what causes an erection



this session is on how men can take self-care of themselves. just like women need to watch theirbreasts for any changes or lumps, men, too need to want to watch for in changes,particularly in their testicles. any small hard lump heavy feeling,accumulation of fluid, any discharge through the penis that is different in urine or seminal fluid. any painful urination, itching, sores, or warts need to be reported immediately to your doctor.just like women need to do self exams, once a month, the weekafter their period, men need to do self exams every one to two timeseach month. women have a period remind them to do this. you men don't have that, so you just need to make a routine to do it the


first of every month when you make yourvehicle payment, your house payment. just figure out a time. you can put a reminder in you calendar. every month you can do a self exam. by doing this, you will roll gently between your thumb and forefinger each testes. you have to do each one. the best time to check is probably while you are in shower because the heat causes them to hang away from the body and make it easier to be tested. once you are 35, something iunderstand you men do not look forward to doing you will need go to your doctor to have aprostate palpation each year. this is a rectal exam. i'm sure you can argue about doing this; but women have to start going in for


their annual exam when they are 21. you get off the hook for many more years. also, smega can be a problem for men who are not circumcised. if you are not circumcised, you will have learned that you will have to retract the foreskin and make sure you cleanse around the corona properly. this is what it would look like to examine each testes, gently rolling between your fingers and your thumb. any lumps, bumps, and swelling of the testes is a signal that something is not right. a hydrocele would be a collection of fluid which would take surgery to remove. a spermatatocele is a cyst of the vassa efferential. this is the space right below the epididymis, so be sure when do testicular self-exam


test up towards the top, right under theridge, which is the epididymis. hernia is a the rupture of the scortal sac. a lot of older men get hernias in their small intestine from too much lifting. you can also get a hernia in your testicle, this, too, needs to be brought to thedoctor's attention. teticular cancer is very rare. only one percent of men get get this cancer. however, early detection is the key and you will have tohave surgery to remove the testes, possible chemotherapy or radiation butif you catch it early and have it removed you can live a very healthy life. the situation with testicular cancer is that while most cancers effect older men,


testicular cancer affects young men, ages 20 to 35. so you need to begin doing your exams at a very early age and continue them,really through your life, because you can older than 35. but, the most common years are between 20 - 25. seminoma is the name of the most common. this shows where a possible problem could be. this would be about the size of the bb or a p. so, it can be very small, it could also be as the size of a marble, so be sure to test the whole testes and also the epididimis is not not marked here; but you could get a possible cystright under theepididymis. so, be sure you test that area as well. diseases of the the testis include anorchism, which is whereboth testes are lacking at birth.


the doctor, once they realize they havenot descended, which can be a situation as well, they would know that there areno tests and that young boy would not produce sperm nor testosterone. so, they would have to have a testosterone supplement. monorchidisim is when only one testes is in the scrotum. so, a boy could be born this way or they could for various reasons, particularly cancer, have one removed.cryptorchidism is basically when they fail to descend. now, i want you to listen carefully. what isnormal for a young boy -- a baby -- to be born to have the testes in the scrotal sac.that's what's normal; however, it is not unusual for the test is to be up in thebody and it may just take them awhile to descend. the doctor will help you figureout how when this is done. the concern is


if you do not have the testes that havedescended into the scrotum, those young boys and they are are in their teens orlate teens, early 20's will have a 40% percent greater chance of testicularcancer. again, early detection is the key. if you get cancer, you're gonna have tohave the testes removed, possible radiation and chemotherapy. testicular failureis when the testis doesn't produce hormones or the sperm, they just fail to produce. they are there, theyjust don't produce. epididymitis is inflammation of the epididymis. obviously, just inflammation. the penis si multi-purpose organ forreproduction, urination, and of course we can't forget recreation. it conveys bothurine and semen through the urethra and is


specialized to elongate and stiffen thatcauses the erection. the glans, we have already learned this in class,that is the head of the penis. the urethral opening which is called the meatus. it has a prepace orforeskin, the skin covering the head of the penis, before the baby would becircumcised. and the greatest number of nerve endings in the penis are found inthe glans and the corona which is the raised ridge. the only time maybe you'veheard the word corona would be the beer; however that means crown. it is the raised ridge of the penis. the frenulum is also sensitive and that is basically just with connectivetissue of skin on the underside that connects the glans to the shaft.


