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. Author manuscript; available in PMC: 2025 Sep 1.
Published in final edited form as: Violence Against Women. 2023 May 2;30(11):2767–2788. doi: 10.1177/10778012231172700

Risks of Severe Assault and Intimate Partner Homicide among Transgender and Gender Diverse Intimate Partner Violence Survivors: Preliminary Findings from Community Listening Sessions

Athena D F Sherman 1, Sarah Peitzmeier 2, Andrea N Cimino 3, Monique Balthazar 1,4, Meredith Klepper 5, Arzina T Chand 4, Carissa Lawrence 5, Kisha Allure 6, Grayson Slink 5, Jacquelyn C Campbell 5
PMCID: PMC10620102  NIHMSID: NIHMS1902355  PMID: 37132033

Abstract

Intimate partner violence (IPV) is an epidemic among transgender and gender diverse (TGD) people. However, intimate partner homicide (IPH) among TGD people is under researched. Thus, thematic content analysis was used to describe and examine antecedents of severe assault and IPH among TGD adults who have experienced IPV (N = 13), via community listening sessions. While some themes resembled known severe assault and IPH risks among cisgender women, several themes were unique to TGD people and should be considered when safety planning with TGD individuals or adapting IPV screening tools for this population.

Keywords: Transgender, gender diverse, intimate partner violence, safety planning, risk assessment

Introduction

Intimate partner violence (IPV)—defined as physical and/or sexual violence, stalking, psychological aggression, or coercive control from an intimate partner or ex-partner—is estimated to affect 1 in 3 cisgender women and 1 in 4 cisgender men in the United States (Black et al., 2011). Less studied is the prevalence of IPV among transgender and gender diverse (TGD) persons, whose gender identity differs from that normatively expected of their sex assigned a birth. In a 2015 survey with 27,715 transgender respondents, 54% reported some form of lifetime IPV (James et al., 2016). Specifically, 35% reported physical IPV, 24% reported severe physical IPV, and 16% reported being sexually assaulted by a partner in their lifetime (James et al., 2016). As with the cisgender population (Black et al., 2011; Stöckl et al., 2013), a portion of TGD IPV victims are at risk of being severely assaulted or murdered by an intimate partner. Aside from evidence that suggests Black TGD people are murdered more often than TGD peers of other races/ethnicities (with the highest portion of TGD people killed identifying as Black transgender women or Black transgender feminine people) little is known about IPH risk among TGD people (Dinno, 2017). This article draws from the cisgender IPH literature to examine antecedents of severe assault and IPH risk among TGD people who have experienced IPV.

Literature Review

Severe IPV refers to physical violence including being hit with a fist, bitten, and/or kicked; being hit with something or an attempted hit with something; being choked or burned; being threatened with or having been injured by a knife or gun; and/or being forced to have sex against one’s will (Gondolf, 2009). In some cases, severe IPV can turn deadly. Over 53% of the 10,018 cisgender women ages 18+ who were murdered from 2003–2014 in 18 states were IPV-related (Petrosky et al., 2017). According to the most recent national Supplementary Homicide Report (SHR) data submitted to the Federal Bureau of Investigation 56.4% (915) of 1622 women (assumed cisgender) who are murdered by men are murdered by an intimate partner and six times more likely to be killed by an intimate partner than anyone else (Kellermann & Mercy, 1992; Planty & Truman, 2013). IPH is in the top 10 leading causes of death for women ages 18–34 (National Center for Health Statistics, 2017), especially women of color (Petrosky et al., 2017).

IPV that turns lethal or nearly lethal follows predictable patterns with predictable risk indicators. According to literature on cisgender women IPH victims, the most dangerous IPV offenders—those who murder their partners—share specific commonalities: a history of IPV against the victim, past attempts/threats to kill the victim often with a weapon, gun ownership and a history of strangling or forcing sex upon the victim (Campbell et al., 2003, 2007; Glass, Laughon et al., 2008; Messing et al., 2021). Prior IPV is a strong and significant predictor of IPH (Campbell et al., 2003, 2007; Glass, Laughon et al., 2008; Harden et al., 2019; Sharps et al., 2001). About 72% of women murdered by a partner or ex-partner were abused by that partner before being killed (Campbell et al., 2003, 2007; Glass, Laughon et al., 2008; Harden et al., 2019; Sharps et al., 2001). Similarly, when cisgender men are killed by cisgender women, cisgender men have histories of using IPV against their partners in about 75% of cases (Campbell et al., 2003; Koziol-McLain et al., 2006). Research estimates that for every lethal IPH there are as many as 8–9 near lethal assaults (i.e., shootings or stabbings to head, neck or torso, strangulation) (Campbell et al., 2003).

