From left: Lynn Nichols, LICSW, panel moderator; Kristen Vella Gray, PA-C; Derek Monette, MD; Annie Lewis-O’Connor, PhD, NP-BC, MPH, FAAN; Isabel Checa, MSW; Deborah Jordan, MSW, LICSW

From left: Lynn Nichols, LICSW, panel moderator; Kristen Vella Gray, PA-C; Derek Monette, MD; Annie Lewis-O’Connor, PhD, NP-BC, MPH, FAAN; Isabel Checa, MSW; Deborah Jordan, MSW, LICSW

When an African-American transgender woman arrived at Brigham and Women’s Emergency Department (ED), she showed signs and symptoms of domestic violence, sexual assault and human trafficking.

Race, gender and exposure to trauma were all key considerations as staff prepared to provide her with the best possible care. A panel of five BWHers recounted the patient’s story at Schwartz Rounds on Nov. 8, reflecting on the case as an example of the challenges facing transgender patients who have been sexually abused and the providers who are caring for them.

One challenge the team encountered was in filling a prescription for post-exposure prophylaxis (PEP) medication to prevent HIV infection. When the patient arrived in the ED, she was identified in Partners eCare as male, but under her insurance provider, she was listed as female.

While this error may seem like a simple one to resolve, the care team discovered that it could not easily be changed in Partners eCare without a proof of gender by legal photo ID. Kristen Vella Gray, PA-C, of the Department of Emergency Medicine, made multiple phone calls to registration in order to fix the mistake and was able to successfully get the patient’s prescriptions processed quickly due to the time-sensitive nature of the PEP medication.

If a BWH patient requests that their gender be changed in their medical record, proper legal documentation should be presented to a registration representative.

Another challenge the team faced was in finding a shelter that would be a safe place for a transgender woman of color.

“Safety is not just about being safe from your abuser,” said Isabel Checa, MSW, from Passageway, the Center for Community Health and Health Equity’s domestic violence intervention program. “Safety is many different things.”

Checa noted that there is a lack of domestic violence shelters in the area and across the country that are trans-specific or trans-friendly. Therefore, shelter staff and those staying at the shelter may not provide a safe and welcoming environment or be prepared to provide the type of care and support needed.

The Passageway team found an out-of-state shelter and referred the patient there. Ultimately, the patient left because of concern for her own safety and biases that she experienced at the shelter. She was not able to maintain contact with her BWH care team because her cell phone was broken, eliminating any opportunity for follow-up care.

Annie Lewis-O’Connor, PhD, NP-BC, MPH, FAAN, nurse scientist and founder and director of the Coordinated Approach to Recovery and Empowerment (C.A.R.E.) Clinic at BWH, did not meet the patient, but she did consult with the team on using a trauma-informed care model while the patient was in the hospital.

Trauma-informed care is built on understanding how exposures to trauma, whether intimate partner violence or other forms of intentional violence, and whether as an individual or as a member of a marginalized group, affects access and delivery of care for survivors. Lewis-O’Connor spoke about the team’s empathetic, forward-thinking and compassionate approach to caring for this particular patient, meeting her where she was by giving her the care she needed when she needed it.

“We can take lessons learned from this patient and others like her to help us be better care providers,” said Lewis-O’Connor.

Carrie Braverman, LICSW, a social worker in the Department of Care Coordination and founding chair of the Brigham and Women’s Health Care LGBT and Allies Employee Resource Group, noted the importance of provider education in caring for this patient population.

“As providers striving not only for excellent patient care, but also social justice and the betterment of communities, we have a responsibility to educate ourselves about individuals who identify as trans and non-binary,” says Braverman. “This includes an understanding and comfort with appropriate language, creating safe spaces, and knowing the specific care needs both from a physical and mental health perspective.”

If you are caring for a patient of suspected intimate partner violence, here are some resources that may help: