Professional Psychology: Research and Practice 2012 American Psychological Association

2012, Vol. 43, No. 5, 452 459 0735-7028/12/$12.00 DOI: 10.1037/a0029604

Effects of Violence on Transgender People

Rylan J. Testa, Laura M. Sciacca, Michael L. Hendricks

and Florence Wang Washington Psychological Center, P.C., Washington, DC
Palo Alto University

Peter Goldblum Judith Bradford

Palo Alto University The Fenway Institute, Boston, MA

Bruce Bongar
Palo Alto University and Stanford University School of Medicine

While recent research on transgender populations has demonstrated high rates of experiencing violence,
there has been little research attention to the mental health implications of these experiences. This study
utilized data collected from the Virginia Transgender Health Initiative Survey (THIS) of transgender
people (individuals who described their gender identity as different from their sex assigned at birth)
collected from 20052006. Current study analyses were limited to two subgroups: trans women (n
179) and trans men (n 92). We hypothesized that, as in the general population, exposure to physical
and sexual violence would be related to suicidal ideation, suicide attempts, and substance abuse. Both
trans women and trans men in this sample were at high risk for physical and sexual violence, as well as
suicidal ideation and suicide attempt. Logistic regression analyses indicated that among both trans
women and trans men, those who had endured physical and/or sexual violence were significantly more
likely than those who had not had such experiences to report a history of suicide attempt and multiple
suicide attempts. In addition, among trans men, history of physical and sexual violence were each related
to alcohol abuse. Among trans women, history of sexual violence was related to alcohol abuse and illicit
substance use. Patterns of violence against transgender people were identified and are discussed,
including frequent gender-related motivation for violence, low prevalence of reporting violence to police,
and variety of perpetrators of violence. Clinical implications and recommendations are provided.

Keywords: physical violence, sexual violence, suicide attempt, substance abuse, transgender

This article was published Online First August 13, 2012.
RYLAN J. TESTA, received his PhD in Clinical Psychology from Temple
University. He is Post-Doctoral Fellow at the Center for LGBTQ Evidence-
Based Applied Research (CLEAR). He also serves as Program Manager of
the Gender Identity Program, within The Gronowski Centers Sexual and
Gender Identities Clinic. His research and clinical work focuses on self-
destructive behaviors, including suicidal behavior, substance abuse, eating
disorders, and health risk-taking, in under-served populations.
LAURA M. SCIACCA received her MA in Mental Health Counseling from
Marist College and MS in Clinical Psychology from the Pacific Graduate
School of Psychology at Palo Alto University. Presently, she is pursuing a
Clinical Psychology PhD at Palo Alto University, with emphasis in Diver-
sity and Community Mental Health. Primary research interests and activ-
ities have focused upon investigating the influence of different cultural
variables upon suicide, analyzing barriers to care seeking among under-
served and high-risk populations, and examining applications of commu-
nity mental health principles, particularly program development and eval-
uation.
FLORENCE WANG earned her BA from the University of California, Santa
Cruz. Currently, she is a third year PhD student at the Pacific Graduate
School of Psychology at Palo Alto University, with an area of emphasis in
the Diversity and Community Mental Health track. Her primary research
interests include suicidology research, with a focus on ethnic and sexual
minority populations.
MICHAEL L. HENDRICKS received his PhD in Clinical Psychology from The
American University. He maintains a clinical and forensic practice as a
partner at the Washington Psychological Center, P.C., in Washington, D.C.
His areas of professional interest include suicidology, LGBT issues, and
forensic evaluation.
PETER GOLDBLUM, PhD, MPH received his PhD from the Pacific Graduate
School of Psychology (now Palo Alto University) in 1984. He is Professor
of Psychology, Director of the Center for LGBTQ Evidence-based Re-
search (CLEAR), Director of the LGBTQ Area of Emphasis, and Director
of the Sexual and Gender Identities Clinic at Palo Alto University. Dr.
Goldblums main area of research is the impact of sexual and gender
minority stress on the psychological well-being of LGBT people.
JUDITH BRADFORD, PhD, is Co-Chair of the Fenway Institute at Fenway
Health and Director of the Center for Population Research in LGBT
Health. She conducts research and program evaluation to address health
concerns of sexual and gender minorities, with a specific emphasis on
community-based participatory research.
BRUCE BONGAR, PhD, ABPP received his PhD from the University of
Southern California in 1977. He is the Calvin Professor of Psychology at
the Pacific Graduate School of Psychology at Palo Alto University, and
Consulting Professor in the Department of Psychiatry and the Behavioral
Sciences at Stanford University School of Medicine. Dr. Bongars main
research focus for many years has been on suicidal behavior and other
clinical emergencieswith a particular interest on standards of care and
risk management.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Rylan
J. Testa, Palo Alto University, 1791 Arastradero Avenue, Palo Alto, CA
94304. E-mail: testa.ry@gmail.com

