Intimate Partner Violence (IPV) Screening and Referral Outcomes among Transgender Patients in a Primary Care Setting

Abstract

Transgender patients are at elevated risk of intimate partner violence (IPV), but national guidelines do not recommend routine screening for this population. This paper explores the feasibility and effectiveness of routine IPV screening of transgender patients in a primary care setting by describing an existing screening program and identifying factors associated with referral and engagement in IPV-related care for transgender patients. An IPV “referral cascade” was created for 1,947 transgender primary care patients at an urban community health center who were screened for IPV between January 1, 2014 to May 31, 2016: (a) Of those screening positive, how many were referred? (b) Of those referred, how many engaged in IPV-specific care within 3 months? Logistic regression identified demographic correlates of referral and engagement. Of the 1,947 transgender patients screened for IPV, 227 screened positive. 110/227 (48.5%) were referred to either internal or external IPV-related services. Of those referred to on-site services, 65/103 (63.1%) had an IPV-related appointment within 3 months of a positive screen. IPV referral was associated with being assigned male at birth (AMAB) versus assigned female at birth (AFAB) (AOR = 2.69, 95% CI 1.52, 4.75) and with nonbinary, rather than binary, gender identity (AOR = 2.07, 95%CI 1.09, 3.73). Engagement in IPV-related services was not associated with any measured demographic characteristics. Similar to published rates for cisgender women, half of transgender patients with positive IPV screens received referrals and two-thirds of those referred engaged in IPV-specific care. These findings support routine IPV screening and referral for transgender patients in primary care settings. Provider training should focus on how to ensure referrals are made for all transgender patients who screen positive for IPV, regardless of gender identity, to ensure the benefits of screening accrue equally for all patients.

Keywords

intimate partner violence transgender health integrated primary care behavioral health community health centers

Background

Transgender individuals, whose gender identity does not align with sex assigned at birth, experience comparable or greater rates of intimate partner violence (IPV) than the general US population (Brown et al., 2015). In the United States, 10 million people experience IPV each year,¹

See data from National Coalition Against Domestic Violence (NCADV), https://ncadv.org/statistics

and the lifetime prevalence of physical IPV is 31.5% among women and 27.5% among men (Breiding et al., 2014). Although nationally representative surveillance data do not exist for transgender individuals, a large national survey study of over 27,000 transgender individuals found that 35% of respondents reported physical IPV, and 19% of respondents reported being sexually assaulted by a partner within their lifetime (James et al., 2016). A recent systematic review and meta-analysis found that transgender people may be as much as 2.2 times more likely to experience physical IPV and 2.5 times more likely to experience sexual IPV compared to cisgender individuals (Peitzmeier et al., 2020). Specific subpopulations within the transgender community may be at even higher risk, such as those who are homeless, engage in sex work, or are undocumented (James et al., 2016). In one study that investigated the prevalence of IPV among primary care patients of diverse gender identities, the likelihood of experiencing physical or sexual abuse was 5.0 times higher among male to female (MTF) transgender patients, 2.4 times higher among female to male (FTM) transgender patients, and 3.0 times higher among nonbinary patients compared to cisgender (i.e., gender identity aligns with gender assigned at birth) female patients (Valentine et al., 2017).

Healthcare settings are a critical access point for IPV services (Day & James, 2018; McCloskey et al., 2006), but transgender individuals face numerous barriers when accessing trans-competent healthcare, including 33% of transgender individuals who report negative experiences such as discrimination or abuse when accessing healthcare in the last year (James et al., 2016). Cisgender women who want to formally disclose IPV often disclose to their healthcare providers (Feder et al., 2006), due to the trust many patients place in healthcare providers and the implementation of universal screening guidelines. However, these guidelines apply only to certain patient groups (MacMillan et al., 2009). The United States Preventive Services Task Force (USPSTF) and the American Academy of Family Physicians (AAFP) recommend screening “women of childbearing age” with no clear guidance on screening transgender patients, although the AAFP does note higher IPV rates among sexual and gender minorities (USPSTF, 2013; Dicola & Spaar, 2016). The American College of Obstetrics and Gynecologists (ACOG) similarly recommends that all women be screened, including lesbian and bisexual women, but has not issued clear guidance on transgender men, transgender women, or nonbinary individuals (American College of Obstetrics and Gynecology [ACOG], 2011, 2012a, 2012b). Although healthcare settings are often the place where cisgender women formally disclose abuse, transgender individuals face systemic barriers, including untrained providers and exclusion from screening recommendations.

