Forensic Exams with Transgender Sexual Assault Survivors


>>michael: Good afternoon everybody. This
is michael munson with FORGE, and I am here today to get us started on the medical and
forensic considerations in caring for transgender sexual assault survivors. I’m really thrilled
that we have two guest speakers today, Kim Day from National Association of Forensic
Nurses, and Eric Stiles from the National Sexual Violence Resource Center. As always,
we have a very full 90 minutes full of lots of interesting information, and we’re really
excited to get going today. I wanted to briefly mention and acknowledge that we’re definitely
not going to be covering Trans 101 issues, and we have many pre-recorded Trans 101 webinars
on our website. So I encourage you, if you need or would like some of those core concept
reviews, to check out our website and review those webinars on Trans 101 issues. So today
we’ll really be focused on forensic exams, and a little bit more of a 201 discussion.
[pause] So many of you that have been on our webinars
before, or seen one of our workshops at conferences, have seen this slide and this image. I just
want to remind everybody that it’s really important that we take care of ourselves,
and so if the content or discussion is painful or difficult, that I encourage you to step
away or do whatever you need to do. We will be recording this, we are recording it, so
you can come back and listen to it at a later time, if that’s better for you to do so.
A question that we get frequently is around if we’re sending out PowerPoint slides afterwards.
We will be sending those out tomorrow, and we’ll be sending it out with a link to the
archived recording, so that you can share the link, or rewatch, or do whatever you’d
like with that archived recording. We’ll have a couple of moments of interaction today
and let me just show you a screen that will help you do that. So if you would like to
ask questions today, or in any way interact with us, Loree Cook-Daniels, FORGE’s other
staff person, is going to be the predominant person that is addressing questions and monitoring
things. So please use that question box for those questions that you have.
We are grateful that this webinar, and all of them in our series, are supported by the
Office on Violence Against Women, and we’re really pleased that they value this content
and we can provide it to you for free. So let me tell you a little bit about who’s
who. As I mentioned, we have two really great presenters today. The first one’s going
to be Kim Day with IAFN, and she’s going to start us off with some really great content.
Eric Stiles is going to come in later in our conversation today, and he is from the National
Sexual Violence Resource Center. Again, I am michael munson with FORGE, and the other
person that you won’t hear very much of today is Loree Cook-Daniels, also with FORGE.
So again, she’ll be handling most of the behind-the-scenes questions, and you’ll
hear more from her at the end of our time today.
So let me review our agenda really briefly. I’m going to spend just a couple of minutes
reviewing some trans basics and making sure that we’re all on the same page around what
population we’re talking about. I will have just a couple of slides on sexual violence
data related to trans folks. And then we’ll turn things over to Kim, who will talk about
the National Protocol and some trans-specific implications with working with trans survivors
and forensic exams. We’ll have a little bit of time then for question and answers
for Kim, right between her section, and then when we move on to a reframing section. So
I’ll kind of recap a lot of what Kim talks about from a slightly different angle. And
then Eric will give us two case examples that will really reinforce all of the content that
Kim and I both talk about, and kind of put it in a way that’s really approachable and
really personal. And we’ll end with some reminders and an additional time for questions.
So I wanted to offer a couple of caveats around language, and we’re going to be spending
a substantial amount of time today discussing bodies, specifically parts of the body that
are often gendered for most people. So all of us, Kim and Eric and I, will likely use
different language as we discuss some of the same parts of the body or some of the same
concepts. So I’ve created this graphic, just to kind of help remind us that we have
medical language that’s going to be really important to use and understand by other medical
staff, or by lawyers, or other legal system people. And there’s also cultural language
terms that are more commonly used within trans communities to refer to specific body parts
or identities, and although there’s no universal consensus on language, you know, we need to
keep in mind that it’s extremely diverse and very plentiful. The third gear of this
graphic is what I’ve labeled “Trans-reflective”, and in an ideal world, providers can reflect
the language of their clients without inserting language that is from a trans cultural lexicon
or from medical terminology. The reality is that we probably need to have kind of a hybrid
of both, you know, more than one of these types of language in our verbal and written
language use, when we’re working with trans or gender non-conforming clients. So please
note today that you will likely hear more medical language than the other forms of language,
and if we have time, we can talk about some of those other language uses at the end.
The other caveat that I wanted to offer today is that normally on webinars and trainings
when we talk about trans issues, we’re not talking about bodies, we’re not talking
about genitals, we’re not talking about some of those very specific bodily realities.
But today because of the nature of what we’re talking about, we are going to be talking
about bodies in specific ways and specific language. So I’ve kind of given it the R
rating, but it’s definitely not really R rated, but it’s just different than what
we’d normally be doing. So before I hand things over to Kim, I wanted
to just give us a brief review of who we’re including when we’re talking about trans
people. So, many times people have very specific ideas
of who’s included when they hear the word “transgender”. When we’re using the
word “transgender”, we’re talking about who’s included under this very broad spectrum
of people. We’re including a lot of people. So we’re including folks who are gender
non-conforming, or people who may, intentionally or not, blur stereotypical cultural lines
of binary gender. We’re including people who transition from one gender to another.
We’re including people who are questioning their gender, or who may not feel like the
gender they were assigned at birth fits who they are right now. We’re including people
who don’t fit the binary, people who may identify with a gender other than male and
female. We’re also including people who are multiply gendered, or who may live parts
of their life in one gender and another part of their life in another gender, or people
who may identify as more than one gender. And we’re also including SOFFAs, or Significant
Others, Friends, Family, and Allies. So we’re including this really wide range of people
when we’re talking about transgender people or communities today.
I wanted to remind folks, too, that when we’re talking about trans folks, we’re talking
about people who might be on a masculine spectrum, who might have been assigned female at birth
and are moving in a more masculine direction. We’re including people who were assigned
male at birth and who are moving in a more feminine direction. And there’s this large
kind of group in the middle that may not identify with masculine or feminine, may not be moving
in any direction, and may have a really fluid identity or expression of their gender outwardly.
So I just would like us to keep in mind that we may see clients that are, you know, very
clearly male or very clearly female, who have transitioned, and we also have a lot of clients
that are going to be in that non-binary or that genderfluid or the gender non-conforming
area. So a couple of reminders around trans bodies
and trans people’s journeys. Not everybody wants to use hormones. There’s a large number
of trans people who can’t afford hormones, or they may not want to use hormones for a
variety of reasons, many many reasons. Similarly, not everybody has had or would like to have
surgery of any kind, so similar to hormones, you know, not everybody wants to, not everybody
can afford to, and those are very complicated and difficult discussions to have, and, you
know, some of our other trainings definitely have looked at those two areas of what people
want and how they have access or don’t have access. Not everybody is uncomfortable with
their body, so sometimes we think that trans people must automatically be uncomfortable
with their body. Contrary to some popular myths, you know, some trans people are very
comfortable in their bodies. We also have to remember that of course some people are
not comfortable in their bodies, as well. Some trans bodies are very different from
non-trans bodies. And some are not. And another reminder is that there might be service implications
around trans bodies. You’re going to hear a lot more today about this specific point,
about how we may need to use different strategies, or there might be different risks, both medical
risks and emotional risks, and there might be different tools that might be used in working
with trans survivors of sexual assault. So those are a couple of reminders around trans
bodies and trans journeys. And at the end of the section, I just wanted
to show this image that will soon be up on your screen, which is from the Trans 100 from
the year 2013, and it’s just a sampling of the diversity of what trans people look
like and who trans people are, and just this wonderful mosaic of trans people.