452
 EFFECTS OF VIOLENCE ON TRANSGENDER PEOPLE
The effects of violence against women and sexual minorities
have received a great deal of attention over the past 30 years.
Trans1 people, however, have largely been left out of both con-
versations. This is true despite indications that they experience
high levels of both physical and sexual violence (Clements-Nolle,
Marx, & Katz, 2006; Kenagy & Bostwick, 2005; Lombardi,
Wilchins, Priesing, & Malouf, 2001; Risser et al., 2005; Xavier,
Bobbin, Singer, & Budd, 2005). Research on sexual minorities
often omits trans people and/or assumes that their findings will be
equally informative to this population. With the recent increasing
visibility of trans people, there is greater awareness that specific
attention to trans people is necessary to identify not only patterns
and effects of violence shared across groups, but also those factors
that are specific to trans individuals (IOM, 2011). This article
begins to address this complex issue.
Over the past 15 years, needs assessment and behavior risk
surveys of trans individuals have addressed gaps in understanding,
including the prevalence of violence (Clements-Nolle et al., 2006;
Kenagy & Bostwick, 2005; Lombardi et al., 2001; Risser et al.,
2005; Xavier et al., 2005). Attempts to survey the trans community
remain particularly challenging due to a tendency for silence
surrounding issues related to gender identity or expression, the
geographic dispersion of this population, and variability in under-
standing of who is included in transgender. To date, no
population-based studies have been conducted. Typically, conve-
nience sampling is used to generate a study population.
Nevertheless, rates of violence reported in these surveys have
consistently demonstrated that trans individuals are subjected to
high rates of both physical and sexual violence (Bradford, Xavier,
Hendricks, Rivers, & Honnold, 2007; Clements-Nolle et al., 2006;
Kenagy & Bostwick, 2005; Lombardi et al., 2001; Risser et al.,
2005; Xavier et al., 2005). Needs assessment surveys have found
that 43 60% of participants report past experiences of physical
violence (Kenagy & Bostwick, 2005; Lombardi et al., 2001;
Xavier et al., 2005) and 43 46% report they had been victims of
sexual assault (Clements-Nolle et al., 2006; Kenagy & Bostwick,
2005; Xavier et al., 2005). While no comparative samples were
gathered as a part of these studies, findings consistently exceed
estimates of violence experienced in the general U.S. population
(Basile, Chen, Lynberg, & Saltzman, 2007; Tjaden & Thoennes,
2000).
Across these studies, researchers have also found that survey
participants consistently reported that the violence they had expe-
rienced was primarily attributable to their gender identity or ex-
pression (Clements-Nolle et al., 2006; Kenagy & Botswick, 2005;
Risser et al., 2005; Stotzer, 2009; Xavier et al., 2005). Gender
nonconforming behaviors, as well as disclosing or exposing ones
gender identity, have been previously identified as risk factors for
violence among trans people (Lombardi et al., 2001; Stotzer, 2009;
Wyss, 2004).
While the high rates of violence inflicted on trans individuals
due to gender identity or expression have been documented, the
cumulative effect of such violence in this community has received
scarce attention. Studies in the general population have demon-
strated that both a history of physical violence and of sexual
violence places victims at a greater risk for mental health issues
including substance abuse and suicidal behavior (Davidson,
Hughes, George, & Blazer, 1996; Hughes, McCabe, Wilsnack,
West, & Boyd, 2010; Kilpatrick et al., 1985; Malinosky-Rummell
453
& Hansen, 1993; Silverman, Reinherz, & Giaconia, 1996; Ullman
& Najdowski, 2009).
Recent studies have also demonstrated a high rate of suicidal
ideation, suicide attempts, and substance abuse among trans people
(Clements-Nolle et al., 2006; Grant et al., 2010; Xavier et al.,
2005). Xavier, Bobbin, Singer, and Budd (2005) found that of their
248 participants, 38% reported a history of suicidal ideation, 16%
reported having attempted suicide, and 48% reported a history of
substance abuse. In Clements-Nolle, Marx, and Katzs (2006)
sample of 515 participants, 32% reported having attempted suicide
and 28% reported having had alcohol or drug treatment. Although
suicide attempt rates vary, they are consistently alarmingly higher
than the rate of 1 6% found in the general population (Weissman
et al., 1999).
In such an understudied population, the reasons for psycholog-
ical distress have been open to speculation. It has been suggested
that these difficulties are primarily related to the experience of
