Toward Affirming Care: An Initial Evaluation of a Sexual Violence Treatment Network’s Capacity for Addressing the Needs of Trans Sexual Assault Survivors

Abstract

There is a global call to action to improve transgender (trans) health to achieve health equity for people of all gender identities. Trans persons experience high rates of sexual assault and have historically had limited or no access to health care that meets their needs. As an initial step in addressing this, we evaluated a sexual assault treatment network’s capacity for addressing the needs of trans sexual assault survivors. Working with an Advisory Group comprising trans community members and their allies who have expertise in trans health, a short online questionnaire was developed and distributed to the program leaders of Ontario’s 35 hospital-based Sexual Assault/Domestic Violence Centres (SA/DVTCs). A total of 27 program leaders completed the questionnaire for a response rate of 77%. The majority of respondents reported that their program collaborates with trans-positive services within their community (70.4%). However, only two in five (40.7%) program leaders indicated that the patient bill of rights at their hospital included a statement pledging nondiscrimination on the basis of gender, gender identity, and/or gender expression. All (100%) program leaders felt that the nurses and physicians working within their programs would benefit from (further) training in the care of trans persons who have been sexually assaulted. This study represents an important step in a research program aimed at enhancing Ontario SA/DVTCs’ response to trans persons.

Introduction

In a recent special series published by The Lancet on transgender (trans) health (Lo & Horton, 2016), leading scholars in this area endorsed a global call to action for measures to address the health of trans persons, typically defined as those whose gender identity does not correspond with their assigned sex at birth (e.g., trans men, trans women, nonbinary, two-spirit, gender diverse, genderqueer, genderfluid identities) (Bauer et al., 2017; Du Mont, Kia et al., 2019; Rainbow Health Ontario, 2016). Given the global lack of appropriate, stigma-free health services specific to the needs of trans populations, articles in this series highlighted particular research and policy development in the area of trans-affirming health care—practices that recognize, account for, and address the unique experiences and needs of trans persons (Du Mont, Kia et al., 2019)—as being critical to the advancement of trans health and, more generally, to the promotion of health equity for people of all genders (Lo & Horton, 2016; Winter et al., 2016).

In light of the dearth of health care services designed to address the needs of trans persons, many in this group are known to experience a range of adverse conditions in the context of accessing health care. Aside from their exposure to prevalent and pernicious expressions of stigma more generally (munson & Cook-Daniels, 2016), they commonly endure specific forms of discrimination targeting their trans identity, often from health care providers, including victim-blaming (Davies & Hudson, 2011; Grant et al., 2010) and harassment (Bauer et al., 2009). In addition, they frequently encounter health care providers who either postpone their care or outright refuse to provide them with care, specifically because they are trans (Bauer et al., 2014). Indeed, in a sample of the 2008–2009 U.S. National Transgender Discrimination Survey, it was discovered that almost one third (30.8%) of trans respondents had delayed seeking needed health care services or did not seek health care services at all due to experiences of such discrimination (Jaffee et al., 2016). Similarly, in a recent study that investigated emergency department avoidance among trans persons in Ontario, Canada, 21% of participants indicated having avoided emergency department care at least once when such care was necessary for fear of discrimination or because of previous experiences of discrimination (Bauer et al., 2014; Bauer & Scheim, 2015).

Trans persons who seek health care following sexual assault are among those affected by the many forms of trans-specific discrimination that pervade health care settings (James et al., 2016; Seelman, 2015). This is salient as rates of sexual assault reported in trans populations are very high throughout the life course (Hoxmeier, 2016; Hoxmeier & Madlem, 2018; James et al., 2016; Langenderfer-Magruder et al., 2016; Stotzer, 2009) and trans persons may have specific health care needs post-victimization (e.g., consideration of potentially heightened risks of poly-victimization and revictimization) (Bauer & Scheim, 2015; Day et al., 2014; Du Mont, Kosa et al., 2019; FORGE, 2014; Herman et al., 2014; James et al., 2016; munson & Cook-Daniels, 2016). The long-term physical effects of sexual assault for trans survivors include physical scarring (14% of victims), chronic medical conditions (10%), and disability (4%) (munson & Cook-Daniels, 2016), as well as negative psychosocial consequences such as serious emotional distress (60%) and lifetime suicide attempts (54%) (James et al., 2016; munson & Cook-Daniels, 2016). However, in a study of 265 members of the trans community, almost 60% of survivors of sexual assault in the sample had not accessed professional emotional help within a year post-victimization and the overwhelming majority (91%) received no medical care (munson & Cook-Daniels, 2016).