So again, I’d like to just cover a couple of data points, couple of statistics, before
Kim really starts talking about the details around forensic exams.
So one of the questions that we’re asked a lot is about the prevalence of sexual violence
within trans communities, and we don’t have really firm answers, but there’s been a
lot of research that’s been done, and there’s an estimate that it’s between 50 and 66%
of trans people have experienced sexual violence at some point in their life. A lot of times,
trans people experience sexual violence more than once in their life, sometimes when they’re
children, sometimes when they’re adults, sometimes both. We don’t really know the
exact numbers, but we’re pretty certain that it’s 50% or higher for trans people.
This number is pretty easily compared to some common rates that we normally hear about,
where it’s 1 in 3 girls or 1 in 6 boys, or women or men. So it’s definitely higher,
and there’s some implications around that. We will talk a little bit about that today.
The other piece of data that I wanted to share with you is something that we found in a survey
that we did in 2004-2005, and we asked people if gender was a contributing factor to their
sexual violence. And of course, when we asked that question, it’s from their perspective.
What was their perception of what happened, and what caused it? And as you can see on
the screen, 43% of respondents said that gender was a contributing factor in their sexual
assault. So a lot of trans people really have this linkage between who the core part of
who they are is, as a gendered person, relates to this violence that’s happened against
them. So I think that’s important to keep in mind, when we look at, how are people healing
from sexual violence? How are they conceptualizing what happened to them? How safe do they feel
walking around in the world? A couple other points on that interaction between who trans
people are and sexual violence is that a lot of times we see things like cutting or disfigurement
happen in conjunction with sexual violence, so we’re seeing sexual violence plus other
forms of violence happening as well. If we look at it from a slightly different way,
when we’re looking at what has happened to trans people who have been murdered, a
lot of times we see that there was sexual violence that happened prior to their murder.
So there’s definitely a linkage between excessive force and different types of violence
and sexual assault within trans communities and trans people.
So that’s all the data that we’re going to cover for this time, because we have a
lot of other things that we’d like to spend our time talking about. I did want to just
kind of point you in the direction of some of the other webinars that we’ve hosted
in the past that would give you a lot more data, if you’re interested in the data and
interested in more of the practical how-to things in general. One is one that we did
quite a while ago, called “Trans Sexual Violence”, and you’ll find it–if you
can see the screen, it will show you how to find those recorded webinars. Another webinar
that might be of particular interest is “Creating a Trans Welcoming Environment”. And the
third one that you might be interested in is “Anti-trans Violence in Prison”. So
all of those, and there’s many other ones that are on the website too. So there are
some places that you can start, if you’d like additional information on research and
data. So now is the more exciting piece, which is
our first guest speaker, Kim Day. So I’m really excited that we have her with us today,
and I’m just going to turn it over to you, Kim, and you can share a little bit about
IAFN and your role there and take us to the next section.
>>Kim: Thanks, michael. I’ll be happy to do that. Many of you who know me know that
this picture is pretty old, and I am totally grey now and have a few more wrinkles. I am
a nurse and work as the
Project Director of the SAFE Technical Assistance Project, which is an OVW-funded project that
provides technical assistance around the National Protocol for Sexual Assault Forensic Exams–Medical
Forensic Exams–of Adults and Adolescents. I’m also a forensic nurse examiner and was
seeing patients in a local SAFE program that I helped develop here in Maryland, and I’ve
been a nurse for over 35 years–that means I started when I was 5 [laughs]–but I’m
bringing my experience with patients who have been sexually assaulted in the National Protocol
to you today. And again, as michael mentioned, language–the language I will use is health
care oriented. For instance, I say “patient-centered” versus “victim-centered”. I’ll try to
remember to clarify if I come upon any terms that I’m using that you may not understand
or that you might not be familiar with, but if you’re wondering what a particular term
means and I don’t clarify, please chat in and ask me to explain that.
And, on the next slide, I also need to go to a thank-you to OVW because I also am an
OVW TA provider, and the disclaimer is that what I’m going to talk to you about today
is my own thoughts and recommendations, and not necessarily those of OVW.
So when I’m talking to you about the second edition of the National Protocol, which there’s
a picture up here, you also have a link on the FORGE website with a direct link to download
the protocol, and there were many revisions and changes in this year’s update, or last
year’s update, some of which were directly related to the care of transgender patients
who’d been victims of sexual assault. Caring for transgender patients in any capacity is
something that we actually rarely discuss in health care, and as a whole, which causes
huge disparities in access to care, and the medical forensic exam access is certainly
no different than that. When the revisions to the protocol were made, this issue was
acknowledged, and the results noted that the unique issues of transgender patients are
neglected in sexual assault response protocols as a whole. As I said, if the issue of trans
access to health care resources who are knowledgeable about their physical issues alone is something
that is rarely discussed in health care as a whole, is it any wonder that we’ve neglected
it in the wider sexual assault responder community? And as you heard michael talking about, the
incidence is really high in this group. So as you can imagine, it contributes and compounds
the victimization that’s happened in their past. And I would also go so far as to even
draw that they don’t get access to criminal justice outcomes because of that. So this
inclusion was really important for all the patients and the wider communities that we
serve as we try to broaden our scope and our net to be able to serve people who have long-term
health consequences from the sexual violence, as SANEs and as forensic nurses in general.
When we come to the next issue, I have a clip of someone with a maze–in a maze, because
as I think about what victims in general and what patients have to go through when they
come to us is just through so many barriers, because I think that a maze kind of pictures
well the issue of navigating medical services and advocacy and criminal justice for anyone,
and it’s difficult and troubling, and in the aftermath of a traumatic event like sexual
assault, it can just be just absolutely overwhelming. The myriad of people that the patient has
to interact with, and all the issues going on around them and in them, coupled with the
fact that when we’re working with transgender survivors, we as providers may be unfamiliar,
and as nurses and advocates, well, you can understand that all of these combined together
can contribute to further trauma for the transgender patient, which is really what we want to avoid.
So you were–so you may ask, “Well, what difference is there from any other victim?
They all have multiple people to interact with, and isn’t it confusing for anyone
who’s been a victim?” Well, I just want to point out, there’s some very unique needs
that transgender victims have when you’re considering how to provide care. And so just
a few of those needs are: Differences in body configuration. And as michael said, there’s
already high degrees of not just one victimization, but sometimes polyvictimization. Also, many
have experienced discrimination and denial of services, including basic health care services.
For those of you who are ER-based, think of how many–of how they have been treated in
the past by the systems that are supposed to be helping them, and even possible abuse
from other providers, including health care providers. For this reason and more–these
reasons–it’s critical for the medical forensic exam settings and the clinicians providing
care that we be culturally aware of trans-specific differences in order to provide sensitive
and effective services, which we’ll be talking about in the next slide. [pause]
This is kind of a wheel picture–and I guess michael and I both are on this kind of same
page with being real visual oriented–of victim centered care. And in the Protocol, and actually
on pages 32 to 42 of the Protocol, 10 pages are devoted to this, and we have a handout
on this. But it was with these things in mind that the second edition of the Protocol incorporated
the special population of transgender patients. On this slide, you see the caveats or principles
of victim centered care, or as we in the health care profession say, patient centered care,
that are emphasized in the Protocol. You can download the handout from the Web as well
as the Protocol. But I think it’s really important that we begin here, because it is
this focus, being victim centered–or being patient centered–that is central to the heart
of the Protocol. And it’s really–this section is a real wealth of information. Specifically
mentioned is: priority of care, privacy issues, adapting the exam, providing culturally responsive
care, offering victim services, accommodation for support and responders, using language
that the patient understands, and respecting the patient’s priorities (realizing they
may not be our own priorities), integration of procedures, safety for the patient, and
physical comfort and patient needs. In other words, it’s important to address the patient’s
fears and concerns that can affect their initial reaction to the assault, their post-assault
needs, their decisions that they make before, during, and after the exam process. It’s
really important to make–stop–don’t make assumptions about the patient, even the offenders
that have offended against them and the assault itself. Also, forms. Forms that we use during
the exam process and the discussion with the patient throughout the process should be framed
in a way that doesn’t assume that they are of a specific background or gender identity
or gender expression. What we see on the outside is not always what’s on the inside. And
we always need to ask questions, and actively listen to the patient’s concerns and their
circumstances, and tailor the exam process to address their specific needs and concerns.
