in being one or the other, I would say they can be overlooked or

marginalized within both the African American and transgender community, which

creates feelings of isolation.

Jamie explained that being a racial minority and a gender minority was the reason

for their experience of double discrimination in the healthcare setting. Jamie stated,

“Being African American and transgender is just a walking target. I don't know. It's only a

dream to get good healthcare, to be honest.” Jamie later on found a new doctor who

treated them “like family.” Jamie shared that they trusted their new doctor and had a

positive experience talking to them. Ariel and Robin perceived that discrimination against

African Americans and transgender individuals was not limited to the healthcare setting,

but in society in general. The two participants stated that they were not respected as

individuals in most settings. Ariel shared that because of the discrimination they

experienced, a positive outcome was that they became more determined to “fight harder”

for their rights to equal access to healthcare services. In the healthcare setting, Robin

shared an experience of a friend who was disrespected by a doctor. Robin narrated: I only

had seen one. He wasn't my specific doctor. It was one prejudice doctor who really

doesn't, I guess, they don't accept us or don't agree. My friend went there. They was really

nasty. He was really trifling to her. Tried to continue to tell her he would not give her

healthcare. I just felt like that was disgusting. I felt a type of way, even though it didn't

happen to me, because it's within the whole community.

In Robin’s experience, the positive aspect was that a nurse intervened and advocated for

them. The nurse also assisted them in finding a new doctor.

Jordan also compared their experiences with their friends, particularly their White

transgender peers who the participant described to have experienced fewer obstacles in

obtaining healthcare services than they did. Jordan perceived that African American

transgender individuals experienced more inequalities in the healthcare setting than White

transgender individuals because of economic status. Jordan thought that White

transgender individuals tended to have better financial resources than African American

transgender individuals to be able to afford quality healthcare. Jordan elaborated: I feel

it's much, much less for people who are just transgender because I have a lot of white

transgender friends and stuff who access healthcare. And most of the time I don't really

hear them having to fight with their doctors about their levels and things and what

medications they're taking… Again, because I think healthcare is expensive and those

sorts of things, and not to be that guy, but a lot of the white transgender people I know

have had their parents finance their transition.

However, in terms of personal experience, Jordan have not had notably positive nor

negative race- or gender-based discrimination. Jordan stated, “Yeah, there's not been

anything particularly noteworthy, really, really good experiences. But there haven't been

any really, really bad experiences either.”

Nonetheless, six of the participants perceived that being transgender led to more

discrimination than being African American in the healthcare setting. The participants

shared their experiences of being misgendered and dismissed. Robin shared, “On my I.D.

it definitely says that I identify as a female. The doctor did start saying he, as in

male…They didn't see my gender how I wanted to be seen…I felt mislabeled.” Jamie

shared:

But even before I transitioned, when I started my period, my cramps were really

bad, so they were going to prescribe me birth control, but my insurance company

had already thought I was a boy, so I couldn't get that. So they had no problem

calling me he or him then. But when I would come in and actually change my

pronouns after they changed my pronouns to she/her after the incident, it was like

they didn't want to call me the correct pronouns, so they just left it alone. But I

could feel the shift in the environment.

Four participants perceived that the inequalities they experienced as African

American transgender adults in the healthcare setting were a systemic issue. Systemic

meant that the issue was prevalent and recurring in society, as in the explanation of

Jamie, “Really just history, honestly. It's the domino effect. Everything repeats itself.”

Casey, Riley, and Ariel shared that the issue of inequalities they experienced in accessing

healthcare services was a result of a systemic problem regarding the lack of policies

specific to minority populations. Riley shared, “So misgendering and deadnaming, they

don't necessarily always have clear protocols in process or in place to respect my gender

identity.”

African American Transgender Adults' Practices of Overcoming the Barriers to

Accessing Healthcare Services

All eight participants shared that with the challenges they experienced in

accessing healthcare, they have established some practices that allowed them to overcome

the barriers. One practice shared by seven participants was to seek HCWs who were

known to be open-minded and accepting of any individuals. The participants found

suitable HCWs primarily through referrals. Casey, Riley, and Jamie sought referrals from

their insurance company. Riley shared:

And then my health insurance, I've called my health insurance before and they've

directed me to the appropriate healthcare professional that could assist and

referrals from other providers as well. I've come in contact with prescribers or

providers that didn't necessarily meet my need as a transgender and so they gave

me a referral for other providers that would be able to meet my needs.

Participants Casey and Riley additionally sought referrals from the LGBT

community as they believed that the community shared similar challenges that they

experienced in accessing healthcare services. Casey shared, “So I access those services

through community support in the LGBT community. We all talk and everybody always

get together and give recommendations of where they went and different clinics that

they've may tried.” Jordan did their researched and asked the online community for

referrals. Apart from referrals, Participants Casey and Riley shared that they found

emotional support from their communities. Casey shared, “The thing is … engaging with

supportive networks and advocacy groups to find information and emotional support and

resources to assist other LGBTQ members who may be experiencing or having the same

experience as I.”

