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

When Sexual Violence Goes Viral: A Literature Review and Synthesis on How the Popularization of the #MeToo Movement Contributed to the Recent Evolution of Nursing Practice With the Student Population in Quebec (Canada)

ABSTRACT

Since the popularization of the #MeToo movement, the prevention and management of sexual violence (SV) has become prominent in North American public discourse, including in the province of Québec (Canada). Despite such an important visibility in the public sphere, there is little scientific evidence of how nursing practice has adapted to the popularization of the #MeToo movement, led by victims of SV. Drawing on critical feminist theories, we describe the results from a literature review on nursing practice in the context of SV on college and university campuses since the #MeToo movement. A literature search was performed in five databases using keywords targeting nursing practice in the context of SV. In total, 45 articles were selected for analysis. Eight studies were added for their relevance (obtained outside the databases). Next, a reflexive thematic analysis inspired by Braun and Clarke (2006) was conducted. The literature review was then used to compare current practices in Québec. The results identify the persistence of numerous myths and stereotypes that contribute negatively to the credibility of persons experiencing SV. The results also describe the difficulty of public institutions to change structures aimed at preventing and managing SV in response to the popularization of the #MeToo movement. The results indicate the relevance of using an intersectional feminist theoretical framework to better understand the complexities of SV. Through our analysis, we show that, more than ever, the evolution of forensic nursing practice must be informed by political and testimonial activism driven by persons experiencing SV.

The Association Between Sexual Violence and Suicidal Ideation Among Transgender Women and the Role of Gender-Affirming Healthcare Providers in Seven Urban Areas in the United States, 2019 to 2020

Transgender women are disproportionately affected by sexual violence and corresponding mental health sequelae; however, many do not access healthcare due to experiences with transphobia. This analysis evaluated the association between sexual violence and suicidal ideation and the moderating effect of having a healthcare provider (HCP) with whom transgender women were comfortable discussing gender-related issues ("gender-affirming HCP"). We analyzed cross-sectional data from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance among Transgender Women (NHBS-Trans). Transgender women were recruited using respondent-driven sampling from seven urban areas from 2019 to 2020 and participated in an HIV biobehavioral survey. This analysis was restricted to transgender women who visited a HCP in the past 12 months ("healthcare-seeking transgender women" [HSTW]) (N = 1,489). Log-linked Poisson regression models provided adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to estimate the association between sexual violence and suicidal ideation in the past 12 months. The interaction between sexual violence and having a gender-affirming HCP was statistically significant (p-value = .034). Among 1,489 HSTW, 225 (15.1%) experienced sexual violence and 261 (17.5%) reported suicidal ideation; 1,203 (80.8%) reported having a gender-affirming HCP. Sexual violence was associated with suicidal ideation (aPR = 2.65, 95% CI [2.08, 3.38]); the association was notably higher among those who did not have a gender-affirming HCP (aPR = 3.61, [2.17, 6.02]) than among those who did (aPR = 1.87, [1.48, 2.37]). Eliminating transphobia and promoting trauma- and violence-informed approaches in healthcare are necessary for sexual violence and suicide prevention among HSTW.

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.

The barriers and enablers to accessing sexual health and sexual well-being services for midlife women (aged 40-65 years) in high-income countries: A mixed-methods systematic review

Midlife, beginning at 40 years and extending to 65 years, a range that encompasses the late reproductive to late menopausal stages, is a unique time in women's lives, when hormonal and physical changes are often accompanied by psychological and social evolution. Access to sexual health and sexual well-being (SHSW) services, which include the prevention and management of sexually transmitted infections, contraception and the support of sexual function, pleasure and safety, is important for the health of midlife women, their relationships and community cohesion. The objective was to use the socio-ecological model to synthesise the barriers and enablers to SHSW services for midlife women in high-income countries. A systematic review of the enablers and barriers to women (including trans-gender and non-binary people) aged 40-65 years accessing SHSW services in high-income countries was undertaken. Four databases (PubMed, PsycINFO, Web of Science and Google Scholar) were searched for peer-reviewed publications. Findings were thematically extracted and reported in a narrative synthesis. Eighty-one studies were included; a minority specifically set out to study SHSW care for midlife women. The key barriers that emerged were the intersecting disadvantage of under-served groups, poor knowledge, about SHSW, and SHSW services, among women and their healthcare professionals (HCPs), and the over-arching effect of stigma, social connections and psychological factors on access to care. Enablers included intergenerational learning, interdisciplinary and one-stop women-only services, integration of SHSW into other services, peer support programmes, representation of minoritised midlife women working in SHSW, local and free facilities and financial incentives to access services for under-served groups. Efforts are needed to enhance education about SHSW and related services among midlife women and their healthcare providers. This increased education should be leveraged to improve research, public health messaging, interventions, policy development and access to comprehensive services, especially for midlife women from underserved groups.