So, [laughs] you could be saying, “Now what? What do I do?” So this might be you right
now, as some of us feel. For those of you who are the health care folks, you may be
spinning or scratching your head. But I want to assure you that first and foremost, the
first and foremost thing is something that you should be totally familiar with, and that’s
treating people with respect, dignity, and professionalism. Let them know that they are
believed and that you’re there to support them and provide them with all the alternatives
necessary if they choose to proceed with the exam. Some other suggestions, if you’re
still struggling: It’s critical not to show surprise, shock, dismay, or concern when you
are either told or inadvertently discover that the person is transgender. So keep the
shock down. Be especially careful about body language. I think, as forensic nurses, we’re
often told things that are kind of difficult to even wrap your brain around, and this is
no different than those other times. You need to control expressions of discomfort, surprise,
shock, or even embarrassment on your part, because it may be very upsetting to someone,
and they may worry that you’re making a judgement or assessment of themself or their
body. And you’ll lose–absolutely lose opportunities to establish rapport. We also need to understand
that transgender people have typically been subjected to other people’s curiosity, prejudice,
and, as michael said, violence. So keep in mind that the victims may be reluctant to
report the crime or consent to the exam, for many reasons, but for fear of being exposed,
or inappropriate questions, or even abusive treatment. If the victim does consent to an
exam, be especially careful to explain what you want to do and why, before each step.
And I’m surely hoping that we do this anyway with all of our patients, but specifically,
respect their right to decline any portion of the exam. Always refer to victims by their
preferred name and pronoun, even when speaking to others. And remember, on rare occasions,
a trans patient may be accompanied by someone who does not know their identity and history.
In these cases, you should ask the patient privately how they would like you to refer
to them in that patient–in that person’s presence. And this brings up an important
place to recall that patients should have the history-taking done in private, so that
they’ll be free to talk about what’s happened to them, and I think that we all need to consider
that, when we’re in some places where there are no private areas, that you need to find
one to be able to do your medical forensic history-taking.
So, an important reminder. And any patient who reports a sexual assault, remember, they
should be referred to health care. This is for advocacy, law enforcement, whoever’s
listening. There are long-term health consequences that a transgender person can have related
to sexual assault, and anyone, and they always should be referred to medical to prevent those
long-term health consequences that can be with them for the rest of their lives. And
another point here is the exam that we do, the medical forensic exam, is relative to
the anatomy that is present, rather than the perceived gender of the patient or affirmed
gender of the patient. Gender identity may include an internal sense of being male, female,
bigender, multigender, pangender, Two-Spirit, or any one of the more of hundreds of gender
identities. And I know that FORGE website has a research link–has a resource sheet
with a few of them–a few of the identity terms that people may use. Always refer to
and treat the patient socially as their preferred gender. Be aware that transgender individuals
may have increased shame or even dissociation from their body, and michael brought this
up a little bit ago. And some are not. So it’s individualized. But some do use non-standard
labels for body parts, and others are unable to discuss sex-related body parts. Reflect
the patient’s language when possible, and use alternative means of communication, such
as, you might be able to have the person draw or write down, if they can’t verbalize what’s
happened to them. Some transgender patients may have extreme discomfort with their bodies,
and may find elements of a physical exam traumatic. So the exam we are doing after a assault can
cause further trauma. And to avoid this type of trauma, it’s important to take your time
with the patient. Remember that establishing good rapport with any patient, especially
a sexual assault patient, is an essential component of the exam. It’s actually critical.
Allow the patient to establish the pace of the exam also, including frequent check-ins
with them throughout the exam process. And here is where it’s critical to have really
strong advocacy with you during the exam, because they often can be a gauge, when we’re
focused on collecting samples and swabs and setting up the room, the advocate can be critical
to letting you know that the patient needs some adjustment in the process.
So specifically we’re going to talk about some considerations in transmasculine patients.
Remember, exams should always be done with sensitivity to the patient’s affirmed gender.
Always address a male-identified patient with masculine pronouns and his preferred name,
even when undergoing a vaginal exam. So right here I’ve listed just basically four small
considerations that can be really large, and they’re very concerning for us as a forensic
examiner. Some of those–the first one is hormone changes, and you’re going to see
this in both the transmasculine and transfeminine patient, but you can see a range of development
in patients that may be undergoing hormone therapy. And I think we’ll point out that
some people choose to do this, and some people do not. So it’s important to note that not
all trans men will have chosen to undergo hormone therapy. However, if they do, they
may have had–they may have beard growth, clitoromegaly (which is an enlarged clitoris),
acne, and androgenic alopecia or hair loss. Those who have bound their breasts for numerous
years may have a rash or yeast infection at the skin under the breast. For those individuals
that are taking testosterone, they can have vaginal atrophy or shrinking of the vaginal
tissue, and the tissues become very un-elastic and fragile. Transgender men who still have
ovaries and a uterus can become pregnant, and this is a really important thing for us
to remember as examiners. If there’s a uterus and ovaries present, they can become pregnant,
even when they’re using testosterone, and many of them don’t realize that, and/or
have not been menstruating. They think if they’re not menstruating, they can’t become
pregnant. And they still could be menstruating, also. So recognizing that pregnancy is a possibility,
and offering and discussing in a really sensitive manner emergency contraception, is important
in this patient population. If the transgender male individual has not had a hysterectomy,
he’s still within childbearing years, and the nature of the assault suggests that the
possibility of pregnancy should be discussed, even if he has not had a period. So emergency
contraception, again, should be offered, and that is a really important concept. Trans
men may also have concerns about using emergency contraception, because they may believe that
any estrogen- or progesterone-based medication may undermine their masculinity. In this same
case, if the uterus and cervix are present, and this is the area of assault, a pelvic
exam should be part of the clinical assessment. I will say it “needs to be”, but remember,
as with any patient population, we always seek consent before we do any part of the
exam as we’re proceeding. Another point to make here is that the vagina, when it’s
exposed to testosterone, especially in doses and over time, becomes more fragile, and it
may sustain injury more readily than the vagina that’s not been exposed to this hormone,
and this also needs to be taken into consideration when preparing for the exam. For example,
you may need to use a smaller-sized speculum, and that may be necessary if the tissues are
atrophied and very fragile, which can often happen. Some of the surgical changes, if the
patient has had surgical intervention, you may see post-chest-surgery or mastectomy scar.
