THE FALLACY OF "SYSTEMS LITERACY": HOW STRUCTURAL VIOLENCE IN SERVICE PROVISION AFFECTS THE HEALTH OF TRANSGENDER AND GENDER NONCONFORMING YOUTH EXPERIENCING HOMELESSNESS

Purpose: Clear health disparities exist both in transgender and gender nonconforming (TGNC) populations and for youth experiencing homelessness (YEH), and TGNC individuals are over-represented within populations of YEH. Many studies describe both homelessness and TGNC identity as risks for health disparities. However, no peer-reviewed research has yet explored the health disparities experienced by TGNC YEH, nor the structural factors that underlie risk for this population. Methods: We conducted a cross-sectional qualitative study aiming to describe key social and structural factors influencing the health disparities faced by TGNC 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 informants. Topics explored included physical and mental health, identity, causes of homelessness, survival strategies, HN risk, PrEP use, violence, stigma, and service access. Interviews were audio-recorded, transcribed, and double-coded. Salient themes were identified using a grounded theory approach. Results: We completed 26 in-depth semi-structured interviews with homeless transgender youth (n=19) and key informants (n=7). Youth participants included 6 transfeminine youth, 4 transmasculine youth, and 9 youth who identified as genderqueer, nonbinary, agender or multiple genders. The mean age among youth was 22.0 years, and just over half were non-white or mixed. Youth described that their physical and mental health was significantly affected by their ability or inability to navigate housing and health services, which in turn was affected by stigma around transgender identity and homeless status. Youth explained the conundrum they faced: they often lacked knowledge or training about how to navigate complicated, bureaucratic health and social services, yet that knowledge was essential to successfully procure secure housing, as well as transgender and general health services. As one nonbinary transfeminine youth said, "I feel like the level of care is varied, especially among the system - and it's just [some] people who can access it better, or are familiar with the system. What's available and actually get[ing] help to tell you what's available is really varied." Moreover, differential possession of that knowledge and a sense of deserving positive outcomes from systems engagement were tied to factors including race, disabilities