Planning an intersectoral network of healthcare and community leaders to advance trans-affirming care for sexual assault survivors

Abstract

Sexual assault against transgender (trans) persons is a complex public health issue requiring the coordinated effort of multiple sectors to address. In response to a global call to improve health equity for persons of diverse gender identities, leaders across health and social service sectors need to enhance collaboration to champion trans-affirming care for sexual assault survivors. In collaboration with Egale Canada Human Rights Trust and the Ontario Network of Sexual Assault/Domestic Violence Treatment Centres, we have undertaken the development of an intersectoral network to connect trans-positive community organizations with hospital-based violence treatment centres to improve support services for trans survivors across Ontario. Guided by the Lifecycle Model for network development outlined by the National Collaborating Centre for Methods and Tools, we describe our approach to planning the intersectoral network, including key insights learned thus far and the potential of the network moving forward.

Introduction

Transgender (trans) persons experience high rates of sexual assault, have limited access to healthcare services that are safe and appropriate, and may have unique care needs after a sexual assault.^1,2 As a complex public health issue, sexual assault against trans persons requires the coordinated effort of leaders from multiple sectors to address. As there is often a lack of appropriate, stigma-free healthcare services sensitive to the needs of trans communities,³ intersectoral collaboration, policy development, and research aimed at improving access to trans-affirming healthcare services are necessary to advance the response to sexual assault against trans persons and critical to the promotion of health equity for trans communities globally.^3,4 Trans-affirming care, in this context, refers to “practices that recognize, account for, and address the unique experiences and needs of trans sexual assault survivors.”^5(p21)

The 2015 US National Transgender Survey found that approximately one in two trans individuals report having been sexually assaulted at least once in their lifetime.⁶ Although there is a scarcity of Canadian population-based research specifically focused on sexual assault among trans persons, data from the Trans PULSE study have revealed that 20% of trans Ontarians have, at some point in their lives, experienced sexual or physical violence specifically targeted toward their gender identity.¹ Because of their exposure to transphobia and other forms of oppression, trans persons may experience additional forms of violence over the life course, including childhood sexual abuse, intimate partner violence, and hate crimes.⁵ These experiences of violence can lead to adverse health consequences, such as increased risk for alcohol and illicit substance abuse, suicidal ideation, and suicide attempts.⁷ However, many trans persons avoid acute healthcare services generally because of past and/or anticipated experiences of stigma and discrimination in healthcare settings⁸ and may not seek support following sexual assault specifically due to fear of mistreatment, judgment, and further abuse.² They also may be unaware of supports, resources, and services that they can access to mitigate the impacts of violence and prevent further victimization.⁹

Research and practice in the area of sexual violence frequently fail to account for the social conditions and experiences of trans persons and their often complex care needs in the context of sexual assault.^1,2 Indeed, there is a dearth of research globally on the experiences of these survivors, their needs post-victimization, and how health and other service providers can respond appropriately. Given the growing international recognition of trans issues as a salient area of policy development and research in healthcare,⁴ as well as the pertinence of attending to the specific concerns of trans sexual assault survivors,² collaborative health leadership aimed at improving the responsiveness and quality of comprehensive post-sexual assault care services for trans persons is critical.

Identifying a need for intersectoral collaboration

To address this pressing need, we have been working closely with the Ontario Network of Sexual Assault/Domestic Violence Treatment Centres (SA/DVTCs), a network comprising 36 hospital-based violence treatment centres.¹⁰ These centres are staffed by specially trained forensic nurses and, less frequently, nurses working with a physician. After a survivor of sexual assault has been cleared medically in the emergency department, these professionals provide acute healthcare, medico-legal evidence collection, crisis intervention, and referrals to social services and other supports.¹⁰ Together, we have undertaken a multiphase program of research to ensure that sensitive and appropriate care is available to trans survivors of sexual assault across Ontario’s SA/DVTCs. As an initial step, in 2017, we performed a needs assessment to evaluate the capacity of these centres to address the needs of trans survivors.¹¹ Based on the results of this survey, we developed, piloted, and successfully evaluated a curriculum on trans-affirming care for frontline nurses working within these centres.¹² Importantly, 97.2% of nurses in the survey indicated that they would benefit from additional knowledge on “available trans-positive resources and service providers in the community for a trans client requiring external support.”^11(p8)

Conceptualizing the intersectoral network

Therefore, to strengthen the connections between health and social service providers and supports across Ontario, we are working now with the Ontario Network of SA/DVTCs and Egale Canada Human Rights Trust to initiate the development of a province-wide intersectoral network on trans-affirming practice to better support sexual assault survivors (hereafter referred to as the intersectoral network). Egale Canada Human Rights Trust is a national organization that works “to improve the lives of LGBTQI2S people…by informing public policy…and promoting human rights and inclusion through research, education and community engagement.”¹³

In developing the intersectoral network with an advisory group of trans community members and their allies (eg, Rainbow Health Ontario, see Acknowledgments section for a full listing), we aim to ensure that organizations across Ontario in the health and social service sectors collaborate to offer up-to-date, appropriate, and sensitive care and support to trans survivors.⁵ We plan to accomplish this goal by facilitating connections between trans-positive community organizations and SA/DVTCs as a catalyst for enhancing policy, practice, and research in this area. We describe our approach to early stages of development of the intersectoral network, including key insights learned thus far and the potential of the network moving forward.