Recommendations to Improve the Nature and Extent of Relationships Among Organizations Within a Network to Enhance Supports for Transgender Survivors of Sexual Assault

CONTEXT

To enhance the provision of comprehensive supports to transgender (trans) survivors of sexual assault, a structurally marginalized group with complex care needs, we developed an intersectoral network of trans-positive health care and community organizations in Ontario, Canada.

OBJECTIVE

As a baseline evaluation of the network, we conducted a social network analysis to determine the extent and nature of collaboration, communication, and connection among members.

DESIGN

Relational data (eg, activities of collaboration) were collected from June to July 2021, and analyzed using a validated survey tool, Program to Analyze, Record, and Track Networks to Enhance Relationships (PARTNER). We shared findings in a virtual consultation session with key stakeholders and facilitated discussion to generate action items. Consultation data were synthesized into 12 themes through conventional content analysis.

SETTING

An intersectoral network in Ontario, Canada.

PARTICIPANTS

Of the 119 representatives of trans-positive health care and community organizations invited to participate in this study, 78 (65.5%) completed the survey.

MAIN OUTCOME MEASURES

Proportion/count of organizations collaborating with other organizations. Network scores for value and trust.

RESULTS

Almost all (97.5%) invited organizations were listed as collaborators, representing 378 unique relationships. The network achieved a value score of 70.4% and trust score of 83.4%. The most prominent themes were "Communication and knowledge exchange channels," "Clearer roles and contributions," "Indicators of success," and "Client voices at the centre."

CONCLUSION

As key antecedents of network success, high value and trust indicate that network member organizations are well positioned to further foster knowledge sharing, define their roles and contributions, prioritize the integration of trans voices in all activities, and, ultimately, achieve common goals with clearly defined outcomes. There is great potential to optimize network functioning and advance the network's mission to improve services for trans survivors by mobilizing these findings into recommendations.

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.

HIV testing among transgender and nonbinary persons in Michigan, United States: results of a community-based survey

INTRODUCTION

Transgender (trans) and nonbinary people (TNB) are disproportionately impacted by HIV. HIV testing is critical to engage TNB people in HIV prevention and care. Yet, scant literature has examined social and structural factors associated with HIV testing among TNB people of diverse genders and in geographies with potentially lower trans acceptance. We: (1) characterized the prevalence of never having been tested for HIV; and (2) identified associated factors, among TNB people in Michigan, United States.

METHODS

Data were from a community-based participatory cross-sectional survey (n = 539 sexually experienced TNB people). The prevalence of never having had an HIV test was reported overall and compared across socio-demographic, clinical, social and structural factors using bivariable and multivariable logistic regression analyses.

RESULTS AND DISCUSSION

Approximately one-quarter (26.2%) of participants had never had an HIV test (20.8% transfeminine; 30.0% transmasculine; 17.8% nonbinary assigned male at-birth; and 32.0% nonbinary assigned female at-birth). In a multivariable socio-demographic model, older age (adjusted odds ratio [aOR] for 1-year increase: 0.93, 95% CI: 0.90, 0.96, p<0.001) and Black/African American race (vs. White) (aOR: 0.28, 95% CI: 0.09, 0.86, p<0.05) were associated with increased odds of HIV testing (aORs for never testing). In separate multivariable models controlling for socio-demographics, ever experiencing sexual violence (aOR: 0.38, 95% CI: 0.21, 0.67, p<0.001), not accessed sexual/reproductive healthcare in the past 12 months (aOR: 4.46, 95% CI: 2.68, 7.43, p<0.001) and reporting a very/somewhat inclusive primary care provider (PCP) (aOR: 0.29, 95% CI: 0.17, 0.49, p<0.001) were associated with HIV testing (aORs for never testing).

CONCLUSIONS

Findings contribute to scant literature about gender-based differences in HIV testing inclusive of transmasculine and nonbinary people. Lack of statistically significant gender differences suggests that broad TNB interventions may be warranted. These could include training healthcare providers in trans-inclusive practices with sexual violence survivors and PCPs in trans-inclusive HIV prevention and care. Findings showing Black participants were less likely to have never had an HIV test suggest the promise of culturally tailored services, though further investigation is needed. Findings identify social and structural factors associated with HIV testing and can inform multi-level interventions to increase TNB person's HIV testing.

Transgender people in the nursing discourse: An integrative review

OBJECTIVE

To integrate and analyse the literature produced by nurses in terms of care, education and understanding of the reality of transgender (trans) people.

