Professional Documents
Culture Documents
7.65, p .006).
Effects of Physical Violence
Suicidal ideation. Trans women who had experienced a phys-
ical violence were significantly more likely to report a history of
suicidal ideation in comparison to those who had not experienced
physical violence (81.7% vs. 53.5%, respectively; age adjusted
odds ratio 3.83, p .001). However, this relationship was not
significant among trans men.
Suicide attempts. Trans women who had experienced phys-
ical violence were also significantly more likely to report a history
of a suicide attempt in comparison to those who had not experi-
enced physical violence (46.5% vs. 13.7%, respectively; age ad-
justed odds ratio 5.13, p .001). The relationship between
physical violence and suicide attempt was also significant for trans
men (45.2% vs. 19.1%, respectively; age adjusted odds ratio
3.52, p .009).
In addition to being at greater risk of attempting suicide, trans
women who had experienced physical violence reported a greater
number of suicide attempts in comparison to those who had not
experienced physical violence. This association was also signifi-
cant for trans men (see Table 2).
Substance abuse. For trans women, history of physical vio-
lence was not found to be associated with history of alcohol abuse.
However, past alcohol abuse was significantly more likely among
trans men who had experienced physical violence compared to
those who had not (46.3% vs. 23.9%, respectively; age adjusted
odds ratio 3.03, p .027). Past illicit drug use was not found to
be associated with history of physical violence for trans women or
trans men.
Effects of Sexual Violence
Suicidal ideation. Trans men who had been forced to engage
in unwanted sexual activity were more likely to report past suicidal
ideation in comparison to those who had not experienced sexual
violence (96.7% vs. 75.4%, respectively; age adjusted odds ratio
9.36, p .036). This relationship was not significant for trans
women in our sample.
Suicide attempts. Trans men who had experienced sexual
violence were also more likely to report history of a suicide
Table 1
Overall and Subgroup Demographic Information for Trans
Participants
Trans women
(n 179)
Trans men
(n 92)
Age
M (SD) 40 (12.4) 30 (10.7)
(%) (%)
Race/ethnicity
Caucasian/White 65.4 71.7
African-American 20.1 15.2
Latino/Latina 5.6 2.2
Other 8.9 10.9
Socioeconomic status
Low ( $30K/year) 33.0 43.5
Middle 42.5 43.5
High ( $100K/year) 19.6 9.8
Education
Some high school 10.0 1.1
High school/GED 14.5 12.0
Associates degree 11.2 5.4
Some college 24.6 46.7
College graduate 17.9 15.2
Some grad school 21.2 19.6
History of suicidal ideation 65.3 83.0
History of suicide attempt 26.3 30.4
Victim of physical violence 39.7 45.7
Victim of sexual violence 24.6 34.8
Past alcohol problem 16.8 32.6
Past illicit drug use 74.3 77.2
Note. Trans women individuals assigned male at birth who have transi-
tioned or plan to transition to living full-time as women; Trans men
individuals assigned female at birth who have transitioned or plan to transition
to living full-time as men.
455
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attempt in comparison to those who had not experienced sexual
violence (53.1% vs. 19.0%, respectively; age adjusted odds ratio
5.08, p .001). This relationship was also statistically significant
for trans women (47.4% vs. 19.4%, respectively; age adjusted odds
ratio 3.60, p .001).
In addition to being at greater risk of attempting suicide, past
sexual violence was associated with a greater number of suicide
attempts in both trans women and trans men (see Table 3).
Substance abuse. A history of experiencing sexual violence
was also found to be associated with a history of alcohol abuse in
trans women (29.5% vs. 12.9%, respectively; age adjusted odds
ratio 3.22, p .007) and trans men (51.6% vs. 24.6%, respec-
tively; age adjusted odds ratio 3.20, p .020). Additionally,
trans women who had experienced sexual violence were signifi-
cantly more likely to report past illicit substance use as compared
to those who had not experienced past sexual violence (90.7% vs.
70.1%, respectively; age adjusted odds ratio 4.08, p .012).
However, the relationship between sexual violence and illicit sub-
stance use was not significant for trans men.
Discussion
The analyses presented were undertaken in order to investigate
the psychological effects of having experienced physical and sex-
ual violence among trans people. We found that, like nontrans
victims of violence (Davidson et al., 1996; Hughes et al., 2010;
Kilpatrick et al., 1985; Malinosky-Rummell & Hansen, 1993;
Silverman et al., 1996; Ullman & Najdowski, 2009), trans victims
of violence experience higher risk of suicidal ideation, suicide
attempts, and substance abuse. We also explored factors specific to
trans victims of violence, including high prevalence of victimiza-
tion due to gender identity or expression, low reporting of inci-
dents to police, and variety of sources of violence.
