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. Author manuscript; available in PMC: 2021 Jun 3.
Published in final edited form as: J Ment Health Couns. 2021 Apr 7;43(2):139–156. doi: 10.17744/mehc.43.2.04

Associations Between Trauma-Informed Care Components and Multiple Health and Psychosocial Risks Among LGBTQ Survivors of Intimate Partner Violence

Nadav Antebi-Gruszka 1, Jillian R Scheer 2
PMCID: PMC8174812  NIHMSID: NIHMS1695128  PMID: 34092983

Abstract

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals disproportionately experience intimate partner violence (IPV) and resulting negative health consequences compared to cisgender heterosexual individuals. This study builds on prior recent work by examining specific trauma-informed care (TIC) components most associated with a comprehensive set of health and psychosocial risks among 298 LGBTQ IPV survivors who sought and accessed trauma-related services (e.g., mental health counseling). Results indicated that TIC components are differentially associated with LGBTQ clients’ health and well-being. Specifically, greater perceptions of providers who fostered agency and mutual respect were associated with better outcomes, whereas greater perceptions of providers who focused on culture and increasing opportunities to connect with other survivors were related to negative outcomes. These findings underscore the need for providers to prioritize LGBTQ clients’ sense of agency and mutual respect and identify for whom focusing on culture and connecting with other LGBTQ survivors might be beneficial.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience higher rates of potentially traumatic events compared to cisgender heterosexual individuals (Alessi et al., 2013; Antebi-Gruszka & Schrimshaw, 2018; Antebi-Gruszka et al., 2019; Chen et al., 2020; Marciano & Antebi-Gruszka, 2020; Scheer, Pachankis, & Bränström, 2020). One of the more pervasive potentially traumatic experiences LGBTQ people face is intimate partner violence (IPV), which includes physical (e.g., threats or actual physical violence), psychological (e.g., controlling one’s behavior), or identity-based abuse (e.g., belittling one’s LGBTQ identity, “outing”) by a current or former intimate partner (Decker et al., 2018; Edwards et al., 2020; Reuter et al., 2017; Woulfe & Goodman, 2018). Consistent evidence demonstrates disparities in IPV victimization rates between LGBTQ individuals and cisgender heterosexual individuals. For instance, lesbian women and bisexual men and women face higher rates of IPV than heterosexual women and men (Walters et al., 2013). Another study found that both lifetime and past-year IPV prevalence was significantly higher among gay men and bisexual women than among heterosexual individuals (Goldberg & Meyer, 2013). Further, several studies point to increased IPV prevalence among transgender and gender-diverse individuals compared to cisgender individuals (Langenderfer-Magruder et al., 2016; Parsons et al., 2018; Shipherd et al., 2011). Relatedly, transgender and gender-diverse young adults experienced more identity-based abuse than cisgender sexual-minority young adults (Scheer, Martin-Storey, & Baams, 2020).

MINORITY STRESS AND INTIMATE PARTNER VIOLENCE RISK AMONG LGBTQ PEOPLE

LGBTQ IPV survivors face minority stress, further elevating their IPV risk (Balsam & Szymanski, 2005; Stephenson & Finneran, 2017). According to the minority stress model (Meyer, 2003), LGBTQ individuals face stigma-related stressors, such as discrimination and identity concealment, alongside general stressors (e.g., financial stress). Previous studies have demonstrated associations between minority stressors and IPV victimization and perpetration (Carvalho et al., 2011; Edwards & Sylaska, 2013). These findings underscore the need for providers to address minority stressors when serving LGBTQ IPV survivors (Scheer & Poteat, 2018). Acknowledging clients’ cultural characteristics (e.g., race, income) and addressing barriers to accessing formal and informal support may also be important service delivery components for IPV survivors (Calton et al., 2016; Goodman et al., 2016; Scheer, Martin-Storey, & Baams, 2020; Wu et al., 2015).

