Qualitative research methods were utilized to engage twenty MTF participants in discussion about their lives, relationships and health-care needs. Data were collected using semi-structured in-depth interviews from clients of a community clinic in a major urban centre. The study was approved by the New York State Psychiatric Institute and Columbia University’s Institutional Review Board. Details of the study location and design are described in detail below. Interviews were conducted between November and December 2003.
The health clinic where the study was conducted is located in a low-income area. The clinic does not cater to lesbian, gay, bisexual or transgender (LGBT) individuals but, rather, sets out to serve the low-income community where it is located, which by and large does not identify as LGBT. Through word-of-mouth, several MTFs came to learn of the clinic where they receive hormone therapy, HIV counselling, testing and treatment and general health-care. The clinic also provides social services to all its clients. Staff have been trained and are accustomed to working with MTFs. The clinic serves mainly Latinos (the majority of which are Puerto Rican) and African Americans; the transgender clientele reflects the ethnic make-up of the non-transgender clinic clients. At last count, there were approximately 80 MTFs who were receiving care at the clinic.
Two medical doctors from the clinic recruited all participants. Transgender individuals were approached by the doctors and asked if they would like to participate in an interview. They were informed that the interview was informal and that they would be asked questions about their lives including HIV health concerns and needs. Patients were told that service access at the clinic would not be affected in any way if they chose not to participate in the study.
All participants were clients of the clinic and 18 years of age or older. All but four of the 20 participants were Latina. The four non-Latina participants identified as African American, with one African-American participant describing herself as Caribbean. Of the 16 Latina participants, one was from Central America, another from South America and the remaining participants were from Puerto Rico or of Puerto Rican descent. The mean age of the participants was 30.7 years (range=18–53, standard deviation=9.8). Four of the 20 participants identified themselves as HIV-positive. To ensure respondents were comfortable discussing their sexual relationships with male, female and transgender individuals, only gender neutral terms were utilized to inquire about sexual partners; however, all participants expressed desire and sexual activity only with men.
The average monthly income for this sample was US$525, although one participant earned as little as US$136 and another as much as US$1,200. Six participants had completed high school, seven had one or two years of high school, five had finished junior high school and one had a fourth grade education. The majority of respondents (16) lived in apartments or houses, two lived in a shelter for homeless individuals and one lived on the street. Almost half of the sample (nine) lived alone. All others lived with family (six), a partner (four) or friends (one).
None of the MTFs in this sample had undergone genital reconstruction surgery and only a handful had had breast augmentation. However, all were currently taking female hormones (with the exception of two participants who had recently lost the ability to pay for their hormones). To protect the confidentiality of participants, pseudonyms replace actual names in the excerpts presented below. This sample represents a unique opportunity for addressing issues that particularly concern ethnic and racial minority MTFs who may have limited resources. It is not known how representative this sample is of MTFs in urban cities in the US.
All interviews were conducted by the first author and were tape-recorded. Since the first author is bi-lingual, participants could select Spanish or English in which to conduct the interview and seven interviews were conducted primarily in Spanish. Occasionally, participants used Spanish words to describe certain feelings or material objects even though the interview was conducted primarily in English, or vice-versa. Quotations taken from the Spanish interviews will appear first in Spanish and then in English to preserve the voice of the participant.
Interviews were conducted in the clinic on the day of recruitment. After a participant told the doctor that she wished to participate in the interview, the doctor would introduce the participant to the interviewer. All interviews were conducted in a private doctor’s office. On occasion, participants were asked by the medical doctors to wait until an interview was concluded. In these instances, participants introduced themselves to the interviewer.
Most interviews lasted about an hour with three interviews extending to two hours. Before the interview commenced there was a careful consenting process. Participants were instructed that they were under no obligation to participate and that their services at the clinic would in no way be affected if they decided not to participate. Participants were given a consent form to complete, the content of which was explained carefully by the interviewer. At several times during this process participants were asked if they had any questions.
An interview protocol was developed which covered broad areas of life such as discrimination, gender roles, stigma, relationships and health-care including medical procedures and hormone usage. The interview protocol was not used as a formal interview guideline; participants were never read questions directly from the protocol. The purpose of the interview protocol was to ensure that the same type of question was asked to all participants and that the same themes would be covered among all the participants. The interviews maintained the feeling of a conversation with pointed questions. An example of a typical question asked during the interview is: ‘Can you tell me about a past relationship?’ Typical follow-up questions include: ‘What did you like about this partner?’ and ‘What did you dislike about this partner?’
Upon commencing the interview, each participant was asked: ‘Is there anything on your mind you would like to discuss?’ This question allowed some participants to ask questions or to discuss concerns regarding their visit to the clinic. Since the location of the study was a health clinic, there were many possible reasons why participants could have been at the clinic (e.g. receiving results of a medical test or coming in for HIV treatment) and it was important to give participants an opportunity to discuss anything that may be on their minds. On occasion, this question led to a discussion surrounding participants’ concerns. For example, one participant described seeking shelter from an abusive relationship, which led to a discussion surrounding her abusive relationship, moved into a discussion of her relationships in general and preceded to other topics such as health-care needs and concerns.
At the end of the interview, each participant was thanked and asked if she would like to receive a list of referrals for HIV services in their area. She was also asked if she would like to receive a safer sex packet containing a number of products including lubricant, male condom, female condom, finger cot and dental dam. Each participant also received $35 cash for their time and transportation costs.
Interviews were transcribed verbatim. A modified form of grounded theory (Strauss and Corbin 1990
) was used to guide the coding of the interviews. Unlike traditional grounded theory, the approach utilised here does not assume an inexperienced orientation to the data on the part of the investigator. It embraces the idea that the researcher’s background, including theoretical orientations, analytic training, skill and experience with the data is necessary and an important part of the analysis (Lincoln and Guba 1985
Three researchers coded the transcripts. To commence analyses, three interviews were randomly selected. From these three interviews a coding schema was developed that included themes relevant to the aims of the study and the focus on gender roles. After establishing a thematic schema, the remaining interviews were read and coded for themes. If new themes emerged they were added to the thematic schema. To enhance reliability, the authors met to discuss the themes coded and discrepancies with codes. All discrepancies were discussed and agreement was reached. The themes reported here are those relating to gender and HIV risk. These themes are in line with what the authors found to be an overarching story told by participants — that of stigma and discrimination leading to feeling unwanted and desiring to have a partner in order to feel loved, resulting in HIV risk.