Five participants shared that they stood up for themselves during experiences of

discrimination by HCWs. They spoke up against the inequalities they experienced. Robin

stated, “I definitely try to fix it. I try to face it head on. Try to speak to the issue, the root.”

Alex and Blake perceived that speaking up and standing up for themselves meant they

were true to who they are. Alex elucidated:

When they see me, they're like, [birth name], and I stand up and they see the way

I dress and they're looking at me, they're look at the clipboard. They was like,

you're [birth name]? And I'm like, yes, is there a problem? No, no, no, just come

on in. And then I explained to them and they're like, okay, now I get it. Because I

basically explained to them first who I am and what I am. And then I lay down the

ground rules really quickly. My mom is basically just like, be honest first and then

let them ask questions later.

Casey recommended one way to advocate for African American transgender

individuals to receive quality healthcare services was to provide cultural competency

training for the HCWs. The participant explained that cultural competency training

includes teaching HCWs to be “sensitive to the unique needs” of specific populations.

Robin perceived that HCWs did not necessarily need more training, but needed to

develop more respect towards minority individuals.

Four participants shared that they consciously avoided HCWs who were already

known to be discriminatory. Alex, Jordan, and Blake used telemedicine to reach doctors

who they find suitable. Blake additionally shared that having friends who worked in the

healthcare industry was helpful in their experience of addressing their health issues. Alex

and Jordan also found the use of telemedicine to be cost-efficient. Jordan stated, “It's just

a bit more easier to access things through telehealth programs online to get it. And it's

often much cheaper in that way.” Jordan also stated that a positive aspect of healthcare

was the ease of access because of the telehealth programs. For services that required

physical appearance, Alex and Jordan shared that they were willing to drive farther to

avoid the discriminatory HCWs in their area. Jordan shared, “I'm not even going to

chance it. I'm going to go into the city, I'm going to go there for [treatment].”

Healthcare Needs of African American Transgender Adults are Unheard and are not

Addressed by Healthcare Workers

All eight participants reported experiencing being unheard and having their

healthcare needs unaddressed. Seven participants believed that some HCWs lacked

knowledge about minority individuals, particularly about transgender people. Alex and

Riley stated that most HCWs did not have “lived experiences” of being an African

American transgender person. Blake and Robin thought that HCWs typically did not

know how to identify them and help them. Jordan specified an experience of HCWs not

knowing about their bodily function. Jordan shared:

I find myself having to explain how certain things about my body works and stuff,

because when I go to a primary care physician and they start asking me questions

about how often I've had my periods and stuff, I don't get regular periods because

of testosterone and stuff. And so they get immediately concerned, start asking me

about could I be pregnant.

Four participants shared their experiences of explicitly being refused or denied

healthcare services which they attributed to their gender and/or their race. Ariel stated, “I

believe, because I'm a transgender. The doctor really didn't want to see me, so I had to go

see another doctor. Just going to the doctors, they just be skipping over me basically like

I'm not even there.” Blake expressed that some HCWs could not be bothered to treat them

like an individual person and address their healthcare needs. Blake shared, “You get

misgendered, um, sometimes there's issues with like getting medication, um, treatment

plans, things like that, because they're looking at you like you're just an it.” Pertaining to

race, Jordan shared their perception certain medication were not suitable for African

Americans but could be effective for Whites. Jordan experienced speaking up about this

concern, but was dismissed by a dentist. Jordan described:

I went to the dentist not too long ago. Just as a general thing, I feel quite often that

things like pain isn't quite treated the same way as it would be when if I was not

black or trans because when they're working on your teeth and they're putting the

orgel and stuff on them, and I'm like, ‘Hey, orgel doesn't necessarily work for me.

I need the injections and stuff.’ . . . I remember reading somewhere…there was

something dealing with the sorts of medications that they give to Black women

during pregnancies versus White women during their pregnancies where it's seen

as black people feel pain differently than white people or something like that.

The participants shared that their transition was one of the reasons they seek

healthcare services. However, four participants stated that HCWs did not take their needs

seriously. In Alex’s experience, doctors they saw questioned their decision to transition.

Alex shared, “Some doctors that basically want you to do something different or really

wants you to see a psych eval just to make sure that you know where you're stepping into

it.” Jordan shared, “So at the beginning it was real uncomfortable things. And it just feels,

I feel you're not being taken seriously I guess.”

Three of the eight participants disclosed that they encountered HCWs who were

not willing to help them. Alex, Blake, and Ariel attributed HCWs’ unwillingness to help

them to poor attitude. Alex stated, “Their attitude shows that they're not willing to help,

not even to accommodate a person.” Ariel stated, “They show us very little respect.

