published_or_final_version / Education / Doctoral / Doctor of Philosophy

Transgender and gender-nonconforming (TGNC) individuals in the United States experience significant marginalization due to stigma enacted at the structural, interpersonal, and individual levels. As a result, this population has reported increased behavioral and physical health needs, as well as unique barriers to healthcare. Moreover, TGNC individuals have reported greater experiences of childhood abuse compared to cisgender individuals. The cumulative experiences of stigma-related stressors and adverse childhood experiences put this population at risk for the development of mental and physical health problems, increasing need for health services. However, TGNC individuals have reported being denied medical care and postponing seeking care due to fear of discrimination, which may increase complications and severity of illness, and result in increased hospitalizations and healthcare costs. Utilizing the Andersen Behavioral Model of Health Services Use and Theory of Planned Behavior, the current study examined robust associations among stigma-related stressors, adverse childhood experiences, personal and physician-related enabling factors, mental, behavioral, and physical health needs, and healthcare utilization, intention, and delay among an online convenience sample of 109 TGNC adults in the United States. A series of multivariate and mediational analyses were conducted to determine the connections among predisposing factors, enabling resources, needs, health beliefs, and healthcare intention, delay, and behavior. Although predisposing factors were not directly associated with healthcare behavior, they were directly associated with healthcare delay. Moreover, mediation analyses indicated an indirect effect of victimization and adverse childhood events to decreased healthcare utilization and increased delay through mental health needs, internalized stigma, negative personal beliefs, perceived TGNC-inclusivity of healthcare providers, and finally, behavioral intention. Thus, the present study illuminated a possible cascade of detrimental effects that are initiated by stigma-related stress and adverse childhood experiences through enabling resources, needs, and beliefs, that ultimately are associated with healthcare utilization intent, behavior, and delay. These findings highlight the need to address both TGNC individuals’ timely use of care, and the quality of care they receive. It is imperative that future research takes a multi-level approach by creating and testing evidence-based interventions to improve both healthcare providers’ competency, as well as for TGNC individuals’ ability to coping with stressors.

The thesis and the two films form a practice PhD in drama exploring ethnofiction - an experimental ethnographic filmmaking approach pioneered by visual anthropologist Jean Rouch. In the mid-1950's Rouch started to experiment with fiction and 'projective improvisation' in ethnographic films such as Jaguar (1957-1967), Moi, unnoir (1957) and La pyramide humaine (1959). Film critics would call these films 'ethnofictions'. After agreeing a story outline, the camera simply follows the subjects' improvisations of their own, and others', lived experiences. The aim is to show aspects of ethnographic research otherwise hard to represent. A key question of the doctoral research has been whether a nuanced understanding of foreign cultures can be created and mediated by combining ethnographic research methods with the processes of dramatic work. Even though Rouch made ethnofictions as part of his ethnographic research, he infused the genre with elements of surrealism and poetry, and often opposed anyone trying to establish theories about his films. Defying Rouch's view on this matter, this thesis explores ethnofiction as an ethnographic filmmaking method by drawing on the experiences from fieldwork and filmmaking among transgendered Brazilians living in São Paulo. The fieldwork resulted in a feature-length ethnofiction and an ethnographic documentary short: Transfiction focuses on identity and discrimination in the daily lives of Brazilian travestis and transsexuals. Informed by transgendered artists, prostitutes, healthworkers and political activists, Fabia Mirassos projected her life through the role of Meg, a transsexual hairdresser confronting intolerance and re-living memories of abuse. Savana 'Bibi' Meirelles plays Zilda who makes her living as one of the many transgendered sex workers in São Paulo, as she struggles to find her way out of prostitution. Drama Queens is an ethnographic documentary short and contains four scenes from the over 200 hours of rushes that were recorded during the fieldwork. The scenes are from São Paulo's annual Pride Parade and present Bibi, Fabia and Phedra who were the main informants of the research conducted at the theatre Os Satyros in central São Paulo.

