RESUMO
BACKGROUND: Stigma contributes to health disparities including increased HIV vulnerability among minority communities. Black transgender women experience multiple forms of stigma (e.g., anticipated, experienced), which can result in poor HIV-related outcomes. We utilized an adapted social ecological model (ASEM) to better understand the levels at which stigma is encountered and its impact on lived experience, particularly related to making healthcare decisions. METHODS: Semi-structured interviews and two focus groups (n = 38) were conducted with Black transgender women and Black transfeminine individuals in Chicago from 2016 to 2017. Participants were asked about discrimination in the community, healthcare experiences, and their thoughts and decision-making process with their healthcare provider regarding HIV pre-exposure prophylaxis. We conducted thematic analysis and organized our findings based on the levels of the ASEM: individual, interpersonal, organizational, community, and structural. RESULTS: Participants experienced and anticipated stigma at each ASEM level. Stigma was not experienced in isolation: stigma experienced at one level caused anticipated stigma at other levels and internalized stigma leading to negative self-image. In each case, stigma adversely impacted health outcomes (e.g., medication nonadherence, disengagement from care). Stigma within healthcare settings, medication-related stigma, and stigma directed at appearance and identity are particularly detrimental to shared decision-making with a healthcare provider. CONCLUSIONS: Recognizing and valuing Black transgender women's experience with stigma are essential for developing social and structural interventions that may work collaboratively across multiple levels of lived experience to reduce stigma and healthcare disparities faced by Black transgender women.
RESUMO
The Republic of Georgia has experienced a rapid growth in the number of youth working and/or living on the street (YWLS). Although research indicates that YWLS are highly stigmatized, few studies have examined perceptions of stigma among Georgian social service providers who serve YWLS. We conducted in-person in-depth interviews with key informants recruited from governmental institutions and social service organizations in Tbilisi and Rustavi, two large urban areas. A semi-structured interview guide was used to explore provider perspectives on the social contexts surrounding the delivery of services to YWLS. Trained coders conducted a thematic analysis of the data in Dedoose. Twenty-two providers (68% female; 32% male) were interviewed, representing diverse professional roles. Providers perceived that YWLS are subjected to strong public stigma and social exclusion at multiple social-ecological levels, with Roma and Kurdish-Azeri youth experiencing the strongest levels of social hostility, discrimination, and exclusion. Providers perceive that these dynamics prevent YWLS from developing trusting relationships with social service, health and educational institutions. Furthermore, we find that providers report encounters with courtesy stigma, i.e., stigma directed towards the people who serve or are associated with a stigmatized group, when working with YWLS, especially those from ethnic minority groups, which they characterize as a stressor. At the same time, we find that some providers reported negative stereotypes about ethnic minority YWLS. While campaigns have targeted public awareness on the plight of YWLS, study findings suggest that additional efforts are needed to address stigma directed towards YWLS, with a specific need to address stigma directed towards ethnic minority young people who work and/or live on the street.