IPV and IPH among Transgender and Gender Diverse People

Although there is a dearth of research on IPV and IPH among TGD people, evidence from a systematic review of the literature suggests that TGD people experience IPV at 2 to 3 times the prevalence of cisgender people (Peitzmeier et al., 2020). Additionally, TGD people face unique risks when it comes to IPV (Messinger & Guadalupe-Diaz, 2020; Yerke & DeFeo, 2016). Namely, TGD people’s experience of IPV is uniquely shaped by cisnormativity (the idea that being cisgender is “normal” and gender diversity is a pathology) and anti-transgender stigma (enacted, anticipated, or internalized prejudice against transgender people; King et al., 2020). For instance, cisnormativity and anti-transgender stigma may be used by abusive partners to shame and control TGD victims, and it can hinder TGD people’s ability to seek help (Messinger & Guadalupe-Diaz, 2020). For instance, threatening to “out” a victim to employers or family members, coercively controlling a victim’s gender presentation, or sabotaging their transition, are trans-specific tactics used by abusive partners (Peitzmeier et al., 2019; White & Goldberg, 2006).

Like cisgender abused women of color, many TGD people mistrust police and other domestic violence first responders because they face victimization and discrimination when seeking help from law enforcement, social services, or health providers (Cicero et al., 2019; Grant et al., 2011; Sherman et al., 2021; Yerke & DeFeo, 2016). For instance, few domestic violence shelters serve TGD people and research shows that close to a quarter of transgender women and half of transgender men experiencing violence were denied shelter (Hines & Douglas, 2011), However, this situation has improved lately and there is now a crisis line for transgender people (https://translifeline.org/) available at 1-877-565-8860 that can direct TGD people to safe shelter. TGD people of color and those with disabilities experience additional barriers accessing domestic violence programs according to a secondary data analysis of the United States Transgender Survey (James et al., 2016, 2017). Moreover, according to one study, about half of domestic violence service providers were “minimally prepared” to serve TGD people (Ford et al., 2013).

Assessing Intimate Partner Homicide Risk

Over the past 30 years, validated risk assessments have been used to predict IPV re-assault and IPH among cisgender women (Graham et al., 2021). Research shows IPV risk assessments (IPVRAs) are more accurate at predicting lethal/near-lethal violence than survivors’ or practitioners’ judgement (Dayan et al., 2013) and therefore are an important tool for IPV prevention. All IPVRAs identify violence risk patterns from actual cases (i.e., known re-assaults or murders) to predict severe IPV re-assault or lethality. For instance, the Danger Assessment (DA), which is the only IPH risk assessment, compared IPV risk factors that differentiated abused cisgender women who did not face lethal threats from their partners, from cisgender women who were killed or nearly killed by their partners. Research showed that the DA was able to accurately predict attempted murder cases with 92% accuracy (Campbell et al., 2009). It is important to note that IPVRAs are designed and tested for use in one population, and therefore may be inappropriate if used with another population or context. The original DA was validated specifically among cisgender women in abusive relationships with cisgender men. A version of the DA (the DA-R) was created for cisgender women in abusive relationships with other cisgender women (Glass, Perrin et al., 2008). Additional unique risk factors were identified for this population, and risk factors were found to have different weight in predicting risk than in the original population (Glass, Perrin et al., 2008). There is no IPVRA validated for use in TGD populations that captures unique contexts and risk factors faced by this population.

Purpose

As we have demonstrated, IPV manifests in unique ways for TGD people. To prevent potential IPH among TGD people in abusive relationships, it is imperative that tools be rooted in TDG experiences of severe IPV. Therefore, the purpose of this analysis was to examine antecedents of severe re-assault and IPH risk among TGD people who have experienced IPV. This study focuses on unique aspects of severe IPV among TGD people, with the goal of learning how best to respond to TGD IPV in inclusive and comprehensive ways.

Methods

The present study is an analysis of existing qualitative data from community listening sessions led by the first author. The purposes of the original data collection were to inform possible recommendations for adaptation of the DA to better meet the needs of TGD people experiencing IPV. Below we provide the methods of the original data collection.

Procedure

Recruitment.

Convenience purposive sampling was used to identify TGD people who had experienced IPV. Participants were recruited via passive flyers at LGBTQ + community organizations and clinics, as well as actively from existing research participant databases (for listening session one only), paid Facebook advertising (for listening session two only), and through word of mouth. Participants had to be over the age of 18, have a gender identity different from that normatively expected based on their sex assignment at birth (e.g., woman assigned male at birth, man assigned female at birth, non-binary person), speak fluent English, report experiencing some form of IPV in their lifetime, and have access to a reliable phone or internet connection to participate in a virtual listening session (listening session two participants only).

Participants.

Community listening sessions were held with 13 TGD adults, ages 20 to 61 years old (M = 33.9, SD = 12.7, Mn = 28, IQR [24.5, 39]). Seven participants were Black and assigned male at birth (AMAB; n = 5 transgender women and n = 2 non-binary persons), and six participants were assigned female at birth (AFAB; n = 3 transgender men and n = 3 non-binary persons; n = 4 White, n = 1 Mexican, n = 1 Black). Inclusion criteria were: (1) have current or previous exposure to IPV; (2) current gender identity is different from that normatively associated with their sex assigned at birth; and (3) 18 years or older. The only exclusion criterion was based on ability to provide consent (e.g., ability to comprehend orally and written provided consent).

Data Collection.

Two separate listening sessions were held – one for transgender women and gender diverse people assigned male at birth (AMAB; n = 7) and one for transgender men and gender diverse people assigned female at birth (AFAB; n = 6). The first listening session was for transgender women and gender diverse people AMAB and occurred in person in Washington, DC prior to the COVID-19 pandemic (February 23, 2020). The second listening session was for transgender men and gender diverse people AFAB and was held virtually using videoconferencing software due to the pandemic (November 8, 2020). The original data were collected to inform culturally appropriate application of the DA tool in community settings serving TGD people. Data collection was fully anonymous, and all names of individuals and organizations mentioned in transcripts have been changed to maintain anonymity. Participants will be referred to by pseudonyms based on plant names. Each participant was compensated $50 for their participation in the study. This current analysis of the existing listening session data was approved by the Emory University Institutional Review Board.

Participants completed a brief survey of demographic characteristics and experiences with IPV using an adapted version of the Revised Conflict Tactics Scale (CTS-2) and the Transgender-related IPV [T-IPV] measure; 0–12 points; binary). Each listening session was co-facilitated by the first author (ADFS – a White American non-binary person AFAB) and a community representatives (KA – a Black American transgender woman and crimes victim case manager at Casa Ruby; GS – a Black American transgender man and transgender rights advocate). Each listening session was guided by a semi-structured interview guide (content areas included defining intimate partners, IPV, and IPH; describing IPV experiences; identifying periods of severe assault and/or risk of IPH; discussing existing community resources and needed resources), which was created and tested with community members and IPV specialists prior to use. Audio data were recorded and transcribed by the DA team.

Analysis

Descriptive statistics described the rate and types of IPV experienced by participants. Thematic content analysis of community listening session transcripts was used to describe antecedents of IPH. Transcripts underwent descriptive inductive coding to identify predictors of severe assault by intimate partners and IPH. Intimate partners were defined according to a definition elicited from participants during the listening sessions, i.e., one-time and reoccurring sex work clients (ranging from daily contact to monthly contact), one-time sexual partners and reoccurring sexual or romantically intimate partners. Participants were invited to share their own stories as well as incidents of severe assault or IPH they had heard of happening in their communities. Two coders (a White American non-binary person AFAB and a Caribbean American cisgender woman) analyzed each transcript separately and discussed and resolved any discrepancies before moving on to a sequential stage of analysis. The codebook was modified based on emergent themes as coding progressed (Riessman, 2008). Once coding was complete, the coders reviewed all codes across and within interviews and identified exemplars for thematic findings separately, then discussed and agreed upon exemplars for each theme to be merged with the quantitative findings.

Trustworthiness

To ensure qualitative rigor, our research and authorship team were comprised of several TGD people, as well as survivors of violence including a Black American transgender woman, a Black American transgender man, a Caribbean American cisgender woman, two Black American cisgender women, an Asian American cisgender woman, a White American nonbinary person, and a White American gender fluid person. These non-dominant perspectives along with memoing and bracketing exercises (reflexive journaling; Patton, 1999; Tufford & Newman, 2012) allowed for in-depth discourse to identify, examine, and reduce the influence of potential biases and presuppositions during study development, data collection, and data analysis (Harding, 2004; Reinharz & Davidman, 1992). Journal entries were reviewed as a team and included the following presuppositions and concerns: (a) participants who were engaged in sex work would be at greater risk of experiencing violence, (b) participants with unstable housing and finances would be at greater risk of experiencing violence, and (c) when the coronavirus (COVID-19) pandemic arose, researchers expressed concern for the TGD community and discussed how this event may affect IPV and IPH risk. These concerns were discussed and considered throughout data analysis to examine and reduce their influence on theme development and interpretation. For instance, although the second listening session occurred several months into the COVID-19 pandemic, no participants reported being in an abusive relationship since the start of the pandemic. Thus, we were unable to interpret the effect of the pandemic on IPV and IPH risk. Lastly, findings were discussed in detail with the co-facilitators of the listening sessions (a Black American transgender woman and a Black American transgender man – both TGD survivors of IPV) as a form of member checking to identify potential bias, resonance, and relevance.

Results

Participant Demographics

Regarding housing status, one participant had nowhere to sleep at night for the last 30 days and one other participant had nowhere to sleep at night for 15 out of the last 30 days. All others were housed. Three participants were engaged in current sex work and two participants in past sex work. All participants had experienced at least one form of IPV (M = 3.5, SD = 2.6, Mn = 3, range = [1, 10], IQR = [1.5, 4.5]). None of the participants were actively in an abusive relationship.

The severity of IPV assault experiences varied among participants. All but two participants had experienced severe assault (i.e., assault that can lead to or results in death, e.g., “hit with a fist, bit, kick; hit with something, attempt to hit with something; choke or burn; threatened with a knife or gun; used a knife or gun; forced sex against will” (Gondolf, 2009) from an intimate partner). Four of 13 participants had severe assault experiences in which they believed that they would be killed. One transgender woman shared a detailed account of the IPH of her friend (another transgender woman). The gender of the perpetrators was not explicitly assessed; however, of the participants who disclosed, violent intimate partners included cisgender men, cisgender women, transgender men, and transgender women.

Key Antecedents of Re-Assault, Severe Re-Assault and/or Intimate Partner Homicide

Antecedents of severe assault or IPH varied among participants. Specific themes identified were: (a) complex social and structural vulnerability (e.g., financial dependence, homelessness, substance use, mental illness, engagement in sex work, citizenship status); (b) pervasive family and community violence and increased weapon use by partners; (c) self-defense – escalation – retaliation; (d) gender disclosure and relationship stigma; and (e) use of physical violence in public.

Complex Social and Structural Vulnerability.

Many participants experienced periods of complex social and structural vulnerability, which were linked to experiences of severe assault, and IPH. Complex social and structural vulnerability has been described as the co-occurrence of multiple factors of social and structural instability, like homelessness, substance use, mental illness, engagement in sex work, institutional racism, citizenship status, and institutional cisgenderism, which decrease one’s ability to be resilient in response to a stressful antecedent, such as violence or illness (Agency for Toxic Substances and Disease Registry, 2021; Sherman, Higgins, et al. 2022; Sherman, Balthazar, et al., 2022). Experiences of complex social and structural vulnerability among those AMAB were seen to increase one’s risk of severe re-assault and IPH. Tulip described her experience managing discrimination, violence, homelessness, mental illness, and physical impairments, which made her particularly vulnerable to IPV from a pastor with whom she was intimately involved:

I’ve just been through a lot. Ok. I feel broken in my spirit. I’m falling apart. My hip is gone. My knee is out of place. I’ve just been robbed a lot. I’ve been through a lot of domestic violence. I’ve been shot. I’ve been stabbed. I had my jaw broke. I have scoliosis…I’ve never had a job. Always had to like struggle in the streets. Like it’s been very hard on me, and my friends and my cousins got killed you know, just experiencing a lot of trauma. I never really had a job…I lost everything I had. All my money all my clothes, all my stuff…Like it’s so hard out here. Like the streets not safe… one dude done tased me in my face and then robbed me of all my pocketbooks and robbed me of all of my government documents… I have been very discriminated against by nonprofit organizations…and I still ain’t got no housing to this day.

At one point Tulip was trading romantic intimacy (i.e., without sexual interaction) for shelter and financial support with a pastor. However, Tulip disclosed being physically abused and removed from her housing by the pastor “…because I didn’t want to have sex with him after he gave me all that money.” Similar to Tulip’s experience, the majority of participants AMAB felt more vulnerable to violence when they were engaged in trading or selling intimacy or sex, experiencing financial instability, or were unhoused.

Complex social and structural vulnerabilities also increased the risk of re-assault among TGD AFAB study participants. Cyprus discussed how their migrant status influenced their decisions to stay in abusive relationships and report abuse. Additionally, Cyprus highlighted how their fear of deportation created an unfair power dynamic in abusive relationships:

Like it’s dangerous for someone like me to be loud and angry, because then they could just fuck up your immigration proceedings and deny you naturalization or deport you. So, deportation for me, has always been like a major component of that power dynamic with the people that have eventually become abusive towards me.

In another instance, Zephyr described the fear of leaving an “unhealthy and dangerous” relationship after 5 years because they were relying on that person financially: “We were living together, and we were splitting the bills. And now having to take on all of that [abuse], it was very scary. And even if I wanted out, I just couldn’t think of more pros and cons for leaving.” Complex social and structural vulnerabilities made it more difficult and complicated for participants to leave violent partners, ultimately increasing their risk of severe assault and potential for IPH.

Pervasive Family and Community Violence and Increased Weapon use by Partners.

Most participants, including all Black identified participants, had high exposure to family- and community-based violence. Often a progression of violence was noted by participants, where one would first experience family violence in the home, followed by community-based violence and IPV. Daisy shared, “You can’t change them, they gonna be who they are regardless… growing up as a kid I learned that early because I was abused by my brothers… [then I had] to go in the street and fight the world.” Many participants were inured to violence given the high saturation of family and community-based violence. Rose, a transgender woman, shared:

Coming from the streets, I was ‘TTG:’ ‘trained to go.’ I was strong, I never felt… or cried when it was over [after my intimate partner stabbed me multiple times in my sleep], I didn’t do that…I was not afraid…it was do or die… Another time… when I went to open the door he [a different man] had the gun like this [pointed in my face] now that was the moment that I was scared.

As seen with Rose, participants were often desensitized to severe assault experiences. In many cases, even violent events involving the use of knives and bottles as weapons did not provoke fear until a gun was involved.

Participants also described the use of weapons, especially knives, as a tool of intimidation and coercion by their partners during experiences of violence. Oleander, a transgender man, described such an experience saying, “I was threatened with a knife… and they, you know, like cornered me against the door… and it was really scary.” Valerian, a gender diverse person AFAB, described a similar experience of having a knife used to hold them against their will, “[He] pulled the knife out… it was at this point where like, I legitimately thought he was going to kill me because he was blocking the door.” These acts of being threatened with weapons and held against their will had a profound impact on their sense of wellbeing and safety. Valerian, a gender diverse person AFAB, shared: “I didn’t know what was going to happen because I knew he could so easily overpower me… but I honestly thought that I was gonna die.” The use of weapons were directly linked to increased risk for severe re-assault among participants.

Self-Defense; Escalation; Retaliation.

Participants were often wearing knives for self-defense and fought back against their attackers. Knives were often successful in stopping immediate violence from intimate partners. However, the use of knife for protection was related to escalated violence and retaliatory gun violence. For example, Acacia, a transgender woman, shared:

He didn’t know I had a knife…he hit me one time [punched me]…and I always carry a pocket knife…so when he came back he didn’t even know I was stabbing him the whole time he was hitting on me. By the time he got to the building [to grab his gun] he was already leaking…the boys I grew up with … went and got me a pistol and said … ‘you goin’ shoot him’… they was trying to protect me.

In this example, the violence continued to escalate and both parties were at risk of being shot. In other cases, participants used video cameras and alarm systems in their home for protection. Often participants gained a sense of security and safety from the video cameras and alarm systems. Acacia shared, “You’re more paranoid because you hear stories about how people coming in and raping women and killing them…that’s why I got cameras now… I have these sneaky cameras in my house… and if I push the button [on my alarm system] … the police is coming.”

Gender Disclosure and Relationship Stigma.

Participants noted that those engaged in trading or selling sex had a greater risk of severe assault and IPH due to sex work-related and gender-related stigma, anti-transgender stigma, or cisgenderism. However, regardless of sex work engagement, the risk of severe assault or homicide increased if the TGD person’s partners were concealing their relationship from others or if participants were thought to be concealing their gender history from their partners. Daisy, a transgender woman, shared:

My girl said ‘Aye y’all go upstairs, I got a date [a sex work client].’ We was all in there upstairs and then we heard a BOOM [gunshot] and then we come downstairs and… she [was] shot in her head and the door was wide open… I know he shot her because he didn’t know her ‘T’ [he didn’t know that she was a transgender woman].

Many participants knew of the murdered transgender woman described in Daisy’s narrative. As a result, several participants elaborated on the complexities of gender disclosure and safety. Participants felt that peers were at greatest risk of severe assault during gender disclosure or following a sexual act with a cisgender person. For example, Acacia, a transgender woman, described her fear of and experience with transphobic violence following sexual encounters:

I hope he don’t really blow my head because he you know [that I am transgender], some men kill and a lot of girls got killed for that… or sometimes the baby mama would wanna kill me… because they didn’t want to accept it.

Some older participants thought that younger transgender women were putting themselves at risk by not disclosing their gender history and/or trading sex in an area known for sex trade among cisgender women instead of the area of town where transgender women are known to trade sex. Dahlia, a transgender woman, shared:

The majority of the girls [trading sex] went down to where guys knew what was going on. But now these days the girls are not telling the men [about their gender history]… and as soon as the men find out, some freak out, some are down [accepting of their gender history]… but I think they put they self in harm’s way.

Whether or not participants thought it was the TGD person’s responsibility to disclose their gender history, all participants agreed that gender disclosure and relationship stigma put transgender women in danger of being murdered by intimate partners.

Use of Physical Violence in Public.

Several study participants described experiences of public violence and humiliation that were, at times, a precursor for an escalation in violence exposure. Cyprus, a gender diverse person AFAB, described a violent experience where their partner began by shoving them around and damaging their vehicle during the daytime in plain view of the public. Cyprus described their partner as being unable to control herself despite their surroundings: “It’s in the daytime, okay? Like, people aren’t even drunk yet. And I was just so shocked, you know, like, she was foaming at the mouth, and like, white foam coming out of her mouth.” This violent encounter quickly escalated: “She demanded that I drive her home… and on the drive… she just kept being very aggressive with her words towards me. And then eventually, she punched me, like, straight on the face while I was driving. And she could have killed us both.” Even in circumstances where the act of physical violence and humiliation in public did not continue to escalate, the experience had a profound and lingering impact on participants. Zephyr, a transgender man, shared: “… I was just scared the rest of the day…Is she gonna come up behind me and do something? Is she gonna come hit me again? Like I just was shook for lack of better words.” As seen with Zephyr, the use of physical violence in public caused a sense of fear knowing the risk for mounting violence existed.

Discussion

In some of the first qualitative work to specifically focus on risk of severe assault and IPH in TGD populations, we identified several key themes that are potential risk factors for or antecedents of severe physical or sexual IPV and or IPH. While stigma-driven social and structural vulnerabilities have been well documented in TGD populations (Wirtz et al., 2020) as contributing to violence risk, survivors in this study spoke specifically to how these vulnerabilities increased risk of IPH and severe assault. Our findings around gender disclosure and relationship stigma strongly align with previous work with transgender women of color in Detroit, where findings from focus groups indicated that cisgender straight men who dated transgender women would resort to murder if they feared that their transfeminine partner was going to “expose” their relationship publicly and “out” them as someone interested in transgender women (Gamarel et al., 2020).

