Eliciting critical hope in community-based HIV research with transgender women in Toronto, Canada: methodological insights.

Critical hope centres optimism and possibilities for change in the midst of struggles for social justice. It was a central tenet of early participatory pedagogy and HIV research. However, critical hope has been overlooked in contemporary HIV research that largely focuses on risk and biomedical interventions in ways that obscure collective agency and community strengths. We conducted a community-based study with transgender (trans) women of colour in Toronto, Canada to adapt an evidence-based HIV prevention intervention. Participants resisted a focus on HIV, instead calling researchers to centre journeys to self-love in contexts of social exclusion. In response, we piloted three arts-based, participatory methods generated with community collaborators: (i) affirmation cards sharing supportive messages with other trans women, (ii) hand-held mirrors for reflecting and sharing messages of self-acceptance and (iii) anatomical heart images to visualize coping strategies. Participants generated solidarity and community through shared stories of self-acceptance within contexts of pain, exclusion and loss. Narratives revealed locating agency and self-acceptance through community connectedness. Critical hope was a by-product of this participatory process, whereby participants shared personal and collective optimism. Participatory and arts-based methods that centre self-acceptance and solidarity can nurture resistance to pathologizing discourses in HIV research. Centring critical hope and participant-generated methodologies is a promising approach to transformative health promotion and intervention research. These methodological insights can be engaged in future participatory work with other marginalized groups facing dominant biomedical risk discourses. Critical hope holds potential as a participatory health promotion strategy for envisioning possibilities for sustainable change.

INTRODUCTION

I am hopeful, not out of mere stubbornness, but out of an existential, concrete imperative. I do not mean that, because I am hopeful, I attribute to this hope of mine the power to transform reality all by itself, so that I set out for the fray without taking account of concrete, material data, declaring, ‘my hope is enough!’ No, my hope is necessary, but it is not enough. Alone, it does not win. But, without it, my struggle will be weak and wobbly. We need critical hope the way a fish needs unpolluted water [(Freire, 2014), p. 2].

Critical hope centres optimism and possibilities for change in the midst of struggles for social justice. Developing critical awareness of social injustices, alongside developing strategies to negotiate, navigate and resist these injustices, are components of critical hope. While critical hope, as Freire (Freire,2014) describes above, is a key element of social change, it is not enough on its own. Freire conceptualized an ontology of hope needed for social justice work.

The concept of critical hope focuses on recreating the world in ways that advance social justice, thus is distinct from false, naïve or simplistic approaches to hope (Freire, 2007). The goal of this pedagogy of hope is not to teach or give hope to others, but rather to awaken and activate it. How researchers can engage with critical hope, and particularly what methods can stir up critical hope for social justice aims, is a salient area for inquiry. Participatory methods are well-placed in critical hope research and practice, as they can be utilized as a way to stimulate hope (Freire, 2014). As conceptualized by Freire, participatory methods include a cyclical process of listening and centring community needs and priorities, producing opportunities for dialogue to enhance critical reflection of one own’s experiences of inequality, engaging in actions for social change, and reflecting on these actions before again engaging in this process (Wallerstein ). The framing of critical hope as belief in the possibility of change in contexts of social injustice is particularly relevant for addressing the social inequities, discrimination and violence experienced by transgender (trans) women of colour. This is salient for the context of HIV research with trans communities who face overrepresentation in the HIV pandemic largely due to social and structural inequities such as pervasive stigma, discrimination and violence (Poteat ).

Trans women’s lives are shaped by social, economic and health care systems that often exclude them (Neumann ; Nuttbrock and Hwahng, 2017; Poteat ; Clark ). Marginalization, stigma and violence experienced by trans women result in reduced access to social and economic capital and health resources, such as employment, housing and healthcare (Nuttbrock and Hwahng, 2017; Poteat ). Intersections of social marginalization, including racism, trans stigma, HIV-related stigma and cisheterosexism create hostile social conditions for trans women of colour and signal the need for approaches, such as critical hope, that can be leveraged as a tool for social justice and change including, yet extending beyond, the context of HIV. Researchers can apply a lens of critical hope to illuminate social inequities and resistance to structural systems of oppression.

