Visibility, transphobia, and resilience: addressing transgender women's health in Lebanon

Abstract

Background: Worldwide, transgender women face a disproportionately high risk of HIV/AIDS, violence, and mental health problems, as well as individual and structural discrimination. In Lebanon, health disparities in transgender women have recently been identified. Transgender visibility, a complex concept that involves “outness”, gender expression, and context, is associated with risky sexual behaviour among transgender women in Lebanon. This analysis, therefore, aimed to explore associations between visibility, transphobia, and resilience among transgender women in Lebanon. Methods: We analysed data from 20 semi-structured interviews and 16 surveys that were conducted in Lebanon during a transgender-specific HIV intervention pilot study in 2016 and 2017. Participants were recruited via peer recruiters and included if they were aged 18 years or older and identified as a transgender woman. Mixed-methods analysis of the data assessed relationships between visibility, transphobia, and resilience. Quantitative and qualitative analyses included bivariate tests (Wilcoxon signed rank test and Fisher's exact test) and the constant comparative method, respectively. Findings: We noted significant associations between “visibility as transgender” and two indicators of resilience: “social cohesion” (p=0·0071) and “community connectedness” (p=0·0380) with other transgender women. Individuals who reported being visible as transgender scored 50·0% and 26·67% lower on these two indicators of resilience, respectively, compared with individuals who reported being not visible as transgender. Qualitative analysis identified three themes: “isolation”, “gender identity affirmation”, and “resilience”. Participants indicated that transgender visibility increased risk of transphobic encounters, resulting in self-isolation as protection from transphobia. Validation of gender identity internally or externally (via physical appearance, gender affirmation procedures, or positive social interactions) was also important. Resilience, for both those self-describing as visibly transgender and those who were not, may be bolstered through positive connections with other transgender women. Interpretation: This analysis supports the importance of understanding visibility as a construct related to transgender women's health. Results indicate that achieving social cohesion and community connectedness with other transgender women could be integral to mitigating the deleterious effects of transphobia in Lebanon, where a hostile environment for transgender women shapes the development of resilience within the continuum of visibilty. Future research should seek to determine whether these associations hold true in larger samples of transgender women in Lebanon and the greater Middle East. Funding: US National Institute of Mental Health.