Given not only the growing recognition of trans health as a salient area of research and policy development (Lo & Horton, 2016), but also the pertinence of attending to the health care needs of trans sexual assault survivors more specifically (munson & Cook-Daniels, 2016), initiatives aimed at improving the responsiveness of post-sexual assault health services for trans persons are relevant and necessary. Across the globe, post-sexual assault services are increasingly being administered by forensic nurses (Du Mont & White, 2007). These are registered nurses with specialized training in the care of “patients who are experiencing acute and long-term health consequences associated with victimization or violence, and/or have unmet evidentiary needs relative to having been victimized” (International Association of Forensic Nurses, 2019a). A review of the impact of forensic nursing–led programs concluded that they offer many benefits, including improved psychological outcomes for victims, more comprehensive provision of specialized care such as the administration of prophylaxis for sexually transmitted infections, more accurate and timely documentation of injuries and other medico-legal findings, improved expert testimonies in court, and increased collaboration among service providers in the provision of care (Campbell et al., 2005).

Although the International Association of Forensic Nurses (2019b) has endorsed lesbian, gay, bisexual, transgender, and queer+ (LGBTQ+)-specific recommendations for victim-centered care on their website, many forensic nurses may not have undergone comprehensive training on the provision of care for trans persons specifically, given their unique needs (Du Mont, Kosa, et al., 2019). Some forensic nursing programs have taken concrete steps toward becoming more inclusive of and responsive to trans persons who have been sexually assaulted such as those taken by The Victoria Sexual Assault Centre in British Columbia, Canada. These steps included hiring a trans inclusion coordinator, changing the center’s name to be gender neutral, forming an advisory group of trans community members and allies, introducing a policy of asking clients’ preferred pronouns, displaying trans inclusive posters, updating and developing novel training for all personnel and decision makers, updating the language on their website and promotional materials, and meeting with trans-positive service providers to discuss “best practices” (Victoria Sexual Assault Centre, 2014). However, despite the pressing need for trans-affirming post-sexual assault care and recommendations from the International Association of Forensic Nurses on the provision of LGBTQ+ care, few such initiatives have been reported on globally.

We recently conducted an evaluation of hospital-based forensic nurse examiner led violence treatment programs in Ontario, Canada, and found that across 30 of 35 hospital-based Sexual Assault/Domestic Violence Treatment Centres (SA/DVTCs), there was limited uptake of these services by trans persons in this region (Du Mont et al., 2013, 2014). Despite learning about the limited engagement of trans persons with these treatment programs, we did not gain insight into these programs’capacity for providing care that adequately responds to the needs of trans persons accessing services. In this study, we present the findings of a subsequent follow-up evaluation in which our objective was to examine program practices and hospital services and policies important to the provision of trans-affirming care (Lambda Legal, Human Rights Foundation, Hogan Lovells, & New York City Bar, 2016), as well as any recent or current trans-specific training activities across Ontario’s SA/DVTCs and emergency department staff. This initial step will lay the groundwork for the enhancement of hospital-based violence services in Ontario to better meet the diverse needs of trans persons who have experienced sexual violence.

Method

Advisory Group

This study was guided by an advisory group of trans community members and their allies with expertise in trans health and violence against trans persons, including representatives from Rainbow Health Ontario, Egale Canada Human Rights Trust, Women’s College Hospital, and the University of Toronto.

Setting

In Ontario, the SA/DVTCs are managed by program leaders who also often provide direct nursing care. These centers offer a broad range of health, psychosocial, and medico-legal services to diverse adults who have recently been sexually assaulted by any assailant or physically assaulted by an intimate partner, as well as children who have been sexually or physically abused, of whom some identify as trans (Du Mont et al., 2013, 2014). Services are accessed through the hospital emergency department where survivors are medically cleared and provided primarily by specially trained Sexual Assault Nurse Examiners (SANEs). These SANEs are registered with the College of Nurses of Ontario, and have completed 16 online learning modules, a 30-hr in-class training, and clinical practice requirements related to post-sexual assault care (Du Mont et al., 2017). These services include crisis intervention, medical care and treatment, documentation of injuries, collection of forensic evidence, on-site follow-up care, and referral to community agencies for ongoing support (Du Mont et al., 2014). Individual and/or group counseling is provided by social workers or counselors. The programs, which serve both urban and rural areas, saw approximately 4,600 clients for acute care from March 31, 2016, to April 1, 2017 (Ontario Network of SA/DVTCs, 2017). The Ontario Network of SA/DVTCs supports these programs through collaborative activities in research, education, and training to establish standardization in service provision across the province.