Conceptualizing critical hope in the context of HIV and trans women of colour

Critical hope was a central tenet of early participatory pedagogy and HIV research. For instance, Simon Watney’s (Watney, 2000) book ‘Imagine Hope: AIDS and the Gay Identity’ situates hope as central to healing, yet also precarious, before there was highly active antiretroviral therapy (ART). The emergence of ART was cause for greater hope, as reflected by the 11th International AIDS Conference 1996 theme of ‘One World, One Hope’ (Holzemer, 1997). However, the hope and promise for ART to address the HIV epidemic is shaped by larger social and structural environments which may sustain or constrain hope. Stable and secure access to HIV care systems may sustain hope, while precarious, fragile health systems characterized by treatment disruptions and uncertainty may constrain hope (Bernays ; Rhodes ). Hope is also key to HIV prevention, as social environments that produce positive, future-oriented expectations and aspirations help people to adopt new practices—including investing in HIV preventive practices (Bernays ).

Few examples from recent HIV research make a case for the continued relevance of critical hope (Abler ; Hill ). Barnett et al. (Barnett ) examine Uganda’s HIV response in rural populations, documenting associations between hope with structural factors including home and land ownership, agency through social support networks, and optimism through perspectives on life. A study with people living with HIV in South Africa explored social environments associated with hope, finding that peer adherence support alongside well-functioning families were linked with higher hope, further underlining the important role of relationships in influencing experiences of hope (Masquillier ). These findings suggest that hope is shaped in larger social and relational contexts and may be a useful concept to understand and leverage to advance HIV prevention, while simultaneously engaging in broader work that illuminates social inequities and areas of concern beyond HIV.

Social and structural forces produce social and health disparities across global contexts among trans women, and trans women of colour specifically, including their overrepresentation in the HIV pandemic (Poteat ). Yet there is limited attention to strengths-based approaches in HIV research among trans persons. Indeed, a scoping review that explored strengths-based health promotion approaches to understanding and assessing lesbian, gay, bisexual and transgender (LGBT) health noted an overemphasis on risks and deficits that can obscure resilience and coping (Gahagan and Colpitts, 2017). Similarly, others call for a focus on positive psychology principles, including hope and love, in LGBT affirmative practice to counteract the heteronormative, cisnormative and often deficits framing of LGBT mental health (Lytle ). Gender affirmation, when transgender persons’ gender identity and expression are validated, recognized, and valued in their social environments is linked with psychological wellbeing (Glynn ), as well as HIV testing and prevention (Jennings Mayo-Wilson ; Lelutiu-Weinberger ). Studies with trans women highlight preferences for interventions that facilitate connection, community and empowerment (Kuhns ; Garofalo ; Sun ; Sevelius ). Hope is also key to community building, and solidarity, community and care can guide social justice movements and produce individual and collective awareness of community interbeing (hooks, 2003). Intersectional movements have long heralded the need for hope for the possibility of change and collective liberation, including the Black feminist Combahee River Collective statement that described: ‘We are dispossessed psychologically and on every other level, and yet we feel the necessity to struggle to change the condition of all Black women’ [(Collective, 1981), p. 239].

Critical hope is understudied in HIV research and practice. This is particularly true with trans women, who are often characterized in terms of HIV acquisition risk rather than as holding personal and collective strengths and resources (Poteat ). To address this knowledge gap, we conducted a multi-method community-based research study to develop and pilot arts-based approaches to address social contexts of HIV with transgender women of colour in Toronto, Canada. Specifically, the objective of the present study is to explore how participatory, arts-based methods can be applied as communicative tools in HIV prevention research with transgender women of colour in Toronto, Canada. We report on empirical and methodological findings and highlight potential applications for future research with particular attention to critical hope.

