Fact Sheet: Crisis Hotlines & Transgender Callers
Unintended Effects of Non-consensual Emergency Interventions
Most crisis hotlines employ non-consensual emergency responder interventions when assessments of callers/texters in crisis are presumed to be experiencing “imminent risk” of suicide. The situational uses of such interventions are not clearly available to callers, and most policies mandate not informing callers of active dispatch, or what these interventions may entail. While intended as a last resort on many hotlines, in practice it is too readily used, causing several unintended harmful consequences to both trans and non-trans people.
Non-consensual interventions can be particularly harmful to trans people, who make up between 7.7-11% of crisis help seekers. 22,23 This non-exhaustive list introduces the trans-specific impacts of non-consensual emergency responder interventions.
Exacerbating Financial Instability
- Employment discrimination based on gender identity/expression makes trans people three times more likely to be unemployed. 14% of trans people are uninsured, making psychiatric holds and forced hospitalization a massive financial burden.14
- Uninsured and underinsured callers are saddled with non-consensual costly medical bills from ambulance transport, emergency room visits, psychiatric holds, medications, and counseling—many of which are court-mandated in involuntary hospitalizations.
- Poverty, financial instability, debt, and job loss are key risk factors for suicide, jeopardizing trans callers’ overall wellbeing.7
Contraindicated Treatment
Withholding trans-affirming healthcare.
- Forcibly hospitalized trans people report a lack of access to gender-affirming care, medication, and resources.12 Denying trans-affirming healthcare to trans patients often leads to psychological harm, including suicidality.1
- A history of involuntary psychiatric hospitalization can be used to deny trans people the ability to give informed consent for trans-affirming surgery or hormones in the future.
Misdiagnosing and mis-medicating trans people.
- Rather than focusing on the root causes of suicidality for trans people which include gender dysphoria, marginalization, family rejection, violence, and discrimination, trans people are often misdiagnosed in psychiatric hospitals, while simultaneously being denied trans-affirming health care and medication.
- Additionally, trans people are more likely than cisgender people to be hospitalized for mental health reasons.11
Trauma & Abuse
Placing trans people in solitary holds.
- Trans people are more likely to be put in solitary confinement in hospitals, jails, prisons, and detention centers for “safety from others,2,4,9,12,13 despite solitary hold being considered a form of torture by the United Nations. 4
Assigning trans people to the wrong gender unit in jails, prisons, psychiatric wards, and detention centers.2,4,9,12,16
- Consequently, trans people, especially trans women, are at heightened risk for sexual and physical assault.7
Outing trans youth to unsupportive guardians.
- Crisis line operators may disclose details regarding a caller’s gender to emergency responders, often outing trans youth to their guardians. Unsupportive caregivers are a key reason that trans youth seek support from crisis lines.
- 27.3% of trans youth who lacked supportive parents have actively attempted suicide.19 Being outed can lead to unsafe housing or homelessness.15
Putting trans people at risk for sexual and physical assault.
- When placed in hospitals, jails, prisons, and detention centers, trans people report sexual and physical assaults by fellow patients, inmates, and detainees and at the hands of staff and officers for being/presenting as trans.2,4,6,8,9,12,13,17
Subjecting trans people to police violence.
- 58% of trans people have reported being mistreated by the police,14 and these numbers increase when trans people identify as BIPOC.
- Trans sex workers are eleven times more likely to be coerced into sex with police to avoid arrest than non-trans sex workers.17
Putting trans people at risk of police shootings or wrongful death.
- People perceived to have an untreated mental health condition are sixteen times more likely to be killed by the police,20 and comprise 1 in 5 police shootings.18
- Non-consensual interventions have thrust trans people into systems that lead to their wrongful death, with no accountability for those responsible.13
Criminalizing Support Seeking
Discouraging future support-seeking behaviors.
- Trans youth who are involuntarily hospitalized are less likely to seek support in the future, and post-hospitalization, are less willing to disclose feelings of suicidality.10
- BIPOC trans people are more likely to be criminalized for support seeking, whereas white people are more likely to be considered as candidates for treatment, especially where drug use is present.
Punishing survival.
- Non-consensual crisis interventions ending in criminalization lead to criminal records, increasing poverty, job and housing discrimination, and homelessness upon release.5
- Trans people forced into underground economies (such as sex work) by employment discrimination are at higher risk for criminalization and police violence when seeking support.14,17
Endangering undocumented callers.
- Deportation is a potential death sentence for trans asylum seekers fleeing from punishment or death for their gender identity,4 and becomes an unnecessary risk they face when utilizing crisis hotlines that utilize non-consensual interventions.