Universal or routine IPV screening in primary care settings is controversial globally (WHO, 2013). While routine IPV screening has been shown to increase IPV detection, some large trials have shown no benefit in terms of decreasing future IPV victimization or improving quality of life (O’Doherty et al., 2015), leading the World Health Organization and others to recommend IPV screening for symptomatic women only, for example, those presenting with an injury (WHO, 2013). Nonetheless, there has also been no evidence that screening is associated with harm (MacMillan et al., 2009; O’Doherty et al., 2015; Spangaro et al., 2009; Taket et al., 2004).

One reason why screening alone may not be associated with benefits is that patients who screen positive may be unsuccessful in connecting with IPV-specific recovery services (MacMillan et al., 2009). Due to methodological barriers, relatively few studies have examined rates of referral to and engagement in appropriate care after a positive IPV screen. These limitations include small sample sizes of individuals who screen positive in some primary care settings (McNutt et al., 2009), lack of routine documentation by clinicians of positive screens (Gerber et al., 2005), and the need to recruit and interview patients who screen positive to determine whether or not they subsequently engage with referred services (Klevens et al., 2012; Raissi et al., 2015). However, one of the larger prospective studies done to date found that 90% (475/528) of patients with positive IPV screens accepted an on-site referral to IPV-related services, and 48.9% (258/528) engaged in follow up care 3–6 weeks after a positive screen (Krasnoff & Moscati, 2002). Importantly, routine screening that connects individuals experiencing IPV with services—preferably via immediate, on-site, or “warm” referral—may also improve quality of life and reduce victimization. Indeed, a meta-analysis of qualitative studies concluded that patients valued both being screened and referred to IPV-specific resources by their providers (Feder et al., 2006).

Given the importance of successful referrals to effective screenings, improving clinician referral processes for transgender patients to IPV services is critical if IPV screening for transgender patients is to be made routine. IPV screening and referral performance in primary care settings has not yet been investigated among transgender patients, even though transgender patients may actually be at increased risk of IPV compared to cisgender patients (Brown et al., 2015; Langenderfer-Magruder et al., 2016; Valentine et al., 2017). The current study is a retrospective electronic health record (EHR) review designed to evaluate routine IPV screening, referral to, and engagement in IPV-related services among transgender patients at an urban, LGBTQ-focused community health center with in-house violence recovery program (VRP) and behavioral health (BH) services. Previous analyses at this same health center found that trans patients of all genders reported higher rates of past-year physical or sexual IPV (6.6–12.1%) as compared to their cis female patient peers (2.7%) (Valentine et al., 2017), which matches patterns found across a variety of samples (Peitzmeier et al., 2020). The health center serves a large transgender patient population, and the EHR includes an IPV documentation sheet where receipt of in-house VRP and BH services is recorded. This represents an ideal test case to examine the acceptability and efficacy of routine IPV screening of transgender patients, because clinicians can perform a “warm referral” to co-located, trans-competent violence prevention services. The focus of our analysis was to create an “IPV Screening and Referral Cascade” (Kirst et al., 2012), similar to cascade or continuum-of-care frameworks used in HIV treatment, to understand at which steps transgender patients may be lost to care even under these ideal clinical settings for IPV screening and referral (Figure 1).

Figure 1.

IPV Screening and Referral Cascade.

Methods

Study Setting and Population

Fenway Health is an LGBTQ-focused, federally qualified community health center in Boston, Massachusetts. In addition to primary care services, Fenway Health has on-site Behavioral Health (BH) services and a VRP, such that immediate or “warm” referrals are possible.