Measurement

A brief questionnaire was developed to examine SA/DVTCs’ capacity for addressing the needs of trans sexual assault survivors. This questionnaire drew on input from the advisory group, previous surveys conducted within the Ontario Network of SA/DVTC programs (Du Mont et al., 2014; Du Mont & Parnis, 2002), and several key policy documents including (a) a U.S. national protocol on post-sexual assault care with recommendations for caring for trans persons (U.S. Department of Justice, Office on Violence Against Women, 2013), which were subsequently endorsed by a pan-American trans anti-violence organization (FORGE, 2014); (b) a checklist for sexual assault programs delineating key policies and practices to support LGBTQ+ inclusion (Colorado Anti-Violence Program, n.d.); and (c) the “Health Services” section of the Policy on preventing discrimination because of gender identity and gender expression (Ontario Human Rights Commission, 2014). The questionnaire was administered on an online platform, SurveyMonkey.

The questionnaire, which was designed for program leaders to take approximately 15 min to complete, captured sociodemographic characteristics and work-related experiences (e.g., age, gender identity, years working for Ontario’s Network of SA/DVTCs, ever provided direct clinical care to a SA/DVTC client who has indicated that they are trans) (Du Mont et al., 2014; Du Mont & Parnis, 2002). Gender identity included the following response options: woman, man, bigender, trans man, trans woman, crossdresser, genderqueer, agender, gender fluid, two-spirited, and other (please specify). The questionnaire also captured program practices including whether clinical documentation in use includes gender-neutral body maps and the programs collaborate with trans-positive service providers in the community. The questionnaire additionally included items about hospital services (e.g., specialized programs/services for trans clients) and policies (e.g., patient bill of rights includes a statement pledging nondiscrimination on the basis of gender, gender identity, and gender expression), as well as on the availability of training for nurses/physicians working within programs and for emergency department staff. Program leaders were then asked whether they provided direct clinical nursing care and, if the response was “yes”, they were asked a series of questions related to having undergone any trans-specific training (modality, type, duration of training). Finally, the questionnaire asked, “Does your hospital face any challenges in the provision of care for trans persons? If yes, please explain” and “Is there anything else you would like us to know about your program with respect to the care of trans persons?”.

Procedure

The link to the online questionnaire was first distributed through email to each of Ontario’s 35 SA/DVTC program leaders on April 25, 2017. Potential respondents were presented with a preamble explaining that participation was voluntary, declining to complete the questionnaire would not adversely affect their relationship with the Ontario Network of SA/DVTCs and its leadership, the questionnaire data were being collected anonymously and, by completing the questionnaire, they were consenting to participate in the study. Informed consent was obtained. Four reminder emails were sent out to program leaders over the course of 9 weeks. Research ethics board approval was obtained for this study from Women’s College Hospital, Toronto, Ontario, Canada (REB # 2017-0005-E).

Data Analyses

The data from SurveyMonkey were imported into Statistical Package for the Social Sciences (version 24). Program leader sociodemographic characteristics, work experiences, and capacity for addressing the needs of trans sexual assault survivors (e.g., including the presence of supportive program practices and hospital services and policies); trans-specific training items; and the presence of challenges faced in providing appropriate care were examined using descriptive statistics, including counts and frequencies. Comments from the written-in responses related to challenges in providing trans-affirming care and the identification of any other relevant issues related to trans care were extracted and, across both questions, collated into two broad themes—barriers and facilitators to trans-affirming care—by two members of the research team.

Sample

A total of 27 of 35 SA/DVTC program leaders across Ontario responded to the questionnaire, representing a response rate of 77%. These program leaders represented a diverse range in age with 7.4% aged 20 to 30 years, 37.0% aged 31 to 45 years, 44.4% aged 46 to 60 years, and 11.1% aged 61 or more years (see Table 1). Nearly all program leaders (96.3%) identified their gender to be a woman; one identified their gender to be a man. The most common level of education achieved for program leaders was a Bachelor’s degree (53.8%), followed by a Master’s degree (30.8%). The majority (66.7%) of program leaders reported having worked within Ontario’s SA/DVTCs for more than 10 years. Most identified their health profession as being a nurse (RPN/RN/NP) (74.1%), whereas the rest reported that they were a social worker or counselor (22.2%) or did not specify (3.7%). Among those who identified as nurses, 73.7% had been trained as a specialized SANE. Among all program leaders, 70.4% indicated that they had provided direct clinical care to a trans client.

