“It just feels right”: Perceptions of the effects of community connectedness among trans individuals

Trans individuals (e.g. trans men and women, non-binary, gender fluid) are at higher risk for mental health concerns, in part due to marginalization. Previous work has documented the effects of social support and community engagement on health outcomes. However, individuals’ perceptions of community engagement effects may point to opportunities for intervention. This mixed methods study examines trans individuals’ perceived effects of participating in trans communities on health outcomes. Semi-structured in-person interviews were conducted with 20 individuals, and 60 individuals participated in cross-sectional online surveys. Perceived discrimination had a strong negative association with self-assessed mental health. Effects of participation included a) positive: contextualization and normalization of experience, self-appraisal, safety, and relief; and b) neutral/negative: energy drain and stigmatization. Effects of not participating included loneliness, depression, isolation, hiding identity, and losing resources. Both discrimination and non-participation in trans communities had negative effects on mental health. Though community participation is often discussed as positive for marginalized populations, it may be important to include possible negative effects (such as energy drain) in research.


Introduction
Trans communities remain an understudied area of research, especially in relation to the effects of community participation and engagement [1]. Trans individuals refer to those whose gender identity differs from societal expectations based on sex assigned at birth (e.g. trans men and women, gender fluid, non-binary). Previous studies of trans individuals are typically focused on transition-related and HIV-related care [2]. Research shows that these individuals are at a higher risk of negative mental health outcomes. These effects may be explained through the minority stress framework, which describes how stress of marginalization within cisnormative (prioritizing and normalizing cisgender, or having one's gender correspond to their sex assigned at birth) societies can lead to negative health outcomes [3]. Another are feeling "overwhelmed and less resilient," and having a community to rely on allows them visibility within society [34]. Though definitions of communities vary depending on context, we use a broadly inclusive definition of a shared similarity between group members [35]. Community resilience is a recent shift in understanding various socioecological levels of resilience from individuals and families. Although subjective community experiences among trans individuals have not been described in academic literature, individual experiences of resilience strategies have [34]. Though trans individuals are not monolithic or a single community [36], it may be relevant to examine groups as an important facet of improving health outcomes among this population. The subjective experience of engaging in communities may influence the success of community resilience; in previous research on community resilience, individuals' sense of community could be used to predict disaster preparedness [37]. Therefore, understanding individuals' perceptions of community engagement may reveal opportunities for intervention and community approaches.
The purpose of this study is to examine trans individuals' perceived effects on health outcomes of participating or not in trans communities. We use survey data to examine the effects of discrimination and interview data to examine the effects of trans community participation. As the study is based in a large urban area in the South (Charlotte, NC), it may be important to describe some aspects of the general context. The racial and ethnic breakdown of Charlotte, NC is approximately 42% white, 35% black/African American, 14% Hispanic/Latinx, 6% Asian, 3% other [38]. The city is largely segregated socially by race and ethnicity, with different organizations focused on different groups. There is a prominent and active LGBTQ+ youth organization in the city but no LGBTQ+ support organization for individuals over 21 years of age. Our community partner for this study, Transcend, is a predominantly white local trans organization that holds bi-weekly support meetings both for trans individuals as well as family/partners/friends and has a clothing closet. Other trans spaces in the city at the time of the study include a comic book store and café, a trans women's support group, HIV service organizations, specific nights at various nightclubs and bars, and annual Pride events.