Patients were included in the analysis if they were transgender primary care patients and screened positive for IPV at any medical visit between January 1, 2014 and May 31, 2016. Patients were identified as transgender if they were enrolled in the trans health program (THP) at Fenway Health. The THP helps identify patients who are transgender regardless of social, medical, or surgical transition status, and is used to identify transgender patients for automated screening reminders. In our analysis, we categorize transgender patients according to (a) sex assigned at birth (SAAB, assigned female at birth (AFAB) or assigned male at birth (AMAB)) and (b) gender identity, which we grouped into binary (i.e., male/masculine or female/feminine) or non-binary identities (gender identity falls outside of the traditional gender binary structure, including identities such as genderqueer) (Fenway Institute, 2020). While patients use diverse and evolving terms to describe their identities, we use “transmasculine” as an umbrella to describe individuals AFAB with more binary identities such as transgender man, and “trans feminine” to describe individuals AMAB with more binary identities such as transgender woman, for the purposes of this manuscript. Patients self-identified as either transmasculine, trans feminine, or gender queer on their intake forms.

IPV Screening and Assessment

Healthcare providers at Fenway Health screen all primary care patients for IPV using a four-item questionnaire adapted from the validated abuse assessment screen (AAS) and self-administered on an electronic tablet (Reichenheim & Moraes, 2004; Valentine et al., 2017; Wiist & McFarlane, 1999). A medical assistant gives patients the tablet in private while waiting for their provider in an exam room; patients can opt in or out of the IPV screener. Results are transmitted electronically to the EHR and appear immediately so that they are accessible to the provider during their interaction with the patient. Data were collected from January 1, 2014 to May 31, 2016 and included n = 1,947 transgender patients screened for IPV where n = 334 were identified as screening positive for past-year IPV. Screening questions addressed four potential types of IPV occurring within the last year: (a) isolation (Have you felt isolated, trapped or like you are walking on eggshells?), (b) coercive control (Has your partner controlled where you go, who you talk to, or how you spend money?), (c) sexual IPV (Has someone pressured or forced you to do something sexual that you didn’t want to do?), and (d) physical IPV (Has someone hit, kicked, punched, or otherwise hurt you?). The first question addressing isolating behavior featured low specificity for capturing true instances of IPV, that is, 80% of patients who reported isolation IPV and no instance of any other type of IPV informed their provider during subsequent discussion that they were not being abused or there was no further record in the EHR. Given this finding, patients who screened positive only for isolation IPV were excluded from the present analysis due to insufficient specificity. Additionally, one other patient was excluded due to no date or screening question information after data query, yielding n = 227 transgender patients with positive IPV screens in the final sample.

Patients are screened at medical visits including annual physicals and episodic care appointments. Given that patients are often eligible for multiple different screening questionnaires for conditions such as depression and substance use, Fenway Health utilizes a scheduler (ePRO) to determine eligibility and prioritizes screens based on insurance requirements, visit type, and screen frequency. Given this complexity, the total number of transgender patients eligible to be screened within the study time period is not available. This analysis instead focuses on the 1,947 screened and 227 patients who screened positive for past-year IPV.

Data Collection

A structured query language (SQL) query was used to identify all transgender patients who had undergone IPV screening during the study period, the results of the screening, and demographic and other patient information available in discrete fields in the EHR (e.g., number of past medical appointments, insurance status). Records of patients who had a positive IPV screen were manually reviewed to extract information on (a) whether a referral was completed to internal resources within Fenway Health; (b) whether a referral was completed to external community resources; and (c) whether a patient engaged in care by completing an appointment at one of Fenway Health’s internal resources within 3 months of the positive IPV screen. A completed referral was defined as when (a) a patient accepted a referral (i.e., agreed to accept or learn about IPV resources, versus declining a conversation with their provider about available services) and (b) the referral was documented in EHR within the provider’s clinical note. Referral was categorized as not attempted if there was no record of the referral in the EMR. In order to track referral outcomes, referrals were separated into (a) internal referrals to Fenway Health’s BH or VRP and (b) external referrals to outside violence prevention and recovery organizations and/or peer groups. Retrospective data review also collected data on internal follow-up appointments after a positive IPV screen. A patient was considered “engaged in care” if an attended appointment was recorded in the EHR with either BH or VRP within 3 months of a positive screen and referral. While VRP appointments are specific to violence-related care, the exact reason for BH appointments was not available to the researchers due to patient privacy considerations. Engagement in care at external resources was not recorded in the medical record and thus was not assessed in this study. However, due to the strength of in-house services, patients were largely referred to internal services (94% of patients with a referral received an internal referral; just 7 patients received an external referral only).

