Standard Practices

Some medical offices have public areas (e.g., waiting areas in x-ray departments) that are divided by gender. If a transgender patient needs a service that usually involves waiting in a gender-segregated space, consider the patient's safety and comfort. Offering to place a patient directly in an exam room without any other patients is a short-term solution. Facilities should address their policies and procedures of sex-segregated spaces and determine if there might be a more effective and comfortable practice for all patients.

If a transgender person requires inpatient medical care, you may play an important role in helping to minimize the additional layers of distress that person may feel. Four primary issues might be particularly distressing:

1. Roommates. Most facilities house patients in shared rooms based on legal gender or sex. If legal gender does not align with gender expression (or gender identity), such room placement may be inappropriate and uncomfortable. Even if legal gender and gender expression align, transgender patients may require additional privacy to avoid potential roommate issues.
2. Gender-specific tests. Some medical tests are highly sex-specific and professionals working in these areas (e.g., people who specialize in transvaginal ultrasounds) may be unaccustomed to working with transgender patients. Many hospitals have gender-segregated changing areas for these sex-specific services.
3. Personal care/bathing. Hospitalized patients may need assistance with personal care, bathing, dressing changes, and other care. Most facilities have a large number of staff providing care to multiple patients. Many transgender individuals rarely undress in front of others, so this level of care may be particularly distressing. If care is typically provided by matching the patient's gender with the provider's gender, consider asking transgender patients if they prefer a male or female nurse or nursing assistant.
4. Gender-related prosthetics and materials. Some transgender individuals use devices to align more closely with their gender identity, which may be difficult to use in a hospital setting. For many transgender people, these items are essential. If not allowed to use them, they may feel increasingly anxious and depressed and may be concerned that others will not see them as the gender with which they identify.

Each patient's needs are unique. Direct, sensitive communication, using inclusive and respectful language, can be a successful first step to collectively determining solutions that meet the facility's needs as well as the patient's.

Patients may need to enter transitional care facilities following hospitalization. Many of the same concerns will apply in other types of residential facilities.

In this e-pub*—

• Tips for Those Who Serve Victims: Disclosure and Confidentiality

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

Whenever possible, consider alternatives to hospitalization or segregated housing, such as outpatient day surgery centers and hospitals with private rooms.

If referring the patient to a sex-segregated service and the patient's gender expression and gender identity align with the sex being served, that may be an appropriate referral. The patient may choose never to disclose gender history to the service provider or other people being served by that provider. If referring the patient to a sex-segregated residential service and the patient's gender identity, appearance, documentation, or genital status does not fit the service's eligibility policies, discuss options with the patient to determine the best course of action. Never disclose a patient's gender when referring that patient to another service provider or agency without overt permission.

In most situations, segregated services will not likely pose any issues for law enforcement officers. The exception would be if the victim is being arrested for a crime while reporting a crime committed against them (e.g., a person damages property during a bar fight but is also sexually assaulted).

When transgender individuals are incarcerated, they are typically housed according to their genital status, gender assigned at birth, or legal gender—even if this is a dangerous situation for the person. For example, a transgender woman who is housed with men may experience extensive harassment and possibly violence or sexual assault from other inmates. According to numerous agencies that work extensively on issues involving transgender individuals and incarceration,¹ some incarcerated transgender individuals are being placed in solitary confinement as a protective custody measure.

The Sylvia Rivera Law Project works extensively with low-income transgender people, who have higher rates of involvement in the criminal justice system as a result of engaging in the underground economy (e.g., involvement in the sex trade, drug dealing). It recommends that—

[A] new policy regarding placement of transgender and intersex prisoners [should be] researched and developed. Criteria for placement should include gender identity (focused on placing inmates in facilities that comport with their current gender identity rather than birth gender) and safety (assessing where an inmate will be least vulnerable to sexual assault).²

Just Detention International, which seeks to end sexual violence in jails and prisons (including sexual violence against transgender inmates), provides national technical assistance and may be a useful resource for local police departments.

Some sexual assault service providers—including therapists—only serve women. Before you refer victims to therapists or other service providers, you must know the attitudes, beliefs, and approaches they have about working with individuals who are male identified or transgender identified (or who have previously identified this way). Referring a victim to providers who are ignorant of transgender people, or who are prejudiced against them, could result in the victim being revictimized by the very people who are supposed to help them.

• Services Outside of the Box: Helping Transgender Clients Navigate Sex-Segregated Services
• Sex-Segregated Services: Finding Resources for Transgender Clients (webinar)

If referring the victim to a sex-segregated service and the victim's gender expression and gender identity align with the sex being served, that may be an appropriate referral. The victim may choose never to disclose gender history to the service provider or other people being served by that provider. If referring the victim to a sex-segregated residential service and the victim's gender identity, appearance, documentation, or genital status does not fit the service's eligibility policies, discuss options with the victim to determine the best course of action. Never disclose a victim's gender when referring that victim to another service provider or agency without overt permission.

Your advertising must accurately represent the populations you actually serve. For example, if you specialize in working with lesbian and bisexual women, be clear that you only serve women. Only use the acronym “LGBT” when serving all members of the lesbian, gay, bisexual, and transgender community.