They're not compassionate and they don't care.”

Nonetheless, another finding was that four participants reported having positive

experiences in obtaining healthcare services. Jamie and Robin shared that they found

allies in some HCWs. Robin shared that a doctor misgendered them, but a nurse called

out the doctor to show them respect. Jamie specifically stated that they experienced

respect and quality healthcare from younger doctors. Jamie shared, “The doctors that I go

to now, they're kind of millennial, Gen Z kind of, and they're cool.” Casey and Riley

shared that they experienced having supportive doctors who made them feel validated and

empowered. Casey stated that a positive aspect of their experience in accessing healthcare

was to have healthcare providers who acknowledged their identity and their needs.

Difficulties With Paperwork and Health Insurance Claims

Five of the eight participants shred their experiences of difficulties with health

insurance including the paperwork and the claims. The participants’ difficulties with

health insurance claims were specific to the rejection of coverage for certain treatment

plans especially in sexual and reproductive health care causing them to pay out of pocket.

The rejection of health insurance claims was a result of supposedly gender-specific

procedures such as pap smear in the experience of Jordan. Jordan shared, “But I do know

that there are some difficulties surrounding getting things like pap smears, gynecologist

appointments and stuff when you are legally recognized as male and things of that

nature." Alex, Casey, and Riley shared that procedures and treatment plans related to

transition were often not covered by insurance. Alex and Jordan stated that they

experienced vague protocols regarding insurance. Alex shared, “I'm having

disqualifications with the insurance and everything because first minute they agree, next

minute they don't.”

Additionally, Alex and Blake experienced challenges in the paperwork related to

health insurance. Blake shared that some forms did not include options to identify as

transgender. Blake stated, “As far as having help and being able to access services . . . the

forms just are straight up black and white, male or female . . . and there's no true [gender]

identity.” For Alex, the challenge regarding paperwork was due to their name change. The

insurance company did not recognize their changed name due to the lack of supporting

documents such as a social security card which were still being processed.

Alex shared:

I have to wait until they change birth certificate, social security card, medicines,

you name it. They got to change all that stuff around and then sometimes it takes

a while for them to change to have that stuff stamped and just basically published

out there that your name is now [Alex] . . . insurance is looking at that you're

violating them and they're still paying for you to get your medicine. So if you ain't

changed your name, they will automatically stop your medicine and you will have

to pay out of pocket, which that costs tons of money. And I'm like, y'all might as

well just keep it underneath my actual name because I don't have that kind of

money to have my name changed. Not right now. I'm still stuck.

Overall, African American transgender adults experienced obstacles regarding

insurance because of their gender. Insurance companies lacked protocols on the coverage

of certain sexual and reproductive healthcare service targeted for transgender individuals.

Additionally, the paperwork regarding insurance claims may not be inclusive of

transgender individuals and the process of obtaining supporting documents for

identification of one’s new legal name took time. These obstacles resulted in the

participants’ experiences of paying for healthcare instead of being able to rely on

insurance.

Summary

This chapter contained the presentation of the results of this study. This study

addressed the purpose experiences of exploring the experiences of African American

transgender adults obtaining necessary healthcare services to manage optimal health

using a generic qualitative design. Eight African American transgender adults from the

Mid-Atlantic region of the United States were purposively selected as the sample of this

study. The participants were interviewed individually and the interview data was analyzed

thematically. The analysis generated four themes that answered the research question,

“What are the experiences of African American transgender adults obtaining necessary

healthcare services to manage optimal health?” The themes were: (a) gender- and race-

based inequalities in healthcare settings, (b) African American transgender adults'

practices of overcoming the barriers to accessing healthcare services, (c) healthcare needs

of African American transgender adults are unheard and not addressed by healthcare

workers, and (d) difficulties with paperwork and health insurance claims.

Overall, the participants of this study experienced more gender-based

discrimination than race-based discrimination; however, double discrimination was

experienced prevalently. Gender-based discrimination by HWCs was manifested through

denial of treatment, disrespect, and bias. The participants’ gender-based needs were not

taken seriously and not addressed by HCWs. Race-based discrimination included unfair

treatment. Some participants perceived that racism and sexism are systemic issues that

are exacerbated in the healthcare setting due to the lack of policies and protocols

specifically for addressing the health needs of minority individuals. In relation, the

participants experienced challenges with health insurance claims particularly in filling up

forms without options for non-binary gender and in dealing with name change. Often, the

participants experienced a prolonged process of paperwork and denial of insurance

claims. Additionally, the participants perceived that HCWs were not well-informed about

transgender individuals and their needs and were not willing to exert extra effort to help

their minority group. Positive experiences with accepting doctors were reported by only

two participants. To overcome the difficulties in accessing healthcare services, the

participants shared that they actively sought suitable doctors through referrals from

trusted people, avoided conflicts and encounters with possibly discriminatory HCWs, and

advocated for themselves.