Data Analysis

Pearson’s chi-squared, Fisher’s exact test, or two-sample t-tests were used to compare demographic factors among (a) patients who were referred vs those who were not referred and (b) patients who engaged in care vs those who did not engage in care, to identify differences between these groups. Multivariable logistic regression models were then used to assess adjusted associations between demographic factors (e.g., sex assigned at birth, gender identity) and the outcomes of (a) IPV referral and (b) engagement in care. Due to small sample sizes, only variables that were significant in the first analyses were included in the regression models.

Results

Referral Cascade

Of the 1,947 transgender patients who were screened between January 1, 2014 and May 31, 2016, n = 227 (11.7%) screened positive for IPV (Figure 1). Of those patients with a positive screen, 110 (48.5%) received a referral. Of the patients who received a referral, n = 103 (93.6%, “internally referred”) received an internal referral to either BH or VRP services. Of those who did not receive an internal referral (n = 7, “no internal referral”), four received an external referral only, while three received an unknown type referral (i.e., specifics of referral not documented). Of those who received a referral (n = 110), none had a BH appointment in the three months prior to the positive screen. Of patients who were internally referred to either BH or VRP services, n = 65 (63.1%, “internally engaged”) completed a BH or VRP appointment within 3 months of their positive IPV screen (n = 49 BH only, n = 11 BH and VRP, n = 5 VRP only). Of those 117 people who screened positive for IPV but did not receive a referral, 29 had a behavioral health appointment prior to the positive screen. Of those 29 people, 12 were AFAB and 17 were AMAB. In a sensitivity analysis where these 29 individuals were counted as having received a referral in order to account for the potential explanation that providers declined to provide a referral on the belief that these patients were already receiving services, we still observed significant differences between referral rates for AMAB and AFAB individuals (sensitivity analysis not shown).

Figure 2.

Referral Cascade.

Factors Associated with Referral

Among transgender patients screening positive for IPV, there were significant demographic differences between those referred to IPV-related services and those who did not receive a referral (Table 1). Specifically, patients who were assigned female at birth (AFAB) were significantly less likely to receive a referral compared to those male assigned at birth (AMAB) (35.6% n = 32 vs. 56.9% n = 78, p = .002).

Table 1.

Demographic Correlates of Receiving a Referral Following a Positive IPV Screen (n = 227).

Referral Prevalence within Group
	n/total n	%	Chi-square or Fisher’s Exact
Sexual orientation
Bisexual	16/35	45.7	p = .867
Don’t know	10/16	62.5
Lesbian, gay, or homosexual	27/50	54.0
Not reported	13/29	44.8
Something else	25/54	46.3
Straight or heterosexual	16/36	44.4
Unknown	3/7	42.9
Race/Ethnicity
American Indian or Alaska native	1/1	100.0	p = .401
Asian	2/4	50.0
Black or African American	7/16	43.8
Multiracial	12/19	63.2
Other	4/7	57.1
Non-Hispanic White	66/151	43.7
Refuse to answer or missing	3/6	50.0
Hispanic or Latino	15/23	65.2
Insurance status
Commercial/private	69/153	45.1	p = .061
Grant	5/5	100.0
Medicaid	21/42	50.0
Medicare	12/18	66.7
Unknown	2/4	50.0
Self-pay	1/5	20.0
HIV status
No	104/220	47.3	p = .059
Yes	6/7	85.7
Sex assigned at birth
Female	32/90	35.6	p = .002
Male	78/137	56.9
Gender identity and sex assigned at birth
Female AMAB	54/105	51.4	p = .001
Nonbinary AMAB	24/32	75.0
Male AFAB	19/58	32.8
Nonbinary AFAB	13/32	40.6
Hormone therapy ever use
No	16/28	57.1	p = .326
Yes	94/199	47.2
Gender affirming surgery
No	87/169	51.5	p = .120
Yes	23/58	39.7
	Mean among referred	Mean among not referred	t-test
Number of medical appointments within the study period	16.5	14.6	p = .377

