Treating the Victim
To ensure successful care of transgender victims of sexual assault, first responders and frontline staff must be trained in how to appropriately and respectfully interact with and treat people who are visibly gender non-conforming, identify as transgender, or have identity documents with names or gender markers that do not match their presentation. First responders and frontline staff set the tone for all subsequent interactions. Inappropriate reactions, questions, or remarks may cause victims to become distrustful or self-protective and they may abandon their efforts to seek help after an assault.
When helping victims of sexual assault, professionals tend to expect someone who appears male while dressed, for example, to have a flat male chest and penis while undressed. When a transgender victim has a body configuration that the professional was not expecting, it can be unsettling and may lead to confusion, delay, or abandonment of appropriate service; inappropriate questions (sometimes voiced in an aggressive tone); or abuse. Some professionals feel deceived if victims being served are not proactively explicit about the configuration of their bodies prior to disrobing. This is one of the many reasons transgender people avoid accessing care, even when they are seriously ill or injured.
Strive to deliver professional, respectful, and equal service to everyone, regardless of gender identity or expression. Your responseeven when subtlecan greatly influence whether victims feel they are being judged. Even slight changes in body language (e.g., pulling back), facial expressions (e.g., eyes slightly widening, lips pursing), or sounds (e.g., gasps, sharp intakes of breath, sighing) cue transgender individuals that they may not be treated with respect, be fully heard, or even be treated at all. Be aware of your nonverbal reactions and avoid conveying surprise or judgment.
Two core principles will promote respectful care:
Implications and Actions for ...
Health Care Providers
Effective treatment begins at reception and intake. It is essential that these frontline staff, and all staff for that matter
If a patient experiences inappropriate behavior or mistreatment by frontline staff, promptly follow up with an apology and a corrective course of action and then move on.
Before beginning any examination
Although this may seem time-consuming, it could help alleviate the concerns of transgender patients who may have a long history of being subjected to invasive questions and procedures that were performed solely for curiosity's sake. It also helps patients gain back a sense of control, which was taken from them during the assault.
Sexual assault survivors are likely uncomfortable in situations in which they feel physically vulnerable, such as in any type of medical procedure that involves disrobing. This may be even truer for transgender patients. Extreme discomfort with genitals and reproductive organs is common among transgender people and even more so among those who have been sexually assaulted.
As you begin examining and treating transgender patients who have been sexually assaulted, you may encounter the following:
Prosthetics or other devices
If your transgender patients use prosthetics or similar devices, they may not want to part with them, even for a short time. For example, some FTMs (female-to-male individuals) bind nearly 24 hours a day and only remove their binders for showering. These patients may be unwilling to remove or uncomfortable removing their binders for an examination. Patience is essential. Work together to find solutions that are tolerable for the patient and that allow you to proceed with the exam. For example, it might be possible for the FTM to remove his binder in the privacy of the exam room before you are present and to wear a t-shirt during the exam.
Similarly, many transgender individuals wish to remain clothed because they do not want otherseven health care providersto know they use items to enhance their gender presentation or function.
In some cases, these devices may not only create barriers to care—they may actually cause health problems. For example, FTMs or gender non-conforming, trans-masculine individuals may have difficulty breathing, rashes, or chronic back pain from binding or heat-related conditions from wearing multiple layers of clothing to create a more masculine appearance. Similarly, MTFs (male-to-female individuals) who frequently gaff with tape may experience rashes or other skin irritations on their genitals, may have difficulties urinating, or may develop infections or scarring under the taped areas. If a device is causing health problems, be sensitive to the patient's emotional and safety needs when discussing options of care or when suggesting that use of the device be discontinued or that an alternative be identified. Many transgender individuals risk increased violence on the street, in the workplace, and even at home without these devices.
If medical issues do arise from the use of these devices, note that it is often possible to chart and describe the patient's symptoms and diagnosis without a detailed report of the assistive devices used.
When asking patients for a full list of medications that they take, normalize this request by informing them that all patients are asked to provide a list of their medications and supplements. Many transgender individuals do not consider hormones a medication, so ask specific, direct questions to find out the type and dosage to provide more informed medical care.
Transgender victims of sexual assault might be seeing therapists for emotional support and may be on medications for anxiety, depression, posttraumatic stress disorder, or issues related to sleep. Talking about all medication prescribed by other providers in nonjudgmental ways will allow patients to fully disclose their medications (and the reasons they are taking them). It may be appropriate to coordinate care with the patient's other prescribing physicians (but see Disclosure and Confidentiality in this e-pub).
FTMs. Because hormones may decrease the plasticity in the vagina, penetration in this area may result in increased physical trauma and/or potentially put an FTM at higher risk for sexually transmitted infections (STIs). If you are conducting a vaginal exam on a transgender patient who uses hormones, consider using a pediatric speculum. Although unlikely, pregnancy is still possible in FTMs who use testosterone, particularly those who are on a "low dose."3 Discuss appropriate pregnancy testing approaches with these patients.
MTFs. MTF victims of sexual assault may not have many medical complications related to hormone use, but this depends on the extent of the injuries sustained. Because sexual assault against transgender individualsparticularly transwomen of colorcan include hate-motivated, physical violence, MTF patients may be bleeding from cuts, abrasions, gunshot wounds, or vaginal/anal penetration. MTFs who are taking estrogen are at substantially increased risk for blood clot complications. Prophylactic anticoagulant care may be appropriate.
The majority of transgender people have not had (or do not want) surgery to alter their body.4 When treating FTM transgender patients who have had surgery as part of their transition, keep the following in mind:
When treating MTF transgender patients who have had surgery as part of their transition, keep the following in mind:
Self-harming behaviors are extremely common in survivors of sexual assault and other trauma. One study estimates that self-injuring behavior may be as high as 60 percent.5 Such behaviors are also extremely common within the transgender community, many of whom are survivors of sexual assault.6 Self-injuring behaviors are likely the result of self-preservation instincts, desperation leading to survival, and emotional, cathartic release.7
Although self-injury is common among transgender individuals (41.8%) and very common among victims of sexual assault, do not assume that any cuts you see on a patient are self-inflicted.8 Hate crime perpetrators often deliberately cut or mark their victims during an assault. If some cuts are self-inflicted, be careful not to assume that other bodily damage is also self-induced. Determining the origin (self-imposed or not) or intention (hate-motivated, non-suicidal, or suicidal) of cuts may be difficult. If you suspect that cuts are self-inflicted, consider referring the patient to a therapist, victim advocate, or victim service provider, who can play a key role in helping patients learn healthier strategies for dealing with stress and trauma.
Silicone use may result in damages not typically seen in most assault survivors. For example, if an MTF has a blunt force injury to her silicone-injected face, it may appear more disfigured than other patients with similar facial injuries due to the migration of the silicone. If an MTF has injected silicone in her chest/breast area and the area was targeted during the assault, that silicone may have migrated as well. Be prepared for these types of injuries and do not show alarm when you see them.
Survivors of trauma sometimes experience flashbacks or dissociate, particularly when they have been triggered by something that reminds them of the trauma. Medical exams or any interaction involving touch can increase the likelihood of dissociative responses such as being confused, distracted, or unresponsive. If the patient you are treating exhibits dissociation, discontinue an exam, test, or procedure until the patient is fully present. Maintain direct eye contact, remind the patient of the date and time, and help the patient reorient. You may also want to suggest that they look at the clock on the wall, remind them of who you are, or even overtly state that you are not the perpetrator to help keep them from continuing to dissociate. Try to ensure that the patient has an immediate support structure in place, which may include staying in the exam room (alone or with a loved one or advocate) until the patient has stopped dissociating and is able to leave the office safely.
If the patient is having forensic evidence collected or is being treated for an injury that requires immediate care, be aware of their dissociation, explain what you are going to do, and ask permission before proceeding. The presence of an advocate or loved one can minimize distress.
1. Rape, Abuse & Incest National Network, "Effects of Sexual Assault,” accessed Jan. 28, 2011.
2. J. Xavier, J. Honnold, and J. Bradford, 2007, The Health, Health-Related Needs, and Lifecourse Experiences of Transgender Virginians, Richmond, VA: Virginia HIV Community Planning Committee and Virginia Department of Health, accessed Sept. 7, 2010.
3. FTMs are usually informed that consistent testosterone use, which typically results in ovarian atrophy and the cessation of ovulation, will make them sterile; however, there have been cases of FTMs unexpectedly becoming pregnant even if they have ceased menstruating.
4. J.M. Grant, L.A. Mottet, J. Tanis, J. Harrison, J.L. Herman, and M. Keisling, 2011, Injustice at Every Turn: A Report of the National Transgender Discrimination Survey, Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force, accessed Feb. 4, 2011.
5. C. Zlotnick, J.I. Mattia, and M. Zimmerman, 1999, “Clinical Correlates of Self-Mutilation in a Sample of General Psychiatric Patients,” The Journal of Nervous and Mental Disease 187:296–301.
6. l.m. dickey, 2010, Non-suicidal self-injury in the transgender community. Unpublished dissertation, University of North Dakota, Grand Forks.
Emergency Medical Personnel
You can take several steps to respectfully serve transgender victims of sexual assault:
In other words, be professional.
While you are treating transgender patients who have been sexually assaulted, please keep the following in mind:
You can take several steps to respectfully serve transgender victims of sexual assault:
In other words, be professional.
