Description of Case
The sexual assault nurse examiner (SANE) was called to see a client at an emergency department in Western Canada. The healthcare team informed the SANE that the patient was female and that the sexual assault had happened 2 days earlier. The SANE entered the client's room and found the client to be middle-aged, with short dark hair, wearing a facial mask and exhibiting a deeper voice than expected. At this time, the SANE realized that the client's secondary sex characteristics (body hair, fat distribution, muscle mass, and vocal pitch) did not align with features the SANE associated with being "female." The SANE looked at the gender marker on the patient's addressograph and noted "F" as the gender marker. The SANE wondered if "female" was the client's assigned sex at birth, gender identity, or both. It was not routine practice to inquire about a client's gender identity, leaving the SANE unsure how to ask about the individual's gender identity safely and comfortably. As a result, the SANE did not ask about the client's gender identity and instead proceeded with gathering a history of the assault. The client reported testosterone as their only current medication.
The client explained that the assailant "assaulted me down there." In response, the SANE was unsure about how to ask which body parts were involved to fully characterize the nature of the assault and felt increasingly confused about the client's assigned sex at birth and gender identity. The client stated, "Do you realize I am trans?" The SANE quickly apologized for not clarifying their gender sooner and asked the client for their chosen pronouns. The client told the SANE that he identifies as transmasculine and used the pronouns he/him. The client reported that the assailant nonconsensually penetrated his vagina and mouth without a condom and nonconsensually penetrated his anus with a condom.
The client declined a standard forensic examination, instead opting for an individualized and focused genital examination. The client did not proceed with police involvement.
Summary of Key Findings
Before the first contact with the client, healthcare staff communicated to the SANE that the survivor was female and used she/her pronouns. As such, the SANE incorrectly assumed the client was cis-female1 until the first encounter with the client. At that time, the client's face was partially covered by a facial mask, and their secondary sex characteristics were different than what is typically associated with cis-females. The SANE was confused by this discrepancy and was uncertain about the client's sex and gender. It is not routine practice to inquire about gender identity, and the SANE was unsure how to inquire about the client's gender identity respectfully-so they did not. This forced the client to verbally clarify his gender identity to the SANE.
Interventions
After discovering that the client identified as transmasculine, the SANE asked for their chosen pronouns and used the preferred pronouns of he/him throughout the remaining portion of the encounter. The SANE also took time to communicate each step of the physical examination, ensuring informed consent was maintained throughout. The SANE clearly articulated the rationale behind parts of the examination and that the client could withdraw consent at any time. The SANE noted a single 1-mm laceration to the posterior fourchette. The SANE did not locate any internal or anal injuries.
The SANE utilized the history of the assault, including the sites of exposure, genital injuries, and what was known about the assailant, and determined the client to be at a moderate-to-high risk of sexually transmitted and blood-borne infection exposure. The SANE therefore offered the client HIV postexposure prophylaxis and hepatitis B prophylaxis in the form of hepatitis B immunoglobulin. The SANE also recommended ceftriaxone intramuscularly and azithromycin for chlamydia and gonorrhea prophylaxis because of the higher rates of resistance and treatment failure in the men who have sex with men (MSM) population (Public Health Agency of Canada, 2021).
While gathering the history, the SANE had learned that the client was currently using testosterone. Although testosterone administration alters the frequency of menstruation and is thought to reduce fertility, the impact on ovulation is not fully known. Thus, it should not be considered an adequate method of contraception (World Professional Association for Transgender Health, 2012). Therefore, the SANE discussed the risk of pregnancy with the client and offered emergency contraception in the form of ulipristal 30 mg orally.
Discussion
It is estimated that up to 0.5% of adults worldwide (Kiran et al., 2019) and approximately 75,000 Canadians (Statistics Canada, 2020) identify as transgender.2 Transgender patients face significant discrimination and barriers when accessing healthcare services and tend to be a chronically underserved population (Jordan et al., 2019). Factors contributing to poor access to and utilization of healthcare among transgender patients include ongoing stigmatization, harassment, being misgendered, and a lack of provider knowledge about trans-specific health needs (Du Mont et al., 2019; Jordan et al., 2019).
The client, in this case, was misgendered by hospital staff and by the SANE. Misgendering of transgender people results in nonaffirmation and negatively impacts their care experience, especially when it is a patterned experience of being repeatedly misgendered (Freeman & Stewart, 2018). This incident of misgendering was rooted in implicit biases and cisnormative assumptions. Cisnormativity refers to the assumption that sex and gender are binary and that an individual's gender identity aligns with their assigned sex at birth (Bauer et al., 2009). Cisnormativity describes instances in which there is a failure or refusal to acknowledge the identifiers or experiences of transgender people (Riggs et al., 2015).
The experiences of gender and sexual minority3 sexual assault survivors have been largely underexamined, given that the prevailing view of gender identity and sexual orientation continues to be cisgender and heterosexual. To date, much of the empirical research on sexual assault has been conducted through cisgender and heteronormative lenses (Murphy-Oikonen & Egan, 2021; Simpson, 2018). The impact of these pervasive and persistent lenses is twofold: the erasure and invisibility of experiences of sexual assault among sexual and gender minority survivors, and further marginalization and discrimination faced by these groups.
In this specific case, the gender marker of "female" on the electronic medical record contributed to cisnormative assumptions and created the potential for precipitous incidents during the client's care, especially given that the client did not exhibit secondary sex characteristics "typical" of cisgender females. People reflexively and often unconsciously cluster individuals by their gender, and these gender stereotypes generate broadly accepted biases about specific characteristics or attributes and perpetuate the notion of binary genders (Ellemers, 2018). Transgender and gender nonconfirming people render visible the dominance of binary cisnormative views that are not reflective of gender and sexual diversity, with significant implications for perpetuating stereotypes, discrimination, and marginalization that can profoundly affect health outcomes for these individuals.
