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Lived experiences of transgender young adults transitioning during the COVID-19 pandemic

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Lived experiences of transgender young adults transitioning during the COVID-19 pandemic

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Lived Experiences of Transgender Young Adults Transitioning During the COVID-19
Pandemic
by
Evangelina Estrada

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

August 2022

© Copyright by Evangelina Estrada 2022
All Rights Reserved

The Committee for Evangelina Estrada certifies the approval of this Dissertation

Cadyn Cathers
Mary Andres
Patricia Tobey, Committee Chair

Rossier School of Education
University of Southern California
2022

iv
Abstract
The discrimination and bias that transgender, non-conforming (TGNC) individuals experience in
health care facilities is a concern that needs to be addressed. The purpose of this was qualitative
study was to elicit the lived experiences of transgender young adults transitioning during the
COVID-19 pandemic. The study consisted of interviews with eight adults, aged 18 to 25, who
reported newly transitioning or continued transition during the pandemic. Semi-structured
interviews consisted of 20 open-ended questions. Utilizing a conceptual framework centered in
queer theory, analysis involved data coding of the interview transcripts, which generated
thematic categories. Themes emerged that exposed providers’ inability to manage these patients’
level of introspection, to the point of not listening. Participants discussed resilience and the
desire to take control of their transition process. Themes exposed increased introspection during
pandemic isolation and the concerning cut-off from queer spaces. The recommendation that
future research explore a more diverse group of individuals is primary. Centering the experiences
of individuals of different ethnic backgrounds, socioeconomic statuses, education levels, and age
groups would provide a richer understanding of the impact of COVID-19 on the transition
process. This future research would also benefit from the involvement of transgender
researchers.
Keywords: transgender, transition, COVID-19, young adults, resilience

v
Acknowledgements
Many thanks to my dissertation committee, all of whom gave time and support. At its
best, this has been a wonderful journey of discovery with insightful leaders. To Dr. Tobey, you
have been both an inspiration in the building process and a solid resting place for ideas; thank
you sincerely for the sanity.
To my OEA Sisters, without whose unwavering support I would not be able to write this
acknowledgment. Words can never describe your unconditional and steadfast devotion to my
process. It has been the gift of a lifetime. Luisa, Donna, and Lisa—I am the blessed one.
To my parents, who have never stopped believing in me; this is for your mothers and
their mothers who never had access to a formal education. Mom, you have always known I
would do it. Gracias. To Dad, the man who taught me that education is the great equalizer, this
4.0 is for you. La Familia Estrada in the house!!
To all my kids, my pride, thank you for seeing me and understanding why I took this
journey. You all stepped up and gave me the space to grow. Your smiles, excitement, and
support on graduation day will be with me always. Your love is the greatest gift I could receive.
Thank you for helping me live my best life.
Andrea, my partner in this wild ride called life, you are my rock. You sacrificed so much
to make this happen. You created the space for our lives to be put on hold. You pushed me
through all the doubt, seeing my strength when I could not. You encouraged me to soar. This
dissertation belongs to you, too.
To the transgender/non-binary/gender fluid community, thank you for allowing me in
your space. I promise to honor all that you shared with me. And finally, this is for Charlie.
Whose pure existence made this possible. Thank you for your trust and belief in me.

vi
Table of Contents
Abstract .......................................................................................................................................... iv
Acknowledgements ..........................................................................................................................v
List of Tables ............................................................................................................................... viii
List of Figures ................................................................................................................................ ix
Chapter One: Introduction to the Study ...........................................................................................1
Context and Background of the Problem .............................................................................2
Purpose of the Project and Research Questions ...................................................................3
Importance of the Study .......................................................................................................3
Overview of Theoretical Framework and Methodology .....................................................5
Definitions............................................................................................................................6
Organization of the Study ....................................................................................................7
Chapter Two: Review of the Literature ...........................................................................................9
Background/History .............................................................................................................9
Current Trends ...................................................................................................................12
Queer Theory .....................................................................................................................23
Conceptual Framework ......................................................................................................27
Conclusion .........................................................................................................................34
Chapter Three: Methodology .........................................................................................................35
Research Questions ............................................................................................................35
Overview of Design ...........................................................................................................35
Data Sources ......................................................................................................................38
Participants/Participating Stakeholders .............................................................................38
Instrumentation ..................................................................................................................40
Data Collection Procedures ................................................................................................41

vii
Data Analysis .....................................................................................................................42
Credibility and Trustworthiness .........................................................................................43
Ethics..................................................................................................................................45
Chapter Four: Findings ..................................................................................................................47
Participants .........................................................................................................................47
Data Collection ..................................................................................................................49
Data Analysis .....................................................................................................................49
Findings..............................................................................................................................50
Summary ............................................................................................................................65
Chapter Five: Recommendations and Discussion..........................................................................66
Recommendations for Practice ..........................................................................................76
Limitations and Delimitations ............................................................................................81
Recommendations for Future Research .............................................................................82
Connection to the Rossier Mission ....................................................................................83
Conclusion .........................................................................................................................84
References ......................................................................................................................................86
Appendix A: Interview Protocol ..................................................................................................105
Appendix B: Coding Sheet ..........................................................................................................109
Appendix D: Informed Consent for Research .............................................................................111

viii
List of Tables
Table 1: Data Sources 36
Table 2: Participant Demographics 48
Table A1: Interview Protocol 106
Appendix C: Theoretical Framework Alignment Matrix 110

ix
List of Figures
Figure 1: Conceptual Framework 33
Figure 2: Development of Admission Policy Utilizing Lewin’s Change Model 80

1

Chapter One: Introduction to the Study
The discrimination and bias that transgender, non-conforming (TGNC) individuals
experience in the health care system is a concern and needs to be addressed. In a study of 350
transgender individuals, Bradford et al. (2013) reported that health care was the most cited
context in which they found discrimination, noting that 41% of respondents reported
discrimination specifically resulting from transgender status. In research involving 182 mental
health clinic participants, Speer and McPhillips (2013) found that most of their transgender
respondents reported psychiatrists were unfriendly, critical, or aggressive. Furthermore, in a
National Transgender Discrimination Survey report, Grant et al. (2011) found that doctors’
knowledge of a patient’s transgender status increases the likelihood of discrimination and abuse.
This problem is important to address because, according to Kcomt (2019), without a significant
paradigm shift in health care providers’ attitudes and overall service delivery to transgender
individuals, this practice of discrimination will endure. Furthermore, research indicates that
implementing transgender-affirming policies in health care will benefit society by decreasing
costs related to problems that arise when individuals delay treatment due to discrimination
(California Department of Insurance, 2012).
Discrimination against transgender individuals must be addressed to make this
community more visible (Cruz, 2014). Making this marginalized community more visible will
inevitably lead to change in social expectations and behaviors. Doan (2016) discussed visibility
and the how of counting transgender lives:
If the purpose of counting is to correct the long-standing neglect of the transgender
community by trying to gauge the number of people subject to fear, discrimination, and
2

potential gender-related violence, “then” under such circumstances counting can be a
queerly radical act. (p. 105)
Additionally, access to gender-affirming care has been limited, even prior to the
pandemic (Cohen et al., 2020). Understanding the potential impact of the COVID-19 pandemic
is important, yet very little research concentrates on the impact of the pandemic on the
transgender community (Torres et al., 2021). In this study, power imbalances were made
transparent by centering the lives and voices of TGNC individuals (Brim & Ghaziani, 2016).
Context and Background of the Problem
This qualitative research addressed the lived experiences of transgender adults who have
been transitioning during the COVID-19 pandemic. Secondary to systematic bias and
inequalities, it is expected that the lesbian, gay, bisexual, transgender, and queer (LGBTQ)
communities will be more adversely affected by the pandemic’s consequences (Salerno et al.,
2020). Specifically, due to distinctive health care needs, discrimination, and barriers to access,
transgender and non-binary individuals may have experienced increased stressors during this
time (Wang et al., 2020). Thus, the impact of the pandemic on a cisnormative system that does
not work in the best interests of transgender individuals should be addressed.
In the current U.S. medical system, health care providers and insurance companies hold
the power to deny services. Grant et al. (2011) found, in a study of over 9,500 participants, that
19% of transgender individuals had been denied health care services secondary to their
transgender identity. Another study found that it was more probable that transgender adults
would experience a denial of health care than their cisgender peers (Kattari et al., 2020). This
denial occurs as a result of the patient’s gender identity (Lerner & Robles, 2017). Denial of care
can also be the result of gatekeeping. During the COVID-19 pandemic, this power dynamic
3

became more entrenched when non-essential services were halted and decreased access to
needed services for these individuals (Flaherty et al., 2020).
Purpose of the Project and Research Questions
The purpose of this qualitative study was to explore the lived experiences of transgender
adults transitioning during the COVID-19 pandemic. This research utilized the narrative lived
experiences of participants who were transitioning during this crisis. Given the strict binary and
cisnormative nature of health care, participants discussed the power relationships in these
settings associated with cisgender bias, discrimination, and cisnormativity. Earlier research
addressing the pandemic’s impact on this community has been limited. Completing this research
addressed the gap in the literature and presented the voices of this marginalized community. By
queering this research, TGNC voices remained at the center to destabilize and challenge societal
binaries. The research questions are
1. How do transgender adults experience cisnormative practices in COVID protocols?
2. How do transgender adults experience the power dynamics created by cisnormative
COVID practices?
3. What are the mental health effects of transitioning during the COVID-19 pandemic as
voiced by transgender adults?
Importance of the Study
It is important to address the effects of the COVID-19 pandemic on transgender adults as
they were transitioning for several reasons. The primary reason is that the added stress of
managing a deadly pandemic amplifies what this population was already experiencing
(Kantamneni, 2020). The pandemic added additional stressors (Nelson et al., 2020) and should
be examined. Another reason is that discrimination against transgender individuals who seek
4

health care services has consequences. Bauer et al. (2009) and Bradford et al. (2013) found that
the experience of discrimination led individuals to delay treatment or not seek treatment at all. In
concurrence, Kcomt (2019) found that nearly 25% of transgender individuals have delayed
required medical care after a negative experience with a health care provider. Additionally,
research by Grant et al. (2011) and James et al. (2016) revealed that fear of future discrimination
by providers led to postponing or avoiding care. In a survey of 417 transgender adults, Seelman
et al. (2017) found that delaying or not seeking care due to fear of discrimination has a negative
effect on mental and physical health. Specifically, by postponing care, these individuals are at an
increased risk of depression, suicidal ideation, and suicide attempts. Addressing discrimination is
vital in making this community more visible and changing social expectations and behaviors
(Cruz, 2014).
By centering TGNC voices, research can destabilize the norm of binary categories
(Pascoe, 2018). Erasure becomes non-existent when voices are sought and heard. Most
concerning are the unaddressed incidents of violence against the TGNC community. Violence
against this community resulting in death disproportionately affects people of color (Human
Rights Campaign, 2021a), with reports that 85% of victims of fatal violence since 2013 were
people of color. Nadal (2016) stated that utilizing queer research can promote systematic change
on various levels. Without systematic change, transphobia and violence will endure.
It is important to note my positionality as the researcher. As a qualitative researcher, I am
also a lesbian, active in the LGBTQ+ community for over four decades. In addition, I am a
licensed therapist with experience working within our community. Having close family ties with
young transgender adults, I came to this research topic given these experiences and
intersectionalities, intimately knowing its importance and value. It is important for the
5

transgender queer community and my positionality in the queer mental health community that
this qualitative research questions be addressed.
Overview of Theoretical Framework and Methodology
The most fitting theory to explore this problem of practice is queer theory. Queer theory
examines how the power dynamics of essential binaries work to reinforce specific and narrow
ideas of sexuality and gender, thereby making any identity that falls outside of the binary
unviable and undesirable (Butler, 2015). According to queer theory, the primary goals of social
change are deconstructing rigid sexual and gender identities and confronting the power,
oppression, and violence that they have produced and made normative. Meeting these goals
allows for exploring and acknowledging multiple and various identities. At its core, queer theory
refutes the essentialist belief that gender and sexuality are biologically driven (Jones, 2021).
Instead, this theory states that expressions of sexuality and gender are socially and historically
constructed. The binary categories of female and male do not apply, avoiding the resultant
judgement of deviance or otherness. In addition, queer theory challenges binary constructs such
as heterosexual versus homosexual, gender being female or male, class status of rich or poor, and
the dualism of racial categories such as White versus non-White. These binaries result in power
dynamics. As a result, there is criticism of anything forcing individuals or systems into
mainstream categories (Butler, 2015).
Queer theory is an appropriate theoretical framework for this study for various reasons.
First, it allows the freedom to explore the gray areas of identities: transgender patients’ perceived
identities and their identities via their lived experiences. Secondly, this theory allows for
emergent design depending on participants’ responses. Because identities are fluid, the probative
interview process must also remain fluid. The theory of change for this research assumes that
6

centering the participants’ lived experiences will lessen this community’s erasure and make
discrimination and cisnormative bias more visible. Experiences of discrimination and
perseverance can be addressed by better understanding the narratives of transgender adults
functioning within a closed binary system. Rules can be changed in this radical-reform space (de
Oliveira Andreotti et al., 2015).
This qualitative study took place remotely via Zoom interviews. Participants were sought
via local LGBTQ support centers, utilizing center outreach and snowball sampling. This
qualitative design allowed for telling the participants’ stories (Creswell & Creswell, 2018). The
expectation was that this would become an emergent design, with my and the participants’
reflexivity shaping its direction.
Definitions
Definitions of gender identity vary depending on the writer. Queer theory states that
gender identity is a construct; therefore, categories and associated labels are fluid. This study
used common and repeated key concepts found in the literature review.
• Cisgender: the description given to individuals whose gender identity or expression
aligns with the gender they were assigned at birth (National Resource Center on
LGBT Aging, 2012).
• Cisgenderism: the privilege experienced by non-trans identified persons that can
denigrate and deny trans identities (Kcomt, 2019).
• Cisnormative: the assumption that all individuals are or should be cisgender, not
recognizing the existence of transgender as a valid identity (Kcomt, 2019).
• Erasure: Erasure is a phenomenon that occurs when institutions and individuals do
not understand transgender people or issues and the assumption that both are neither
7

important nor relevant. Active erasure is seen when individuals or institutions take
part in activities ranging from denial of services to a refusal to acknowledge gender
beyond the essentialist definition (Bauer et al., 2009).
• Misgendering: occurs when one uses pronouns that do not correctly reflect the gender
with which a transgender person identifies, either intentionally or unintentionally
(Gridley et al., 2016).
• Non-binary or gender queer: individuals who identify as both male and female or as
neither. Within this definition, some may identify as being more masculine or more
feminine (Richards et al., 2016).
• Transgender/non-conforming: individuals whose gender identity or expression is
different from the gender they were assigned at birth (National Resource Center on
LGBT Aging, 2012).
Organization of the Study
The study is presented in a five-chapter format. Chapter One introduces the problem of
practice and the context of the problem. The theoretical framework and methodology are briefly
explained, and the research questions are introduced. Chapter Two provides a review of the
literature pertinent to theorizing and understanding the study. The literature review addresses the
historical story of bias and discrimination of transgender individuals in daily living and
healthcare. Chapter Three describes the methodology for the study. This includes research
questions, an overview of the design, participant sampling, narrative collection process, and
narrative analysis. Chapter Four provides a thematic summary of the deconstructed narratives.
Chapter Five offers a discussion of the participants’ lived experiences. Recommendations are
based on the participants’ narratives, with the participants remaining at the center of the study.
8

The chapter includes recommendations for further research regarding cisnormative healthcare
practices and connection to queer spaces.

