| |||||||||
Victim IssuesMistrust of ProfessionalsProviding culturally competent care is critical to successfully serving members of marginalized communities. In the joint report by the National Coalition of Anti-Violence Programs (NCAVP) and the National Center for Victims of Crime, Why It Matters: Rethinking Victim Assistance for Lesbian, Gay, Bisexual, Transgender, and Queer Victims of Hate Violence and Intimate Partner Violence, 93 percent of NCAVP member programs and 51 percent of mainstream victim assistance programs said that victim assistance programs need more population-specific training on transgender people.11 Many transgender individuals avoid seeking help after an assault because they fear that the professionals who are supposed to serve them will be ignorant about transgender people at best or outright prejudiced or hostile at worst. These concerns are not unfounded.
In FORGE's survey, 9 percent of survivors had been forced into mental health care (including psychiatric inpatient admissions), and nearly 3 percent had been subjected to unwanted medical care. Abuse by therapists is also a problem:
Even those who have not personally experienced problems may fear what might happen based on the experiences of friends or publicity about particularly egregious incidents of transphobia. One of the best known examples is the gross negligence that resulted in the death of Tyra Hunter in Washington, D.C., in 1995. Tyra had been involved in a car accident. Once fire department personnel at the scene discovered that she had male genitals, they stopped treatment and began joking about her. The negligence continued at the local hospital's emergency department, where a doctor refused to provide treatment. She later died of her injuries. According to experts who testified at the trial, had she received proper medical care, she would have had an 86-percent chance of survival. Due to past experience and fear based on other people's experiences, transgender victims of sexual assault may not trust law enforcement, health care providers, therapists, or other professionals. This is one of the primary reasons why reporting rates among this population are so lowonly 9 percent of survey respondents reported their sexual assaults to law enforcement. As one respondent stated, "Now that I am out as trans, I'm less likely to report anything or seek medical attention, even if I need it."16 Trauma research clearly shows that the initial responses a victim of violence receives can make a huge difference in how traumatic the incident feels and how well the victim heals over time. Responding with compassion and care and listening closely to victims can make a huge difference in their lives.17 Training personnel is key. According to the Gay and Lesbian Medical Association, "all employees need to understand that discrimination against transgender clients, whether overt or subtle, is as unethical and unacceptableand in many states as illegalas any other kind of discrimination. Employers should make it clear to employees that discrimination 'will not be tolerated.'"18 In addition, any training that is effective will need ongoing monitoring: "It is important to monitor compliance [with nondiscrimination training] and provide a mechanism for patients to report any disrespectful behavior."19 Training for staff members should include instruction on anti-transgender bias and unique transgender concerns. According to Public Health: Seattle and King County, "all staff dealing directly with clients should be able to talk comfortably about all forms of sexuality and all gender identities. Have staff practice with each other until they are comfortable."20 Because transgender individuals' relationships with mental health care providers and law enforcement officers are particularly complicated, more information about each is found below. Mental health care providersMental health care providers can often provide high levels of support, care, and survivor-specific skills and resources for sexual assault survivors, both directly following an assault and throughout years of followup. The uniquely complicated relationship that can exist between transgender people and mental health care providers is due to transgender health care protocols [e.g., World Professional Association for Transgender Health (WPATH) Standards of Care]21 and newer informed-consent models of care.22 The WPATH Standards of Care protocols position the therapist as a gatekeeper who can allow or deny a client the right to a letter to access hormones or surgery. Informed-consent models, while providing transgender clients with increased agency over their mental and physical health, may still include screening for mental health stability before prescribing hormones or writing surgery letters. Transgender individuals are often uncomfortable being pathologized by therapists, mental health providers, and society. For many, being transgender is as natural for them as being cisgender is for non-transgender people. Being diagnosed with a mental health or medical condition is therefore highly upsetting. Transgender people who do access therapists often do not reveal past traumas, current mental health issues, or drug or alcohol use because they fear the therapist will use that information as justification for not writing the letter they need to access hormones or surgery. Others will seek a therapist specifically for healing from sexual assault and will not disclose information about their transgender status or history. Some therapists believe that transness causes abuse/assaults. Others believe that abuse/assault causes transgenderism. Many transgender people fear encountering a therapist who believes either of these. Many, fortunately, do not believe in causality in either direction. Law enforcement officersLaw enforcement officers may be the first people a transgender survivor encounters after an assault. The role of law enforcement to help victims of crime may be forgotten (or not believed) by