Although the medical transition of a transgender victim of sexual assault is generally not relevant for law enforcement officers, please keep the following issues in mind:
As an advocate, you provide critical assistance to transgender victims of sexual assault during medical treatments (e.g., physical examinations, collection of forensic evidence). In advance of these visits, discuss with the victim how the advocacy process works. Smooth the way for victims by ensuring that medical providers act professionally, stay focused on the victim's crime-related medical needs, make no unnecessary remarks, and refrain from questioning the victim to fulfill their own curiosity about hormone or surgical status.
If needed, help victims set medical priorities with providers. For example, a male-to-female (MTF) transitioning victim may have deep emotional and financial investment in her facial appearance. This victim may have had one or more facial feminizing surgeries, expensive electrolysis, or silicone injections and may care much more about injuries to her face than to other parts of her body. In some cases, an MTF may view her face as the primary component that keeps her safe from anti-transgender discrimination, harassment, and violence. In these cases, encourage physicians to attend to the victim's facial injuries, cuts, scars, or abrasions first, before evaluating other injured areas.
You may also play a critical role in some forms of medical exams. For example, female-to-male (FTM) victims who use testosterone may experience vaginal atrophy. If the victim has been vaginally assaulted and wishes to have evidence collected or needs medical care of any kind on this area of his body, encourage the use of a pediatric speculum or remind the medical provider that the victim's vaginal tissue may not respond like a non-transgender woman's tissue. Also reinforce the use of male pronouns (if that is the victim's preference), as most providers conducting vaginal exams frequently and automatically use female pronouns.
Two of the biggest challenges transgender people contend with are other people's curiosity and the belief that others have a right to determine if someone's gender is "true" based on their hormone status, genitals, or other bodily configuration. If accompanying a transperson who is asked about these matters, it may be appropriate to intervene. Ask the professional to explain why they need to know and ensure that the question is medically necessary. If it isn't, set boundaries with the provider. A clear exception to the usual boundaries is when a health care professional needs to know which medications a patient takes to ensure there are no side effects or contraindications; victims should disclose hormone use for those reasons. Some transgender individuals do not consider hormones a medication, however, so you may need to ask specific, direct questions about hormone use.
Effective treatment begins at reception and intake. It is essential that these frontline staff, and all staff for that matter—
If a client experiences inappropriate behavior or mistreatment by frontline staff, promptly follow up with an apology and a corrective course of action and then move on.
As you work with transgender clients who have been sexually assaulted, keep in mind that many sexual assaults of transgender people include some form of "message" injury that results in greater damage to the genitals, chest, or face. Transgender people may be especially devastated by these injuries because their identity and sense of self-worth are often strongly linked to these areas of the body. Many have saved for a decade or more to pay for surgical intervention. If a perpetrator causes permanent damage, the victim may feel even more despair, frustration, and hopelessness. Transgender victims face additional challenges if they have to explain to coworkers, friends, or family what happened and why their physical appearance may be radically different after an assault.
If the physical harm was severe enough to warrant corrective/reparative surgery, the client’s insurance company may not cover the expenses. If this is the case with your client, consider reaching out to transgender-sensitive, creative victim service providers to help the client find local resources and options.
If surgery of any type is needed post-assault—such as placing a pin in a broken bone—individuals taking estrogen are often asked to discontinue it due to an increased risk for blood clots. This can be emotionally devastating as well as mood altering. If your client needs to stop taking estrogen, reassure them that it is a temporary precaution and help them develop coping strategies to deal with discrimination, prejudice, and stress.
Do not ask questions about bodily injuries or configuration for curiosity’s sake. If clients need to discuss the implications of damage to their bodies, or have any other reasons to talk about their bodies or surgical status, they will likely initiate the discussion, as long as you have created a safe and welcoming environment.
1. C. Zlotnick, J.I. Mattia, and M. Zimmerman, 1999, “Clinical Correlates of Self-Mutilation in a Sample of General Psychiatric Patients,” The Journal of Nervous and Mental Disease 187:296–301.
2. l.m. dickey, 2010, Non-suicidal self-injury in the transgender community. Unpublished dissertation, University of North Dakota, Grand Forks.
Support Group Facilitators
One of the most useful purposes of support groups—for both transgender and non-transgender individuals—is as an environment where participants feel free to share their experiences without being judged or discriminated against, and it is the facilitators who must set the stage and moderate the group discussion to achieve this safe environment. The diversity of experiences shared within the group can help all members see the range of emotions, reactions, processes, and solutions that are possible. Transgender people may discover that their experiences as survivors are not transgender specific, but are instead survivor specific or simply human experiences.