These results show the participants’ experiences of the barriers to obtaining

desired and necessary healthcare services. These barriers and the practices to overcome

them were identified from the participants’ experiences as both African American and

transgender. This intersectionality will be interpreted and discussed in the next chapter

through the lens of Crenshaw’s (1990) intersectionality theory. The conclusions of the

study are also presented in the next chapter.

Chapter 5: Discussion, Conclusions, and Recommendations Transgender

adults face significant barriers to obtaining desired and necessary health care services to

manage optimal health (Howard et al., 2019; Seelman et al., 2021). Because of the

importance of health care, when these barriers prevent access for an already vulnerable

community, such as African American transgender people, there is a profoundly

detrimental effect on the members of that community that can create serious hardships

and even trauma (Hobster & McLuskey, 2020; Milner et al., 2019). However, little is still

known about the intersectional barriers facing those who are both African American and

transgender within a health care context (Cicero et al., 2019; Kcomt et al., 2020; Howard

et al., 2019).

The purpose of this generic qualitative study was to explore the experiences of

African American transgender adults obtaining necessary health care services to manage

optimal health. The sample of this study was eight African American transgender adults

living in the Mid-Atlantic region of the United States. Specifically, the participants of this

study were: African American, identified as transgender, lived in the Mid-Atlantic region

of the United States for at least one year, were at least 18 years of age, had accessed

health care or attempted to access health care in the Mid-Atlantic region to ensure

relevant experiences, and had experienced barriers when accessing or attempting to

access health care in the Mid-Atlantic region. The data was collected using

semistructured one-on-one interviews. Seven participants reported seeking the services of

a primary care doctor, while five participants stated additionally seeing sexual health

doctors. One participant sought the services of a dermatologist. Six participants sought

health care services for hormone therapy, routine check-ups, general health concerns, and

other illnesses.

The interview data was then analyzed thematically, and this analysis generated

four themes that answered the research question: “What are the experiences of African

American transgender adults obtaining necessary health care services to manage optimal

health?” These themes were (a) gender and race-based inequalities in health care settings,

(b) African American transgender adults' practices of overcoming the barriers to

accessing health care services, (c) health care needs of African American transgender

adults are unheard and not addressed by health care workers, and (d) difficulties with

paperwork and health insurance claims.

Overall, the participants of this study experienced more gender-based

discrimination than race-based discrimination. However, the intersectionality of double

discrimination was experienced prevalently. Gender-based discrimination by health care

workers was manifested through denial of treatment, disrespect, and bias. The

participants’ gender-based needs were not taken seriously and not addressed by health

care workers. Race-based discrimination included unfair treatment.

Some participants perceived that racism and sexism were systemic issues that

were exacerbated in the health care setting due to the lack of policies and protocols that

were designed to specifically address the health needs of minority individuals. The

participants also experienced challenges with health insurance claims, particularly when

filling in these forms without options for non-binary gender and when dealing with a

name change. Often, the participants experienced a prolonged process of paperwork and

denial of insurance claims.

Additionally, the participants perceived that health care workers were not

wellinformed about transgender individuals and their needs and were not willing to exert

extra effort to help their minority group. Positive experiences with accepting doctors were

reported by only two participants. To overcome these difficulties in accessing health care

services, the participants shared that they actively sought suitable doctors through

referrals from trusted people, avoided conflicts and encounters with possibly

discriminatory health care workers, and advocated for themselves.

Interpretation of the Findings

In this section, an interpretation of the findings of this study will be given that will

discuss in further depth how these key findings answered the research question. In the

process, these key findings as previously noted will be discussed within the context that

they confirm, disconfirm, or extend the related extant literature. These key findings will

then be analyzed within the context of the conceptual framework.

Experiences of Gender and Race-Based Inequalities in Healthcare Settings

The first significant theme that answered the research question of the current

study was experiences of gender and race-based inequalities in healthcare settings. All

eight participants reported experiences of gender and or race-based inequalities in their

access or attempt to access health care services. These inequalities were experienced from

health care workers such as doctors, nurses, and health insurance staff. Seven participants

shared their perceptions of experiencing double discrimination for being both African

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American and transgender. However, for one participant, there was a positive aspect to

experiencing these inequalities when a nurse intervened, advocated for, and assisted this

participant with finding a new doctor.Several studies in the literature reviewed also

revealed discriminatory practices in their findings within health care settings that were

based on gender and or race-based inequalities. Alizaga et al. (2022) used a quantitative

research methodology and conducted a latent class analysis to better understand the types

of discrimination faced by transgender people of color. These researchers found that

many transgender people of color either experienced or anticipated discrimination, and

those who experienced discrimination received decreased quality of health care service or

no health care service at all. Salerno et al. (2020) also specifically studied Black

transgender people and concurred with Alizaga et al. (2022) that there were

discriminatory practices that influenced this population’s access to quality health care.