Implications for Safety Planning

Our findings have implications for how to build on existing TGD-specific safety planning tools for survivors and service providers created by TGD survivor-led anti-violence organizations (FORGE, n.d.-a, n.d.-b, 2013; The National Coalition of Anti-Violence Programs, 2014; The Network / La Red, 2011). The normalization of violence from a variety of actors, including intimate partners, among participants, underscores the importance of service provision and safety planning for TGD survivors (Table 1). Lethality assessment tools, such as the DA, have been shown to help cisgender women better recognize homicide risk in their relationships when violence had previously been normalized or minimized (Campbell et al., 2009), and could be highly useful for TGD survivors when making a safety plan. Findings around retaliation and escalation of violence by responding with weapons could also inform safety planning efforts. Service providers could help clients identify a range of responses and tools to use in the moment as alternatives to weapons-based self-defense. When this type of self-defense is necessary, service providers can help clients identify strategies for keeping themselves safe in the aftermath of such an incident. Strategies might include finding another place to stay for a period after the incident, given threats by abusive partners to return shortly with a gun.

Table 1.

Implications of Each Theme for Safety Planning with Trans Survivors and for Developing Potential Items to Validate in a Transgender and Gender Diverse-Specific Version of the DA for Their Ability to Predict Severe re-Assault or Homicide

Theme Safety planning considerations Potential item to test in TGD-specific version of DA*
Complex social and structural vulnerability Support housing stability and financial independence Support other sources of social and material support (e.g., friends, family) Have you ever wanted to leave the relationship, but felt you could not due to financial dependence, homelessness, citizenship status, or other factors that would make you vulnerable without this partner?
Does your partner provide you money or housing in exchange for sexual acts?
Do you have a safe place to sleep at night?
Pervasive community violence and increased weapon use by partners Use risk assessment tools to help trans survivors recognize severe violence despite pervasive nature of violence
As with cisgender survivors, identify if partner has weapons and how/where they are stored		 Does your partner own a gun?
Has your partner ever used a weapon against you or threatened you with a weapon, such as a knife or gun? (If yes, was the weapon a gun? check here:__)
Has your partner threatened you with a gun over the past year? (DA-R)
Self-defense – escalation – retaliation; Build alternative strategies for self-defense besides weapons-based self-defense
When necessary to use weapons in self-defense, create safety plan to protect self from retaliation in the short term after the incident		 Have you used or threatened to use a weapon against your partner in self-defense, such as a knife or gun?
Gender disclosure and relationship stigma Assess context around gender identity disclosure and encourage safe disclosure Does your partner hide your relationship from their friends or family because of your gender identity or expression? 1
Does your partner know about your gender transition?
Use of physical violence in public Consider options for attracting help from bystanders Has your partner hit you in public?
Has your partner’s behavior ever made you fear for your own life?
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*

Text in italics indicates new language that is not found in either the DA or the DA-R

1

Gamarel, K. E., Reisner, S. L., Laurenceau, J. P., Nemoto, T., & Operario, D. (2014). Gender minority stress, mental health, and relationship quality: a dyadic investigation of transgender women and their cisgender male partners. Journal of Family Psychology, 28(4), 437.

2

Peitzmeier, S., Wirtz, A., Humes, E., White Hughto, J., Cooney, E., Reisner, S., American Cohort to Study HIV Acquisition Among Transgender Women (LITE). Validation of a brief scale to measure transgender-specific intimate partner violence for research and practice. (Under review).

Disclosure of gender identity was also identified as a potential high-risk period in a relationship when abusive partners may perpetrate severe assault, consistent with previous research (Gamarel et al., 2020), as well as so-called “trans panic” legal defenses that justify homicide against transgender women (American Bar Association, 2013). Current literature suggests that TGD people heavily prioritize safety (physical and otherwise) surrounding these types of disclosures and may go to great lengths to conceal their TGD status until they feel safe (Gamarel et al., 2020). It may be problematic and potentially stigmatizing for cisgender service providers to have conversations about safe gender identity disclosure with TGD clients—there is a huge potential for these suggestions to come off as patronizing or as normalizing of transmisogynistic beliefs and behavior. However, to support TGD people, service providers can assess the context surrounding gender disclosure within relationship, such as “Does your partner hide your relationship from their friends or family because of your gender identity or expression?” or “Does your partner know about your gender transition?” (Table 1). Additionally, if the client is interested, service providers can help clients plan the time, location, and manner of disclosure to minimize risk for violence. For instance, survivors can think through whether to disclose in-person or by phone, text, or other modality; at what stage in the relationship; and whether to have other people present.

