Victim Issues

Transgender individuals may believe that they are not entitled to respectful medical care or that only some parts of their body deserve to be treated. Because of past discrimination in health care settings, they may feel that discussing their body is risky and makes them vulnerable. Embarrassment, shame, and apprehension may prevent transgender victims of sexual assault from revealing the extent of their injuries or lead them to refuse treatment. This may include being unwilling to have forensic evidence collected directly after an assault.

Internalized transphobia may also deter victims from seeking care because they fear disrobing for physical examinations. Remind these patients that they can undress to the level of their comfort and that they can wear gowns or be draped to feel less exposed and vulnerable, which will encourage them to return for additional care if needed. Also consider asking patients if they would like a nurse, certified nursing assistant, friend, partner, or another ally present during the exam (but see Companions as Abusers in this e-pub).

Treat transgender patients with the utmost respect and dignity, without commenting on or visibly reacting to the person's gender identity or body. As you would with any sexual assault victim, be gentle, respectful, patient, and dignified. No disgust or judgment should be shown, as patients are likely to internalize those responses as being about their gender identity, appearance, or behavior. Responsibility for the assault should be fully assigned to perpetrators, even if victims' behavior may have placed them in dangerous or risky situations.

If you treat transgender patients as part of their routine health care, be aware that transgender victims of sexual assault may forgo routine care or care of specific medical conditions after being assaulted. For example, it is common for people on the female-to-male spectrum to delay or avoid routine gynecologic care. If they have been sexually assaulted, they may avoid this form of medical care even more due to shame stemming from the assault. You may want to schedule longer appointment times for these patients to allow ample room for discussion, and proceed through the exam more slowly. Make sure not to "scold" patients or make them feel guilty if they are unwilling or unable to receive medically suggested treatment, testing, or care.

Patience and relationship building will increase trust and may gradually lead to patients who are more willing and able to receive more comprehensive care.

Treat transgender patients with the utmost respect and dignity, without commenting on or visibly reacting to the person’s identity or body. Because certain aspects of a sexual assault may feel more shaming than others, patients may well try to avoid discussing these components and may also resist care. As you would with any sexual assault victim, be gentle, respectful, patient, and dignified. No disgust or judgment should be shown, as patients are likely to internalize those responses as being about their gender identity, appearance, or behavior.

Internalized transphobia may result in transgender individuals resisting medical care, even if injuries are significant. They may also minimize the injuries they sustained. If this is the case, consider stressing that everyone deserves quality health care and the opportunity to pursue criminal justice options. Victims of sexual assault may be unaware of their options; you can help them understand the importance of receiving timely medical care.

Transgender individuals may believe that the sexual assault was their fault and may be hesitant or elusive or make statements that do not align with professional observations or experience. This reticence to share or the focus on other aspects of the assault are not necessarily signs of deception. For example, it may be clear that a victim has sustained an injury caused by another person, yet the transgender victim focuses on how they were at fault for wearing makeup or for walking down a specific street instead of describing the perpetrator or what happened. Although this line of thought is common in a wide range of sexual assault survivors, it may be more prevalent for transgender survivors.

Treat transgender victims with the utmost respect and dignity, without commenting on or visibly reacting to the person's identity or body. Because certain aspects of a sexual assault may feel more shaming than others, victims may well try to avoid discussing these components and may also be reluctant to file a police report or pursue evidence collection. As you would with any sexual assault victim, be gentle, respectful, patient, and dignified. No disgust or judgment should be shown, as victims are likely to internalize those responses as being about their gender identity, appearance, or behavior.

Internalized transphobia may result in transgender individuals resisting medical treatment, even if injuries are significant. They may also minimize the crime that occurred and be less willing to make a formal report to law enforcement. If a victim resists or hesitates to access medical care or a forensic examination, consider stressing that everyone deserves quality health care and the opportunity to pursue criminal justice options. Victims of sexual assault may be unaware of their options, so it is important for law enforcement officers to fully explain possible courses of action, including forensic examination, detailed reporting, access to sexual assault advocates, and other resources within the community. One of your overarching goals is to help victims regain control over what happens to them; respect and affirm their decisions of whether or not to seek care. You may encourage victims to pursue evidence collection and reporting, as long as you do so in a respectful way that does not pressure the victim.

Transgender individuals may believe that the sexual assault was their fault and may be hesitant or elusive or make statements that do not align with professional observations or experience. This reticence to share or the focus on other aspects of the assault are not necessarily signs of deception. For example, it may be clear that a victim has sustained an injury caused by another person, yet the transgender victim focuses on how they were at fault for wearing makeup or for walking down a specific street instead of describing the perpetrator or what happened. This line of thought is common in a wide range of survivors of sexual assault, but it may be more prevalent for transgender survivors.

