Enhancing care for transgender and gender diverse survivors of intimate partner violence: an Ontario-wide survey examining health and social service providers’ learning needs

Abstract

Objectives

To better understand healthcare and social/community service providers’ learning needs associated with supporting transgender and gender diverse (trans) persons who have experienced intimate partner violence (IPV).

Setting

An online survey was distributed through the trans-LINK Network in Ontario, Canada.

Respondents

163 of 225 healthcare and social/community service providers completed the survey (72.4% response rate) between November 2022 and February 2023.

Main outcome measures

Expertise, training, workplace practices and learning needs related to supporting trans survivors of IPV.

Method

Quantitative survey results were analysed descriptively and open-ended responses were organised thematically. In March 2022, survey results were shared with 33 stakeholders who helped define goals and objectives for an e-learning curriculum using Jamboard, data from which were collated and organised into themes.

Results

Most (66.3%) survey respondents described having provided professional support to trans survivors of IPV, but only one-third (38.0%) reported having received relevant training, and many of the trainings cited were in fact focused on other forms of violence or trans health generally. The majority reported a mid (44.9%) or low-mid (28.5%) level of expertise and almost unanimously agreed that they would benefit from (further) training (99.4%). The most commonly recommended goal/objective for a curriculum emerging from the stakeholder consultation was to facilitate collaboration, knowledge sharing and (safe) referrals among organisations.

Conclusions

The results of this study highlight the critical need for an IPV curriculum specific to trans survivors and responsive to the needs of providers. As no one profession can address this complex issue in isolation, it is important that the curriculum aims to facilitate collaboration across sectors. In the absence of appropriate training and referrals, practitioners may perpetuate harm when caring for trans survivors of IPV.

Correspondence to Dr Janice A Du Mont; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• This study was designed in accordance with a widely used and well-supported six-step approach to curriculum development for medical education.

• Trans, gender diverse and allied stakeholders, including healthcare- and community-serving organisations, were consulted on the development of the learning needs assessment survey as well as the interpretation of results.

• The survey measure drew on standardised questions where available and employed a two-step measure to capture gender, as recommended by trans health experts.

• The learning needs identified in this study may not generalise to all providers working across community and healthcare sectors in Ontario.

Background

A recent Canadian study, which systematically incorporated the perspectives of more than 200 diverse stakeholders across Canada, identified the establishment of training as the highest research priority for improving the care of trans survivors of sexual assault and intimate partner violence (IPV).¹ Educational initiatives for health and social service providers can measurably increase their ability to care for particular client populations when designed in accordance with evidence-based approaches.^{2 3} We have therefore undertaken a programme of research to develop a curriculum for service providers on addressing IPV against trans people, using a well-established needs-based approach.^{4 5}

Six-step approach to curriculum development for medical education

Kern’s⁴ six-step approach to curriculum development for medical education has demonstrated promise in facilitating the development of curricula that are responsive to provider needs and can enhance quality of care for particular client populations, including marginalised persons.^3–8 This approach includes (1) problem identification and general needs assessment, (2) targeted needs assessment, (3) determination of goals and objectives, (4) selection of educational strategies and content, (5) implementation and (6) evaluation and feedback. This approach has since been adapted by Chen and colleagues⁵ for use in developing online curricula, an increasingly popular mode of education that can expand the reach of educational programmes to a large and diverse audience across professions and geographical locations. As compared with in-person curricula, e-learning curricula may reduce costs associated with development and delivery and improve accessibility through accommodation of diverse personal and professional schedules and needs.^{8 9}

Problem identification and general needs assessment

As the first step, we completed a review of relevant literature and existing resources¹⁰ and found that trans people (those whose gender often does not correspond with their sex assigned at birth, including genderqueer, gender fluid, non-binary and two-spirit individuals) are more likely than cisgender people (those whose gender does align with their sex assigned at birth) to experience IPV.^11–13 Indeed, Peitzmeier and colleagues¹² found in a systematic review and meta-analysis that trans individuals were 1.7 times more likely than cisgender persons to experience IPV and 2.2 and 2.5 times more likely to experience physical and sexual forms of IPV, respectively; these rates remained elevated even when comparisons were made with cisgender women, specifically. In Canada, formative research on IPV in trans populations by the Trans PULSE Canada Team¹⁴ revealed that three in five trans women experienced IPV since the age of 16. High rates of IPV in trans populations can be exacerbated by concurrent experiences of discrimination and structural oppression at the intersections of gender, sexual orientation, race, class, disability, occupation (eg, sex work) and beyond.^{11 15} One population-based study in the USA that focused on trans people’s experiences found lifetime rates of IPV were 54%, with highest rates among sex workers (77%), Indigenous persons (‘American Indian’, 73%) and people of colour (eg, multiracial, 62%; Middle Eastern, 62%).¹¹