Guiding framework

Development of the intersectoral network is being guided by the Lifecycle Model outlined by the National Collaborating Centre for Methods and Tools, which includes sequential stages for the planning, formation, maturation, and sustainability of a network (see Table 1).¹⁴

Table 1.

Lifecycle Model for guiding network development

Lifecycle stage	Main activities
Planning	Connect key members, define purpose of network, discuss value of network to individuals and organizations
Formation	Develop collaborations, negotiate network focus and identity, exchange/share knowledge, develop sense of collective and shared ownership over the network
Maturation	Focus and expand the network
Sustainability	Continue network activities considered effective
Termination or transition	Identify when network effectiveness has diminished and transition to other issues or goals

^a Adapted from Robeson.¹⁴

Planning stage

In this stage, we linked trans-positive community organizations with SA/DVTCs for the purpose of establishing longer term referral relationships, increasing collaboration, and enhancing the continuum of care for trans survivors regionally. We also collectively identified and discussed the purpose and value of the proposed network and facilitated dialogue about how such a network could strengthen services and supports provincially.¹⁴ We worked with our advisory group to identify trans-positive health and social services and supports in communities across Ontario (eg, those providing mental healthcare, HIV/AIDS care, housing supports, education and training, advocacy, settlement services, indigenous, and two-spirit focused care). We then connected leaders from these services and supports to managers of Ontario’s SA/DVTCs in seven regional meetings held between June 7, 2019 and July 11, 2019, in each of Ontario’s Central (Toronto), Central West (Mississauga), Central East (North York), Southwest (London), East (Ottawa), Northeast (Sudbury), and Northwest (Thunder Bay) regions. In total, 106 representatives from 96 SA/DVTCs and community organizations attended these meetings.

These meetings drew inspiration from literature on community development, in which the experiences, opinions, and insights of community members are brought to the forefront of action and research through the establishment and maintenance of mutualistic and empowering relationships.¹⁵ During these meetings, we promoted intersectoral networking and collaboration, in which our role was to “[find] connections, [create] opportunities for shared activities and [encourage] dialogue across apparent boundaries.”^15(p84) In the World Café Conversations activity, suggested by Robeson¹⁴ and described in depth by Brown and Isaacs,¹⁶ guiding questions were used to facilitate smaller group discussion on current and potential opportunities for intersectoral collaboration to enhance support services for trans survivors at both regional and provincial levels. We also solicited participants’ insights on barriers and facilitators to collaboration, opportunities for further collaboration, and how emerging relationships could work to enhance practice, policy, research, and education focused on the issue of sexual assault against trans persons. Finally, in small groups, we collectively discussed insights for the prospective mission, vision, and values of the intersectoral network. In a full group discussion, these insights were subsequently synthesized and interest from participants in joining the network was gauged. This activity was adapted from literature on design-thinking, a process for developing collaborative and creative solutions to complex problems used in the context of healthcare,¹⁷ and informed by both the University of Kansas’ Community Tool Box and Prevention Solutions@EDC, which provided guiding concepts for the mission, vision, and value statements of organizations,¹⁸ and instructions for how to conduct an interactive brainstorming activity.¹⁹

Key insights

At the meetings, 93 (97%) of the 96 organizations represented expressed interest in remaining part of the network’s development. Service providers and supports across sectors spoke not only to the need for the intersectoral network to act as a platform for collaborative health leadership in the response to sexual assault against trans communities but also voiced several key insights that could inform priority areas for network development, focus, and action. Prominent participant insights clustered thematically as education and training, peer involvement, advocacy, accessibility, and knowledge sharing and exchange (see Table 2).

Table 2.