Table 1.

Characteristics of Program Leaders at Violence Treatment Centers.

Characteristics	N	%
Age	n = 27
20–30 years	2	7.4
31–45 years	10	37.0
46–60 years	12	44.4
>60 years	3	11.1
Gender identity	n = 27
Woman	26	96.3
Man	1	3.7
Level of education*	n = 26
Hospital-based nursing program	2	7.7
Community college	3	11.5
Bachelor degree	14	53.8
Master’s degree	8	30.8
Professional program	2	7.7
Number of years working at an SA/DVTC	n = 27
<1	3	11.1
1–5	2	7.4
6–10	4	14.8
>10	18	66.7
Health profession	n = 27
Nurse (RPN/RN/NP)	20	74.1
Social worker/counselor	6	22.2
Did not specify	1	3.7
Sexual Assault Nurse Examiner trained (nurses only)	n = 19
Yes	14	73.7
No	5	26.3
Provide direct clinical nursing care at an SA/DVTC	n = 27
Yes	17	63.0
No	10	37.0
Ever provided direct clinical care to an SA/DVTC client who has indicated they are trans	n = 27
Yes	19	70.4
No	8	29.6

Note. SA/DVTC = Sexual Assault/Domestic Violence Treatment Centres.

^*Categories are not mutually exclusive.

Results

Program Practices and Hospital Services and Policies Supporting Trans-Affirming Care

The majority (70.4%) of program leaders indicated that with regard to program practices they collaborate with trans-positive services in the community (see Table 2). In addition, 14.8% indicated that gender-neutral body maps were part of the clinical documentation used. As per hospital policy, 40.7% of program leaders indicated that their institution had a statement pledging nondiscrimination on the basis of gender, gender identity, and/or gender expression in place, although just 34.6% indicated that persons who registered at their hospital are able to be identified in the record as trans or as having medically transitioned. Only 11.1% of program leaders indicated that specialized programs/services for trans persons were available within their hospital. Just over half (51.8%) responded that their hospital has faced challenges to providing appropriate care to trans persons.

Table 2.

Hospital Policies and Services and Their Violence Treatment Center Program Practices Related to Trans-Affirming Care.

Hospital policies and services and program practices	N	%
Hospital policies
Patient able to identify as trans or as having medically transitioned at registration at hospital	n = 26
Yes	9	34.6
No	9	34.6
I don’t know	8	30.8
Patient bill of rights includes a statement pledging nondiscrimination on the basis of gender, gender identity, and/or gender expression	n = 27
Yes	11	40.7
No	5	18.5
I don’t know	11	40.7
Hospital services	n = 27
Specialized programs/services for trans clients	3	11.1
Program practices	n = 27
Collaboration with trans-positive service providers in the community	19	70.4
Clinical documentation includes gender-neutral body maps	4	14.8

Program Leader, Program, and Hospital Training Related to Trans-Affirming Care

Of the 17 program leaders who identified as nurses who also provide direct clinical care and responded to training related items, 10 (58.8%) had undergone any training in the care of trans persons in the context of providing nursing care (see Table 3). That training was most often self-directed learning (80.0% of those who had training), by a community organization/group (e.g., Rainbow Health Ontario Program), through workshops/webinars (70.0%), and/or at a conference (70.0%).

Table 3.

Hospital and Violence Treatment Center Training Related to Trans-Affirming Care.

Training related to trans-affirming care	N
Hospital	n = 27
Emergency department staff undergo training to care for trans persons
Yes	2	7.4
No	15	55.6
I don’t know	10	37.0
Program	n = 27
Nurses/physicians undergo training to care for trans persons	8	29.6
Nurses/physicians would benefit from (further) training to care for trans persons	27	100.0
Program leaders (who provide direct clinical nursing care)
Training to care for trans persons	n = 17
Yes	10	58.8
No	7	41.2
Modality	n = 10
Online	3	30.0
In-person	2	20.0
Both	5	50.0
Type*	n = 10
Undergraduate nursing course	0	0.0
Sexual Assault Nurse Examiner training curriculum	2	20.0
Self-directed learning	8	80.0
Community organization/group workshop/webinar	7	70.0
Conferences	7	70.0
Community of practice	3	30.0
Duration	n = 10
<5 hr	3	30.0
5–<10 hr	6	60.0
10–<15 hr	1	10.0
15+ hr	0	0.0

^*Categories are not mutually exclusive.