The patient may have scar tissue consistent with a particular type of procedure that was
done, including large nipples that may be present, or there maybe small grafted nipples,
depending upon the surgical technique used. As there are several different options that
may have been utilized for surgery on trans men, you may also find that they have had
a neo-phallus, which is created from the release of an augmented clitoris and looks much like
a small penis, or a grafted penis constructed by a phalloplasty which will be larger, comparable
to the adult-sized penis but more flaccid than the natal male, unless of course there
is a prosthetic implanted in the penis. Anticipate the need for specialty consultation. As you
can see, many patients may have had surgical procedures done, and they may need a specialty
surgeon to come in to see them if there’s damage to the structures. Individuals with
a masculine identity may also sustain additional physical and emotional damage when vaginally
assaulted, and if they’re undergoing surgical procedures, like in the process of having
surgery done, there may be a special need to have consultation done with specialty surgeon.
You should definitely be prepared for that as an examiner program by knowing which surgical
staff is prepared to care for these injuries, by gynecological staff or by plastic surgery,
and have them as on-call. It’s probably good to meet with them ahead of time and discuss
the possibilities, because you probably will find some in your area that are willing to
come in and have experience of this nature. Be sensitive to the evidentiary value of prosthetics
and patient choices. Now this is really an important point, because you may get the patient
coming in who uses prosthetic devices, and they can be very costly and difficult to replace,
and they probably don’t have more than one, and they also can be more vulnerable about
their prosthetics. They may not want to part with them, such as penile prosthetics and
breast binders. For this–for reasons of safety and/or cost, in cases where the prosthetic
may be of evidentiary value, we need to consider alternative ways to collect forensic samples,
such as swabbing the prosthetic and collecting samples from the surface of it, rather than
actually bagging it up and sending it with the kit. Make sure, if the patient declines
to have it sent, that we do think of alternative methods for collection of forensic samples.
Also remember that victims’ compensation funds may be available for purchasing new
items, and this may help with concerns that the patient may have about the cost–the replacement
cost–for these devices, these items. So as we move on to the trans woman patient,
similarly, we should also address them–the female identified patient–with female pronouns
and her preferred name. Some of the hormone changes that we also may see–again, this
is patient dependent, whether or not they’re using hormones–they may have feminine breast
shape and size, often with relatively underdeveloped nipples. The breast may appear fibrocystic
in nature if there have been silicone injections. And galactorrhea, or leaking from the breasts,
is sometimes seen in trans women with high prolactin hormone levels, and that’s another
hormone, especially those who are using breast pumps to stimulate development. Injected silicone
may be common, and physical assault that may be involved in assault can dislodge that silicone,
resulting in disfigurement, serious illness, or death, and we need to be aware of that,
and be observing those areas and documenting any injury. There may be minimal body hair
present, with variable facial hair, depending on the length of time they’re on hormones,
and they may have had manual hair removal such as electrolysis. If testicles are present,
they may be small and soft, with defects or hernias at the external anguinal ring area
that may be present due to the practice of tucking the testicles up near or into the
anguinal canal. So that would be another part of your evaluation, and also a part where
they could be injured. Some of the surgical changes that you may see in the trans woman
is a surgically constructed vagina, which is generally created from the skin of the
inverted penis, and it will be less resilient than the typical vagina, which stretches,
and as we all know, that usually it can stretch to have a child come out, so very stretchy,
and the surgically constructed one may not be–will not be–as well as, it’s not as
deep. Using a shorter-billed or smaller speculum is probably going to be necessary, and should
be considered before you set up for your exam. You need to have your supplies ready. Also,
because of those factors, there is also an increased likelihood of tearing and other
physical damage during an assault, which, again, should raise our suspicion, because
it raises the risk of HIV and STIs. And trans women may place substantial emotional and
financial value on their vaginas, and therefore be especially distraught if it is assaulted
and/or damaged. So, again, this may anticipate a need for specialty consultation. You may
have to call a surgeon in. The surgical construction may also require specialty consult if the
surface of the vagina is damaged. The walls may be thinner and may be perforated more
easily. Be prepared for that, knowing which surgical staff, again, is capable of caring
for these injuries. Sometimes they may need to consult with their primary surgeon who’s
done the original procedure. And again, here we come to the sensitive evidentiary value
of prosthetics and patient choices. As with trans men, a trans woman patient may be more
vulnerable to safety concerns if they leave things like breasts or wigs or breastforms
as evidence, since these items are often essential to publicly presenting as female. When possible,
make sure that the trans woman has access to makeup and other items that will help them
leave the facility presenting their gender in a way that will make them feel safe and
create to the highest level of safety possible. As you all know, documentation is an essential
component of the exam, and includes both the written and photographic record of the patient
encounter. Here are some specific recommendations–there are some specific recommendations for forms
and body maps in the second edition of the Protocol. And you have a picture of the form
up here, and you have a download on the FORGE website and on the SAFEta website for you
to download and use. In terms of written documentation, I love the additional information given on
the handout from FORGE that includes informing the patient if you are using gender-conforming
body maps, because your program uses them, or your kit has that type of form, keep in
mind the concept of “know and tell why”, to let the patient know that you’re not
disrespecting their gender by using a particular form. Let them know why you used the form
that you did, affirming that it’s because you want to best record their injuries from
the assault. When using photography to document, be sure to be sensitive as you do for all
patients. First, obtain consent for each photograph that you need, verbally, and allowing the
patient to decline. You need to recognize that many trans patients have had bad experiences
in the health care in general, and I know I’ve said that a couple times, but I can’t
emphasize it enough. We don’t want to cause further trauma. Being sensitive to explain
the necessity of all photographic documentation is important, keeping the “know and tell
why” in mind in this portion of the documentation also. Another component when we are discussing
documentation is to recognize that some transgender people, as well as other populations we see,
may engage in self-harm or cutting as a coping mechanism, and I think we often see this in
teen populations, of any patient population. However, recognize that cutting and genital
mutilation are also frequently a part of anti-transgender hate crimes. With this in mind, it is important
to remain non-judgemental and careful not to make assumptions when documenting any scars
or even new injuries. I always ask the patient, if I see evidence of cutting, if the scars
are recent or older. Most times, they share with you, if you’re not making any judgements,
if you’re just asking about them. If they are a component of the crime, it should also
be documented. So how can we make it better? What we want
to know is, how can we better serve the transgender patient? I thought this little girl with the
Bandaid was really good. How can we fix this? Well, there’s several things that we can
work on process-wise that might help, and this is where kind of the rubber meets the
road. Being victim centered. This is where we started and this is where we end up. This
may be something you have never even looked at, as a SANE program and as an individual,
and I’m always for seeking out new kind of information on how to do it better. One
of the great things about webinars like this is, they offer great resources for us to use
and practice. In fact, FORGE has created a fact sheet called “Know and Tell Why”,
which you can find on the website for more information on how to be more culturally sensitive,
including how to distinguish between appropriate and inappropriate questions. Because we’ve
all done it. We’ve all asked the wrong thing. And as soon as it comes out of your mouth,
you want to pull it back, but you can’t. Ensure safety. Some victims, including transgender
people, may also fear assault or belittlement by health care professionals’ and/or law
enforcement officials’ responses to their gender identity or expression and/or their
body, and this may be different. This may be some treatment they have suffered in the
past. And remember that. Treat the knowledge that the person is transgender as protected
medical information, subject to all confidentiality and privacy rules. Really important, especially
remembering the companion of the patient may not even know their identity or orientation
or sexual orientation. Safety planning also includes assuring the patient has a safe place
to go. We know that as SANEs, but we need to make sure there’s a safety plan in place
for all patients, and there also should be some sort of evaluation for suicidal ideation
prior to discharge with every single patient. I hope that you all are doing that. Forms
and body maps. We already spoke about this some. But take an opportunity, this is a great
opportunity to look at your intake forms and process, as well as your other documents that
you use that ask about gender or sex. They should allow patients to write in a response,
or include transgender and intersex options. Make sure the questions appropriately distinguish
between sexual orientation–which is the gender someone is attracted to, gender identity–the
internal sense of being a man, woman or gender non-conforming, and their sex. And discharge
planning. Some victims may want to talk about their perceptions of the role that their gender
identity may have played in making them vulnerable to an assault. Because of their value in possible
prosecutions under anti-hate-crime laws, documenting what they say may be helpful for them. Otherwise,
listen to their concerns as they’re discharged. Assure them it was not their fault that they
were sexually assaulted. If needed, encourage follow-up discussion with counseling and advocacy.
