Standard Practices

Some providers believe that patients are being deceptive or are intentionally withholding information if they do not disclose their transgender identity or history. Some patients may disclose only after they have developed adequate trust in the provider. This could take one visit or many months. Choosing when and how to disclose information is often self-empowering for victims and should be validated, not scorned.

If you inadvertently learn that a patient is transgender during an examination, do not show surprise, shock, dismay, or concern. Instead, your reaction should be much the same as when encountering an unexpected scar. Do not allow the disclosure, whether intended or not, to distract you from the reason you are treating the patient. Ask more questions only if they are necessary for effective treatment.

One reason that transgender victims of sexual assault may hesitate to disclose is that they are concerned that their transgender identity will be shared with others (e.g., other staff in your office, companions who do not yet know of their transgender status). Carefully explain, follow, and reiterate your confidentiality policies and procedures. Make sure that all patients receive HIPAA privacy documents when beginning treatment, and review these documents together. Be willing to create additional statements regarding privacy rights, confidentiality, and codes of conduct if needed.

Ensure that patients understand the circumstances under which their medical records might be released to health insurance providers or others. Although a transgender patient's medical charts may indicate preferred or former names, it is gratuitous to overtly chart that a patient is transgender.

To maintain patient confidentiality, consider the following:

• Note preferred names and pronouns in sections of medical charts that are not released to other professionals.
• Use codes or nondescript colored stickers "so that only the health care provider or other key people in the office can identify this information."¹
• If you use paper charts, make a simple notation in the inside of the patient's folder noting the preferred name and pronoun.
• Regarding electronic records, many medical software systems have customizable fields that securely store information and only allow access to staff treating a patient.

In this e-pub*—

• Tips for Those Who Serve Victims: Insurance and Financial Matters

*Clicking these links will take you to other sections in this e-pub. To return, hit your browser's "back" button.

When in doubt, refer to the requirements of your profession and local laws and ask patients how they would like you to handle their personal information. Reassure patients who are concerned about confidentiality by informing them that they can place limits on the information released to third parties and that they can request copies of their records at any time.² Patience, reassurance, and overt reminders of your professional boundaries may be helpful as well.

It is critical to note that transgender patients may be accompanied by someone who does not know they are transgender (e.g., partners, parents, children). Be very careful to treat the patient's transgender identity or history with the utmost confidentiality, and do not discuss it with companions unless given explicit permission.

If someone in the office breaks confidentiality, advise the patient of their rights and let them know how to make a formal complaint. Administrative staff should follow up with both the patient and the staff in question and work to resolve the issue.

Emergency medical personnel may never know that a patient is transgender. In many cases, the location and type of injuries (e.g., head trauma, abrasions) would not physically disclose the patient’s transgender identity or history.

In critical care situations, the patient may not be able to verbally disclose (even if they wanted to). Through the course of medical treatment, however, you may inadvertently discover that a patient is transgender. Emergency medical personnel see a wide variety of bodies and bodily configurations. Most can and do stay focused on the presenting medical situation—concussion, lacerations, broken bones, or other injuries. If you find out that the patient is transgender, continue to focus your attention on the patient’s urgent care needs.

Transgender people are acutely aware when their documentation does not match their appearance and will often disclose prior to treatment. If the patient’s documentation and presentation do not align, you can nonjudgmentally ask if the person uses another name to allow for more respectful interaction. If patients ask you to call them by a specific name or pronoun, respect their preferences regardless of documentation, and insist that others do the same. However, if others who do not know that the patient is transgender are present, be careful how you refer to the patient; you do not want to out the patient accidentally.

If you are unable to gain a patient’s consent to disclose (e.g., if the patient is unconscious), use language that is respectful, accurate, and detailed if there is a disparity between legal name/gender and preferred name/gender. For example, "Susan Smith (given name, Travis Smith) was sexually assaulted at <location>. Susan is white, 33 years old. She will be transported to <hospital name> via ambulance." Although this outs Susan as a transgender individual, it does so in a respectful way by using her preferred name and pronoun.

Information gathered about the patient’s injuries should center on those injuries; a person's transgender identity or expression should not be the focus of your questioning or interactions. A patient’s transgender history is just one piece of information among many that may or may not have relevance.