Materials and methods
This community-based participatory research study used semi-structured interviews (n = 20) and an online survey (n = 60). The interview guide and survey were developed by study authors JB and TL, based on existing literature and preliminary conversations with the community partner, a trans support organization. The community partner's leadership (two individuals) reviewed the guide and survey and made edits; due to time and financial limitations, we did not conduct a pilot study. Eligibility criteria for both the survey and interviews included being at least 18 years of age, identifying as other than cisgender (e.g. trans, genderqueer, etc.), living in the Charlotte, NC region, and an English speaker. Participants were recruited simultaneously for both methods through word of mouth and social media posts in LGBTQ+ and trans groups. Participants were selected if they met eligibility criteria. All protocols and procedures were approved by the Institutional Review Board of the University of North Carolina at Charlotte.
Potential interview participants were directed to an online screening questionnaire after indicating informed consent electronically. Interviews took place in private rooms within an LGBTQ+ community organization or on the phone for those in extenuating circumstances (e.g. lacking transportation; n = 2). The interviewer was a trans individual familiar with the community, identified by the community partner. Interviews lasted approximately 45 minutes and focused on experiences of community engagement and local trans organizations. Example questions included, "What are the effects on your daily life when you participate in gender diverse groups/services?" and "What are the effects on your daily life when you don't participate in gender diverse groups/services?" Participants selected their own pseudonyms and these are used in this paper. Participants received a $20 gift card for their participation. All interviews were audio recorded and transcribed verbatim.
Interview transcripts were coded using inductive thematic analyses [39] with Dedoose online qualitative analysis software [40]. Common ideas were grouped together to form "themes." A codebook was created based on the interview guide and then augmented during initial analyses. Two different trained coders coded each interview such that each interview was coded twice. Reliability was confirmed among the coding team using Dedoose's test function, with any codes corresponding to a Kappa of less than 0.80 discussed and refined until consensus was reached. Coders used "memo"ing, or digital notes tied to excerpts or interviews, to track their assumptions and biases while coding [41]. Initial analyses were presented as a summary report to the community partner's leadership for verbal feedback during an in-person meeting.
Surveys were conducted using Qualtrics online software. Survey questions focused on physical and mental health, discrimination, community connectedness, strengths and weaknesses of the community partner organization, and effects of participating with trans communities. Participants received $15 Amazon gift cards for completing the survey.
In addition to the qualitative analysis, a quantitative assessment of the influence of discrimination on both physical and mental health was performed. Survey data was mapped in ordered form so that higher values of the ordered variable were associated with higher levels of the underlying latent construct. A description of this mapping is found in Table 1. A latent variable modeling approach was designed to extract information from the categorical (ordered) survey responses into latent constructs. Associations between latent constructs were explored using the R package lavaan [42]. The latent variable discrimination was constructed from seven ordered responses, defined on a 6-point Likert scale, relating to the topic, and it was used as a latent covariate in regression against self-assessment measures of physical and mental health, defined on a 5-point Likert scale, provided by the respondents.

Results
A general overview of the themes and subthemes that emerged from this study is included in Table 2.  Table 3. All measures of discrimination reported in Table 1, with the first measure set to 1 for identifiability purposes, provided similar, statistically significant contributions to the latent construct, as reflected in Table 3. Negative values of the regression coefficients between perceived discrimination and self-assessed mental and physical health indicate that higher levels of perceived discrimination are associated with lower levels of self-assessed mental and physical health. While both estimated regression coefficients follow that negative pattern, only the one relating to the relationship between perceived discrimination and self-assessed mental health was statistically significant (β = -0.519; p<0.0001).

General connectedness
Interview participants in our study were predominantly white (n = 18, 90%), 23-30 years of age (n = 7, 35%), and trans women/feminine (n = 8, 40%) (see Table 4 for participant demographic information). In general, some participants reported it was difficult to discern the effects of connecting with trans groups because they had adjusted to a negative and stigmatizing normality. "I got so used to normal day-to-day life without a lot of exposure to other trans people. . .So, really it was kind of like living life. . . as a regular person" (S, 51-60 years, male (female to male; FTM)). Similarly, others had trouble describing effects because there was no distinction between when they felt connected or not to trans groups; these individuals had friends and family who were trans, and they were in nearly constant contact with trans Participants' level of engagement with trans communities varied, with some more deeply embedded in activism and advocacy and others hardly involved with other trans individuals. Amy (51-60 years, male to female (MTF) trans) spent most of her time disconnected from trans communities: "Considering that I am not out professionally at all, assuming that I'm not  Table 1 regarding the Likert-scale questions in the questionnaire. Boxed numbers represent the model estimates, as listed in Table 3.
https://doi.org/10.1371/journal.pone.0240295.g001 working on the weekends, the weekends is all that I have. Weekends and evenings once I get home." Amy's disconnection was, in part, tied to her belief that individuals navigate their own paths, but she looked forward to connecting with more trans people through a support group.

Effects of trans community connection
Many participants described their connection as making them feel better, "balanced" (Jim Henson, 23-30 years, nonbinary), or "bolstering their emotional health" (Gio, 18-22 years, nonbinary/agender). Part of this was in relation to contextualizing their experiences.  One facet of social support can be assisting in self-appraisal. Elizabeth describes seeing themselves as a resource, which may be tiring while also affirming.

"I guess my participation in gender diverse groups or services is very different from someone who relies on them as a resource, because in many cases I am the resource. My phone goes off
constantly. There's always somebody popping up in my messenger." (Elizabeth, 41-50 years, transfeminine nonbinary) Their networks were constructed through involvement in trans communities. Trans community connections normalized and validated participants' experiences. Online communities were helpful for general information finding (such as hormone advice) and for a wide variety of identities.