HEALTH AND PSYCHOSOCIAL CORRELATES OF LGBTQ INTIMATE PARTNER VIOLENCE

IPV-exposed LGBTQ individuals are at increased risk of health and psychosocial problems (Miller et al., 2016). For instance, LGBTQ IPV survivors report elevated rates of posttraumatic stress disorder (PTSD) symptoms (Alessi et al., 2013; Roberts et al., 2010), depressive and anxiety symptoms (Reuter et al., 2017; Woulfe & Goodman, 2020), somatic symptoms, and substance use (Roberts et al., 2010; Scheer et al., 2019). Many LGBTQ IPV survivors hold beliefs about betrayal, shame, and fear of future victimization—stemming both from IPV victimization and minority stress—which may contribute to their social isolation and withdrawal (Baker et al., 2013; Scheer, Pachankis, & Bräström, 2020; Shipherd et al., 2011; Turell & Herrmann, 2008). Associations between IPV and sexual risk behavior in LGBTQ people are also documented (Parsons et al., 2018; Reuter et al., 2017; Williams et al., 2015). Relatedly, research has demonstrated a relationship between IPV and chronic physical health problems in LGBTQ samples (Scheer & Pachankis, 2019).

Further, LGBTQ IPV survivors may use substances to cope with and regulate negative feelings related to IPV victimization and minority stress (Hatzenbuehler, 2009; Stults et al., 2015). Similarly, LGBTQ IPV survivors may have difficulty with certain cognitive coping skills, such as cognitive reappraisal (i.e., refraining one’s appraisal of a stressful experience to reduce distress or change the intensity of the emotional response; Gross & John, 2003; Scheer & Mereish, 2019). Overall, these findings highlight several deleterious health and psychosocial correlates of IPV among LGBTQ individuals and point to the need to explore associations between IPV-related service components and these outcomes in this population.

SIGNIFICANCE OF TRAUMA-INFORMED CARE DIMENSIONS FOR LGBTQ INDIVIDUALS

Trauma-informed care (TIC) represents the “gold standard” for working with survivors (Kulkarni, 2019) and is designed to minimize the risk of re-traumatization. TIC includes five dimensions: (a) fostering agency and mutual respect, (b) providing psychoeducation, (c) increasing opportunities to connect with other survivors, (d) building on clients’ strengths, and (e) practicing cultural sensitivity (Goodman et al., 2016). When applying TIC to LGBTQ IPV survivors, it might be beneficial also to address minority stressors (Miller et al., 2016; Scheer & Poteat, 2018). Indeed, growing evidence points to the role of TIC in alleviating clients’ health symptoms and shortening treatment periods across diverse settings (Butler et al., 2011; Morrissey et al., 2005; Muskett, 2014), underscoring the relevance of TIC for LGBTQ IPV-exposed people.

THE CURRENT STUDY

Despite its promise in facilitating the health and well-being of LGBTQ IPV survivors, research on associations between specific TIC components and health and psychosocial risks in this population is scarce (Calton et al., 2016; Edwards et al., 2020). Recent findings demonstrated that LGBTQ IPV survivors who perceived greater overall TIC in their services reported greater empowerment and emotion regulation and lower social withdrawal (Scheer & Poteat, 2018). The present study aims to build on these initial findings by providing a more nuanced understanding of which specific TIC components may relate to a more comprehensive set of self-reported health and psychosocial risks than previously examined. Such knowledge could inform affirming prevention and intervention efforts, including trauma-focused cognitive-behavioral therapy for LGBTQ IPV survivors (Murphy & Hardaway, 2017).

METHOD

Participants and Procedures

Participants were 298 self-identified LGBTQ individuals (M = 28.0, SD = 9.9, range = 18–78). Inclusion criteria were (1) being 18 or older, (2) identifying as LGBTQ, (3) reporting lifetime IPV exposure, and (4) seeking IPV-related services (e.g., therapy, legal counseling) in the past year. Participants were recruited from online groups and listservs (e.g., social media and email broadcasts distributed by LGBTQ and IPV organizations). All potential participants were directed to a link to the Qualtrics survey, where they consented to participate. There were 1,344 people who began the survey and 298 (22.2%) who met full inclusion criteria. The survey took 30–45 minutes to complete. Boston College’s institutional review board approved the study protocols.

