Statements from interviews with 20 TW revealed important considerations for optimizing TW access to HIV prevention and primary health care, especially in relation to community-based clinics that serve low-income racial and ethnic minority populations. The clinic where interviews took place was a good example of a community-based setting that was not specifically devoted to LGBT communities yet committed to providing health care services for TW. Many of the practices at the clinic resulted in HIV prevention by initially attracting TW into a health care setting. After primary care was established, HIV prevention became a routine part of care for many TW clinic clients. A number of factors drew TW to the clinic, including the following:
- They could identify as women and were not assigned a transgender identity.
- They had access to health care that accommodated their need to receive hormones.
- They perceived a caring attitude among clinic personnel and health care providers that created an atmosphere that was conducive to culturally congruent HIV prevention and primary health care.
Identity emerged as an important consideration with regard to access to care for TW. Results reflected a separation of some TW from the umbrella term of LGBT
and especially gay communities, a trend that has been documented by other researchers (Broad, 2002
; Drescher, 2002
). Although LGBT health clinics provide valuable services to large numbers of transgender clients, study results illustrate that TW may prefer to not receive services at these clinics. Some TW (a) perceive gay
as a derogatory term and/or perceive gay individuals as the “other,” (b) do not believe they belong to the gay community or feel accepted by the gay community, and (c) do not identify as transgender and may be less likely to seek and receive care at clinics that specialize in serving the LGBT community. By making health care more comfortable for TW and easy for them to access, a number of HIV prevention and primary care services were made available to TW at the general community-based clinic.
Although the clinic did not specialize in transgender care, because clinic personnel and health care providers treated TW with respect, word-of-mouth recruited many TW to the clinic. Most TW traveled long distances to come to the clinic. In many cases, TW traveled for close to 1 hour through a county with several LGBT health care settings. The diversity among TW demands that there be a variety of health care options for them. Results suggested that community-based clinics may be well-suited to provide health care for TW, especially TW of color. However, clinics must employ well-trained personnel who are prepared to provide health care to accommodate the specific needs of TW.
The community-based clinic provided many services under one roof, a fact that also increased attendance of TW at the clinic. Although many TW came to the clinic seeking hormone therapy, they received comprehensive examinations and were counseled to receive HIV and STI tests. The underlying poverty among the TW who attended the clinic and the economic incentives associated with unprotected sex in exchange for drugs or money, as well as the high rates of HIV infection among TW (Clements-Nolle et al., 2001
), underscore the importance of HIV testing for all TW. It is also crucial to provide hormone therapy for TW who are HIV-infected and who desire hormone therapy. Provision of hormones may increase interest in the clinic and may provide a means for health care providers to encourage HIV and STI testing, counseling, and treatment. TW need to retain a feminine appearance for their psychological well-being as well as to avoid harassment and violence. Ensuring hormone therapy for TW who desire estrogen may help make HIV treatment more palatable for these TW. Onsite psychosocial support (i.e., support groups, mentoring, social and recreational activities) may also help retain TW in care.
Limitations of this study included the small sample size of TW selected exclusively from one clinic. It is unknown if a select group of TW from the clinic was sampled because participants were recruited by clinic physicians. Therefore, results cannot be generalized to the TW population. However, results suggest areas in which clinics could increase access to HIV prevention and primary care for TW. Many of the clinic practices and procedures can be used as examples for other community clinics (both general agencies and agencies specifically focused on LGBT health) to improve the quality of services for TW, increase the number of TW accessing culturally congruous services, and reduce HIV infection in this population (see ).
Connections Between Themes, Interview Data, Clinic Procedures, and Recommendations for Optimal Health Care Services for Transgender Women
The clinic provided an environment that was acceptable to TW. The clinic had properly trained clinic personnel to reach out to TW and provide holistic care. Although the acceptance of transgender individuals in non-LGBT clinics may be challenging, it seemed to be easily achieved in this clinic with proper staff training and compassion. Training materials for health care personnel have been created and are available free of charge on the Internet (see National Coalition for LGBT Health, 2004
). Additionally, it was the personal contact with the clinic that motivated TW to tell other TW about the clinic; hence, the clinic built its TW clientele through word-of-mouth. Transgender individuals face immense stigma and discrimination throughout their lives. Finding nonjudgmental, caring, and knowledgeable health care providers is crucial for their health. Practice environments that are safe and welcoming are a vital part of providing culturally congruous health care for TW.