Stratifying further by binary and non-binary gender identities, there were significant differences across gender identity groups. While the major distinction remained SAAB, with all AMAB individuals more likely to receive a referral than all AFAB individuals, non-binary individuals were more likely to receive a referral than their binary peers assigned the same sex at birth. Among AMAB individuals, non-binary individuals were referred significantly more often than were trans feminine individuals (75.0% n = 24 vs. 51.4% n = 54, p = .02). Among AFAB individuals, these differences were not statistically significant, but non-binary AFAB individuals were referred slightly more often than were transmasculine individuals (40.6% n = 13 non-binary vs. 32.8% n = 19 transmasculine).

There were no significant differences in receiving a referral by sexual orientation, race/ethnicity, insurance status, HIV status, hormone therapy usage, gender-affirming surgeries, or number of medical appointments.

As a subanalysis, we examined whether referral rates differed significantly by demographic characteristics for specific types of IPV, that is, physical IPV, sexual IPV, and coercive control. Among patients who screened positive for physical and/or sexual IPV, disparities in referral rates by SAAB were not significant, though AMAB individuals were slightly more likely to be referred than AFAB individuals (55.7% n = 59 of AMAB individuals vs. 42.0% n = 29 of AFAB individuals, p = .07). However, AMAB individuals were significantly more likely to receive a referral for coercive control compared to AFAB individuals (61.3% n = 19 vs. 14.3% n = 3, p = .001). In a multivariate model (Table 2) controlling for type of IPV experienced, being AMAB was associated with 2.69 times greater odds of receiving a referral compared to being AFAB (AOR = 2.69, 95% CI 1.52, 4.75); non-binary individuals were also more likely to receive a referral compared to binary individuals (AOR = 2.07, 95% CI 1.09, 3.73).

Table 2.

Referral Prevalence by Sex Assigned at Birth (SAAB) and IPV Type.

	AMAB		AFAB
Referral Prevalence	n/total n	%	n/total n	%	Chi-square orFischer’s Exact
Physical and/or sexual	59/106	55.7	29/69	42.0	p = .07
Controlling	19/31	61.3	3/21	14.3	p = .001

Patients Engaged in IPV-related Care

Among patients who ultimately received an internal referral after a positive IPV screen, there were no significant differences between patients who engaged in care compared to those who did not engage in care within 3 months of the screen and referral by sex assigned at birth, race, sexual orientation, insurance status, hormone use, or gender-affirming surgery (Table 3). In multivariate models, sex assigned at birth, gender identity, and number of medical appointments were all unassociated with engagement in IPV-related services (Table 4).

Table 3.

Demographic Correlates of Engaging in Care Following an Internal Referral (n = 110).