We do this with all of our patients. Encourage follow-up with counseling and advocacy on
this issue. And another way to assure that you’re meeting the needs of these patients
is to include opportunities for trans patients to influence the development–include the
patients to influence the development of sensitive responses for sexual assault. And referrals.
We’ve been talking about referrals throughout this; referrals for surgery, referrals to
advocates. Ensure that the referrals that you give the victim, that they’ve been trained
or have experience with the special needs of transgender survivors of sexual assault.
Recognize that you may have to connect with the patient’s primary MD or primary physician
for a consult, with permission, or with the surgeon who’s working with the patient.
If there are referrals that need to be made to caregivers that are not familiar with the
patient, then remember that some transgender people may want your assistance in sharing
their status with other providers. Or some may not. It’s just individual, according
to the patient.>>Loree: Kim, this is Loree Cook-Daniels.
I have a quick question for you.>>Kim: Sure.
>>Loree: Someone has asked about the interaction between testosterone, and estrogen or progesterone
hormones that are used for next-day contraception. I’m thinking we don’t actually know how
they work together because we don’t have enough experience. But do you have a comment?
Do you know more than I do?>>Kim: I’m going to say that if it’s
a one-time dose of emergency contraception, they’re not going to be on it long-term
like they may be on the testosterone, it should not affect a one-time dose. It’s not like
we’re putting them on estrogen for 30 days or 60 days. It’s the one-time dose of emergency
contraceptive.>>Loree: Thank you. michael?
>>Kim: Yep.>>michael: Well, Kim, thank you so much for
sharing all of that just incredibly dense information.
>>Kim: [laughs] Yeah, there’s a lot of stuff.
>>michael: [laughs] Yeah, there’s a lot of stuff, which is really really great. And
I know that you need to leave a little bit early. Do you have some time to answer any
additional questions that may come up right now, or….
>>Kim: I actually don’t right now–>>michael: Okay…
>>Kim: –but I’m happy to take email questions, and my email is right up on the slide, so
I will be happy to answer any questions that I can.
>>michael: That’s perfect. And so the people that are listening, we can–you can directly
write Kim, it sounds like? Or you can–>>Kim: Sure!
>>michael: –you can feed them through us, and we can send them off and, you know, maybe
share the answers with everybody, which would be probably more helpful to everybody that’s
attending, so–>>Kim: Great.
>>michael: Well, thank you very much–>>Kim: Happy to do that, yep.
>>michael: –thank you for being here. All right. I really appreciate the information
that you shared, and I know that this was really very valuable to so many of us who
are not as familiar with forensic exams, and these very specific things that you talked
about today, so thank you. [pause] We’re going to change pace a little bit, and I’m
hoping that Eric is on the line with us, and we’re going to skip ahead a little bit.
We had a little bit of content that we were going to share, and I think that Loree and
I will record it separately later, and then add that to the recordings that are available
online. So, Eric, are you on the line?>>Eric: Yes I am.
>>michael: Excellent. Let me just forward–>>Eric: Okay.
>>michael: Let me forward to your slide and–we’re really thrilled that you’re here with us
too, and I know you’re calling in remotely and I’m wondering if you could share a little
bit about who you are and who you work for and then lead us into the couple of case examples
that you’re going to share with us.>>Eric: Sure. Thank you, michael. My name’s
Eric Stiles. I work for the National Sexual Violence Resource Center and I’m the Rural
Project Specialist. And what that means is, I go around and I do a lot of training, TA–technical
assistance–around issues in rural communities, but I also work a lot with the LGBTQIAH communities
as well as men. Previously though, prior to this work, I worked as an advocate in a rural
community, and I just want to highlight that starting off working in a rural community,
individuals think that you can’t possibly have worked with trans community. That’s
not the case. Trans folks are throughout all the communities. So the two case studies I
have today, both are experiences I have had, that I’m going to shield as much detail
to keep everybody confidential, but I’d like to share them to give a little bit more
of the story behind what happens maybe after the fact of having sexual assault examinations
and it’s really important of how we interact with survivors really plays a role in their
well-being long-term. So, the first one that I’d like to talk
about is a young male–to actual sexual assault examination–contact–was referred to our
agency because they knew there was somebody there that could work with him, and he was
struggling with follow-up. So as Kim was talking about with having birth control, he had to
go to an OB/GYN for follow-up to take care of what had taken place at the assault, to
make sure that rips and tears were taken care of. But a lot of our job as advocates was
working with the post-OB/GYN visit and pre-OB/GYN visit because there was a lot of shame and
guilt and confusion over gender, meaning that he felt that his gender had let him down;
if he was more masculine, if he could pass better, he wouldn’t have been assaulted,
and that his own body parts betrayed him, because now he’s going to an OB/GYN, and
so highlighting the body parts that he felt were not true to his being who he was. So
my job as an advocate really got pushed beyond that initial, “Oh, let’s go to an OB/GYN,”
but also having session to help wrap up before he could go back in the community and socialize
and interact. He felt like the way that he was perceived in the community was too feminine,
so he was really concerned about his gender identity, and sexual violence took that to
the core of his being, and going to the sexual assault examination, as Kim mentioned, can
be a very traumatizing experience in itself for highlighting those aspects of–that he
did not feel were appropriate and aligned with his gender. So that’s the first one.
And I know we’re in a place where we’re kind of tight on time, so I’ll go into the
second one real quick, and then we’ll have some time for questions. And the second one
deals with–this is years down the road. A female was–I’m sorry–coming in because
they were assaulted previously, they were drinking, they believed that something maybe
was put in their drink when the assault took place, and when they came to after being beat
up–also in the assault, the sexual violence assault–they came to without a wig on, without
any bra, and they felt completely naked, and they were just–she was just totally mortified
that he or she woke up not feeling like herself, and then she had to walk out, and she felt
like she was this big joke, and that no one took her seriously, and that was years and
years after this took place that I was meeting with her. So a lot of our time spent together
was working on how to deal with all of that trauma that took place in that actual examination
after the assault, because everything was taken, and they kept referring to her as male.
She felt very stripped down, very alone in the world, and [coughs] it consequently caused
a lot of problems for her down the road, because she felt she couldn’t pass before, she felt
like she can’t pass now, and having all those things taken away from her that made
it so that in her mind she felt like she would be expressed as herself as a woman, that really
made her journey to healing a lot more traumatic for her. So I address to you about both those
examples, but the key point to them, for advocates on the phone right now on this webinar, and
anyone working with survivors, is really slowing down and being present for everybody and being
in the moment. So being with the individual survivor in the moment and hearing what their
needs are, and seeing them for their needs, and not kind of conforming to some sort of
form, conforming to the stated protocol. And like Kim said, being very sensitive to the
idea of how we address ourselves and how we make our appearances is extremely important,
and taking away those things that make us a whole person can really cause problems for
how much trauma we’ve received from that examination. So really being present and listening,
and seeking their guidance. With both survivors, I asked them what’s worked for them in the
past, and I asked them how they’ve gotten through it, because they both had a lot of
resiliency, but I also asked them what type of support they needed. And at times they
didn’t know, so I just stayed around, and hearing my language now is “I just stayed
around”, I listened, I made times with them, until they came up with what they did need.