Howard et al. (2019) explored the health care experiences of transgender people of color

using a qualitative method with data from interviews and focus groups among 22

participants. These researchers further concurred that all participants described negative

experiences with health care providers because of discriminatory biases against their race

or gender identity.

Similarly, Kattari et al. (2020) supported the possibility of such discriminatory

biases when studying the intersecting experiences of health care denials among this

population. These researchers conducted a quantitative study with data that was gathered

from a nationally representative 2015 trans study with 27,715 participants. Around 8%

had been denied trans-specific healthcare, while over 3% had been denied general health

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care (Kattari et al., 2020). Health care denial was also most strongly predicted by older

age, biracial or multiracial status, and lower-income status.

Clear consensus was found in the current literature reviewed that there were

biased and discriminatory practices within health care settings against those who were

transgender and or African American (Alizaga et al., 2022; Howard et al., 2019; Kattari et

al., 2020; Salerno et al., 2020). Kattari et al. (2020) also had findings that recognized age

and income status as significant factors that may further contribute to these inequalities

and discriminatory practices within health care settings. Therefore, the first key finding of

the current study of experiences of gender and race-based inequalities in healthcare

settings confirmed the consensus in the existing literature.

The conceptual framework of this study was intersectionality theory (Crenshaw,

1990) that provided a foundation to particularly focus on problems arising from the

intersection of people who are both African American and transgender. Crenshaw

introduced the concept of intersectionality that was initially derived from critical race

theory (Carastathis, 2016; Meer, 2014). This theory's concept emphasizes the interaction

of gender and race and the lack of understanding of how this intersectionality can further

marginalize people, that was first exemplified in the experiences of African American

women (Meer, 2014). Crenshaw also revealed that intersectionality was a concept used to

theorize how the law responded to issues about race and gender discrimination (Meer,

2014).

This theory was applied to the current study to better understand the

intersectionality of being both African American and transgender. The first key finding

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from this study indicated that seven out of the eight participants perceived that they had

experienced double discrimination within health care settings because of both gender and

race-based inequalities. Therefore, this first key finding supported the tenets of this

conceptual framework.

African American Transgender Adults' Practices of Overcoming the Barriers to

Accessing Healthcare Services

The second significant theme that answered the research question was African

American transgender adults’ practices of overcoming barriers to accessing healthcare

services. All eight participants shared that with the challenges they experienced in

accessing health care, they established some practices that allowed them to overcome

these barriers. One practice shared by seven participants was to seek health care workers

who were known to be open-minded and accepting of any individual. The participants

also found suitable health care workers primarily through referrals. Five participants also

shared their positive experiences of learning to stand up for themselves when overcoming

discrimination with health care workers. Two participants reported the positive

experiences of finding needed emotional support in their communities.

Multiple studies in the literature reviewed also recognized the barriers that African

American transgender adults faced when attempting to access health care services. First,

it was noted in the literature that African Americans alone, without the added minority

status of gender identification, faced significant barriers to health care (Cheatham et al.,

2008; Hammond et al., 2010; Wheeler et al., 2007). These barriers were further described

in the literature to also be related to cultural and religious beliefs among their population,

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bias and discriminatory practices, socioeconomic status, disparities in health care costs

based on race, and a lack of knowledge (Ali et al., 2018; Chandler et al.,

2021; Charron-Chénier & Mueller, 2018; Muvuka et al., 2020; Planey et al., 2019; Sacks,

2018). When these racial inequities were combined with other minority characteristics,

such as variances in gender identity, the problem of barriers to accessing health care

increased (Carter et al., 2020; da Silva, 2020; Salerno et al., 2020; Teti et al., 2021).

Other studies in the literature reviewed focused research on solutions to these

barriers. These solutions included increased education for health care providers (Ali et al.,

2018; Butkus et al., 2020; Moseson et al., 2020; Oliphant et al., 2018). Gender

affirmation was also recognized as a solution to these barriers (Butkus et al., 2020;

Moseson et al., 2020; Oliphant et al., 2018; Snow et al., 2022).

Sevelius et al. (2021) further elaborated that out of all of the suggestions for ways

to mitigate barriers for transgender people of color, the most prevalent involved

practitioners using proper gender affirmation and patients being able to obtain treatments

that suited the gender with which they identified. This quantitative study included a

sample of 858 transgender women of color. Their results yielded that affirming a person's

gender and empowering health care choices significantly influenced the overall impact of

sexual orientation-related intolerance on viral inhibition (Sevelius et al., 2021).

However, there were contrasting perspectives that were also found in the

literature reviewed regarding these solutions of increased education for health care

providers and gender affirmation. Stoumsa et al. (2019) conducted a quantitative study on

the topic of formal education for health care providers on transgender health. These

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researchers found no correlation between increased hours of education and enhancement

of the health care providers’ knowledge of transgender health care. The discrepant

findings of Stoumsa et al. (2019) from the previous consensus of the solution of increased

education for health care providers to mitigate the barriers that African American

transgender people face (Ali et al., 2018; Butkus et al., 2020; Moseson et al., 2020;

Oliphant et al., 2018) therefore indicates the need for further research on this topic to

better understand what significant factors are involved that may make transgender health

education more or less effective.

Goldenberg et al. (2020, 2021) examined health care access for transgender youth

of color. These researchers found that the youth participants reported more stigmatization

associated with health care, even when they had received gender affirming care. These

findings of Goldenberg et al. (2020, 2021) contrasted as well with the previous consensus

of gender affirmation as a solution to help mitigate barriers for African American

transgender people when accessing health care (Butkus et al., 2020; Moseson et al., 2020;

Oliphant et al., 2018; Snow et al., 2022). Therefore, more research is also needed to better

understand specific variables like stigmatization or other significant factors that may still

be barriers to accessing health care for the African American transgender population,

even when they are receiving gender affirming care.

Consensus was found in the literature reviewed that the African American

transgender population faced barriers to accessing health care (Carter et al., 2020; da

Silva, 2020; Salerno et al., 2020; Teti et al., 2021). Therefore, the second key finding of

the current study of African American transgender adults’ practices of overcoming

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barriers to accessing healthcare services partially confirmed this consensus in the existing

literature by recognizing that these barriers exist. The extant literature did focus also on

solutions to these barriers, with some discrepant findings, pertaining to the education of

health care providers and gender affirmation. However, none of these studies focused on

the solutions of the African American transgender population themselves for overcoming

these barriers. Therefore, this second key finding also extended the literature by providing

valuable insight into specific ways that this population overcomes these barriers through

seeking health care workers who were known to be open-minded and accepting of any

individual and through the referral process.

Regarding the conceptual framework, the intersectionality of being both African

American and transgender was illustrated again through the second key finding of this

study. The double discrimination these participants experienced of gender and race-based

inequalities in health care settings manifested into the need to then also have to overcome

real barriers when accessing health care. Therefore, the second key finding of the current

study also supported the tenets of this conceptual framework.

Healthcare Needs of African American Transgender Adults are Unheard and are not

Addressed by Health Care Workers

The third significant theme that answered the research question was healthcare

needs of African American transgender adults are unheard and not addressed by health

care workers. All eight participants reported experiencing being unheard and having their

health care needs unaddressed. Seven participants believed that some health care workers

lacked knowledge about minority individuals, particularly about transgender people. Four

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participants further believed that most health care workers did not have the lived

experience of being an African American transgender person or typically did not know

how to identify and help them. However, four participants also reported having positive

experiences when obtaining health care services that included finding allies in health care

workers who were willing to advocate for them, and health care workers who were more

sensitive to their needs or made them feel validated and empowered, particularly among

younger doctors.

A few studies in the literature reviewed also examined culturally insensitive health

care practices in depth as a specific type of barrier that the African American transgender

population may have to overcome. Harb et al. (2019) and Tishelman et al. (2019)

requested awareness of structural inequities among health care practitioners to increase

culturally-sensitive care among this population. Macdonald et al. (2019) studied access to

oral health care among transgender youth and young adults. The 36 participants in this

qualitative study reported wanting to be treated like an average person, yet feeling

exhausted from constantly reminding practitioners of their identified gender. However,

these participants also reported primarily positive results, with negative results occurring

from misgendering that were corrected immediately by the oral practitioners. This

improvement in knowledge was further determined to possibly indicate increased

awareness among practitioners, or particularly among dentists who may have received

better culturally-sensitive training on transgender health than in other healthcare

industries (Macdonald et al., 2019).

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These findings of Macdonald et al. (2019) in particular partially mirrored the

expression of all eight of the participants in the current study from this third key finding

of experiencing being unheard, as the participants in the Macdonald et al. study reported

feeling exhausted from constantly reminding practitioners of their identified gender.

However, also like the participants in this study, the participants in the Macdonald et al.

study expressed having ultimately positive results. It is unclear if these positive results

came from the self-advocacy efforts of these participants or was only due to dentists

possibly receiving better culturally-sensitive training on transgender health, or the

interaction of both of these significant factors. Therefore, despite the need for further

research, this third key finding confirms findings in the extant literature, although further

research is needed on this topic to better understand the interaction between the

selfadvocacy efforts of African American transgender people and increased

culturallysensitive training for health care providers that may help to mitigate this specific

type of barrier when they are seeking to access health care.

