Trauma informed care

While trans and gender diverse people are strong and resilient, many have experienced trauma during their lifetime. These experiences include (but are not limited to) sexual assault and coercion, intimate partner violence, family violence and violence in healthcare settings.

Trauma informed care is a framework that aims to support people to feel safe, overcome their fear of harm or betrayal, and to build trust between clinicians and patients.

The US’s Substance Abuse and Mental Health Services Administration defines trauma informed care as:

Trauma informed care involves a process that is enacted over time and across an entire organisation. In resisting re-traumatisation, a trans patient should feel that they are being heard, respected, and trusted. This relationship can take time to develop, with the core of this practice being an understanding of trauma and the impact it has.

A key feature of trauma-informed practice is the way in which a service is offered - i.e. the whole context in which it is provided - not just `what’ it entails. As healing from interpersonal trauma occurs in relationship, the wider relational context in which healing takes place is critical.

blueknot.org.au 2

Orygen, The National Centre of Excellence in Youth Mental Health, defines the core principles of trauma-informed care as follows (which you can read more about in their 2018 report 3:

Safety - everyone in an organisation, including clients, partners and family, friends, and staff should feel physically and psychologically safe

Trustworthiness and transparency - decisions are conducted with transparency, which helps to build trust and create clear expectations e.g. Explaining exactly what a procedure will consist of, or the gender of a provider

Collaboration and mutuality - staff working to remove the power imbalance between them and clients, and meaningfully share power and decision-making e.g. informed consent models.

Empowerment - recognising and building on the strengths of clients and their communities, helping them feel and be involved in their own care

Voice and choice - allowing choice to be central in a decision making process, and the voice of the client to be present and heard

Culture, historical and gender issues - implementing policies, protocols, and processes that recognise and are responsive to the racial, ethnic, cultural, gender and sexuality, ability, and communication needs of the client.

By recognising that trauma is a common experience, and that even people who do not share those experiences may benefit from a care model that is trauma informed, we can begin to implement strategies and practices that affirm all people, including their experiences, decisions, and lives.

Positive experiences of relationships are central to trauma recovery. They are also important to general well-being. By employing trauma-informed principles, we can build a ‘trauma-informed’ society. This create possibilities for psychological and physical healing on a grand scale.

Blueknot.org.au

Offering before asking

Consider providing your own name, pronouns, and identity before asking to be trusted with those of your patient. This might be simply starting an appointment by introducing yourself, eg. “Hi, my name is Dr Sarah, and my pronouns are she and her.” Offering can help show your patient that you will listen and understand their identity and language.

Not making assumptions

It is important to recognise that we do not know, nor can we assume, another’s lived experience, or their history of past trauma, regardless of how they may present to us.

For many trans people, negative interactions and past trauma experienced within the healthcare system will impact on their ability to form trusting relationships with new clinicians. Past trauma commonly remains undisclosed by the individual but may be expressed through their communication style, emotional responses or behaviour.

As a clinician, understanding the role that trauma has had on the lives of many trans people will go a long way to building a trusted therapeutic relationship over time.

Making space for complication and silence

Past experiences of trauma can sometimes make otherwise simple conversations and interactions suddenly overwhelming or difficult.

A person may not be able to answer questions regarding their past history, or feel able to share them, and it’s important to make space for these experiences. Trust can take time to develop, and giving it the time it requires is valuable.

Additional time and space may be required for someone to undertake an examination or procedure, with cervical screening being one example that can be distressing. For a trans person who has experienced sexual violence4, or for whom their genitals are a source of mental or emotional discomfort, the procedure may take additional time to complete, and may need to be done with gradual steps or multiple appointments over time.

Using an inclusive patient registration form, like the one below, allows patients to share sensitive information on their own terms and can help build trust.

Collaboration - explaining why things happen

For some trans people, medical interactions can be disempowering when their own expertise regarding their body and experiences are not recognised, nor properly considered by the clinician involved. Medical decisions need to be made collaboratively, and in partnership, between clinician and patient, with consideration for the differing expertise being brought together during the consultation.

Emphasise the possibility of connection

Most of all, building trust requires the development of a respectful, therapeutic relationship, whether you see a trans patient once, or you’re their regular clinician. Building this connection together takes time and practice but can be extraordinarily rewarding. Making mistakes, owning up to your mistakes and taking responsibility for them is part of this process.