METHODS

Design

We conducted a community-based study with transgender (trans) women of colour in Toronto, Canada with the objective to adapt and pilot-test an evidence-based HIV prevention intervention. The intervention development implementation science methods (step 1 and 2) have been published elsewhere (Logie ). Briefly, we undertook a three-part process to developing the TRANScending Love intervention. The first step involved conducting a focus group with African, Caribbean and Black women in Toronto, with the aim to identify HIV prevention priorities and adapt the United States Centre for Disease Control (CDC) intervention Trans Sisters Informing Sisters about Topics on AIDS (T-SISTA) developed for African American trans women (Guiterrez-Mock ) for the Toronto context. Focus group participants (n = 8) expressed disinterest in an HIV-risk focused intervention, calling instead for researchers to centre journeys to self-love among trans women in contexts of stigma and social exclusion. In response, the second step was to work with two trans women community leaders and research team members (including study co-authors) to generate ideas for an intervention to address this call for attention to self-love in stigmatizing contexts. Through this consultation, the team developed three arts-based methods (described below) to pilot-test with trans women of colour. The third and final step was to pilot-test these arts-based methods in three workshops. Workshops were approximately 3 h; this time included 60–90 min to conduct the arts-based activities, followed by a 15–20 min break, and then a 60 min focus group to share the arts products and reflect on their experiences. Workshops were audio-recorded and transcribed verbatim, participants completed a brief socio-demographic form, and arts products were photographed.

Research ethics board approval was obtained from the University of Toronto and participants provided written informed consent prior to participation. Purposive sampling with trans research team members, listservs and agencies serving trans women (an LGBT centre, a sex work outreach centre, and an African and Caribbean AIDS Service Organization) was used to recruit focus group and workshop participants, and persons could take part in both stages. Inclusion criteria were being 18 years and older, able to provide informed consent, identifying as a trans woman or a person with transfeminine experience, and identifying as being African, Caribbean, Black and/or a person of colour.

The research team consisted of individuals with unique and overlapping positionalities to the participants that shape our work. We are white and Black researchers and activists with diverse sexualities (gay, lesbian, bisexual, queer, heterosexual), gender identities (cisgender, trans), and genders (men, women). Reflexive memos were written to document and consider analysts’ reactions and thoughts to participant data, ongoing conversations with the team were held to ensure data adhered to participants’ stories, and reflexive questions were posed to team members to better understand how positionality might impact analysis (Mauthner and Doucet, 2003). We conducted thematic analysis (Attride-Stirling, 2001; Braun and Clarke, 2006) of the reflections on the arts activity products, analysing the transcript as well as the art products’ visual and/or written messages. Participant descriptions of the art products they created alongside the products’ visual/written components can also be considered production texts (Fiske, 2010). Production texts are visual approaches to engage participants in research through creative and productive methods (Mitchell, 2008). Following thematic analysis steps, two investigators reviewed the transcripts and accompanying arts product to note ideas for initial codes, developed preliminary codes by noting examples from the data, synthesized codes to produce larger themes across the dataset, and finally produced a thematic map and worked with the larger team to refine themes and illustrative examples (Attride-Stirling, 2001; Braun and Clarke, 2006). Themes were shared with other team members, including trans women community leaders, for feedback and interpretation as a form of member checking (Barusch ).

Arts-based activity descriptions

Three arts-based activities were developed in the consultation (step two above). These included hand-held glass mirrors with which participants were invited to reflect on their strengths and to use glass markers to write affirming messages to themselves and to decorate the mirror. The second activity was drawings of anatomical hearts with stickers, markers, coloured pencils and crayons to colour, decorate and express the ways in which participants coped with stressors and challenging emotions that may constrain possibilities for self-love or be ‘stuck’ in their hearts. The third activity included providing blank affirmation cards, with the words ‘you are loved’ on each card and lines where participants were encouraged to write messages of support and solidarity for other trans women. The goals of these activities were to provide a space for reflecting on journeys to self-acceptance and the ways in which participants navigated stigma and other life challenges, and to build opportunities for social support and connection among trans women of colour.