being trans, as well as the gender dysphoria that one may experi-
ence (Steiner, Blanchard, & Zucker, 1985; Stoller, 1968). Alter-
natively, psychological distress and related suicide attempts and
substance abuse may be attributable to the repeated experiences of
victimization among trans individuals detailed above. Meyers
(2003) Minority Stress Model for LGB individuals describes how
hostile and stressful social environments (p. 674) faced by LGB
individuals result in various mental health risk factors, including
stress related to the incident, negative expectancies concerning
future victimization, internalized homophobia, and concealment.
Hendricks and Testa (in press) have proposed an adaptation of
Meyers model for trans individuals to address ramifications spe-
cific to gender identity and expression. This adaptation uses both
Meyers (2003) model and Joiners (2010) theory of suicidal
behavior to explain suicide attempts as resulting from a combina-
tion of the particular stresses encountered by trans individuals and
an absence of belongingness that ordinarily fosters resilience in the
face of such stresses (Hendricks & Testa, in press).
Using this adapted model, in these analyses we hypothesized
that, as in the general population, exposure to physical and to
sexual violence would each be independently related to suicidal
ideation, suicide attempts, and substance abuse. We also examined
patterns of violence experienced in this sample to begin identifying
factors that may be critical in understanding violence against trans
people.
The Present Study
The Virginia Transgender Health Initiative Study (THIS), im-
plemented by the Community Health Research Initiative (CHRI)
of Virginia Commonwealth University, was a multiphase, multi-
year project, culminating in a statewide survey of trans people
living in and/or attending school in Virginia (Bradford, Reisner, &
Honnold, in press; Bradford et al., 2007). The principal research
questions of the initial survey were to identify the social, environ-
mental, and structural risk factors associated with HIV and other
health consequences in this population and to examine how trans
1
In this article, we use trans to refer to the range of persons who
identify or present as transsexual, transgender, or gender nonconforming.
Proposed by Lev (2004), this term has met with broader acceptance than
many other terms that have been previously proposed or used.
454 TESTA ET AL.
people access medical and mental health services. Construction of
the survey questionnaire was informed by an earlier phase of
THIS, in which qualitative data were collected from focus groups
of trans individuals (Bradford et al., 2007; Xavier et al., in press).
The survey was based upon a model that proposed that the social
stigma of being trans and its manifestations (e.g., discrimination,
violence) are the root cause of a number of poor somatic and
mental health outcomes, including HIV-positive serostatus, sub-
stance abuse, and suicidal ideation and attempts (Bradford et al.,
2007). Survey questions addressed perceived trans-related discrim-
ination in health care, employment, and housing.
The survey was distributed in both paper and Internet versions
in English and in a paper version in Spanish, in order to reach a
diverse group of trans people throughout all regions of Virginia.
Since terminology to self-identify or refer to transgender and
gender nonconforming people varies, eligibility criteria in terms of
gender was operationalized as: having lived or wanting to live
full-time in a gender opposite their birth or physical sex; having or
wanting to physically modify their body to match who they feel
they really are inside; or having or wanting to wear the clothing of
the opposite sex, in order to express an inner, cross-gender iden-
tity. Participants were required to be 18 years or older and resi-
dents of or attending school in Virginia. A financial incentive of
$15 was paid to each participant who requested it. Participants who
wished to receive the incentive submitted a form (via Internet for
those who completed the survey online; via mail for those who
completed the paper form) on which they indicated that they had
completed the survey and provided a name and address to whom
a $15 money order was subsequently mailed. The money orders
were mailed with the payee field left blank.
Participants were recruited through service providers, trans sup-
port groups, and informal peer networks. Data were collected from
September 2005 through July 2006. In order to obtain a diverse
sample of trans people, THIS team members recruited participants