So they might need more time going to the visit for OB/GYN and speaking with me afterwards,
or they might need longer sessions because it’s the anniversary date of the hospital
coming in. So, really taking into account every individual for where they’re at. And,
michael, I know you might have some questions, but I think I made it in time for us.
>>michael: You made it in super time! You could have taken a little bit more time, and
I’m wondering if we could have–>>Eric: [laughs] Okay.
>>michael: –we could have a little bit of a dialogue about it, because I think that
these two cases are really–they’re really great examples of what people might be experiencing
and what providers may, you know, see in their everyday work when a trans client is coming
in. And, you know, I know you spoke at the end about that process of just–not just listening,
but–listening, just, you know, spending time listening to what’s going on, and I’m
wondering if you want to talk a little bit more about that in reference to both of these
cases, or in other situations that you may want to share.
>>Eric: Yeah. I will definitely–we can talk about both these cases, but in general as
well. The first thing I think it takes to listen is “thoughts make assumptions”.
Especially the communities that I’ve worked in, individuals have a variety of experience
of their gender expression, and also a lot of it came down to money. So if there’s
sexual violence that took place–so both individuals were not going through surgery, both individuals
were not transitioning, they were considering themselves and they do consider themselves
to be the gender they express–so to listen to someone’s story when they’re–when
you have an outside culture that is surrounding them, kind of telling them they’re wrong,
the hospital treats them like a different gender, really takes some balancing act, because
now we’re listening at one part, but also kind of advocating in the second part. So
when they express to you, “Refer to me as male,” you refer to them as male, of course,
but when you go out into the community or you talk to an OB/GYN, and you’re helping
them and you’re advocating, it’s taking that with you. And that one step that seemed
natural at the moment for me, for example with the first individual, by telling the
nurse or the OB/GYN center that his name is X, really meant a lot because it meant I listened,
and I didn’t even take into account how much that meant to the survivor, but the survivor
appreciated that I listened enough to take into account the pronouns being used and referring
to him as who he was. So, we need to slow down, listen, and really take what they say
to heart. And what that means is being attentive, and not looking for the right answer. There
were lots of times I wanted to fix things, meaning, the second individual, when she would
talk about how she was treated in the community and ridiculed and treated as she wasn’t
a woman, I wanted to fix it. I wanted to go out and do all these things to change, but
I couldn’t. But what I could do was be there in the moment and hear what she was expressing
to get her feelings behind it. Part of that active listening with individuals from any
community is, you have to take your time. It really is against my nature to rush through
things like this, like this webinar, but in the moment with these survivors, you need
to make that time, and working with trans survivors, sometimes that time takes longer.
I did not hear the story from the second individual–I did not hear from her the complete story of
what happened to her in the hospital years before until maybe 3 or 4 months, 5 months,
into working with her, and then she expressed it because she needed to have that time for
herself to figure out how to communicate with me. And there were missteps on my part, too,
as well, that I did not necessarily think about. So it’s a combination of offering
time, but also just being very, “Well, you make mistakes.” And one of my mistakes with
her–in my communication, I should say, not “with her”–in our communication was when
she expressed very early on that the sexual assault examination that she went through–the
“trip to the ER”, as she put it–was very traumatic. I didn’t pick up on how traumatic,
because I didn’t ask. I just let it go. I was like, “Okay, I understand that,”
and in my mind I understood that, so I thought I understood, so I didn’t ask any more questions
or be supportive of that. So it took months to come back around to that, for her to find
her space to bring that up.>>michael: Yeah, that makes a lot of sense.
And, you know, you kind of brought up some points that we continually kind of remind
providers around, about, with being patient and persistent and compassionate. And sometimes
I think trans survivors really need–I don’t want to say more patience than other people
do, but sometimes there’s a history of mistrust, and an uncertainty of how people are going
to respond, so it takes a little while for those stories to come out, and it sounds like
that’s what was happening with the second case, for you.
>>Eric: Yes. And it takes–I don’t think that trans survivors need more patience from
us. In my mind, I framed it over time as, it takes a very lot of–it takes a lot of
patience for us to overcome the damage done by society.
>>michael: Yes.>>Eric: It’s not them that need it. It’s
the damage that’s done that needs it. So there’s a lot more space that we need to
create in our environments for them to have a space space, because so much space has been
taken from them in the communities they live in. So, it takes more time to build that space,
and it takes more time to build all of that, and it’s not because of them individually.
It’s because of what society has done, not because of them
>>michael: Exactly. Do you have some comments on how people can create that space?
>>Eric: One is very kind of fundamental space building, and that is, in our offices, of
course, having literature and information and being open and having trainings and receiving
things from something like FORGE, and other things on these concerns, starts creating
that culture and creating that change in your agency. But it doesn’t stop there. It has
to be communicated to your hospital, to law enforcement. So you now become the advocate
in the community before you ever see someone come in. And then beyond that is, when you
start creating that space and getting that time, being aware, if we’ve worked with
children, for example–and I’m not comparing trans people to children–but advocates kind
of get this niche, whether you’re adult survivors, or you’re working with children,
or you work with this community or that community, and we kind of get pigeonholed in that. But
working with trans survivors, they’re all different ages. So we have to look at it across
the life span. And we have to look at how does that play out its role, and how can we
create more time? So if we go out to a school with a trans individual who’s being sexually
harassed and bullied and has been sexually assaulted, what do we need to do to create
that space in that school, versus what do we need to do to create that space in the
hospital setting? And then, in ourselves, we need to have somebody to go to to debrief,
somebody to go to to bounce ideas off from, and we need to build a sense of real investment
in the community. It can’t be just lip service, like “here’s a specialized population
to work with”. We need to make real allies within the community, and have real conversations,
and at times those conversations can be very uncomfortable, because if you’re not from
the community, you’re going to hear really solid and concrete truths. So you make partnerships.