RESULTS

Workshop participants’ (n = 18; mean age: 32.4, standard deviation: 9.4) gender identities included women (n = 12) and other gender diversities (n = 5), and most identified as immigrants (n = 12). Ethnicities included Caribbean (n = 6), Indigenous (n = 3), Latinx (n = 3), African (n = 2), Asian (n = 1), South Asian (n = 1) and one as white (n = 1; with guidance from trans team leaders this participant was allowed to stay). Further participant demographics have been reported elsewhere (Logie ).

Three themes were identified across data sources: self-acceptance, community connectedness and optimism. These themes are interconnected and discussed in relationship with one another to reflect critical hope. First, participants shared stories of self-acceptance within contexts of pain, exclusion and loss. Participant narratives explained that self-acceptance and love is often not taught to trans women and instead was learned by themselves and in relation with others in the trans community over time. Second, narratives revealed the ways in which participants located agency and self-acceptance through community connectedness, and that to be able to better support one another, trans women need to feel self-acceptance and self-love. The third theme reflected critical hope, whereby participants shared personal and collective optimism. Through learning self-acceptance and love, hope for the future grew, both for themselves and other trans women who may not yet have experienced self-acceptance, love and support. Illustrative quotes and selected images of participant art products are presented to ground the interpretation in the data and evoke emotion.

Self-acceptance: ‘I saw the best person in the world in the mirror’

Participants shared stories of adversity and described the ways in which they developed self-understanding and acceptance when growing up in contexts characterized by rejection and violence from social networks. Narratives across participants noted that self-acceptance was a journey and at times took many years. Several participants reported being deprived of love from families and friends when they were younger, which led to learning the need to love oneself. A participant who wrote on her mirror ‘I love me some me’ described her mirror to the group:

I think the reason why I'm so strong it because I start loving me from a very young age, not thinking about what my mother thinks, my family, the society, I start loving me, because they were not giving me the love that I needed. And I tried loving, taking loving from a man, taking loving from the society, taking love from the parties, but that was not enough. Because I still was feeling incomplete (ID #11).

When describing this journey to self-acceptance while presenting her mirror art, a participant who wrote on her mirror ‘Beauty is in the eye of the beholder’ noted that she realized self-acceptance when shifting from trying to align with societal expectations of femininity to accepting herself as beautiful the way she is:

I think when you are beginning to transition, I think the aim is to look more feminine, and I think that's a challenge other trans have, and I think that's what break a lot of us. Because we think, we think in order to be trans we need to be, we need to look a certain way, or we need to fit a certain type of woman. But in reality, there are various types of women, so, when you're look in the mirror you're going to see you. And when you see you, you should see beauty (ID #04).

This sentiment of self-acceptance in the present was also shared by a participant (ID #06) who wrote on her mirror (see Figure 1); ‘I am a trans woman. Take me as I am’.

Fig. 1:

Mirror of participant 06.

Others similarly described that they embraced being unique, not meeting societal expectations, and finding strength by loving themselves in spite of rejection. Most women were taught a limited perspective of what a woman is and is supposed to be. This led to negative perceptions of their bodies. A participant (ID #16) who wrote ‘Unique. Important. Special’ on her mirror described:

I always had a very low self-esteem. But it's like one day I woke up and I realized I can't change who I am, I can't change my height, or my skin, you know?… I think we just buy into these things that society wants, you're only passable if you're 5ft nothing, or if you're this weight, or if you're this height. It took me a long time to love myself to where I'm at, and once I started doing that I just, I'm unstoppable…it allowed me to actually go for what I want and change people's ideas (ID #16).

This participant also noted sharing this self-acceptance and embracing being unique with others:

I’m glad to be the only person that looks like this (laughs), you know what I mean? At one time I wasn't, you know what I mean, so I'm so happy and that's something I really relay to people, that we're all unique, and we're all beautiful and we're all important (ID #16).