Measures

Demographics

Participants reported their age, sexual orientation, gender identity, and race/ethnicity. Participants also reported their ability to pay bills as a proxy for socioeconomic status and the time passed since their treatment participation for their most utilized service.

Intimate Partner Violence

Participants indicated whether they had ever experienced any physical, psychological, or identity-based IPV. Physical abuse was assessed with the Conflict Tactics Scale, short form (Straus & Douglas, 2004). Psychological abuse was assessed with the Psychological Maltreatment of Women Inventory (Tolman, 1999). Identity abuse was assessed with the 28-item Identity Abuse Scale, which evaluates exposure to identity abuse in intimate partnerships (Woulfe & Goodman, 2018). Response options ranged from 0 (did not occur) to 7 (≥ 20 times in the past year) across each IPV measure. A dichotomous variable was created to indicate any lifetime exposure to physical, psychological, or identity-based IPV, demonstrating strong reliability (α = .88, .95, and .91, respectively).

Trauma-Informed Care

The 28-item Trauma-Informed Practice Scales (Goodman et al., 2016) measure clients’ perceptions of receiving TIC from a service provider based on (a) agency and mutual respect (e.g., “staff respect the choices that I make”; α = .93), (b) trauma psychoeducation (e.g., “I have the opportunity to learn how abuse affects responses in the body”; α = .95), (c) opportunities for connection (e.g., “in this program, I have the opportunity to col led with others”; α = .93), (d) emphasis on strengths (e.g., “the strengths I bring to my relationships with my children, my family, or others are recognized in this program”; α = .85). and (e) emphasis on culture (e.g., “people’s cultural backgrounds are respected in this program”; α = .86). Response options ranged from 0 (not at all true) to 3 (very true). Higher scores represented greater perceptions of receiving TIC dimension in their service.

Minority Stress-Related Trauma-Informed Care

A 7-item scale assessed perceptions of receiving minority-stress-sensitive TIC (e.g., “Staff ask about LGBTQ-specific forms of discrimination that I have experienced”; Scheer & Poteat, 2018). Response options ranged from 0 (not at all) to 3 (very true). An exploratory factor analysis demonstrated that the items represented a unidimensional factor (eigenvalue = 4.66; 66.5% variance accounted for; factor loadings = .87, .83, .79, .79, .77, .74, and .67). Higher scores represented perceptions of greater minority-stress-related TIC in their service (α = .91).

Intimate Partner Violence-Related Service Seeking

Participants reported whether they sought the following IPV-related services within the past year: housing (shelter and/or transitional living program), support services (hotline use, advocacy, and/or legal services), mental health (group and/or individual therapy), and medical (medication management and/or medical services). Response options for each service ranged from 0 (never) to 4 (≥ 10 times in the past year).

Depression Symptoms

The 9-item Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001) assessed self-reported symptoms of depression over the past 2 weeks. Response options ranged from 0 (not at all) to 3 (nearly every day). A sum score was computed. Higher total scores represented greater depressive symptoms (α = .89).

Posttraumatic Stress Disorder Symptoms

The 17-item PTSD Checklist—Civilian Version is a self-report measure corresponding to the DSM-1V PTSD symptoms over the past 30 days (Weathers et al., 1993). Response options ranged from 0 (not at all) to 4 (extremely). Higher sum scores represented greater PTSD symptoms (α = .94).

Somatic Symptoms

The 7-item Somatization Subscale of the Brief Symptom Inventory (Derogatis, 1993) assessed for past-year somatic symptoms. Response options ranged from 0 (not at all) to 4 (extremely). Higher mean scores represented greater somatic symptoms (α = .81).

Sexual Risk Behavior

Past-month sexual risk behavior was assessed with one item assessing the frequency of condomless sex with casual partners without knowing the person’s HIV/sexually transmitted infection (STI) status. Response options were on a 6-point scale from 0 to 5+. Higher values on this item indicated greater sexual risk behavior.

Substance Use

Participants indicated whether used any of the following in the past 6 months: marijuana, cocaine, stimulants, depressants, heroin, and hallucinogens. Response options ranged from 0 (never) to 5 (every day). A dichotomous item was created for whether a particular substance was used (0 = no, 1 = yes), and a sum of substances used was computed.