9

Chapter Two: Review of the Literature
A review of the literature serves as a roadmap for this study. This chapter discusses the
background and history of transgender lives, definitions, and current trends. Also described is an
introduction to queer theory as the theoretical framework, including key concepts. Finally, the
chapter presents an application of queer theory to the problem of practice and the conceptual
framework for addressing it.
Background/History
The following presents a general overview of transgender individuals in the United
States. According to Beemyn (2013), writing a thorough history is made difficult by the modern
use of the word “transgender,” as it excludes individuals who may have been transgender but,
due to culture or lack of terminology, did not identify as such. Significant events on more recent
dates are offered.
Transgender Individuals in the United States
Creating a common place of understating requires a basic history and background of
transgender individuals in the United States.
Historical Timeline
Being transgender or gender nonconforming in the United States is not a new
phenomenon. There is a rich history that cannot be sufficiently covered here. Important dates are
noted. These individuals have lived among cisgender individuals for hundreds of years.
Transgender identities have been described as far back as the Middle Ages (Hines, 2007). Prior
to 1800, Indigenous Americans had names and roles for individuals considered gender-variant
(de Vries, 2009). Keeping with modern American history, the following sections offer some
notable dates. Though most likely not the first to do so, in 1951, Christine Jorgenson became
10

known for her medical transition, bringing the experiences of White transgender lives to the
forefront (GLAAD, 2012). Lucy Hicks Anderson, a Black transgender woman, became an
advocate for trans rights before the label existed. Arrested in 1945 for her advocacy, she was not
afforded the same visibility as Ms. Jorgensen (Carroll, 2020). The 1960s brought political action.
In 1966, the Compton Cafeteria Riots saw transgender women taking a stance against police
discrimination and harassment (GLAAD, 2012). Led by transgender women of color opposing
police harassment, the Stonewall Riots of June 1969 are considered the birth of the LGBT fight
for rights (Bockting et al., 2013; GLAAD, 2012). Transgender participation in sports has its
history as well. In 1977, the U.S. Supreme Court ruled in favor of Renee Richards, a transgender
woman, allowing her to play professional tennis as a female (GLAAD, 2012).
However, history has not always been positive. In 1999, the first International
Transgender Day of Remembrance was held in honor of people murdered because of anti-
transgender violence. Laws were passed to protect these Americans’ rights. In 2012, gender
identity was added to the federal Equal Employment Opportunity Commission’s list of protected
classes, clarifying that discriminating against these individuals violates Title VII of the Civil
Rights Act of 1964 (GLAAD, 2012). More recently, transgender Americans’ ability to serve in
the military underwent changes. In 2017, President Donald Trump announced that transgender
persons would no longer be allowed to serve in the military in any capacity (Stewart & Chiacu,
2017). When Joe Biden took office in 2021, he overturned this ban (Wamsley, 2021).
Transgender individuals have a rich history in this country, and when addressing discrimination,
definitions are vital. The sections that follow discuss these definitions.

11

Prevalence of Transgender Individuals in the Community
Determining the number of transgender or nonconforming individuals in the United
States is not easy, and results have varied. In a 2016 population-based survey, The Williams
Institute (2016) found that 0.6% of adults, about 1.4 million people, in the United States
identified as transgender. Research on population numbers is inconsistent. In a study of
population-based probability samples, Meerwijk and Sevelius (2017) found this population to
measure at 390 per 100,000 or .39% of the total population. The authors acknowledged the
discrepancy and postulated that not all transgender individuals identify with that label. Research
also categorized populations by racial groups. The Williams Institute (2016) further found that
those who identify as transgender are less likely to identify as White. In fact, transgender
individuals are more ethnically and racially diverse than the overall population of the United
States. Given the existence of these individuals in the United States, how the community is
received is important.
Transgender Demographics
A brief overview of gender categories is presented to provide consistency and clarity to
terms and labels used in this research.
Gender identity and gender identity categories: Gender is a construct and is, therefore, in
a constant state of change and evolution as an identity. Gender identity is defined as an
individual’s personal and internal experience of gender (Airton et al., 2019). This research uses
the following gender identity categories:
• Cisgender: Anyone who is not transgender, non-binary, or gender non-conforming
(Riggs & Sion, 2017).
12

• Non-binary or gender queer: individuals who identify as both male and female or as
neither. Within this definition, some may identify as being more masculine or more
feminine (Richards et al., 2016).
• Transgender or gender nonconforming (TGNC): An overarching term for used people
whose gender identity or expression differs from the sex they were assigned at birth.
Not all transgender people decide to alter their bodies via hormones or surgery
(National Resource Center on LGBT Aging, 2012).
Current Trends
Transgender and non-conforming people experience injustice in almost every area of life
(Grant et al., 2011). No place is safe. The following sections present the various areas in which
this lack of safety, bias, and discrimination, is found. They also discuss the resultant effects.
Bias and Discrimination
Bias and discrimination touch almost all areas of a transgender individual’s life. The
following is not an exhaustive listing of areas where bias is present.
In Employment
Unless independently wealthy, people must work to survive. Unemployment is a problem
in this country overall, but according to the National Center for Transgender Equality (2015),
transgender individuals experience unemployment at double the rate of the population in general.
Reasons for unemployment vary. The National LGBTQ Task Force (2012) found that these
individuals were either not hired or fired due to their gender identities. In addition, employment
discrimination is not equal. In a large online survey, Kattari et al. (2016) found that employment
discrimination is higher for transgender individuals of color. In fact, the higher rate of
discrimination is significant. The National Center for Transgender Equality (2015) found that
13

transgender individuals of color experienced employment discrimination at rates two to three
times higher than their White counterparts. The effects of employment discrimination can be
profound, as the National Center for Transgender Equality (2015) found that 15% of transgender
participants lived in dire poverty. Experiencing employment discrimination is damaging. If
individuals are unable to work due to discrimination, housing can also become problematic.
In Housing
Transgender and non-conforming individuals are not always afforded equal access to
housing. In their large online survey, Kattari et al. (2016) found that transgender adults were
more likely to experience housing discrimination than their cisgender counterparts. Housing
discrimination has a direct impact on the stability of living situations. The National Center for
Transgender Equality (2015) reported that 195 respondents were denied a house or apartment
because of their identity. In addition, 11% were in the process of being evicted for the same
reason. Discrimination that led to homelessness was significant. The National Center for
Transgender Equality found that 19% of their survey participants experienced homelessness
secondary to their identity. In a double jeopardy bind, 29% of these individuals were turned
away from homeless shelters due to gender identity. Housing insecurity and homelessness are of
great concern. The resultant effects of such discrimination may lead to a need for healthcare.
In Healthcare
Understanding that the transgender community experiences discrimination in housing and
employment, critical thinking advises that this occurs elsewhere. This community has also
experienced discrimination and bias in healthcare. According to a study of 350 transgender
individuals, Bradford et al. (2013) found that health care was the most common area in which
discrimination was found, with 41% reporting discrimination specifically resulting from
14

transgender status. These patients sense that providers cannot provide appropriate intervention.
Poteat et al. (2013) interviewed 55 transgender individuals and 12 medical providers and found
that health care providers had not been trained to treat TGNC individuals and felt uncertainty
when treating them. To worsen matters, patients who are out to their providers are at greater risk
of discrimination. In a National Transgender Discrimination Survey report, Grant et al. (2011)
stated that doctors’ knowledge of a patient’s transgender status increases the likelihood of
discrimination and abuse by eight percentage points. These studies focused on the historical
existence of healthcare-related discrimination. Differing research addresses the existence of
discrimination in mental healthcare settings.
In Mental Healthcare
Prior sections established the existence of bias and discrimination against TGNC
individuals in healthcare. Studies have found this phenomenon in mental healthcare as well. A
survey of 142 psychiatrists regarding attitudes revealed that gender-minority groups face
discrimination and bias often (Ali et al., 2015). This discrimination has been described as more
than simply microaggressions. In research involving 182 mental health clinic participants, Speer
and McPhillips (2013) found themes reported by the majority of their transgender respondents
showing psychiatrists to be unfriendly, critical, and even aggressive. Bias and discrimination are
prevalent and remain unaddressed. There is reason for concern. With bias and discrimination
well established, the effects of this institutionalized behavior need to be noted.
Concerning Current Trend
It is important to note the ultimate consequence of anti-transgender bias and
discrimination. Transgender lives are on public display in the United States. At the time of this
study, there are over 100 state house or senate bills under consideration that would limit rights
15

for this population (ACLU, 2021), and the governor of Arkansas recently signed a bill banning
gender-affirming therapy for minors. Transgender rights are also under attack in academics. A
federal appeals court recently paved a pathway for a professor to sue his employer, a public
university in southern Ohio, which reprimanded him for refusing to address a transgender student
by her preferred pronouns (Stempel, 2021). Using his claim of religious freedom, the results of
this case could have serious ramifications. Most concerning is individuals’ general safety. By the
end of 2021, 47 transgender Americans had been murdered. Of these, 38 were transgender
women of color (Human Rights Campaign, 2021a). Living in a society with this level of negative
visibility and potential for threat has consequences for these individuals’ lives.
Effects of Bias and Discrimination
Bias and discrimination have damaging effects. Specifically, the literature noted that
misgendering results in feeling stigmatized. In two online surveys involving 249 participants,
McLemore (2015) found that TGNC individuals felt stigmatized when misgendered and
experienced more negative effects. In like manner, misgendering added to feelings of exclusion.
According to Bosson et al. (2012), in a study of 83 undergraduates, misgendering was
psychologically disconcerting and harmed an individual’s sense of belonging and association.
Similarly, stigmatization affects connectedness to others. In an online survey of 1,093
respondents, Bockting et al. (2013) found that stigma relating to transgender identity positively
correlated with a lessened sense of well-being. These experiences of stigmatization have
unhealthy consequences. In consonance with gender minority stress theory (Hendricks & Testa,
2012), the experience of the stress of stigmatization has serious effects on mental health.
Stigmatization as the result of misgendering is not the only consequence of bias and
discrimination.
16

In addition to stigma, individuals who experience bias and discrimination respond with
avoidance. The experience of discrimination leads to a delay in seeking treatment. In a rapid
systematic review on the prevalence of healthcare discrimination against transgender individuals
in the United States, Kcomt (2019) found that close to 25% of respondents had delayed required
medical care because of a prior negative experience with a health care provider. Others avoided
treatment in general. Bauer et al. (2009) and Bradford et al. (2013) found that the experience of
discrimination led to delaying treatment or not seeking treatment at all. In a large study of almost
3,500 TGNC individuals, Jaffee et al. (2016) found that one in three participants postponed or
did not pursue medical care secondary to discrimination.
Even future discrimination proved to be a deterrent to seeking treatment, as a prior
history of discrimination causes individuals to avoid seeking health care (Lambda Legal, 2013).
Research by Grant et al. (2011) and James et al. (2016) revealed that fear of future discrimination
by providers led transgender individuals to postpone care or not seek care at all. Postponing or
not seeking treatment is a concern. In a survey of 417 respondents, Seelman et al. (2017) found
that delaying or not seeking care due to fear of discrimination has a negative effect on mental
and physical health. Specifically, postponing care increases the risk of depression, suicidal
ideation, and suicide attempts. The existence of and the effects of bias and discrimination in
outpatient settings are well documented. However, the question regarding transgender
individuals’ experiences while transitioning during the COVID-19 pandemic remains.
Standards of Care
Discrimination in health care is an unacceptable practice. Numerous professional and
legal organizations address this basic standard of care. According to the American Medical
Association’s (AMA, n.d.) Code of Medical Ethics, physicians must ensure access to care for all
17

and treat all patients with respect for human dignity and compassion. The World Professional
Association for Transgender Health (WPATH, 2012) is devoted to improving transgender health
by ensuring the development of research, education, advocacy, public policy, and evidence-
based care. Included in this mission is the development of standards of care for healthcare
providers. As a result, hospitals and medical practices have been encouraged to develop and
implement transgender-inclusive policies and practices, as well as properly train staff. Whether
this occurred during the pandemic remains to be seen.
Existing Literature
Uncovering information regarding the impact of the COVID-19 pandemic on the
transgender community, specifically those needing gender-affirming care, has been limited but
growing. Current research-based data has been consistent. Indicators leave room and direction
for continued focus and study. Subsequent sections define the manner in which this path will be
managed.
COVID-19 Pandemic
According to the Centers for Disease Control and Prevention (CDC), COVID-19 is a
disease caused by the SARS-CoV-2 virus first uncovered in Wuhan, China, in December 2019.
Highly contagious, it spread across the country and globally. The disease frequently causes
symptoms and can feel like the flu or pneumonia. The primary means of transmission is
breathing in air containing droplets from a person infected with the virus. More importantly,
asymptomatic infected persons can pass the virus to others. As of May 5, 2022, the death toll
from COVID-19 neared a million (Centers for Disease Control and Prevention, n.d.). To lessen
the severity of the disease and inhibit the spread, the CDC recommended social distancing, mask
wearing, and becoming vaccinated (Centers for Disease Control and Prevention, n.d.). Beginning
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March 26, 2020, attempting to slow the spread, the lockdowns and restrictions on mobility were
enacted (White House, 2020). The lasting impact of COVID-19 remains unknown (United
Nations Sustainable Development Group, 2020). Despite the documented need for specific
attention, the LGBTQ community received little attention during the pandemic (Salerno et al.,
2020)
Access to Services
One area of impact of the COVID-19 pandemic has been access to health care services.
In a large study surveying 964 transgender and non-binary adults, nearly 50% of participants
reported that their access was restricted when seeking gender-affirming care during the pandemic
(Jarrett et al., 2020). In another large study exploring the negative impacts of COVID on
transgender and non-binary individuals, 40% reported that COVID impacted their ability to
access hormone replacement therapy (HRT; O’Handley et al., 2020). Of those who had planned
to begin HRT pre-COVID, 78.6% reported that the pandemic impacted their ability to start
(O’Handley et al., 2020). Participants who had gender-affirming surgery planned pre-COVID
reported that the pandemic negatively affected their ability to move forward (O’Handley et al.,
2020). As for mental health services, the pandemic most damaged the ability to access
counseling and therapy (Jarrett et al., 2020). Changing living situations, such as from a dorm to
the family home, may sever relationships with mental health providers (Salerno et al., 2020).
Lack of access to needed care during the pandemic had an effect, as it also created isolation.
Pandemic Isolation
As mentioned earlier, to slow the spread of this deadly virus, lockdown and restrictions
began in March 2020. The pandemic added extra stressors to the lives of transgender individuals
(Nelson et al., 2020). One of these added stressors is isolation. Social isolation is a pandemic
19

challenge hitting LGBTQ communities (Salerno et al., 2020). Closing schools may send young
people home to toxic, abusive, and isolated environments (Green et al., 2020). In other words,
many students were sent home and trapped in unwelcoming environments when their colleges
closed (Gonzales et al., 2020). Additionally, 19.1% of transgender participants in O’Handley et
al.’s (2020) study reported that the pandemic hindered access to social support; most stated they
faced the loss of a sense of community. How the transgender community responds to this
isolation is important.
Intersectionality
Collins and Bilge (2020) stated that the concept of intersectionality is studied by many
and many having varying definitions of what the concept mean. They offer a good definition of
intersectionality:
Intersectionality investigates how intersecting power relations influence social relations
across diverse societies as well as individual experiences in everyday life. As an analytic
tool, intersectionality views categories of race, class, gender, sexuality, class, nation,
ability, ethnicity, and age – among others- as interrelated and mutually shaping one
another. Intersectionality is a way of understanding and explaining complexity in the
world, in people, and in human experiences. (para. 3)
Jourian (2015), building on other research, developed the dynamic gender and sexuality
model. This model postulates that gender and sexuality are dynamic and not static. Each category
can shift depending on the individual’s perception of each. Functioning on a plane rather than
being liner, identity characteristics are fluid and can change proximities to each other, changing
identities in differing contexts. Identities should be viewed through this dynamic lens rather than
20