Effects of Violence Consistent With the General
Population
Among trans people in our sample, both physical and sexual
violence were related to having a history of suicidal ideation,
history of suicide attempts, higher number of attempts, and to
substance abuse. This is consistent with distress and negative
coping responses seen in the general population as a result of
physical and sexual violence (Davidson et al., 1996; Hughes et al.,
2010; Kilpatrick et al., 1985; Malinosky-Rummell & Hansen,
1993; Silverman et al., 1996; Ullman & Najdowski, 2009).
The relationship between violence and mental health was clear
in this sample. Over two thirds reported a history of suicidal
ideation. Physical abuse was related to suicidal ideation in trans
women and sexual violence was related to suicidal ideation in trans
men. Furthermore, an alarming 26.3% of trans women and 30.4%
of trans men reported a history of suicide attempts. These numbers
are striking compared to the estimated lifetime prevalence of
suicide attempt in the general population of 16% (Weissman et
al., 1999). For both trans women and trans men, both forms of
violence were associated with history of suicide attempt. Of addi-
tional concern is the high number of suicide attempts reported per
individual. Among attempters, one third reported attempting once,
one third attempting twice, and one third attempting suicide three
or more times. Number of suicide attempts was also significantly
related to both forms of violence. Finally, there were associations
Table 3
History of Sexual Violence and Number of Suicide Attempts
Trans women
(n 179)
Trans men
(n 92)
No Sexual Violence
n (1 Attempt) 12 3
% 9.0 5.2
n (2 Attempts) 7 3
% 5.2 5.2
n (3 Attempts) 7 5
% 5.2 9.6
Sexual violence
n (1 Attempt) 4 4
% 9.1 12.5
n (2 Attempts) 7 5
% 15.9 15.6
n (3 Attempts) 10 8
% 22.7 25.0
Age adjusted odds ratio 4.21 4.72
p .001 p .004
Note. Trans women Individuals assigned male at birth who have
transitioned or plan to transition to living full-time as women; Trans men
Individuals assigned female at birth who have transitioned or plan to
transition to living full-time as men.
Table 2
History of Physical Violence and Number of Suicide Attempts
Trans women
(n 179)
Trans men
(n 92)
No physical violence
n (1 Attempt) 6 6
% 5.9 12.8
n (2 Attempts) 2 1
% 2.0 2.1
n (3 Attempts) 6 2
% 5.9 4.3
Physical violence
n (1 Attempt) 10 1
% 14.1 2.4
n (2 Attempts) 12 7
% 16.9 16.7
n (3 Attempts) 11 11
% 15.5 26.2
Age adjusted odds ratio 5.30 4.36
p .001 p .006
Note. Trans women Individuals assigned male at birth who have transi-
tioned or plan to transition to living full-time as women; Trans men
Individuals assigned female at birth who have transitioned or plan to transition
to living full-time as men.
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between both forms of violence and substance use and abuse.
Specifically, history of sexual violence was related to alcohol
abuse in trans men and trans women, and to illicit substance use
among trans women. History of physical violence was related to
alcohol abuse among trans men.
Trans-Specific Aspects of Physical and Sexual Violence
Consistent with prior studies of trans people, past incidents of
physical and sexual violence were demonstrated to be very high in
this sample, with almost half reporting history of victimization.
Interestingly, rates of reported violence among trans participants
were consistent across most demographics. Despite suspicions that
gender nonconformity exhibited by those assigned male at birth
would elicit more violence, trans men reported rates of physical
and sexual violence related to their gender identity or expression
that were comparable to those reported by trans women. Reports of
violence also did not vary based on race, SES, or age, with the one
exception that higher SES participants were less likely to have
experienced sexual violence.
The reported sources of violence were also telling. Within this
sample, key violent offenders were identified as both people far
removed from the respondents social networkscomplete strang-
ersand those closest to these respondentsimmediate family
members.
Following violent incidents, only about 10% of trans victims
reported to the police. This echoes prior research demonstrating
underreporting and fear or distrust of police within the trans
community (Xavier et al., 2004). Fear may be based on previously
demonstrated secondary victimization, in which victims seeking
help were at increased risk of victimization again by the very
people from whom they had sought help (Xavier et al., 2004).
Indeed, eight participants in the current study indicated that a
police officer had been the perpetrators of their physical abuse and
five reported sexual abuse from a police officer.