Responsibility for the assault should be fully assigned to the perpetrator, regardless of the situation, location, or circumstances. Sexual assault is never the victim's fault; it was the perpetrator's choice to assault the victim. In the words of one transgender victim of sexual assault, initial responders could have helped the victim "to have realized that I was not to blame, and that I didn't 'ask for it' by being trans."¹

By modeling respect and compassion, you can help victims understand that they are not at fault and that they deserve respectful treatment.

Because certain aspects of a sexual assault may feel more shaming than others, victims may well try to avoid discussing these components and may also resist medical care. As you would with any sexual assault victim, be gentle, respectful, patient, and dignified.

If a victim resists medical care or hesitates to receive that care or a forensic examination, consider stressing that everyone deserves good health care, and offer to accompany the victim to the medical exam. Concurrently, one of your overarching goals is to help victims regain control over what happens to them, so it is also important to affirm their decisions of whether or not to seek care. (Do consider reminding them, however, that evidence collection is time-sensitive.)

As a result of internalized transphobia and shame, some transgender individuals are reticent to share information about their bodies, identities, or experiences, including sexual assault. You may need to address these layers of transgender-specific shame and self-blame before you can help clients begin healing from the assault; the healing process may be more prolonged as a result. Acknowledging clients’ small steps toward self-understanding and self-acceptance is key. Overall—

• Be patient. Do not “scold” transgender clients or make them feel guilty about the pace or progress of their therapeutic process.
• Reassure them that they are normal.
• Help them realize that what happened to them is not their fault.
• Remind them that other survivors feel the same types of emotions and have the same types of responses.

Shame is common in most sexual assault clients, regardless of their gender history. With transgender individuals, it may be difficult to determine the exact root of their shame. Understanding the complex relationship between shame and transgender identity is essential, but it is more important to listen carefully and empathically, reflect language and concepts, and assist transgender clients in lessening their feelings of shame and guilt. According to one FORGE survey respondent who was sexually abused by their therapist:

Shame has kept me silent all these years. This survey is one of the few times that I have discussed these events. No one wants to hear about this, because therapists are supposed to be God and cannot do any wrong.¹

If clients begin to blame themselves, remind them that they did not cause the assault. This may be especially difficult for transgender clients to believe. Many perpetrators frequently claim the client’s gender identity, expression, or non-congruence “caused” the assault. This can enhance clients’ preexisting anxieties and contribute to a heightened belief that the assault was their fault.

If possible, encourage clients to join transgender support groups or participate in organized transgender events, which can help them create a more positive self-image. That said, it is important to keep in mind that the transgender community is small and tightly knit, which may make them feel too exposed (everyone knows everyone) or may put clients in contact with their perpetrators within the transgender community. Assess clients’ comfort with their peers before steering them toward these options.

For more information on shame and its treatment, read Treating Survivors of Childhood Abuse: Psychotherapy for the Interrupted Life, by Marylene Cloitre, Lisa R. Cohen, and Karestan C. Koenen. One of their main recommendations is that therapists wait until late in treatment to tackle shame, after much relationship building and previous therapeutic work has already taken place.

Some transgender survivors may need individual therapy to work on internalized transphobia or shame before they are ready to enter a support group.

Because shame tends to be a common emotion for many survivors, it will likely emerge within support group settings. With transgender clients, it may be difficult to determine the exact root of their shame. Understanding the complex relationship between shame and transgender identity is essential, but it is more important to listen carefully and empathically, reflect language and concepts, and assist transgender individuals in lessening their feelings of shame and guilt. According to one FORGE survey respondent who was sexually abused by their therapist:

Shame has kept me silent all these years. This survey is one of the few times that I have discussed these events. No one wants to hear about this, because therapists are supposed to be God and cannot do any wrong.¹

If clients begin to blame themselves, remind them that they did not cause abuse. This may be especially difficult for transgender clients to believe because so many assaults of transgender survivors are reported as being related to transgender identity or expression. Many perpetrators target transgender people because of their transgender status, which can create a heightened belief that survivors are at fault.

Make sure not to "scold" clients or make them feel guilty if shame is overriding their ability to address other therapeutic issues. These clients may need additional time and tools to help them feel less shame, or they may need to work individually with a therapist to become ready to participate in a support group.

For more information on shame and its treatment, read Treating Survivors of Childhood Abuse: Psychotherapy for the Interrupted Life, by Marylene Cloitre, Lisa R. Cohen, and Karestan C. Koenen. One of their main recommendations is waiting until late in treatment to tackle shame, after much relationship building and previous therapeutic work has already taken place.