A victim may elect to disclose a transgender identity or history to you, or you may learn that a victim is transgender from an external source (e.g., another professional on the scene, conflicting documents, physical "incongruity"). In other cases, you will not and do not need to know that a victim is transgender. If you do know, treat this information with the utmost care and confidentiality. After disclosure, if the victim is conscious, it may be appropriate to ask them what name and pronoun they would prefer to allow more respectful interaction. Whenever possible, call victims by their preferred names and pronouns regardless of documentation, and insist that others do the same. However, if others who do not know that the victim is transgender are present, be careful in how you refer to the victim; you do not want to out the victim accidentally.

Because law enforcement officers are trained to look for documentation discrepancies and to confirm that a person is who they report to be, there might be additional scrutiny or questioning. Identity documents generally have information that helps confirm a person's identity, even if name or gender markers are different from a person's appearance. For example, height, weight, and eye color on the identity document should match the person's appearance. The person's address should also be consistent. If the victim's documentation and presentation do not align, you can nonjudgmentally ask if the person uses another name and determine what the victim's legal name and gender are for reporting purposes.

Transgender people are acutely aware when their documentation does not match their appearance and will often disclose prior to any additional questioning by law enforcement. Some carry a notarized statement or "carry letter" from their therapist or physician which indicates that they are in the process of transition and are living as one gender yet have documentation in another. Asking victims if they have a carry letter or where they are in the legal process of changing their name or gender marker may help them recognize your awareness of transgender issues. This can increase their sense of trust and their willingness to engage.

In this e-pub*—

• Transgender 101: Documentation
• Tips for Those Who Serve Victims: Preferred Language

*Clicking these links will take you to other sections in this e-pub. To return, hit your browser's "back" button.

You may encounter transgender victims who are unconscious or seriously injured. In these situations, the victim may not be able to verbally disclose (even if they want to). When calling in the crime and there is a disparity between legal name/gender and preferred name/gender, use language such as the following: "A 24-year-old woman, Jane Smith, with driver's license identification as John Smith, gender male, was found unconscious at <address>." Avoid language such as "A 24-year-old male, John Smith, was found unconscious at <address>," or "A 24-year-old cross-dresser was discovered at <address>." Although this outs Jane as a transgender individual, it does so in a respectful way.

Information gathered about the crime should center on injuries sustained and the potential criminal actions against the victim. A victim's transgender identity or expression should not be the focus of your questioning or interactions. A victim's transgender history is just one piece of information among many that may or may not have relevance in the case.

A victim may elect to disclose a transgender identity or history to you, or you may learn that a victim is transgender from an external source (e.g., another professional, conflicting documents, physical "incongruity"). In other cases, you will not and do not need to know that a victim you are helping is transgender. If you do know, treat this information with the utmost care and confidentiality. When sexual assault victims trust advocates enough to reveal their transgender identity, they are taking a significant risk in doing so. Disclosing to one person does not imply permission for that person to disclose to others, even other professionals.

Get explicit permission from victims about if, when, and with whom you may share the information. Never discuss or mention transgender-related topics with other professionals, partners, family members, or other companions of the victim without the victim's consent. This includes careful use of a victim's preferred name or pronoun. For example, if the victim's family is present and does not know that the victim is transgender, be careful in how you refer to the victim.

In this e-pub*—

• Tips for Those Who Serve Victims: Preferred Language

*Clicking these links will take you to other sections in this e-pub. To return, hit your browser's "back" button.

If you are unable to gain a victim's consent to disclose (e.g., in an emergency in which the victim is unconscious and you have to call for help), use language that is respectful, accurate, and detailed if there is a disparity between legal name/gender and preferred name/gender. For example, "Susan Smith (given name, Travis Smith) was sexually assaulted at <location>. Susan is white, 33 years old. She will be transported to <hospital name> via ambulance." Although this outs Susan as a transgender individual, it does so in a respectful way by using her preferred name and pronoun.

You may need to advocate on behalf of the victim if other professionals do not treat disclosed information with the appropriate level of sensitivity and discretion. In addition, consider that disclosure can lead to additional complications for the victim (e.g., disclosing to a young person's family may result in unwanted questions or possibly even violence at home). In most cases, victims will be able to identify areas of particular concern so that you can help prevent, mitigate, or address these complications.