transgender people who have had unhelpful interactions with law enforcement in the past. Officers can reinforce positive contact with survivorseither directly after an assault (e.g., when taking a report) or in the weeks or months following an assaultby actively reminding survivors that they are there to help. In 2011, the National Coalition of Anti-Violence Programs reported that lesbian, gay, bisexual, and transgender crime victims who reported to law enforcement received "indifferent" responses 38 percent of the time, with 18 percent encountering a "hostile" response. Nearly one-third (32 percent) of those who contacted law enforcement reported misconduct, including misarrest (38 percent), excessive force (19 percent), and entrapment (12 percent).23 Unprovoked street harassment, assaults, arrests, and officers' ignorance or insensitivity may make transgender individuals hesitant to interact with law enforcement under any circumstances. In addition, some transgender people, particularly those who transition from male to female, become involved in the sex trade or engage in survival sex (i.e., the exchange of sex for food, shelter, safety, or other essentials) to support their basic needs. Because of their involvement in the underground economy, these individuals may not want to involve law enforcement, even when they are victimized. Reporting sexual assault is therefore relatively uncommon among the transgender population. In FORGE's survey, only 9 percent of survivors reported their assaults to law enforcement.24 Implications and Actions for ...
Health Care ProvidersWhen transgender patients first come to the hospital or your office seeking care, they should receive a patient's bill of rights and information about HIPAA to help them understand their privacy rights and what their recourse is if they feel that a provider is not acting in a culturally competent manner or has violated their rights. Frontline staff should review the bill of rights with patients. When possible, remind transgender patients that you are committed to respectful and competent care and that they will be treated with respect and professionalism. Consider the benefits of specifically stating that the relationship is professional and will not be abusive or exploitive in any way. You may want to model your bill of rights after others that have created inclusive, welcoming, and victim-empowered statements of rights. One trans-aware example is from Johns Hopkins Hospital, which states, in part1
Transgender people may arrive at emergency rooms reluctantly, sometimes due to well-intentioned pressure from partners, family, or friends. If the patient comes in with someone, allow the support person to be present in examinations and interviews if the patient requests this (but see Companions as Abusers in this e-pub). If the patient comes in alone, ask if there is someone who can be called in to serve as support. All victims can benefit from the support and services victim advocates provide. (If your facility does not have victim advocates, patient advocates can work with victims to contact local victim advocates or victim service providers.) Proactively connect victims with an advocate, regardless of whether the victim arrives alone or with a companion. Some larger facilities have sexual assault response teams that have well-trained, LGBT-knowledgeable advocates. Staying highly focused on the patient's injuries and overtly stated medical concerns, without becoming distracted by asking questions about transgender history, will help patients develop greater trust in you. Overtly stating that the role of the medical team is to assess and address the patient's medical conditions may help reduce their concerns related to revictimization or exploitation. In urgent care settings, patients often see multiple providers. Due to the sensitive nature of sexual assault coupled with the patient's transgender identity, it may be beneficial to reduce the number of providers the patient sees. The need to repeatedly disclose the details of the assault or the patient's transgender identity or history may cause the patient additional emotional stress. The presence of an advocate can reduce many of the stresses of disclosure for patients. You may need to make referrals to mental health care providers or work with law enforcement to best serve transgender patients who have been sexually assaulted. Information on how to navigate the often complicated interactions that transgender people have with these professionals follows. Mental health care providersIf you believe a transgender patient may benefit from mental health services, be aware that some transgender people have had previously negative or discriminatory experiences with therapists or other mental health care providers, particularly related to their gender. Expressing concern for patients' overall well-being and overtly stating that untreated mental health issues can have negative health implications may help them understand that you are not pathologizing their gender but are truly concerned about their health. If a patient talks about suicide or hopelessness, a prompt referral to a mental health care provider or crisis team is necessary, if not mandated. When possible, prescreen mental health care providers before making a referral to ensure that they are knowledgeable about and welcoming of transgender clients. Most urban communities have therapists who specialize in working with transgender clients, and every state has at least one transgender support group that may have a referral list of transgender-friendly therapists (see Outreach in this e-pub). You can also contact FORGE, which maintains a database of mental health care providers across the country who work with transgender clients. Contacting your local LGBT anti-violence program is also an excellent source for transgender-informed referrals; see the member list on the National Coalition of Anti-Violence Programs' Web site. Patients may be more open