Chronic Physical Health Problems

Past-year chronic physical health problems were assessed for migraines, respiratory problems, HIV/STIs, diabetes, heart attacks, hypertension, arthritis, visual/hearing impairment, and stomach/gall bladder trouble. Response options were 0 (no) and 1 (yes). Higher scores represented greater chronic physical health problems.

Shame

Using the 10-item shame subscale of the Personal Feelings Questionnaire-2 (Harder & Zalma, 1990), participants reported the frequency of experiencing shame-based devaluations of the self over the past year (e.g., “embarrassed” and “self-consciousness”). Response options ranged from 0 (never experience the feeling) to 3 (experience the feeling continuously or almost continuously). Higher mean scores indicated greater shame (α = .90).

Loneliness

Loneliness in the past year was measured with the 6-item short form of the 11-item De Jong Gierveld Loneliness Scale (De Jong Gierveld & Van Tilburg, 2006). Response options ranged from 1 (never experience the feeling) to 5 (experience the feeling continuously or almost continuously). Higher mean scores represented greater social withdrawal (α = .77).

Cognitive Reappraisal

The 6-item cognitive reappraisal subscale of the Emotion Regulation Questionnaire (Gross & John, 2003) assesses respondents’ use of emotion regulation strategies in the past year. Response options ranged from 1 (strongly disagree) to 7 (strongly agree). Higher mean scores indicate greater cognitive reappraisal (α = .89).

Empowerment

Past-year empowerment was measured with the 13-item Measure of Victim Empowerment in Relation to Safety (Goodman et al., 2015). Response options ranged from 1 (never true) to 5 (always true). Higher scores represented greater empowerment (α = .87).

Data Analysis

There were minimal missing data (0.6% to 2.5% across the items), and nearly all items (90.0%) had no missing data. Little’s missing completely at random (MCAR) test was not significant (χ2 = 1,286.55, df = 1241, p = .18); therefore, these data were considered to be MCAR (Little et al., 2002). First, using SPSS version 24, Pearson’s r correlations were conducted to determine bivariate relationships among the study variables for continuous-continuous associations, point-biserial correlations for continuous-binary associations, and phi coefficients for binary-binary associations. Second, a total of 10 separate multivariable linear regression models were tested, one for each outcome variable. TIC components were entered into each regression model simultaneously. Due to the Bonferroni correction for multiple testing of dependent variables, significance was determined at p < .005. All models included sexual orientation, race/ethnicity, gender identity, age, time passed since treatment participation, and socioeconomic status as control variables, as suggested by prior research (Morrissey et al., 2005). Third, we employed a canonical correlation analysis to assess TIC components (independent variate) most associated with health and psychosocial outcomes (dependent variate). Specifically, the overlap twin both sets of variables creates a canonical correlation coefficient (r), indexing the size of the relationship between the two variable sets (Abu-Bader, 2010). For each canonical correlation analysis, several canonical correlations are generated, equal to the number of variables in the smaller of the two sets (in this case, TIC with six variables). Typically, the first canonical correlation is the largest and most significant (Tabachnick & Fidell, 2007). As a result, only the first canonical correlation is interpreted in this article, although information on the second and third canonical correlations is presented in Table 3 for reference. Standardized canonical loadings from each variable set were used to identify the most significant pattern of connections among indices of these larger constructs. A post hoc power analysis revealed that an n ~ 98 would be needed to obtain statistical power at the recommended .80 level (Cohen, 1988); thus, we were sufficiently powered to test the aforementioned models.

Table 3.