from all five of Virginias health districts and from participants in
urban, suburban, and rural areas. In addition, the team collected an
oversampling of African American participants to ensure that
comparisons could be made between Virginias two largest racial/
ethnic groups: Whites and African Americans.
A detailed description of the methodology of the study and a
more complete analysis of the demographic variables is reported in
Bradford, Reisner, and Honnold (in press).
Survey Questions
The survey questionnaire is contained in the technical report,
which is available for download at http://tinyurl.com/c4jwhr7.
Physical violence. Physical violence was evaluated with the
single question, Other than the incidents already mentioned [in
the previous question], since the time you were 13 years old, have
you ever been physically attacked? with response options of
Yes or No. Those who answered Yes, were also asked, In
how many of these cases was your transgender status, gender
identity or expression the primary reason for the physical at-
tack(s)? with a write-in response format.
Sexual violence. Sexual violence was evaluated with the sin-
gle question, Since the time you were 13 years old, have you ever
been forced to engage in unwanted sexual activity?2 with re-
sponse options of Yes or No. Those who answered Yes, mandate of reporting to law enforcement any harm done to children.
were also asked, In how many of these cases was your transgen-
der status, gender identity or expression the primary reason for the
forced engagement in unwanted sexual activity? with a write-in
response format.
Suicidal ideation and attempts. Participants were asked,
Have you ever thought about killing yourself? with response
options of Yes or No. Participants who answered Yes were
asked, Have you ever tried to kill yourself? Those who answered
Yes to this question were then asked, How many times have
you tried to kill yourself? with write-in response format.
Alcohol abuse. Participants were asked, Has drinking EVER
been a problem for you? with response options of Yes and
No.
Illicit substance use. Participants were asked to indicate
whether they had ever used the following substances: heroin,
cocaine, crack cocaine, hallucinogens, club drugs, methamphet-
amine, PCP, or poppers. Examples of each drug class were listed.
Those who responded Yes to any item were classified as having
a history of illicit substance use for this analysis.
Participants
The full THIS sample consisted of 350 self-identified transgen-
der persons who lived in or attended school in Virginia. Partici-
pants in the sample were predominantly White, low to middle class
individuals, representing a wide range of education levels and
ranging in age from 18 to 69 (M 37, SD 12.7). Prior
qualitative and quantitative research has indicated fundamental
differences in the development and experiences among different
subgroups of the trans community (Beemyn & Rankin, 2011;
Hwahng & Nuttbrock, 2007). Recent work on the experiences of
trans people recognize four subgroups: (a) assigned males at birth
who transitioned or would like to transition at some point to
identify consistently as women or trans women, (b) assigned
females at birth who have transitioned or would like to transition
at some point to identify consistently as men or trans men, (c)
assigned males at birth who do not identify consistently or totally
as men and do not desire to transition full-time to living as women
or trans women, and (d) assigned females at birth who do not
identify consistently or totally as women and do not desire to
transition full-time to living as men or trans men (Beemyn &
Rankin, 2011). Dividing our sample based on assigned sex at birth
and history of or intention to transition full-time, our four
subgroups were comprised of: (a) 179 trans women, (b) 92 trans
men, (c) 50 nontransitioning trans people who were assigned male
at birth, and (d) 29 nontransitioning trans people who were as-
signed female at birth.
The focus of this article is limited to the first two subgroups
trans women and trans men, as research has revealed that these
subgroups, unlike the two nontransitioning subgroups, share many
experiences of identity development (Beemyn & Rankin, 2011)
which may influence the risk for violence and the psychological
effects of violence. For example, unlike nontransitioning sub-
groups, trans women and trans men subgroups live full-time as a
gender different from their sex assigned at birth so their trans
status must be revealed in a wider range of settings (Beemyn &
2
The age 13 cutoff was used in order to avoid invoking Virginias
 EFFECTS OF VIOLENCE ON TRANSGENDER PEOPLE 455