to a referral (and actually keeping an appointment) if given a prescreened referral list, and even more so if you have actively partnered with mental health care providers who work with transgender clients. If a patient refuses a therapy referral, consider support groups and/or online support services, such as FORGE's online course Writing to Heal, its Survivors Listserv, and The Network/La Red's all-gender LGBT phone-based support group (the latter of which is not regularly offered). When permissible, it may be preferable not to document a mental health care referral, which could be included in a forensic file that is released to the police, prosecutors, and defense counsel in the event of prosecution. Documented mental health care referrals may also have an impact on an insurance company's willingness to pay for medical services, particularly if there is any notation about the patient's transgender status. Health care providers should be familiar with local rules and requirements regarding record-keeping and record submission and should be clear about these rules when meeting with patients. Speak with patients ahead of time about which information can be shared and which information they would prefer not be revealed. Law enforcementRemind patients of confidentiality policies and any limitations on maintaining their confidentiality, and reassure them that police or other authorities will not be called unless the patient agrees to have them called, except in cases of mandatory reporting (e.g., the patient is under age or has developmental disabilities). Sexual assault victims may not know their options regarding whether or how to report the assault as a crime and whether or when they need to talk with law enforcement. Ensure that the patient is connected with an advocate who can explain the choices; outline potential risks/consequences and benefits; and soothe the client's fears. If a patient has reported the assault to the police and the case goes to court, a health care provider may be asked to give a statement or testify. Speak with patients ahead of time about which information can be shared and which information they would prefer not be revealed. Do not make promises that cannot be kept. Having one or more transparent conversations ahead of time will build trust and reduce fears. (See Disclosure and Confidentiality for more information.) If a jurisdiction has the option, inform the patient that forensic evidence can be collected within the first 72 hours after an assault, and the patient therefore has some time to decide if police will be involved. Some states and jurisdictions allow for up to 120 hours. Regardless of evidence collection, some victims may have months to decide to involve the police; however, waiting this long may affect the success of a case if prosecuted. Note: Some jurisdictions will collect evidence without calling the police. It may also be useful for the patient to understand that police need to be involved if the client wants to file for crime victim compensation. An advocate can explain the process and rules to the patient. Emergency Medical PersonnelBecause so many transgender people have had negative experiences with professionals who are supposed to help themtherapists, physicians, emergency medical personnel, and many other people in positions of authoritytransgender victims of crime may be hesitant to call 911 or to interact with emergency medical personnel (EMPs) (see more information about these negative experiences). Rather than viewing emergency medical personnel and other first responders as people who are there to help them, transgender individuals may be concerned that first responders will blame, harass, abuse, assault, or arrest them, even when they have done nothing wrong. Some EMPs may perceive a patient’s reticence as an indication of defensiveness or deception, which may lead them, or law enforcement officers on the scene, to question the legitimacy of the person’s story. With a transgender patient, this reticence is more likely related to self-protection and fears of being wrongly arrested, falsely accused, or treated with disrespect. Providing patients with sensitive and respectful care and using phrases such as “I'm here to help you,” and “Can you tell me more about what happened, so I can better serve you?” may help reduce their fears and resistance. Remaining professional at all times will also help lessen transgender patients’ anxieties about interacting with helping professionals in uniform. Remind patients that what is most important for them in the minutes or hours post-assault is to receive care for their medical injuries, and consider informing them that they have more than one opportunity to have forensic evidence collected. Although forensic evidence is most effective when collected directly after an assault, it can often be collected up to 72 hours post-assault. Some states and jurisdictions allow for up to 120 hours. Reminding patients of their options and providing them with information on how to contact law enforcement at a later date gives them options and control. It is also useful to remind patients that they are entitled to have a sexual assault victim advocate present during all interactions with medical staff at the hospital, if their injuries warrant hospital care. They should also be informed that the advocate can be present in discussions with law enforcement or if they consider pursuing victim compensation or for other emotional support. It is rare for EMPs to receive any form of diversity training on transgender issues unless there is a specific incident or need. Some transgender communities have mobilized efforts to raise awareness of transgender issues and have pushed for training of people who serve transgender victims of violence, including EMPs. Unfortunately, a lack of staff time, limited resources, and other training priorities mean most fire departments and other first responders have no or minimal formal training in these issues.