Trans persons also face unique forms of IPV linked to their gender identity. For example, abusers may employ a ‘cisgenderist paradigm’ (ie, the prevailing norms promoting the expectation that people’s identities and expressions are to be limited to the ‘confines of the gender binary’)¹⁶ to target and denigrate trans persons’ identities. Abusers may also sabotage their partner’s transition by hiding or destroying prosthetics, hormones and other transition-related items; threaten to or ‘out’ their trans partner; or coerce their victim into staying in the relationship by employing a cissexist narrative that trans people are undesirable and unlikely to find companionship elsewhere.¹⁷ As a result, many trans survivors have difficulty recognising their own experiences of IPV as such.¹⁸

IPV can have profound deleterious effects on trans persons’ health, social and economic well-being. Consequences among this population include physical injuries, chronic health issues, psychological distress, suicidality, substance abuse, social isolation and difficulties with housing, employment, family and/or finances.^{12 19 20} IPV against trans persons has also been linked to internalised transphobia, low self-esteem and feelings of devaluation.²¹ These consequences may in turn compound pre-existing challenges, such as lack of familial supports, histories of mental health issues and lifetime exposure to other forms of violence (eg, heightened rates of child physical, sexual and psychological abuse; bullying).^{18 22–26}

The needs presented by these complex and intersecting issues may, however, remain unmet, as trans survivors attempting to navigate healthcare and social/community services encounter myriad barriers to care.^{18 27} Service providers may fail to recognise IPV among trans populations, relying on the presumption that IPV is experienced only by cisgender heterosexual women at the hands of cisgender heterosexual men; this, in turn, severely inhibits providers’ responses to trans survivors and can manifest as stigma or inability to provide appropriate supports.^{18 21 28 29} Trans survivors may also face pervasive trans-exclusionary and/or gender-specific organisational mandates, policies and practices (including those that are explicitly hostile to trans persons) and, as a result, delay or choose to not access services at all, at times remaining in abusive relationships.^{18 28–31}

Educational interventions for those who serve trans survivors of IPV have the potential to increase providers’ competence, eliminating obstacles to providing appropriate care.^{2 18 32} Some training programmes and tools that are dedicated to building service provider capacity in addressing IPV against trans people have been developed, including FORGE’s webinar recordings, self-help guides, safety planning tool and tipsheets³³; The Network/La Red’s synchronous training and associated manuals and brochures³⁴; and METRAC’s webinar recordings, guidelines and infographics.³⁵ While these resources are important contributions to the topic’s educational landscape, no comprehensive, freely accessible interactive e-learning curriculum currently exists for health and social service providers in Canada, nor has a curriculum been developed to date as shaped by these providers’ identified needs.

Targeted needs assessment and determining goals and objectives

Having identified a clear problem, IPV against trans persons and established a general need for related education, the current study represents the second and third steps of Chen and colleagues’⁵ approach, in which we seek to understand the needs and learning environments of identified learners and set goals and objectives for the curriculum. Within Step 2, our primary aim was to examine the need for and desired content of (additional) training for diverse health and social service providers who are or may be engaged in the care and support of trans survivors of IPV. A secondary aim was to examine professionals’ current practices and the factors that may impact their ability to provide care and support. Within Step 3, our aim was to determine the direction of the curriculum, specific and measurable expectations for learners’ achievements, anticipated impact on services, and curricular boundaries. Together, the results of this study will inform a curriculum that has potential to revolutionise care for trans IPV survivors in Canada and beyond.