You find local agencies, whether that local agency is within the state, or a national
agency, to start building some focus groups and some conferences. But we don’t just
take from the community. We give back. And as individually and as an advocate, we prepare
ourselves to have the ability to be more trauma-focused in all of our work, not just with trans, but
to give ourselves time for each individual to have the time they need. So if they need
two hours, we give two hours. If they need an hour, we give them an hour. Does that answer
some of those questions for you, michael?>>michael: That’s perfect. That’s really
really perfect. I’m wondering if we should shift a little bit next to some take-home
reminders and just reminders for folks about what other things FORGE can offer people,
and then we’ll have some time for some questions. So, if people are thinking about questions,
feel free to type that in that question area, and Loree will sort through them. And, I think,
Eric, you and I are the only two left, and we’ll sort the other questions for Kim and
get those to her for her responses later on. So let me just bring us through a couple of
very very brief take-home reminders. One is, I wanted to make sure that folks know
what we, FORGE, can offer you, and a lot of you have seen this slide before if you’ve
been on our webinars, but we offer training and technical assistance for providers–victim
service providers–and some of what that involves is doing one-on-one support. We do an incredibly
high volume of one-on-one support. So you email us or call us with a question about
a trans client or a trans survivor or a situation that you’re thinking about, and we will
work through with you the best that we can to get to a solution that feels comfortable
and right for you and/or for your clients. We obviously offer webinars just like this
one every month, and we’re really pleased that we have really a wide variety of topics
that we’ve covered and that we will be covering, so please join us in the future on additional
webinars. May is going to be another guest speaker, Rebecca Dreke from the Stalking Resource
Center, so we’ll talk about stalking in May. We also provide trainings across the
country. I know Eric is training across the country, too, right now. And yeah, I really
enjoy traveling, and Loree enjoys traveling, and so we’re at many of the conferences
across the country and we’re pleased to do that. We also do some individualized trainings
when we’re asked to come places, so we do that when we can, and we’re able to. And
the other thing that we offer for providers is a variety of different publications. Kim
referenced a couple of them when she was speaking, and you can easily see them–when I send out
the follow-up, I’ll link to a couple of specific ones that you may be particularly
interested in. And then we also offer support directly to trans survivors, because a lot
of times, trans survivors don’t get access to the healing services that they need, because
they’re in places that don’t have a lot of trans support, or don’t have a lot of
providers with trans knowledge. So we have listservs that are 24/7 where people can connect
to other survivors and other loved ones. We do a lot of referrals, so if people don’t
know where to go or who to go to, and we can try to help get them connected in a place
that’s closer to them geographically to get the support that they need. We offer an
online Writing to Heal group, because a lot of times we’re finding that, trans survivors
are not able to access in-person support groups, so we’ve chosen to do Writing to Heal as
our type of support group for folks, and it’s a trauma-informed, writing based group, but
it’s all online, so anybody can access it from anywhere in the country if they have
access to a library or public computer or private computer. And the fourth thing that
we offer for survivors is a relatively new project called the Espavo Project, and the
two photos that you saw in the slides when Eric was talking are from the Espavo Project,
so they’re professionally-taken photographs of people who want to be involved in this
project, and the people are crafting statements of resilience, so it’s a really healing
process to have an image that they feel really proud of and really good about, and then craft
a statement that shows how they’ve survived and who they are as this current thriving
person. So that’s a little bit about what we can offer you.
So a couple of take-home reminders about assumptions, and Kim and Eric both talked about a lot of
these things, and so I’m just going to very quickly go through them, and we can do some
questions. So if you have assumptions, you know, check in with yourself about what gender-based
assumptions that you’re making, and try to leave them at home, or before you enter
that exam room or that office with somebody. Another reminder is something that I don’t
think we think about very often, but to celebrate the limitless ways that bodies can be configured.
We all have different bodies, and trans bodies are no different, in that, you know, we all
have different bodies, so let’s figure out how we can be celebratory and appreciative
of the differences in our bodies. Another reminder is to kind of keep calm and
be prepared. So we all need to be prepared to hear anything, and I know Kim specifically
talked about, a lot of times we hear really difficult information when we’re talking
with survivors, and when we’re talking with trans survivors, we may hear unexpected information.
So we need to be prepared, and not show our surprise even if we feel a little bit surprised.
Another reminder is to “know and tell why”, and I know Kim talked in much more detail
than I was expecting her to about “know and tell why”. So know why you need to ask
a question, and let your client or patient or survivor know why you’re asking, so they
don’t feel objectified or that they’re the object of your curiosity.
Another reminder is to think creatively to find workable solutions. So, you know, sometimes
people do not fit into the service systems that we have. And so if they don’t fit into
those, what can we figure out about how to help them get the service and the care and
the healing that they deserve and need? So sometimes that’s really tricky, and sometimes
it takes time, and sometimes it takes a lot of time. But I think that if we are patient
enough, and persistent enough, that we can end up getting to a place that will do something
to help the survivors that are in front of us.
And I think all of us really know this last slide very well, but, you know, I think that
it’s really important to empower our clients with respect and compassion and information
and choices. And, you know, I think that all of us who work with victims or survivors do
this, and I think sometimes it’s important just to have it be articulated and overtly
stated, you know, that we keep that empowerment as a primary focus when we work with clients.
And I think it’s especially true for trans people, who oftentimes feel disempowered,
and then when they’re sexually assaulted, they feel disempowered around that as well.
So those are the couple of take-home reminders, and I’d love to move on to questions, if,
Loree, you’ve collected some of them?>>Loree: Yes, I–
>>michael: Let’s do some questions.>>Loree: Yes, I have some questions. And
one that I think both of you may want to address, we’ve had two people say, “What else should
be in our kits at the–in our SANE kits to help things like with the wigs?” “…some things that people may want to add to their kits?”
>>michael: Eric, would you like to start with these? I’d like to probably have you
start with most of the questions.>>Eric: Okay, sure. Well, one thing you can
do is, I know there’s some advocates in Vermont that have caring carts where they
have different items that they can have at the hospital or have at their center ready
for individuals to use. So makeup, wigs, bindings, items they can put–give to the survivors
so they can help address how they look before they leave the hospital. I know it takes a
lot of communication to get a hospital around to–I know a lot of times–just to have rape
kits and extra clothing there, so having this come up seems like a burden, but it’s really
not. You can actually start pulling in, because some of these items don’t always go just
to transgender folks in your community, because I’ve had makeup used at our hospital for
individuals who aren’t from the trans community. I’ve had wigs used from people who aren’t;
I had a cancer survivor use a wig. So there are survivors–there are other purposes for
most of these items, that you can just put that stuff at the hospital for them there.
Or, you can have them at your agency that someone can stop by and take to the hospital
with them before going to the hospital accompanying them. The list–I would suggest–and michael,
maybe you would know the individual I’m thinking from Vermont. Maybe she has a concise
list. I think she actually does, if memory serves me right.
>>michael: That would be really great if she did. I don’t know that she does. I know
who you’re talking about, and I will contact her directly to see if she has a list. But
like you were saying, Eric, I think that there’s a lot of things that are used by non-trans
people as well, like wigs for people who have cancer. Things like ACE bandages can be used
for binding, but they can also be used for lots of other things. Or scarves to cover
heads. I mean, there’s lots of items that have dual purposes. I think, in particular,
things like larger-size clothing. A lot of trans women are larger sized, but there’s
a lot of larger-sized people who are not trans as well. So, you know, having some of those
items available, whether they’re on site or at somebody’s agency, is very useful.
We will try to–>>Loree: Thank you. Thank you. “How do
you balance the importance of getting the patient alone for the medical history with
their desire to be accompanied by their support person if they don’t want that person to
be sent out of the room? What are the patient’s rights regarding having other people present
with them during their medical visit?” [pause]>>Eric: Well, I know that in–I’ll speak
to Pennsylvania, and michael, I hope you can go to nationally, and I know something about
other states. Support people–I know that I sat behind curtains for survivors before.
I’ve had other individuals, like, their family support that they had there–and I
say “family” because they refer to them as family–that’s really important to take
into account what they signify others to mean–be there as well to show support for them, behind
curtains and in the room.>>michael: And we had some lovely noise in
there. Sorry about that. Did you have more to say, Eric? It was hard to hear with the
screeching.>>Eric: I think it’s a fire alarm in the
building. But it went off, so–no, that was it.
>>michael: And I just wanted to add a little bit to that. One of the things we recommend,
and I think others are starting to recommend as well, is it’s fairly–you can do a fairly
quick assessment of if somebody is accompanying with somebody who might be an abuser or to
just determine whether they are or not, or what the level of comfort is with that person,
and so that alone time can happen prior to the medical history, which a trans person
or anybody may want to have somebody present. So I heard what Kim said, and, you know, I
wish she was still on the call, because I think there’s some variation around when
it’s important for people to have somebody in the room with them, and I think, you know,
my primary concern tends to be around, we want to make sure that that other person,
the accompanying person, is not the abuser or not the perpetrator. Loree, are there other
questions?>>Loree: Yes. “Thank you for the case scenarios.