Regarding seven participants who believed that some health care workers lacked

knowledge about minority individuals, particularly about transgender people, in this third

key finding, this part of the finding confirmed again the previous consensus in the

literature of the need for increased education for health care providers on minority

transgender health (Ali et al., 2018; Butkus et al., 2020; Moseson et al., 2020; Oliphant et

al., 2018). This third key finding also provided specific insight on cultural sensitivity and

extended the literature through revealing that four participants further believed that most

health care workers did not have the lived experience of being an African American

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transgender person. The significance of having the lived experience of being an African

American transgender person and how this experience may also interact with increasing

the education and culturally-sensitive awareness of health care providers in these training

efforts invites further research on this topic as well of how effective or ineffective these

training efforts may ultimately be if these health care providers do not have this lived

experience.

Pertaining to the conceptual framework of intersectionality of the current study,

the third key finding supported the basic tenets of the framework as well by finding that

the healthcare needs of African American transgender adults are unheard and not

addressed by health care workers. This intersectionality of being both African American

and transgender continued to progress through the findings of this study from the broader

aspect of this intersectionality of experiencing double discrimination when accessing

health care, to the need to then overcome real barriers when receiving desired health care,

to then further describing the lack of cultural sensitivity as a specific type of barrier of

being unheard that was related to a lack of knowledge and not having the lived

experience of being an African American transgender person among health care

providers. The last aspect of this third finding of a lack of knowledge and not having the

lived experience of being an African American transgender person further emphasized the

lack of understanding of how this intersectionality can further marginalize people that

was explained in this theory.

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Difficulties With Paperwork and Health Insurance Claims

The last significant theme that answered the research question was difficulties

with paperwork and health insurance claims. Five of the eight participants shared their

experiences of difficulties with health insurance including the paperwork and the claims.

The participants’ difficulties with health insurance claims were specific to the rejection of

coverage for certain treatment plans, especially in sexual and reproductive health care,

causing them to pay out of pocket.

A few studies in the literature reviewed also examined challenges with health

insurance claims, and particularly as they were related to sexual and reproductive care

among the transgender population. For example, Lee et al. (2018) suggested the need to

improve health care insurance for transgender people through intervention programs,

agreeing with other researchers such as Houssayni and Nilsen (2018), Reback et al.

(2018), and Vermeir et al. (2018). All of these researchers further concurred that low

access to health insurance and health disparities in insurance claims negatively impacted

transgender people's abilities to obtain primary care or access medications related to

gender confirmation, such as hormone therapy. Houssayni and Nilsen (2018), Reback et

al. (2018), and Vermeir et al. (2018) recommended additional research into this issue to

heighten awareness of the need for more education and culturally-sensitive knowledge as

well.

Consensus was found in the literature reviewed that transgender adults

experienced challenges with health insurance claims, particularly as they were related to

sexual and reproductive care (Houssayni & Nilsen, 2018; Lee et al., 2018; Reback et al.,

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2018; Vermeir et al., 2018). However, none of these studies specifically focused on

transgender adults who were also African American. Therefore, this fourth key finding of

the current study of difficulties with paperwork and health insurance claims both

confirms and extends the extant literature on this topic with a specific focus on African

Americans.

Pertaining to the conceptual framework of intersectionality, this fourth key finding

revealed another specific type of barrier that African American transgender people may

experience of difficulties with paperwork and health insurance claims, especially in

sexual and reproductive health care. It is further emphasized from this finding that

African Americans may experience this struggle more than transgender people who are

not African American. Therefore, this fourth key finding also supported the tenets of this

conceptual framework.

Limitations of the Study

There were several limitations that were noted by the researcher of this study.

First, utilizing qualitative research presented limitations because it yielded no statistical

data. Therefore, the results could not be generalized and relied on subjective data instead

(Rahman, 2017). However, the researcher participated in an external audit that examined

the study’s process, interpretations, and findings to help ameliorate this weakness. This

audit involved an external reviewer with accredited expertise who reviewed the study

procedures to ensure they were sound and adequate for addressing the research question.

Additionally, the generic qualitative research design involved only one source of data.

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Therefore, the proposed study was limited because it did not include multiple sources of

data for the purposes of triangulation. A final limitation of particular importance was the

recruitment process that may have yielded a smaller sample size because the study

focused on a twice marginalized population who were both African American and

transgender that may have been distrustful of the research and its intentions (Marks et al.,

2017).