Standardized Canonical Coefficients of Correlations I Through 3

Canonical correlations 1 2 3
Dependent variate (Set I)
 Depression 0.21 0.46 0.45
 PTSD −0.09 −0.95 −0.29
 Somatic symptoms −0.07 −0.01 −0.24
 Substance use 0.21 −0.05 −0.35
 Chronic physical health problems −0.03 −0.21 0.79
 Sexual risk behavior 0.13 −0.12 −0.33
 Shame −0.34 −0.05 −0.02
 Loneliness 0.21 −0.19 0.20
 Cognitive reappraisal −0.12 −0.39 −0.24
 Empowerment −0.83 0.04 0.24
Independent variate (Set 2)
 Agency −0.77 1.23 0.39
 Information −0.36 −0.84 0.71
 Connection 0.02 0.18 −0.55
 Strengths 0.37 0.03 −0.49
 Minority stress −0.35 −0.48 −0.85
 Culture 0.05 −0.39 0.38
Coefficients
 Wilks’s λ 0.53 0.70 0.82
 F-statistic 3.17*** 2.33*** 1.77**
 Variance (R2) 0.59 0.31 0.21
 Redundancy 0.14 0.05 0.02
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Note. PTSD = posttraumatic stress disorder; agency = agency and mutual respect; information = access to psychoeducation and information; connection = opportunities for connection; strengths = emphasis on strengths; minority = focus on minority stress; culture = emphasis on culture. Boldface indicates numbers a 0.40, indicating coefficients that tended to cluster together.

*

p < .05.

**

p < .01.

***

p < .001.

RESULTS

As presented in Table 1, most participants identified as queer (24.2%), cisgender women (46.6%), White (53.0%), and college educated (56.4%). A total of 191 (64.1%) participants reported past-year IPV exposure, and 100.0% reported lifetime IPV exposure.

Table 1.

Sample Characteristics (N = 298)

Characteristics n (%)
Sexual orientation identity
 Heterosexuala 5 (1.7%)
 Lesbian 47 (15.8%)
 Gay 49 (16.4%)
 Bisexual 71 (23.8%)
 Queer 72 (24.2%)
 Other non-heterosexual identity 54 (18.1%)
Gender identity
 Cisgender woman 139 (46.6%)
 Cisgender man 35 (11.7%)
 Transgender woman 18 (6.0%)
 Transgender man 19 (6.4%)
 Gender non-binary 71 (23.8%)
 Other TGD identity 16 (5.4%)
Race/ethnicity
 White 158 (53.0%)
 African American/Black 7 (2.3%)
 Hispanic/Latinx 15 (5.0%)
 Asian/Asian American 14 (4.7%)
 Biracial/multiracial 59 (19.8%)
 Other 45 (15.1%)
Education
 High school graduate/CED test or less 37 (12.4%)
 Some collage 93 (31.2%)
 College graduate 99 (33.2%)
 Advanced or graduate degree 69 (23.2%)
Socioeconomic status
 I simply can’t pay my bills 22 (7.4%)
 I have trouble paying my regular bills 61 (20.5%)
 I can pay my regular bills, but a bill that was bigger than usual would cause a hardship 122 (40.9%)
 I can easily pay my bills, but need to be careful 70 (23.5%)
 I do not worry about paying for things I ware and need 23 (7.7%)
Service use in the past year
 Mental health counseling 253 (84.9%)
 Medication management 130 (43.6%)
 Support group 93 (31.2%)
 Advocacy/support service 87 (29.2%)
 Medical care 82 (27.2%)
 Hotline 66 (22.1%)
 Legal services 45 (15.1%)
 Transitional living program 17 (5.7%)
 Shelter 17 (5.7%)
Mean (SD)
Age (in years) 28.0 (9.9)
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Note. GED = General Educational Development; TGD = transgender or gender diverse.

a

Heterosexual TGD individuals.

Bivariate Associations Between Trauma-Informed Care Components and Health and Psychosocial Risks

Variables were associated in conceptually consistent directions. Specifically. TIC components were positively associated with each other (r = .12, p < .05) to r = .71, p < .001). Some TIC components were moderately associated with outcomes variables only at the bivariate level. Specifically, focus on agency and mutual respect was negatively associated with loneliness (r = −.28), depression (r = −.12), and PTSD (r = −.13) and positively associated with cognitive reappraisal (r = .17) and empowerment (r = .43). Access to information on trauma was positively associated with cognitive reappraisal (r = .26) and empowerment (r = .32). Fostering opportunities for connection was positively associated with substance use (r = .16) and sexual risk behavior (r = .22). Focus on strengths was positively associated with cognitive reappraisal (r = .22) and empowerment (r = .26) and negatively associated with loneliness (r = −.19). Focus on minority stress was positively associated with cognitive reappraisal (r = .26) and empowerment (r = .34) and negatively associated with loneliness (r = −.19). Emphasis on culture was associated with cognitive reappraisal (r = .14), shame (r = .12), and empowerment (r = .20).