Implications for Potential Risk Factors to add to the Danger Assessment DA

These findings offer preliminary qualitative evidence that suggests how the DA might ultimately be adapted for TGD people in abusive relationships. First, basic wording adaptations to existing risk factors should be made, including referring to abusive partners with the gender-neutral pronoun “they” (or simply “your partner”) rather than “he” (in the original DA) or “she” (in the version for cisgender women in abusive relationships with other cisgender women; DA-R), to reflect the range of partner gender identities reported by participants who experienced severe abuse. This reflects that TGD people are much more likely to have intimate partners of diverse genders than are cisgender women; validating separate DAs for TGD people with abusive partners who are men, women, and nonbinary would be difficult due to small sample sizes for quantitative validation studies. A gender-neutral version of the original DA does exist; however, the use of gendered terms is still incorporated throughout the document; which may confuse both the service provider and the client (Campbell, 2019). That version of the DA uses “they” pronouns but was originally envisioned as a version for cisgender men abused by cisgender women or other cisgender men and needs to be carefully examined for appropriateness and word use by TGD people.

The first section of the DA asks individuals to mark a calendar of the last 12 months with abusive incidents to promote accurate recall of the severity and frequency of abuse. Individuals are asked to use a severity scale ranging from 1–5 for each incident, ranging from 1 (“slapping, pushing; no injuries with lasting pain”) to 4 (“threat to use weapon; head injury, internal injury, permanent injury, miscarriage or choking”) or 5 (“use of weapon; wounds from weapon”). Given findings from participants from participants (of varying races and ethnicities) that knives were a common weapon used, the directions for this part of the DA may need to explicitly mention knives and other types of weapons to promote recall of abuse involving weapons other than guns. Life history calendar approaches have been validated in diverse samples of cisgender women to improve recollection of abuse experiences, which can be challenging for memory retrieval given 1) the fragmented way in which traumatic memories are stored, 2) the tendency for some survivors to minimize abuse, and 3) the pervasive, repeated, daily nature of some abuse (Hayes, 2018; Yoshihama et al., 2005). Findings from participants indicated that violence from a wide range of perpetrators was so commonplace that they became desensitized to violence. Given this, additional memory supports or recall aids may need to be validated to help participants remember abusive incidents specific to their intimate relationship.

The second half of the DA focuses on validated risk factors for homicide or severe assault. In work to revalidate the DA for cisgender women in abusive relationships with other cisgender women (DA-R), 79 potential risk factors were identified via qualitative focus groups and interviews, and then tested in a longitudinal quantitative dataset for their ability to predict re-assault in women who had previously experienced IPV (Glass, Perrin et al., 2008). Ultimately, eight of the original risk factors and 10 new risk factors were included to this revised version of the DA (DA-R), including more coercive control and psychological aspects of abuse, such as trying to control a partner’s spirituality. Further, there are three items that focus specifically on LGBTQ + related barriers to seeking help, which were validated to increase risk of re-assault (e.g., “If you were being abused by her, would fear of reinforcing negative stereotypes about LGBTQ and/or being discriminated against prevent you from seeking help? For example, from friends, domestic violence advocates, or health care providers.”). There are likely to be several risk factors that are specific for TGD survivors of IPV. Our findings from this study suggest several risk factors linked to each of the themes elucidated above (Table 1).

Limitations

This study has many strengths, including its novel population of focus regarding the DA (Campbell et al., 2009). The listening sessions from this study were also conducted by researchers and community members who were diverse in terms of race and gender identity. There are also several limitations to this study. The focus group format of listening sessions, although a potential strength in terms of the breadth of perspectives and increased depth of narratives, may have limited the discourse to normative opinions and emphasized participant voices who dominated the groups’ interactions (Smithson, 2000). Each of the groups also had demographics that were unbalanced in terms of race, ethnicity, relationship structure, and location. For example, in the AMAB group, all participants were Black and in the AFAB sample, most participants were White. While the AMAB group was local to Washington, D. C. and participated in-person, the AFAB group participated virtually and was sampled from a larger geographic area. This virtual participation required a level of technological capability that unhoused or similarly vulnerable community members may not have been able to access. Recall bias is also a potential issue since none of the participants were actively in an abusive relationship and reports of assault are most accurate when they are recent (Yoshihama et al., 2005). Finally, inclusion criteria required participants to speak English and so these findings did not capture ways that non-English speaking TGD individuals may experience IPV survivorship. Despite these limitations, the findings from this study offer insight into the experiences of TGD people who have survived violence and are instructive to inform future DA development tailored to these communities’ specific needs.

Future Research

Future qualitative research could build on these initial findings by conducting more focus groups with diverse samples of TGD survivors of severe IPV, as well as in-depth interviews to better capture the specifics of individual survivor stories. This qualitative work could be used to identify more potential risk factors for validation in a quantitative lethality risk assessment tool, as well as develop a bank of survivor stories that can be used to help sensitize service providers and TGD survivors as to what lethality risk often looks like for TGD survivors. Quantitative work to validate a lethality risk assessment tool like the DA for TGD survivors would create a valuable tool to help promote safety in intimate relationships for TGD survivors.

