Assessment of nurses' competence to care for sexually assaulted trans persons: a survey of Ontario's Sexual Assault/Domestic Violence Treatment Centres

Bridging Gaps in Collaboration Between Community Organizations and Hospital-Based Violence Treatment Centers Serving Transgender Sexual Assault Survivors

Community and healthcare organizations have not historically collaborated effectively, leaving gaps in the continuum of care for survivors of sexual assault. These gaps are particularly acutely felt by transgender (trans) survivors, who experience additional barriers to care and face higher rates of sexual assault. To bridge these gaps and enhance the provision of comprehensive support for trans people, we developed an intersectoral network of trans-positive community and hospital-based organizations in Ontario, Canada. As part of a baseline evaluation of the network, we conducted a social network analysis to determine the extent and nature of collaboration between members within and across these two sectors. Using a validated social network analysis tool (PARTNER survey), data were collected from June 22 to July 22, 2021. The extent of collaboration was examined by relationship type: intrasectoral (same sector) and intersectoral (different sectors). The nature of collaboration was examined using relational scores (value: power, level of involvement, potential resource contribution; trust: reliability, mission congruence, openness to discussion). Fifty-four community organizations (65.9% of 82 invited) and 24 hospital-based violence treatment centers (64.9% of 37 invited) responded. The majority of collaborations were within, rather than across, the two sectors: of all 378 collaborations described, 70.9% (n = 268) were intrasectoral collaborations and 29.1% (n = 110) were intersectoral collaborations. Intersectoral relationships were characterized by lower scores for level of involvement, trust, reliability, and mission congruence than intrasectoral relationships, but higher scores for power. These findings were shared in a virtual consultation session of key stakeholders, in which some participants expressed "surprise" and concern for the lack of collaboration and character of relationships across sectors. Recommendations to increase intersectoral collaboration, which included intersectoral program planning and service design and supporting increased opportunities for intersectoral training and knowledge exchange, are presented.

Enhancing care for transgender and gender diverse survivors of intimate partner violence: an Ontario-wide survey examining health and social service providers' learning needs

OBJECTIVES

To better understand healthcare and social/community service providers' learning needs associated with supporting transgender and gender diverse (trans) persons who have experienced intimate partner violence (IPV).

SETTING

An online survey was distributed through the trans-LINK Network in Ontario, Canada.

RESPONDENTS

163 of 225 healthcare and social/community service providers completed the survey (72.4% response rate) between November 2022 and February 2023.

MAIN OUTCOME MEASURES

Expertise, training, workplace practices and learning needs related to supporting trans survivors of IPV.

METHOD

Quantitative survey results were analysed descriptively and open-ended responses were organised thematically. In March 2022, survey results were shared with 33 stakeholders who helped define goals and objectives for an e-learning curriculum using Jamboard, data from which were collated and organised into themes.

RESULTS

Most (66.3%) survey respondents described having provided professional support to trans survivors of IPV, but only one-third (38.0%) reported having received relevant training, and many of the trainings cited were in fact focused on other forms of violence or trans health generally. The majority reported a mid (44.9%) or low-mid (28.5%) level of expertise and almost unanimously agreed that they would benefit from (further) training (99.4%). The most commonly recommended goal/objective for a curriculum emerging from the stakeholder consultation was to facilitate collaboration, knowledge sharing and (safe) referrals among organisations.

CONCLUSIONS

The results of this study highlight the critical need for an IPV curriculum specific to trans survivors and responsive to the needs of providers. As no one profession can address this complex issue in isolation, it is important that the curriculum aims to facilitate collaboration across sectors. In the absence of appropriate training and referrals, practitioners may perpetuate harm when caring for trans survivors of IPV.

Gender-Affirming Sexual Assault Nurse Examiner Care: A Program Evaluation and Quality Improvement Project at a Community-Based Rape Crisis Center

BACKGROUND

Transgender and non-binary (trans*) individuals face disproportionately high rates of sexual violence yet experience discrimination at rape crisis centers (RCCs). Sexual assault nurse examiners (SANEs) who receive targeted education are better equipped to care for the trans* community.