Method

This study has been reported in compliance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines and checklist.³⁶

Patient and public involvement

Two groups composed of representatives of the trans-LINK Network (an Ontario network of trans-led or trans-positive community and healthcare organisations dedicated to improving the response to trans persons experiencing gender-based violence) collaborated in the early stages of curriculum development (www.translink.com).³⁷ An Advisory Group—members of the Network’s education and training team—aided in the development and pilot of the survey, among other tasks (Egale Canada, Indus Community Services, METRAC Action on Violence, Ontario Association of Interval and Transition Houses, Ontario Network of Sexual Assault/Domestic Violence Treatment Centres, Sexual Assault/Domestic Violence Treatment Centre of Kitchener and Waterloo Region). A Stakeholder Consultation Group was engaged in interpreting the results of the survey and determining the goals and objectives of the curriculum (see details in the Stakeholder consultation section). Additionally, a peer leader advisor provided editorial input during the development of this survey, aided in the interpretation of survey results and critically reviewed and revised presentations and publications. As a trans community member, the peer leader advisor represented their own unique perspective grounded in lived experience rather than organisational affiliation. The involvement of diverse providers and a trans peer leader advisor in the research helped in ensuring that their voices, experiences and needs were at the forefront of the study.

Measures

A learning needs assessment survey was developed drawing on literature related to curriculum development; IPV in trans populations and existing curricula/training on this topic, employing standardised questions where available. The survey development was led by an experienced research team with expertise in survey construction and implementation, IPV and violence against trans persons, including an international expert in gender-based violence against marginalised populations (JADM), a global leader in healthcare responses to IPV (SM), a health research methodologist with substantial experience in research related to violence (SDK) and the developer of multiple curricula/training programmes for professionals who support and serve survivors of violence (RM).^{2 32 38–42} The survey was piloted on 19 July 2022 at an Advisory Group meeting, where members tested the survey, made notes and provided feedback, which was subsequently used to revise the survey.

The survey, used in this study, consisted of four sections with 19 closed-ended and 4 open-ended questions, included respondent characteristics, prior training, workplace practices and learning needs (see online supplemental material 1). Variables examined for (1) Respondent characteristics were age, gender identity and assigned gender at birth (adapted from Kronk et al⁴³), ethnicity/racial background,⁴⁴ highest level of education, population primarily served, years’ experience as a health or social/community service provider, experience supporting a trans client experiencing IPV, current role and level of knowledge/expertise on supporting trans survivors of IPV (adapted from Haverkamp et al⁴⁵); (2) Prior training were previous training on IPV against trans persons (including type of training, organisation providing training, content covered and reasons if no training) (adapted from Bovero et al⁴⁶ and Li et al⁴⁷) and modality and length of training (adapted from Bovero et al⁴⁶); (3) Workplace practices were available training on supporting trans survivors of IPV (adapted from Fraser et al⁴⁸), adherence to specific guidelines/protocols and reasons if not (adapted from Fraser et al⁴⁸) and barriers to supporting trans persons experiencing IPV (adapted from Fraser et al⁴⁸); (4) Learning needs were benefit of (additional) training, desired topics for an e-learning curriculum (options drawn from the literature, pre-existing resources and expert opinion); other suggestions for an e-learning curriculum and insights into what would help in supporting trans clients experiencing IPV (adapted from Fraser et al⁴⁸) (see tables 1–3 and figures 1–2 for full response options).

Figure 1. Barriers to supporting transgender and gender diverse persons experiencing IPV. Note. IPV, intimate partner violence; not mutually exclusive.

Figure 2. Desired topics for an e-learning curriculum on supporting transgender and gender diverse persons who have experienced IPV. Note. IPV, intimate partner violence; not mutually exclusive.

Table 1

Respondent characteristics

Sociodemographic characteristics	n	%	N
Age group, in years			163
18–24	5	3.1
25–34	45	27.6
35–44	48	29.4
45–54	52	31.9
55–64	12	7.4
Prefer not to disclose	1	0.6
Gender			163
Cisgender female; woman	130	79.8
Cisgender male; man	8	4.9
Transgender and gender diverse*	22	13.5
Female; woman	3	1.8
Male; man	1	0.6
Non-binary	13	8.0
Questioning; exploring	4	2.5
Other: ‘trans woman’	1	0.6
Other: ‘trans man’	3	1.8
Other: ‘transmasculine’	3	1.8
Prefer not to disclose	3	1.8
Ethnicity/racial background*			163
Black	14	8.6
East/Southeast Asian	9	5.5
Indigenous	11	6.7
Latino	5	3.1
Middle Eastern	2	1.2
South Asian	12	7.4
White	115	70.6
Other: ‘multiracial’	1	0.6
Prefer not to disclose	2	1.2
Highest level of education			163
<High school	2	1.2
High school	1	0.6
College, trade school	16	9.8
Undergraduate degree	72	44.2
Graduate or professional degree	70	42.9
Other: Gestalt diploma; unspecified	2	1.2

