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This project utilized a Community-Based Participatory Research (CBPR) approach to conduct qualitative interviews with 30 transgender adults living in a rural state. Participants’ identities spanned from trans women and men to nonbinary and Two-Spirit. The aim of this study was to better understand the experiences, needs, and priorities of the participants as well as to examine possible determinants of mental health, well-being, and suicidality for transgender individuals in Montana. These factors were investigated at individual, interpersonal, community, and societal levels using an ecological framework. Qualitative results indicate that participants experienced discrimination at all levels. Participants noted that discrimination contributed to mental health challenges and limited access to adequate general and transgender-specific health care services, both of which impacted overall well-being. This is reflected most notably in the elevated rate of past suicidal ideation attempts among the sample. Participants reported that the ability to transition, as well as other protective factors, played a role in reducing suicidality and improving mental and physical health. Our findings highlight the need to address transgender mental health through implementing changes at multiple ecological levels.