Multivariable Regression Models

Adjusting for sexual orientation, gender identity, race/ethnicity, age, time passed since treatment participation, and socioeconomic status, 10 multivariable regressions were tested, each with six TIC components simultaneously predicting each of the 10 health and psychosocial outcomes separately (see Table 2). Greater emphasis on agency and mutual respect was associated with lower depression symptoms (β = −3.08, p < .005), and greater focus on culture was associated with greater depression symptoms (β = 1.91. p < .001). Greater emphasis on agency and mutual respect was associated with lower PTSD symptoms (β =−11.41, p < .001), and greater focus on culture was associated with greater MD symptoms (13 = 3.61, p < .005). Greater focus on culture was associated with more chronic physical health problems (β = .34, p < .001). Greater connection opportunities were associated with greater sexual risk behavior (β = .60, p < .001). Greater emphasis on agency and respect was associated with lower shame (β = −.31, p < .001), loneliness (β = −.36, p < .001), and greater empowerment (β = .48, p < .001).

Table 2.

Trauma-Informed Care Components Predicting Health and Psychosociol Outcomes

Outcomes Agency Information Connection Strengths Minority stress Culture R2
β SE β SE β SE β SE β SE β SE
Health outcomes
 Depression −3.08* 0.92 0.50 0.55 −0.19 0.38 −0.03 0.69 0.20 0.66 1.91** 0.51 0.15
 PTSD −11.41** 2.08 3.46 1.24 −0.55 0.86 −0.58 1.55 3.44 1.49 3.61* 1.16 0.22
 Somatic symptoms −0.37 0.11 0.07 0.07 0.03 0.05 −0.07 0.09 0.16 0.08 0.17 0.06 0.13
 Substance use −1.28 0.64 −0.38 0.38 0.48 0.26 0.27 0.47 0.53 0.46 0.09 0.35 0.07
 Chronic physical health problems −0.45 0.20 0.40 0.12 −0.08 0.08 −0.12 0.15 −0.26 0.14 0.34** 0.11 0.12
 Sexual risk −0.88 0.44 0.13 0.26 0.60** 0.18 −0.05 0.33 −0.21 0.32 0.53 0.25 0.11
Psychosocial outcomes
 Shame −0.31** 0.09 0.08 0.05 0.02 0.04 0.02 0.06 0.06 0.06 0.13 0.05 0.19
 Loneliness −0.36** 0.09 0.10 0.05 −0.04 0.04 −0.01 0.06 −0.04 0.06 0.06 0.05 0.14
 Cognitive reappraisal −0.17 0.17 0.26 0.10 −0.10 0.07 0.10 0.12 0.21 0.12 0.03 0.09 0.13
 Empowerment 0.48** 0.09 0.09 0.06 0.04 0.04 −0.15 0.07 0.09 0.07 −0.04 0.05 0.26
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Note. Each of the 10 regression models included all six trauma-informed care components along with six covariates, namely, gender identity, sexual orientation, age, race/ethnicity, socioeconomic status, and time passed since treatment participation. PTSD = posttraumatic stress syndrome; agency = agency and mutual respect; information = access to psychoeducation and information; connection = opportunities for connection; strengths = emphasis on strengths; minority = focus on minority stress; culture = emphasis on culture. Unstandardized coefficients ((3) are presented with their standard errors.

*

p < .005.

**

p < .001.

Canonical Correlation Analysis

The Dimension Reduction Analysis test revealed that only the first three canonical variate pairs were statistically significant (see Table 3). The first canonical correlation examining the association between TIC components and health and psychosocial outcomes was r = 0.49 (32.0% overlapping variance), Wilks’s λ = .53, F(60, 1482.54) = 3.17, p < .001 ), indicating a large-sized effect. Standardized canonical coefficients were used to examine the contribution of each variable to the overall canonical correlations. In the first canonical correlation, the standardized canonical coefficients for TIC components demonstrated that agency (−0.77) was the only TIC component that met the conventional cutoff score of 0.40. For the health and psychosocial variables, empowerment (−0.83) was the only variable that met the conventional cutoff score of 0.40. This pattern of shared variance suggests that LGBTQ IPV survivors who reported greater perceptions of experiencing a provider ho fostered agency reported greater empowerment. Results for the second and third canonical correlation are reported in Table 3.

