"A Chance to Actually Feel Safe.” The Successes & Challenges in Creating Gender-Affirming Mental Health Care
By Kristen Parsons, Research Associate
Through its Trauma Healing and Resilience Initiative for Transgender Survivors of Violence (THRIV), Mount Sinai provided dozens of transgender and gender non-binary (TGNB) people with trauma-focused, gender-affirming care. In an evaluation of the program, Icahn School of Medicine highlights positive program impact among participants and offers recommendations for creating a more affirming healthcare experience for TGNB people, including the importance of hiring staff that reflect participants’ identities.
Research shows that transgender and gender non-binary (TGNB) people are disproportionately affected by violence and trauma compared to cisgender adults. A 2016 survey found that 48 percent of transgender respondents had been hit, beaten, physically attacked, or sexually assaulted compared to 36 percent of cisgender heterosexual adults.[1] Such experiences are associated with poorer physical and mental health outcomes, yet TGNB people are often reluctant to engage with supportive services, citing fear of negative treatment and discrimination by healthcare providers. Nearly half (47 percent; n=1,528) of all transgender respondents in a 2020 survey reported at least one form of discrimination from a healthcare provider; among transgender respondents of color, this number rose to two-thirds (68 percent).[2]
Nearly half of all transgender respondents in a 2020 survey reported at least one form of discrimination from a healthcare provider
To create more inclusive, culturally competent medical services and staff to serve this population, Mount Sinai created the Trauma Healing and Resilience Initiative for Transgender Survivors of Violence (THRIV). THRIV is a TGNB-centered program designed to increase access to trauma-focused, gender-affirming therapy for TGNB survivors of interpersonal violence and trauma. The program offered individual and group therapy, a peer support group, a creative expression group, and educational speaker events highlighting best practices in serving TGNB individuals in the healthcare setting. Through funding from the Manhattan District Attorney’s Criminal Justice Investment Initiative (CJII) with guidance from CUNY ISLG, THRIV’s a goal was to support TGNB participants to heal from trauma resulting from criminal victimization. Under this funding, the Icahn School of Medicine recently completed a process evaluation that laid out the successes, challenges, and lessons learned from the programming.
Improved Self-Worth Through Connection to Care
The evaluation found that THRIV had a positive impact on TGNB participants in a number of ways. Participants reported improvements in self-worth, feelings of empowerment, and ability to self-advocate. In particular, THRIV participants highlighted that connecting with other TGNB people through clinical and art-based supports helped them understand how to refine trauma coping skills and develop healthy, supportive relationships. Overall, 94 percent of participants were satisfied with THRIV services, including 81 percent who were “strongly” satisfied. One pariticipant noted, “I just have much better coping strategies now...I’m just generally able to better manage as things come up, and I think a lot of that has come through the sessions with [THRIV’s Program Coordinator]."
Fostering Trust & Safety through Culturally Competent Staff
As the impetus for this program implies, many TGNB folks have faced challenges receiving quality mental and physical healthcare due to a lack of trans-specific knowledge among medical staff. With THRIV staff educated on best practices in working with TGNB participants, participants said they “felt respected by [staff] and felt that they could genuinely trust them,” with one participant noting “This has been a chance to actually feel safe regarding talking to doctors.”
THRIV participants expressed high levels of satisfaction with the primary clinician, who was a white, cisgender woman; for instance, describing her as “warm,” “trustworthy,” “respectful,” and “knowledgeable” of trans issues. On several occasions, however, some prospective clients opted not to participate in THRIV due to their preference to work with a trans clinician of color . As context, about two-thirds of THRIV participants were people of color. As the clinician recounted: “There definitely were folks that got referred to me…and were like, ‘actually, no offense, but I want to work with a trans person of color.’ And I get that.”
Lessons for the Field: Staff should Reflect Participants
Results of this evaluation begat a set of recommendations for service providers to best meet the needs of TGNB individuals: primarily, by ensuring that staff identities reflect those of participants to address the lack of TGNB representation in healthcare.
In response, THRIV hired a full-time Program Associate from the transgender community to serve as a peer advocate, provide administrative support, and lead therapeutic groups. Still, many THRIV participants did not feel their identities were reflected in program staff; while the Program Associate identified as a trans man, nearly three-quarters (71 percent) of participants were trans women.
Hiring more TGNB healthcare professionals is a core solution to making healthcare more accessible to the broader trans community; yet, in 2021, only 1.2 percent of matriculating medical students identified as TGNB.
Hiring more TGNB healthcare professionals is a core solution to making healthcare more accessible to the broader trans community; yet, in 2021, only 1.2 percent of matriculating medical students identified as TGNB. Another study found that approximately one-fifth to one-third of TGNB medical students expected to drop out due to verbal or physical harassment at school.[3],[4] Therefore, hiring more TGNB healthcare professionals will ultimately require a more intentional and supportive participant-to-staff pipeline. This could include opportunities for TGNB individuals to learn professional skills through organized trainings and direct work experience, rather than relying solely on traditional pathways.
About the CUNY Institute for State & Local Governance (ISLG) and the Criminal Justice Investment Initiative (CJII)
The CUNY Institute for State & Local Governance manages the Criminal Justice Investment Initiative (CJII), which was established by the Manhattan District Attorney’s Office in 2015. ISLG provides technical assistance, conducts oversight, measures performance, and manages all CJII grantees.
The CJII focuses on three investment areas—crime prevention, reentry and diversion, and supports for survivors of crime. The Transgender Healing and Resilience Initiative for Survivors of Violence (THRIV) and this evaluation were funded through the CJII’s investments in Survivors of Crime. This blog accompanies the Icahn School of Medicine’s final evaluation report of THRIV. Its earlier findings are available here.
[1] Meyer, I.H. (2021). TransPop, United States, 2016-2018, (ICSR 37938). Retrieved from https://www.icpsr.umich.edu/web/ICPSR/studies/37938/summary.
[2] Medina, C., Santos, T., Mahowald, & Gruberg, S. (August 2021). Protecting and advancing health care for transgender adult communities. Center for American Progress and NORC at the University of Chicago. Retrieved from https://www.americanprogress.org/wp-content/uploads/sites/2/2021/08/Advancing-Health-Care-For-Transgender-Adults.pdf.
[3] Westafer, L.M., Freiermuth, C.E., Lall, M.D., Muder, S.J., Ragone, E.L. & Jarman, A.F. (2022). Experiences of transgender and gender expansive physicians. JAMA Network Open: Diversity, Equity, and Inclusion, 5(6). Retrieved from https://jamanetwork.com/journals/jamanetworkopen/articlepdf/2793769/westafer_2022_oi_220570_1655908685.2578.pdf.
[4] James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.
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