"I was really afraid to transition for a long time because I thought that because my sister is trans, because my partner is trans, that it wasn't okay for me to also be trans. And I think that hearing from other trans people, that's another place where the internet portion comes in, because there's not a whole lot of people in the whole world whose sibling is also trans. But if you're going to find them, you will find them online and I'm not the only one and that's pretty encouraging." (Jeff, 23-30 years, genderfluid trans man)
The mere fact of others' existence was enough to normalize a wide range of experiences.
"It was enough confirmation that there were other people, that it wasn't necessarily something that I needed for support. At the same time, I was just transitioning and I just had some chest surgery, so it was kind of a confirmation or affirmation of who I was. . . but something that, 'wow, there are other people like me.'" (Cooper, 41-50 years, male (FTM)) Similarly, participants described a freedom of expression in their communities not only in identity and appearance but also ideas. "I just like scrolling through my feed and it's nice. . .I like seeing content that is both body and size positive and trans positive 'cause that's something that I struggle with." (Gio, 18-22 years, nonbinary/agender) This was related to participating in both online, as well as virtual, groups (such as a local trans community Discord group, a chat app that allows users to create anonymous profiles).

"Through the Facebook page, it was always kind of tough. I did some through the messenger there. For some reason, that didn't seem as 'let your hair down' kind of thing. Whereas [with] the Discord server, I jump on and I'm part of any conversation I want to be in and they know me and I know them and it's more of a conversation." (Nicole, 41-50 years, trans woman)
They could also learn about others' gender diversity through the full range of identities participating in their communities. Unsurprisingly, participants often described feeling safety and relief from the risks and stress of their lives outside of trans communities. "I know that I have something that week where I can comfortably be myself; so, even if I am having one of those terrible days at work or with my parents, then I at least have that relief coming." (Chaucer, 23-30 years, genderqueer/ gender fluid) For Max (23-30 years, nonbinary transmasculine), this was relief from constantly having to be the only trans, or even LGBTQ+, person at work or in spaces, "I'm usually the only trans person in a room and that's exhausting; so, I love being around other trans people who are just living their lives, and I'm like 'Thank God.'" Not all of the effects of participation were fully positive. One neutral effect was the drain of social interaction, though trans community participation was also regenerative. "While I can't come to [community organization] every week because of my social battery,. . .going to gender diverse groups gives me energy a lot. It takes energy to get here, but it gives me energy in return." (Mike, 18-22 years, gender changes daily but masculineish sometimes) There were two types of negative effects identified by participants. The most common was that hearing others' similar negative experiences (such as stigma or family trouble) was triggering, and participants sometimes felt exhausted or sad because of the triggers. Moreover, action steps in relation to these negative experiences were often not discussed.
"I find that when we are just getting together and having fun, I find those like really, really refreshing. And I do want to seek out spaces where trans people are trying to learn how to cope with trauma, but I haven't found a space that does it in a way that I think is actually healthy." (Max, 23-30 years, nonbinary transmasculine) A second negative effect was that being in a group of trans individuals in public can be more stigmatizing than just being by oneself.

Effects of not connecting with trans communities
Nearly universally, participants said that when they did not connect with trans communities or groups, they felt lonely. "I get depressed. I get very-I don't want to say irritable, but I get very sensitive to things." (Nicole, 41-50 years, trans woman) Participants also described feeling more guarded. "I become a little bit [more] guarded. I'm more comfortable and at ease amongst those of my own kind, basically." (Wonder Woman, 51-60, elder trans woman) Participants said that when they felt less connected to trans groups or communities, they began to isolate themselves in general. "I am just kind of like, more reclusive and lonely 'cause coming to [community organization] right now is one of my main social outlets. So, I would just be kind of a shut in." (Mina, 23-30 trans woman) This isolation resulted in the loss of relationships for some, like Susan. "I kind of lose touch. I isolate. I do forgo and sometimes get way too lost and everything else. . .so, the loss there is just really relationships." (Susan, 31-40, transgender female) More specifically, some participants said they began "hiding" in relation to their gender identity, as Nicole (41-50 years, trans woman) says, "I go back into hiding once I leave here." This 'hiding' meant not expressing themselves as fully, or correcting people when they are misgendered. Participants described this as detrimental and grief-causing. Scotland reported feeling "shitty" when they are less connected and do less advocacy for themselves.

"The lack of participating in these groups is what gets me. It irks me, and I know a lot of it is on me, but I always have this kind of itty bitty internal knee jerk when anyone refers to me as 'Mr' or use male pronouns. But part of the reason they do is because I haven't corrected them. And the reason I haven't corrected them is, frankly, I don't want my head broken and I want my contract renewed. . . And that's a shitty way of hiding in the patriarchy." (Scotland, 41-50 years, agender)
Related to isolation, participants had trouble finding resources in the community because they were less connected with trusted individuals to whom they could turn for ideas and referrals. S described what would be lost if he was not connected with other trans individuals in the community.
"[Local groups are] good for local resources, because sometimes you look for resources and either you can't find it in your area or it's dated or the doctor is no longer practicing or has moved. So it's nice here that you have all of that information you can access and it's local and its current." (S, 51-60 years, male (FTM)) When they were not as connected to trans communities, participants' work or daily lives became more encompassing. This was often described as problematic because these spaces were stigmatizing or non-affirming.