Recommendations

Recommendations for further research within the context of the strengths and

limitations of the current study and the literature reviewed will now be discussed. This

current study offered many strengths from a specific focus on African American

transgender adults and their personal struggles and strategies when overcoming barriers

to accessing health care. However, several limitations to this study were noted that invite

further research. Therefore, it is recommended that further studies on this topic include

African American transgender adults from regions of the United States other than the

Mid-Atlantic region that may enhance generalizability. Further research could also utilize

different types of research designs and methodologies that are quantitative and measure

specific variables such as the age groups of African American transgender adults and how

this may interact as a significant factor when seeking health care, their financial and

socio-economic level, and how this may interact as a significant factor when seeking

health care, and their education level, and how this may also interact as a significant

factor when seeking health care. Longitudinal studies may also follow African American

transgender adults through the stages of their health care journey, to better understand the

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nature of these different stages, from initial access or denial of health care, to achieving

their desired health care results, and beyond.

Several areas for further research were also recognized from the existing literature

reviewed. The discrepant findings of Stoumsa et al. (2019) from the previous consensus

of the solution of increased education for health care providers to mitigate the barriers

that African American transgender people face when accessing health care (Ali et al.,

2018; Butkus et al., 2020; Moseson et al., 2020; Oliphant et al., 2018) indicated the need

for the recommendation of further research on this topic to better understand what

significant factors are involved that may make transgender health education more or less

effective. The discrepant findings of Goldenberg et al. (2020, 2021) regarding gender

affirming care that contrasted as well with the previous consensus of gender affirmation

as a solution to help mitigate barriers for African American transgender people when

accessing health care (Butkus et al., 2020; Moseson et al., 2020; Oliphant et al., 2018;

Snow et al., 2022) also indicated the need to recommend further research to better

understand specific variables like stigmatization or other significant factors that may still

be barriers to accessing desired health care for the African American transgender

population, even when they are receiving gender affirming care. Moreover, the findings

of Macdonald et al. (2019) pointed to the recommendation for further research to better

understand how the self-advocacy efforts of African American transgender people interact

with increased culturally-sensitive training for health care providers that may help to

mitigate this specific type of barrier when they are seeking to access health care.

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Houssayni and Nilsen (2018), Reback et al. (2018), and Vermeir et al. (2018)

recommended additional research to heighten awareness of the need for more education

and culturally-sensitive knowledge as well specifically in the area of health insurance

claims.

Implications

Implications of this study and its potential impact for positive social change on the

individual, family, organizational, and societal/policy level will now be discussed. Next,

methodological and theoretical implications will be discussed. Then, recommendations

for practice will also be discussed.

On the individual level, better understanding the personal experiences of African

American transgender adults when obtaining necessary health care services to manage

their optimal health may help to empower these individuals to realize they are not alone

in their struggle and to advocate more for themselves and others. On the family level,

better understanding these experiences and struggles may foster greater empathy that

facilitates being more supportive of these other family members. Better understanding

these personal experiences and struggles of African American transgender people on the

level of health care organizations may create enhanced opportunities for improved

education and gender affirmation training for health care providers that will more

effectively remove the current barriers that prevent this population from receiving optimal

health care. Positive social change could also occur at the societal/policy level as health

care organizations respond more favorably and then further facilitate such positive social

114

change in areas like health insurance and in other policy areas that would continue to

remove these barriers for the African American transgender population.

Regarding methodological implications, there is a need for future studies as

previously noted that will explore the research topic of this study with an expanded

sample of African American transgender adults from other regions of the United States to

enhance generalizability, and with different types of research designs and methodologies

to further enhance validity and reliability. Regarding the theoretical implications, this

study makes a valuable contribution to Crenshaw’s intersectionality theory with its

specific focus on the intersectionality of being both African American and transgender

and how this impacts accessing and receiving optimal health care.

Recommendations for practice within the field of health care from the findings of

this study point to the need for greater understanding and empathy of the struggles and

barriers that African American transgender adults face when they are accessing health

care. Such greater understanding and empathy are strongly recommended to be further

facilitated by providing more education and gender affirmation training for these health

care providers. Also including educators and trainers who have the lived experience of

being an African American transgender adult may prove to make such efforts even more

effective.

Conclusion

The purpose of this generic qualitative study was to explore the experiences of

African American transgender adults obtaining necessary health care services to manage

optimal health. Key findings from this study indicated that there were gender and

115

racebased inequalities in health care settings that created barriers when seeking to access

health care services. These barriers were also more specifically described as these African

American transgender adults being unheard and not having their health care needs

addressed by health care workers and experiencing difficulties with paperwork and health

insurance claims. However, some practices were reported by these participants to help

them to overcome these barriers by seeking health care workers who were known to be

open-minded and accepting of any individual and through the referral process. Other

positive experiences these participants shared were finding allies in health care workers

who were willing to advocate for them, learning to stand up for themselves in the face of

discrimination from health care workers, and finding health care workers who were more

sensitive to their needs or made them feel validated and empowered, along with finding

emotional support in their communities. Access to necessary health care for African

American transgender adults must no longer be denied to ensure their optimal health and

quality of life.

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