Unfortunately, some support groups are not the safest, most sharing environments. Transgender people often feel censored by facilitators or excluded by other group members. If a transgender client discloses to the group and is neither censored nor excluded outright, that client still may encounter anti-transgender bias among the group or staff in your office. Beyond confronting this bias, you must also be aware of some of the specific concerns that transgender clients may have, so that you can address them appropriately when they are raised in a group setting.
Some facilitators ask transgender people not to discuss any aspect of their transgender status, experience, body, or reality with the group. For example, female-to-male survivors who were vaginally penetrated during an assault have been asked not to share this information in a group for men. This prohibition may also mean that a person cannot talk about an assault that occurred in childhood or at any time in their lives when they were perceived as or living as another gender. If the assault occurred within the context of a hate crime, it forces them to conceal this as well.
Some groups have inclusion/exclusion rules that are enforced through discussion and/or voting within the group, and some have used this process to expel transgender individuals simply because they feel uncomfortable around them. An existing policy that defines who is or is not allowed into groups is a good place to start if the group initiates this discussion (see Segregated Services: Implications and Actions for Support Group Facilitators for information about such policies). If there is no policy, consider what this dynamic would feel like if most group members were white and they did not feel "comfortable" with a person of color in the group. Would you, as a facilitator, allow the group to vote out participants because of the color of their skin?
As the support group facilitator, you should address cultural bias, transphobia, and incorrect assumptions and statements when they happen, regardless of who states them. Confronting bias and ensuring a safe space for all participants is one of your primary roles.1
You can help by getting group members to stay focused on the purpose of the group and steering discussion away from intrusive or inappropriate questions. As noted in FORGE's Confronting Client Bias handout,2 you can reduce bias among group members and staff in these four ways:
The Men's Project in Eastern Ontario, Canada, has very successfully screened potential group members for homophobia before they are admitted into mixed sexual orientation groups. Potential members with biases are offered individual therapy until they are able to safely be in groups with members of different sexual orientations. A similar process could be used to screen group members about anti-transgender bias or other possible biases that could affect the safety and effectiveness of the group. Potential group members should also be screened for abusive behavior by loved ones, to prevent survivors from being in the same group as perpetrators (see Companions as Abusers in this e-pub for more information).
As facilitator, you should help the group construct ground rules and enforce those rules as necessary. Failure to do so may result in transgender (and other) clients deciding to leave the group. According to one transgender sexual violence survivor: "I've never been in an emotional support environment where I felt safe discussing transgender issues."3
If a client doesn't feel supported within the group, and you cannot find other local options for group support, several online and phone options are available, regardless of a client's location:
As you work with transgender clients who have been sexually assaulted, keep in mind that many sexual assaults of transgender people include some form of "message" injury that results in greater damage to the genitals, chest, or face. Transgender people may be especially devastated by these injuries because their identity and sense of self-worth as male or female are often strongly linked to these areas of the body. Many have saved for a decade or more to pay for surgical intervention. If a perpetrator causes permanent damage, the victim may feel even more despair, frustration, and hopelessness. Transgender victims face additional challenges if they have to explain to coworkers, friends, or family what happened and why their physical appearance may be radically different after an assault.
It is not uncommon for both providers and the general public (including members of support groups) to be curious about and to ask inappropriate questions regarding a transgender person's surgical status. One of the most common questions transgender people field is "Have you had genital surgery?" These questions are almost always inappropriate, insensitive, and damaging. Non-transgender people are rarely asked questions about their genitals or other personal details, and the same should hold true for transgender individuals. If a member of a support group asks about someone else's genitals, intervene immediately. A simple, firm statement of "that question is not appropriate" will remind everyone of the appropriate boundaries of discussion as well as reassure the transgender person that you will not allow intrusive questions.
Self-harming behaviors are extremely common in survivors of sexual assault and other trauma. One study estimates that self-injuring behavior may be as high as 60 percent.4 Such behaviors are also extremely common within the transgender community, many of whom are survivors of sexual assault.5 You can play a key role in helping clients learn healthier strategies for dealing with stress and trauma and enhancing their ability to cope with their emotions.
1. L. Cook-Daniels, 2001, Making Space Safe, Milwaukee, WI: FORGE, accessed Jan. 28, 2011. [A Transgender Support Group Facilitator's Guide is expected to be published in 2013 and will be available on FORGE’s Web site.]
2. FORGE, 2009, Confronting Client Bias, Milwaukee, WI: FORGE.
3. FORGE, 2005, Sexual Violence in the Transgender Community Survey, quotation from narrative response, unpublished data.
4. C. Zlotnick, J.I. Mattia, and M. Zimmerman, 1999, “Clinical Correlates of Self-Mutilation in a Sample of General Psychiatric Patients,” The Journal of Nervous and Mental Disease 187:296–301.
5. l.m. dickey, 2010, Non-suicidal self-injury in the transgender community. Unpublished dissertation, University of North Dakota, Grand Forks.