GGEB Dissertation Defense - Elle Lett

Transgender and ethno-racial 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 addressing health inequity, specifically focusing on transgender individuals from ethno-racial minoritized subpopulations. In the first two studies we use the Behavioral Risk Factor Surveillance System (BRFSS) to comprehensively assess healthcare access, behavioral 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. In this study 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. In order to characterize drivers that underly this increased prevalence, in the third study, we used multilevel modeling to 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 and interpersonal transphobia were associated with increased odds of 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 from ethno-racial minoritized groups. Through this dissertation we demonstrate the importance of investigating structural racism and transphobia as fundamental causes of health inequities and contribute to the growing literature that emphasizes the unique challenges these factors pose to the health of transgender people of color in the United States.