as fixed traits. When adding the intersectionalities of race, education, age, and employment
status described above, the potential for differing experiences grows.
Resilience
Resilience is key when confronting disconnection from needed support. various
disciplines have addressed the concept of resilience in young transgender adults. As a response
to a noted paucity of research, Bilodeau’s (2005) study of transgender college students found that
lifespan identity development mirrored that of sexual orientation identity development postulated
by D’Augelli (1994). In this model, identity development spans various processes as an
individual addresses emerging identity. Bilodeau (2005) utilized this framework, adapting the
processes relevant to transgender young adults. The adaptation includes six processes labeled
exiting a traditionally gendered identity, developing a personal transgender identity, developing a
transgender social identity, becoming a transgender offspring including coming out to families,
developing a transgender intimacy status, and becoming part of a transgender community
involving commitment to battling transphobia via social action. It is in this final process that
resilience is found.
More current research has since addressed resilience. When confronted with challenges,
the transgender community utilizes agile communication, absorbs information, and relays
knowledge and strategies to others (Edenfield, 2020). Social media is key to keeping the
community connected (Salerno et al., 2020). This resilience may have eased the negative mental
health effects experienced by this queer community during the pandemic (Goldbach et al., 2021).
Transgender resilience remains, and the community will take care of itself when the next crisis
occurs (Edenfield, 2020).
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Resilience has also been addressed in works not originally focused on transgender
communities. Yosso (2005) discussed distinct community cultural wealth, as opposed to social
capital held by White communities, and developed a model identifying cultural capital in
communities of color. This cultural capital is used by communities of color to resist systematic
societal oppression. Yosso delineated six forms of cultural capital: aspirational capital (the hopes
and dreams held in the face of adversity), familial capital (resources gained by living in
communal environments), linguistic capital (language and communication skills, including story
telling), social capital (networks of people in the community), navigational capital (the ability to
navigate social institutions not created for communities of color), and resistant capital (the skills
learned via adversarial behavior that when opposing inequality). In this body of work, resilience
is a proactive skill held by marginalized communities.
Pennell (2016) postulated that Yosso’s (2005) cultural capital model could also apply to
queer communities. In addition, Pennell argued that while resistant capital is real, it is reactive.
She added a seventh category of cultural capital called transgressive capital. This transgressive
capital is more proactive in its response to oppression. She added a seventh form of capital,
transgressive capital. Transgressive capital is the ability to actively buck the system, not simply
resist it. Pennell (2016) noted expressive behavior in transgressive capital. This expressive
behavior can be simple political protest or online trolling. Transgressive capital refers to attitudes
and active behaviors that queer communities use to disrupt the binary and proactively generate
new actualities. Not only found in queer white communities, Pennell (2016) noted transgressive
capital in queer, undocumented, and migrant communities, too. Without the protection and
privilege experienced by white queer communities, undocumented queer, especially transgender,
are faced with a host of unknowns and oppression. The queer community, which includes
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transgender folx, is not a monolith. It is a community that is comprised of an intersection of ever-
changing identities (Loutzenheiser, 2007). By synthesizing these various aspects of their
identities, strength can be found (Pennell, 2016). Resilience is marked by community and
cultural engagement as a means of survival (Cover, 2016).
In a study of transgender young adults, Wagaman, et al. (2019) found that the study of
resilience in the transgender community is in its infancy. Bockting et al., (2016), reviewing
development and quality of life of transgender adults reported that there needs to be research
nurturing resilience. In discussing gender-based oppression and the ensuing psychosocial
challenges difficulties facing many transgender adults, Burdge (2007) found that “there is much
to learn from the transgender community about courage, resilience, authenticity, and social
justice” (p. 249). Young adults felt a sense that they had the capacity to manage anything put in
their path, reporting a firm belief in their own strength. Data suggest that transgender young
adults are authorities in their own experience and adept at knowing what they need (Wagaman, et
al., 2019). Involvement and connection to the transgender community, is a measure of resilience.
This connection is a stabilizing factor and serves as a buffer preventing destabilization
Addressing healthcare refusal amongst transgender adults, White Hughto et al. (2016)
found that younger transgender adults experienced less care refusal that older transgender adults.
This could be due primarily to the fact that older adults have had more opportunities to be
refused care. This study also found that transgender adults of color experience refusal of care at a
higher rate than their White counterparts. These intersectionalities correlated with refusal of care
are similar to those characteristics affecting resilience.
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Queer Theory
The most fitting theory to explore this problem of practice is queer theory. Though
difficult to define, queer theory (QT) can be summarized as both an academic theory and
political action directive (Butler, 2015; Jones, 2021). According to Tierney (1997), QT
challenges the institutionalized norms that promote cisgenderism and heterosexism found in all
areas of academia and organizations. Primarily related to sexuality and gender identity, QT
addresses oppressive binary norms that create socially isolating power dynamics between groups
(Butler, 2015). By definition, there is no methodology attached to QT as that would create
another systematic binary norm (Ward, 2018). The challenge becomes how researchers address
these institutionalized social norms. Butler (2015) summarized that gender is essentially fluid
and varies per person and context. In addition, QT challenges binary constructs such as
heterosexual versus homosexual, gender being female or male, class status of rich or poor, and
the dualism of racial categories such as White versus non-White. As a result, there is a
denunciation of paradigm forcing individuals or systems into mainstream categories for it risks
resultant power dynamics.
Key Principles
To better conceptualize basic tenets of QT, the following sections present key principles
factoring into this problem of practice.
Confrontation of Binary Systems
Butler (2015) postulated extensively about gender binary essentialism. Butler stated that
cultural interpretation oversimplifies the essential gender binary. Given this gender binary,
individuals must fit in. Adherents to this binary react to those who do not fit the norm and punish
them socially (Butler, 2015). These punishments occur in the form of stigmatizing and
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marginalizing the offenders. In response, society creates gender trouble to unsettle these binary
ideals (Butler, 2015). Without disruption, strict binary systems resulted in power imbalances and
dynamics.
Power Imbalances and Dynamics
Resultant power imbalances and dynamics do not occur by chance. Butler (2015) stated
that power dynamics are established to ensure the sustainment of the gender binary system. The
power imbalance can also be seen in its consequences. Sullivan (2003) found that individuals do
not necessarily experience mental health problems because they are transgender but rather
because of the oppressive system in which they live. Binaries create hierarchies that imply
imbalance. Frank and Cannon (2010) summarized that these binary categories develop in relation
to the status quo and keep marginalized people in subordinate positions. Confronting the power
dynamics resulting from strict binary systems is well documented. The sections below discuss
the effects they have on transgender lives.
Centering Lived Experiences
Queer theorists suggest queering methodologies. Bringing real people’s lived experiences
to the forefront highlights transgender insights (Pascoe, 2018). These insights can be disruptive
to the status quo. By centering transgender voices, research can destabilize the norm of binary
categories (Pascoe, 2018). Discrimination against transgender individuals must be transparent so
that this community becomes more visible (Cruz, 2014). Queer theory applies to the
conceptualization of transgender discrimination in health care services.
Application to Problem of Practice
Understanding the tenets of QT requires a review of the connection to the literature and
problem of practice.
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Evidence of Binary Essentialism in Health Care
Institutional cisnormativity is at the heart of binary essentialism in health care
organizations. According to Pitcher (2017), cisnormativity is a gender essentialist belief that
involves a set of social expectations based on the assumption that people are and will remain
cisgender. Supported by transphobia and erasure, cisnormativity reinforces the concept that all
people are cisgender (Bauer et al., 2009). This systematic belief system exists at individual and
institutional levels. Health care organizations, like all organizations, are so systematically
entrenched in cisnormativity that they have no clear policies to address transgender access to
care. According to The Human Rights Campaign (2022), of 906 facilities surveyed, only 14%
reported that they had LGBTQ+ clinics elevated publicly. Cisnormative systems do not prioritize
this need.
Binary essentialism can also appear in the microaggression of misgendering, which is
when one intentionally or unintentionally uses pronouns that do not correctly reflect the gender
with which a person identifies. Misgendering is also defined as assigning binary gender to non-
binary or non-conforming individuals (McLemore, 2015). As a response to binary essentialism in
health care settings, transgender individuals find ways to cope. In a study of 506 undergraduate
students, Goldberg et al. (2019) found that transgender students, primarily those who identified
as non-binary, opted not to entertain a discussion of gender with mental health professionals to
avoid being misgendered or questioned. Systematic binary essentialism in health care settings is
well documented, and how this institutionalized process results in power dynamics is important.
Power Imbalances in Health Care
As a result of institutionalized gender binary essentialism, power dynamics can be found
in health care settings. Current and differing state requirements require mental health
26

professionals to provide written proof of evaluation before an individual begins a medical or
surgical transition process (Hendricks & Testa, 2012). This requirement creates a gatekeeping
role for mental health clinicians in which they hold decision-making power over their patients
(Bradford et al., 2013). Knowledge is also power. Because health care providers are likely not
trained to treat TGNC individuals, they feel uncertainty when treating them (Poteat et al., 2013).
In turn, TGNC individuals sense that providers cannot provide appropriate care, creating an
imbalance inf the normal power differential of the doctor-patient relationship. Also, interpersonal
stigma in provider-patient interactions reinforces the return of authority to the provider, re-
establishing homeostasis.
The primary manner in which this power dynamic is seen is via mental health
professionals’ transphobic behaviors. In a national study with over 9,500 respondents, Grant et
al. (2011) found that over one-quarter of participants reported verbal harassment by a mental
health provider. In an online study of 152 transgender adults, respondents described being
specifically mocked or belittled by providers (Kosenko et al., 2013). In a systematic review of
the literature, Kcomt (2019) found that one in 50 transgender individuals reported experiencing a
physically abusive interaction with a health care provider. In research of 182 mental health clinic
participants, Speer and McPhillips (2013) found themes of psychiatrists as unfriendly, critical,
and aggressive.
Coming full circle, the resultant power dynamic of cisgenderism is concerning. Ansara
(2015) found that cisgenderism, the privilege experienced by cisgender individuals, is the result
of a society that holds cisgender assumptions. Cisgenderism is described as pathologizing trans
identities, misgendering TGNC people, marginalizing, coercive queering (i.e., imposing an
LGBT label on TGNC individuals who identify as heterosexual), and objectifying biological
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language. Institutional erasure and systematic cisgenderism hinder a TGNC individual’s access
to needed care. In a large-scale survey, James et al. (2016) found that 33% of transgender
respondents experienced denial of care. This power dynamic requires dismantling.
Focus on Transgender Voices
Queering methodology is one way to dismantle. Ending the practice of discrimination
against transgender individuals requires a significant paradigm shift in health care providers’
attitudes and overall service delivery to these patients (Kcomt, 2019). Research can begin this
shift by focusing on transgender individuals’ lived experiences. Research can destabilize the
norm of binary categories by centering transgender voices (Pascoe, 2018). Research can no
longer determine the narrative. Lombardi (2018) stated that cisgender researchers have retained
the power to define transgender individuals and whether they are visible. Switching to
transgender voices directing the narrative will disrupt this definition. With QT outlined, the next
section describes how it shaped the conceptualization of this study’s problem of practice.
Conceptual Framework
This conceptual framework presents the application of QT to the problem of practice.
Three key concepts are discussed in detail: adherence to a binary definition of gender and
cisnormativity in health care, created power imbalances in these healthcare contexts, and the
centering of transgender voices to tell the story of the impact of the COVID-19 pandemic.
Adherence to a Binary Definition of Gender in Psychiatric Hospitals
The adherence to a binary definition of gender discussed in QT helps explain the
systematic gender essentialism and cisnormativity seen in health care settings.

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Cisnormativity in Elective Versus Non-Elective Treatment
Cisnormative processes in health care are strong. The process used to determine what is
medically necessary and what is elective, utilizing the identification of body parts and not gender
identity, is contradictory to what is known about gender dysphoria and established protocols for
transgender health (Dubov & Fraenkel, 2018). There is no current definition of medical necessity
(Abbott & Stevens, 2013). According to The Human Rights Campaign (2022), only 14% of 906
facilities surveyed had clinics dedicated specifically to LGBTQ+ equitable care. Focusing on
gender identity is key in determining appropriate services. The Human Rights Campaign further
found that 46% of facilities did not have policies that outlined a protocol to ensure equitable and
positive interactions with transgender patients. Another study found that transgender patients feel
shunned by intake forms that do not reflect their gender identities (Mollon, 2012). Due to binary
gender essentialism in most health care facilities, transgender patients must choose a binary
gender identity to place themselves in the system (Walton & Baker, 2019). Given the binary
cisnormative system in which health care facilities operate, without a clear protocol for
determining which services are medically necessary and which are not, the decision is up to the
cisnormative system that created the problem.
Need for Closure
Founded on gender binary essentialism, American culture gives rise to individuals who
desire gender to be logical and sensible. The need for closure, a construct defined as a desire for
absolute and conclusive information (Kruglanski & Webster, 1996), describes those who find
ambiguity aversive and have an urgency for topics to make sense in an effort to retain order. In a
study that analyzed data from 250 undergraduate students, Tebbe and Moradi (2012) found
unique links between a need for closure and traditional gender role attitudes with anti-
29

transgender prejudice. In concurrence, in a large study on transphobic attitudes in Europe,
Makwana et al. (2018) summarized that among individuals with a high need for closure, their
perception of gender ambiguity in others indicates future anti-transgender bias. This construct is
not limited to adults. In a survey of 194 adolescents, Costa and Davies (2012) found a positive
correlation between a need for closure regarding gender identity and transphobia. Though gender
is a construct, health care facilities’ institutionalized cisnormativity and staff with a potential
high need for closure regarding gender identity result in power dynamics with transgender
patients.
Created Power Imbalances in Health Care
Queer theory addresses power imbalances and connections to binary gender definitions
and cisnormative practices. How power imbalances play out in health care settings is a primary
foundation of the conceptual framework.
Denial of Care
In the current medical system in the United States, health care providers and insurance
companies hold the power to deny services. During the COVID-19 pandemic, this power
dynamic became more entrenched. Grant et al. (2011) found, in a study of over 9,500
participants, that 19% of transgender individuals had been denied health care services secondary
to their identity. Another study found that transgender adults were more likely to experience a
denial of health care than their cisgender peers (Kattari et al., 2020). This denial occurs as a
result of the patient’s gender identity (Lerner & Robles, 2017) but can also be the result of
gatekeeping.

30

Gatekeeping
The power dynamic of who determines treatment direction, usually resting with
providers, is called gatekeeping. Diagnoses in health care fall to professionals, but self-reports of
gender dysphoria do not (Ashley, 2019). Various factors lead providers and patients to an
impasse when it comes to who decides when treatment should begin and what is in a patient’s
best interest (Gerritse et al., 2021). Another study found that transgender participants felt a lack
of respect and invalidation when it came to the acknowledgement of their ability to make their
own decisions (Brown et al., 2020). In addition, transgender respondents reported that requiring
referral letters from therapists to access gender-affirming treatment added to the obstacles to
needed care (Austin & Goodman, 2017). These gatekeeping experiences are troublesome for
transgender patients who desire forward progress.
Transgender Status Known by Providers
When the COVID-19 pandemic limited access to services and isolation made seeking
assistance even more difficult, the power imbalance of disclosing one’s gender identity may have
been difficult to overcome. Grant et al. (2011) reported that transgender individuals had been
denied health care services secondary to their identity. The simple exposure of that identity has
ramifications. Grant et al. (2011) found that doctors’ knowledge of a patient’s transgender status
increased the likelihood of discrimination and abuse by eight percent. Having the choice of
disclosure is important. Grant et al. (2010) found that 23% of TGNC individuals were denied
services altogether when they were out or mostly out to their medical providers. The question
might follow about what might happen due to the added stress of the pandemic and more
restrictive access to care when managing this power dynamic.
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Transgender Voices Tell a Story and Are the Source That Should Be Considered
Given this conceptual framework, who will be telling the story is not in question. The
lived experiences belong to the transgender community.
The methodologies driving studies that seek to answer questions about transgender
individuals are not appropriately aligned. The power of storytelling lies with the cisgender
researcher. According to Lombardi (2018), cisgender researchers currently have the power to
define transgender lives and are the gatekeepers of visibility. The methodological question is
whether cisgender-centered views of transgender populations can be accurate. This domination
by cisgender voices restricts what is known about these populations’ experiences (Lombardi,
2018). Thus, a paradigm shift is in order. Lombardi (2018) found that the lived experiences of
transgender communities need to be told by those communities. Coming full circle is the
changed attitude and knowledge resulting from seminal research. In a recent interview, Judith
Butler, one of the original authors of QT, stated that by listening to transgender voices over the
years, they have had to rethink their position on gender identity as performative (Jones, 2021).
They reinforced that they gained new knowledge by listening where they had not listened before.
A conceptual framework emerges from synthesizing the literature. When health care
providers and the staff who work in conjunction adhere to a binary essentialist definition of
gender, power dynamics emerge in treating transgender patients. Adding to the power
differential are the additional stressors of the COVID-19 pandemic. Deeming transgender needs
to be non-essential, gatekeeping the decision-making process, and denying health care further
marginalizes this community. The resultant vulnerability of these individuals becomes even more
apparent. Only by listening to their voices will their lived experiences be told. Figure 1 gives a
32

visual representation of the synthesized interplay of these factors. The current research employs
this framework.