Work experience	n	%	N
Population primarily served			163
Remote	4	2.5
Rural	14	8.6
Small town	7	4.3
Medium-sized city	40	24.5
Large city	47	28.8
Very large city	50	30.7
Other: provincial/national	1	0.6
Experience as health or social/community service provider, in years			163
<1	2	1.2
1–5	31	19.0
6–10	30	18.4
11–15	27	16.6
16–20	19	11.7
21+	54	33.1
Ever supported a trans client experiencing IPV	108	66.3	163
Current role*			163
Coordinator	38	23.3
Educator	29	17.8
Executive	3	1.8
Frontline provider	106	65.0
Manager	36	22.1
Support staff	6	3.7
Volunteer	4	2.5

*Not mutually exclusive.

IPV, intimate partner violence.

Table 2

Prior training

	n	%	N
Previous training on IPV against trans persons			158
Yes*	60	38.0
Community of practice	16	26.7
Community organisation/group	24	40.0
Convention/conferences	18	30.0
Graduate education	8	13.3
Media/social media	9	15.0
Self-directed	27	45.0
Training through workplace	46	76.7
Undergraduate education	8	13.3
Workshop/webinar	17	45.0
Other: lived experience	1	1.7
No*	98	62.0
Do not need to be trained	1	1.0
No time or opportunity to train	13	13.3
Not aware of any training	17	17.3
Training does not exist	58	59.2
Did not specify	9	9.2
Training, in hours			55
<1	2	3.6
1–5	21	38.2
6–10	11	20.0
11–15	2	3.6
16+	19	34.5
Modality*			55
In-person	28	50.9
Synchronous, online	31	56.4
Asynchronous, online	42	76.4

*Not mutually exclusive.

IPV, intimate partner violence.

Table 3

Workplace practices

	n	%	N
Training offered on supporting trans survivors of IPV			158
Yes	51	32.3
No	107	67.7
Adherence to specific guidelines/protocols on supporting trans survivors of IPV			151
Yes	38	25.2
No	113	74.8
Do not follow guidelines/protocols that are available	3	2.0
Unaware of guidelines/protocols being available	103	68.2
There are no such guidelines/protocols	7	4.6

*Not mutually exclusive.

IPV, intimate partner violence.

Procedure

The survey was sent out via personalised emails on 10 November 2022 to 225 representatives of member organisations on the trans-LINK Network. Emails contained brief information about the study, including the offer of a $C25 e-gift as a token of appreciation for survey completion, and an invitation to complete the 10-minute survey on Qualtrics (2023), a survey platform. Before proceeding to the survey, interested individuals answered four eligibility questions. Those who indicated that they did not work in Ontario healthcare/health services or social/community services and/or could not read and write comfortably in English or provide informed consent were thanked for their time, while eligible individuals were directed to a letter of information/informed consent form. This form delineated the purpose of the study, eligibility to participate, participant rights and responsibilities, potential harms and benefits of participation and information on confidentiality and compensation. Respondents who completed the survey were provided the option to receive the gift card and redirected to a separate, unlinked form to input their details. The survey remained open for approximately 13 weeks, with five reminders disseminated via email.

Analysis

Data from Qualtrics were imported to Excel (Microsoft Corporation, 2018). The variable ‘gender’ was computed by using responses for questions on gender identity and gender assigned at birth following a process recommended by trans health experts for capturing trans identities.^{43 49} Survey responses for respondent characteristics, prior training, workplace practices and learning needs were calculated using descriptive statistics, including frequencies and counts. Responses for the open-ended responses were collated, organised thematically and used to illustrate quantitative findings associated with learning needs.

Stakeholder consultation

We invited representatives of trans-LINK Network member organisations to participate; 33 representatives from 30 distinct organisations across the health and social/community services sectors served as the Stakeholder Consultation Group and represented diverse areas of expertise (eg, sexual assault, IPV, trans advocacy, HIV/AIDS, 2SLGBTQIA+ supports, community health, education, youth). In March 2023, two members of the research team (HS and CEK) facilitated a 1-hour consultation via Zoom. Facilitators explained to participants that the consultation served as an opportunity to gain their valuable input, supporting the evidence-informed and learner-driven approach guiding development of the e-learning curriculum. A summary of survey results was then provided and participants were invited to set curriculum goals. The participants then took the lead on the discussion using a collaborative digital whiteboard (Jamboard, hosted by Google) by posting sticky notes with their comments and insights. Forty-six relevant comments were posted in the approximately 30-minute period dedicated to this activity. This format allowed participants to expand and build on each other’s ideas. The comments were exported to Excel, collated and organised into 12 themes, which were illustrated using direct quotes.

