Discussion
During 2019–2020, transgender women participating in NHBS-Trans reported high prevalence of homelessness. Numerous personal characteristics and social factors were associated with longer duration of homelessness, with four out of 10 transgender women experiencing homelessness during the past 12 months (4), approximately three out of 10 experiencing 30–365 nights homeless, and approximately one out of 10 experiencing 1–29 nights homeless. Longer duration of homelessness was positively associated with younger age groups, lower educational attainment, income at or below the Federal poverty level, having a disability, experiences of abuse during the past 12 months, incarceration, eviction or denial of housing because they are transgender or gender nonconforming, and exchange sex. Longer duration of homelessness was negatively associated with social support. Efforts to prevent HIV transmission and to address housing instability for transgender women are urgently needed. These efforts should focus on systemic problems of economic instability, housing discrimination, and antitransgender discrimination that affect transgender women’s ability to access safe and affordable housing.
The proportion of younger transgender women experiencing homelessness, especially those aged <40 years, is of concern and is consistent with previous studies (21,22). Younger transgender women might experience a lack of familial support (23,24) and economic marginalization because of fewer employment opportunities and employment discrimination (21). Transgender youths experience higher rates of violence victimization, substance use, suicide risk, and sexual risk than their cisgender counterparts (25), which affect options for housing and employment. Transgender youths are also more likely to engage in survival sex, which is associated with homelessness (26).
Psychological distress was associated with longer duration of homelessness among transgender women. Multiple studies, including a systematic review that applied the minority stress model as a framework for reviewing 77 studies of mental health conditions among transgender or gender nonconforming persons (27), found mental health conditions and psychological distress to be higher among transgender women than among their heterosexual counterparts (28). Other researchers have found psychological distress, as identified in this study, to be associated with experiences of housing instability (27).
Social factors (e.g., low educational attainment) were associated with longer duration of homelessness, supporting the findings of a study that reported that young transgender women who had dropped out of school because of stigma or harassment for being transgender were more likely to experience negative consequences, including incarceration (29). Higher educational attainment directly affects employment opportunities and poverty status. Requiring training for teachers and administrators that focuses on strategies to reduce stigma, discrimination, and bullying in school systems could improve retention in school for young transgender women (25).
Social support was lower among transgender women experiencing longer duration of homelessness than among those not experiencing homelessness. A lack of social support for transgender women can increase depression and anxiety (30) and affect resilience (31), which are associated with housing instability. Further, social isolation can affect engagement and retention in HIV care and viral suppression for transgender women with diagnosed HIV infection (32). Family members, friends, health providers, and community members can access resources to self-educate and learn how to express support for their transgender loved ones (e.g., through resources for parents from the Trans Youth Equality Foundation [http://www.transyouthequality.org/for-parents] and PFLAG [https://pflag.org/glossary_term/transgender]).
Experiences of violence and abuse also were associated with longer duration of homelessness, indicating another layer of harm that can interfere with access to basic needs for transgender women. In this analysis, transgender women experiencing various forms of abuse, either physical intimate partner violence or forced sex, experienced longer duration of homelessness. More than half of transgender women who experienced any form of abuse during the past 12 months reported experiencing homelessness. These findings are supported by an analysis that reported rates of lifetime homelessness in the 2015 U.S. Transgender Survey were associated with all forms of interpersonal violence, including physical and psychological violence, and experiencing forced sex during the past 12 months (33). Certain transgender women might experience housing instability because of abusive partners (34). Transgender women who have experienced intimate partner violence might be deterred from seeking or have difficulty accessing intimate partner violence services because of transphobic discrimination or rigidly gender-segregated services (34). Further, transgender women often experience physical or sexual violence in homeless shelters; unsafe shelters can force them out on the street (35).
Another social determinant, housing discrimination, was prevalent in the sample; transgender women who were evicted or denied housing because they are transgender or gender-nonconforming had higher odds of experiencing longer duration of homelessness. These results are consistent with previous findings (9,26) illustrating that systemic factors driving housing instability (e.g., economic insecurity, housing discrimination, and antitransgender discrimination) are known barriers to housing for transgender women (36). The Fair Housing Act prohibits discrimination on the basis of gender identity (https://www.hud.gov/program_offices/fair_housing_equal_opp/fair_housing_act_overview); transgender women who have experienced housing discrimination can file a complaint with the U.S. Department of Housing and Urban Development (https://www.hud.gov/program_offices/fair_housing_equal_opp/online-complaint). Further, homeless shelters and domestic violence shelters and services can consider expanding services for transgender clients, ensure shelters and services are safe, and provide cultural competency training to staff members to better support transgender clients.