Study Limitations
Because to this date no data exists about the population of trans
people in Virginia, a probability sampling approach could not be
created. Despite using a robust community-based participatory
research model to gather a demographically diverse sample, the
studys sample cannot be used to describe all trans people in
Virginia or elsewhere. Because participants were primarily re-
cruited through service providers, trans support groups, and infor-
mal peer networks, individuals who do not access such services or
engage with such peer networks may be underrepresented in this
sample. Moreover, due to insufficient numbers of participants who
did not intend to transition full-time, our analyses were limited to
trans people who had or intended to transition to living full-time as
a sex other than that assigned at birth. Therefore, findings cannot
be generalized to people who identify as trans but do not plan to
transition in this way. Additional limitations are presented by the
retrospective and self-report nature of key variables in the dataset.
Retrospective self-report introduces potential sources of error due
to inability to accurately remember or discomfort reporting infor-
mation, especially related to sensitive topics such as suicide,
substance abuse, and sexual violence. Finally, since chronology of
events was not examined and analyses were correlational, no
causal relationships could be conclusively demonstrated.
Implications and Future Directions
Program Development and Policy Advocacy
A number of studies including THIS (Clements-Nolle et al.,
2006; Kenagy & Bostwick, 2005; Lombardi et al., 2001; Risser et
al., 2005; Xavier et al., 2005) indicate that gender-based violence
is of serious concern for trans women and trans men. Researchers
and clinicians are well positioned to develop and disseminate
programs as well as advocate for policies aimed at preventing
gender-based violence across society. Model programs and re-
sources have been developed for community and school-based
prevention interventions through organizations such as Commu-
nity United Against Violence (CUAV; www.cuav.org), FORGE
(forge-forward.org), and the Human Rights Campaigns Welcom-
ing Schools Program (www.welcomingschools.org). Consistent
with evidence suggesting a high level of gender-based victimiza-
tion in schools (Goldblum et al., in press), prevention efforts must
be initiated at a young age. Future research should also direct
policy interventions aimed at prevention. There is a current need
for evaluation of the need for and effectiveness of potential hate
crime and nondiscrimination laws that are inclusive of trans indi-
viduals.
Program and policy development should be done with consid-
eration of the primary sources of violence against trans people. To
address the prevalence of violence from family members, pro-
grams and policy initiatives are necessary to assist families in
acceptance of trans family members, as modeled by the Family
Acceptance Project at San Francisco State University (familyproject.
sfsu.edu). Safe alternative housing for trans individuals experienc-
ing violence at home is also needed, as many shelters are currently
not safe for trans individuals (Xavier et al., 2005).
Findings, including those presented here, point to a need for
programs and policies to ensure that trans victims have access to
support from law enforcement (Clements-Nolle et al., 2006; Ke-
nagy & Bostwick, 2005; Lombardi et al., 2001; Risser et al., 2005;
Xavier et al., 2005). Psychologists can lead in partnership with the
trans community to develop and disseminate trainings for police
departments aimed at increasing knowledge and comfort in work-
ing with trans victims of violence. Considering the prevalence of
gender-based violence experienced by trans people, policy should
mandate that current diversity trainings for law enforcement spe-
cifically cover working with trans victims.
Clinical Application
Considering the prevalence of physical and sexual violence,
substance abuse, suicidal ideation, and suicide attempts revealed in
our analyses across demographics, it is important that clinicians
assess and be prepared to treat these issues among all trans clients.
In light of repeated findings that experiences of violence are often
perceived to be related to gender identity or expression (Clements-
Nolle et al., 2006; Kenagy & Bostwick, 2005; Lombardi et al.,
2001; Risser et al., 2005; Xavier et al., 2005), clinicians should
have a reasonable level of comfort discussing issues of gender
identity and expression within the context of both assessment and
implementation of evidence-based treatments. Kaufmans (2008)
Introduction to Transgender Identity and Health can be very
helpful in this regard.
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Our research findings demonstrate links between violence and
mental health effects in trans individuals, as have been established
in the general population. In this sense, clinicians should feel
comfortable utilizing existing evidence-based treatments to ad-
dress the effects of trauma on mental health in trans clients.
However, the violence that trans people face specifically related to
gender identity or expression may have additional ramifications.
The adaptation of Meyers (2003) Minority Stress Model proposed
by Hendricks and Testa (in press) delineates ways in which vio-
lence that is perceived to be related to ones gender identity or
expression disproportionately increases distress, compared to vio-
lence motivated by other reasons. Such violence leads to internal-
ized transphobia, which can involve negative self-appraisal and
rejection of this critical aspect of the persons sense of self, as well
as expectations for future rejection and/or victimization. Experi-
ences of violence related to ones gender, alongside these resultant
sources of stress, may also lead to concealment of ones trans
identity or expression. For example, more than half of the partic-
ipants in Beemyn and Rankins (2011) study reported that they had
concealed their trans identity. Concealment also distances the
individual from community resources that may otherwise be a
source of resilience. Concealment, internalized transphobia, and
expectations of future violence, may also exacerbate hesitancy to
seek help, which may in turn prolong or intensify distress.