1. FORGE is not aware of any EMP-specific transgender resource. The resources listed may be useful, even if they are not profession specific.
Law EnforcementBecause so many transgender people have had negative experiences with professionals who are supposed to help themtherapists, physicians, law enforcement officers, and many other people in positions of authoritytransgender victims of crime may be hesitant to call 911 or to interact with law enforcement (see more information about these negative experiences). Rather than viewing law enforcement officers as people who are there to help, transgender individuals may be concerned that they will be blamed, harassed, abused, assaulted, or arrested, even when they have done nothing wrong. Within the transgender community, there are many true stories of transgender people being targeted for using the "wrong" public bathroom, for example, or being accused of solicitation while walking down the street.1 Some law enforcement officers may perceive a victim's reticence as an indication of defensiveness or deception, which may lead them to question the legitimacy of a victim's story. With the transgender victim, this reticence is more likely related to self-protection and fears of being wrongly arrested, falsely accused, or treated with disrespect. Providing victims with sensitive and respectful care and using phrases such as "I'm here to help you" and "Can you tell me more about what happened so I can better serve you?" may help reduce victims' fears and resistance. Remaining professional at all times will also help lessen victims' anxieties about interacting with law enforcement officers. Consider informing victims that they have more than one opportunity to talk to law enforcement or to make a report. The additional time allows victims to access medical care (if needed or appropriate) and to determine if they want to file a police report or have evidence collected. Although forensic evidence is most effective when collected directly after an assault, it can often be collected up to 72 hours post-assault. Some states and jurisdictions allow for up to 120 hours. Reminding victims of their options and providing them with information on how to contact you at a later date gives them control. It is also useful to remind victims that they are entitled to have a sexual assault victim advocate present during all interactions with law enforcement, which may encourage reporting or cooperation. It is rare for law enforcement to receive diversity training on transgender issues unless there is a specific incident or need. Some transgender communities have mobilized efforts to raise awareness of transgender issues and have pushed for training of people who serve transgender victims of violence, including law enforcement officers. Unfortunately, a lack of staff time, limited resources, and other training priorities mean most police departments and other first responders have no or minimal formal training in these issues.
1. Make the Road New York, 2012, Transgressive Policing: Police Abuse of LGBTQ Communities of Color in Jackson Heights, New York, NY: Make the Road New York, accessed June 18, 2013.
AdvocatesYour role is to support the victim, no matter what the victim's gender identity is or the circumstances of the assault. Due to previous experiences of abused trust, transgender people may be wary of anyone serving in a supportive role and it may be difficult to earn their trust. To increase trust, be consistently respectful, avoid asking inappropriate and insensitive questions, and support the victim's need for control. Other steps, such as reminding victims that your role is to support them in what they want and need, providing them with options, and encouraging them to determine the course of action, will help them feel safer with you. Simple actions can have a big impact. For example, accompanying victims to visits with other professionals may help them feel less vulnerable. When victims give you explicit and advance permission, help educate these other professionals about transgender issues so that victims do not have to and can instead focus on their sexual assault-related needs. This helps maintain a victim's dignity and privacy and ensures that the other professionals (e.g., health care providers) act professionally and ethically. When you combine these actions with those used to support all victims, such as keeping track of questions and making sure they are answered in a way that makes sense to the victim, you can have a significant impact on the success of a victim's care. Some advocates are able to participate in community events and educational opportunities. Advocating for systematic change can have a significant impact on client services. When possible, training other members of sexual assault response teams and engaging in public education with transgender audiences may help build trust within the transgender community. See Outreach in this e-pub for more information. You may need to make referrals to mental health care providers or work with law enforcement to best serve transgender victims who have been sexually assaulted. Information on how to navigate the often complicated interactions that transgender people have with these professionals follows. Mental health care providersWith good cause, transgender victims may refuse referrals to mental health care providers. Victims may be more open to a referral (and actually keeping an appointment) if given a prescreened referral list, and even more so if you have actively partnered with mental health care providers who work with transgender clients. If a victim