here is a picture of those structures that we were talking about. you can see the glans and urethral opening, better known as the meatus. the corona, the raised ridge. the frenulum is that connective tissue that connects the foreskin to the glans and then the sulcus is just basically that extra skin. the penis has three cylinders. two on top -- the two copora cavernosum and the way to remember that, the two cc's. they're vascular spaces with the blood flowing into them. the blood becomes trapped and that's what causesan erection. it is also has a fibrous coating around the capora cavernosumthat will help keep the penis hard when


it becomes erect. the coupus spongiosum on the bottom on the base of the penis.basically, the urethrapasses through this. the next slide will will be a picture of it. here's a diagram of the penis you cansee the two copora cavernosum t on top and the corpus spongiosum, bottom part of the penis. the urethra goes through it. upon an erection the corpus spongiosum becomes a raised ridge on the bottom of the penis because that's going to enlarge andalso, it is going to take on a blue hue because blood that flows through thecorpus spongiosum.the corpus spongiosum does not get hard. it just increases in size, wherethe copora cavernosum, the two on top, the


blood becomes trapped into those. that'swhat makes the penis erect. you see the smiley face here under thethree sizes of the penis. i always ask my students in class what would those be . the answer i get is small, medium, and large every time. the true answer is:huge, gigantic, and so big you can't get it to the door. this basically just tellsyou that size is important to a male. but, remember, to a vagina, it is not thatimportant because just the outer third of the vagina has nerve endings. if you have a penis that is an inch and a third,. you're going to please a vagina. i doubtany of you would have a problem doing that. it is interestiing the study that you see on your slide andthere's a new edition of your text that


just came out. i just got a copy of thatand it is sill the same study. i keep thinking that they are going to update the study; but they haven't. this tells me that penis size has not changed over theyears. the average non-erect penis is three and a half inches in length and3.9 inches in circumference. the average erect penis is 5.1 inches long and 4.9 inches in circumference so it gains length and circumference. the range oferect penises ranges from 2.8 to 7.2. the really cool is there's a thing calledthe equalizing effect, because smaller penises gain more size upon erection. so don't go laughing at the guy in the locker room that has the littlest penis because he's probably the biggest stud in the bedroom.


what causes an erection


one last thing about penis size -- there is no demonstrated relationship between heighth and body size or any other particular organ and the penis size. however, there has been evidence of significant differencesin corpus spongiosum in a different ethnic groups. this concludes the information on self-care and the penis.


penis erections



interviewer: what aout impotence, do dld cover anything on impotence? dld: as i said when i first got into penis enlargement is because i was suffering from someof those type, impotent type problems. i wasn't completely impotent but i wanted a harder erection the basic exercises are meant to increaseblood flow the to the penis


penis erections

increase oxygen supply in thepenis so that itself is gonna give you harder erections, so yes impotence is covered here did the basicexercises are going to improve


your erection strength.


penile prosthetics



>> michael: good afternoon everybody. thisis michael munson with forge, and i am here today to get us started on the medical andforensic considerations in caring for transgender sexual assault survivors. i’m really thrilledthat we have two guest speakers today, kim day from national association of forensicnurses, and eric stiles from the national sexual violence resource center. as always,we have a very full 90 minutes full of lots of interesting information, and we’re reallyexcited to get going today. i wanted to briefly mention and acknowledge that we’re definitelynot going to be covering trans 101 issues, and we have many pre-recorded trans 101 webinarson our website. so i encourage you, if you need or would like some of those core conceptreviews, to check out our website and review


