15. The Fallacy of “Systems Literacy”; How Structural Violence in Service Provision Affects the Health of Transgender Youth Experiencing Homelessness

Abstract

Clear health and mortality disparities exist both in transgender populations and for youth experiencing homelessness (YEH). Furthermore, transgender youth are overrepresented within populations of YEH. However, no peer-reviewed research has yet explored the structural factors that underlie health disparities experienced by transgender YEH. We conducted a qualitative study to better understand the mechanisms by which structural factors cause health disparities in a population of transgender YEH in the San Francisco Bay Area. Semi-structured, in-depth interviews were conducted with (1) youth ages 19-24, recruited through flyers at service provision sites and via snowball sampling, and (2) key stakeholders. Topics explored included physical and mental health, identity, causes of homelessness, survival strategies, HIV risk, violence, stigma, and service access. Interviews were audio-recorded, transcribed, and double-coded. We conducted a grounded theory analysis of our data. We completed 27 in-depth semi-structured interviews with transgender YEH (n=20) and key informants (n=7). Youth participants included 6 trans women, 3 trans men, and 11 youth who identified as genderqueer, nonbinary, agender or multiple genders. Youth’s median age was 22 years, and two-thirds were people of color or mixed. Youth described within-group differences in health and social service systems success and outcomes, tying these differences to a structurally-produced set of skills, attitudes, knowledge, and other traits that allow them to successfully access systems – a concept we are naming “systems literacy.” Systems literacy affected systems access, which ultimately impacted trans YEH health, and was itself shaped by structural factors including bias and stigma, criminalization, formal education, childhood economic class, and social ties. Youth also offered systems access-focused recommendations for health and social service provision organizations. Trans YEH face significant health disparities, mediated by social and structural determinants of health, including structurally-produced systems literacy. In coining the term systems literacy, we frame systems literacy as a structural determinant of health and a form of structural violence. In addition, we aim to draw attention to the bias inherent in systems that require subjects’ systems literacy as a prerequisite for systems success and health. Incorporating feedback from trans YEH, we point to modifiable targets for intervention in health and social service provision, toward decreasing systemic violence, decreasing risk exposure, and improving health for trans YEH and diverse marginalized populations.