Figure 1
Conceptual Framework

32
34

Conclusion
This literature review discussed this country’s institutionalized belief in a binary
definition of gender and gender identity. This chapter laid out the ramifications of that belief
system. From employment and housing discrimination to the murder of transgender women of
color, the transgender community is at risk due to the high need for closure many possess. Health
care needs endure, but the literature showed that anti-transgender bias and discrimination
occurred. The COVID-19 pandemic added to an already bleak picture. During this crisis, this
community’s needs continue within this cisnormative system. Two years into the pandemic, how
this power dynamic changed and its impact remain to be seen. This literature review supports the
need to look to transgender voices to answer this important question.

35

Chapter Three: Methodology
This qualitative research examined the lived experiences, via their voices, of transgender
individuals who had been transitioning since the COVID-19 pandemic began. The study
provided insight into the cisnormative practices in healthcare, the resultant power dynamics, and
the mental health effects of transitioning during the COVID-19 pandemic. This chapter restates
the research questions, describes participants, outlines the methodology used for data collection
and analysis, reviews ethical considerations, and discusses the study’s limitations and
delimitations.
Research Questions
The research questions are
1. How do transgender adults experience cisnormative practices in COVID protocols?
2. How do transgender adults experience the power dynamics created by cisnormative
COVID practices?
3. What are the mental health effects of transitioning during the COVID-19 pandemic as
voiced by transgender adults?
Overview of Design
This study utilized a qualitative design consisting of semi-structured interviews. Saldaña
(2011) stated that sampling in research is used to gather participants from a wide or narrow
perspective, depending on the study’s need. Sampling is the most appropriate approach (Saldaña,
2011). Purposeful sampling gives this study the focus to address the research questions and gain
needed insight (Merriam & Tisdell, 2016). Convenience and snowball sampling provided a pool
of participants who met the interview criteria (Creswell & Creswell, 2018; Merriam & Tisdell,
36

2016). These methods resulted in rich data centered on transgender individuals’ voices. Table 1
introduces the research questions and data sources for this study.

Table 1
Data Sources
Research questions Interviews Secondary data
How do transgender adults experience
cisnormative practices in COVID
protocols?
X X
How do transgender adults experience
the power dynamics created by
cisnormative COVID practices?
X X
What are the mental health effects of
transitioning during the COVID-19
pandemic as voiced by transgender
adults?
X X

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Research Setting: Zoom Interviews
Given the COVID-19 pandemic and the unpredictability of virus mutations and surges,
this study used the Zoom platform to conduct all interviews. In addition, because the questions
used in the interview addressed sensitive topics, I utilized headphones to increase confidentiality
and help increase the participants’ comfort. Participants chose their location for interviews. All
interviewees were selected for participation via their response to a request for participants. Each
was a transgender adult who reported transitioning during the COVID-19 pandemic. Participants
who met these criteria were deemed most fit to address the research questions.
Researcher Positionality
Positionality is described as the social context that forms the researcher’s identity and
how it relates to the study (Merriam & Tisdell, 2016). Awareness of how this positionality
influences study design, data collection, and data analysis can mitigate potential biases. I am an
active member of the LGBTQ community. I have close ties with the LGBTQ community in
Southern California. Because the community is close-knit, it is possible that the participants and
I were acquainted with people in similar circles. Since all interviews were completed using the
Zoom platform, there were no setting issues with which to be concerned. In addition, I am a
licensed therapist and well established in the local community.
Having worked in health care and as a member of the LGBTQ community, I have
witnessed a multitude of incidences of bias and discrimination against transgender individuals.
With this background, assumptions and biases regarding potential discrimination in health care
are apparent. I was aware of this expectation and requested peer review when constructing
interview questions, remaining cognizant of leading participants to expected responses. Along
those same lines, I was aware that this personal experience might also have brought an intimate
38

understanding of participants, with the ability to create a safe space for disclosure. Bias in data
analysis was mitigated by triangulating secondary data and utilizing peer review (Merriam &
Tisdell, 2016).
Data Sources
The data for this study were collected through interviews with participants, centering
their voices to describe their experiences. A secondary source of data consisted of internet blogs
and opinion editorials describing the impact of the pandemic on transgender individuals’
experiences while transitioning.
Interviews
In alignment with QT’s centering of transgender voices, interviews provided the data.
Patton (2015) stated that qualitative research uses participants’ own words to describe their lived
experiences via interviews. This study utilized a semi-structured interview protocol that followed
a list of questions that allowed for interviewer flexibility with follow-up questions, also known
as probing (Merriam & Tisdell, 2016).
Secondary Data
Personal documents such as internet blogs and opinion editorials provided context.
Bogdan and Biklen (2016) stated that personal documents are first-person narratives centered on
individuals’ lived experiences. Given that observation was not possible for this study, these
secondary data provided additional insight into transgender individuals’ experiences.
Participants/Participating Stakeholders
This study utilized purposeful sampling to locate participants. Purposeful sampling is
used when a specific sample is needed to gain insight regarding a specific issue (Creswell &
Creswell, 2018; Merriam & Tisdell, 2016). For this study, transgender adults who have been
39

transitioning during the COVID-19 pandemic could address the research questions with their
lived experiences. I utilized convenience sampling first. Merriam and Tisdell (2016) described
convenience sampling as sampling whoever meets the research criteria and is available.
Snowball sampling, when interviewees refer others for participation (Merriam & Tisdell, 2016),
was utilized to recruit the remaining participants. Saldaña (2011) suggested obtaining a diverse
group of participants within this strict criterion to gain differing perspectives.
Recruitment Procedures
I recruited participants with the assistance of local LGBTQ support centers and social
media outreach. The announcement of the study and the need for participants was brought to
transgender support groups by group facilitators, who requested voluntary participation of those
who meet the criteria. Strict confidentiality practices protected the volunteers. The LGBTQ
centers had my contact information listed on the announcement, and interested parties contacted
me directly. In addition, there was concerted outreach to local transgender organizations and an
announcement on social media, such as Facebook, Instagram, and Twitter, to locate potential
participants. All participants were compensated with $15 gift cards. Only I had access to the list
of participants.
Participant Specifics
All participants were transgender adults who self-identified as transitioning during the
pandemic. Participants responded to a request for participation via the recruitment efforts
described earlier. I interviewed eight participants, and the data reached a point of saturation. This
study did not examine ethnicity or race. A balance of gender identities (transgender female,
transgender male, non-binary) via purposeful sampling was obtained.
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Instrumentation
Interview Protocol
The interview protocol consisted of 20 semi-structured, open-ended questions addressing
the participants’ personal experiences. Although direct observation of interactions between them
and their families or healthcare providers would allow for a firsthand experience of attitudes and
behavior (Creswell & Creswell, 2018) and would have been preferable, this was not possible.
Interviews allowed participants to provide information from their perspectives when firsthand
observation was not possible (Creswell & Creswell, 2018).
Rationale for Interview Questions
Interview questions’ design was based on the need to bring participants’ lived
experiences into the center of needed insight (Pascoe, 2018). The questions were designed to
elucidate these lived experiences, allowing the narrative storytelling of each participant’s history,
removing the bias of the cisgender researcher. The study destabilizes the norm by remaining
focused on the center of these voices (Pascoe, 2018). Interview questions were piloted through
two mock interviews, after which I made appropriate clarifications, changes, and additions. In
addition, interview questions overlapped in the addressing of the research questions. Twelve
interview questions addressed the first research question, seven addressed the second research
question, and 13 addressed the third research question.
Connection to Research Questions
Johnson (2019) discussed the importance and vitality of queer oral history. Following his
suggestion, the research questions focused on obtaining and understanding the historical
transgender experience in dealing with healthcare providers and families. There was an added
variable of potential reaction to the COVID-19 pandemic. Semi-structured interviews were the
41

means to reach these goals. The questions in the interview protocol sought to engage participants
in freely discussing their experiences, keeping the focus on their perceptions. Binary structures
and power imbalances were uncovered by directly discussing what has often been systematic
cisgender bias and cisnormative practices. Appendix A presents the interview protocol.
Data Collection Procedures
Interviews
Data for this study were collected via face-to-face Zoom interviews. Interviews were an
appropriate choice for data collection because direct observation could not be completed. In
addition, interviews allowed participants to provide historical information (Creswell & Creswell,
2018). Participants’ responses determined the length of the interviews, and each lasted
approximately 50 to 60 minutes. The Zoom recording feature was the most time-efficient
approach for documenting responses. The platform also has a transcription feature. All
interviews were conducted in a private space, and I utilized headphones to provide an increased
sense of privacy for each participant. Participants chose their location and privacy for interviews.
Participants were all English-speaking.
Secondary Data
The study gathered secondary data such as internet blogs and opinion editorials written
by transgender individuals or gender-affirming providers addressing their experiences with
health care. This collection took place prior to the interviews to support interview question
construction. This information was also utilized to support interview findings. This type of
secondary data was appropriate as it can be accessed at any time and in an unobtrusive manner
(Creswell & Creswell, 2018). A thorough internet search will utilize blogs, opinion editorials, or
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written articles addressing transgender adults’ treatment and experiences in health care. Narrative
trends were documented.
Interview Data Analysis
Creswell and Creswell (2018) stated that qualitative data analysis should be a process of
steps, moving from general to specific, and employing several levels of analysis. Data analysis
utilized a five-step process described by Creswell and Creswell (2018).
Step 1
Once collected, interview data were organized and prepared for analysis. Data were
transcribed and verified for accuracy, with no identifying information included.
Step 2
I reviewed all transcripts, becoming increasingly familiar with the content. I reflected on
the content and what the participants expressed as their lived experiences. At this stage, it was
important to understand what they were saying and note potential commonalities.
Step 3
Data coding began by dividing responses into general a priori categories and assigning a
descriptive word to each. These labels can be words used by participants in their responses. The
a priori coding sheet can be found in Appendix B. The conceptual framework, research
questions, and interview protocol items were aligned to support the identification of a priori
coding. The theoretical framework alignment matrix can be found in see Appendix C.

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Step 4
Generating a description and themes involves describing participants in detail along lines
that make sense to the study. Within these newly developed categories, I generated themes based
on responses for each category.
Step 5
The final step in the data analysis process was to represent the descriptions and themes
generated. I did this by presenting a narrative account of the data analysis. This narrative
included an extensive discussion of themes and how they related to each other.
Secondary Data
The analysis of secondary data followed a process similar to that used with interview
data. I identified narrative trends. Availability of secondary was limited, and all data located
were utilized. Triangulation of data from both sources was the final step.
Credibility and Trustworthiness
According to Merriam and Tisdell (2016), the credibility of qualitative research depends
on the researcher’s trustworthiness and ability to remain ethical while conducting a study.
Credibility and trustworthiness refer to a researcher’s ability to present believable and plausible
findings (Lincoln & Guba, 1985). There are various ways to ensure findings’ credibility and
trustworthiness in qualitative research (Merriam & Tisdell, 2016).
The following are various strategies to increase the study’s credibility and
trustworthiness.
Positionality/Reflexivity
I spent significant time identifying biases and positionality. I noted these biases and
addressed their effects on study and protocol design. I explored positionality during data analysis
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regarding the shaping of interpretation of data gathered. In addition, I used ongoing engagement
in reflexivity by writing reflective memos throughout the data collection and analysis phase
(Merriam & Tisdell, 2016). These efforts helped prevent the effects of researcher bias from
occurring.
Member Checking
Member checking was central to this research. The purpose of the study was to reveal the
participants’ lived experiences. Ensuring participants’ words and meaning were accurately
detailed guaranteed that the stories remained centered and authentic (Merriam & Tisdell, 2016).
It was imperative to contact participants after interviews to clarify answers to questions and to
allow them to review transcripts, tentative findings, and summaries.
Peer Review
I am a cisgender female. I sought the input of a transgender doctoral community member
to review the research process. His input on study and protocol design ensured that all angles
were covered. His review of the data analysis kept the study on track, ensuring that
interpretations aligned with the theoretical framework. After data collection, I included this peer
and others in the review of data analysis (Merriam & Tisdell, 2016).
Rich and Descriptive Data
According to Merriam and Tisdell (2016), rich and descriptive details about the
participants, interview setting, and findings increase transferability. The use of rich and
descriptive details aligns with QT and its focus on centering the voices of transgender
individuals.

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Point of Saturation
I conducted interviews until data began to repeat. This repetition meant that I completed
only eight interviews. By interviewing until a point of saturation or redundancy, it is understood
that no new information or insight was expected (Merriam & Tisdell, 2016).
Triangulation
Data triangulation occurs when data are gathered from multiple sources (Creswell &
Creswell, 2018). Credibility increases by gathering data from more than one source, such as
interviews and personal documents.
Ethics
Rubin and Rubin (2012) discussed the treatment of participants in three general
principles. The first is to show respect for participants. Participants are volunteers and are not
obligated to participate in any study. It is imperative to be mindful of the time they are giving
and to show respect for their first-person experience of the questions asked. Second, there was no
pressure to participate. Participation in this study was completely voluntary. I reminded
participants that their involvement was voluntary, and they could stop the interview, without
reason, at any time. Finally, I did my best to prevent and mitigate harm to participants. The
interview questions covered sensitive topics, and there was potential for emotional reactivity
triggered by uncomfortable memories. I remained mindful of this, making sure to offer closure to
participants at the end of the interview. Resources for support were offered when necessary.
There were general ethics musts in this study. No participants were contacted, and no
data were collected prior to institutional review board approval. Participants’ identities and
responses remained confidential. I destroyed the interview transcripts after data analysis. As
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stated previously, participation remained voluntary throughout the entirety of conducting
interviews. I reminded the participants that they could stop the interview at any time.
This study did not require informed consent. I used an information sheet for exempt
studies to explain the confidentiality of participation, ensuring that participation was voluntary,
and that data would remain confidential. The information sheet also addressed the timing of the
deletion of data. The information sheet for exempt studies is included in Appendix D.

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Chapter Four: Findings
The purpose of this study was to elicit the lived experiences of transgender adults as they
have transitioned during the COVID-19 pandemic. This research utilized the narrative lived
experiences of participants who either began or continued their transition process during the
pandemic. Given the cisnormative structure of healthcare provision that generally does not
benefit transgender patients, the participants’ stories of described power dynamics in these
settings associated with bias and discrimination. This study addressed what has occurred in the 2
years of this pandemic in the participants’ lives, lifting their voices. By queering this research,
TGNC voices remained at the center to destabilize and challenge societal binaries. The research
questions addressed are
1. How do transgender adults experience cisnormative practices in COVID protocols?
2. How do transgender adults experience the power dynamic created by cisnormative
practices?
3. What are the mental health effects of transitioning during the COVID-19 pandemic as
voiced by transgender adults?
Participants
In alignment with QT, this study sought interview participants for data collection. All
participants were transgender adults who identified as actively transitioning during the COVID-
19 pandemic. They responded to a request for participation via outreach at local LGBTQ center
and social media postings. I interviewed eight participants. Having reached a point of saturation
and triangulating data with secondary resources, I did not seek additional participants. Sampling
resulted in a participant age range of 19 to 25 years. All participants were employed, with four
remaining in college. All lived independently at the time of interview. I interviewed a balance of
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various transgender identities. This study did not define transgender identities, rather, identities
are listed verbatim as reported by participants. Though an important variable, this study did not
examine ethnicity or race. Table 2 presents the participants’ demographics.