Discussion
This study provides evidence of positive effects from community connectedness for trans individuals. The vast majority of participants reported that they noticed the effects on their lives when they did or did not participate in trans communities. Participants described effects on their own mental health, but also how community engagement built their social support networks which may be an important aspect of resilience. Previous reviews have documented how community engagement positively affects physical and psychological health [among African American women, 43], self-confidence, self-esteem, sense of personal empowerment, and social relationships [44]. Participants were less likely to describe effects that were prosocial, or focused on helping others; though a few participants mentioned that they were a resource for others, they did not discuss this as a benefit. Other studies have found cultivating empathy and providing support to others as themes of community support among trans individuals [45].
Hendricks and Testa [46] report that disclosing gender identity may facilitate community resource utilization. Given that participants in our study discussed learning about gender identities and receiving self-appraisal support, they may be navigating their own gender identity. Thus, the barrier of self-disclosure may be problematic for those who most need community. In other words, trans individuals without language to talk about their gender identity may be less able to access community yet in need of resources and support. Participants in our study described some negative effects of engaging in trans communities, such as being triggered by negative events or emotions that were similar to their own. Other work with trans individuals found competition in groups, of being "trans enough" [45]; participants in the current study did not discuss this, in part perhaps due to the diversity of gender identities present in the group. In community organizing or support, it may be important to build skills around coping with vicarious trauma [occuring from working with individuals with trauma; 47]. Or, as Max discussed, ensuring that trans individuals have different ways of interacting other than sharing negative experiences. As Mike described the energy drain of participating in groups, this may have implications for collective action. Previous work has identified how trans people of color can be drained from activism efforts [25,48]. This may be tied to findings that higher levels of antitrans discrimination are associated with collective action [49].
Emotional support was the most common benefit from community participation, and reported as a loss when not participating in trans communities. This was described as validation, freedom of expression, and empowerment. Furthermore, participants described informational support in obtaining referrals for local providers or resources; this can also be described as "investing in community knowledge" [45] as individuals continue to share this awareness within and among trans groups.
Matsuno and Israel's [50] transgender resilience intervention model highlights community resilience and intervention opportunities for trans individuals. Group interventions include group therapies and support groups, mentoring programs, and/or family/couples' therapy. As many participants in our study appreciated learning about other trans identities as well as describing being triggered by others' experiences, interventions that offer distraction, are socially focused, or non-therapy focused (such as outings to restaurants or game nights) may be important interventions for positively supporting trans individuals. Further, Case and Hunter [51] describe the power of "counterspaces" in supporting positive adaptation for marginalized individuals by "challenging deficit-oriented narratives." We find evidence of all of the counterspace framework domains: narrative identity work in which participants described learning about others' identities, acts of resistance in which participants described the value of freedom of expression that are not sanctioned in larger society, and direct relational transactions in which individuals offer social support, safety, and security.
Trans community interventions may expand outside of in-person modalities, including virtual and online. As Metthe [45] points out, online communities are a key part of trans social support. Though we did not specifically ask about online networks, many participants in this study differentiated the benefits of in-person communities (deeper connections, being known), virtual communities such as Discord chats (easy access, anonymity, local knowledge), and online communities (wide range of individuals, numerous communities). In localities where individuals have limited transportation access or with widespread geographic areas, virtual and online communities may become more salient.
In addition to the qualitative analysis of connectedness, we identified a strong quantitative association between perceived discrimination and self-assessed mental health; though, a similar statistically significant result was not confirmed for the association between perceived discrimination and physical health. This relationship between discrimination and mental health is reported in other samples of trans individuals [5,52]. This may be a factor of both a potentially weaker negative association between perceived discrimination and physical health, as well as the smaller sample size of the study. Within the qualitative results, we see participants more focused on mental health impacts than physical health; the one subtheme that connected with physical health was that participants had difficulty finding resources (including healthcare providers) when they were less connected to the trans community. The impact on self-assessed mental health of any perceived discrimination, and the potential impact (primary or secondary) of this association on self-assessed physical health, should grant further study in this area. These results serve a dual purpose: (1) they provide further evidence of the hypothesis that discrimination has a negative impact on mental health; and (2) they can serve as a pilot or feasibility study, providing measurable outcomes that can help assess statistical power in future studies on the impact of discrimination on both physical and mental health within the trans community.

Strengths and limitations
This study used community-based participatory research approaches and a diverse research team, which may have increased the validity of our findings. However, as most participants were connected to the community partner, our findings may reflect experiences of trans individuals who are more involved in trans communities. Because all in-person interviews were conducted at the community partner location, this may have excluded the experiences of those uncomfortable with the organization. Individuals who are less connected may not notice or experience the same benefits of participating in trans communities. Interview participants were mostly younger and white, in part due to our community partnership and recruitment through social media.