Internally Engaged Prevalence within Group
	n/total n	%	Chi-square or Fisher’s Exact
Sexual Orientation
Bisexual	8/16	50.0	p = .442
Don’t know	6/10	60.0
Lesbian, gay, or homosexual	16/27	59.3
Not reported	9/13	69.2
Something else	17/25	68.0
Straight or heterosexual	10/16	62.5
Unknown	0/3	0
Race/Ethnicity
American Indian or Alaska native	0/1	0	p = .391
Asian	2/2	100.0
Black or African American	4/7	57.1
Multiracial	7/12	58.3
Other	3/4	75.0
Non-Hispanic White	40/66	60.6
Refuse to answer or missing	0/3	0
Hispanic or Latino	10/15	66.7
Insurance status
Commercial/private	39/69	56.5	p = .688
Grant	3/5	60.0
Medicaid	14/21	66.7
Medicare	8/12	66.7
Unknown	2/2	100.0
Self-pay	0/1	0
HIV status
No	64/104	61.5	p = .215
Yes	2/6	33.3
Sex assigned at birth
Female	20/32	62.5	p = .732
Male	46/78	59.0
Gender identity and sex assigned at birth
Female AMAB	31/54	57.4	p = .806
Nonbinary AMAB	15/24	62.5
Male AFAB	13/19	68.4
Nonbinary AFAB	7/13	53.8
Hormone therapy ever use
No	10/16	62.5	p = .292
Yes	56/94	59.6
Gender-affirming surgery
No	50/87	57.5	p = .292
Yes	16/23	69.6
	Mean among engaged	Mean among not engaged	t-test
Number of medical appointments within the study period	17.7	14.6	p = .311

Table 4.

Logistic Regression of Referral Outcome and Engaged in IPV Care by Sex Assigned at Birth, Gender Identity, and Type of IPV.

	Referred (n = 110 of n = 227 Positive Screen)		Internally Engaged in Care (n = 65 of n = 103 Internal Referral)
	Bivariate OR	Multivariate AOR	Bivariate OR	Multivariate AOR
	OR (CI 95%)	OR (CI 95%)
Sex assigned at birth
Female	1.0 (ref)	1.0 (ref)	1.0 (ref)	1.0 (ref)
Male	2.40 (1.38, 4.14)*	2.69 (1.52, 4.75)	0.99 (0.41, 2.38)	1.02 (0.42, 2.51)
Gender identity
Binary	1.0 (ref)	1.0 (ref)	1.0 (ref)	1.0 (ref)
Nonbinary	1.69 (0.94, 3.03)	2.07 (1.09, 3.73)	0.98 (0.42, 2.29)	0.98 (0.42, 2.29)
Type of IPV
Physical & sexual	1.0 (ref)	1.0 (ref)	1.0 (ref)	1.0 (ref)
Controlling	0.73 (0.38, 1.35)	0.69 (0.35, 1.31)	0.81 (0.31, 2.11)	0.80 (0.30, 2.14)

Discussion

Routine IPV screening in an urban community health center with embedded, trans-competent behavioral health and violence recovery services resulted in referral to and engagement in IPV-related services among transgender patients: 48.5% of eligible patients received a referral, and of those, 63.1% engaged in care within 3 months. Although there are higher rates of IPV and different barriers to providing IPV services among transgender patients than cisgender women, studies examining cisgender women IPV screening provide the most robust benchmark: in those studies, referral rates range from 50% to 90% and engagement rates range from 23% to 48.9% (Gerber et al., 2005; Krasnoff & Moscati, 2002; Raissi et al., 2015). Our study’s referral and engagement rates are comparable to those referral and engagement rates found in studies of cisgender women, demonstrating that similar referral and engagement rates can be achieved with on-site, trans-competent IPV-related recovery services for transgender patients following screening. Transgender patients experiencing IPV are willing to disclose and receive referrals in the primary care setting and to use the IPV-related services recommended to them, when those services are co-located and patients are confident they will be treated respectfully. This study also found that there were significant differences in rates of IPV referral by SAAB, gender identity, and type of IPV. Specifically, patients who were AMAB had 2.69 times greater odds of receiving a referral compared to patients who were AFAB, and nonbinary patients had 2.07 times the odds of receiving a referral compared to binary patients. Interestingly, the magnitude of the disparity by SAAB in referral rates was greater when patients screened positive for coercive control than when patients screened positive for physical and/or sexual IPV; rates of referral were particularly low among AFAB individuals who screened positive for experiencing coercive control. Given that AFAB individuals were no more likely than AMAB individuals to engage in care when they were referred, it is possible that provider practices are driving this disparity in referral receipt. Myths that men and masculine individuals are not likely to experience certain types of IPV (Carney et al., 2007; Paisner, 2018) and high-profile cases of intimate partner homicides of transgender women without similar visibility of IPV perpetrated against transgender men may bias providers toward offering more referrals to their trans feminine AMAB patients (Brammer, 2018; Waters, 2017).

In reality, a recent systematic review demonstrated no difference in IPV victimization prevalence between AMAB and AFAB individuals, nor between binary and non-binary transgender individuals (Peitzmeier et al., 2020). Furthermore, providers may perceive physical or sexual IPV to be more serious than coercive control, despite evidence suggesting similar negative health outcomes (Kramer et al., 2004; Yoshihama et al., 2009). Providers might also be more likely to refer AMAB patients due to differences in IPV frequency or severity that were not collected in this analysis. Because the IPV screener is self-administered while the patient is waiting for the appointment, some providers may have failed to provide a referral because they did not review the positive screen until after the appointment. However, this explanation does not explain significant disparities by gender identity. Within this study among those not referred, 24.7% (n = 29) had an appointment with BH or VRP prior to the screening suggesting providers may not have referred patients who they believed were already engaged in care. Individuals of all genders who screen positive for IPV should have equal access to services. Future research should include qualitative work with providers and patients to understand why AMAB patients are referred at higher rates than are AFAB patients who screen positive for IPV. Further, primary care settings may wish to consider not just universal screening but “assessment” and “universal education and anticipatory guidance” approaches that provide information and referrals about IPV regardless of whether a patient actually screens positive for IPV (Conron et al., 2017). These approaches recognize that not all patients feel comfortable disclosing violence and abuse, an issue that may be particularly relevant for transgender patients who disproportionately experience discrimination and abuse in medical settings (James et al., 2016). Furthermore, providing referrals to all patients may help reduce provider-driven disparities in making referrals to some patients but not others.

In our study setting, screening was automatically administered by an electronic system while the patient was waiting to see their provider. This may eliminate some disparities in who is screened for IPV since screening happens without provider involvement. Once these patients screen positive for IPV, providers did not exhibit any patterns in issuing referrals based on the number of prior medical appointments, which was our proxy measure for the length of time that the provider may have had a relationship with the patient, or other factors that might present barriers to care, such as insurance status. In many past studies, convincing providers of the “need to screen” or increasing provider comfort and self-efficacy with screening has been a big focus of interventions to improve IPV screening in primary care settings (O’Campo et al., 2011). Our clinic mitigates these issues through how screens are administered. A prior systematic review confirms that patients are most likely to disclose IPV when using a self-administered electronic screener as compared to a face-to-face screener, which is another benefit of this method (Hussain et al., 2015).

Interestingly, this study did not find meaningful differences in the demographics of patients who engaged in care after an internal referral and those who did not do so. Specifically, there were no major differences by number of prior medical appointments, insurance status, gender identity, sexual orientation, hormone therapy use, or gender affirming surgeries. Although lack of significant findings is not conclusive due to small sample sizes, this finding does suggest that all patients, regardless of potential barriers to care (e.g., socioeconomic status, sexual orientation, gender identity, etc.), are able to engage in IPV-related care if referral to easily accessible (i.e., on-site) services is offered. Instead, disparities emerge at the stage of receiving a referral. This finding counters narratives that marginalized groups are “unwilling” to access IPV services when offered and places the onus on providers to provide referrals when indicated.

Virtually all patients for whom a referral was indicated received a referral to an internal resource at Fenway Health rather than an external provider. Fenway Health utilizes an integrated behavioral health model designed to facilitate the connection of primary care patients to mental health services. This integrated care model is validated in both general primary care populations and marginalized populations for improving access, increasing utilization, and providing better patient outcomes (Archer et al., 2012; Campo, 2015; Katon et al., 2010; Keuroghlian, 2018; Minnesota Evidence-Based Practice Center, 2008; WHO & Wonca, 2008). Fenway Health also provides IPV referral to an on-site VRP that includes victim advocates and focuses on LGBTQ patients’ unique needs. This study aimed to quantify the outcome of internal referral and use of trans-competent resources. Having internal services that are familiar to primary care providers may increase provider confidence in making a referral, versus referring to an external, unfamiliar organization. Internal services also allow for a “warm handoff”, where a provider can directly introduce a patient to BH or VRP personnel, potentially increasing the likelihood that a patient will use the service (Pace et al., 2018; Ratzliff et al., 2014). Primary care settings that implement IPV screening should strive to have a mental health provider, social worker, or victim advocate on staff who is able to provide violence recovery services. Where this is not possible, primary care providers have a responsibility to personally familiarize themselves with trans-competent anti-violence services in their community, so that they can make a knowledgeable and confident referral and assist the patient in connecting to the referred service. However, access to trans-competent healing and recovery services is often limited and can be challenging depending on the resource setting.