Less than one third (29.6%) of program leaders reported that their programs have training for nurses/physicians working within them related specifically to the care of trans persons, although 100% of program leaders indicated that these professionals would benefit from such training. Only 7.4% of program leaders indicated that their hospitals provide any specialized training for emergency department staff on the provision of care for trans persons.

Barriers and Facilitators to Provision of Trans-Affirming Care

Across the written-in comments to the questions, “Does your hospital face any challenges in the provision of care for trans clients? Please explain” (n = 12 respondents) and “Is there anything else you would like us to know about your program with respect to the care of transgender clients?” (n = 6 respondents), we identified a number of barriers and, less commonly, facilitators to the provision of trans-affirming care as highlighted below with representative comments from program leaders.

Barriers to providing trans-affirming care were as follows:

• 1. A lack of knowledge/discriminatory attitudes and limited opportunities for training and education among staff and/or physicians (n = 10):

“Discrimination, lack of understanding or education”

“[L]ack of funding to provide/bring in experts to provide training for staff”

“Education would be of benefit to all staff”

• 2. Hospital policies and resources that were not trans-positive (n = 4):

“Re [patient bill of rights], I don’t believe it is as specific as gender identity and gender expression, just gender”

“[N]o neutral gender identity on documentation, no gender-neutral washrooms”

• 3. A paucity of trans-positive services for referral/collaboration (n = 3):

“I had to put ‘no’ [re program collaboration with trans-positive service providers in the community] as there was no other option, but in reality there are no specialized programs for trans clients in our community”

“Police sensitivity towards these clients is lacking”

• 4. Limited previous program experience with trans clients (n = 1):

“[W]e have never served a [trans] client”

Facilitators to providing trans-affirming care were as follows:

• 1. Efforts to promote trans-positive environments (n = 2):

“We self-educate and provide a positive space . . . [this] is posted”

“We teach in orientation that every individual is to be treated with dignity and respect”

• 2. Establishment of trans-positive hospital policies (n = 1):

“We are soon going to have [electronic patient record] which has transgender identifiers”

• 3. Partnership building with LGBTQ+ services (n = 1):

“[C]ompetence of staff/physicians . . . is improving slowly with the assistance of our local queer alliance”

Discussion

It is essential that hospitals and their in-house violence treatment centers and other forensic nurse examiner–led programs globally take steps to ensure that they provide equitable access to services for trans persons. In our study, we found that two program practices, use of gender-neutral body maps and collaboration with trans-positive services, as recommended by the Second Edition of the National Protocol for Sexual Assault Medical Forensic Examinations (SAFE) Adults/Adolescents (U.S. Department of Justice, Office on Violence Against Women, 2013) and FORGE (2014), a trans anti-violence organization, were varyingly adopted across the network of Ontario’s SA/DVTCs. Only 14.8% of program leaders indicated that gender-neutral body maps were part of the clinical documentation in their program. Since the time of the study, gender-neutral body maps have been implemented as part of the Sexual Assault Evidence Kit used in SA/DVTCs in Ontario. However, it may be necessary to implement these in other jurisdictions globally, if they are not already commonly in use. One sample map, developed by FORGE, is freely available on the websites of the International Association of Forensic Nurses (2019c) and U.S. Office of Justice Program (Office for Victims of Crime, 2014).

More than two thirds of program leaders indicated that their program collaborates with trans-positive service providers in the community. Such collaborations were viewed by one program leader, who had established a partnership with a LGBTQ+ organization, as a facilitator to providing trans-affirming care, noting the positive effects on nurse and physician competence. Program leaders, who indicated that their programs did not collaborate with trans-positive services, commented that a barrier to collaboration and the provision of trans-affirming care was often a lack of availability of such services. This issue similarly has been documented in previous research which found that health and social service organizations frequently lack partnerships with LGBTQ+ organizations and have insufficient resources to address service disparities (National Center for Victims of Crime & National Coalition of Anti-Violence Programs, 2010; Seelman, 2015). It would be optimal if 100% of SA/DVTCs were collaborating with trans-positive services in the community. Therefore, in future program development, it will be critical to identify trans-positive services across the province that are found in proximity to local SA/DVTCs, and formalize linkages with those services, so that both program leaders and nurses providing care are aware of and able to consult with and refer to them as appropriate. Where such services are not available, it may be necessary for the Ontario Network of SA/DVTCs, as an ally to the trans community, to highlight their paucity to policy-makers and advocate for their establishment within communities. Internationally, it is critical that those seeking to develop trans-affirming health programs reach out to key stakeholders in trans communities and trans-positive agencies to build such partnerships (Lambert et al., 2018).