AIMS

This quality improvement project aimed to increase SANEs' self-perceived competence in caring for trans* assault survivors. The secondary purpose was to promote a trans*-inclusive environment at an RCC based on an environmental assessment.

METHODS

The project involved creating and implementing a virtual continuing education course on providing gender-affirming and trans*-specific care for sexual assault survivors and an environmental evaluation at an RCC. A questionnaire measured SANEs' perceived competency pretraining and posttraining, and paired t tests were conducted to examine the change in competencies. A modified assessment tool was used to evaluate the RCC's capacity for addressing trans* survivors needs.

RESULTS

The training increased self-perceived competency in all four components measured ( p < 0.005). More than one third of participants (36.4%, n = 22) indicated having no expertise, and 63.7% reported having some expertise in caring for trans* clients. Two thirds (66.7%) had prior trans*-specific training; however, only 18.2% received trans*-specific content in their SANE training. Most strongly agreed (68.2%) they would benefit from additional training. The organizational assessment identified key areas for improvement.

CONCLUSIONS

Trans*-specific training can significantly impact SANEs' self-perceived competency in caring for trans* assault survivors and is feasible and acceptable. This training could have a global impact on SANEs if disseminated more widely, particularly with inclusion in SANE curriculum guidelines.

An Account From a Sexual Assault Nurse Examiner on Caring for a Transgender Survivor: A Case Report

ABSTRACT

Transgender individuals represent a gender minority population that has been underserved within the healthcare system and underrepresented in population health and sexuality research, specifically as it pertains to sexual assault. This case report aims to explore how sexual assault nurse examiners (SANEs) approach the care of transgender people who have survived sexual assault. Key components and findings related to the SANE's encounter will be examined including an evaluation of the biases and assumptions held by the SANE and other healthcare providers. Concepts such as cisnormativity, heteronormativity, and intersectionality will be examined in terms of how these can shape the experience of the survivor, influence the care provided by SANEs, and interact with gender stereotypes and nonaffirming practices faced by transgender people. This case report highlights the importance of acknowledging and undermining nursing approaches that can (re)traumatize sexual assault survivors and explores ways in which SANEs can help to shift views of gender and bodies with the goal of providing better care for gender minority populations.

Evaluation of an e-Learning Curriculum for Forensic Nurses on Trans-Affirming Postsexual Assault Care

Trans survivors of sexual assault have called for the development and implementation of training for care providers. To answer this call, we developed and evaluated an innovative e-learning curriculum for forensic nurses working across Ontario, Canada, on the provision of trans-affirming care. The e-learning curriculum, developed in Storyline 360 by Articulate, was launched in August 2019. The competence of nurses (N=65) completing the curriculum improved significantly from pre- to post-training across all content domains (Initial assessment, Medical care, Forensic examination, and Discharge and referral). This e-learning curriculum could be of utility in training forensic nurses worldwide.

Ready for Anything: A Holistic Approach to Training Sexual Assault Nurse Examiners

Although numerous training options exist for sexual assault nurse examiner certification, most focus on specific certification-related content rather than on creating a holistic preparation for sexual assault nurse examiner (SANE) practice. Holistic preparation may be preferable for SANE trainees who are early in their nursing careers or who have practiced in limited clinical environments. This article describes a holistic training approach implemented at a SANE training site funded by the Advanced Nursing Education initiative of the Health Resources and Services Administration. Training covers hands-on pelvic and anal examinations, community education, underserved communities, self-care, and other topics that support newly trained SANEs in establishing and maintaining practice. This content has prepared trainees for a wide variety of patient encounters as well as for engaging with the community. With this approach, our trainees have the opportunity to enhance their ability to provide SANE care and to provide additional resources within their primary practice environments.

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

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.