- Trans detainees experience extreme emotional and physical abuse. 20% of verified sexual abuse cases involve trans people, with trans women being thirteen times more likely to be sexually assaulted than other detainees.4 They are also typically denied gender-affirming care and placed in the wrong gender unit.4
Lack of Cultural Competency
- Non-consensual emergency responder interventions often put trans people in institutions that lack trans competency and care.4,9,12,21
- Trans people report predominantly negative experiences when utilizing emergency services due to a lack of provider training.3,11,21
- 50% of trans people report having to educate their medical providers about trans-affirming care.8
Sources
1 Bailey, L., J. Ellis, S. and McNeil, J. (2014). “Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt”, Mental Health Review Journal, Vol. 19 No. 4, pp. 209-220. https://www.emerald.com/insight/content/doi/10.1108/MHRJ-05-2014-0015/full/html
2 Brown, J. & Jenness, V. (2020). LGBT people in prison: Management strategies, human rights violations, and political mobilization. Oxford Research Encyclopedia of Criminology. https://doi.org/10.1093/acrefore/9780190264079.013.647
3 Chisolm-Straker, M., Jardine, L., Bennouna, C., Morency-Brassard, N., Coy, L., Egemba, M. O., & Shearer, P. L. (2017). Transgender and gender-nonconforming in emergency departments: A qualitative report of patient experiences. Transgender Health, 2(1), 8-16. https://pubmed.ncbi.nlm.nih.gov/28861544/
4 Committee on Sexual Orientation and Gender Diversity. LGBTQ asylum seekers: How clinicians can help. American Psychological Association. https://www.apa.org/pi/lgbt/resources/lgbtq-asylum-seekers.pdf
5 DeFina R, Hannon L. The Impact of Mass Incarceration on Poverty. Crime & Delinquency. 2013;59(4):562-586. https://journals.sagepub.com/doi/10.1177/0011128708328864
6 DeVylder, J. E., Jun, H-J., Fedina, L., Coleman, D., Anglin, D., Cogburn, C., Link, B., Barth, R. P. (2018). Association of exposure to police violence with prevalence of mental health symptoms among urban residents in the United States. JAMA Network Open, 1(7). https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2715611
7 Elbogen, E. G., Lanier, M., Montgomery, A. E., Strickland, S., Wagner, H. R., Tsai, J. (2020). Financial Strain and Suicide Attempts in a Nationally Representative Sample of US Adults, American Journal of Epidemiology. https://academic.oup.com/aje/article/189/11/1266/5874604
8 Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. National Center for Transgender Equality and National Gay and Lesbian Task Force. https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf
9 International Detention Coalition (IDC). (2016). LGBTI persons in immigration detention [Position paper]. https://idcoalition.org/wp-content/uploads/2016/06/LGBTI-Position_web_June-2016.pdf
10 Jones, N., Gius, B. K., Shields, M., Collings, S., Rosen, C., & Munson, M. (2021). Investigating the impact of involuntary psychiatric hospitalization on youth and young adult trust and help-seeking in pathways to care. Social Psychiatry and Psychiatric Epidemiology, 56(11), 2017-2027. https://link.springer.com/article/10.1007/s00127-021-02048-2
11 Lam, J. S. H., Abramovich, A., Victor, J. C., Zaheer, J., Kurdyak, P. (2021). Characteristics of transgender individuals with emergency department visits and hospitalizations for mental health. Psychiatric Services, 0(0). https://ps.psychiatryonline.org/doi/10.1176/appi.ps.202100306
12 Lydon, J., Carrington, K., Low, H., Miller, R., & Yazdy, M. (2015). Coming out of concrete closets: A report on Black & Pink’s national LGBTQ prisoner survey. Black & Pink. https://www.issuelab.org/resources/23129/23129.pdf
13 Manson, J. (2019, July 22). Transgender women of color face crushing rates of incarceration, solitary confinement, and abuse: Death of Layleen Polanco on Rikers Island highlights wider injustice. Solitary Watch. https://solitarywatch.org/2019/07/22/transgender-women-of-color-face-crushing-rates-of-incarceration-solitary-confinement-and-abuse
14 National Center for Transgender Equality. (2015). The report of the 2015 U.S. transgender survey. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
15 Quintana, N. S., Rosenthal, J., Krehely, J. (2010). “Gay and Transgender Youth Homelessness by the Numbers.” American Progress.
https://www.americanprogress.org/article/gay-and-transgender-youth-homelessness-by-the-numbers/
16 Saw, C. (2017). Transgender patient care in the inpatient psychiatric unit. The American Journal of Psychiatry Residents’ Journal, 12(11). https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2017.121103
17 Stenersen, M. R., Thomas, K., & McKee, S. (2022). Police and transgender and gender diverse people in the United States: A brief note on interaction, harassment, and violence. Journal of Interpersonal Violence. https://journals.sagepub.com/doi/10.1177/08862605211072161
18 Tate, J., Jenkins, J., Rich, S., & Muyskens, J. (2015). Fatal force database. Washington Post. Retrieved May 18, 2022 from https://www.washingtonpost.com/graphics/investigations/police-shootings-database/
19 The Trevor Project. (2019). The Trevor Project research brief: Accepting adults reduce suicide attempts among LGBTQ youth. https://www.thetrevorproject.org/wp-content/uploads/2019/06/Trevor-Project-Accepting-Adult-Research-Brief_June-2019.pdf
20 Treatment Advocacy Center. (2015). Overlooked in the undercounted: The role of mental illness in fatal law enforcement encounters. Office of Research & Public Affairs. https://www.treatmentadvocacycenter.org/storage/documents/overlooked-in-the-undercounted.pdf
21 Vermeir, E., Jackson, L. A., & Marshall, E. G. (2018). Barriers to primary and emergency healthcare for trans adults. Culture, Health, & Sexuality, 20(2), 232-246. https://psycnet.apa.org/record/2018-04321-008
22 Larsen, Mark E., Michelle Torok, Kit Huckvale, Bilal Reda, Sofian Berrouiguet, and Helen Christensen. 2019. “Geospatial Suicide Clusters and Emergency Responses: An Analysis of Text Messages to a Crisis Service.” In2019 41st Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC), 6109–12. https://doi.org/10.1109/EMBC.2019.8856909
23 Pisani, Anthony R., Madelyn S. Gould, Carlos Gallo, Ashkan Ertefaie, Caroline Kelberman, Donald Harrington, Daniel Weller, and Shannon Green. 2022. “Individuals Who Text Crisis Text Line: Key Characteristics and Opportunities for Suicide Prevention.” Suicide and Life-Threatening Behavior 52 (3): 567–82. https://doi.org/10.1111/sltb.12872