Others noted the importance of patience on the journey to self-acceptance. For instance, a participant who wrote ‘I love Trans’ on her mirror discussed how her transition was key to self-acceptance, as was patience:

I mention that patience is love, that can be attributed to my transition. I believe that in the beginning was a bit… like, is this going to work? What's going to happen? And then I said that even though I have been denied of love for various reasons, I believe that love is everywhere and we should take time to really, to discover it (ID #03).

Others described self-acceptance and self-love as a way of resisting external challenges and struggles. For instance, a participant (ID #05) who wrote on the front of her mirror ‘This is the best in you’ and on the back ‘Spread your wings to fly’ described her mirror in this way:

I saw [an] amazing person in the mirror. Amazing person, who go through a lot of shit in her life. And, still she is standing, herself. And you know, I felt like, I saw the best person in the world in the mirror.

The same participant, when describing her anatomical heart to the group revealed the power of self-love and identifying as a survivor in a challenging world. The journey of self-acceptance was often described as ongoing and continued work amid challenges and daily negative encounters. Participants learned to survive, love and accept themselves, specifically as trans women. A participant (ID #02) described the words inside her anatomical heart that are depicted as blocking the arteries:

What is talking in my heart, it does not belong to me, because it belongs to the society: law, anger, fear, transphobia. You know, I don't deserve that because I don't feel that way. I know who I am - I am a trans person, and I love to say it, I'm a trans person, because I feel unique, I feel authentic… I'm different than everyone else, men and women, you know? It's like I'm happy the way I am born, really. Cost me a lot of time to find out that, but in the end I love myself, I love who I am, I love to be trans, I love to be a trans woman of course (ID #02) (Supplementary File S1).

In sum, when sharing mirrors and anatomical hearts, participants reflected on social exclusion trajectories from childhood continuing into adulthood and finding acceptance and appreciation for being trans over time. This acceptance was nurtured from being in the present, recognizing societal expectations and seeing the value of being unique, and from naming societal challenges (e.g. ignorance, transphobia) and separating themselves from that.

Acceptance through community connectedness: ‘rise each other up more’

Participants described the need for a foundation of self-care in order to care for others in their communities. They shared their personal feelings of self-acceptance along with hopes that others might find the same acceptance. For instance, a participant (ID #02) who wrote ‘I love trans’ in her mirror described this message and the aspiration that other trans women could feel this same self-acceptance:

I wish every trans person see what I see in the mirror, you know? Because the majority of the community look in the mirror like I did in the beginning- [I am] no good, because I don't belong in this body. I was born in a different era, and different and difficult life, but even like that I still love myself (ID #02).

Participants expressed wanting to share their joy and experiences with other trans women. They explained that connecting with other trans women was important to support journeys to self-acceptance due to a lack of societal support and social exclusion. As a participant explained when describing her mirror:

The message says ‘you are worth it’ or it should have been ‘I am worth it’. But I feel like that’s really important in terms of how we as trans folks value ourselves and the value that we receive from society, and sometimes we don't always receive the love and the worth and the value from society, and so for me, this has been a message that has been on my mind recently, that I'm worth it, we are worth it (ID #12).

This participant applied her message of worthiness to both herself and to other trans women, intricately connecting her own worth (‘I'm worth it’) with the worth of other trans women (‘we are worth it’). Similarly, another participant (ID #13) who declared in writing on her mirror ‘You were made for this!’ shared how she hoped her confidence could inspire others:

The message that I thought of that was a message for myself is, ‘you are made for this’, just you know, whenever I’m not feeling totally confident in the morning or if I have something to do I'm just like ‘no, no, you got this, you’re good, you can do it’. So, that is also something I really hope somebody else can see and take some inspiration from (ID #13).

Participants also wanted to stand up to violence and mistreatment so that other trans women would not face the same challenges. For instance, a participant described how her courage to stand up for herself in public spaces was interconnected with her concerns for other trans women who did not feel safe to do so:

When people meet me and say ‘oh you’re so brave’ it’s like, for what? For being me? So, I don't see dressing up and getting out and doing what I have to do as being brave. I just be myself, and represent the women who don't feel the same way, and don't have that courage to take the subway [public transportation], to go to the mall. I do that for them, and I tell people every day, I stand up for people who are unable to do this, and I know there is a lot of girls who doesn't have the confidence to get on the subway (ID #06).