Results

Survey

Sociodemographic characteristics and work experience

The survey achieved a 72.4% response rate, with 163 of 225 representatives of invited organisations participating. The most reported age range was 45–54 years (31.9%), and approximately four-fifths of respondents were cisgender women (79.8%), followed by trans persons (13.5%). A majority of respondents identified as white (70.6%) and having either an undergraduate degree (44.2%) or a graduate or professional degree (42.9%). Respondents primarily served populations in large cities (28.8%) and very large cities (30.7%) and were highly experienced; more than three-fifths (61.4%) had over 10 years of experience working as a health or social/community service provider and one-third reported having 21+ years’ experience (33.1%). Most respondents reported having provided professional support to a trans client experiencing IPV (66.3%) and held a range of professional roles, including frontline provider (65.0%), coordinator (23.3%) and/or manager (22.1%) (table 1). Respondents rated their expertise in supporting trans persons who have experienced IPV most often as mid (44.9%, 71/158), low-mid (28.5%, 45/158) or low (8.9%, 14/158) level, followed by mid-high (13.9%, 22/158) or high (3.8%, 6/158).

Prior training

Less than two-fifths of respondents (38.0%) reported completing training related to supporting trans persons who have experienced IPV, and when asked to specify the name and organisation providing this curriculum or training, most (66.7%) referenced Providing Trans-Affirming Care for Sexual Assault Survivors^{2 50 51} housed on the trans-LINK Network WebPortal; few (8.3%) of the listed trainings appeared to be IPV and trans-specific. Trainings were delivered in many modalities, but most commonly took place online, in an asynchronous format (76.4%). Content covered in these trainings included an introduction to trans-affirming care (including appropriate terminology and language), trans persons’ unique needs and barriers faced by trans persons seeking care and supports. Of those who reported not having completed training, nearly three-fifths (59.2%) responded that such training did not exist (table 2).

Workplace practices

One-third (32.3%) of respondents reported that their current workplace offered education and/or training in supporting trans persons who have experienced IPV. By and large, respondents reported not adhering to particular guidelines/protocols for supporting trans persons who have experienced IPV (68.2% indicated that they were unaware of such guidelines/protocols being available) (table 3). Existing guidelines or protocols referenced primarily concerned addressing IPV and/or providing trans-affirming care, broadly, rather than those specifically related to trans experiences of IPV. Barriers most commonly reported to supporting trans clients experiencing IPV included lack of awareness, knowledge and training (54.3%) and difficulty raising IPV issues in a sensitive way (eg, fear of offending and/or embarrassing client not knowing when the ‘right time’ is to raise IPV issues; 19.9%) (figure 1).

Learning needs

Almost all respondents indicated they would benefit from training to improve their ability to support trans persons who have experienced IPV (99.4%). Respondents selected from a list a range of specific topics they thought should be included in an e-learning curriculum, in particular information about help-seeking behaviours (74.0%), revictimisation by care providers (73.3%) and intersectionality (eg, transmisogyny; 72.0%) (figure 2). Nearly all (92.6%) provided insights into what would help them support trans clients experiencing IPV and suggestions for a curriculum; these included tailored training, curricula or other forms of education specific to IPV against trans persons. One respondent noted they had “taken 2SLGTBQ+ fundamentals courses and webinars in regards to supporting trans clients following sexual assaults, but not IPV” and recognised the need for “[a] course specific to caring for trans clients experiencing IPV.” Others stated that they had to bring together their knowledge of IPV and trans health in order to attempt an appropriate response:

I have supported non-binary and trans folks who have experience[d] IPV. … I had to combine my knowledge of trauma treatment with my knowledge of supporting those in this community and make my best guess as to what sort of language and approach to use.

Similarly, one respondent noted their workplace offered training relevant only to serving ‘the white, cis and heterosexual community’, further elaborating, “all the [trans-specific] training I have acquired is due to my own diligence.” Readily accessible resources or information on the subject area, guidelines or protocols on which to rely and trans-affirming referrals were also among the most identified needs. A respondent characterised the profound dearth of information on trans-affirming IPV care/supports as prohibitive to their learning, saying, “I feel I don’t know enough to know how much I don’t know.”