Planning an intersectoral network to address sexual assault against trans persons: key insights

Education and training	Develop cross-sector training and professional development opportunities for intersectoral network members and other professionals (eg, law enforcement, emergency department staff) to improve the provision of trans-affirming supports to survivors
Peer involvement	Centre the voices, experiences, and needs of trans community members in the continued development of the intersectoral network and in partnership building within and among regions Empower trans communities and adequately acknowledge and compensate peer workers and advocates
Advocacy	Advocate for broader and lasting change in the response to sexual violence against trans communities as a key role for the intersectoral network at the institutional level (eg, develop hospital policies/procedures to ensure safer environments for trans survivors) and structural level (eg, promote policies that address the underlying social causes of violence against trans communities)
Accessibility	Enhance the geographical, physical, and/or social accessibility of services and supports for trans survivors as a focus of the intersectoral network Address the emergency department as a barrier specifically to accessing healthcare services, including those offered by the SA/DVTCs, as trans persons often perceive the emergency department to be unsafe
Knowledge sharing and exchange	Identify modes of effective communication and knowledge mobilization among service providers and supports that form the intersectoral network Share resources through digital platforms that could be accessed by all intersectoral network members for training and communication Develop a comprehensive, up-to-date, and accessible resource list to facilitate more seamless referrals among services and supports and opportunities for consultation more broadly

Abbreviation: SA/DVTCs, Sexual Assault/Domestic Violence Treatment Centres.

Next steps: formation, maturation, and sustainability of the intersectoral network

As a next step, we will continue to facilitate relationship building and knowledge exchange among intersectoral network participants, as well as further negotiate network identity and develop a sense of shared ownership.¹⁴ Informed by the critical insights learned at the meetings, we have developed and circulated a survey to all meeting participants who expressed an interest in the intersectoral network to gather further information on perceived barriers to forming collaborations and providing reciprocal referrals across regions and solidify expectations of the network (eg, priorities, mandate, resources, additional members; see Table 1: Formation stage).¹⁴ After synthesizing the survey data, we will host an opportunity for all members of the network across Ontario to meet in order to share the results and negotiate formal roles within the network.¹⁴

In the future, we will support the maturation of the intersectoral network by co-developing and sharing tangible resources, as described by Robeson,¹⁴ such as terms of reference for the network, an internal report on research and training priorities, a communications plan to articulate and promote the purpose and value of the network, and a service directory listing all participating organizations. To ensure sustainability of the network, we will work to facilitate long-term collaboration and growth through ongoing opportunities for interaction to discuss identified priorities for research, professional development, and cross-sector training initiatives on trans-affirming care. We will also do so by potentially broadening the reach of the network to other areas of violence experienced by trans persons (eg, intimate partner violence). Using indicators and metrics outlined by Robeson¹⁴ (eg, number of members; number of policies, resources, and programs developed), as well as data from our survey, we will develop and implement an evaluation plan to assess the success of the network and guide its ongoing and future activities (see Table 1: Maturation and Sustainability stages).

Potential impact of the intersectoral network

As indicated by the high proportion of organizations across Ontario interested in continued involvement in this project (97% of 96 organizations that attended the regional meetings, as well as an additional 31 organizations not in attendance), sexual assault against trans persons is a timely and topical issue for which the intersectoral network has the potential to take a provincial lead. By championing a robust and coordinated effort that ensures the provision of up-to-date and sensitive care and support for trans persons across Ontario, this network could also inform new and enhanced partnerships leading to future research, training initiatives, programming, and policy in this area. These relationships could be scaled up and formalized at the national and international levels as emerging partnerships initiated within this network create opportunities for leadership in related work beyond Ontario or serve as a model for other jurisdictions. Given that researchers, service providers, and community members often work in silos, collaborations within the network could be valuable in addressing the global problem of discrimination and violence against trans persons. These collaborations could also lead to enriched professional and public discourse on the intersection of gender identity and sexual assault specifically and promote the importance of working with policy-makers across sectors to take action on this issue globally.

Finally, further analyses of the initial findings from this planning stage of the development of the intersectoral network could advance health leadership practice by providing the impetus for the creation, for example, of educational initiatives aimed at training diverse health professionals in the care of trans survivors of sexual assault. These findings could be further disseminated as well among managers and staff in the health sector, outlining the importance of advocacy, peer involvement, accessibility, and knowledge exchange in advancing the care of trans survivors.

Conclusion

Health leaders have a significant role to play in addressing the problem of sexual violence against trans persons and improving health equity for people of all gender identities.⁴ Findings from our initial engagement in the planning stage of this network indicate a clear imperative to advance policy in this area and engage with leaders in the community to reduce barriers to accessing appropriate post-sexual assault services for trans persons.⁴ Our findings can inform health leadership in this area with respect to priority issues facing trans communities, effective collaborations with community leaders, and barriers and facilitators to accessing sensitive, patient-centred care. Using critical insights learned thus far, we will consolidate relationships formed during the initial planning stage of the network and identify key strategies moving forward for enhancing the care provided to trans survivors of sexual assault across Ontario. As the network unfolds, we will evaluate our approach to its development, including the benefits and challenges to the use of the Lifecycle Model,¹⁴ as well as continue to analyze and share short- and long-term outcomes associated with the network’s membership, structure, and activities.