DISCUSSION

This study’s findings suggest that perceptions of receiving various TIC components are differentially associated with LGBTQ IPV survivors’ health and psychosocial well-being. Overall, positive associations were found between LGBTQ clients’ perceptions of experiencing a provider who fostered agency and psychosocial well-being, indicating that this TIC component may represent the most beneficial therapeutic factor in promoting LGBTQ IPV survivors’ well-being. This study also found that LGBTQ IPV survivors’ perceptions of experiencing a provider who focused on culture and promoted opportunities to connect with other survivors were related to negative health and psychosocial risks in this population. Previous research demonstrated that LGBTQ IPV survivors who perceived greater overall TIC in their services reported greater empowerment and emotion regulation and lower social withdrawal (Scheer & Poteat, 2018). Extending these prior findings, the current study highlights heterogeneity in LGBTQ IPV survivors’ perceptions of receiving specific TIC components and associations between these perceptions and a more comprehensive set of risk factors than previously examined.

In mental health counseling, a successful therapeutic process depends on a meaningful client—provider relationship, which requires effective communication and promotion of clients’ sense of agency and respect (Lambert & Barley, 2001). Fostering agency and mutual respect is particularly important when working with LGBTQ IPV survivors, as some LGBTQ people may exhibit hypervigilance and anxiety related to non-affirmative treatment concerns (Calton et al., 2016; Kaysen et al., 2019; Kelly. & Garland, 2016; Pachankis, 2018). While providing psychoeducation, fostering strengths, and focusing on minority stressors were not associated with IPV survivors’ health and psychosocial risks in this study, they represent important treatment components for LGBTQ people in general (Chaudoir et al., 2017; Pachankis, 2018; Pachankis et al., 2020). TIC approaches, which generally focus on safety, trustworthiness, collaboration, empowerment, and choice and are delivered in the context of evidence-based treatment components (e.g., cognitive-behavioral techniques), could prove helpful for LGBTQ IPV survivors (Substance Abuse and Mental Health Services Administration, 2014). For example, providers serving LGBTQ IPV survivors might use imaginal and in vivo exposure procedures in a safe and affirming environment to improve these clients’ skills for tolerating difficult emotions associated with trauma and minority stress (Kaysen et al., 2019).

Findings also identified that perceptions of a provider who fostered opportunities to connect with other IPV survivors were related to greater sexual-risk behavior. Given that IPV survivors often report experiencing isolation, facilitating opportunities to access and provide informal social support is particularly important (Boyda et al., 2015; Dodson & Beck, 2017; Hyland et al., 2019). This might be especially true for LGBTQ IPV survivors, who report more social isolation compared to non-LGBTQ individuals (Meyer, 2003). Extending these findings, providers might consider discussing potential barriers to reducing HIV- and STI-risk behavior when working LGBTQ IPV-exposed clients.

Lastly, emphasis on culture was related to more PTSD and depression symptoms and chronic physical health problems. Across different communities and cultures, IPV survivors experience stigma, which may help to explain these associations (Sardinha & Catalán, 2018). That is, if a client’s cultural norms are emphasized in treatment, particularly institutionalized norms that condone violence or that are non-accepting toward IPV survivors, clients may experience psychological and physiological distress (Fattah & Camellia, 2020). Healthcare facilities are encouraged to invest in programming that supports LGBTQ communities to challenge norms promoting explicit and tacit approval of IPV (García-Moreno et al., 2015).