Others also shared the important ways that trans community members supported one another to maintain self-acceptance and worth in larger contexts of violence. To illustrate, a participant who wrote ‘Your life matters, love yourself’ on her mirror explained:

There's always so much coming at us, so much hate…So being able to stop that and rise each other up more, like bring each other’s spirits up and bringing people's self-worth up. Cause not all of us have the same level of self-respect and self-endurance, so I feel like that's important (ID #15).

With the opportunity to share what they would say to other trans women through affirmation cards, participants demonstrated the importance of community connectedness. For instance, affirmation cards shared messages of encouragement (‘Girl, get your life’), validation and appreciation (‘you are beyond beautiful’, ‘your existence is a gift’) and the importance of self-love (‘love yourself unconditionally’ and ‘acceptance and approval comes from within’). In another affirmation card, a participant shared: ‘You are so special to me. Your beauty is unique in this world. You are a star in my sky. Your heart is an ocean. I love you because I feel you’.

In sum, participants discussed their own self-care journeys and wanting to share these journeys of self-acceptance and self-worth with other trans women as a source of inspiration and because they recognize their interconnectedness with other trans community members. Yet the examples participants provided also signalled that this commitment to the trans community extended beyond self-acceptance to include social acceptance, such as being visible in public spaces in order to create social change by expanding opportunities for social inclusion among trans women at large.

Optimism: ‘it will get better’

Participants described both personal, individual optimism as well as a collective optimism for other trans women. First, participants shared that as they cultivated self-acceptance, they were better positioned to realize their potential for happiness and grew hope for stronger relationships, better jobs, increased health and more love. Having been through a long and often arduous journey of acceptance, participants expressed that it was this journey that has crafted them into who they are today and provided them a perspective that they would be able to overcome current struggles. For instance, when describing her anatomical heart, a participant (ID #04) described:

There were [a] few things in my past that, at the times they felt very hard on me, and I wondered why they were happening. But when I sit back and look at those things, if those things didn't happen, I wouldn't be here today, and I wouldn't be who I am. So like, every time I encounter a struggle like now, I don't see it as something bad, because I just look forward to what this struggle is going to bring in the future (ID #04).

Another participant, when describing her anatomical heart, communicated her ability to accept and contextualize her struggles and their emotional impacts:

I am reflection of my heart, and what my heart went through. And all the times, whether the good or the bad, and that's why my heart looks so chaotic, and that's just what it is, and I'm embracing the fact that it's scattered. But it's not broken, but it's scattered, and that's just all it is (ID #11).

Others described having patience with personal growth and the understanding that things will improve in their lives over time. For instance, a participant wrote on her mirror, ‘Give yourself time to grow. You’ll eventually blossom’ (ID #03). She further elaborated this belief in future growth when describing her anatomical heart: ‘I believe that somehow we should give time, we should give it time to just discover yourself, and let yourself blossom into beautiful sort of human beings’ (ID #03). Needing time to grow and change was also described as natural in the face of challenges that participants may have faced: ‘sometimes you just need time to grow, like to get over these different aspects in life that basically come at you to try to pull you down’ (ID #04) (Supplementary File S2).

Others described being guarded to protect themselves from further harm. Yet through connecting with themselves and communities, participants also discussed healing and hope for the future. For example, a participant when sharing her anatomic heart described:

I put green, sort of bit of hope…And I surrounded the heart with a layer of blackness, as I tend to sort of protect my heart a bit. It's a quite sensitive thing to just let loose, even though I probably should have added another lighter layer, because I feel like the layer’s sort of thinning as I gain in confidence and just become more accepting of myself (ID #03).