Incarceration was associated with longer duration of homelessness among the transgender women participating in this study. Incarceration among transgender women has been found to affect mental health (e.g., anxiety and depression) and substance use, and has been associated with homelessness, sex work, school dropout, and multiple incarcerations (29). Transgender women who are incarcerated experience victimization, harassment, and violence at very high rates (37). They are often misgendered, denied health care, punished for expressing their gender identity, and susceptible to sexual violence (https://www.aclu.org/news/lgbtq-rights/sex-work-is-real-work-and-its-time-to-treat-it-that-way). Additionally, the majority of NHBS-Trans participants were Black or Hispanic transgender women, who are targeted by law enforcement and incarcerated at high rates (38). Law enforcement policies and priorities that criminalize homelessness make transgender women experiencing homelessness, especially transgender women of color, vulnerable to harassment, policing, and incarceration (38). Addressing violence toward transgender women through education and training, public awareness, and policies that criminalize discrimination of transgender persons in schools, the workplace, and housing can positively affect housing stability and quality of life for transgender women.
Approximately half of transgender women who had exchanged sex for money or drugs had experienced 30–365 nights homeless. Discrimination and stigma in the workplace are often barriers to employment for transgender women, limiting options for income and encouraging engagement in sex work (39). Because of the illegality of sex work in the United States, sex work and incarceration are highly correlated, and both are associated with mental health conditions and sexual behaviors associated with HIV transmission (40). A cyclical relation between sex work and housing instability can exist if transgender women engage in sex work to generate income for housing. This type of survival sex for income interferes with housing stability and can affect mental and physical health outcomes and can increase chances of acquiring HIV infection (26,41). Another study found that transgender women who participated in sex work experienced lower social support and higher rates of violence, stigma, and HIV than their non–sex-working peers (42,43). Decriminalizing sex work and decreasing stigma and victimization could reduce criminal justice involvement among transgender women and facilitate employment and housing opportunities.
The findings in this study demonstrated that multiple personal characteristics and social factors are associated with longer duration of homelessness; providing stable housing for transgender women could improve physical and mental health outcomes and safety. Specific housing interventions could address different durations of homelessness, either short-term or episodic or longer-term or chronic homelessness. Transgender women who experience less than 30 days homeless could benefit from emergency assistance programs that provide support and services for rent or utilities to prevent eviction, the need to move frequently, couch surfing, and other circumstances that could lead to longer-term homelessness. Despite being illegal, stigma and discrimination in housing and employment based on transphobia (11) limit options for transgender women, decreasing opportunities for engagement in the licit economy. Stable housing, using the Housing First model that prioritizes safe and affordable housing with wrap-around social services for mental health and substance use, can improve quality of life and HIV outcomes (44). Approaches to treatment using a trauma-informed care model (https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf) specifically designed for transgender women can also be implemented to address a history of abuse and violence often experienced by transgender women. Structural interventions that address HIV prevention among transgender women need to focus on stigma, discrimination, and poverty (45). Forty-two percent of the participants in NHBS-Trans were HIV-positive and might qualify for the Housing Opportunities for Persons with AIDS (HOPWA) program (https://www.hud.gov/program_offices/comm_planning/hopwa). CDC funded a toolkit, developed by community partners, for providing HIV Prevention Services to Transgender Women of Color (https://www.cdc.gov/hiv/effective-interventions/prevent/toolkit-transgender-women-of-color/index.html). This toolkit, for use by community organizations, health departments, clinics, and other organizations that provide services for transgender women of color, outlines services and interventions to address important topics (e.g., healthy partner relationships, sexual risk behaviors, stress, social support, gender affirmation, HIV or STI knowledge, and engagement in care). Employing these varied evidence-based interventions could address certain social factors and personal characteristics affecting housing stability among transgender women.