Transgender people may decide not to disclose their gender identity to therapists because they do not want them to think that being sexually assaulted caused them to be transgender or that being transgender caused the sexual assault. Some transgender people have two therapists: one with whom they discuss sexual assault issues and one with whom they discuss gender issues. This prevents the gender therapist—whom the client may be relying on to “write a letter” giving them access to hormones or surgery—from using the sexual assault as a reason to slow down or stop the person’s gender transition.¹ As one respondent put it—

I'm afraid to go to a mainstream provider because I don't want to have to justify my existence to receive help, but I am afraid to go to a trans-knowledgeable provider because I know the SOC [typical Standards of Care for transgender people] are more harsh if you are an assault survivor. I feel like I'm falling through the cracks and no one cares.²

Some mental health providers believe that clients are being deceptive or are intentionally withholding information if they do not disclose their transgender identity or history. Some clients may disclose only after they have developed adequate trust in the therapist. This could take one session or many months. Choosing when and how to disclose information is often self-empowering for clients and should be validated, not scorned.

If and when a client discloses, keep in mind that this is only one piece of data. If a client determines that navigating gender identity is not a therapeutic goal, extensive discussion of gender identity is likely irrelevant and often offensive or insensitive. Only ask questions that are relevant to their care (e.g., about personal history, experiences, trauma, desires). Be nonjudgmental and sensitive, and satisfy your curiosity about transgender issues elsewhere rather than using your client to acquire more knowledge about general transgender issues. One way to know whether a question is appropriate is to consider if you would ask the same question of a non-transgender client or if the information you are seeking is general information you could research on your own time versus your client’s time.

Asking about a client’s surgical status, prior name (if not relevant to billing paperwork), hormone use, or other information about a person’s gender transition or gender journey is generally not appropriate, unless the client initiates the discussion as part of the healing process. Asking about medical interventions is inappropriate and often impolite and frequently indicates that a provider is not culturally competent. These questions presume that an individual has medically transitioned and that mental health professionals are entitled to this very intimate information. They also create an impression that a person's gender identity is less valid if they have not pursued medical steps toward transitioning.

One reason that transgender victims of sexual assault may hesitate to disclose is that they are concerned that their transgender identity will be shared with others (e.g., other staff in your office, companions who do not yet know of their transgender status). Carefully explain, follow, and reiterate your confidentiality policies and procedures. Make sure that all clients receive HIPAA privacy documents when beginning treatment, and review these documents together. Be willing to create additional statements regarding privacy rights, confidentiality, and codes of conduct if needed.

When in doubt, refer to the requirements of your profession and local laws and ask clients how they would like you to handle their personal information. Reassure clients who are concerned about confidentiality by informing them that they can place limits on the information released to third parties and that they can request copies of their records at any time.³ Patience, reassurance, and overt reminders of your professional boundaries may be helpful as well.

If someone in the office breaks confidentiality, advise the client of their rights and let them know how to make a formal complaint. Administrative staff should follow up with both the client and the staff in question and work to resolve the issue.

Some providers believe that clients are being deceptive or are intentionally withholding information if they do not disclose their transgender identity or history. Some clients may disclose only after they have developed adequate trust in the provider. This could take one visit or many months. Choosing when and how to disclose information is often self-empowering for clients and should be validated, not scorned.

If and when a client discloses, it is important to keep in mind that this is only one piece of data. If a client determines that navigating gender identity is not a therapeutic goal within the support group setting, extensive discussion of gender identity will likely be irrelevant. Only ask questions that can be answered by clients and are relevant to their care. Be nonjudgmental and sensitive and satisfy your curiosity about transgender issues elsewhere rather than using your client to acquire more knowledge about transgender individuals.

Asking if or when a client had surgery or physically transitioned is generally inappropriate, unless the client initiates the discussion as part of the healing process. Not only is asking impolite, but it also assumes that an individual has had surgery and that you are entitled to this very intimate information. Such questions could also create an impression that a person's gender identity is less valid if they have not pursued medical steps toward transitioning.

Disclosure may play an essential role in a support group. If a transgender survivor discloses during a group discussion, other group members may start asking questions, expressing interest that diverts discussion, or voicing concerns. Although some level of discussion about transgender issues may be appropriate and necessary, it may also sidetrack the group's primary purpose. As facilitator, be mindful of the needs of the group but also of specific individuals and keep the group focused on its goals. You may want to meet with individual group members if they express discomfort or have questions about transgender issues. (In most cases, discussing specifics about the transgender person in the group is inappropriate, but having a general conversation about transgender lives and experiences often helps other group members begin to understand and accept transgender individuals.)

Ideally, support groups are safe places where participants can feel comfortable and safe when discussing intimate details about their assault and how their lives have been affected. Confidentiality is often a critical component of support groups, and most members will want to feel some level of certainty that the information they share in the group will stay within the group. Establishing ground rules about confidentiality at the first meeting—with reminders at subsequent meetings—may help all individuals feel more confident that the other members will remember to keep the information shared at meetings confidential.