Table 2
Participant Demographics
Pseudonym Age Gender identity Self-reported
race/ethnicity
Amy 24 Non-binary, woman White
Ava 22 Female Caucasian
Beacon 19 Genderqueer Hispanic
Finch 25 Male, mostly White
Grey 19 Transgender girl White
John 19 Transgender male White
Mike 21 Male, transgender White
Tiresias 24 Genderfluid, non-binary feminine White

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Data Collection
Interviews
Data for this study were collected via face-to-face Zoom interviews. As previously stated,
all interviews were conducted in a private space, and I used headphones to provide an increased
sense of privacy for each participant. Participants chose their location and privacy for interviews.
Their responses determined the length of interviews, with the average length being 45 minutes.
The Zoom recording feature was the most time-efficient approach for documenting responses. I
utilized the embedded transcription tool on the platform. All participants were English-speaking.
Secondary Data
Before conducting interviews, I gathered secondary data from internet blogs and opinion
editorials written by transgender individuals addressing their experiences during the COVID-19
pandemic. This information was utilized to support interview findings. A thorough internet
search utilized blogs, opinion editorials, and articles addressing the authors’ treatment and
experiences during the pandemic. I documented narrative trends.
Data Analysis
After transcribing the interviews, I completed a coding process to analyze the data.
Moving from general to specific, I reviewed all interview transcripts, becoming increasingly
familiar with the content. Utilizing QT as a framework, I reflected on the content and what the
participants expressed as their lived experiences. I coded responses utilizing a priori categories
based on the QT framework.
The analysis generated categories describing what participants shared regarding the
impact of the pandemic on their transition process. Within these newly developed categories,
themes emerged. The following is a narrative account of the data analysis. The sections include
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an extensive discussion of themes and how they relate to each other. Being a cisgender
researcher, careful attention was paid to every step of the data analysis process.
Findings
Research Question 1: How Do Transgender Adults Experience Cisnormative Practices in
COVID Protocols?
Acceptance of the Binary: What Is Elective?
Themes emerged exhibiting that the participants felt treatment could not automatically be
deemed either, and doing so was concerning. Surgery may be lifesaving for one but not for
another. They noted a delay in services as a result. Mike reported,
Once, my doctor even said we’ll catch up later because our office is very busy with
COVID-related things right now. I think there was a period of time where, towards the
beginning where non-essential surgeries were delayed, and now, I think, waitlisted.
The impact of waiting could be damaging. Beacon stated that if they could not receive
top surgery, “it would make me very frustrated and not want to leave the house. It would
probably make me want to hide even more.” If denied treatment, Mike shared, “it would have
compounded with everything else, especially considering how much time there was alone. It
probably would have made my dysphoria overall worse because I would have had more time to
dwell on things because of the lockdown.” Mike reinforced that “it would feel super invalidating
and that you’re non-essential. But in what way?” Amy agreed in her response: “I’d feel like shit.
I would feel very upset about that. Not angry. It would depress me.” Ava reinforced, “I don’t
even want to think about where my mental health would have gone if I hadn’t had that option.”
John’s primary concern was with treatment that had already begun and could be stopped:
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It would feel like my body would be shutting down, and it would be huge withdrawals,
and symptoms would happen. My body would literally be in pain. It would damage your
body. I would be super, super, super, super sad. Like super down. Sad because I’m not
getting the things I need. It would do a lot to my mental health. So, for it just to be taken
away, it would just, everything would feel like it was falling apart.
Participants felt their needs were essential and not elective. Mike offered an alternative to the
current system:
In that type of scenario, the patient has the ability to analyze how much they need at the
time, and there are some people that if they don’t get it that week, it’s like, dude, you
don’t want to subject them to that. And then there might be some who are like, “I can
wait ‘til things cool down a little as long as you had me at the top of the list for next
appointment.”
Overall, participants felt the healthcare system must understand the need to center transgender
voices to make more effective decisions about treatment necessity. The impact of not centering
voices to determine need resulted in a negative emotional impact for most, even if the impact
was anticipatory.
Participants stated that transgender adults do not give in easily, and transitioning will still
occur even when cisnormative practices try to prevent it. Participants stated that they would be
unaccepting of being told “no transition can take place” if services were deemed elective or non-
essential. The theme emerged that participants felt that a bucking of the cisnormative system was
important. They did not tolerate the power dynamic on various levels. In response to questions
about being denied treatment or the gatekeeping process, Amy said, “Reaction would be not to
confront it, and then do it anyway on my own time. I would want to do whatever I was going to
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do anyway and not listen to them.” Tiresias responded similarly: “I would see what’s going on in
Oregon. I would actively seek it out. It’s not an option.” After more thought, Tiresias stated, “I
don’t think I would stop. I would sort of walk right out and find a new provider. I would very
vehemently. I’m gonna get it one way or another.”
Healthcare System Needs to Manage Transgender Introspection
Themes addressing the healthcare system’s inability to manage transgender individuals’
introspection emerged. Participants noted an overall inability of the system to listen to
transgender adults or even feel seen. This was exhibited in various ways.
Participants overall had a very defined sense of self. Given this insight, providers and
loved ones still questioned their identities and convictions. Finch noted that doctors’ gatekeeping
“makes it sound like I’m delusional. They are really just being even more offensive and ignorant
than usual.” He also noted that even after knowing his need and being prescribed hormones,
“How hard it is to find pharmacy techs that won’t keep you from getting hormones if they think
you’re trans.” John reported the experience that even after providing his correct name and
pronouns to providers, “Staff only refer to someone with birth name and pronouns instead of
preferred name and pronouns, assuming everyone wants to use their name and pronouns given to
them at birth.” Tiresias reported an inability to explain what they have learned because of
introspection: “I feel like my mind makes sense to me in ways that it didn’t before I came out. It
feels like the hormones have just given my brain a little kiss, if I’m going to be honest.” Doctors
and providers do not understand this. Mike felt ignoring that he knew himself well and the
requirement to be involved with a doctor very negative: “I feel like the continuous contact with
doctors is an extra disruption to my life that contributes to more feelings of ‘I wish I weren’t
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trans.’” Finch summed up the emotions: “In this country, we just don’t believe people just about
anything.”
Overall, there is a strong sense that providers and the health care system do not truly
understand, resulting in needs not being met. Themes emerged exhibiting how cisnormative
ways of thinking and living made it hard for the system to conceptualize transgender people’s
basic needs, even when explained. Participants felt this was intentional, requiring them to
become exceptionally verbal to have their needs met. Finch noted that some language “is often
used to disguise willful misgendering and erases our entire lived experience down to genital
shorthand.” They also reported that “healthcare workers ask unnecessary and invasive questions
about your body because they’re curious. John responded, “pronouns being mistaken doesn’t
start until someone comes out as transgender. With me, they always use he/him perfectly until I
tell someone I’m transgender, and then they randomly start messing up my pronouns. Happens a
lot with nurses.” John reinforced that sentiment: “Nurses and doctors using terms that make me
dysphoric. Even after I tell them to change their vocabulary. I wish they asked me what terms
make me comfortable.” Finch added,
The healthcare system blatantly has no idea how to handle trans people all the way up
through systemic bureaucracy. People will get the language right or think they do but do
not do the work to actually change the ways the system harms and erases us.
He also had concerns about how trans people responded to that system: “I can explain
things in a way that doesn’t make my provider feel stupid. This is important. Managing
healthcare workers’ feelings directly affects the standard of care you’ll receive.”
The participants took note of healthcare practices. Systems and providers determine what
is lifesaving without centering their input on what is needed. Participants reinforced that
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transitioning would continue regardless. They offered experiences of providers not listening and
often not seeing their introspection, which results in erasure. The second research question
addressed this power dynamic.
Research Question 2: How Do Transgender Adults Experience the Power Dynamics
Created by Cisnormative Practices?
No One Is Listening
Participants shared a general desire to have cisgender people understand them. There
was a sense that transgender identity is misunderstood and that being believed is primary. This
desire led to several individuals deciding to participate in this study. They responded with a
general and surrendered sense of providers and loved ones not listening to their convictions or
concerns. They felt providers were generally all-knowing, often dismissing concerns presented at
visits. Participants felt that this went as far as questioning gender identities. Finch stated, “There
are things that are true about the trans experience that are hard to explain.” Ava reported, “What
threw me off was the fact that my mom outright didn’t believe me at first.” John stated that
“providers seem to have a knee-jerk reaction to not believe a transgender person’s own sense of
identity.” Finch added that healthcare providers lack such basic understanding that “they
misgender me and make it sound like I’m delusional.” Finch continued in their concern:
I needed two letters from independent psychiatrists and one letter from my PCP to
confirm that, yes, I was actually trans and not just nuts. The first psychiatrist I saw, who
absolutely not have been able to tell if I was faking being trans, wrote a letter calling me
female, misgendering me, and it makes me sound delusional.
This gatekeeping is ongoing. Finch stated, “The gatekeeping around surgery is huge. Letters
were the most pointless side-quest.” Mike felt that “the medical system got a lot more, which is
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not optimal for someone at the beginning of transition.” Even when decisions are thoroughly
processed and solid, Amy noted that “doctors remain in power and inform that steps cannot be
pursued.” Finch reported the oddness of being told, “I can’t diagnose you if you don’t want to be
on hormones immediately. If you don’t want surgery immediately. And this is weird.” Tiresias
noted, “I can’t get surgery as I have to be a year on hormones anyway.” Participants reported that
their medical providers appeared to intentionally not listen to them, making medical decisions
contrary to what they desired. Finch stressed that this lack of understanding or trust in their
decision making is significant and concerning because “they could easily hurt or kill me with
their lack of knowledge, so I don’t trust them in the first place.”
Participants appeared resigned to the long-standing cisnormative power, control, and not
being listened to. When asked about being denied treatment, there was a general acceptance of
this dynamic. Participants had come to expect that their desires would not be heard. When
decisions might be made for her, Grey responded, “That’d be fine. More time to finalize
whatever I want to get done.” Beacon reported, “What else can I do if I was supposed to get this
thing and it’s gone and taken away from me?” When asked the same questions, Mike stated, “I’d
also be kind of like helpless. There’s nothing I can do about that. I understand.” Even when
participants understood that decisions made for them were wrong, resignation to the power
remained. Finch responded, “And if they told me that I needed to wait, it would have been fine.”
Ava felt, “I guess I don’t think it would seriously impact me.”
Participants wanted to be heard and believed. The desire to be trusted regarding their
insights and decisions was strong. Nevertheless, like many other power dynamics that result
from entrenched binaries, learned helplessness and resignation occur. Still, the participants had
fight remaining. Resignation did not sit well, and a resurfacing of empowerment was seen.
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We Must Take Control
The participants felt that a bucking of the cisnormative system was important, aligning
with the finding reported earlier. Acceptance of the power dynamic was not tolerated, on various
levels, by participants. In response to questions about being denied treatment or gatekeeping,
Amy responded with a reaction to not confront anything but refuse to listen to the denial of
service. Similarly, Tiresias said that they would look elsewhere, out of state, for alternative
means of treatment. This willingness to do so was fueled by knowing that not seeking receiving
services was not an option. Tiresias added that the conviction to do this was strong and that they
would find services no matter which obstacle existed.
The power dynamics created by cisnormative practices had an impact on participants
since the pandemic began. The impact of these practices had been ongoing since well before the
COVID crisis. Participants stated that no one was listening and that decisions were being made
for them, even when they knew more about what they needed. There was also a sense of
resignation to all of it. Still, they reported a fight and a will to fight the system, even actively
working against it to have their needs met.
Research Question 3: What Are the Mental Health Effects of Transitioning During the
COVID-19 Pandemic As Voiced by Transgender Adults?
Increased Introspection
The COVID-19 pandemic, lockdown, and restrictions created increased isolation for
transgender individuals. Isolation resulting from lockdown and shelter-in-place orders created
increased introspection and reflection. Isolation allowed for a pause and for the opportunity to
live in a vacuum without the pressures of cisgender bias and cisnormative expectations. This was
an unexpected but welcome event. An unexpected consequence was that participants reported
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that the lockdown and restrictions resulted in introspection and reflection, an enhanced mirror
into self. Participants reported stories of disconnect from loved ones and friends. Amy stated, “I
definitely feel more introspective.” In agreement, Ava reported that the lockdown isolation
allowed “to really be myself. That time to just kind of like almost to soak in it, you know, figure
it out. Figure out what I need to do.” For some participants, introspection brought new
awareness. Amy reported that after lockdown isolation with their girlfriend began,
It wasn’t until I got to really talk with B and show her what I was thinking and who I am,
and even let her into my inner thought processes of gender and being unsure of who I am
and feeling like I can’t belong to like queer spaces because I’m not trans enough or
something like that.
Amy further clarified that “interacting with myself and being alright with whatever I feel
comfortable with, and that didn’t come into fruition until the pandemic started.” Beacon
concurred, adding, “I think if it didn’t happen, I wouldn’t have been forced to think about myself
as much. Because I like said it was something I was starting to think about, but I was always able
to push it aside.” Beacon continued, “Now I was so isolated. I had to focus on myself. I had to do
something.” Some participants noted an escape from society’s cisgender bias and cisnormative
expectations. Amy reported that the isolation “kind of let me incubate and kind of meditate on a
lot of who I am without the learned social interactions that I’ve had.” Ava reported, “I did
appreciate that it gave me the personal space to kind of figure out on my own.” She added that
the combination of isolation and forced self-reflection resulted in good feelings:
I think there’s something really awesome about the idea of transitioning in terms of not
only understanding yourself but kind of understanding the systems that are at play and
kind of understanding how you think about the world.
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This did not occur for two participants who were initially isolated with toxic family members, as
the influence of transphobia and cisnormative expectations continued, limiting the space for
introspection.
Loss of Oxygen AKA Disconnect From the Queer Community and Spaces
The COVID-19 lockdown and restrictions created isolative situations for all participants.
Aside from the disconnect from loved ones and difficulty obtaining medical care, isolation meant
being cut off from queer spaces and queer communities. The participants stated that the
connection to these spaces is like oxygen. Mike reported, “It is a pretty common experience that
I go somewhere where I will be properly named and gendered.” Grey added, “They call me by
my name. They refer to me as a girl. They do all that stuff; they haven’t missed a beat on it.”
Amy stressed, “I like the feeling that I can be a part of queer spaces without the feeling like I’m
forcing anything.” Amy reinforced that “it’s very affirming.” Finch reinforced that the isolation
“had an effect on my ability to access the queer community.” Finch specified the difference
between friends and queer spaces: “I have friends, but that’s not quite the same as being part of a
social group of queer people or going to a place to specifically like find your people.” They also
added that the pandemic restrictions limited movement that would lead to access: “I haven’t been
to really any places where queer and trans people gather intentionally.” More importantly, Finch
emphasized, “It’s so hard to explain how vital queer community is to like your psyche and your
experiences. It’s really challenging to only be around people who are not like you at all.”
For some, being cut off from queer spaces directly affected their mental health. John
shared that when he had access to queer connection, “I didn’t feel miserable.” John felt he had
experienced the connection and then when COVID struck, “I kind of disappeared. Before the
lockdown, I had a place. When I say place, I mean an environment. I had that environment. It
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was wonderful. It was great.” John emphasized that queer space is where “I’m always feeling
safe and loved and valid.” Mike agreed that when in queer spaces, “Finally, I can get some of
that external validation.” When thinking of the consequences of isolation, Finch summarized,
“Even if I hadn’t been physically isolated and not around other people, being removed from
access to queer community is kind of isolation in itself.” He understood that reconnection was a
must:
We had a queer pandemic of our own, and because of that, we have very few elders. But
we do have history. We have stories that need to be told and shared and kept alive.
Without access to that and that culture, it’s really hard to explain the gravity of that to
people who don’t understand. It would be cool to have a queer task force. You know,
local people who are willing to reach out and provide community for people who are
isolated. That would be wonderful. To have sort of a sponsor or sort of a big brother/big
sister transgender.
Ava shared a similar, but slightly different, view: “I can pull up an app on my phone, and
I go to just who I’m following. I’m basically just rolling through like a little transgender micro-
community with a bunch of support people who are all in the same boast as me and who are all
going through these things.” She also noted that places like Discord and Instagram group chat are
“social spaces where a lot of queer kids are figuring out who they are. It was their everything
during the pandemic.”
Participants unanimously reported that the pandemic severed their access to the queer
community and queer spaces, which was significant. All discussed the significance of the queer
community, as a group or with individuals, and that it is necessary for survival.
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Secondary Data Findings
To support the study’s findings, an internet search yielded websites, blogs, and opinion
articles providing comments addressing the study’s themes. This secondary data were offered by
both individuals and health care providers. Both sources centered transgender voices.
Information was COVID-19 pandemic related or historical, addressing transgender health care
needs in general. The secondary data are valid as they relate to the research questions and
emergent themes.
Acceptance of the Binary: What Is Elective?
Various writers co-signed the ambiguous function of elective versus non-elective
treatment. Becker (2021) reported that “in March 2020, the Federal government directed health
providers to postpone elective surgeries and non-essential medical procedures” (para. 3). A basic
question was put forth, “Who decides what counts as essential health care?” (Becker, 2021, para.
8). This was left undefined, and “these indefinite cancellations have been devastating” (Becker,
2021). Neira (n.d., as cited in Clarendon, 2020.) reported that “gender affirming surgery is
medically necessary care and part of the problem calling it elective is that it implies that it may
be unnecessary” (para. 17). Sakran (n.d., as cited in Becker, 2021) also noted that “the term
elective care is misleading” (para. 5). A sociologist commented on researching how the “binary
system of lifesaving versus elective can be used and abused” (Berndt, n.d., as cited in Becker,
2021, para. 7). Centering transgender voices, an individual in Coronado’s (n.d., as cited in
Daniari, 2020) work emphasized that “this surgery was not elective for me. It’s something that I
need to continue to get up in the morning and live a normal life” (para. 10). Becker (2021)
suggested that “the best alternative to the binary system was a tiered system framework which
groups different types of care based on varying degrees of urgency” (para. 27). Does the
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healthcare system have the ability to understand the level of transgender insight to accommodate
this tiered process?
Healthcare System Needs to Manage Transgender Introspection
Looking again at internet sources, one author expressed that “it always leaves me
deciding what kind of toll I want to experience today” (Onion, n.d., as cited in Daniari, 2020).
“People don’t realize the daily challenges trans folks have to endure. This surgery is not
cosmetic; it is about being comfortable enough to function” (Onion, n.d., as cited in Daniari,
2020). Ruddick (n.d., as cited in Gorvett, 2020) added that “for those who identify as non-binary,
the situation is much murkier. The system has no idea what to do with them” (para. 43). Hawn
(n.d., as cited in Clarendon, 2020) asserted that they would
prefer that patients make the emergent versus non-emergent distinction … In my
experience, such as now, during the pandemic, people are being very honest about
whether they feel it’s possible for them to manage a delay in receiving the surgery versus
others who feel it’s unbearable. (Hawn, n.d., as cited in Clarendon, 2020, para. 19).
An organization to support self-direction in choice making with specialized experts in LGBTQ+
care stated that “bodily autonomy is a necessary human right, no matter what” (Folx Health,
2022, para. 4). The system does understand what transgender individuals know and has not been
able to incorporate this knowledge. This has been seen in the continued use of the binary elective
versus non-elective process of deeming who receives treatment.
No One Is Listening
A search of internet websites, blogs, and opinion articles supported the findings
addressing the second research question and the theme that participants felt that no one was
listening and the existence of continued gatekeeping during the pandemic. Green (n.d., as cited in
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Gorvett, 2020) noted, “I think this is the biggest problem in transgender health, that people are
denied basic care” (p. 29). Coronado (n.d., as cited in Daniari, 2020.) commented that they were
not heard and that “it took so much for me to get approval for the surgery and now I just feel it’s
been yanked away” (para. 7). Folx Health (2022) asserted that contrary to gatekeeping, “medical
decisions should be left to patients, parents, and medical providers” (para. 4). Supporting what
participants voiced, there is a surrender in this power dynamic. Cha (2020) posited that
“something beyond myself seemingly had control over my life, so I did what I do best: adapt and
learn how to thrive in the present” (para. 9). Even in that declaration, there was a notation of
thriving.
We Must Take Control
Internet commentary supported the theme of taking control of one’s life and a refusal to
surrender. One article noted the reality of the existence of barriers to treatment. Stroumsa (n.d.,
as cited in Mostafavi, 2020) stated, “Those who can’t, may seek alternative ways to get their
medications. People who need hormones for gender affirmation may turn to riskier sources”
(para. 5). Another noted that those needing help turn to other avenues. For example, “someone in
a Facebook group for people that are focused to do DIY trans health asked if there was a way to
clean needles so they could be reused just in case” (Stratis, 2020, para. 11). A blogger
commented on the strength of survival during the pandemic. He felt that “queer people, by
nature, are resilient as hell” (Cha, 2020, para. 8). In addition, he stated, “I truly believe in queer
strength. I believe that LGBTQ+ people, so used to a system not created for us, possess a unique
disposition for survival and perseverance through adverse times like these” (Cha, 2020, para.
17).