those webinars on trans 101 issues. so todaywe’ll really be focused on forensic exams, and a little bit more of a 201 discussion.[pause] so many of you that have been on our webinarsbefore, or seen one of our workshops at conferences, have seen this slide and this image. i justwant to remind everybody that it’s really important that we take care of ourselves,and so if the content or discussion is painful or difficult, that i encourage you to stepaway or do whatever you need to do. we will be recording this, we are recording it, soyou can come back and listen to it at a later time, if that’s better for you to do so.a question that we get frequently is around if we’re sending out powerpoint slides afterwards.we will be sending those out tomorrow, and


we’ll be sending it out with a link to thearchived recording, so that you can share the link, or rewatch, or do whatever you’dlike with that archived recording. we’ll have a couple of moments of interaction todayand let me just show you a screen that will help you do that. so if you would like toask questions today, or in any way interact with us, loree cook-daniels, forge’s otherstaff person, is going to be the predominant person that is addressing questions and monitoringthings. so please use that question box for those questions that you have.we are grateful that this webinar, and all of them in our series, are supported by theoffice on violence against women, and we’re really pleased that they value this contentand we can provide it to you for free.


so let me tell you a little bit about who’swho. as i mentioned, we have two really great presenters today. the first one’s goingto be kim day with iafn, and she’s going to start us off with some really great content.eric stiles is going to come in later in our conversation today, and he is from the nationalsexual violence resource center. again, i am michael munson with forge, and the otherperson that you won’t hear very much of today is loree cook-daniels, also with forge.so again, she’ll be handling most of the behind-the-scenes questions, and you’llhear more from her at the end of our time today.so let me review our agenda really briefly. i’m going to spend just a couple of minutesreviewing some trans basics and making sure


that we’re all on the same page around whatpopulation we’re talking about. i will have just a couple of slides on sexual violencedata related to trans folks. and then we’ll turn things over to kim, who will talk aboutthe national protocol and some trans-specific implications with working with trans survivorsand forensic exams. we’ll have a little bit of time then for question and answersfor kim, right between her section, and then when we move on to a reframing section. soi’ll kind of recap a lot of what kim talks about from a slightly different angle. andthen eric will give us two case examples that will really reinforce all of the content thatkim and i both talk about, and kind of put it in a way that’s really approachable andreally personal. and we’ll end with some


reminders and an additional time for questions.so i wanted to offer a couple of caveats around language, and we’re going to be spendinga substantial amount of time today discussing bodies, specifically parts of the body thatare often gendered for most people. so all of us, kim and eric and i, will likely usedifferent language as we discuss some of the same parts of the body or some of the sameconcepts. so i’ve created this graphic, just to kind of help remind us that we havemedical language that’s going to be really important to use and understand by other medicalstaff, or by lawyers, or other legal system people. and there’s also cultural languageterms that are more commonly used within trans communities to refer to specific body partsor identities, and although there’s no universal


consensus on language, you know, we need tokeep in mind that it’s extremely diverse and very plentiful. the third gear of thisgraphic is what i’ve labeled “trans-reflective”, and in an ideal world, providers can reflectthe language of their clients without inserting language that is from a trans cultural lexiconor from medical terminology. the reality is that we probably need to have kind of a hybridof both, you know, more than one of these types of language in our verbal and writtenlanguage use, when we’re working with trans or gender non-conforming clients. so pleasenote today that you will likely hear more medical language than the other forms of language,and if we have time, we can talk about some of those other language uses at the end.the other caveat that i wanted to offer today


is that normally on webinars and trainingswhen we talk about trans issues, we’re not talking about bodies, we’re not talkingabout genitals, we’re not talking about some of those very specific bodily realities.but today because of the nature of what we’re talking about, we are going to be talkingabout bodies in specific ways and specific language. so i’ve kind of given it the rrating, but it’s definitely not really r rated, but it’s just different than whatwe’d normally be doing. so before i hand things over to kim, i wantedto just give us a brief review of who we’re including when we’re talking about transpeople. so, many times people have very specific ideasof who’s included when they hear the word