Limitations include generalizability of this single-site study at an urban, LGBTQ-focused health center that offers both integrated behavioral health and on-site anti-violence services. We would not expect rates of referral or engagement in care to be as high at institutions where co-located trans-competent care is currently not available. Further, we used attendance at a BH or VRP appointment as a proxy for receipt of IPV-related services. While we can assume that patients who engaged with the VRP received IPV-related services, some of the patients who accessed BH services following referral may not have received IPV-related services if other mental health concerns were prioritized. While no patient in the referral group had attended BH services in the prior 3 months, we cannot definitively confirm if they attended an appointment shortly after receiving a BH referral solely because their provider had made them a referral on the basis of a positive IPV screen. However, they were connected with BH services that had the capacity to help the patient heal from past trauma or safety plan around current violence if the patient desired. Finally, this study also only looked at internal engagement (i.e., referral to and engagement in IPV-related services within the health center) and not IPV victimization outcomes (e.g., reduced victimization, enhanced quality of life) and did not obtain data on engagement with external referral services. Six of the 38 patients who did not engage in internal BH or VRP services did also receive a documented referral to an external organization; these patients or others may have chosen to engage in other external services not documented in the EHR.

Despite these limitations, this study presents some of the first data on experiences of transgender patients with IPV screening and referral for IPV-related services in a trans-competent primary care setting. Findings emphasize the feasibility and utility of routine IPV screening among transgender primary care patients, who are currently excluded from national screening guidelines despite experiencing higher rates of IPV, and similar rates of engagement in IPV-related services after receiving a referral from their primary care provider. Organizations such as USPSTF should move toward inclusion of transgender people in guidelines for routine IPV screening, but this move must be accompanied by increased resources allocated toward making trans-competent violence recovery and behavioral health services more widely accessible if screening and referral are to be successful in this population. Marked disparities emerged between AFAB and AMAB patients in our sample, with AFAB patients much less likely to actually receive a referral from their provider after a positive screen for coercive control. This finding highlights potential gaps in provider training surrounding which segments of the transgender community are at-risk for IPV. Given IPV victimization rates as high or higher in transgender communities as compared to cisgender communities, primary care encounters represent important and currently underutilized opportunities to identify and connect transgender survivors of IPV with services.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Kirsten J. H. Das

Sarah Peitzmeier

Author Biographies

Kirsten J. H. Das, MD, is an obstetrics and gynecology resident at the George Washington University in Washington, DC. Her research efforts have focused on underserved populations, especially LGBTQ patients with a focus on reproductive health, preventive care, and telemedicine.

Sarah Peitzmeier, PhD, MSPH, is an assistant professor in the Department of Health Behavior and Biological Sciences at the University of Michigan School of Nursing. She is a mixed-methods researcher focusing on violence and sexual health in marginalized populations, especially LGBTQ communities.

Iman K. Berrahou, MD, is an obstetrics and gynecology resident at the University of California, San Francisco. Research and clinical interests include health disparities, LGBTQ health, medical education, and gynecologic surgery.

Jennifer Potter, MD, is a professor of medicine at Harvard Medical School, Co-Chair of The Fenway Institute, and founding director of the Women’s Health Center at Beth Israel Deaconess Medical Center. Her scholarly work focuses on reducing health disparities among populations of diverse sexual orientations and gender identities and implementing clinical quality improvement initiatives.

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