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Increased Introspection
Internet secondary data addressed the theme of increased introspection. Dannhauser
(2021) noted that “while COVID-19 has shuttered businesses and quarantined countless people,
it has also motivated many transgender individuals to begin gender-affirming hormone therapy”
(para. 5). The author continued,
The reasons vary from the chance to transition away from gossiping co-workers to, to
realizing what’s important in life when the death count is daily news, to coming to terms
with the self-image looking back during online work, school and socializing sessions.
(Dannhauser, 2021, para. 5)
Tierney (n.d., as cited in Dannhauser, 2021) stated that COVID-19 and isolation “either it makes
you feel incredibly unstable, or it gives you the opportunity to make all the changes you ever
wanted to make” (para. 12). In addition, “A lot of transgender people were like this is the time -
it’s now or never” (Tierney, n.d., as cited in Dannhauser, 2021, para. 12). Cha (2020) described
introspection as
an odd thing about the sudden lack of public interaction was that I would never know
where I stood in my transition. How would I be read when amongst other people? When,
if ever, would I pass? How would life feel like on the other side? (para. 14)
Loss of Oxygen AKA Disconnect From the Queer Community and Spaces
In reference to secondary data supporting participant commentary, most was written
about the disconnect from queer spaces and the need to reconnect, affirming what study
participants reported. Some insights described that “connection to community is a resilience
factor” (American Psychological Association, 2020, para. 10). In addition, “in times of trauma or
crisis, queer and trans folk often turn to social media to reclaim identity, offer support, and
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strengthen in-group bonds” (Jenkins et al., 2019, as cited in American Psychological
Association, 2020, para. 12).
Alvord (n.d., as cited in Neighmond, 2020) spoke to this theme extensively, stating,
“social connection is one of the key protective factors in resilience” (para. 26). The writer
discussed loss of connection when isolated in toxic spaces. They reported that transgender
individuals “don’t have any of those sources of support, at least physically and they’re with
people who don’t accept them, which leaves many young people feeling completely alone”
(Paley, n.d., as cited in Neighmond, 2020, para. 22). Also, “Maintaining social connection is
critically important during this crisis” (Alvord, n.d., as cited in Neighmond, 2020, para. 24).
Further, “The disparity between how good and supported these young people felt before and how
lonely and rejected they might feel at the moment makes the situation even more painful” (Paley,
n.d., as cited in Neighmond, 2020, para. 22). More importantly, “the Trevor’s project’s crisis
services program has increased dramatically, at times spiking more than double the volumes
from earlier in 2020. There were just so many young people who are impacted and scared and
frightened and in unsafe or challenging situations and many of them are reaching out for help
and to talk about that they are going through” (Paley, n.d., as cited in Neighmond, 2020).
McKellar (2020) noted that “the closure of schools, community centers, and places where
queer communities gather made staying protected and connected incredibly difficult” (para. 14).
The writer asserted, “We must maintain emergency support services during the pandemic that
ensure the inclusion and dignity of diverse sexual orientations, gender identities and expressions
(SOGIE) communities (McKellar, 2020, para. 24). In support of comments made in this study
regarding reconnection, Prothero (2021) noted that “nearly 70% of transgender young adults said
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they find affirming spaces online” (para. 7). When transgender individuals become isolated from
queer spaces and queer communities, reconnection is a must.
Summary
Participants provided valuable insight into their processes during the past 2 years of
living and transitioning during the COVID-19 pandemic. The cisnormative practices and
cisgender bias in the healthcare system remain profound. Themes emerged describing a system
that has the power to deem what is essential treatment with an inability to manage the
transgender introspection that can guide self-direction. Despite thoughtful insight and self-
knowledge that participants felt should not be questioned, decisions are being made for
transgender people. Participants reported not being heard, which resulted in a strong sense of
taking control if being denied access to treatment. Although submission to the power dynamic
occurred at times, the community remains perseverant in its desire for self-direction. Pandemic
isolation resulted in increased introspection and self-awareness. It also highlighted how cut-off
participants felt from queer spaces and communities. This cut-off was heartfelt, and the need to
reconnect was strong.