If referring your client to a sex-segregated service (e.g., support group, single-gender retreat, spiritual gathering) and the client’s gender expression and gender identity align with the sex being served, that may be an appropriate referral. A client’s choice not to disclose gender history to the service provider or other clients must be respected and held confidential. If referring your client to a sex-segregated residential service and the client’s gender identity, appearance, documentation, or genital status does not fit the service's eligibility policies, discuss options with the client to determine the best course of action. Never disclose a client’s gender when referring that client to another service provider or agency without overt permission.

• Services Outside of the Box: Helping Transgender Clients Navigate Sex-Segregated Services

If your client requires inpatient psychiatric care, you can play an important role in helping to minimize the additional layers of distress that client may feel. Four primary issues might be particularly distressing:

1. Roommates. Most facilities house clients in shared rooms based on legal gender or sex. If legal gender does not align with gender expression (or gender identity), such room placement may be inappropriate and uncomfortable. Even if legal gender and gender expression align, transgender clients may require additional privacy to avoid potential roommate issues.
2. Gender-segregated group activities. Many inpatient facilities continue to create group activities based on gender. Although some transgender individuals are easily able to determine which gender group feels most comfortable and appropriate, not all facilities allow individuals to self-select their group placement. Additionally, many transgender individuals do not identify with a binary gender, so neither group would be an ideal placement. Consider allowing these individuals to use the group time to meet privately with the psychiatrist or to engage in other formal or unstructured activities.
3. Supervised showering. Many inpatient units have a staff member supervise each client's showering and other typically private activities. Supervised showering is invasive for all individuals but may be especially troubling for transgender clients, particularly those who have not disclosed their transgender history and may have anatomy that does not align with the staff's expectations of their gender. Even clients who have disclosed their gender identity or history may not have disclosed possible surgical interventions or hormone use. Work with clients and facility staff to mutually determine the best solution for supervised showering (e.g., allowing the client to select the gender of the supervising staff member).
4. Gender-related prosthetics and materials. Some transgender individuals use devices to align more closely with their gender identity, which may be difficult to use in inpatient facilities that restrict the use of certain items as a way of reducing the risk of suicide. Restricting access to these items (e.g., tape to secure wigs, binders to flatten chests) may severely increase the person’s anxiety, depression, and even suicidality. Lack of access may also influence the client's ability to be actively engaged in their inpatient treatment. Work with staff to secure exceptions and/or to help your client develop specific strategies to compensate for the loss of these supports.

Each client's needs are unique. Direct, sensitive communication, using inclusive and respectful language, can be a successful first step to collectively determining solutions that meet the facility's needs as well as the client's.

Clients who have been hospitalized for mental health reasons may move to transitional housing at some point during their treatment. The majority of transitional housing is segregated by sex. Similar types of advocacy may be necessary if transitional housing is recommended.

Whenever possible, consider alternatives to hospitalization or segregated housing. All-day mental health programs, housing with friends or family, or combining multiple types of services may yield the same results as being hospitalized or living in shelter or transitional housing.

Support groups for survivors are often segregated by gender, sexual orientation, or another demographic variable. Most are for women only and very few are for men or for people of all genders. These groups may not accept a male-to-female (MTF) survivor, particularly if they are told she is transgender or if she is visibly gender non-conforming. Female-to-male (FTM) survivors would not be welcome either, unless they presented as female and did not discuss their masculine identity. According to one FORGE survey respondent:¹

There was a "survivor of male childhood sexual abuse" group in my community, but until I transitioned completely physically, I could not attend it. Once I transitioned, I didn't need the group.

Having clear, well-thought-out written policies and procedures in place for eligibility requirements is an excellent place to begin. If your support group has gender-based restrictions, be clear about the entrance requirements. The clearer the policy, the better clients—both transgender and non-transgender—will be served. Some support groups that are segregated by gender determine entrance eligibility by factors such as legal gender (e.g., M or F on a driver's license), surgical/genital status (which would not be asked of non-transgender clients or clients not perceived to be transgender), or even hormone status. These screening protocols are discriminatory. Policies related to eligibility requirements should be carefully constructed, clear, and as unbiased as possible and uniformly applied to all potential group participants.

• Sex-Segregated Services: Finding Resources for Transgender Clients (webinar)
• Creating a Trans-Welcoming Environment (webinar)

If no policy exists, consider developing a work group to outline the implications of various policy choices. After the policy is finalized, make sure that all staff are fluent in its meaning and application and make the policy available to any potential group member who wishes to see it.

If transgender individuals are eligible for your group, can they openly discuss their whole lives, including their gender histories and gendered bodies, in ways that are similar to what non-transgender individuals can share? Or are they restricted from broaching certain topics, as was the case with one FTM survivor, who was told by a facilitator that he could attend the male sexual assault survivors group "if I did not talk about my vaginal rape"?²

If unsure whether group members will be receptive to a transgender member, create a plan with the transgender client about their preferences regarding your response, while assuring them that they are not the problem. Some transgender participants may want to be "out" in the group while others may not want to disclose. Do not assume that a particular transgender person prefers a group of a specific gender. If possible, allow participants to select which group they would like to attend. In working with an all-LGBTQ survivor's group, it is considered best practice to integrate all genders.

If a prospective client is ineligible for your services, make sure you have appropriate referrals on hand so that the survivor can receive services elsewhere. Develop strong connections with local transgender groups, LGBT community centers, or providers who extensively work with transgender clients so that you can better refer clients who do not meet your eligibility requirements.

For the long term, consider revising your policies so that all survivors, including transgender survivors, are eligible to participate.