To address cisnormative assumptions and prevailing gender stereotypes, healthcare providers must acknowledge and explore the implicit biases and assumptions they bring to patient encounters. Although the SANE recognized that this client did not meet characteristics typically associated with a cisgender female, the SANE failed to properly address this assumption earlier in the encounter. A better approach must exist for SANEs, to address patterns of implicit thinking and assumptions about gender. One strategy is for practitioners to initiate all patient interactions with an introduction that includes their chosen pronouns alongside a polite request for the client's chosen name and pronouns (i.e., "My name is Jane Doe, and I use the pronouns she/her. To begin, may I ask your chosen name and chosen pronouns?"). Moreover, when confirming the client's identity, healthcare providers should acknowledge the gender marker assigned on the electronic medical record or identification bracelet in a way such as "I see female listed as your gender marker. Is this your assigned sex at birth, and does this align with your gender identity?" This approach incorporates gender identity into routine practice and, in doing so, acts to affirm the survivor's identity from the beginning and aims to prevent misgendering.
As a SANE, it is necessary and relevant to inquire about not only which body parts the client has but also what terms they use to describe their body parts (i.e., "I would like to ask you some questions about what body parts you have and what contact was made as it will determine which tests or treatments are recommended, is that okay?"). To establish a client care relationship based on inclusivity and trauma-informed principles, the SANE should identify the rationale behind inquiring about specific body parts and specify that they will use terms of their choosing, such as "front hole" or gender-neutral language such as "chest." Failing to address these biases and assumptions can lead to misgendering, which can be (re)traumatizing for the survivor.
Intersectionality must also be discussed in the context of this case and all cases of sexual assault within a gender-diverse population. Intersectionality describes how multiple and overlapping identities-such as gender, race, class, and abilities-can impact experiences of oppression and prejudice (Ussher et al., 2020). For example, an individual who is a member of more than one underserved group may experience multiple layers of intersecting oppressions (Staples & Fuller, 2021). The visibility of a person's gender identity or expression has also been shown to be a risk factor for victimization partly because of the intersection of gender and sexual diversity (Callander et al., 2019).
Although there is a paucity of research specific to healthcare experiences after sexual assault among transgender people in Canada, data from the Trans PULSE survey in Ontario reported that 20% of transgender people have experienced physical or sexual assault because of their transgender identity (Bauer & Scheim, 2015). In 2018, 23.5% of transgender individuals experienced sexual assault compared with 19.4% of cisgender individuals (Statistics Canada, 2020). Because of the small sample size of transgender respondents, precise estimates for this population were not provided; however, it is probable that rates of sexual assault were likely underestimated among this population (Statistics Canada, 2020). Although transgender people are often included under the 2SLQBTQI+ umbrella, it is critical to distinguish between an individual's gender identity and sexual orientation. Although transgender people are also considered a sexual minority (Statistics Canada, 2020), it is important to distinguish that identifying as transgender is unrelated to sexual orientation. As a result, when transgender people are grouped among the collective sexual minority, it becomes difficult to fully examine the scope, issues, and experiences of transgender sexual assault survivors, rendering their experience invisible and repudiated from the collective concern.
An important part of the SANE assessment is forensic evidence collection and police involvement. However, rates of sexual assault reporting to police in Canada have declined as much as 20% over the past decade, resulting in an overall reporting rate of 5% (Statistics Canada, 2018). Unfortunately, these statistics are not stratified by gender identity or sexual orientation (Simpson, 2018), and reporting may be even lower among 2SLQBTQI+ populations (Langenderfer-Magruder et al., 2016). Lack of reporting among survivors may be because of fear of blame or embarrassment and beliefs that police cannot or will not assist them (Meyer, 2003; Murphy-Oikonen & Egan, 2021). For the 2SLQBTQI+ population, these reasons are further complicated by issues of heterosexism, homophobia, and transphobia (Murphy-Oikonen & Egan, 2021). Practitioners, including SANEs, must approach and provide care for their transgender clients through a lens that considers how intersecting marginalized identities (i.e., gender, sexual orientation, race) influence the care they provide and shape the experience and health outcomes of the client.
Healthcare providers must critically examine their implicit biases and assumptions, including how they would meet the needs of a transgender survivor. A survey conducted in Ontario, Canada, among staff in sexual assault and domestic violence treatment centers, revealed that only 39% of SANEs had any specialized training to meet the needs of transgender survivors of sexual assault (Du Mont et al., 2019). Nearly all nurses surveyed strongly agreed that they would benefit from specialized training, and all program leaders identified trans-specific training as a fundamental need (Du Mont et al., 2021). Therefore, principles of gender-affirming care must be integrated throughout every aspect of SANE training and underpin all forensic nursing care.
Conclusion
This case report explored an encounter of a SANE providing care for a transgender survivor and highlighted how unconscious patterns of behavior and communication, such as misgendering, can cause harm. Cisnormativity, heteronormativity, and gender stereotypes persist in the clinical environment and serve to retraumatize survivors. Although the SANE recognized the problematic thinking underpinning this encounter with a transgender survivor, this is only the first step. Healthcare providers, including SANEs, must transform their understanding of how individuals of sexual and gender minorities experience sexual assault. SANEs are uniquely positioned to confront rigid binary gender constructs by countering biases, assumptions, and stereotypes. In doing so, they will help foster a healthcare environment based on principles of diversity and inclusion, advance gender-affirming care, and contribute to practice and institutional changes toward achieving health equity.
References