Genom kvalitativa intervjuer med fem kriminalvårdsanställda och en transidentifierad intagen ville jag bidra med kunskap om hur Kriminalvårdens möten med fängelsedömda transpersoner kan se ut. Syftet med studien var att undersöka normer, värderingar och praktiker som intervjudeltagarna gav uttryck för när det gäller intagna transpersoner. Intervjudeltagarna uttryckte en medvetenhet kring gruppens utsatta position i fängelsemiljön men vittnade samtidigt om avsaknad av såväl riktlinjer som strukturerade arbetssätt i frågorna. Praktiker fokuserade snarare på det avvikande och direkta än det normativa och förebyggande. Intagna själva förväntades begripliggöra sin identitet för omgivningen, samtidigt som insatser riktade mot personalens (o)medvetenhet saknades. Kriminalvården kan sägas bidra till att upprätthålla normativa föreställningar om två binära kön genom att inte tillhandahålla handlingsplaner eller självklara alternativ för personer som sträcker sig mellan, bortom eller är föränderliga mellan de två könskategorierna kvinna och man. Att inte ta ställning illustrerar maktutövning, osynliggörande och kan innebära en kränkning i sig själv. / Through qualitative interviews with five employees in the Swedish correctional system and one trans-identified inmate, I sought to get an understanding of transgender inmates are dealt with in the Swedish correctional system. The aim of this study was to examine norms, values and practices expressed by the interview participants regarding transgender inmates. The interview participants expressed an awareness of the group’s vulnerable position in the prison environment, but also the lack of guidelines as well as structured methods to handle the group. Responses focused on the deviant and direct rather than the normative and preventive. The transgendered inmates themselves were responsible to explain their identity to others. At the same time there were no efforts to make the staff members aware of questions concerning gender identities and/or expressions. The Swedish correctional system can be said to maintain normative conceptions of two binary sexes by failing to provide action plans or natural options for persons with gender identities that extend beyond woman or man, or fluctuate between the two categories. To refuse to take a stand is to exercise power, make transgender inmates invisible, and perhaps even be seen as a violation in itself.

Within both the scientific discourse on workforce diversity, and diversity management practice, intersexuality and transgender issues have hitherto remained marginalized topics. This chapter gives an overview of the discourses on both phenomena, and proposes starting points for more inclusive organizational diversity management initiatives. It is shown that both topics represent different aspects of the category of "gender". The common practice of conceptually lumping together intersexuality, transgenderism, and sexual orientation can be seen as one important reason that intersexuality and transgenderism are rarely considered in organizational diversity management programs in terms of concrete action. Against this background, a modified, and more integrated approach to structuring the workforce alongside the different dimensions of diversity is proposed. It is shown that the categories of "biological sex and gender", "gender identity", and "sexual orientation" cannot be regarded as being separate from each other. They represent, rather, an interrelated organizational field of action that should be considered as being one interrelated topic for organizational diversity practices. This chapter derives this claim theoretically and discusses the consequences for organizational diversity management practices. For most organizations, this would mean a fundamental rethinking of their goals, in terms of workforce diversity, and the shaping of their diversity management programs.

Context: The transgender community experiences excessive discrimination in in healthcare. Data continue to reveal that health care providers lack sufficient knowledge in transgender health, as well as difficulty in referring individuals to competent providers, to ensure the continuum of care (Brennan, Barnsteiner, Siantz, Cotter, & Everett, 2012; Cruz, 2014). Methods: A modified Cross-Cultural Care Survey consisting of 56 questions was implemented via Qualtrics to 1,134 nurse practitioners (NPs) in the California Association of Nurse Practitioner to measure their cultural competence through the domains of attitude, knowledge, and skill. Results: Completed responses were obtained from 30 out of 38 NPs (78.9%). Knowledge was positively correlated with Skills (Pearson's r = .688, p < .001); negatively correlated with Negative Attitude (Pearson's r = -.458, p = .011) and positively correlated with Positive Attitude (Pearson's r = .371, p = .043). Skills was positively correlated with Positive attitude (Pearson's r = .646, p < .001); however, the negative correlation between Skills and Negative Attitude was not statistically significant at the .05 level (Pearson's r = -.345, p =.062). There was a negative correlation between Negative Attitude and Positive Attitude, but this correlation was only marginally not significant at the .05 level (Pearson’s r = -.358, p = .052). Conclusion: The results indicated that the balance between skills and negative attitudes may have created a barrier to care in transgender patients.

Introduction: The risk factors involved in treating transgender individuals with hormone therapy have been documented, but a full understanding of them remains elusive. Much of the research performed in transgender medicine is old or being completed overseas. It is thus the responsibility of current providers and investigators to expand our current knowledge, so this often marginalized population can receive the best quality care. Methods: A group of 28 transgender men and women who received care from the Endocrinology Clinic at Boston Medical Center were randomly selected as part of a quality control project to evaluate the risk factors involved in hormone therapy. Analysis was two-fold. First, change in lab values associated with known risk factors over a two-year period were assessed in individual patients. Second, group analysis sought to correlate changing hormone levels with lab values associated with known risk factors. Results: The result of the analysis was the majority of the patients who were observed did not suffer from any of the risk factors commonly associated with hormone therapy, and if anything benefited from the consistent clinical care. Several correlations were calculated between hormone levels and the lab values associated with the risk factors, however further analysis must be completed to confirm any connection. Discussion: The goal of this project was to not only evaluate care at Boston Medical Center, but also to draw attention to transgender health. In doing so, we have given an example of safe and effective hormone therapy and shown additional avenues for future research.