Really helpful advice. I am a rape crisis coordinator in an adolescent health center.
I refer adolescents for the forensic exams and for follow-up care. Are there specific
needs to trans youth versus trans adults?” [pause]
>>michael: Eric, you’re probably going to have a much better answer for that than
I will. [pause]>>Loree: I wonder if we just lost Eric.
>>michael: We may have. [pause] Well, let me start with the question, and
hopefully Eric will be able to get back on. So the question was around “are there specific
concerns or things to prepare for trans youth versus other youth?” Was that the question?
>>Loree: No. Trans youth versus trans adults.>>michael: Trans youth versus trans adults.
Yeah, I think one of the primary concerns is going to be is that trans youth–out to
their family? What are some of the legal challenges that they might be concerned about? They may
be worried about if their parents find out certain things. I think there’s a lot of
just privacy concerns that trans youth might be experiencing, that trans adults could better
take care of because they’re not dependent.>>Eric: This is–can you hear me now?
>>michael: Yes.>>Eric: Great. I’m sorry. Couple things
to think about is the age group of trans youth. So youth are very young. Often the parents
are very supportive, and they have identified that and can be around that. I’m not saying
often, but they–parents often support, and buy their children the clothing for the children,
so if they are below the age of 10, and this something has taken place, then parents might
be one of the strongest advocates. So taking into account, when the parents are there,
if they’re strong advocates, helping them with the process. Certainly with teens, like
michael said, there might be a disconnect between what parents know and don’t know
about their youth, and that becomes the problem now, of how they identify themselves, especially
after the assault, in the emergency room, especially if they are called in. In our state,
below a certain age, parents get called in, but they still might be [unclear] differently
from what their parents think they should be [unclear]. So taking all that into account,
the difference between youth and the adults would be really trying, as an advocate, to
establish where that relationship is, from the survivor, about the relationship to their
parents and support, and then going from there and taking their lead.
>>Loree: Thank you. I have another one. “I have heard from our SANE nurses that when
a trans individual does not reveal the bio parts, it is a waste of resources. For example,
doing a pregnancy test on a trans woman. What are some responses I can have to their comment
while advocating for the population in general?” [pause]
>>Eric: Oh. Okay. I’ve never been faced with that before, but off the top of my head,
something I would come up with is, “Pregnancy tests for a woman who might not be able to
conceive a child, would that be a wasted test?” and if the person says “No, because how
would they know?”, that’s the same difference as to what response that we give. How would
we know? We treat individuals for who they are coming in, and if they identify as. My
concern is about where that’s coming from, that question, if the nurses or the individuals,
doctors who are asking this question about wasting resources is coming from, like, a
bigoted place, and also what type of conversation are they having with the individuals that
come in that identify as trans but they don’t feel comfortable enough to share information,
if there’s something–that there’s a breakdown between the way they provide services.
>>Loree: Thank you, Eric. I have someone else here, saying, “I have advocated for
trans men and women. Since LEA and SANE were both very insensitive, I asked to speak to
my client first to ask permission to speak directly to LEA and SANE about how they were
treating my clients. One didn’t want me to, so we discussed the treatment they received
after. Eventually they gave me a release of info to speak with LEA and SANE. The other
client was okay with me advocating for them. After speaking–” I just turned my thing
off. [laughs] I am sorry, I have lost the question.
>>Eric: Okay.>>Loree: “After speaking to LEA….”
[pause] [sighs] I really dislike how these come up. I’m sorry. [pause]
>>michael: I’m looking for the question too, so…. [pause]
>>Loree: [sighs]>>michael: Loree, do you want to go to the
next one while I look to see if I can find the original that you were reading?
>>Loree: Okay. “I learned from our pharmacy that some drugs are dosed based on parameters
that take into account the patient’s biologic sex. Thankfully, none for sexual assault patients
directly, but maybe so if critical injury and admitted. How would hospitals handle that?
The gender is a field that registration handles on arrival.” [pause]
>>Eric: I don’t really have an answer for that. Do you, michael?
>>michael: I don’t, because I’m multitasking, so maybe Loree has an answer to that one.
[laughs]>>Loree: I think that when we start dealing
with the health care of transgender people and medical norms, there needs to be some
creative thinking about, what is it that the norms are set by? For instance, are they set
by the average weight of men versus women? Are they set by the testosterone present or
the estrogen present? We need to–we may need to go back a little bit and think about “why
are there differences?” in order to figure out what would be appropriate ways to handle
that difference with regard to a person who is transgender. [pause]
>>Eric: Thank you for that. [pause]>>michael: So I did find the original question,
which is talking about working with trans men and trans women and LEA and SANE, and
the last part of that question was, “After speaking to LEA and SANE, interview and exam
was more respectful and went a lot better. Is there any other way that this could have
been handled, the problem being LEA and SANEs don’t like being interrupted?” [pause]
>>Eric: I think that goes to, kind of–and this is kind of my mindset, michael, and maybe
you have different points–is kind of getting ahead of the curve with this. I think the
more we look at individuals as a whole being, and we know that there’s no cookie cutter
for any type of individuals, then that really pushes us as advocates to get out there and
ahead of the curve and really start advocating before we see a certain individual from a
certain community come in, includes those who are trans. Now I’m not saying we can
do that, like, before any trans people have come in, but before we are faced with that
in the ER. So we go out, we start talking to them about ways that we know. We can use
trainings, we can use resources from FORGE, definitely some from FORGE. Helping the law
enforcement and nurses slow down their practice, make room for more questions, like Kim said,
explain why they’re asking questions more, and really put that into practice. And through
doing that advocacy work prior to someone coming in and seeing them in that crisis moment,
you have more ability and resources and bridge to go back to them and say, “Well, this
is a time for us to take a break or slow down,” and that might mean something you work in
while you’re talking to these other agencies.>>michael: That’s a really great example–great
answer to that question. I’m really aware of our time, too, that we’ve got a couple
minutes left, and I believe that there are more questions that we will feed out and send
by email to people or post on the web and send you the link to those questions and answers,
because I’m hoping that Eric would be willing to participate in some more of those questions
offline, and I know Kim is as well.>>Eric: Sure.
>>michael: I wanted just to–yeah, good, thank you! [laughs] I was hoping that would
be the answer. I really wanted to just remind folks of a couple things that we mentioned
at the beginning. One is that we’ll be sending out the PowerPoints tomorrow. You’ll get
an email tomorrow. It’ll have link to the PowerPoints and a link to the recording of
today’s session. When the window closes today at the end of the webinar, there will
be a very short survey, and we really care about your feedback. It’s also another place
that you can ask questions, so feel to ask more questions in that brief survey, but we
really value your input, and we try to adjust our webinars to meet your needs better. Next
month’s topic is–I think I mentioned before–is on stalking, so May 8th, the webinar is already
open for registration, and I hope that you will consider joining us next month. Rebecca
Dreke with Stalking Resource Center will be online with us. And I really wanted to thank
Kim and Eric for being with us today and sharing their really amazing knowledge with us. It’s
really amazing to have guests, and guests who are so smart and bright and caring, so
thank you very much. And thank you everybody for attending, and caring about trans survivors
and how to work better with the trans community. So thank you everybody.
>>Eric: Thank you, michael, and thanks to FORGE for all the work that you do, and thanks
to all the advocates and nurses out there right now for all the work that you’re doing.
And just take it easy, take time, and be patient with yourself and do this work. It’s all
growing. Thanks again.>>michael: Thanks Eric.
>>Loree: Thank you.

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