Only approximately 1-in-10 program leaders noted that the hospitals within which SA/DVTC programs are based had specialized programs and services for trans persons. The limited availability of trans specialized services in Ontario, both in the hospital and community, has been documented previously in other jurisdictions (Lo & Horton, 2016; Nemoto et al., 2008; Taylor, 2006). At a policy level, only slightly more than a third of program leaders indicated that persons who registered at their hospital were able to identify as trans or having medically transitioned. One program leader indicated that this situation was changing with modernization of the hospital electronic record. If more hospitals offered persons these options at registration, which has been identified as a principle of trans-inclusive care (Colorado Anti-Violence Program, n.d.), it would help ensure that needed data surrounding the care of trans persons could be captured (Winter et al., 2016). In addition, only two fifths of program leaders indicated that the hospital had a statement in their bill of rights that clearly insists on nondiscrimination on the basis of gender, gender identity, and gender expression, as is called for by the Ontario Human Rights Commission (2014). Including such a statement in policy is a concrete step that hospitals can take to address discrimination against, and promote inclusivity of, gender-diverse individuals (Roberts & Fantz, 2014).

Over half of program leaders believed that their hospital faces challenges in caring appropriately for trans persons, which was particularly evident in their comments related to discriminatory attitudes based on a lack of education and training for providers. This finding is also supported by literature documenting trans persons’ negative interactions with emergency services (Bauer et al., 2014), as well as research in trans persons’ receipt of HIV care (Sevelius et al., 2013). These studies found that trans individuals often do not perceive health care services as welcoming and do not feel safe identifying themselves as trans due to past experiences of discrimination. In future research, it would be important to examine whether the challenges faced by services to providing trans-affirming care may vary by program characteristics (e.g., size, jurisdiction) and available resources.

Although almost three fifths of program leaders who provide direct clinical care reported having undergone some kind of trans-specific training themselves, less than one third reported that their programs provide such training to their nurses/physicians. Encouragingly, 100% of program leaders were supportive of these staff receiving further training in the care of trans survivors of sexually assault. Only 7% of program leaders indicated that the emergency department staff in their hospitals undergo specialized training to care for trans clients, even though these staff work within the setting in which trans sexual assault survivors are first medically cleared. This finding is concerning, but would seem consistent with previous research by Samuels et al. (2017), which identified a need for training of emergency department staff. In this study, 32 trans persons surveyed and interviewed reported experiences with care providers in emergency departments who lacked knowledge about trans health (Samuels et al., 2017).

Insights arising from this study on program practices, hospital services and policies, and training activities relevant to the provision of trans-affirming care across Ontario’s SA/DVTCs corroborate and expand on issues that are commonly highlighted in the literature on trans health and, more specifically, in the limited scholarship on sexual victimization among trans persons. Trans health, as noted earlier, has recently been foregrounded in a global call to action as an increasingly salient area for research and policy development across several domains (Lo & Horton, 2016). In this call, the writers argue that a global lack of awareness surrounding the health of trans populations, both in scholarly and professional communities, substantiates the growing relevance of addressing trans health (Lo & Horton, 2016). Consistent with this perspective, SA/DVTC program leaders participating in our questionnaire recognized significant gaps in knowledge of trans health yet, overwhelmingly, expressed support for making professional training opportunities in this area available to health care providers. In addition, given that rates of sexual victimization in trans populations are often exceptionally high (Hoxmeier, 2016; Hoxmeier & Madlem, 2018; James et al., 2016; Langenderfer-Magruder et al., 2016; Stotzer, 2009) and trans persons often avoid mainstream health services for fear of being stigmatized or discriminated against (Bauer et al., 2014), the need for trans-positive post-sexual assault care has been highlighted in the past (munson & Cook-Daniels, 2016). Our work builds on the existing literature in this area by drawing attention to policy and program gaps perceived by local program leaders of hospital-based violence treatment services in the area of trans-affirming post-sexual assault care and, in turn, strengthens the case for services that address these gaps globally.