Rankin, 2011). This wider exposure may increase the frequency, violence. Almost all individuals who had experienced physical
and possibly even the intensity, of related violence and its effects. violence (97.7%) reported that in at least one of these instances,
Demographic information and prevalence of violence, suicidal gender identity or expression was the primary reason for the
ideation, suicide attempt(s), and substance abuse are presented in violence. Similarly, 89.2% of those who experienced sexual vio-
Table 1 for trans women and trans men subgroups, the subjects of lence reported that their gender identity or expression was the
this analysis. primary reason for the violence. Physical violence was most often
perpetrated by a complete stranger (47.4%), acquaintance (27.1%),
Data Analyses family member (23.3%), or primary partner (14.3%), while sexual
violence was most often perpetrated by an acquaintance (48.4%),
Logistic regression was used to analyze the association between family member (33.3%), complete stranger (25.8%), or primary
each of the independent variables (physical violence and sexual partner (24.7%). Acts of violence were infrequently reported to
violence) and the binary dependent variables: history of suicidal police, with only 11.1% of physical violence and 9.1% of sexual
ideation, history of suicide attempt(s), past alcohol problem, and violence reported. Rates of physical violence did not differ signif-
past illicit drug use. All analyses were duplicated with age entered icantly by age, SES, race/ethnicity, or between trans men and trans
as a control variable to ensure that age did not account for any women. Rates of sexual violence also did not differ significantly
significant relationships. Ordinal logistic regression was used to by age, race/ethnicity or between trans men and trans women.
analyze the association between each of the independent variables, However, those with higher SES reported fewer occurrences of
physical violence and sexual violence, and the dependent variable, sexual violence (annual household incomes above $100k; 2
number of past suicide attempts. These analyses were completed 7.65, p .006).
for each of the two subgroups, trans women and trans men. All
statistical analyses were performed using SPSS Version 19. Effects of Physical Violence
Suicidal ideation. Trans women who had experienced a phys-
Results
ical violence were significantly more likely to report a history of
suicidal ideation in comparison to those who had not experienced
Violence physical violence (81.7% vs. 53.5%, respectively; age adjusted
Overall, a substantial portion of participants in the analysis odds ratio 3.83, p .001). However, this relationship was not
sample were victims of past physical (38.0%) or sexual (26.6%) significant among trans men.
Suicide attempts. Trans women who had experienced phys-
Table 1 ical violence were also significantly more likely to report a history
Overall and Subgroup Demographic Information for Trans of a suicide attempt in comparison to those who had not experi-
Participants enced physical violence (46.5% vs. 13.7%, respectively; age ad-
justed odds ratio 5.13, p .001). The relationship between
Trans women Trans men physical violence and suicide attempt was also significant for trans
(n 179) (n 92)
men (45.2% vs. 19.1%, respectively; age adjusted odds ratio
Age 3.52, p .009).
M (SD) 40 (12.4) 30 (10.7) In addition to being at greater risk of attempting suicide, trans
(%) (%) women who had experienced physical violence reported a greater
Race/ethnicity
Caucasian/White 65.4 71.7 number of suicide attempts in comparison to those who had not
African-American 20.1 15.2 experienced physical violence. This association was also signifi-
Latino/Latina 5.6 2.2 cant for trans men (see Table 2).
Other 8.9 10.9 Substance abuse. For trans women, history of physical vio-
Socioeconomic status
lence was not found to be associated with history of alcohol abuse.
Low ( $30K/year) 33.0 43.5
Middle 42.5 43.5 However, past alcohol abuse was significantly more likely among
High ( $100K/year) 19.6 9.8 trans men who had experienced physical violence compared to
Education those who had not (46.3% vs. 23.9%, respectively; age adjusted
Some high school 10.0 1.1 odds ratio 3.03, p .027). Past illicit drug use was not found to
High school/GED 14.5 12.0
Associates degree 11.2 5.4 be associated with history of physical violence for trans women or
Some college 24.6 46.7 trans men.
College graduate 17.9 15.2
Some grad school 21.2 19.6 Effects of Sexual Violence
History of suicidal ideation 65.3 83.0
History of suicide attempt 26.3 30.4 Suicidal ideation. Trans men who had been forced to engage
Victim of physical violence 39.7 45.7 in unwanted sexual activity were more likely to report past suicidal
Victim of sexual violence 24.6 34.8
Past alcohol problem 16.8 32.6
ideation in comparison to those who had not experienced sexual
Past illicit drug use 74.3 77.2 violence (96.7% vs. 75.4%, respectively; age adjusted odds ratio
9.36, p .036). This relationship was not significant for trans
Note. Trans women individuals assigned male at birth who have transi-
tioned or plan to transition to living full-time as women; Trans men
women in our sample.
individuals assigned female at birth who have transitioned or plan to transition Suicide attempts. Trans men who had experienced sexual
to living full-time as men. violence were also more likely to report history of a suicide
456 TESTA ET AL.