Implementation of Sexual Assault Services in a Clinic Setting

Sexual assault services cost Americans more than $420,000,000 annually for medical and mental health services. Personal costs include lost wages, lost quality of life, and victim assistance. Public costs include police work, legal adjudication, and sanctioning (penalties). In 2014, an estimated 284,350 adult women were sexually assaulted in the United States. Sexual assault is significantly underreported by those who are assaulted. Upon determination that sexual assault services in a clinic setting were nonexistent, services for sexual assault were developed and implemented in a clinic setting in a Midwestern state. The purpose of clinic services was to provide support, assessment, and forensic examinations for adult women and to evaluate the number of women receiving services. A quality improvement approach was used to determine how and when sexually assault victims received sexual assault services. Persons who have been sexually assaulted vary in gender and age; however, for the purpose of the pilot project, implementation initially included services to women over 18 years of age. Although the number of female patients receiving care was low in the inaugural clinic during the implementation and evaluation period, the services provision remains a viable option for women who experienced sexual assault in a community that previously had no access to clinic services.

Underserved survivors of sexual assault: a systematic scoping review

Background: Despite knowledge about the extensive and often long-lasting consequences of sexual assault, many survivors remain underserved by formal support systems (e.g. medical, mental health and criminal justice systems). Reasons for underutilizing services are as diverse as the survivors themselves, and little is known about which survivors are most underserved and why they are underserved. Objective: To help organize existing findings on this topic, a systematic scoping review was conducted to identify adult survivors of sexual assault, who may be particularly underserved when attempting to obtain services in Western countries. Method: Five databases (PsycINFO, Embase, MEDLINE, Scopus and CINAHL) were systematically searched for studies published in English from 2000 onwards using terms such as 'sexual assault', 'help seeking', 'formal support', 'barriers' and variations thereof. Results: A total of 41 studies were included in the present scoping review, resulting in seven main categories of underserved survivors: Ethnic and cultural minorities, Disabilities, Financial vulnerability, Sexual and gender minorities, Mental health conditions, Problematic substance use, and Older age. Barriers encountered by survivors with these characteristics included limited access to formal supports and insufficient training and awareness among service providers about how to best support survivors. Conclusions: Recommendations include the need for more survivor-centred, culturally appropriate and trauma-informed services and more attention to survivors belonging to underserved groups in policy, practice and research.

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

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.

Providing trans-affirming care for sexual assault survivors: An evaluation of a novel curriculum for forensic nurses

BACKGROUND

Transgender (trans) persons experience high rates of sexual victimization, often face discrimination by healthcare providers, and may have unique and diverse needs post-victimization. However, there remains a lack of comprehensive trans-specific training among healthcare professionals, including nurses.

OBJECTIVES

Our primary objective was to develop and evaluate a novel curriculum for its efficacy in improving the competence of forensic nurses in providing sensitive, informed, and appropriate healthcare services for trans survivors of sexual assault.

METHODS

The curriculum was evaluated among forensic nurses working in sexual assault treatment centres across Ontario, Canada. Forty-seven nurses participated in this study, all of whom were selected by their respective programs to receive in-depth formal Sexual Assault Nurse Examiner training. Changes in participants' perceived expertise and competence in providing trans-affirming care were assessed on a 5-point Likert scale (5 being the highest level) using pre- and post-training questionnaires. Participants were asked to indicate their level of agreement with 31 competency-based statements, which were organized thematically into four domains: Initial Assessment, Medical Care, Forensic Examination, and Discharge and Referral. A clinical vignette assessed participants' demonstrated competence in providing care across four questions.