Thesis advisor: Ana M. Martínez Alemán / The contemporary American women's college boasts an illustrious history of providing superior education for women, one that leads to significantly more positive educational outcomes for women than a coeducation college experience (including graduate degree attainment, persistence in science and mathematics, and achievement of high-level positions in many career fields). Recently, a small but vocal group of students who identify as transgender and who are living as male, genderqueer, or transitioning to live as male have emerged as a visible sub-population in many highly selective women's colleges. In this qualitative, phenomenological study of the perceptions of student affairs administrators (n=31) regarding their perceptions of and experiences working with transgender students, these key facilitators of student growth and development expressed beliefs and actions that characterized them almost uniformly as supporters of transgender students. A smaller subset of participants (advocates) took decisive and change-oriented action on their campuses, resulting in a shift of policy and practice. The data indicated that there appeared to be coherence between these two identities and adherence to a philosophy of feminist and/or womanist identity and practices. By effectively navigating what one participant named `discourses of discomfort' about transgender students on campus, participants demonstrated professional identities typified by an ethics of care and social justice in their work, as well as demonstrating practices that were defined by normalizing belonging for transgender students. Implications for practice include continued attention to advancing social justice at women's colleges, enhancement of learning and teaching about transgender lives and identities at women's colleges, and increased commitment to trans-formation of coeducational college environments. Further research about transgender students' experiences at women's colleges, as alumni of women's colleges, and the effects of policy implementation regarding transgender students at women's colleges is warranted. / Thesis (PhD) — Boston College, 2009. / Submitted to: Boston College. Lynch School of Education. / Discipline: Educational Administration and Higher Education.

Recently there has been an increase in academic scholarship focused on the lived experiences and health of transgender people; however, few studies have explored the romantic relationships of transgender individuals, particularly of transgender men. Among the general population, relationships have been shown to be central to both identity formation and as support in terms of health and wellbeing, and are therefore a potential factor of resilience of vital importance given the health disparities found among the transgender population. This dissertation is comprised of three articles investigating the dating and relationship experiences of transgender men from both individual and couple level perspectives, and employs Sexual Script Theory as a conceptual framework through which to analyze and interpret study findings. The first article provides a comprehensive review of the literature that has examined the relationships of transgender men and makes recommendations for future research to address gaps and limitations identified in these studies. The second article presents the findings from an investigation of N = 24 couples of transgender men and their cisgender female (n = 12) or male (n = 12) partners who completed in-depth qualitative, individual and dyadic interviews. The third article is a secondary analysis of data from a mixed-methods study on gender and HIV risk among N = 228 cisgender men who have sex with transgender men exploring their characteristics, attractions, identities, behaviors, relationships, sexuality, and health. Findings reported and discussed in these three articles include that transgender men and their partners, despite a number of identified barriers, form enduring and satisfying relationships. Prevailing cultural scripts of heteronormativity and homonormativity provide transgender men and their partners a blueprint for actualizing gender identity and for obtaining recognition and validation as a couple. However, these normative scripts are not always a perfect fit and include barriers to private and public affirmation of identity and fulfillment of sexual and intimacy needs. Transgender men and their partners simultaneously reinforce and challenge normative, relationship scripts, and in doing so, contribute to the evolution of social norms regarding gender and sexuality. Implications for the health and wellbeing of both transgender men and their partners are discussed.

This qualitative study examines the healthcare provision for gender dysphoria patients by the National Health Service (NHS) in England. The thesis takes as its starting point the experiences of those providing and receiving care following the A, D &amp; G vs North West Lancashire Health Authority court decision in 1999. The aims of the research are threefold: To examine what trans narratives tell us about individual understandings of gender, to explore what practitioner narratives tell us about the understandings of gender utilised in NHS treatment, and to determine what issues are important to consider when providing gender services. It undertakes an empirical thematic analysis through a triangulation of data sources - a literature review, qualitative interviews with specialists and focus groups with trans patients. The research is underpinned by three central questions: Do differences exist between the ways in which trans people and their doctors understand gender identity? Can the ways in which trans people formulate and express their gender identity map onto the notions of gender that practitioners employ? What are the wider implications for healthcare policymaking? The research questions were intended to investigate how trans people formulate and express their gender, whether and how those understandings differ from those that practitioners employ, whether trans narratives can map onto medicalised notions, and the implications for healthcare policymaking.