A collective optimism was apparent throughout the discussions and particularly in the affirmation cards that participants wrote to other trans women. For instance, affirmation cards included the messages: ‘It will get better’, ‘Everything will be ok ’, ‘It’s ok, it gets better’ and ‘You were born for a reason’. Messages of optimism for the future were also shared on mirrors, for instance, one mirror (ID #07) had ‘It will get Better!!!’ written on the front and ‘Love’ on the back. The participant described the meaning behind these messages:

Basically, my mirror is just love and it'll be better. I feel like a lot of people start off very rocky and it's good to remind you that things get better. So, that's my message to my younger self and also to any other person who wants motivation (ID #07). (Supplementary Figure S3).

Others discussed how having hope for their own ability to change helped them to in turn give back and help others to change and practice self-acceptance:

I said to myself, ‘now it’s time for change. And for you to make a positive impact on other people, it has to come from you, and it has to start from within’. So if you look at yourself and you say ‘I can do it’ or ‘I’m loving me’ no matter what you see, no matter what you think, if I look ugly today or have on the wrong size of clothes, that’s on you. I left my house feeling happy about what I’m presenting to you all. So, no matter what you think… I am totally happy with me. (ID #11)

In sum, participants shared the belief that in their own lives and for other trans women, life gets better. Some reflected on their younger selves when discussing hope and change, while others shared the need for patience when undertaking changes, particularly for those who may be guarded from past pain. Optimism about the future of their own lives and the lives of other trans women helped participants to resist negative societal messages and past experiences to have hope for a brighter future.

DISCUSSION

In this multi-method arts-based study, we found that providing activities such as mirrors, affirmation cards and anatomical hearts provided the opportunity for participants to reflect on their own journeys to self-acceptance and how these were shaped by connections with trans community members. Participants were also able to share messages of hope with other trans women, grounded in personal experiences of pain and struggles with societal expectations of gender conformity and beauty. Change was also discussed as a gradual and continual process. Together these findings signal the potential of these innovative arts-based methods to provide a space for reflection on self-acceptance, community care, and personal and collective hope.

Participants’ discussions of their journeys towards wholeness, self-acceptance, learning and growth in the face of rejection and social injustices towards trans women align with conceptualizations of critical hope (Freire, 1972, 2007). For instance, narratives and art pieces discussed in the findings (e.g. ‘I want to love my life beyond this hatred, beyond this ignorance…I respect myself, even they don't respect me’) assert self-love in larger contexts of hate, ignorance and discrimination. Narratives also reflect Freire’s understanding of transformative hope (Freire, 2007), including personal aspirations to persevere and beliefs that hardships would pass and could foster learning (e.g. ‘I just look forward to what this struggle is going to bring in the future’), and collective aspirations that other trans women would experience new and improved ways of being in time (e.g. ‘It will get better’, ‘You were born for a reason’). Similar to hooks' conceptualization of interbeing and liberating mutuality (hooks, 2003), participants discussed how realizing their own self-acceptance inspired them to provide support to help other trans women (e.g. ‘being able to stop that [hate] and rise each other up more, like bring each other’s spirits up and bringing people’s self-worth up’). At times this meant being publicly visible to increase safety and social acceptance for other trans women, signalling the powerful role of community connectedness and cohesion in normalizing experiences and advancing safety among trans communities (Bowling ).

Arts-based methods hold promise for nurturing empowerment by providing opportunities for expression and communication, generating new ideas and possibilities, and for building connections with others in the shared arts creation process (Mitchell and Sommer, 2016; Lys ; Teti and van Wyk, 2020). Findings align with literature on arts-based methods as a transformative approach for sparking new ways of thinking and exploring identity construction and positive valuation (Mitchell, 2008; Gubrium ). The affirmation card activity emerged as helpful in eliciting reflections on personal and collective hope for a better future, hand-held mirrors appeared to be a useful tool in guiding reflection on self-acceptance, and the anatomical hearts provided a platform for sharing coping strategies. Using this selection of arts-based qualitative methods offers a dynamic, multi-faceted and multi-dimensional understanding of pathways to self-acceptance and hope. Providing opportunities for participants to discuss their artwork and what they make of their art (i.e. production texts) following the activities also provided valuable insights into the meaning of the process and product (Mitchell, 2008). It also facilitates crystallization, a triangulation process where different methods offer different insights into experiences of hope and self-acceptance journeys (Fiske ; O’Cathain ). Additionally, findings align with those of a multi-method study of hope employing longitudinal interviews and audio-diaries among people with HIV in Serbia, who found that these alternative forums ‘illustrate the significant influence of different qualitative methods on the articulation of hope’ as well as hope’s fluctuations (Bernays ). Our methods employed were developed with and for trans women of colour as a preferred alternative to body-mapping’s focus on the body (Logie ). While body-mapping differed from our methods, as it is a guided process centred on creating and reflecting on life size images of the body, our methods offer similar opportunities for exploring identity and social relationships, sparking new insights, and reflecting on social inequities and body politics (MacGregor, 2009; Gubrium ; Lys ).