DESIGN

An integrative review methodology guided by the framework proposed by Whittemore and Knafl.

DATA SOURCES

The search strategy was applied in the following databases: Medline, Embase, Scopus, Web of Science and CINAHL, as well as in Biblioteca Virtual de Saúde, during February and March 2021, with no time frame.

REVIEW METHODS

The references found were assessed according to the eligibility criteria established. The information of the articles included was extracted, and a thematic analysis was performed to synthesize the review findings.

RESULTS

The searches in the databases yielded 2859 articles; 985 after removing duplicates, and 33 articles were included in this review. Three major themes were identified: (1) Understanding the trans universe through the trans perspective; (2) Understanding health and nursing care for trans people; and (3) Trans women as the focus of health and nursing care. The themes evidenced in the lens of nurses and clients the importance of nursing training at all levels to prepare professionals on how to provide culturally competent nursing care for this population and reduce healthcare inequities.

CONCLUSION

Nurses must work to provide a space for convergence and enhancement of the rights of trans people and cease to be a verticalized care model. To such end, it is necessary to devise places and possibilities to teach and learn, to construct and reconstruct a culturally competent nursing care.

IMPACT

This review highlighted the current knowledge and identified gaps in the understanding of nurses, health professionals and students about the experience lived by trans people, resulting from the lack of training and continuing education of these professionals.

Context, Types, and Consequences of Violence Across the Life Course: A Qualitative Study of the Lived Experiences of Transgender Women Living With HIV

Violence is a known driver of HIV vulnerability among transgender (trans) women, who are disproportionately impacted by HIV globally. Violence is also a barrier to accessing HIV prevention, treatment, and support. Yet, little is known about the everyday experiences of violence faced by trans women living with HIV, who live at the intersection of a marginalized gender identity and physical health condition. To address this gap, this study draws on semi-structured, individual interviews conducted 2017-2018 with a purposive sample (selected based on diverse identities) of trans women living with HIV (n = 11) participating in a large, community-based cohort study in three Canadian provinces. Framework analysis was used to identify key themes, patterns within themes between participants, and patterns across themes among participants. Findings showed that trans women living with HIV experience specific contexts of violence shaped at the intersection of stigma based on gender identity, gender expression, and HIV status, among other identities/experiences. Violence experienced in childhood (e.g., familial rejection, bullying) increased trans women's likelihood of being exposed to a violent social context in young adulthood (e.g., state violence perpetuated by the police, interpersonal violence perpetuated by sexual partners, and community violence perpetuated by society-at-large/the general public), which increased trans women's HIV vulnerability; once living with HIV trans women were subjected to discursive violence from healthcare providers. These multiple forms of violence have serious consequences for trans women living with HIV's ongoing social, mental, and physical well-being. The findings suggest that interventions are urgently needed to reduce violence against trans women in childhood and young adulthood, in addition to reducing violence against trans women living with HIV perpetuated by healthcare providers in adulthood, to both proactively and responsively promote their safety, health, and well-being.

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.

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.

The promise of an intersectoral network in enhancing the response to transgender survivors of sexual assault

OBJECTIVES

This study explores the promise of an intersectoral network in enhancing the response to transgender (trans) survivors of sexual assault.

METHODS

One hundred and three representatives of healthcare and community organizations across Ontario, Canada were invited to participate in a survey. Respondents were asked to: 1) identify systemic challenges to supporting trans survivors, 2) determine barriers to collaborating across sectors, and 3) indicate how an intersectoral network might address these challenges and barriers. Descriptive statistics were used to summarize quantitative data and qualitative data were collated thematically.

RESULTS

Sixty-seven representatives responded to the survey, for a response rate of 65%. Several themes capturing the challenges organizations face in supporting trans survivors were identified: Lack of knowledge and training among providers, Inadequate resources across organizations and institutions, and Limited access to and availability of appropriate services. Barriers to collaborating across sectors considered important by the overwhelming majority of respondents were: Lack of trans-positive service professionals (e.g., a paucity of sensitivity training), lack of resources (e.g., staff, staff time and workload, spaces to meet), and Institutional structures (e.g., oppressive policies, funding mandates). Four ways in which a network could address these challenges and barriers emerged from the data: Center the voices of trans communities in advocacy; Support competence of professionals to provide trans-affirming care; Provide the platform, strategies, and tools to aid in organizational change; and Create space for organizations to share ideas, goals, and resources.

CONCLUSION

Our findings deepen our understanding of important impediments to enhancing the response to trans survivors of sexual assault and the role networks of healthcare and community organizations can play in comprehensively responding to complex health and social problems.