Respondents described desired format or content of the curriculum, which ranged from introductory (eg, appropriate language when speaking to trans clients) to complex (eg, supporting trans persons postincarceration) material. The need for ongoing, regularly reviewed or in-depth content was also expressed. One respondent described their team as having ‘anxiety’ about appropriately serving trans clients, stating, “we get so few that when we actually do see someone who is transgender, our nurses don’t always remember what they have learned or forget what they have learned.” Another concurred that the lack of trans clients ‘makes it difficult to maintain competence in that area’. Contextualising learning experiences with trans persons’ insights, providing case studies to apply newly gained knowledge and competencies, and addressing or understanding systemic barriers trans persons face within or beyond practitioners’ own sectors, especially in the context of referrals and ensuring a continuum of care, were also characterised as particularly salient.

Stakeholder consultation

Desired goals and objectives of the curriculum

The most commonly occurring theme was to facilitate collaboration, knowledge sharing and (safe) referrals among organisations. One attendee envisioned “[s]ervices that work together and know what each other is doing so the person [client] has options for what they need.” Another theme concerned improving provider capacity to identify IPV and promote disclosure. As stated by an attendee, “one of the main objectives should be to support providers in asking the right questions. Oftentimes, if an individual is not asked, they will not disclose.” Providing education and training on IPV against trans persons to all professionals who may encounter them in health and social/community service settings was also a salient theme. In the healthcare context, an attendee commented, it is “[i]mportant that the education is hospital-wide including all staff … nurses/doc[tors]/housekeeping/porters, etc., as all can create harm with the wrong words” (see online supplemental material 2 for themes and supportive quotations).

Discussion

In the face of the pressing health, social and human rights issue presented by IPV against trans persons, providers from whom survivors seek care must be equipped with the knowledge and skills to appropriately respond. The findings of this needs assessment and stakeholder consultation point to a critical need for specific curricula on this topic as a strategy through which to increase the competence of practitioners in health and social services. Despite most providers describing having served this population and reporting extensive experience in their role, few reported participating in training or following guidelines related to trans experiences of IPV, and many of the trainings/protocols that the providers cited were primarily focused on other forms of violence against or general care for trans persons. Providers themselves acknowledged their profound learning needs in this area and were in almost unanimous agreement that they would benefit from such a specific training. These findings are consistent with Du Mont et al’s learning needs assessment of Ontario-based forensic nurses providing sexual assault services, nearly half of whom reported providing direct clinical care to trans clients and nearly all of whom (95.7%) agreed that they would benefit from related training in responding to trans survivors of sexual assault.⁵²

Service providers in our study reported mid or low-mid expertise in supporting trans survivors of IPV, unsurprising given their expression of need for specific education, training, guidelines and resources. Although concerning, relatively low levels of competency and training reflect a broader trend identified among healthcare and social service providers working with trans persons and LGBT IPV survivors.^53–56 While there is little to no research examining the expertise of providers serving trans survivors of IPV specifically, Du Mont and colleagues reported even lower levels of expertise in their study of forensic nurses providing care to trans survivors of sexual assault.⁵²

In the absence of appropriate expertise and associated training and guidance, practitioners may perpetuate significant harm against trans persons. Trans persons seeking care post-IPV may experience transphobic discrimination, being ‘outed’, victim-blaming, negative judgement, as well as stigma associated with being both an IPV survivor and identifying as trans.^{18 27} Moreover, uninformed providers may be unable to meet trans survivors’ health needs due to lack of knowledge about their often-unique body configurations and hormone use.⁵² Not surprisingly, the research has shown that damaging and inadequate care leads to a lack of trust in providers as well as general hesitancy to disclose experiences of IPV and access-related services.^{18 22 27 29} It is promising, then, that providers in our survey recognised their own potential for causing harm, prioritising revictimisation as a core content area for an e-learning curriculum and emphasising the need to ensure safe, affirming care and spaces at the stakeholder consultation.

