title: Cant Help You Here; Barriers to Access and Necessary Measures for Improving Health Inequities for Transgender Sex Workers
Creators: name: Colvin, Andrew
Publisher: name: Georgia State University
Year: 2025

description: <p><strong>Introduction:</strong><strong> </strong>Transgender sex workers (TSW) are subjected to compounded stigma (Balon et al, 2015), but its impact on health outcomes has not been thoroughly explored beyond an HIV lens. This paper looks at stigma as described by Parker and Aggleton in 2003 as constantly shifting, a social process that takes into consideration the structural conditions of living in an oppressive society. The socio-ecological model (SEM) (McLeroy et al., 1988), was used to apply how stigma impacts TSW at the individual, interpersonal, institutional, community, and policy levels.</p>
<p><strong>Aim: </strong>The purpose of this study is to examine how stigma and discrimination result in health inequities within healthcare services outside of HIV/ AIDS for TSW. By looking into stigma experienced when receiving health services by the separate communities of sex workers and people who are transgender, and combining it with information related to stigma experienced by TSW, this paper seeks to identify stigmas impact on TSW health and interventions to decrease this stigma.</p>
<p> <strong>Methods: </strong>For the literature review forty-two studies that discussed the impact of stigma and barriers to accessing health services were originally identified and twenty-five of these studies were used in this review. The SEM (McLeroy et al., 1988) framework was used to discuss how stigma causes barriers to accessing healthcare for TSW at each level of the SEM (McLeroy et al., 1988) and appropriate associated interventions that can be utilized to decrease this stigma.</p>
<p>            Primary data was gathered from personal interviews with four TSW and one cis-gender ally who is a sex worker and is involved in advocating for the rights of TSW. Convenience sampling was used to identify participants via previously established social networks in the non-profit sector. NVivo data analysis software was utilized to help identify themes that emerged in interview data. An intersectional lens was applied the thematic analysis, which was used with an inductive approach and identified two large overarching themes: community interventions and changes needed, both thoroughly discussed throughout the literature review.</p>
<p><strong>Results:</strong><strong> </strong>At the individual level stigma is associated with internalized negative self-thought and poor health literacy. Solutions are individual empowerment via counseling, support groups, and activism; and active distribution of educational materials for TSW. At the interpersonal level discrimination can be seen in transgender people experiencing hostile interactions such as being turned away or denied services, and poor communication between patients and providers. Institutional level changes to educate providers on appropriate approaches to care for people who are transgender, sex workers, and TSW will improve direct patient-provider interactions. Institutional level barriers are poor health literacy around navigating the healthcare system, lack of access to gender-affirming care due to discrimination, a shortage of providers, or financial barriers. Interventions include peer-led education around healthcare navigation, the implementation of the normalization process theory, and policy level changes for gender-affirming services to be covered under insurance. At the community level gender-based violence and experiencing social stigma result in poor health outcomes and can be mitigated with the establishment of advocacy groups and collective action from community level participants that allows for fully utilized resources. At the policy level anti-sex work and anti-transgender laws negatively impact health outcomes for TSW, and can be combatted with community level political advocacy around the decriminalization of sex work and the rights of people who are transgender, and previously established interventions as each of the SEM (McLeroy et al., 1988) levels.</p>
<p><strong>            </strong>Five interviews were conducted to discuss individual experiences with stigma or discrimination when seeking health services. These discussions allowed for insights into interactions in the healthcare setting as well as when receiving assistance from transgender or TSW health services organizers. Interviewees provided insight about personal involvement in TSW worker organizing, gaps in services for TSW, and best practices that all places offering services to TSW should implement. Excerpts from the interviews are used to reinforce the literature and necessary stigma-reducing measures at each level.</p>
<p><strong>Discussion: </strong>Each level of the SEM as it is broken down in this paper has interventions necessary on other levels to be successful, a feature that reinforces McLeroy et al.s (1988) holistic nature of the SEM. Being able to identify how stigma impacts TSW at each level of the SEM (McLeroy et al., 1988) allows for a comprehensive look at interventions necessary to improve health outcomes for this highly stigmatized community. The perspective of stigma as fluid and shifting throughout the SEM (McLeroy et al., 1988) will hopefully allow future successful interventions that change the structural conditions we currently have living in an oppressive society.</p>