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Serving Transgender Victims of Sexual Assault
Message From the DirectorAbout This Guide
Transgender 101Sexual Assault in the Transgender CommunityTips For Those Who Serve Victims
June 2014
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Victim Issues

Mistrust of Professionals

Providing 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 of transgender sexual assault survivors, one-third of the respondents did not access services because they were afraid to.12 According to the survey, 5 percent reported being sexually assaulted by a law enforcement officer and 6 percent reported being assaulted by a health care professional or social service provider. One survivor told FORGE—

    One assault was in an emergency room at a hospital, by a female doctor who I believe was angered by my appearance (I looked male and my hospital bracelet/chart said "female").

  • NCAVP reports that of the anti-LGBTQ hate crimes that came to its attention in 2011, 9 percent were perpetrated by law enforcement officers and 4 percent by service providers.13
  • According to the National Transgender Discrimination Survey, 28 percent of transgender individuals reported being harassed in medical settings, 19 percent reported being refused care outright, 2 percent reported being physically attacked in a doctor's office, 50 percent indicated they had to teach their medical providers about transgender care, and 1 in 10 reported that they had been sexually assaulted in at least one health care setting.14

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:

I was inappropriately used sexually by my gender therapist in [city withheld]. He began sexually advancing to show me how to be a "real man," as a way of modeling masculine behavior. It became obvious that I needed to be sexual with him in order to receive the required letter to have chest surgery. We had sex a countless number of times—sometimes in his office, sometimes my house, sometimes he would make me take him out to dinner and pay the bill. When I realized that this was wrong, I asked him for my surgery letter so I could discontinue "therapy." He refused and I had to pay thousands of dollars to reestablish a relationship with another therapist in order to get a surgery letter.15

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 low—only 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 unacceptable—and in many states as illegal—as 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 providers

Mental 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.

Gender Identity Disorder and the DSM

In December 2012, the American Psychiatric Association removed gender identity disorder from the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM–V). Gender identity disorder had long been used to diagnose transgender individuals with a mental illness, which has frequently resulted in both stigma and denial of both mental health and physical health services due to insurance exclusions based on this diagnosis. The former diagnosis was in the DSM under "sexual disorders."

Due to the predominance of "gender dysphoria" language in the professional literature, gender identity disorder has been renamed "gender dysphoria" and has been moved out of the "sexual disorders" category. Separate diagnostic criteria have been developed for children and adults.


Law enforcement officers

Law 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 survivors—either directly after an assault (e.g., when taking a report) or in the weeks or months following an assault—by 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

Read More

In this e-pub*

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

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 Providers

When 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

  • You have the right to receive considerate, respectful, and compassionate care in a safe setting regardless of your age, gender, race, national origin, religion, sexual orientation, gender identity, or disabilities.
  • You have the right to be called by your proper name and to be in an environment that maintains dignity and adds to a positive self-image.
  • You have the right to have a family member or person of your choice and your own doctor notified promptly of your admission to the hospital.
  • You have the right to have someone remain with you for emotional support during your hospital stay, unless your visitor's presence compromises your or others' rights, safety, or health. You have the right to deny visitation at any time.
  • You can expect full consideration of your privacy and confidentiality in care discussions, exams, and treatments. You may ask for an escort during any type of exam.

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 providers

If 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 enforcement

Remind 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.

Improve Your Reputation by Improving Your Knowledge

In general, providers receive very little formal training about best practices in working with transgender people. Become better informed of transgender issues by—

  • Attending conferences. Transgender-specific or -inclusive workshops are increasingly offered at professional conferences primarily intended to enhance general therapeutic knowledge and skills (e.g., conferences of the American Medical Association, American Academy of Physician Assistants, and American Society on Aging) and at trauma-specific conferences (e.g., National Center for Victims of Crime's national conference, National Sexual Assault Conference, Sexual Assault Response Team Training Conference). There are also quite a few transgender-specific conferences with tracks or workshops focused on providers, including the following:
  • Participating in webinars.
  • Reading books specifically on working with transgender people.
    • Transgender Emergence: Therapeutic Guidelines for Working With Gender-Variant People and Their Families, Arlene Istar Lev, 2004
    • Guidelines for Transgender Care, edited by Walter O. Bockting and Joshua Goldberg, 2007
  • Joining special interest groups, which often offer listservs that allow you to network with other providers.
  • Viewing documentary films.
  • Participating in listservs. Many health care providers are benefitting from one-on-one, direct responses to their questions by participating in the trans-medicine listserv. The listserv, which is limited to health care providers, addresses a wide range of medical questions with peer-to-peer, evidence-based responses and dialogue.
  • Developing or strengthening relationships with local LGBT and transgender organizations and other professionals working with transgender individuals (see Outreach in this e-pub).
  • Building relationships and partnerships with local service providers. No single discipline can provide the victim-centered services and support that every transgender victim of sexual violence deserves. You are not alone. Research and join local multidisciplinary or coordinated response teams (e.g., sexual assault response teams, sexual assault councils or committees) to play a role in first response and to build awareness of transgender issues in your community.

1. See Johns Hopkins Hospital's "Participating in Your Care" for its patient bill of rights.

Emergency Medical Personnel

Because so many transgender people have had negative experiences with professionals who are supposed to help them—therapists, physicians, emergency medical personnel, and many other people in positions of authority—transgender 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.

Improve Your Reputation by Improving Your Knowledge

Most first responders treat all patients with professionalism and respect and are not intentionally ignorant or prejudiced toward transgender people. A lack of formal training in transgender issues, however, may result in accidentally engaging in behavior that is inappropriate or prejudicial. Become better informed of transgender issues by—

  • Attending trainings and conferences, a growing number of which are including LGBT (and even trans-specific) workshops and educational materials.
  • Encouraging the appointment of an LGBT liaison who can represent lesbian, gay, bisexual, and transgender community members.
  • Being part of a diversity group and raising issues related to serving transgender individuals more sensitively.
  • Accessing and suggesting resources that can be shared at staff meetings. Even a 10-minute awareness video or quick fact sheet can help people respond more appropriately when encountering a transgender individual. Consider some of the following resources1:
  • Building relationships and partnerships with local service providers. No single discipline can provide the victim-centered services and support that every transgender victim of sexual violence deserves. You are not alone. Research and join local multidisciplinary or coordinated response teams (e.g., sexual assault response teams, sexual assault councils or committees) to play a role in first response and to build awareness of transgender issues in your community.

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 Enforcement

Because so many transgender people have had negative experiences with professionals who are supposed to help them—therapists, physicians, law enforcement officers, and many other people in positions of authority—transgender 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.

Improve Your Reputation by Improving Your Knowledge

Most law enforcement officers treat all victims with professionalism and respect and are not intentionally ignorant or prejudiced toward transgender people. A lack of formal training in transgender issues, however, may result in accidentally engaging in behavior that is inappropriate or prejudicial. Become better informed of transgender issues by—

  • Attending trainings, conferences, and roll call meetings, a growing number of which are including LGBT (and even trans-specific) workshops and educational materials.
  • Encouraging the appointment of an LGBT liaison who can represent lesbian, gay, bisexual, and transgender community members.
  • Being part of a diversity group and raising issues related to serving transgender individuals more sensitively.
  • Accessing and suggesting resources that can be shared at roll call and staff meetings. Even a 10-minute awareness video or quick fact sheet can help people respond more appropriately when encountering a transgender individual. Consider some of the following resources:
  • Building relationships and partnerships with local service providers. No single discipline can provide the victim-centered services and support that every transgender victim of sexual violence deserves. You are not alone. Research and join local multidisciplinary or coordinated response teams (e.g., sexual assault response teams, sexual assault councils or committees) to play a role in first response and to build awareness of transgender issues in your community.

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.

Advocates

Your 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 providers

With 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 enforcement

Becoming 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.

Improve Your Reputation by Improving Your Knowledge

For the long-term improvement of care of transgender victims, advocates can ease the way by educating themselves about transgender issues and advocating for widespread professional education as well. Become better informed of transgender issues by—


Therapists

When 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

  • You have the right to receive considerate, respectful, and compassionate care in a safe setting regardless of your age, gender, race, national origin, religion, sexual orientation, gender identity, or disabilities.
  • You have the right to be called by your proper name and to be in an environment that maintains dignity and adds to a positive self-image.
  • You have the right to have a family member or person of your choice and your own doctor notified promptly of your admission to the hospital.
  • You have the right to have someone remain with you for emotional support during your hospital stay, unless your visitor’s presence compromises your or others’ rights, safety, or health. You have the right to deny visitation at any time.
  • You can expect full consideration of your privacy and confidentiality in care discussions, exams, and treatments. You may ask for an escort during any type of exam.

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.

Reporting to Law Enforcement

Some clients you are treating may need support when interacting with law enforcement officers, and others may need additional support after this interaction. If a client decides to report a sexual assault to law enforcement, consider stepping out of your office role to accompany that client to the police department or to be present as an advocate and witness during interviews. Before making this offer, however, be mindful of your confidentiality requirements and consider consulting with colleagues or your clinical supervisor or licensing board.

If a client you are treating has reported to law enforcement and is pursuing legal action or there is a prosecution in a case, disclosure of therapeutic records and client notes may be requested or compelled. Familiarize yourself with the local rules and requirements regarding record-keeping and record submission, and be clear about these rules when meeting with clients. Keep in mind that written notes, even if not in the primary file, may be subject to disclosure (e.g., through a subpoena) in legal proceedings. Discuss confidentiality and the possible subpoena of records in advance with the client. Do not make promises that cannot be kept. Having one or more transparent conversations ahead of time may help to build trust and reduce fears. (See Disclosure and Confidentiality for more information.)

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).

Improve Your Reputation by Improving Your Knowledge

In general, therapists receive very little formal training about best practices in working with transgender people. Become better informed of transgender issues by—


1. See Johns Hopkins Hospital's "Participating in Your Care" for its patient bill of rights.

Support Group Facilitators

Some 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).

Discussions Related to Police Officers

Some support group members may have reported their sexual assault to law enforcement and may want to talk about it during the group. Others may have strong emotions about law enforcement because they may have experienced previous police misconduct. Sensitivity to and awareness of this issue are helpful in creating a space that will ideally not revictimize individuals.

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 group—for 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 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 support they need.

Improve Your Reputation by Improving Your Knowledge

Most support group facilitators are not intentionally ignorant or prejudiced. They simply have limited or no experience in working with transgender people. Of course, transgender victims are more likely to seek out services from well-informed support group facilitators, and to trust those facilitators as well. The following resources may be useful in improving your knowledge about core transgender issues:

Also consider developing or strengthening relationships with local LGBT and transgender organizations and other professionals working with transgender individuals (see Outreach in this e-pub) and building relationships and partnerships with local service providers. No single discipline can provide the victim-centered services and support that every transgender victim of sexual violence deserves. You are not alone. Research and join local multidisciplinary or coordinated response teams (e.g., sexual assault response teams, sexual assault councils or committees) to play a role in first response and to build awareness of transgender issues in your community.


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.