Service Delivery Implications for LGBTQ Intimate Partner Violence-Exposed Clients

The current study’s findings have several implications for mental health counselors working with LGBTQ IPV survivors. First, this study’s findings underscore the need for clinicians working with LGBTQ IPV survivors to prioritize the working alliance. In particular, intervention approaches emphasizing clients’ agency (i.e., ability to act on one’s own will to create a change) and service providers’ respect for their clients’ viewpoints and experiences may facilitate LGBTQ IPV survivors’ healing and recovery (Hall & DeLaney, 2019). This can be achieved in relatively simple ways, such as providers making clear that the client is “in the driver’s seat” throughout treatment and that it is ultimately the client’s decision to seek and engage in services. Providing clear explanations about the therapeutic process (e.g., goals, expectations) may further foster LGBTQ clients’ agency. Conveying a non-intrusive, judgment-free positive regard of LGBTQ clients’ experiences and respecting LGBTQ clients’ pace and level of insight remain equally important, as IPV survivors may be hesitant to disclose their victimization experiences (Morse et al., 2012; Sylaska & Edwards, 2015).

This is among the first studies, to our knowledge, to demonstrate that trauma-informed approaches should be accompanied by sexual risk prevention and intervention efforts. Sexuality-specific social support (i.e., support regarding engaging in sexual practices, including sexual risk) may represent an important avenue for intervention when working with IPV-exposed LGBTQ clients (Scheer & Antebi-Gruszka, 2019). This study’s findings also suggest that TIC approaches should be delivered within the context of LGBTQ-affirmative and transdiagnostic evidence-based treatments, such as the ESTEEM (Effective Skills to Empower Effective Men) or EQuIP (Empowering Queer Identities in Psychotherapy) intervention (Burton et al., 2019; Pachankis, 2018; Pachankis et al., 2020), mindfulness-based stress reduction interventions (Gayner et al., 2012), behavioral treatments (Shoptaw et al ., 2008), and eHealth interventions, among others (Riggle et al., 2014), in order to improve LGBTQ IPV survivors’ health and well-being. Providers could also consider incorporating these TIC approaches while working with LGIVIQ clients to reframe or reinterpret the meaning of IPV- and stigma-related experiences. For example, providers could help LGBTQ clients attribute physiological reactivity or psychological distress to IPV or to stigmatizing experiences rather than to LGBTQ individuals’ inadequacies or personal failures (Burton et al., 2019). These strategies could modify the emotional impact of IPV and help holster LGBTQ clients’ agency and self-esteem.

Limitations and Directions for Future Research

This study is not without limitations. This study’s inclusion criterion for past-year engagement in an IPV-related service was not specific to trauma-informed services. In addition, given the limited sample size of this study, analyses grouped all LGBTQ populations together, which prevents us from identifying associations across LGBTQ subgroups or service type. The online sampling methods utilized in this study could limit the generalizability of this study’s findings. Similarly, given the snowball sampling method employed in this study, a response rate could not he estimated. However, online snowball sampling methods have been recommended for hard-to-reach LGBTQ individuals (Meyer & Wilson, 2009). Results relied on self-report; as such, future studies should corroborate data from diverse sources (e.g., service providers). Finally, future research should use the PTSD Checklist for DSM-5, or PCL-5, for greater specificity and sensitivity.

CONCLUSION

Trauma-informed service delivery approaches should be expanded to effectively address LGBTQ IPV survivors’ diverse health and psychosocial needs. Indeed, providers have a moral and ethical responsibility to deliver accessible, culturally relevant, and effective services to individuals from historically oppressed background, including LGBTQ people (Pachankis, 2018). Our findings underscore the need for comprehensive assessment of IPV experiences among LGBTQ individuals and for service providers to foster LGIVIQ IPV survivors’ agency and self-respect when working with this at-risk population.

Acknowledgments

This study was funded in part by the LGBT Dissertation Grant to Jillian Scheer from the Society for the Psychology of Sexual Orientation and Gender Diversity of the American Psychological Association and by the Boston College Lynch School of Education Doctoral Dissertation Fellowship in support of Jillian Scheer. Manuscript preparation was supported in part by the Yale Center for Interdisciplinary Research on AIDS training program, funded by the National Institute of Mental Health under award number T32MH020031-20, in support of Jillian Scheer. The research presented herein is the authors’ own and does not represent the views of the funders, including the National Institutes of Health.

Footnotes

No competing financial interests exist.

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