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Chapter Five: Recommendations and Discussion
The purpose of this study was to center the voices of transgender adults who were
transitioning during the COVID-19 pandemic. The research utilized the narrative lived
experiences of participants who, during the pandemic, had various experiences with health care
providers, family members, school and work, and connections with queer spaces and
communities. Given the strict binary nature of the health care system, the COVID-19 pandemic
added further expectations of this binary system to determine who would receive treatment. Prior
research suggested that transgender individuals would be denied treatment and that their mental
health would be poor. By queering this research, TGNC voices remain at the center, and societal
binaries can become destabilized and challenged. This chapter discusses the emergent themes
derived from eight interviews. Given these findings, recommendations for a plan of action to
address cisnormative practices and cisgender bias in healthcare facilities and reconnection of
transgender adults to queer spaces and communities during the crisis are offered.
Recommendations for future research are addressed, as are the study’s limitations and
delimitations.
Discussion of Findings
Narrative stories resulting from interviews and secondary data addressed the impact of
the COVID-19 pandemic on transgender adults’ transition process. Emerging themes answered
research questions and were supported by the literature in Chapter Two. Queer theory dictates
the focus, centering on transgender voices and not the researcher’s interpretation. The following
findings are reported in alignment with this tenet.
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Acceptance of the Binary: What Is Elective to Delay?
Elective versus non-elective treatment decision making is another binary power dynamic
to be tackled. What defines essential lifesaving treatment, and what is elective? Because the
transgender population is not a monolith, they should not be addressed or treated as such. There
is no current definition of medical necessity (Abbott & Stevens, 2013). In addition, research has
reported that nearly 50% of participants have had access to gender-affirming treatment during
the pandemic (Jarrett et al., 2020). For those who had planned to begin HRT pre-COVID, 78.6%
reported that the pandemic hindered their ability to start (O’Handley et al., 2020). The same was
reported for those who had surgery planned, with the delay having a negative impact (O’Handley
et al., 2020). Historically, transgender patients have been denied care simply based on their
gender identity (Grant et al., 2011). Current research themes were that participants felt treatment
could not automatically be deemed as either, and doing so was concerning. Surgery may be
lifesaving for one but not for another. The delay in services was noted as a result.
Participants also felt that the significance of transgender need was diminished secondary
to COVID-19. Participants unanimously expressed their understanding of why this occurred, but
some noted that their need remained. The impact of waiting could be damaging. Participants
discussed the effect of waiting for needed treatment, such as increased isolation given the desire
to hide. In addition, some reported that being denied care would worsen negative feelings, which
was concerning given the COVID cut-off from transgender spaces and community. Most
concerning was the report of potential increased dysphoria. One participant who had been
allowed to continue their treatment was concerned about what may have happened had the
situation been different. Another reported concern over potential future delays having already
begun their process and what physical and emotional pain they might have to endure.
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Participants strongly felt their needs were essential, even lifesaving, and not elective. One
participant discussed the concept of allowing transgender individuals to self-determine whether
treatment could be delayed or that choice would be adverse. Overall, participants felt the
healthcare system must understand the need to center their voices to make more effective
decisions about treatment necessity. The impact of not centering voices to determine these
decisions is impactfully harmful. Even with this concern, the cisnormative system functions
unwaveringly. Butler (2015) stated that power dynamics are established to ensure the
sustainment of the gender binary system. Frank and Cannon (2010) postulated that these binary
categories develop in relation to the status quo and keep marginalized people in subordinate
positions.
Healthcare System Needs to Manage Transgender Introspection
Themes addressing the healthcare system’s inability to manage the introspection of
transgender folk emerged. Participants noted an overall inability of the system to listen to
transgender adults or even feel seen. This was exhibited in various ways. Participants overall had
a very defined sense of self. Given this insight, providers and loved ones still questioned their
identities and convictions. The literature supported this finding. Participants felt a lack of respect
and invalidation when it came to the acknowledgement of their ability to make their own
decisions (Brown et al., 2020). Gatekeeping was common, with providers implying that
participant insight possibly was a function of mental instability. Respondents in another study
shared that requiring referral letters from therapists to access gender-affirming treatment added
to the existing obstacles in obtaining needed care (Austin & Goodman, 2017).
Participants shared the experience of being misgendered, essentially ignored by those
who were just informed of their pronouns. One participant reported his experience of being
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misgendered only after he told nurses he was transgender. Research shows misgendering to be
psychologically disconcerting and harmful to an individual’s sense of belonging and association
(Bosson et al., 2012). Participants shared about the inability to have others understand what they
know about themselves because of introspection. This was true primarily for doctors who could
not comprehend what they were being told. For one participant, this led to a poor relationship
with providers and a desire not to be trans so that the doctor-patient relationship could cease. The
entrenched cisnormative bias meant that transgender patients were just not believed.
Overall, there was a strong sense of providers and the health care system not truly
understanding their needs, resulting in needs not being met. Another theme exhibited how
cisnormative ways of thinking and living made it hard for the system to conceptualize the basic
needs of transgender individuals, even when explained. One participant felt this was intentional,
requiring them to become exceptionally verbal to have their needs met. One participant felt this
imbalance was important to note because giving a provider direct feedback without managing
their potential response could change the standard of care received. Given the doctor-patient
dynamic, this imbalance reinforces providers’ need to re-establish authority to return the
relationship to homeostasis (Poteat et al., 2013). Participants noted language used as a means of
dismissing needs. They added that health care providers asked unnecessary questions, often
invasive ones, and that it appeared the only purpose was only to settle curiosity. Misgendering
was reported as an example of not being understood and needs not being met. Participants
reported that providers used terms that create dysphoria, even when corrected. Needs cannot be
met, as transgender patients are not seen correctly. Some participants felt this behavior was
intentional. One participant stated that the problem was clearly systematic.
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Overall, participants felt cisnormative healthcare practices. Systems and providers
determine what is lifesaving without centering trans input on what they feel is needed or if
delaying treatment would put them at risk. Participants reinforced that transitioning would
continue regardless. Participants reported that providers did not understand that their level of
insight resulted in the erasure of their needs. As summarized earlier by Frank and Cannon
(2010), these binary categories and power dynamics keep marginalized people in subordinate
positions.
No One Is Listening
Similar to the theme previously presented, participants shared a general desire to be
understood by cisgender health care providers and that no one was listening. Participants
reported a sense of surrender to what they perceived as providers, and loved ones, who do not
listen. Participants felt providers were generally omniscient and that this went as far as
questioning gender identities, with disbelief being a “knee-jerk” reaction to self-report.
Participants likened this lack of listening to provider gatekeeping. Participants’ reports of
the need for gender-affirming treatment was ignored, and letters from psychological
professionals were required instead. Even when decisions were carefully made after lengthy
introspection, doctors retained the power to change the direction. Medical providers appeared to
intentionally ignore their patients and make medical decisions contrary to what their patients
desired. Various factors lead providers and patients to an impasse regarding who makes the
decision regarding treatment beginning and what is in the patient’s best interest (Gerritse et al.,
2021).
Participants seemed to have normalized and accepted resignation to the long-standing
cisnormative power, control, and not being listened to. They shared their understanding and
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acceptance of this dynamic even when it was clear that provider behavior was transphobic. There
was a sense that they had learned to expect that they would not be heard. They sometimes
rationalized provider behavior as not that impactful. Still, as reported previousy, this gatekeeping
behavior in providers leaves transgender patients feeling a lack of respect and invalidation when
it comes to their ability to make their own decisions (Brown et al., 2020).
Overall, participants wanted to be heard and believed. The was a strong desire to be
trusted regarding their own insights and decisions strong. Still, learned helplessness and
resignation occurred secondary to entrenched binaries and power dynamics. Even with this,
participants showed resilience. Resignation did not sit well, and an inclination of empowerment
was seen. Edenfield (2020) stated that transgender resilience remains, and the community will
take care of itself. This desire led to numerous participants deciding to participate in this study.
We Must Take Control
Another theme emerged that spoke directly to participant resilience. Participants spoke
about the desire to buck the cisnormative system that was not working in their best interest. The
participants accepted that the power dynamic existed, but they did not tolerate it on various
levels. It was apparent that the silent acceptance of this power dynamic would be followed by a
fight to honor what participants knew about themselves. Not seeking and obtaining gender-
affirming treatment was not an option. Participants shared that these power dynamics created by
cisnormative practices had an impact, and these practices had been ongoing since well before the
COVID-19 crisis. Mental health clinicians hold the decision-making power over transgender
individuals (Bradford et al., 2013). Participants stated that no one was listening and that
decisions were being made for them, even when it was clear that they knew more about what
they needed. The literature supports this sense. Research itself can destabilize the norm of these
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binary categories by centering transgender voices (Pascoe, 2018). There was a silent resignation
to all of it but an even more loud resistance and an insistence to get needs met. When confronting
challenges, the transgender community utilizes agile communication, absorbs information, and
then relays knowledge and strategies to others (Edenfield, 2020). This finding of resilience and
taking control aligns with Pennell’s (2016) discourse on transgressive cultural capital found in
queer communities. The proactive behaviors seen in battling transphobia.
Participants in this study were young and White. Given White Hughto et al.’s (2016)
findings, this would indicate less experience with refusal of care. Transgender young adults have
different experiences of being transgender compared to their White counterparts (Wagaman et
al., 2019). For example, transgender women of color experience more violence than any other
transgender subgroup (Wagaman, et al., 2019). In alignment with the findings of Wagaman, et al.
(2019), participants shared stories of reliance and a strong level of introspection, self-knowing.
When dealing with adversity, they verbalized not accepting no as an answer and seeking
alternative means to meet their own needs. Future research should consider asking if the lack of
experience related to refusal of care with transgender young adults discussed by White Hughto
and colleagues is related to a sense of empowerment and feelings of resilience.
Because participants made up a homogenous group, thematic results were likely limited
in perspective. It is worth noting that different themes may have arisen with a different mix of
participants. Varying intersectionalities as mentioned by Collins (2020) and dynamic, ever
moving gender identities discussed by Jourian (2015) make each potential transgender
participant quite unique. Diversifying to add differing ethnicities would produce different stories.
The privilege of being White cannot be ignored, especially in the realm of resilience. Raised in a
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world of White privilege may or may not influence resilience. Future research is needed to
uncover age, gender, and racial differences in reference to resilience.
Increased Introspection
An important theme addressed the impact of the COVID-19 pandemic isolation on
participants. Isolation resulting from lockdown and shelter-in-place orders created an unexpected
increased introspection and reflection. The pandemic isolation allowed for a pause and for the
opportunity to live in a vacuum without the pressures of cisgender bias and cisnormative
expectations. Another study reported similar findings. Participants shared the positives of
lockdown introspection and gender expression sans the feedback from others (Howard Brown
Health, 2021). Participants reported this introspection as an enhanced mirror to self. Though
there was a disconnect from loved ones and friends, the was a gift of opportunity to completely
be themselves and time to reflect more deeply. For some participants, introspection brought new
awareness. One participant shared that the pandemic forced introspection that may not have
occurred otherwise. Howard Brown Health (2021) reported that after adjusting to pandemic life,
participants shared that the pandemic provided an opportunity for increased introspection and
self-care.
Some participants reported isolation as an escape from society’s cisgender bias and
cisnormative expectations. This escape allowed internal growth away from societal pressure.
This combination of isolation and forced self-reflection resulted in good feelings. Two
participants did not share this experience. Pandemic lockdown and restrictions left them initially
isolated with toxic family members. This was not uncommon. Gonzales et al. (2020) reported
that many students were sent home to unwelcoming environments when colleges abruptly
closed. These participants reported that these environments included explicit transphobia and
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cisnormative expectations. This limited opportunities for the introspection the other participants
experienced.
Loss of Oxygen AKA Disconnect From the Queer Community and Spaces
The final theme was the strong and noted disconnection from queer spaces and
communities. Pandemic lockdown and restrictions created a disconnection from loved ones and a
significant disconnection from queer spaces and queer communities. This was found in earlier
research. O’Handley et al. (2020) found that 19.1% of participants reported that the pandemic
negatively impacted access to social support, and most experienced a loss of queer community.
Social isolation is a pandemic challenge for LGBTQ communities (Salerno et al., 2020). In a
study conducted by Kidd et al. (2021), over half of the respondents reported decreased access to
transgender social support. In addition, perceptions of seclusion are associated with negative
mental health outcomes (Lazaroiu, 2021). Some participants described this connection to queer
spaces and community as oxygen. Connection to queer spaces provided a safe place to be oneself
without judgement or explanation. Participants shared that queer spaces do not misgender or
dead name. Queer spaces are affirming. Participants reinforced that non-queer people do not
understand the significance of this cut-off. Participants struggled with describing the
significance, saying that the connection was intentional and vital. Loss of connection to queer
spaces during the pandemic was associated with increased negative psychological impact (Kidd
et al., 2021).
For some participants, disconnection from queer spaces and communities adversely
affected mental health. Participants reported feelings of hope when connected to the validation of
queer spaces prior to the pandemic and the feelings of loss when forced isolation occurred.
Participants described queer spaces as a place where one can always feel safe, loved, and valid.
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Stay-at-home orders decreased social and community access found at schools, such as gender
alliances and affirming organizations (Reger et al., 2020). As a result, participants felt that
reconnection was a must. Galea et al. (2020) noted that ensuring connection to community for
marginalized groups is essential. Participants noted how social media was helping connection,
especially for younger people. The ease of access to social media provided what one participant
called micro-communities. One participant shared the idea of creating a transgender network,
pairing people with each other to fend off future crisis disconnection. Salerno et al. (2020) found
that the utilization of social media to keep the community connected was key.
Participants’ lack of access to the queer community and spaces was significant. Queer
leisure spaces remain important during the pandemic (Anderson & Knee, 2020). All discussed
the significance of the queer community and how it is necessary for a sense of belongingness and
survival. Anderson and Knee (2020) stated that physical spaces for queer communities to gather
are very important. Some participants suggested solutions to prevent further disconnection.
Again, utilizing social media is key to keeping the community connected (Salerno et al., 2020).
Still, social media is not a replacement for physical community (Anderson & Knee, 2020). Queer
space is a place where one is understood without question and where one belongs. Not having a
connection to this space is detrimental.
In addition, the theme addressing queer spaces and queer communities aligns with the
findings of Wagaman et al. (2019), who stated that a sense of belonging is a stabilizing force of
resilience. Participants described how the COVID-19 pandemic prevented connection to queer
spaces and queer communities left them feeling isolated. This finding as well as the finding of
resilience are interrelated. Trans affirming spaces cannot be undervalued.

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Recommendations for Practice
The narrative stories and themes in this study led to recommendations for practice, both
specific and broad. Participants discussed the effect of problematic cisnormative practices on
access to necessary services. Pandemic isolation and the resultant cut-off from queer spaces and
communities were highly concerning. Centering the participants’ concerns, three
recommendations for practice were identified.
Recommendation 1: Support the Development of a Transgender Outreach Program
A primary theme in this study addressed the participants’ pandemic isolation and cut-off
from queer spaces and communities. One participant described this cut-off as profound and as a
loss of oxygen. Two participants experienced this loss so profoundly that each offered possible
solutions to address future isolation. Anderson and Knee (2020) discussed the use of technology
to aid in connecting people but stressed that it cannot serve as a replacement for needed physical
queer spaces.
This study provides insight into this need for in-person connection as an ongoing
concern. Physical connection in queer spaces helps to create queer communities (Anderson &
Knee, 2021). The recommendation is to support LGBTQ+ organizations in developing
comprehensive outreach programs to address the lack of in-person connection when individuals
are physically isolated. Utilizing transgender voices, whether suggestions of mentoring networks
or a queer connection task force, organizations can develop comprehensive programs to address
potential cut-off and resultant isolation, warding off negative impact. Ensuring social resources
and connection with queer communities can stimulate and advance resilience for transgender
individuals (Goldbach et al., 2021).
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Recommendation 2: Support Health Care Facilities in Identification of Cisnormative
Practices
All participants voiced concern regarding health care providers’ cisnormative practices.
The topic they addressed included inappropriate questions, misgendering, not being heard, and
gatekeeping. All discussed the impact this had on their lives. I recommend that health care
providers and organizations identify these cisnormative practices and understand the danger of
allowing them to continue. Secondary to cisnormative practices, overt or subtle discrimination
can be harmful, even if unintentional (Nadal et al., 2014). In addition, identifying and disrupting
cisnormativity transforms systems, reflecting biases and deconstructing assumptions (Malpas,
2018).
Identifying cisnormative systems disrupts the norm. Butler (2015) stated that these
systems are constructed to maintain power dynamics. Those who adhere to this system react to
those who do not conform and punish them socially (Butler, 2015). The identification process
will require time and allow for the space of discomfort. Lewin’s change model is appropriate for
this change process (Wojciechowski et al., 2016). Utilizing three phases called unfreeze, change,
and refreeze, these phases of organizational change allow for the centering of transgender voices
and the disruption and discomfort that will result. Lewin recognized that restraining forces
battling with the drive to change maintain the status quo. As a result, concerted change of the
status quo demands planned phases of change (Manchester et al., 2014).
Recommendation 3: Support the Organizational Development of Policies to Decrease
Barriers to Access to Treatment
Participants in this study discussed various obstacles to health care access during the
pandemic. Worsened during the pandemic, these barriers to treatment have been long-standing.
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In conjunction with the recommendation stated above, I recommend that providers and
organizations address healthcare policies that serve as barriers to treatment and develop more
inclusive and welcoming policies and procedures. According to the Human Rights Campaign
(2017), only 39% of 590 facilities surveyed had policies focused on eradicating bias and
providing transgender patients a welcoming environment. Further, only 29% had had an
established record-keeping system that documented a patient’s stated gender identity when it
differed from the one assigned at birth. Secondary to cisnormative practices and binary
essentialism, transgender patients are forced to choose a binary gender to place themselves in the
system (Walton & Baker, 2019). Even disclosing transgender identity has proven to be
troublesome. Grant et al. (2011) showed that a doctor’s knowledge that their patient was
transgender increased the likelihood of discrimination and abuse by eight percent. In addition,
23% of transgender individuals were denied services altogether if they were out to their
providers (Grant et al., 2010).
Policy development is a common practice in business. It is somewhat more challenging
when new policy development will disrupt entrenched practices and systems. Barriers to access
are symptomatic of a cisnormative system, so these two recommendations go hand in hand.
Integrated Recommendation
An integrated recommendation for organizations, utilizing Lewin’s change model is
offered. Understanding the entrenched cisnormative practices in healthcare and the need to
confront and deconstruct these systematic practices, I suggest that facilities address their
cisnormative practices and barriers to access by developing more welcoming policies and
procedures. Specifically, this integrated recommendation focuses on hospital admission policies
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for transgender patients. Pandemic-related or not, admission policies are first-contact policies
and make for a good starting point.
The power dynamics in health care settings associated with cisnormative practices,
transgender bias, and discrimination often serve as a primary reason transgender patients do not
seek or receive essential care. In addition, the current research found that cisnormative practices
in healthcare continue to serve as an obstacle to needed care during the COVID-19 pandemic. As
stated earlier, professional and legal organizations address a basic standard of care. According to
the AMA Code of Medical Ethics, providers must ensure access to care for all, treating all
patients with respect for human dignity and compassion (AMA, n.d.). The WPATH includes in
its mission statement the development of standards of care for transgender healthcare providers
(WPATH, 2012). This has resulted in directives to hospitals encouraging the development and
implementation of transgender-inclusive policies and practices as well as properly trained staff.
Per The Human Rights Campaign (2017), only 39% of hospitals had policies regarding the adept
treatment of transgender patients.
In 2019, PSI Inc., a local psychiatric hospital, lacked a comprehensive admission policy
for transgender patients, and admissions were being denied. In response, the hospital developed
and attempted to implement a new admission policy. Implementation failed, and the policy was
abandoned after 60 days. At present, the hospital remains without a policy (anonymous staff,
personal communication, October 2020). Staff spoke regarding hospital policy on the condition
of anonymity.
Acknowledging that Lewin’s change model works well in organizational health care
settings (Wojciechowski et al., 2016), these phases of change can assist in the development of
appropriate admission policies. The unfreezing phase allows the organization to address
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cisnormative systems and practices, allowing for the discomfort of this discovery process. The
change phase encourages the planning and development of needed policies. Lastly, the refreezing
phase is where implementation takes place. When implementation is reinforced and managed for
necessary changes, the new policy becomes business as usual. See Figure 2 for details.

