Culturally Competent Service Provision to Lesbian, Gay, Bisexual and Transgender Survivors of Sexual Violence
Sabrina Gentlewarrior With contributions from Kim Fountain
Sexual violence is a public health issue and epidemic (Basile, Chen, Black & Saltzman, 2007; Hammond, Whitaker, Lutzker, Mercy, & Chin, 2006; Irwin & Rickert, 2005). Nationally, ""11.7 million women and 2.1 million men... experienced forced sex at some point in their lives"" (Basile, et al., 2007, p. 441). While the expansion of sexual violence intervention and prevention in the last three decades has been remarkable, a focus on the needs of lesbian, gay, bisexual and transgender (LGBT) survivors of sexual violence has been largely missing (Morris & Balsam, 2003).
This paper provides an overview of the research focusing on LGBT survivors of sexual violence. For the purpose of this paper, it will be useful for readers to be aware of the meaning given to terms by the author. Sexual violence is defined as sexual abuse occurring at any time in the lifespan, including instances of sexual harassment. Prior to defining the terms of lesbian, gay, bisexual and transgender, it is important to note that the meanings ascribed to these words are influenced by personal, cultural, historical, and societal factors (Cassese & Mujica, 2000; Pierce, 2001; Scheer, et al., 2003). Ideally, these terms are defined by individuals in the way that best fits their life circumstances. The definitions here are offered to facilitate common understanding between readers and the author's intended meaning. Lesbians and gay men are individuals that develop intimate and/or sexual connections with members of the same sex. Homophobia is defined as any attitude or behavior that is predicated in the assumption that heterosexuality is both normative and desirable, resulting in the marginalization of lesbians and gay men at personal, familial, and/or societal levels. Bisexuals are individuals that develop intimate and sexual connections with people regardless of that person's sex. Biphobia is defined as any attitude or behavior that is predicated in the assumption that engaging in intimate/sexual behavior solely with those of the opposite sex is both normative and desirable, resulting in the marginalization of bisexuals at personal, familial, and/or societal levels. Transgender individuals are broadly defined as individuals who feel that their gender is not congruent with their biological sex. Transphobia is defined as any attitude or behavior that is predicated in the assumption that biological sex and gender are binary and synonymous, resulting in the marginalization of transgender individuals at personal, familial and/or societal levels.
Due to historical and current patterns of individual and societal oppression directed at members of LGBT communities, members of these groups are often reluctant to self-identify to others such as service providers or strangers administering surveys, making accurate statistics on the size of these groups difficult to obtain. The 2000 US Census reports that ""nationwide, 594,000 same-sex unmarried-partner households represented 1 percent of all coupled households"" (Simmons & O'Connell, 2003, p. 3). This finding has been critiqued as a severe under-counting of same-sex families (Smith and Gates, 2001). For instance, this Census population estimate also does not take into account non-partnered lesbian, gay, bisexual or transgender individuals. In 2002 the National Survey of Family Growth estimated that ""4.1% of the US populations aged 18 to 44 years (more than 4.5 million individuals) identified as homosexual or bisexual"" (Mayer, et al., 2008, p. 991). The estimates of transgender individuals in the US general population range from 3-10% (Carroll, Gilroy & Ryan, 2002).
Much is still to be learned about the prevalence of LGBT survivors of sexual violence, their needs, and how best to serve them. Sexual violence research has often failed to differentiate heterosexual and/or non-transgender respondents from lesbian, gay, bisexual and transgender ones. This lack of attention to LGBT survivors of sexual violence may be due in part to bias that results in rendering these survivors invisible (Girshick, 2001; Waldner-Haugrud, 1999). While the research on lesbian, gay, and bisexual survivors of sexual violence is limited, there is even less information available on transgender survivors of sexual trauma. Those studies that have included LGBT respondents typically recruit them either from LGBT resources and services or draw small sub-samples from larger population-based samples. In addition, when researchers do invite the participation of LGBT survivors, some survivors may hesitate to either report their victimization or identify themselves as sexual or gender minorities in an effort to protect themselves from prejudice and/or discrimination (Bauer & Wayne, 2005; NCAVP, 2008).
As a result, the majority of these studies have methodological limitations that include non-representative samples, limited statistical power in their analyses, and a possibility that some respondents identified as being heterosexual and/or non-transgender individuals may actually be LGBT individuals (Austin, et al., 2008; Walder-Haugrud, 1999). C omparison across studies examined for this paper is difficult due to the lack of consistency in the different research studies' sampling techniques employed, definitions of trauma utilized, and range and number of variables examined. In view of the current limitations of the scholarship focusing on LGBT survivors of sexual violence, much of the information presented here is an important, yet preliminary, discussion of the topic.
This paper offers a brief review of research focusing on LGBT survivors of sexual trauma. The paper will conclude with an overview of the theoretical and empirical literature focusing on providing culturally competent services to LGBT survivors of sexual violence.
Importance of Including LGBT Survivors in our Anti-violence Work
Herman (1997) has written eloquently regarding the stigma that trauma workers can experience due to society's discomfort with facing the issue of trauma and victimization. This may be even more true for those organizations and individuals that develop outreach, intervention and prevention programs aimed at meeting the needs of LGBT survivors (Girshick, 2002). This then begs the question why we, as clinicians, activists, educators, and researchers, should focus our efforts on serving LGBT survivors of sexual violence. First, we have an ethical mandate to serve all survivors and end all oppressions (APA, 2000; NASW, 1996; NASW 2001). The National Sexual Violence Resource Center as well as the National Resource Center on Domestic Violence ñ two premiere organizations leading the violence intervention and prevention efforts nationally ñ have also both committed themselves to addressing all forms of domestic and sexual violence.
The rape and domestic violence intervention movements began with the understanding that the cultural underpinnings of and reliance on power and control lead to sexual and domestic violence. Sexual violence has been conceptualized as one mechanism used to maintain unequal and discriminatory sex role rights and expectations and support a status quo that empowers males and disempowers females (Robinson, 2003; Women's International Network News, 2002; Witten & Eyler, 1999). Similarly, sexual violence aimed at lesbians, gay men, bisexuals and transgender individuals has been perceived as a violent attempt to keep those who are deemed socially inferior in terms of sexual and gender expression ""in line"" (Gentlewarrior, Martin-Jearld, Sweetser, Skok & Langevin, 2007/2008; HaleyNelson, 2005; Kidd & Witten, 2007/2008; Lombardi, Wilchins, Priesling & Malouf, 2001; Sullivan, 2003; Wilets, 1997; Witten & Eyler, 1999).
People perceived to be deviating from sexual and gender norms are often sexually targeted. Willis (2004) summarizes this point: ""society's constructions of sexuality, socioerotic identity, and gender identity have consequences"" (p. 125). For example, boys who display behaviors typically viewed as feminine in nature are at an increased risk for all kinds of victimization ñ including sexual trauma (Brady, 2008); this can place gay and bisexual boys at greater risk for child sexual abuse. Lesbians and bisexual females experience sexual abuse based in both gender bias and homophobia/biphobia. When speaking about sexual violence across the lifespan, HaleyNelson (2005) states:
the penalty for women who do not conform to gender and sexuality standards is sexual violence such as rape, forced sodomy, and sexual slavery. Lesbians [and bisexual women], as more obvious gender and sexuality nonconformers, are targeted more frequently and severely for sexualized, physical violations"" (167).
Transgender individuals are often targeted by sexual perpetrators because of their gender non-conformity (Kidd & Witten, 2007; Lombardi, et al., 2001; Mizock & Lewis, 2008). This point was illustrated by a transgender female respondent in a qualitative research study when she discussed her ""ëpunishment for deviating from gender norms. She shared how prior to her gender transition she was raped as an 11-year-old boy by two older boys who said, ëYou wanna be a girl? Well this is how girls get treated'"" (Gentlewarrior, et al., 2007/2008, p. 15).
In addition, when gay men are raped by strangers they ñ like heterosexual women ñ are likely to be blamed for their trauma experience and perceived as unconsciously desiring victimization (Wakelin & Long, 2003). Finally, Aoesved & Long (2006) suggest ""that there are interrelationships between sexism, racism, homophobia, ageism, classism, and religious intolerance and rape myth acceptance at both the individual level and across individuals at the cultural level"" (p. 489). Our work must include LGBT survivors not only because it is right, but as suggested by this information, because it is necessary in order to create a comprehensive response to sexual violence.
Types and Incidence of LGBT Sexual Violence
Research has often failed to differentiate verbal harassment that is specifically sexual in nature from that which is predicated upon other aspects of homophobia, biphobia and transphobia. Based on available information, however, sexual harassment is a form of sexual trauma that many LGBT individuals experience. Fineran's (2002) work on sexual harassment in junior and high school settings found that sexual harassment must be considered one of the factors correlated with the fact that ""when gay, lesbian and bisexual students were compared to their peers, they were four times more likely to have attempted suicide and five times more likely to have missed school because of feeling unsafe"" (p. 67). These post-harassment reactions are understandable when one considers that i n addition to typical age-appropriate developmental tasks, LGBT youth often face the realization that their sexuality and/or gender identity expression is in conflict with the societal standards held by many for normalcy. Failing to find positive depictions of sexual and gender minorities in the media, and, as is too often the case, to receive emotional and/or financial support from families and friends, the harassment experienced by some LGBT youths may be especially traumatic (K. Fountain, personal communication, January 20, 2009).
A 2006 American Association of University Women (AAUW) national survey of college students found that 73% of LGBT college students experience sexual harassment (both noncontact and contact forms of abuse), and that 61% of heterosexual and non-transgender counterparts report similar experiences. This harassment is perpetrated not only other by other students, but also by faculty and other college employees. In addition, LGBT students report being more upset by the sexual harassment than their heterosexual and non-transgender peers; "" an estimated 6 percent of all LGBT college students either change their school or their major as a result of sexual harassment"" (AAUW, 2006; p. 32). S exual harassment is a concern for adults in non-educational settings as well. The National Coalition of Anti-Violence Programs (NCAVP), a coalition comprised of 35 organizations dedicated to monitoring, researching, and eliminating violence owing to bias against lesbians, gay men, bisexuals, and transgender individuals, states that over one-third of the hate crimes reported to them in 2007 were verbal and sexual harassment. In the National Lesbian Health Care Survey of 1,925 lesbians, 52% had experienced verbal harassment based in homophobia (Bradford, Ryan & Rothblum, 1993). Almost a quarter of the 213 transgender-identified respondents in the Transcience Longitudinal Research Survey reported experiencing sexual harassment based in gender bias (Kidd & Witten, 2007/2008).
Child Sexual Abuse (CSA)
While only a few studies were identified that included heterosexual as well as lesbian, gay and bisexual respondents in the same study, in each instance the rates of trauma were higher among the LGBT participants. (Table 1 can be found at the end of the document and provides an overview of studies examined in this paper that included LGBT survivors of CSA). Further, the research that has compared the rates of CSA experienced by lesbians of color versus white lesbians is limited. What exists suggests that lesbians of color often experience victimization, including CSA (Bradford, et al., 1993; Descamps, Rothblum, Bradford & Ryan, 2000), at higher rates than do white women (Morris & Balsam, 2003). The authors clearly state that future research needs to have larger samples allowing for different races and ethnicities to be examined separately versus grouping together all women of color in the analysis (Austin, et al., 2008; Bradford, et al., 1993; Descamps, et al., 2000; Hughes, Hass, Razzano, Cassidy & Matthews, 2000; Morris & Balsam, 2003). We are reminded that ""women of color's multiple marginalized status may leave them particularly vulnerable to victimization"" (Morris & Balsam, 2003; p. 82).
Similar to research focusing on general community studies ñ and therefore presumably on largely heterosexual samples (Filipas & Ullman, 2006; Johnson, Pike & Chard, 2001; Thompson, Arias, Basile & Desai, 2002) ñ CSA experienced by lesbians and bisexual women is associated with stress, an overall increased rate of psychological distress, revictimization later in life, depression, alcohol abuse, and high risk sexual behaviors (Bradford, et al., 1993; Descamps, et al., 2000; Morris & Balsam, 2003; Saewyc, et al., 2006).
CSA experienced by gay and bisexual male survivors is characterized by high levels of forced penetration, physical force, instances of multiple perpetrators, and abuse that occurred over an extended period (Paul, et al, 2001). Paul and colleagues (2001) report that the vast majority of gay and bisexual male survivors of CSA found the abuse upsetting at the time of the victimization and approximately half continue to find memories of the trauma upsetting. A range of additional adult difficulties including mood disorders, chemical dependency, and HIV/AIDS subsequent to high-risk sexual behaviors is associated with histories of CSA for gay and bisexual male survivors (Brady, 2008; Brennan, Hellerstedt, Ross, & Welles, 2007; Cassese, 2000; King, 2000; Paul, Catania, Pollack & Stall, 2001; Saewyc, et al., 2006). CSA that occurred on a regular basis was found to be associated with having a ""HIV-positive status, a history of exchanging sex for payment, and current use of sex-related drugs"" in a sample of gay and bisexual men (Brennan, et al., 2007, p. 1110).
In a review of the research examining the violence experienced by transgender individuals, Stotzer (2009) states that ""what becomes clear from surveys of trans-people is that there is a high prevalence of sexual assault and rape starting at a young age"" (pp. 171-172). Xavier, Honnold, and Bradford (2007) state that while their respondents reported on their lifetime victimization rates, the median age of the respondents' first sexual abuse experiences was 14-15 years of age. Similarly, Kidd & Witten (2007/2008) did not differentiate child from adult abuse experiences experienced by transgender respondents, but state that ""much of this abuse and violence is suffered before the age of 18"" (Kidd & Witten, 2007/2008, p. 38).
In view of the high rates of child sexual abuse experienced by LGBT individuals, it is important to address the cultural mythology that seeks to explain homosexuality, bisexuality and transgender identities as a pathological response to child sexual abuse (King, 2000). This deficit-oriented explanation posits that individuals become members of the LGBT communities due to the trauma of child sexual abuse. Recent research refutes this contention. For example, Morris & Balsam (2003) found no evidence that CSA influenced sexual identity of lesbians and bisexual women in their large community-based quantitative study. Tomeo and colleagues' (2001) research echoes this finding, as the majority of both gay men and lesbians in this sample stated that they identified as homosexual prior to their CSA experiences.
Sexual Trauma in Adulthood
Bias related to homophobia, transphobia and biphobia is often directed at LGBT adults in the form of sexual violence. In their 2007 study of anti-LGBT violence, NCAVP states that ""reports of [adult] sexual assault rose 61% from 70 to 113"" in one year (p. 2). It has been estimated that 3-7% of LGBT individuals have experienced sexual trauma due to bias (Herek, Gillis & Cogan, 1999; Rose & Mechanic, 2002). Gays and lesbians are more likely to experience sexual assault, sexual harassment/attempted assault, assault and stalking compared to other groups typically targeted for bias-oriented aggressions known as hate crimes (Dunbar, 2006, p. 323). In addition, crimes against LGBT individuals are likely to be more violent than those motivated by race/ethnicity and religious bias (Dunbar, 2006). The bias-oriented sexual violence experienced by LGBT survivors is often characterized by multiple perpetrators: ""any incident involving multiple perpetrators takes on a more menacing quality when the victim is confronted by a group of assailants"" (Rose & Mechanic, 2002, p. 24). Perceived life threat and the severity of the sexual violence likely contribute to the finding that sexual violence based in bias results in long-term difficulty, including PTSD symptomatology (Rose & Mechanic, 2002). Despite the violence of the crimes, hate crimes motivated by homophobia and transphobia are much less likely to be reported to authorities than other types of hate crimes due to perceived bias in the criminal justice system towards members of LGBT communities (Dunbar, 2006; Herek, Cogan & Gillis, 2002).
Clearly, homophobia, biphobia and transphobia are not the only reasons LGBT individuals are sexually abused in adulthood, however. For instance, while lesbian, gay and bisexual individuals were quite similar in the rates of bias-oriented sexual violence reported, lesbian and bisexual women experienced markedly more instances of sexual violence that were not attributed to homophobia/biphobia compared to gay and bisexual men (Herek, Gillis, Cogan, 1999). It can be inferred that this difference underscores the risk for sexual abuse associated with being female in US culture. (See Table 2 for an overview of studies reviewed for this paper focusing on LGBT adult survivors of sexual violence). While lesbians are slightly less likely to be sexually abused in adulthood than heterosexual women (Bernhard, 2000; Hughes, et al., 2000; Long, Ullman, Long, Mason & Starzynski, 2007), lesbians are more likely to experience gang rape than heterosexual women (Hughes, et al., 2000). In addition, there is some evidence to suggest that lesbians are more likely to be sexually abused after age 14 by relatives than bisexual or heterosexual women (Long, et al., 2007).
Research on the general populationóand therefore on largely heterosexual and non-transgender respondentsóindicates that child sexual abuse is a risk factor correlated with adult sexual trauma experiences (Filipas & Ullman, 2006; Koss & Dinero, 1989; Messman-Moore & Long, 2003). Lesbians, gay men and bisexuals who have histories of child sexual victimization are also more likely to report being sexually traumatized in adulthood (Descamps, et al., 2000; Heidt, Marx, & Gold, 2005). Research examining the sexual violence experiences of lesbians and bisexual women estimates that women who were sexually abused as children are ""four times more likely"" to experience sexual violence and ""about twice as likely"" to experience physical violence in adulthood than those who were not abused as children (Morris & Balsam, 2003, p. 77). Bisexual individuals and gay men who were sexually abused in childhood appear to be even more likely to be revictimized in adulthood than lesbians (Heidt, et al., 2005). As research shows that men are more likely to perpetrate sexual violence than women, this difference in revictimization rates may ""simply be due to the fact that these individuals are more likely to have male sexual partners in adulthood"" than are lesbians (Heidt, et al., 2005, p. 538).
In general, ""the transgender community is disproportionately affected by violence"" (Mizock & Lewis, 2008, p. 336). This is true when considering experiences of sexual violence as well. While research has focused on the lifetime sexual violence experiences of transgender individuals (e.g. Clements-Nolle, Marx, & Katz, 2006; Lombardi, et al., 2001), making it impossible to know when the trauma occurred, rates of sexual violence directed at transgender people over the course of their lives are extremely high: ""the most common finding across surveys and needs assessments is that about 50% of transgendered people report unwanted sexual activity"" at some point in their lives (Stotzer, 2009, p. 172).
In recent years, empirical attention has been placed on the sexual violence perpetrated by intimate partners. In the National Violence Against Women Survey, 7.7% of women and 0.3% of men reported a history of sexual violence in their intimate relationships; this study combined heterosexual and lesbian, gay and bisexual respondents (Tjaden & Thoennes, 2000). Between 44-60% of battered women have reported also being sexually abused in their intimate relationships; the researchers did not inquire about the sexual orientation of respondents (Cattaneo, Deloveh & Zweig, 2008; Howard, Riger, Campbell & Wasco, 2003). Almost a quarter of the heterosexual women seeking services at a medical clinic reported partner-perpetrated sexual violence (Coker, et al., 2000).
Before considering available information on sexual violence that occurs in LGBT relationships, it is important to acknowledge that many academics, intervention workers and survivors are reluctant to call attention to sexual coercion occurring in LGBT intimate relationships due to concern that the information will be used to further solidify prejudice and discrimination against LGBT individuals (Chavis & Hill, 2009; Walder-Haugrud, 1999). While this information must be used in a sensitive and nonbiased manner, it is essential that research and intervention efforts focus on sexual violence in intimate relationships in order to help LGBT survivors face the compounded difficulties of being at risk both in society (Chavis & Hill, 2009), as well as in the most intimate of personal acts. Table 2 provides an overview of studies that examined abuse in LGBT intimate relationships (e.g. Heintz & Melendez, 2006; Turell, 2000).
Due to the lack of adequate research examining prevalence rates of sexual victimization in intimate relationships of heterosexual and LGBT respondents within the same studies, comparison across groups is difficult. One study did find that similar strategies were used by sexually coercive partners in both heterosexual and same sex relationships: perpetrators used alcohol and drugs, guilt, and the perceived emotional vulnerability of their intended victims as part of the sexual coercion (Christopher & Pflieger, 2007).
Little is known about the post-victimization experiences of LGBT survivors of adult sexual abuse. In terms of coping behaviors, the most common post-trauma responses of lesbians and heterosexual women to sexual abuse are to avoid the perpetrator(s), do ""nothing,"" and tell someone the survivor trusts about the sexual victimization (Bernhard, 2000, p. 78). When survivors do tell others about their trauma experiences, bisexual women not only receive less favorable support subsequent to their post-trauma disclosures, but also tell more people about their trauma ñ likely in an attempt to receive support (Long, et al., 2007). Bisexual female survivors also reported higher levels of depression and PTSD than the heterosexual or lesbian women; the authors encourage future researchers to examine whether this reaction was due to the lack of support they receive post-disclosure (Long, et al., 2007). LGBT survivors appear to experience greater symptoms of psychological distress after bias-oriented victimization than victimization that is not predicated in discrimination (Herek et al., 1999).
The studies discussed above have focused on samples largely residing in the United States. Ample evidence exists that sexualized violence directed at LGBT individuals is a world-wide problem as well (Dworkin & Yi, 2003; HaleyNelson, 2005; Hawthorne, 2005/2006; Amnesty International; Kidd & Witten, 2007/2008; Mizock & Lewis, 2008; Wilets, 1997).
Culturally Competent Intervention
This review of the research focusing on LGBT survivors of sexual violence has surfaced the paucity of work in this area. ""Data are a cornerstone of any public health system, and the lack of data on sexual minorities [and transgender individuals] correlates with the failure of public health to address this group's needs"" (Kadour, 2005, p. 31). In addition, the absence of research on sexual and gender minorities hinders the advancement of civil rights (Sell & Becker, 2001), and the creation of best practice intervention strategies. In view of the limited research establishing effective trauma services for LGBT survivors, this information on culturally competent intervention with LGBT survivors is offered as a preliminary introduction to a much-needed discourse in our field.
Clinical theory and research on sexual violence intervention have typically supported the importance of safety, the transformation of the narrative of trauma, and a reconnection with a broader community as key elements in the sexual violence healing process (Bloom, 1997; Briere & Scott, 2006; Herman, 1997). It should be emphasized, however, that aiding survivors in the creation of safety and reconnection with community may very likely be more difficult when working with LGBT survivors of sexual violence. LGBT survivors of sexual violence must contend not only with the aftermath of their sexual violence experiences, but with the systemic victimization of living with pervasive discrimination (Mallon, 2008; Morris & Balsam, 2003). LBGT survivors ""may need specific advice to help find a safe haven in the community"" (McLeod-Bryant, Robinson, Benton, Srinisasaraghavan, Bialer, 2008, p. 39).
Theory and research support the importance of providing culturally competent services to LGBT individuals that effectively attend to cultural norms and characteristics, as well as the ways in which prejudice and discrimination can affect healing processes (Bauer & Wayne, 2005; Gentlewarrior, Martin-Jearld, Skok, & Sweetser, 2008; Girshick, 2002; Heidt, et al., 2005; Witten & Eyler, 1999). Ensuring that our services are culturally competent is key as currently members of LGBT communities may hesitate to seek sexual victimization support services out of fear that if they do not self-identify as lesbian, gay, bisexual and/or transgender that service providers will assume they are heterosexual and/or non-transgender individuals and effectively silence the LGBT survivors from sharing about their identities and lives. On the other hand, if LGBT survivors do come out to service providers, they risk facing discriminatory reactions and services (Long, et al., 2007).
Theoretical and empirical work delineates the three aspects of cultural competence for mental health workers as self awareness, knowledge and skill (Anderson & Holliday, 2007; Gentlewarrior, et al., 2008; Van Den Bergh & Crisp, 2004). First, practitioners need to examine the assumptions and beliefs they have regarding lesbian, gay, bisexual and/or transgender individuals. Broad indicators that attitudinal shifts are warranted include: believing that being heterosexual or non-transgendered is preferable (Crisp, 2006); experiencing discomfort when socially interacting with LGBT individuals; refusing to serve LGBT survivors (Van Den Bergh & Crisp, 2004); and assigning responsibility for clients' issues ñ including their trauma experiences ñ to their sexual orientation or gender construction rather than addressing their presenting issues and the discrimination they may have experienced (Anderson & Holliday, 2007; Van Den Bergh & Crisp, 2004).
Mental health workers are also encouraged to develop LGBT affirmative knowledge and practice skills. Culturally competent practitioners assess clients not only for sexual violence experiences, but other forms of discrimination and their impacts (Gentlewarrior, et al., 2007/2008). LGBT affirming practitioners, educators, researchers and activists also use language ñ both verbally and in written forms and information provided ñ that is inclusive of all individuals (Bauer & Wayne, 2005; Gentlewarrior, et al., 2008; NASW, 2001; Van Den Bergh & Crisp, 2004). In order to serve LGBT survivors of sexual violence, culturally competent practitioners are well informed regarding the groups' historical and current oppression (ACA, n.d.; APA, 2000; Bauer & Wayne, 2005; Carroll, et al, 2002; Van Den Bergh & Crisp, 2004) and are able to discuss with them what role, if any, this oppression has had in their victimization and recovery processes. In addition, culturally inclusive workers are knowledgeable about and able to share information regarding LGBT-specific and sensitive resources ranging from the community to the international levels with those survivors desiring this information (APA, 2000; Girshick, 2002; Mallon, 2008). If these sensitized resources do not exist, it is incumbent upon us to work with the LGBT communities to help create them.
As members of LGBT communities demonstrate a wide variety of different comfort and disclosure levels regarding their sexual and gender identities, effective practitioners are conversant in the information regarding coming out and identity development processes and are able to sensitively explore these issues and their potential impact on the sexual healing process with LGBT survivors (Crisp, 2006). Culturally sensitive practitioners are also able to explore the impact of the trauma on LGBT relationships and families. For example, the shame and secrecy so often experienced by survivors of sexual violence can be compounded for LGBT individuals who may already be dealing with internalized oppression and its accompanying feelings of secrecy and shame (Booker & Dodd, 2008).
It is also important to emphasize that there is vast diversity within LGBT communities. Survivors of LGBT sexual violence not only differ along individual and familial domains, but in terms of their interconnected and multiple identities. Culturally competent work is guided by a commitment to looking at the intersection of all of the clients' (and workers') identities of not only survivor status, gender and sexual orientation, but also race/ethnicity, class, age, religion, (dis)ability status, and others (ACA, n.d.; APA, 2000; Gentlewarrior, et al., 2008; Sell & Becker, 2001; Smith, Foley & Chaney, 2008). Practitioners and researchers are reminded to attend to ""the complex interaction of social identities that are unique to each person we serve"" (Gentlewarrior, et al., 2008. p. 220) as the ""jeopardy"" of discrimination ñ and its resultant difficulties ñ is likely to increase with each disenfranchised status that the survivor embodies. While all workers should engage in the development of a culturally competent knowledge and skill base, agencies need to hire workers at all levels of the organization that reflect the diversities of those we serve (NASW, 2001).
Finally, while not all acts of sexual violence experienced by LGBT individuals are due to bias, the preceding discussion supports the contention that in order to decrease the incidence of sexual violence experienced by these groups, hate crimes and other forms of discrimination experienced by LGBT individuals must be addressed. As of June 2009, only 31 states and Washington DC have legislation addressing hate crimes based in sexual orientation; 12 states and Washington DC have similar laws addressing hate crimes based in bias directed at transgender individuals (Human Rights Campaign, n.d.). Attempts to expand the federal hate crime legislation to include hate crimes based on sexual minority or gender identity (The Local Law Enforcement Hate Crimes Prevention Act/the Matthew Sheperd Act H.R. 1592/ S. 1105) have passed the House of Representatives, but remain stalled in the Senate (Human Rights Campaign, n.d.). Culturally competent work with LGBT communities includes helping to create legislation and policies that offer protection and equity for its members (ACA, n.d.; Gentlewarrior, et al., 2007/2008; NASW, 1996; NASW, 2001). As policies and legislation regarding LGBT individuals are a quickly evolving area, readers are encouraged to consult the Human Rights Campaign and the National Gay and Lesbian Task Force, two of the largest LGBT civil rights groups in the United States, for information on the current status of social policies supporting LGBT rights and equity.
Recommendations and Conclusion
This paper, while offering an overview of issues relevant to LGBT survivors of sexual violence, has some clear limitations. For instance, the lack of research focusing on LGBT survivors of sexual violence, as well as the brevity of this paper, precludes a thorough examination of many of the subjects under consideration. For example, the coming out and identity development processes are unique to each member of the LGBT communities; as such, their influence on the sexual violence healing process is complex. In addition, the experiences and needs of LGBT people of color can differ from their white counterparts due to the additional jeopardy of racism that they experience. The special needs of transgender individuals during medical rape exams is a vitally important topic that needs attention by our field. The impact of sexual violence on LGBT families is also an area that deserves study. These are but a few of the substantively important issues that sexual violence workers must be versed in to provide effective and culturally competent services to LGBT survivors of sexual violence. Readers are encouraged to consult the reference list and web addresses at the end of this paper for additional professional development resources.
This paper has offered some recommendations to those in the sexual violence field in order to effectively serve LGBT survivors of sexual trauma. These include:
1) Engage in ongoing identification and rectification of any attitudes or behaviors predicated in homophobia, biphobia, and/or transphobia.
2) Prioritize the production and dissemination of information focused on LGBT survivors of sexual violence in community-based and peer-reviewed venues.
3) Ensure that our agencies have workers and administrators that reflect the social identities of all of those we serve.
4) Commit to developing a knowledge base about LGBT individuals that includes: a) Information about their historical and current experiences of oppression and b) Knowledge regarding the coming out and identity development processes.
5) Develop and utilize LGBT-affirmative practice models. Initial steps toward this goal include: a) Use of inclusive language verbally and in all written forms and literature; b) Assessment of all survivors for bias as well as non-bias oriented victimizations; and c) Ability to honor clients' multiple and interconnected social identities and effectively serve clients' in view of these identities.
6) Identify ñ or if needed ñ create LGBT community resources dedicated to offering safe, affirming support on a range of issues relevant to members of these communities.
7) Provide professional development opportunities for area agencies focused on the self awareness, knowledge and skills needed to offer culturally competent services to LGBT survivors of sexual violence.
8) Participate in policy and social change work dedicated to providing equity of treatment and acceptance to members of the lesbian, gay, bisexual and transgender communities.
Sexual violence clinicians, educators, activists and researchers have a proud history of joining survivors in naming and addressing the causes and impacts of trauma. Working to ensure equal attention and efficacy in serving lesbian, gay, bisexual and transgender survivors of sexual violence in our clinical, research, education, prevention, advocacy, legislative and policy efforts is an appropriate next step in our work (Bauer & Wayne, 2005; Carroll, Gilroy & Ryan, 2002; Gentlewarrior, et al., 2007/2008; NASW, 2001; Van Den Bergh & Crisp, 2004; Walder-Haugrud, 1999).
Author of this document:
Sabrina Gentlewarrior, Ph.D., LICSW, ACSW
Social Work Department and Office of Institutional Diversity
Bridgewater State College
95 Burrill Avenue
Bridgewater, MA 02325
Kim Fountain, Ph.D.
New York City Gay & Lesbian Anti-Violence Project
Distribution Rights: This Applied Research paper and In Brief may be reprinted in its entirety or excerpted with proper acknowledgement to the author(s) and VAWnet (www.vawnet.org), but may not be altered or sold for profit.
Suggested Citation: Gentlewarrior, S. (2009, September). Culturally Competent Service Provision to Lesbian, Gay, Bisexual and Transgender Survivors of Sexual Violence. Harrisburg, PA: VAWnet, a project of the National Resource Center on Domestic Violence/Pennsylvania Coalition Against Domestic Violence. Retrieved month/day/year, from: http://www.vawnet.org
American Association of University Women (2005). Drawing the line: Sexual harassment on campus. Author: Washington, DC.
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Table 1: Overview of Studies Focusing on LGBT Survivors of CSA
Study Name & Description
National Lesbian Health Care Survey: National sample of 1,925 lesbians completed surveys asking if respondents had """"sex with a relative"""" or were """"raped or sexually attacked by non-relative while growing up"""" (Bradford, et al., 1993; Descamps, et al., 2000, p.34).
Nurses' Health Study: Sample of 63,000 women were asked if they had experienced """"unwanted touching or forced sexual activity"""" when they were 17 years of age or younger (Austin, et al., 2008, p.600).
lesbians 19%; bisexual women 20%; heterosexual women 9%
Chicago Lesbian Community Cancer Project: Convenience sample of 550 lesbians and 279 heterosexual women completed survey asking if """"anyone ever forced you to engage in any form of sex you didn't want to"""" before age 15 (Hughes, et al., 2000, p. 66).
lesbians 41%; heterosexual women 24%
Lesbian Wellness Survey: Community-based national sample of 2,431 lesbian and bisexual women; 25% were women of color; inquired about being """"forced to engage in sexual activities"""" before age 16 (Morris & Balsam, 2003).
39% of lesbians/bisexual women combined
Convenience sample of 155 college students completed a survey asking if """"anyone ever touched you in a sexual way"""" that was unwanted or experienced forced sex (Garcia, et al., 2002, p.10).
53% of lesbians/bisexual women combined; 44% heterosexual women; 36% of gay/bisexual men combined; 10% heterosexual men
311 lesbians, gay men and bisexuals of both sexes recruited at LGBT meetings completed surveys and reported on sexual contact to age 18 (Heidt, et al., 2005).
22% lesbian women; 15% bisexual females and males combined; 19% gay men
Urban Men's Health Study: Telephone probability sample of 2,881 gay/bisexual men asked about experiences of being """"sexually coerced by age 17"""" (Paul, et al., 2001, p. 565).
21% of gay/bisexual men
Nonclinical samples of 942 college students and gay pride attendees completed surveys asking about experiences of """"sexual contact"""" before age 16, with abuser """"being at least 16 years of age and at least 5 years older than victim"""" (Tomeo, et al., 2001, p. 538).
43% lesbians, 25% heterosexual women; 49% gay men; 24% heterosexual men
Twin Cities' Men's Health and Sexuality Study: 936 randomly selected gay/bisexual men attending a LGBT Pride Festival completed survey asking if as a """"child or adolescent"""" they """"were ever forced to have unwanted sexual activity with adults"""" (Brennan, et al., 2007, p. 1108).
16% of gay & bisexual men
Virginia Transgender Health Initiative Study: 350 transgender individuals living in Virginia completed self-administered questionnaires asking about experiences of being """"forced to engage in unwanted sexual activity"""" (Xavier, et al., 2007, p. 21).
35% Trans males; 23% Trans females
Transcience Longitudinal Aging Research Survey: Snowball sample of 213 transgender individuals completed surveys regarding types of bias-related sexual abuse they had experienced (Kidd & Witten, 2007/2008).
15% sexual abuse; 6% rape
Table 2: Overview of Studies Focusing on LGBT Survivors of Adult Sexual Abuse
Study Name & Description
Sample of 2,259 lesbians, gay men, and bisexuals completed survey on victimizations that occurred """"because someone thought you were lesbian, gay or bisexual""""; also asked if victimized for reasons other than bias (Herek, et al., 1999, p. 946).
Lesbians: sexual assault 3% bias, 19% nonbias
Bisexual women: sexual assault 4% bias, 29% nonbias
Gay men: sexual assault 4% bias, 2% nonbias
Bisexual men: sexual assault 7% bias, 5% nonbias
Chicago Lesbian Community Cancer Project: Convenience sample of 550 lesbian and 279 heterosexual women completed survey asking if they were """"forced to have sex"""" (Hughes, et al., 2000, p. 66).
Lesbians: 7% by male partner, 16% by male date, 4% raped by group of men
Heterosexual women: 12% by male partner, 17% by male date, <1% raped by group of men
Convenience sample of 215 lesbian and heterosexual women completed surveys asking if they were """"pressured or forced to engage in any form of sex when you didn't want to""""; ages when traumatized reported (Bernhard, 2000, p. 71).
Lesbians: Ages 20-29 44%; Ages 30-39: 19%; Ages 40-49 0%; Ages 50-59 3%
Heterosexual women: Ages 20-29 49%; Ages 30-39 20%; Ages 40-49 6%; Ages 50-59 11%
National Lesbian Health Care Survey: National Sample of 1,925 lesbians completed surveys examining experiences of being """"raped or sexually attacked"""" (Bradford, et al., 1993; Descamps, et al., 2000).
Lesbian Wellness Survey: Community-based national sample of 2,431 lesbian and bisexual women; 25% women of color. Asked if ever """"forced to engage in sexual activities"""" from age 16 and older (Morris & Balsam, 2003).
Lesbian and bisexual women combined: 36% sexually abused by anyone; 13% sexually abused by male partner; 4% sexually abused by female partner
311 lesbians, gay men and bisexuals of both sexes recruited at LGBT meetings completed surveys; reported on adult sexual abuse and being victimized sexually in childhood and adulthood (Heidt, et al., 2005).
Lesbian women: 21% adult sexual trauma only; 15% sexually victimized as child & adult
Bisexual men & women: 20% adult sexual trauma only; 39% sexually victimized as child & adult
Gay men: 17% adult sexual trauma only; 25% sexually victimized as child & adult
Convenience sample of 51 racially diverse transgender females ages 16-25; completed surveys including reasons they did not use condoms in the last year; """"sex against will"""" was one factor examined (Garofalo, et al., 2006, p.234).
51% transgender females
499 ethnically diverse lesbian, gay, bisexual & transgender individuals completed surveys on same-sex relationship violence; asked about experiences of """"forced sexual activity"""" and """"hurt you during sex against your will"""" (Turrell, 2000, p. 285).
Lesbian & bisexual women combined: 12%
Gay & bisexual men combined: 12%
Transgender individuals: 28% (note: sample was only 7 people; interpret results with caution)
58 lesbian, gay, bisexual and transgender clients of HIV treatment center completed surveys on same-sex violence; """"asked if ever forced to have anal or vaginal penetrative sex ... and if so, if partner used condom"""" (Heintz & Melendez, 2006, p. 199).
Lesbian & bisexual women combined: 27%
Gay & bisexual men combined: 45%
Transgender individuals: 40% (note: sample was only 5 people; interpret results with caution)
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