“transgender”. when we’re using theword “transgender”, we’re talking about who’s included under this very broad spectrumof people. we’re including a lot of people. so we’re including folks who are gendernon-conforming, or people who may, intentionally or not, blur stereotypical cultural linesof binary gender. we’re including people who transition from one gender to another.we’re including people who are questioning their gender, or who may not feel like thegender they were assigned at birth fits who they are right now. we’re including peoplewho don’t fit the binary, people who may identify with a gender other than male andfemale. we’re also including people who are multiply gendered, or who may live partsof their life in one gender and another part


of their life in another gender, or peoplewho may identify as more than one gender. and we’re also including soffas, or significantothers, friends, family, and allies. so we’re including this really wide range of peoplewhen we’re talking about transgender people or communities today.i wanted to remind folks, too, that when we’re talking about trans folks, we’re talkingabout people who might be on a masculine spectrum, who might have been assigned female at birthand are moving in a more masculine direction. we’re including people who were assignedmale at birth and who are moving in a more feminine direction. and there’s this largekind of group in the middle that may not identify with masculine or feminine, may not be movingin any direction, and may have a really fluid


identity or expression of their gender outwardly.so i just would like us to keep in mind that we may see clients that are, you know, veryclearly male or very clearly female, who have transitioned, and we also have a lot of clientsthat are going to be in that non-binary or that genderfluid or the gender non-conformingarea. so a couple of reminders around trans bodiesand trans people’s journeys. not everybody wants to use hormones. there’s a large numberof trans people who can’t afford hormones, or they may not want to use hormones for avariety of reasons, many many reasons. similarly, not everybody has had or would like to havesurgery of any kind, so similar to hormones, you know, not everybody wants to, not everybodycan afford to, and those are very complicated


and difficult discussions to have, and, youknow, some of our other trainings definitely have looked at those two areas of what peoplewant and how they have access or don’t have access. not everybody is uncomfortable withtheir body, so sometimes we think that trans people must automatically be uncomfortablewith their body. contrary to some popular myths, you know, some trans people are verycomfortable in their bodies. we also have to remember that of course some people arenot comfortable in their bodies, as well. some trans bodies are very different fromnon-trans bodies. and some are not. and another reminder is that there might be service implicationsaround trans bodies. you’re going to hear a lot more today about this specific point,about how we may need to use different strategies,


or there might be different risks, both medicalrisks and emotional risks, and there might be different tools that might be used in workingwith trans survivors of sexual assault. so those are a couple of reminders around transbodies and trans journeys. and at the end of the section, i just wantedto show this image that will soon be up on your screen, which is from the trans 100 fromthe year 2013, and it’s just a sampling of the diversity of what trans people looklike and who trans people are, and just this wonderful mosaic of trans people.so again, i’d like to just cover a couple of data points, couple of statistics, beforekim really starts talking about the details around forensic exams.so one of the questions that we’re asked


a lot is about the prevalence of sexual violencewithin trans communities, and we don’t have really firm answers, but there’s been alot of research that’s been done, and there’s an estimate that it’s between 50 and 66%of trans people have experienced sexual violence at some point in their life. a lot of times,trans people experience sexual violence more than once in their life, sometimes when they’rechildren, sometimes when they’re adults, sometimes both. we don’t really know theexact numbers, but we’re pretty certain that it’s 50% or higher for trans people.this number is pretty easily compared to some common rates that we normally hear about,where it’s 1 in 3 girls or 1 in 6 boys, or women or men. so it’s definitely higher,and there’s some implications around that.


