Professional Psychology: Research and Practice 2012, Vol. 43, No.

5, 452 459

2012 American Psychological Association 0735-7028/12/$12.00 DOI: 10.1037/a0029604

Effects of Violence on Transgender People

Rylan J. Testa, Laura M. Sciacca, and Florence Wang
Palo Alto University

Michael L. Hendricks
Washington Psychological Center, P.C., Washington, DC

Peter Goldblum
Palo Alto University
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Judith Bradford
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 EvidenceBased 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 selfdestructive 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 Diversity and Community Mental Health. Primary research interests and activities have focused upon investigating the influence of different cultural variables upon suicide, analyzing barriers to care seeking among underserved and high-risk populations, and examining applications of community mental health principles, particularly program development and evaluation. 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 452

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 Research (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

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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 conversations. 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 understanding of who is included in transgender. To date, no population-based studies have been conducted. Typically, convenience 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 experienced was primarily attributable to their gender identity or expression (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 demonstrated 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

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& 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 psychological 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 experience (Steiner, Blanchard, & Zucker, 1985; Stoller, 1968). Alternatively, 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 specific 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 combination 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), implemented by the Community Health Research Initiative (CHRI) of Virginia Commonwealth University, was a multiphase, multiyear 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, environmental, 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.

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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, substance abuse, and suicidal ideation and attempts (Bradford et al., 2007). Survey questions addressed perceived trans-related discrimination 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 identity. Participants were required to be 18 years or older and residents 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 support 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).

were also asked, In how many of these cases was your transgender 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, methamphetamine, 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 transgender persons who lived in or attended school in Virginia. Participants 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 assigned 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 subgroups, 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 mandate of reporting to law enforcement any harm done to children.

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 attack(s)? with a write-in response format. Sexual violence. Sexual violence was evaluated with the single question, Since the time you were 13 years old, have you ever been forced to engage in unwanted sexual activity?2 with response options of Yes or No. Those who answered Yes,

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Rankin, 2011). This wider exposure may increase the frequency, and possibly even the intensity, of related violence and its effects. Demographic information and prevalence of violence, suicidal ideation, suicide attempt(s), and substance abuse are presented in Table 1 for trans women and trans men subgroups, the subjects of this analysis.

Data Analyses
Logistic regression was used to analyze the association between each of the independent variables (physical violence and sexual violence) and the binary dependent variables: history of suicidal ideation, history of suicide attempt(s), past alcohol problem, and past illicit drug use. All analyses were duplicated with age entered as a control variable to ensure that age did not account for any significant relationships. Ordinal logistic regression was used to analyze the association between each of the independent variables, physical violence and sexual violence, and the dependent variable, number of past suicide attempts. These analyses were completed for each of the two subgroups, trans women and trans men. All statistical analyses were performed using SPSS Version 19.

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violence. Almost all individuals who had experienced physical violence (97.7%) reported that in at least one of these instances, gender identity or expression was the primary reason for the violence. Similarly, 89.2% of those who experienced sexual violence reported that their gender identity or expression was the primary reason for the violence. Physical violence was most often perpetrated by a complete stranger (47.4%), acquaintance (27.1%), family member (23.3%), or primary partner (14.3%), while sexual violence was most often perpetrated by an acquaintance (48.4%), family member (33.3%), complete stranger (25.8%), or primary partner (24.7%). Acts of violence were infrequently reported to police, with only 11.1% of physical violence and 9.1% of sexual violence reported. Rates of physical violence did not differ significantly by age, SES, race/ethnicity, or between trans men and trans women. Rates of sexual violence also did not differ significantly by age, race/ethnicity or between trans men and trans women. However, those with higher SES reported fewer occurrences of sexual violence (annual household incomes above $100k; 2 7.65, p .006).

Effects of Physical Violence

Suicidal ideation. Trans women who had experienced a physical 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 physical violence were also significantly more likely to report a history of a suicide attempt in comparison to those who had not experienced physical violence (46.5% vs. 13.7%, respectively; age adjusted 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 significant for trans men (see Table 2). Substance abuse. For trans women, history of physical violence 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.

Results Violence
Overall, a substantial portion of participants in the analysis sample were victims of past physical (38.0%) or sexual (26.6%) Table 1 Overall and Subgroup Demographic Information for Trans Participants
Trans women (n 179) Age M (SD) Race/ethnicity Caucasian/White African-American Latino/Latina Other Socioeconomic status Low ( $30K/year) Middle High ( $100K/year) Education Some high school High school/GED Associates degree Some college College graduate Some grad school History of suicidal ideation History of suicide attempt Victim of physical violence Victim of sexual violence Past alcohol problem Past illicit drug use 40 (12.4) (%) 65.4 20.1 5.6 8.9 33.0 42.5 19.6 10.0 14.5 11.2 24.6 17.9 21.2 65.3 26.3 39.7 24.6 16.8 74.3 Trans men (n 92) 30 (10.7) (%) 71.7 15.2 2.2 10.9 43.5 43.5 9.8 1.1 12.0 5.4 46.7 15.2 19.6 83.0 30.4 45.7 34.8 32.6 77.2

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

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.

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Table 2 History of Physical Violence and Number of Suicide Attempts

Trans women (n 179) No physical violence n (1 Attempt) % n (2 Attempts) % n (3 Attempts) % This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Physical violence n (1 Attempt) % n (2 Attempts) % n (3 Attempts) % Age adjusted odds ratio 6 5.9 2 2.0 6 5.9 10 14.1 12 16.9 11 15.5 5.30 p .001 Trans men (n 92) 6 12.8 1 2.1 2 4.3 1 2.4 7 16.7 11 26.2 4.36 p .006

trans victims of violence, including high prevalence of victimization due to gender identity or expression, low reporting of incidents 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 1 6% (Weissman et al., 1999). For both trans women and trans men, both forms of violence were associated with history of suicide attempt. Of additional 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

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.

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%, respectively; age adjusted odds ratio 3.20, p .020). Additionally, trans women who had experienced sexual violence were significantly 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 substance use was not significant for trans men.

Table 3 History of Sexual Violence and Number of Suicide Attempts

Trans women (n 179) No Sexual Violence n (1 Attempt) % n (2 Attempts) % n (3 Attempts) % Sexual violence n (1 Attempt) % n (2 Attempts) % n (3 Attempts) % Age adjusted odds ratio 12 9.0 7 5.2 7 5.2 4 9.1 7 15.9 10 22.7 4.21 p .001 Trans men (n 92) 3 5.2 3 5.2 5 9.6 4 12.5 5 15.6 8 25.0 4.72 p .004

Discussion
The analyses presented were undertaken in order to investigate the psychological effects of having experienced physical and sexual 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

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.

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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.

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 resources have been developed for community and school-based prevention interventions through organizations such as Community United Against Violence (CUAV; www.cuav.org), FORGE (forge-forward.org), and the Human Rights Campaigns Welcoming Schools Program (www.welcomingschools.org). Consistent with evidence suggesting a high level of gender-based victimization 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 individuals. Program and policy development should be done with consideration of the primary sources of violence against trans people. To address the prevalence of violence from family members, programs 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 experiencing 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; Kenagy & 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 working 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 specifically cover working with trans victims.

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 strangersand 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.

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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 recruited through service providers, trans support groups, and informal 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 information, 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.

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 (ClementsNolle 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 address 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 violence that is perceived to be related to ones gender identity or expression disproportionately increases distress, compared to violence motivated by other reasons. Such violence leads to internalized 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. Experiences 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 participants 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 individuals 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 developing and implementing evidence-based treatments designed particularly 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, including 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 environments 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 examine 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 resilience 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.

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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. Factors 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 reporting 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