The participatory nature of this project shaped the research process and outcomes. As detailed elsewhere (Logie ), community members rejected notions of HIV risk and advocated for methods focused on self-acceptance. The participatory approach to community-based research employed in this study encouraged this shift in focus. Our findings were likely shaped by the flexibility and adaptability in changing the research focus, alongside the following strategies we employed to meaningfully engage participants: data collection methods that were arts-based, low-barrier, and did not require literacy; focus groups hosted in spaces designed for participants who were sex workers, and/or trans and/or Black to feel supported and affirmed; providing a social worker available for research participants during the focus groups; and providing gender affirming training to staff in the spaces we held the focus groups. Further detail on participant experiences are reported elsewhere (Logie ). Our study team created and shared hundreds of decks of TRANScending Love cards that are openly accessible for printing and sharing that include affirmation messages and heart images; they have been well received at health clinics and community centres serving LGBTQ persons (Supplementary File S4).

There were several study limitations. Workshops were conducted at a single point in time, precluding an understanding of any lasting workshop benefits. Due to the small number of participants and tight-knit trans women of colour community in Toronto, we do not provide socio-demographic descriptors for the quotations; a larger multi-site study might offer opportunities for assessing socio-demographic differences. In line with participants’ rejection of a focus on HIV risk, we did not explicitly explore hope and its associations with HIV; future research could examine this alongside health-related improvements with engagement in these methods. There were also tensions that existed in the study: a focus on self-acceptance and community support did not engage with larger discussions of ways to dismantle complex systems of oppression; the research was funded as an HIV prevention study, so despite the expressed disinterest on HIV risk the ways that the findings have been presented has been in the larger framing of HIV research; there were no explicit discussions of HIV unless raised by participants, precluding engaging in dialogue about the ways that sexual health outcomes are shaped by larger systems that reproduce power inequities. Finally, we did not collect participant identifiers on the affirmation cards; future research could do this to triangulate the three methods. Future studies could employ mixed-methods and a control group design to assess self-acceptance and critical hope over time and associations with workshop participation.

CONCLUSION

This study underscores the utility of innovative, low-cost methods such as affirmation cards, hand-held mirrors and anatomical hearts, for sparking reflection on self-acceptance, community connectedness and personal and collective hope with trans women of colour. While our methods did not explicitly address HIV, there is evidence that hope is salient for HIV prevention across diverse global contexts (Abler ; Hill ). Thus this methodological focus on collective sharing of pathways to hope and self-acceptance could be seen as creating ‘strong capacity for investment in HIV prevention’ [(Bernays ), p. S6] in the high-risk environments that trans women of colour live in shaped by stigma and discrimination.

Participatory and arts-based methods that centre self-acceptance and solidarity can nurture resistance to pathologizing discourses in HIV research. Centring critical hope and participant-generated methodologies is a promising approach to transformative health promotion and intervention research. These methodological insights can be engaged in future participatory work with other marginalized groups facing dominant biomedical risk discourses. Critical hope holds potential as a participatory health promotion strategy for envisioning possibilities for sustainable change and wellbeing.

SUPPLEMENTARY MATERIAL

Supplementary material is available at Health Promotion International online.

Click here for additional data file.