we will talk a little bit about that today.the other piece of data that i wanted to share with you is something that we found in a surveythat we did in 2004-2005, and we asked people if gender was a contributing factor to theirsexual violence. and of course, when we asked that question, it’s from their perspective.what was their perception of what happened, and what caused it? and as you can see onthe screen, 43% of respondents said that gender was a contributing factor in their sexualassault. so a lot of trans people really have this linkage between who the core part ofwho they are is, as a gendered person, relates to this violence that’s happened againstthem. so i think that’s important to keep in mind, when we look at, how are people healingfrom sexual violence? how are they conceptualizing


what happened to them? how safe do they feelwalking around in the world? a couple other points on that interaction between who transpeople are and sexual violence is that a lot of times we see things like cutting or disfigurementhappen in conjunction with sexual violence, so we’re seeing sexual violence plus otherforms of violence happening as well. if we look at it from a slightly different way,when we’re looking at what has happened to trans people who have been murdered, alot of times we see that there was sexual violence that happened prior to their murder.so there’s definitely a linkage between excessive force and different types of violenceand sexual assault within trans communities and trans people.so that’s all the data that we’re going


to cover for this time, because we have alot of other things that we’d like to spend our time talking about. i did want to justkind of point you in the direction of some of the other webinars that we’ve hostedin the past that would give you a lot more data, if you’re interested in the data andinterested in more of the practical how-to things in general. one is one that we didquite a while ago, called “trans sexual violence”, and you’ll find it--if youcan see the screen, it will show you how to find those recorded webinars. another webinarthat might be of particular interest is “creating a trans welcoming environment”. and thethird one that you might be interested in is “anti-trans violence in prison”. soall of those, and there’s many other ones


that are on the website too. so there aresome places that you can start, if you’d like additional information on research anddata. so now is the more exciting piece, which isour first guest speaker, kim day. so i’m really excited that we have her with us today,and i’m just going to turn it over to you, kim, and you can share a little bit aboutiafn and your role there and take us to the next section.>> kim: thanks, michael. i’ll be happy to do that. many of you who know me know thatthis picture is pretty old, and i am totally grey now and have a few more wrinkles. i ama nurse and work as the project director of the safe technical assistance project, which is an ovw-funded project thatprovides technical assistance around the national


protocol for sexual assault forensic exams--medicalforensic exams--of adults and adolescents. i’m also a forensic nurse examiner and wasseeing patients in a local safe program that i helped develop here in maryland, and i’vebeen a nurse for over 35 years--that means i started when i was 5 [laughs]--but i’mbringing my experience with patients who have been sexually assaulted in the national protocolto you today. and again, as michael mentioned, language--the language i will use is healthcare oriented. for instance, i say “patient-centered” versus “victim-centered”. i’ll try toremember to clarify if i come upon any terms that i’m using that you may not understandor that you might not be familiar with, but if you’re wondering what a particular termmeans and i don’t clarify, please chat in


and ask me to explain that.and, on the next slide, i also need to go to a thank-you to ovw because i also am anovw ta provider, and the disclaimer is that what i’m going to talk to you about todayis my own thoughts and recommendations, and not necessarily those of ovw.so when i’m talking to you about the second edition of the national protocol, which there’sa picture up here, you also have a link on the forge website with a direct link to downloadthe protocol, and there were many revisions and changes in this year’s update, or lastyear’s update, some of which were directly related to the care of transgender patientswho’d been victims of sexual assault. caring for transgender patients in any capacity issomething that we actually rarely discuss


in health care, and as a whole, which causeshuge disparities in access to care, and the medical forensic exam access is certainlyno different than that. when the revisions to the protocol were made, this issue wasacknowledged, and the results noted that the unique issues of transgender patients areneglected in sexual assault response protocols as a whole. as i said, if the issue of transaccess to health care resources who are knowledgeable about their physical issues alone is somethingthat is rarely discussed in health care as a whole, is it any wonder that we’ve neglectedit in the wider sexual assault responder community? and as you heard michael talking about, theincidence is really high in this group. so as you can imagine, it contributes and compoundsthe victimization that’s happened in their