Table 2 trans victims of violence, including high prevalence of victimiza-

History of Physical Violence and Number of Suicide Attempts tion due to gender identity or expression, low reporting of inci-
dents to police, and variety of sources of violence.
Trans women Trans men
(n 179) (n 92)
Effects of Violence Consistent With the General
No physical violence Population
n (1 Attempt) 6 6
% 5.9 12.8 Among trans people in our sample, both physical and sexual
violence were related to having a history of suicidal ideation,
n (2 Attempts) 2 1
% 2.0 2.1 history of suicide attempts, higher number of attempts, and to
substance abuse. This is consistent with distress and negative
n (3 Attempts) 6 2 coping responses seen in the general population as a result of
% 5.9 4.3 physical and sexual violence (Davidson et al., 1996; Hughes et al.,
Physical violence 2010; Kilpatrick et al., 1985; Malinosky-Rummell & Hansen,
n (1 Attempt) 10 1 1993; Silverman et al., 1996; Ullman & Najdowski, 2009).
% 14.1 2.4 The relationship between violence and mental health was clear
in this sample. Over two thirds reported a history of suicidal
n (2 Attempts) 12 7
ideation. Physical abuse was related to suicidal ideation in trans
% 16.9 16.7
women and sexual violence was related to suicidal ideation in trans
n (3 Attempts) 11 11 men. Furthermore, an alarming 26.3% of trans women and 30.4%
% 15.5 26.2 of trans men reported a history of suicide attempts. These numbers
are striking compared to the estimated lifetime prevalence of
Age adjusted odds ratio 5.30 4.36
p .001 p .006 suicide attempt in the general population of 1 6% (Weissman et
al., 1999). For both trans women and trans men, both forms of
Note. Trans women Individuals assigned male at birth who have transi- violence were associated with history of suicide attempt. Of addi-
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 tional concern is the high number of suicide attempts reported per
to living full-time as men. 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
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 Table 3
ratio 3.60, p .001). History of Sexual Violence and Number of Suicide Attempts
In addition to being at greater risk of attempting suicide, past
Trans women Trans men
sexual violence was associated with a greater number of suicide (n 179) (n 92)
attempts in both trans women and trans men (see Table 3).
Substance abuse. A history of experiencing sexual violence No Sexual Violence
n (1 Attempt) 12 3
was also found to be associated with a history of alcohol abuse in % 9.0 5.2
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- n (2 Attempts) 7 3
tively; age adjusted odds ratio 3.20, p .020). Additionally, % 5.2 5.2
trans women who had experienced sexual violence were signifi-
n (3 Attempts) 7 5
cantly more likely to report past illicit substance use as compared % 5.2 9.6
to those who had not experienced past sexual violence (90.7% vs.
70.1%, respectively; age adjusted odds ratio 4.08, p .012). Sexual violence
However, the relationship between sexual violence and illicit sub- n (1 Attempt) 4 4
% 9.1 12.5
stance use was not significant for trans men.
n (2 Attempts) 7 5
Discussion % 15.9 15.6