Figure 2
Development of Admission Policy Utilizing Lewin’s Change Model

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Limitations and Delimitations
According to Simon and Goes (2013), limitations are a study’s restrictions that can
influence outcomes but over which the researcher has no control. Along the same lines,
delimitations are a study’s constraints and boundaries that the researcher actively chooses during
study design. The following are the noted limitations and delimitations of this study.
This study’s limitations included the number of participants. In addition, snowball
sampling prevented the sample from being more diverse in age, ethnicity, education level, and
employment status. When questions are asked, and data is scarce, queer researchers must gain
data via alternative methods even if it means disrupting the research methodological norms
(Murphy & Lugg, 2016). In alignment with the conceptual framework of this study, this is
queering the methodology. When participants were very slow to respond to requests for
participation, a decision was made to accept the homogeneous subject pool, noting the
limitations. Supportive secondary data were sought via Internet blogs, social media, and opinion
articles. The subject pool was a very small group from an already small population, during a very
specific time-period, a pandemic. Queering the methodology was needed. As a result,
participants were almost exclusively Caucasian, and all were young, educated, employed, and
insured. Though this qualitative study did not attempt to generalize findings to the transgender
community as a whole, this group of participants remains quite homogenous, and findings are
understood with that in mind. Because White and middle-class queer spaces can be exclusive and
actively marginalizing (Villarejo, 2005), transgender communities of color need to be included in
future research.
There were also limitations when addressing participants’ self-reports. According to
Robinson and Leonard (2019), events connected to stronger emotions are more easily retrieved.
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Given the sensitivity of the topic and potential emotion involved, information may be retrieved,
but responses may not reveal all. When centering voices of marginalized communities, this
limitation is expected and acceptable.
Centering participants’ voices and listening to their narratives is central to this conceptual
framework, but it has limitations. Given this concern, there remains no better way to gather the
data. Interviews center voices on narratives and history. Given the conceptual framework, it is
essential to focus on the voices of transgender adults experiencing transition during the pandemic
versus whether a provider offered treatment. These active choices framed interview question
construction and shaped data analysis, ensuring all stayed in alignment with one another. Noted
is the limitation that I am a cisgender female. This lack of concordance may have affected the
probative questions asked and participants’ responses.
Though, by theory, not considered a limitation, the conceptual framework significantly
impacted data analysis. When QT contradicts the notion of being defined, centering the
participants’ voices should have also remained undefined. The coding process for data analysis
inadvertently centered my voice, utilizing the themes to explain findings. It is a limitation that I
am not transgender.
Recommendations for Future Research
Centering transgender voices and allowing the space for narrative disclosure brought rich
and deep experiences. However, snowballing sampling resulted in a mostly homogenous group
of participants. All participants were attending college or fully employed, had fixed addresses
where they felt safe, and had medical insurance. Most identified as Caucasian and one as
Hispanic. All were ages 18 to 25. Though qualitative work cannot be generalized, the
experiences explored in the study were limited to a specific group. Future research should
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explore a more diverse group of individuals. Centering the experiences of individuals of different
ethnic backgrounds, socioeconomic statuses, education levels, and age groups would provide a
richer understanding of the impact of COVID-19 on the transition process.
Future research should also include transgender researchers. Academia is never surprised
when cisgender researchers speak for transgender participants (Radi & Perez, 2016). Though I,
the cisgender researcher in this study, utilized peer review to support data analysis, a transgender
interviewer may have brought in an added level of trust and disclosure that concordance elicits.
The probative questions utilized reflect the limited insight of a cisgender interviewer. Future
research would benefit from the involvement of transgender researchers. Eyes and ears with
insight and understanding of the community will lead to a different interview method and
potentially different answers.
Connection to the Rossier Mission
As stated on its website,
The mission of the USC Rossier School of Education is to prepare leaders to achieve
educational equity through practice, research and policy. We work to improve learning
opportunities and outcomes in urban settings and to address disparities that affect
historically marginalized groups. We teach our students to value and respect the cultural
context of the communities in which they work and to interrogate the systems of power
that shape policies and practices. Through innovative thinking and research, we strive to
solve the most intractable educational problems (University of Southern California, 2022,
para. 1).
This study was born in support of this mission.
84

Given how the transgender community has been historically overlooked or ignored by
healthcare providers, it was vital to address the stressors experienced by the transgender
community during the first two years of the COVID-19 pandemic. For a community
systematically erased for decades, isolation was concerning. Eliciting transgender voices and
their narrative stories of transition experiences during the pandemic helped to highlight and
tackle inequities in the healthcare system and reinforce the connection to queer spaces and
communities.
Conclusion
At the conclusion of this study, Americans and others saw flags flying at half-mast,
marking 1,000,000 lives lost to COVID-19 in the United States. All have felt the pandemic’s
impact, but some more than others. Despite the documented need for specific attention, the queer
community has received little attention (Salerno et al., 2020).
This research centered the voices of adults who had been newly transitioning or
transitioning during this pandemic and how this context impacted their process. The narrative
stories painted a picture of continued erasure by practitioners and frustration dealing with
worsened barriers to access. Ongoing cisnormative practices enhanced gatekeeping activities
during a time when gender-affirming services were deemed non-essential yet were lifesaving for
some. While pandemic isolation brought unexpected but welcomed introspection, it also
disrupted access to queer communities and spaces. Participants shared their resilience and
commitment to move forward despite obstacles.
Recommendations for practice are offered. Healthcare providers and organizations must
take stock of their cisnormative practices to decrease barriers to services, even if pandemics
become non-existent. Awareness that transgender individuals have a self-awareness that can
85

steer treatment decisions is a must. Providers need to learn to listen. Equally important is
developing outreach and programs that can connect individuals to queer spaces if and when
physical isolation re-emerges. The transgender community, like other marginalized communities,
relies on itself to persevere. Planning for potential disconnection will equal survival.

86

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Appendix A: Interview Protocol
Hello XXXX. Thank you for agreeing to join me today. As you know, we are here to talk
about your experience transitioning during the COVID-19 pandemic. You can see that I am
wearing headphones. This is to protect your privacy. Are you in a place where you can speak
freely?
I would like to record this interview so I can focus on listening to your story and not on
taking notes. Your privacy will be protected, and this recording will be destroyed after I
transcribe it. Do I have your permission to record this? This is a safe space. There are no right or
wrong answers about your transition experience. Your journey is yours. This process is about
giving transgender people, you, a voice and a real desire to hear your story. I will be asking you a
series of 20 questions. There may be some follow-up questions if I do not understand something
or need more information. The interview process will take approximately one hour. This process
is completely voluntary and there is not a requirement that you participate or even complete the
interview process. I understand that we will be discussing possibly a very sensitive topic for you.
If you would like to stop, for any reason, please let me know. Do you have any questions?

106

Table A1
Interview Protocol
Interview questions Potential probes RQ addressed CF Key
concept
addressed
Patton
Q-type
How are you feeling
today?
Any hesitancy
about this
process?
3 3 Feelings/emotion
What is your age? It is okay to
decline to state
Demographic
only
3 Background
What is your highest level
of education
It is okay to
decline to state
Demographic
only
3 Background
If employed, what kind of
work do you do?
It is okay to
decline to state
Demographic
only
3 Background
How do you identify your
race or ethnicity?
It is okay to
decline to state
Demographic
only
3 Background
How do you identify your
gender?
(if needed) Can
you elaborate?
Help me
understand
what that
means.
Demographic
only
3 Background
What are your pronouns?

Demographic
only
3 Background
When the pandemic first
began in 2020, what was
your living situation at
that time?
Did you feel it
was a
supportive
environment?
1, 2, 3 2, 3 All
How did the pandemic and
restrictions affect your
living relationships?
Probative
questions will
depend on
responses
1, 2, 3 1, 2, 3 All
What happened with your
employment or school
during the lockdown in
2020?
Probative
questions will
depend on
responses
1, 2, 3 2, 3 All
What was your experience
with isolation, if any?
Probative
questions will
depend on
responses
3 1, 2, 3 All
107

Interview questions Potential probes RQ addressed CF Key
concept
addressed
Patton
Q-type
For yourself, how do you
define transitioning?
Specific
probative
questions if
needed
2, 3 3 All
When did you begin your
transition?
Specific
probative
questions if
needed
Demographic
only
2, 3 Background
Were you ever asked to
wait or delay any of your
transition process during
the pandemic? If so, how
did that request affect
you?
Probative
questions will
depend on
responses
1, 2, 3 1, 2, 3 All
If not requested to delay,
in what ways did you
feel pressure to wait or
delay any of your
transition process, if
any?
Probative
questions will
depend on
responses
1, 2, 3 1, 2, 3 All
How did having to delay
your transition process
affect you?
What would it
have meant if
you had to
delay your
process?
1, 2, 3 1, 2, 3 All
If pandemic restrictions
prevented you from
seeking or continuing
gender-affirming
hormone therapy, what
effect would/did that
have on you?
Probative
questions will
depend on
responses
1, 2, 3 1, 2, 3 All
If pandemic restrictions
prevented you from
seeking or obtaining
gender-affirming
surgery, what effect
would that have on you?
Probative
questions will
depend on
responses
1, 2, 3 1, 2, 3 All
Overall, how would you
describe the effect the
Probative
questions will
1, 2, 3 1, 2, 3 All
108

Interview questions Potential probes RQ addressed CF Key
concept
addressed
Patton
Q-type
pandemic has had on
your transition process?
depend on
responses
Is there anything else you
would like to add
regarding your
experience?
Probative
questions will
depend on
responses
1, 2, 3 1, 2, 3 All

Conclusion to the Interview
Thank you so much for participating in this interview. Would you like to add anything
else before we end? Do you have any questions? After reviewing the recording, I may have some
follow-up questions for clarification. Would it be okay if I contacted you with further questions?
Thank you again.
109

Appendix B: Coding Sheet
A PRIORI CODES

access to queer
community ACCS

queer spaces/queer
community QS/QC

trans awareness AWAR

reaction to delay REAC

barrier BAR

Reflection REFL

bubble BUB

bad living situation TOX

concordance CCRD

Transition TRAN

concern for others CFO

Transphobia TRPH

cisgender bias CGB

Urgency URG

combat isolation CI

felt valued VAL

closer relationships CLR

tg voices VOIC

cisnormativity CN

shock reaction SHOC

cisnormative practices CNP

shelter in place
reaction SIPR

cut-off CO

Stuck STUC

concern COVID CONC

Support SUPP

connection CONN

sense of control CONT

Emergent Themes

cut-off struggle COS

IN, OX ACCS RQ THEME
COVID reaction COVR

MN, NL CCRD RQ 1-1 EL
transition definition DEF

EL, MN, NL CN RQ 1-2 MN
delay DEL

EL, MN, NL CNP RQ 2-1 NL
dysphoria DYS

CT, IN, MN, NL,
OX CONT RQ 2-2 CT
escape ESCA

CT, EL, MN, NL DEL RQ 3-1 IN
fear of reaction FEAR

IN, OX ISO RQ 3-2 OX
further relationships FR

IN ISOG

space to grow GROW

OX, NL LOSS

isolation ISO

CT, EL, MN, NL NB

isolation bad ISOB

CT, EL, MN, NL PD

isolation good ISOG

OX QS/QC

sense of loss LOSS

CT, EL, MN REAC

misgender MG

IN, OX REFL

mental health MH

OX SHOC

not believed NB

OX STUC

out OUT

IN, OX SUPP

power dynamics PD

CT, EL, MN, NL URG

how others perceive
you PERC

NL, OX VAL

privilege PRIV

CT, IN, NL, OX VOIC

110

Appendix C: Theoretical Framework Alignment Matrix
Research question Theoretical framework Data instrument questions
How do transgender
adults experience
cisnormative
practices in COVID
protocols?
Queer theory (Butler, 2015) Interview Questions 8–10, 14–20
How do transgender
adults experience the
power dynamics
created by
cisnormative COVID
practices?
Queer theory (Butler, 2015) Interview Questions 8–10, 12,
14–20
What are the mental
health effects of
transitioning during
the COVID-19
pandemic as voiced
by transgender
adults?

Queer theory (Butler, 2015) Interview Questions 1, 8–12, 14–
20
Demographic questions Interview Questions 2–7, 13

111

Appendix D: Informed Consent for Research
Study Title: Lived Experiences of Transgender Adults Transitioning During the COVID-19
Pandemic
Principal Investigator: Evangelina Estrada
Department: Rossier School of Education
Introduction
We invite you to take part in a research study. Please take as much time as you need to
read the consent form. You may want to discuss it with your family, friends, or your personal
doctor. If you find any of the language difficult to understand, please ask questions. If you decide
to participate, you will be asked to sign this form. A copy of the signed form will be provided to
you for your records.
Key Information
The following is a short summary of this study to help you decide whether you should
participate. More detailed information is listed later in this form.
1. Being in this research study is voluntary–it is your choice.
2. You are being asked to take part in this study because you responded to a request
for participants in this study. The purpose of this study is to highlight the lived
experiences of transgender adults who have experienced the transition process
during the current pandemic. Your participation in this study will last
approximately 60–90 minutes. Procedures will include a recorded interview
consisting of 20 questions and any needed follow-up.
3. There are risks from participating in this study. The most common risks are
recalling or reliving memories that may not be positive. Recollection may be
112

uncomfortable. More detailed information about the risks of this study can be
found under the “Risk and Discomfort” section.
4. The possible benefits to you for taking part in this study may include a sense of
empowerment resulting from discussing your personal your experiences.
You may not receive any direct benefit from taking part in this study. However, your
participation in this study may help us learn more reaching those who have been impacted by
the pandemic directly from the vantage point of a transgender person.
Detailed Information
Purpose
The purpose of this study is to highlight the lived experiences of transgender adults who
have experienced the transition process during the current pandemic. We hope to learn how the
pandemic has affected the transition process of transgender adults. You are invited as a possible
participant because you responded to a request for transgender participants who meet these
criteria. About 12–15 participants will take part in the study.
Procedures
If you decide to take part, this is what will happen:
• You will be contacted via email to schedule a pre-screening interview to determine
eligibility for participation.
• Once it has been determined that you are eligible for participation, a study interview
will be scheduled.
• You and the study investigator will meet via Zoom. Your location will be your
choice. The study investigator will be in a private location to ensure your
confidentiality.
113

• Interview will consist of 20 questions and any follow-up questions for clarification.
You will be given the opportunity to ask any questions before, during, and after the
interview.
• If you have agreed, follow-up contact may occur should other questions arise.
• Interview will be approximately 60–90 minutes in duration.
Risks and Discomforts
Possible risks and discomforts you could experience during this study include:
• Discussing your experience during the pandemic may be both positive and negative.
Recalling negative experiences may be uncomfortable and leave you feeling
vulnerable.
• Though all steps are taken to protect confidentiality, the use of the internet for
interviews involves potential breaches in confidentiality.
Surveys, Questionnaires, and Interviews
Some of the questions may make you feel uneasy or embarrassed. You can choose to skip
or stop answering any questions you don’t want to.
Privacy and Confidentiality
We will keep your records for this study confidential as far as permitted by law.
However, if we are required to do so by law, we will disclose confidential information about
you. Efforts will be made to limit the use and disclosure of your personal information, including
research study and medical records, to people who are required to review this information. We
may publish the information from this study in journals or present it at meetings. If we do, we
will not use your name.

114

The University of Southern California’s Institutional Review Board and Human Subject’s
Protections Program May Review Your Records
Your responses, which are also called “data,” and/or your specimens, such as blood or
tissue, which are also called “samples” will be reviewed by the study investigator and research
assistant only. Once recorded interviews are transcribed, recordings will be deleted. The research
assistant will review your transcribed interview which will be identified by pseudonym of your
choice. Names and identifying information will not be utilized in transcription. Your data
collected as part of this research will not be used or distributed for future research studies, even if
all your identifiers are removed.
Alternatives
There are no alternatives to participating in this study. Participation is not mandatory.
Payments and Compensation
You will be compensated with a $15 gift card for your participation in this research.
Voluntary Participation
It is your choice whether to participate. If you choose to participate, you may change
your mind and leave the study at any time. If you decide not to participate, or choose to end your
participation in this study, you will not be penalized or lose any benefits that you are otherwise
entitled to.
Contact Information
If you have questions, concerns, complaints, or think the research has hurt you, talk to the
study investigator Eva Estrada at estradae@usc.edu.
This research has been reviewed by the USC Institutional Review Board (IRB). The IRB
is a research review board that reviews and monitors research studies to protect the rights and
115

welfare of research participants. Contact the IRB if you have questions about your rights as a
research participant or you have complaints about the research. You may contact the IRB at
(323) 442-0114 or by email at irb@usc.edu.

Abstract (if available)

Abstract The discrimination and bias that transgender, non-conforming (TGNC) individuals experience in health care facilities is a concern that needs to be addressed. The purpose of this was qualitative study was to elicit the lived experiences of transgender young adults transitioning during the COVID-19 pandemic. The study consisted of interviews with eight adults, aged 18 to 25, who reported newly transitioning or continued transition during the pandemic. Semi-structured interviews consisted of 20 open-ended questions. Utilizing a conceptual framework centered in queer theory, analysis involved data coding of the interview transcripts, which generated thematic categories. Themes emerged that exposed providers’ inability to manage these patients’ level of introspection, to the point of not listening. Participants discussed resilience and the desire to take control of their transition process. Themes exposed increased introspection during pandemic isolation and the concerning cut-off from queer spaces. The recommendation that future research explore a more diverse group of individuals is primary. Centering the experiences of individuals of different ethnic backgrounds, socioeconomic statuses, education levels, and age groups would provide a richer understanding of the impact of COVID-19 on the transition process. This future research would also benefit from the involvement of transgender researchers.

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Asset Metadata

Creator Estrada, Evangelina (author)

Core Title Lived experiences of transgender young adults transitioning during the COVID-19 pandemic

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-08

Publication Date 07/20/2022

Defense Date 06/02/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag COVID-19,OAI-PMH Harvest,resilience,transgender,transition,Young adults

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Tobey, Patricia (committee chair), Andres, Mary (committee member), Cathers, Cadyn (committee member)

Creator Email estradae@usc.edu,evaestradalmft@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111373663

Unique identifier UC111373663

Legacy Identifier etd-EstradaEva-10883

Document Type Dissertation

Format application/pdf (imt)

Rights Estrada, Evangelina

Type texts

Source 20220721-usctheses-batch-958 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu