Centering The Multiply Marginalized: Using Intersectionality To Characterize Health Inequities Faced By Ethnoracial Minoritized Subpopulations Within The Transgender Community

Elle Lett, University of Pennsylvania


Transgender and ethnoracial minoritized populations are subject to severe health inequities, but few studies have centered individuals with both identities. In this dissertation we articulate a framework for designing studies using an intersectional approach to address inequity, specifically focusing on transgender individuals from ethnoracial minoritized subpopulations. In the first two studies we use the Behavioral Risk Factor Surveillance System (BRFSS) to comprehensively assess healthcare access, risk factors, chronic conditions, and perceived health status for the US transgender Black and Hispanic populations, respectively. In the first study we found that transgender Black individuals were more likely to experience severe mental distress and activity limitation due to poor health than cisgender Black individuals and had lower self-reported health than either cisgender Black or transgender white individuals. One challenge of working with BRFSS data is that the survey procedure differentially misclassifies sex assigned at birth for transgender individuals, potentially biasing design-weighted estimates. Therefore, as an alternative to design-weighted analyses, in the second study we used a case-control approach with propensity score-matching to estimate health inequities affecting transgender Hispanic individuals. We found that transgender Hispanic individuals experienced more severe barriers to healthcare than cisgender Hispanic or transgender white individuals and reported more activity limitation due to poor health than cisgender Hispanic individuals. Both studies also highlighted the increased prevalence of sexual behaviors associated with HIV transmission (SBAHT) in the transgender Black and Hispanic populations. To characterize drivers that underly this increased prevalence, in the third study, we estimate the association between SBAHT and interpersonal and structural racial and transphobic discrimination among a diverse cohort of transgender young adults. We found that interpersonal racism transphobia were associated with reporting drug or alcohol consumption during sex as well as engaging in transactional sex, and that the combined association of structural and interpersonal racism and transphobia greatly increased the estimated odds of engaging in transactional sex among transgender individuals. Through this dissertation we demonstrate the importance of investigating systemic discrimination as a fundamental cause of health inequity and emphasize the unique challenge it poses to the health of transgender people of color in the United States.