The analyses presented were undertaken in order to investigate n (3 Attempts) 10 8

the psychological effects of having experienced physical and sex- % 22.7 25.0
ual violence among trans people. We found that, like nontrans Age adjusted odds ratio 4.21 4.72
victims of violence (Davidson et al., 1996; Hughes et al., 2010; p .001 p .004
Kilpatrick et al., 1985; Malinosky-Rummell & Hansen, 1993;
Note. Trans women Individuals assigned male at birth who have
Silverman et al., 1996; Ullman & Najdowski, 2009), trans victims transitioned or plan to transition to living full-time as women; Trans men
of violence experience higher risk of suicidal ideation, suicide Individuals assigned female at birth who have transitioned or plan to
attempts, and substance abuse. We also explored factors specific to transition to living full-time as men.
 EFFECTS OF VIOLENCE ON TRANSGENDER PEOPLE
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 networks complete 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.
457
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.
458 TESTA ET AL.

Our research findings demonstrate links between violence and Transgender, and Gender Nonconforming People, Version 7
mental health effects in trans individuals, as have been established (which can be accessed at www.wpath.org).
in the general population. In this sense, clinicians should feel
comfortable utilizing existing evidence-based treatments to ad- Applied Research
dress the effects of trauma on mental health in trans clients.
It is recommended that psychologists take leadership in devel-
However, the violence that trans people face specifically related to
oping and implementing evidence-based treatments designed par-
gender identity or expression may have additional ramifications.
ticularly for trans survivors of trauma. Since the preponderance of
The adaptation of Meyers (2003) Minority Stress Model proposed
findings demonstrate that violence is often perceived to be related
by Hendricks and Testa (in press) delineates ways in which vio-
to gender (Clements-Nolle et al., 2006; Kenagy & Bostwick, 2005;
lence that is perceived to be related to ones gender identity or
Lombardi et al., 2001; Risser et al., 2005; Xavier et al., 2005), it
expression disproportionately increases distress, compared to vio-
will be useful for research studies to specifically investigate the
lence motivated by other reasons. Such violence leads to internal-
effects of this violence on trans individuals mental health, includ-
ized transphobia, which can involve negative self-appraisal and
ing their acceptance of their gender identity and comfort with
rejection of this critical aspect of the persons sense of self, as well
expressing their gender in the world. As a result, treatments may
as expectations for future rejection and/or victimization. Experi-
be augmented or redesigned to address any found gender-specific
ences of violence related to ones gender, alongside these resultant
consequences of violence in this population. It will also be useful
sources of stress, may also lead to concealment of ones trans
to assess how intersectionality of identities influences rates of
identity or expression. For example, more than half of the partic-
violence, mental health effects of violence, and resilience.
ipants in Beemyn and Rankins (2011) study reported that they had
Longitudinal studies are needed to better ascertain the pathways
concealed their trans identity. Concealment also distances the
between violence and mental health outcomes in this population.
individual from community resources that may otherwise be a
Future research can advance current knowledge by assessing more
source of resilience. Concealment, internalized transphobia, and
details about violence, such as the frequency, severity, and envi-
expectations of future violence, may also exacerbate hesitancy to
ronments in which gender-based violence occurs. In addition,
seek help, which may in turn prolong or intensify distress.
standardized measures of mental health symptomatology will help
Clinicians should therefore also be comfortable assessing and
to establish the impact of violence on this community. Similarly,
treating these unique issues. Clinicians may find it helpful to ask