refuses a therapy referral, consider support groups and/or online support services such as FORGE's online course Writing to Heal, its Survivors Listserv, and The Network/La Red's all-gender LGBT phone-based support group (the latter of which is not regularly offered). Law enforcementBecoming familiar with the local officers who respond to sexual assault allegations and exploring whether you can request a particular officer can be useful in minimizing police misconduct and increasing the victim's willingness to engage with law enforcement. If you do request particular officers because of their sensitivity, let the victim know. Remind victims that they are entitled to have you present for all interactions with law enforcement, which may encourage reporting and cooperation with police investigations. If a jurisdiction has the option, inform the victim that forensic evidence can be collected within the first 72 hours after an assault and the victim therefore has some time to decide if law enforcement will be involved. Some states and jurisdictions allow for up to 120 hours. Regardless of evidence collection, some victims may have months to decide to involve law enforcement; however, waiting this long may affect the success of a case if prosecuted. Note: Some jurisdictions will collect evidence without calling law enforcement. It may also be useful to explain that law enforcement needs to be involved if the victim wants to file for crime victim compensation. TherapistsWhen transgender clients first come to your office seeking care, they should receive a client's bill of rights and information about HIPAA to help them understand their privacy rights and what their recourse is if they feel that a provider is not acting in a culturally competent manner or has violated their rights. Frontline staff should review the bill of rights with clients. When possible, remind transgender clients that you are committed to respectful and competent care and that they will be treated with respect and professionalism. Consider the benefits of specifically stating that the relationship is professional and will not be abusive or exploitive in any way. You may want to model your bill of rights after others that have created inclusive, welcoming, and client-empowered statements of rights. One trans-aware example is from Johns Hopkins Hospital, which states, in part1
As you begin treatment, be mindful of the fact that some transgender people have had previously negative experiences with therapists, particularly related to their gender. Some transgender people were forced into therapy as children to “cure” them of their gender non-conformity, and others have had to endure mental health providers who are ignorant or prejudiced in order to obtain documentation necessary for medical transition. Keep these factors in mind, and make sure to be patient and consistent during the trust-building stages of the therapeutic relationship. Do not assume that just because a client is transgender, they are seeking mental health services to explore their gender identity. Knowing one or two facts about a person—transgender status, sexual assault history, or any other trait—is only a small piece of who that person is. Asking questions, paying attention to a person’s explanation of what is important to them, and not presuming causality will better ensure that transgender clients receive the care they need. Because transgender people often experience improper behavior from professionals, they may need multiple sessions before they can begin to trust you. Allowing them to bring a companion with them to sessions may encourage them to make and keep their appointments (but see Companions as Abusers in this e-pub). Support Group FacilitatorsSome transgender victims may hesitate to join support groups for fear that they will encounter anti-transgender bias, not just from support group professionals but also from other clients within the group. Confronting bias can be challenging and is often not a well-developed skill; ignoring it, however, creates an unsafe and unhealthy environment for everyone involved. Tackling bias is discussed in the Treating the Victim section of this e-pub (see Implications and Actions for Support Group Facilitators in that section). When transgender people do decide to join a support group, make sure that they and everyone else in the group receives a client's bill of rights to help them understand what their recourse is if they feel that a provider is not acting in a culturally competent manner or has violated their rights.1 Review the bill of rights together. When possible, remind transgender clients that you are committed to respectful and competent care and that they will be treated with respect and professionalism. Consider the benefits of specifically stating that the relationship is professional and will not be abusive or exploitive in any way. It is important to focus on the reason that a transgender client entered the groupfor support following a sexual assault. Transgender issues may not need to be discussed at all or may only need tangential comments. Knowing one or two facts about a persontransgender status, sexual assault history, or any other traitis only a small piece of who that person is. Asking questions, paying attention to a person's explanation of what is important to them, and not presuming causality will better ensure that transgender clients receive the support they need.
1. Clients should also receive information about HIPAA, if applicable, e.g., the support group is facilitated by a psychotherapist or a professional with specific licensure, such as an MSW.
|