RESULTS

Participants level of expertise improved significantly from pre- to post-training (Mean [M] = 1.89, Standard Deviation [SD] = 0.84 vs. M = 3.47, SD = 0.62, p< 001), as well as their competence across all content domains: initial assessment (M = 3.79, SD = 0.63 vs. M = 4.70, SD = 0.31, p < .001), medical care (M = 3.33, SD = 0.73 vs. M = 4.69, SD = 0.33, p < .001), forensic examination (M = 3.40, SD = 0.75 vs. M = 4.72, SD = 0.35, p < .001), and discharge and referral (M = 3.62, SD = 0.80 vs. M = 4.59, SD = 0.40, p < .001). There were also significant improvements in competence associated with the clinical vignette pre- to post- training (M score = 2.13, SD = 1.06 vs. M score = 3.23, SD = 0.87, p < .001).

CONCLUSIONS

The success of this curriculum may have relevance to the more than 5000 members of the International Association of Forensic Nurses who practice and support forensic nursing across the globe, as well as to other healthcare professionals.

Intimate Partner Violence in Transgender Populations: Systematic Review and Meta-analysis of Prevalence and Correlates

Background: Transgender individuals experience unique vulnerabilities to intimate partner violence (IPV) and may experience a disproportionate IPV burden compared with cisgender (nontransgender) individuals.Objectives: To systematically review the quantitative literature on prevalence and correlates of IPV in transgender populations.Search Methods: Authors searched research databases (PubMed, CINAHL), gray literature (Google), journal tables of contents, and conference abstracts, and consulted experts in the field. Authors were contacted with data requests in cases in which transgender participants were enrolled in a study, but no disaggregated statistics were provided for this population.Selection Criteria: We included all quantitative literature published before July 2019 on prevalence and correlates of IPV victimization, perpetration, or service utilization in transgender populations. There were no restrictions by sample size, year, or location.Data Collection and Analysis: Two independent reviewers conducted screening. One reviewer conducted extraction by using a structured database, and a second reviewer checked for mistakes or omissions. We used random-effects meta-analyses to calculate relative risks (RRs) comparing the prevalence of IPV in transgender individuals and cisgender individuals in studies in which both transgender and cisgender individuals were enrolled. We also used meta-analysis to compare IPV prevalence in assigned-female-sex-at-birth and assigned-male-sex-at-birth transgender individuals and to compare physical IPV prevalence between nonbinary and binary transgender individuals in studies that enrolled both groups.Main Results: We identified 85 articles from 74 unique data sets (n_total = 49 966 transgender participants). Across studies reporting it, the median lifetime prevalence of physical IPV was 37.5%, lifetime sexual IPV was 25.0%, past-year physical IPV was 16.7%, and past-year sexual IPV was 10.8% among transgender individuals. Compared with cisgender individuals, transgender individuals were 1.7 times more likely to experience any IPV (RR = 1.66; 95% confidence interval [CI] = 1.36, 2.03), 2.2 times more likely to experience physical IPV (RR = 2.19; 95% CI = 1.66, 2.88), and 2.5 times more likely to experience sexual IPV (RR = 2.46; 95% CI = 1.64, 3.69). Disparities persisted when comparing to cisgender women specifically. There was no significant difference in any IPV, physical IPV, or sexual IPV prevalence between assigned-female-sex-at-birth and assigned-male-sex-at-birth individuals, nor in physical IPV prevalence between binary- and nonbinary-identified transgender individuals. IPV victimization was associated with sexual risk, substance use, and mental health burden in transgender populations.Authors' Conclusions: Transgender individuals experience a dramatically higher prevalence of IPV victimization compared with cisgender individuals, regardless of sex assigned at birth. IPV prevalence estimates are comparably high for assigned-male-sex-at-birth and assigned-female-sex-at-birth transgender individuals, and for binary and nonbinary transgender individuals, though more research is needed.Public Health Implications: Evidence-based interventions are urgently needed to prevent and address IPV in this high-risk population with unique needs. Lack of legal protections against discrimination in employment, housing, and social services likely foster vulnerability to IPV. Transgender individuals should be explicitly included in US Preventive Services Task Force recommendations promoting IPV screening in primary care settings. Interventions at the policy level as well as the interpersonal and individual level are urgently needed to address epidemic levels of IPV in this marginalized, high-risk population.