future research should better inquire as to the lethality of suicide
questions about how experiences of violence relate to a clients
attempts, by asking about expectations of outcome by attempters
experience of their gender, their expectations for how their gender
and the need for medical attention. In addition, the temporal
will be received by others, their choices about concealment, and
proximity of these attempts to experiences of violence should be
their ability to access resources and resilience through engagement
assessed in future studies. Further, research should begin to exam-
with community resources. By establishing and maintaining good
ine whether experiences of violence are also related to completed
therapeutic rapport with trans clients, and providing a safe space in
suicide among trans individuals.
which clients can explore their experiences and beliefs related to
In addition to identifying elements of risk, it is crucial that
gender, clinicians create an opportunity for clients to break through
psychologists examine buffering experiences or aspects of resil-
the cycle of distress and concealment. Working within their own
ience that might differentiate those trans people who are better able
orientation, clinicians can utilize cognitive, behavioral, relational,
to cope with violence, such as those described by Hendricks and
or other techniques to further address internalized transphobia and
Testa (in press). Similarly, aspects of families and communities
negative expectations for future events, and facilitate access to
that are predictive of safe environments for trans people should be
community-based resources and resilience.
identified. Once these factors are better understood, psychologists
Finally, as was true of our sample in seeking help from police,
can incorporate this into programs and policy initiatives aimed at
clinicians should be aware that trans clients may be hesitant to seek
family and community.
out or may be distrustful of psychologists as well. Prior research
has demonstrated that trans peoples reluctance in this regard may
Conclusion
stem from past experiences of discrimination or rejection in health
care settings, perceived higher risk of discrimination or rejection This article reviews the literature addressing the impact of
based on others accounts, and suspected risk of being denied violence on trans individuals and provides an analysis of the first
access to transition-related medical care if they divulge mental reported state-level survey of trans men and trans women. The
health concerns (Bockting, Knudson, & Goldberg, 2006). For rates of physical and sexual violence were found to be very high in
many in the trans community, continued inclusion of Gender this sample of trans men and trans women. This violence was
Identity Disorder diagnosis in the DSMIVTR is interpreted as shown to be associated with suicidal ideation, suicide attempt,
offensive or even hostile. To address these particular hesitancies increased number of suicide attempts, and substance abuse. Fac-
trans people may have in seeking mental health treatment, it is tors specific to trans victims of violence were identified, including
recommended that psychologists who are working with trans in- high reported prevalence of violence related to gender identity or
dividuals familiarize themselves with both Bockting, Knudson, expression, varied sources of this violence, and low rate of report-
and Goldbergs (2006) Counseling and Mental Health Care of ing these incidents to police. As increased attention is devoted to
Transgender Adults and Loved Ones (which can be accessed at the trans community in popular culture and research, psychologists
http://transhealth.vch.ca/resources/careguidelines.html), and The have a clear opportunity to act by increasing understanding of the
World Professional Association for Transgender Healths impact of violence on trans individuals mental health, and by
(WPATH, 2011) Standards of Care for the Health of Transsexual, responding with appropriate prevention and treatment efforts.
 EFFECTS OF VIOLENCE ON TRANSGENDER PEOPLE
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Received December 25, 2011
Revision received June 10, 2012
Accepted June 20, 2012