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Compared to their cisgender counterparts, transgender and gender non-conforming (TGNC) individuals experience a higher prevalence of adverse health outcomes, such as mental health issues, substance abuse, sexually transmitted infections, and HIV. The health outcomes experienced by TGNC individuals are impacted by multiple social determinants, including economic stability, education access, healthcare access, and social and community context. However, existing research among TGNC in China has largely focused on their HIV risk, overlooked social determinants of health, and has predominantly consisted of cross-sectional studies. Thus, this qualitative study aimed to explore the social determinants of health and healthcare experiences of TGNC individuals in China.
Methods
A total of 18 transgender and gender non-conforming participants were recruited through purposive and snowball sampling between October 2023 and January 2024. Recruitment was facilitated through key opinion leaders within local transgender communities. Semi-structured individual interviews were carried out with participants through video conferencing software, Tencent Meeting and Jitsi. Each participant was interviewed twice within a four-week period. Each interview lasted approximately 40 to 60 minutes. Participants received 150 RMB ($22 USD) as compensation for participating in two interviews. Individual interviews were digitally recorded and transcribed verbatim. Data were coded and analyzed, using open coding and pattern coding, to identify key themes.
Results
The mean age was 25.17 years (SD=5.52). Eleven out of 18 participants had a bachelor’s degree or higher and half were employed full- or part-time. More than half of the participants (61.1%) reported being on hormone replacement therapy, and three underwent at least one gender-affirming surgery procedure (e.g., top surgery). Two overarching domains emerged from the data analysis: (1) social and cultural environment, which included experiences of family rejection, discrimination at school and in the workplace, barriers to employment, exposure to social and cultural environments that emphasize gender binary, and social support from transgender community; (2) barriers and facilitators to accessing healthcare, which included limited access to and resources of gender-affirming care, high cost associated with gender-affirming care, a lack of knowledge and understanding regarding transgender health among healthcare professionals, avoidance of healthcare utilization, policy barrier (strict requirement for gender-affirming surgery and gender marker change), and generally positive interactions with medical teams providing gender-affirming care.
Conclusion and Implications
TGNC individuals in China face significant challenges related to social determinants of health and healthcare. While some reported receiving quality care from medical teams that provide gender-affirming care, these medical resources are extremely limited and primarily concentrated in metropolitan areas. The intersection of social stigma and economic and policy barriers exacerbates the difficulties in accessing healthcare for TGNC individuals. Influenced by deeply rooted gender binary values in Chinese society, family rejection, discrimination in various settings, and a lack of knowledge about transgender health among healthcare professionals further contribute to these challenges. Addressing these issues requires multifaceted interventions, including policy changes to ease the requirements for gender-affirming surgery, improved access to affordable and comprehensive gender-affirming care, and enhanced cultural competency training for healthcare professionals.