Conclusion

IPV is an epidemic among TGD people, particularly among transgender women of color. A large body of research among cisgender people has provided a foundation to guide risk assessment and safety planning for survivors of IPV. However, wide-spread cisgenderism contributes to variations in IPV experiences and IPH risk among TGD people. Understanding the differences and similarities to how antecedents of severe assault and IPH manifest for TGD people are imperative to tailoring available risk assessment tools (such as the DA) and developing culturally appropriate safety plans with this group. Our findings provide a preliminary foundation upon which to adapt existing measures and highlight the need for psychometric evaluation of such measures among diverse groups of TGD people. Thus, future research should focus on measure adaptation and accompanied psychometric evaluation to examine the predictive validity of antecedents of severe assault and IPH among TGD people of various races, ethnicities, and relationship structures to ensure the cultural appropriateness of such measures.

Acknowledgments and Funding

We would like to thank the participants, institutions, individuals, and funders who contributed time and resources to the original project. Specifically, this project was supported by Grant No. 2015-SI-AX-K005, awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this publication/program/exhibition are those of the author(s) and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women. Research reported in this publication was supported by the National Institute Of Nursing Research of the National Institutes of Health under Award Number K23NR020208. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Funding

The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by Grant No. 2015-SI-AX-K005, awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this publication/program/exhibition are those of the author(s) and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women. Research reported in this publication was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number K23NR020208. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Biographies

Athena D. F. Sherman, PhD, PHN, RN, CNE (xe/they/she) is an assistant professor at the Nell Hodgson Woodruff School of Nursing at Emory University. Sherman’s program of research focuses on improving our understanding of how complex systems of racism, cisgenderism, and heterosexism influence health and health equity for racially and ethnically diverse LGBTQ + communities, with a focused lens on the impacts of trauma, violence, and substance use on mental health among transgender and gender diverse people.

Sarah Peitzmeier, PhD, MSPH (she/her) is an Assistant Professor at the University of Michigan School of Nursing, with a joint appointment in the School of Public Health. Her work focuses on better screening for, and prevention of, gender-based violence, with a particular focus on gender-based violence in transgender communities and feminist empowerment approaches to prevention.

Andrea N. Cimino, PhD, MSW (she/her) is a research strategist at Rogue Scholar Consulting, where she develops, manages, and directs interdisciplinary, mixed-methods research initiatives for government, academic, and non-profit sectors. She is an expert on intimate partner violence.

Monique Balthazar, DNP, PhD, FNP-BC, AGACNP-BC (she/her) is an Assistant Professor at the Georgia State University Byrdine F. Lewis College of Nursing and Health Professions. Her research interests include sleep health in vulnerable populations, specifically among people living with HIV.

Meredith Klepper, MS, RN, CPN (they/them/theirs) is a third-year PhD candidate at Johns Hopkins School of Nursing. They are interested broadly in LGBTQI + health inequities and their doctoral research focuses on strength-based, family-centered, and intersectional approaches to the health and well-being of transgender and gender diverse youth.

Arzina T. Chand (she/her) pre-medical student at Georgia State.

Carissa Lawrence, MSN, CNM, WHNP-BC (she/her) is a PhD student at Johns Hopkins School of Nursing. Her research interests are in health disparities, gender-affirming care, reproductive access, mental health disorders and understanding the concepts of stigma and discrimination as barriers in health promotion for underserved communities of color and LGBTQI + individuals.

Kisha Allure (she/her) is a crime victims specialist, transgender rights advocate, and entertainer. Kisha Allure aka “DejaVu”, opened for the famous RuPaul, gaining national recognition as “Deja’Vu “ from Gay Prides to Drag Musical productions, “The Five Heartbeats”, and “What Shi-quita Lee Got To do With It”. She previously served as crimes victims case manager at Casa Ruby and currently works closely with community-based researchers throughout the Southeastern Unites States.

Grayson Slink (he/him) is a transgender health advocate and community liaison working throughout the Southern United States.

Jacquelyn C. Campbell, PhD, RN, FAAN (she/her) is the Anna D. Wolf Chair and a Professor at Johns Hopkins University School of Nursing. She has been conducting research and advocacy in the field of intimate partner violence (IPV) and health outcomes for 3 decades, authoring or coauthoring more than 300 publications and seven books.

Footnotes

CRediT Author Statement

Athena D. F. Sherman: Conceptualization, Methodology, Investigation, Original draft preparation, Writing- Reviewing and Editing, Formal analysis, investigation; Sarah Peitzmeier: Original draft preparation, Writing- Reviewing and Editing; Andrea N. Cimino: Original draft preparation, Writing- Reviewing and Editing; Monique Balthazar: Original draft preparation, Writing- Reviewing and Editing, Formal analysis; Meredith Klepper: Original draft preparation, Writing- Reviewing and Editing; Arzina T. Chand: Transcription, Original draft preparation, Writing- Reviewing and Editing; Carissa Lawrence: Writing, Reviewing, Editing; Kisha Allure: Investigation, Writing, Reviewing and Editing; Grayson Slink: Investigation, Writing, Reviewing and Editing; Jacqueline C. Campbell: Supervision, Writing- Reviewing and Editing.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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