Based on the findings from this study, the next step in our program of research has been to develop and evaluate an in-person training in trans-affirming care for forensic nurses working across Ontario’s SA/DVTCs (Du Mont, Kia, et al., 2019). This training incorporates an intersectional framework acknowledging experiences, social conditions, and identities that intersect with gender identity such as colonialism, poverty, and race (Baker & Etherington, 2015) that heighten susceptibility to sexual victimization, as well as affect access to and treatment within health services (Bauer & Scheim, 2015; Marcellin et al., 2013). This training, we believe, holds the potential to ensure that trans survivors, who historically have had limited or no access to comprehensive and sensitive services that address the violence perpetrated against them (National Center for Victims of Crime & National Coalition of Anti-Violence Programs, 2010), receive informed and appropriate care from Ontario’s violence treatment centers. This training also may have relevance to forensic nursing training globally, including educational activities offered through the International Association of Forensic Nurses.

Limitations

Although we had a strong response to our questionnaire (77%), it is important to acknowledge that as 27 of the 35 program leaders from Ontario’s SA/DVTCs responded to the email invitation to participate, the results may be subject to potential volunteer bias. Those program leaders who completed the questionnaire may have had a greater interest and engagement in trans issues and therefore their programs may have been more likely to have been guided by trans-positive policies and had available trans-specific training. In addition, recall bias is potentially a limitation of the study, as program leaders may not have been able to accurately remember all hospital policies and services in place, which is reflected in the “I don’t know” responses for some such items. Nonetheless, it is valuable to know what program leaders did not know, as this may be a further indicator of the need for additional education and training. Overall, our results may be limited in their generalizability to hospital-based violence treatment centers; however, the forensic nursing model of sexual assault care has been widely adopted, with over 950 programs in regions across the globe (International Association of Forensic Nurses, 2018). Still, it is important to consider in future research that within these programs and affiliated institutions, policies may differ widely based on the degree of systemic discrimination against trans persons, the availability of resources to support trans survivors, and other jurisdiction related factors.

Conclusion

This study identified that violence treatment centers in Ontario and the hospitals in which they are based need to take steps to ensure that they provide an environment that is trans-inclusive and affirming. Such steps for hospitals could include, but are not limited to, offering an option for a client to identify as trans or as having medically transitioned when they register and implementing policies that clearly insist on nondiscrimination on the basis of gender, gender identity, and/or gender expression (Colorado Anti-Violence Program, n.d.). The development and evaluation of trans-affirming training for physicians and emergency department staff as well as the establishment of an intersectoral network of trans-positive organizations in the community with which all SA/DVTCs can collaborate in the care of trans survivors of sexual assault are clear priorities. These important next steps to improving care for trans sexual assault survivors are not only critical in the Ontario context but also relevant to fostering health equity for people of all genders in other jurisdictions across the globe (Lo & Horton, 2016; Winter et al., 2016).

Author Biographies

Janice Du Mont, EdD, an applied psychologist, leads an interdisciplinary program of research to address gender-based violence, with a focus on sexual assault, intimate partner violence, and elder abuse. She is a senior scientist at Women’s College Research Institute at Women’s College Hospital and a professor in at the Dalla Lana School of Public Health at the University of Toronto. She is also director of the Collaborative Specialization in Women’s Health at the University of Toronto.

Sarah D. Kosa, MSc, is a PhD candidate in Health Research Methodology at McMaster University and a research associate for the Ontario Network of Sexual Assault/Domestic Violence Care and Treatment Centres.

Rebecca Abavi, MPH, is currently a data analyst at the Canadian Centre to End Human Trafficking, and holds a Master of Public Health from the Dalla Lana School of Public Health at the University of Toronto.

Hannah Kia, MSW, PhD, is currently an assistant professor at the University of British Columbia’s School of Social Work. Her program of research broadly addresses lesbian, gay, bisexual, transgender, and queer (LGBTQ+) aging.

Sheila Macdonald, MN, is the Director of the Ontario Network of Sexual Assault/Domestic Violence Treatment Centres and a Sexual Assault Nurse Examiner. She is an adjunct professor with the University of Toronto’s Faculty of Nursing. Her research has focused on improving services for sexual assault survivors.