"My Identity Is up for Inspection": A Qualitative Exploration of Intersectional Stigma As a Barrier to Non-HIV STI Care Access Among Transgender and Gender Diverse Adults

Background and Purpose: Despite the rising rates of non-HIV sexually transmitted infections (STIs) in the general population and transgender (trans) and gender diverse (TGD)-specific health disparities, research and healthcare resources have predominantly focused on HIV and trans women, leaving a critical gap in understanding and addressing non-HIV STI care, especially among TGD populations including trans men and nonbinary people. TGD persons are disproportionately affected by non-HIV STIs, driven in part by pervasive transphobia and intersecting stigmas that disrupt access to care. This study aims to highlight the barriers that TGD adults encounter in accessing sexual healthcare, specifically in relation to interdependent and intersectional systemic oppression. By investigating how societal forces such as homophobia, transphobia, cisgenderism, racism, classism, ableism, and capitalism converge and are constitutive, this study seeks to reveal the specific manifestations and consequences of intersectional stigma across all TGD identities. The focus of this study transcends individual identities to critically assess the structural systems that hinder TGD individuals from accessing sexual healthcare services.

Methods: Ten semi-structured focus groups were conducted virtually with a purposive sample of 36 TGD adults. The sample included nonbinary individuals (72%), trans men (19.4%), and trans women (8.3%). Most of the sample were between the ages of 18 and 45, and 28% percent of the sample identified as a person of color. Data were analyzed using reflexive thematic analysis and virtual tabletop coding to identify themes related to intersectional stigma and oppression.

Results: Findings revealed multiple axes of oppression that TGD populations face when accessing health care, including racism, transphobia, cisgenderism, classism, capitalism, ableism, relationship configuration stigma, protestant Christian hegemony, fatphobia, heteronormativity, vanilla-normativity, and age of consent and bodily autonomy. These axes of systemic oppression manifested as institutional stigma (e.g., intake forms exclude LGBTQIA+ identities), healthcare provider stigma (e.g., doctors provide misinformation regarding STI risks), and individual intrapersonal stigma experienced by TGD sexual healthcare seekers (e.g., internalized sexual guilt). Findings also underscored how these multi-level axes of oppression intersect to create and reinforce barriers to sexual healthcare accessibility.

Conclusions: The study illuminates the critical need for healthcare systems to address the intersectional barriers TGD persons face in accessing non-HIV STI care. It emphasizes the importance of training healthcare providers on TGD health issues in addition to addressing intersecting systems of oppression in health. For example, healthcare providers should be trained on issues related to fatphobia, ableism, heteronormativity, and relationship configurations stigma, among other stigmas to provide the most effective and affirming care. Furthermore, institutional policies and practices need to be more inclusive and foster healthcare environments that address intersectional stigma – such as ensuring all staff respect pronoun use and do not assume heterosexuality and monogamy. Addressing these barriers, among others highlighted in this study, is essential for improving the sexual health outcomes of TGD populations and ensuring equitable access to healthcare services.