Clinicians should therefore also be comfortable assessing and
treating these unique issues. Clinicians may find it helpful to ask
questions about how experiences of violence relate to a clients
experience of their gender, their expectations for how their gender
will be received by others, their choices about concealment, and
their ability to access resources and resilience through engagement
with community resources. By establishing and maintaining good
therapeutic rapport with trans clients, and providing a safe space in
which clients can explore their experiences and beliefs related to
gender, clinicians create an opportunity for clients to break through
the cycle of distress and concealment. Working within their own
orientation, clinicians can utilize cognitive, behavioral, relational,
or other techniques to further address internalized transphobia and
negative expectations for future events, and facilitate access to
community-based resources and resilience.
Finally, as was true of our sample in seeking help from police,
clinicians should be aware that trans clients may be hesitant to seek
out or may be distrustful of psychologists as well. Prior research
has demonstrated that trans peoples reluctance in this regard may
stem from past experiences of discrimination or rejection in health
care settings, perceived higher risk of discrimination or rejection
based on others accounts, and suspected risk of being denied
access to transition-related medical care if they divulge mental
health concerns (Bockting, Knudson, & Goldberg, 2006). For
many in the trans community, continued inclusion of Gender
Identity Disorder diagnosis in the DSMIVTR is interpreted as
offensive or even hostile. To address these particular hesitancies
trans people may have in seeking mental health treatment, it is
recommended that psychologists who are working with trans in-
dividuals familiarize themselves with both Bockting, Knudson,
and Goldbergs (2006) Counseling and Mental Health Care of
Transgender Adults and Loved Ones (which can be accessed at
http://transhealth.vch.ca/resources/careguidelines.html), and The
World Professional Association for Transgender Healths
(WPATH, 2011) Standards of Care for the Health of Transsexual,
Transgender, and Gender Nonconforming People, Version 7
(which can be accessed at www.wpath.org).
Applied Research
It is recommended that psychologists take leadership in devel-
oping and implementing evidence-based treatments designed par-
ticularly for trans survivors of trauma. Since the preponderance of
findings demonstrate that violence is often perceived to be related
to gender (Clements-Nolle et al., 2006; Kenagy & Bostwick, 2005;
Lombardi et al., 2001; Risser et al., 2005; Xavier et al., 2005), it
will be useful for research studies to specifically investigate the
effects of this violence on trans individuals mental health, includ-
ing their acceptance of their gender identity and comfort with
expressing their gender in the world. As a result, treatments may
be augmented or redesigned to address any found gender-specific
consequences of violence in this population. It will also be useful
to assess how intersectionality of identities influences rates of
violence, mental health effects of violence, and resilience.
Longitudinal studies are needed to better ascertain the pathways
between violence and mental health outcomes in this population.
Future research can advance current knowledge by assessing more
details about violence, such as the frequency, severity, and envi-
ronments in which gender-based violence occurs. In addition,
standardized measures of mental health symptomatology will help
to establish the impact of violence on this community. Similarly,
future research should better inquire as to the lethality of suicide
attempts, by asking about expectations of outcome by attempters
and the need for medical attention. In addition, the temporal
proximity of these attempts to experiences of violence should be
assessed in future studies. Further, research should begin to exam-
ine whether experiences of violence are also related to completed
suicide among trans individuals.
In addition to identifying elements of risk, it is crucial that
psychologists examine buffering experiences or aspects of resil-
ience that might differentiate those trans people who are better able
to cope with violence, such as those described by Hendricks and
Testa (in press). Similarly, aspects of families and communities
that are predictive of safe environments for trans people should be
identified. Once these factors are better understood, psychologists
can incorporate this into programs and policy initiatives aimed at
family and community.
Conclusion
This article reviews the literature addressing the impact of
violence on trans individuals and provides an analysis of the first
reported state-level survey of trans men and trans women. The
rates of physical and sexual violence were found to be very high in
this sample of trans men and trans women. This violence was
shown to be associated with suicidal ideation, suicide attempt,
increased number of suicide attempts, and substance abuse. Fac-
tors specific to trans victims of violence were identified, including
high reported prevalence of violence related to gender identity or
expression, varied sources of this violence, and low rate of report-
ing these incidents to police. As increased attention is devoted to
the trans community in popular culture and research, psychologists
have a clear opportunity to act by increasing understanding of the
impact of violence on trans individuals mental health, and by
responding with appropriate prevention and treatment efforts.
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Received December 25, 2011
Revision received June 10, 2012
Accepted June 20, 2012
459
EFFECTS OF VIOLENCE ON TRANSGENDER PEOPLE
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