Providers prioritised additional topics that could transform care as critical to the goals and content of any e-learning curriculum. Intersectionality was of particular interest, signalling their need for learning about the experiences of trans persons with multiple marginalised identities who may face additional challenges in care settings.¹⁸ Intersectionality must be incorporated throughout the future curriculum, as individual identities and life experiences vary significantly within trans communities and may shape trans persons’ needs throughout all stages of care.¹⁸ Providers also acknowledged the importance of disclosure and identifying IPV, while indicating a specific desire to understand help seeking. These gateways to promoting trans clients’ access to services and providing care were also high-priority items within a recent survey of providers and other stakeholders on research priorities for sexual assault and IPV against trans persons.^{1 18 31} Any curriculum development effort must consider the challenges inherent to providing education on these under-researched topics.¹ Moreover, as identified by providers within the stakeholder consultation, a curriculum should have the primary goal/objective of fostering collaboration, knowledge sharing and (safe) referrals among organisations. It is only through the efforts of multiple diverse and coordinated organisations, within which all staff are trained, that IPV against trans persons can be comprehensively addressed.⁵⁷

Strengths and limitations

To our knowledge, this study addressed an important gap as the first survey of its size and scope in Canada to examine the learning needs of healthcare and social/community service providers serving trans survivors of IPV specifically. While the results offer critical insights into the learning needs of Ontario-based service providers working with trans survivors of IPV, they may not be generalisable to other jurisdictions where providers working in health and community-based organisations could operate under different conditions (eg, legislation, training environments). Providers in other areas of Canada may have needs and concerns particular to their cultural and geographical contexts (eg, Francophone, rural setting), especially as there may be no comparable network to the trans-LINK Network to serve an educative function related to post-IPV care for trans persons elsewhere in the country. Moreover, this study may over-represent health and social/community service providers with many years of professional experience, in particular as frontline providers; as such, the survey may not have captured insights from the full range of providers with whom trans survivors of IPV interact. Given the experience of this sample and their membership in the trans-LINK Network, it may be that the need for training would be greater in a general population of providers. In designing the planned curriculum, we will consider the potential diversity in expertise represented both in this sample and in the population of learners more generally. To this end, we will incorporate flexible content navigation and develop additional resources to allow learners to customise their learning experience.

Conclusion

This study highlights the critical need for tailored curricula on IPV against trans persons for providers who may work with this vulnerable and highly marginalised demographic. While most providers reported having encountered these clients, few indicated that they had the requisite education to do so in a sensitive, appropriate manner. However, almost all indicated that they would benefit from such training, suggesting that its development could lead to meaningful improvements in the care and support of trans survivors of IPV. The results of this study will guide curriculum development efforts to ensure that training is responsive to the needs of all providers and their trans clients. The resulting curriculum and its implementation across all professionals with whom trans survivors may interact can serve as a model for other jurisdictions to address IPV against trans persons, a globally pervasive and pernicious issue warranting immediate action.

We would like to express thanks to our Advisory Group members Jakki Buckeridge (Indus Community Services), Brittany Jakubiec (Egale Canada), Wendy Komiotis (METRAC Action on Violence), Sheila Macdonald (Ontario Network of Sexual Assault/Domestic Violence Treatment Centres), Julia Manuel (Sexual Assault/Domestic Violence Treatment Centre of Kitchener and Waterloo Region) and Amber Wardell (Ontario Association of Interval & Transition Houses) for their contributions to this project. We would also like to thank all social/community service and healthcare providers who responded to the survey and participated in the stakeholder consultation.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. The data supporting the conclusions of this study are included in the article or as supplemental material.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study was approved by the Women’s College Hospital Research Ethics Boards (REB#2020-0070-E). Participants gave informed consent to participate in the study before taking part.

Footnote

X @DrJaniceDuMont

Contributors JADM is responsible for the overall content of the study, having conceived of and designed the study, cleaned the data, interpreted the findings, wrote the manuscript and secured the funding. CEK collected, cleaned and analysed the data, interpreted the findings and wrote the manuscript; HS designed the study, collected, cleaned and analysed the data and critically reviewed the manuscript; SB-C interpreted the data and critically reviewed the manuscript; RM designed the study, critically reviewed the manuscript and secured the funding. SM critically reviewed the manuscript and secured the funding; SDK conceived of and designed the study, collected, cleaned and analysed the data, critically reviewed the manuscript and secured the funding. JADM is gaurantor and a ll authors read and approved the final manuscript.

Funding Funding for this research was provided by the Government of Ontario, grant number 2022-02-1-1677271263. The views expressed in this article are the views of the researchers and do not necessarily reflect those of the Province.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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