past. and i would also go so far as to evendraw that they don’t get access to criminal justice outcomes because of that. so thisinclusion was really important for all the patients and the wider communities that weserve as we try to broaden our scope and our net to be able to serve people who have long-termhealth consequences from the sexual violence, as sanes and as forensic nurses in general.when we come to the next issue, i have a clip of someone with a maze--in a maze, becauseas i think about what victims in general and what patients have to go through when theycome to us is just through so many barriers, because i think that a maze kind of pictureswell the issue of navigating medical services and advocacy and criminal justice for anyone,and it’s difficult and troubling, and in


the aftermath of a traumatic event like sexualassault, it can just be just absolutely overwhelming. the myriad of people that the patient hasto interact with, and all the issues going on around them and in them, coupled with thefact that when we’re working with transgender survivors, we as providers may be unfamiliar,and as nurses and advocates, well, you can understand that all of these combined togethercan contribute to further trauma for the transgender patient, which is really what we want to avoid.so you were--so you may ask, “well, what difference is there from any other victim?they all have multiple people to interact with, and isn’t it confusing for anyonewho’s been a victim?” well, i just want to point out, there’s some very unique needsthat transgender victims have when you’re


considering how to provide care. and so justa few of those needs are: differences in body configuration. and as michael said, there’salready high degrees of not just one victimization, but sometimes polyvictimization. also, manyhave experienced discrimination and denial of services, including basic health care services.for those of you who are er-based, think of how many--of how they have been treated inthe past by the systems that are supposed to be helping them, and even possible abusefrom other providers, including health care providers. for this reason and more--thesereasons--it’s critical for the medical forensic exam settings and the clinicians providingcare that we be culturally aware of trans-specific differences in order to provide sensitiveand effective services, which we’ll be talking


about in the next slide. [pause]this is kind of a wheel picture--and i guess michael and i both are on this kind of samepage with being real visual oriented--of victim centered care. and in the protocol, and actuallyon pages 32 to 42 of the protocol, 10 pages are devoted to this, and we have a handouton this. but it was with these things in mind that the second edition of the protocol incorporatedthe special population of transgender patients. on this slide, you see the caveats or principlesof victim centered care, or as we in the health care profession say, patient centered care,that are emphasized in the protocol. you can download the handout from the web as wellas the protocol. but i think it’s really important that we begin here, because it isthis focus, being victim centered--or being


patient centered--that is central to the heartof the protocol. and it’s really--this section is a real wealth of information. specificallymentioned is: priority of care, privacy issues, adapting the exam, providing culturally responsivecare, offering victim services, accommodation for support and responders, using languagethat the patient understands, and respecting the patient’s priorities (realizing theymay not be our own priorities), integration of procedures, safety for the patient, andphysical comfort and patient needs. in other words, it’s important to address the patient’sfears and concerns that can affect their initial reaction to the assault, their post-assaultneeds, their decisions that they make before, during, and after the exam process. it’sreally important to make--stop--don’t make


assumptions about the patient, even the offendersthat have offended against them and the assault itself. also, forms. forms that we use duringthe exam process and the discussion with the patient throughout the process should be framedin a way that doesn’t assume that they are of a specific background or gender identityor gender expression. what we see on the outside is not always what’s on the inside. andwe always need to ask questions, and actively listen to the patient’s concerns and theircircumstances, and tailor the exam process to address their specific needs and concerns.so, [laughs] you could be saying, “now what? what do i do?” so this might be you rightnow, as some of us feel. for those of you who are the health care folks, you may bespinning or scratching your head. but i want


to assure you that first and foremost, thefirst and foremost thing is something that you should be totally familiar with, and that’streating people with respect, dignity, and professionalism. let them know that they arebelieved and that you’re there to support them and provide them with all the alternativesnecessary if they choose to proceed with the exam. some other suggestions, if you’restill struggling: it’s critical not to show surprise, shock, dismay, or concern when youare either told or inadvertently discover that the person is transgender. so keep theshock down. be especially careful about body language. i think, as forensic nurses, we’reoften told things that are kind of difficult to even wrap your brain around, and this isno different than those other times. you need


to control expressions of discomfort, surprise,shock, or even embarrassment on your part, because it may be very upsetting to someone,and they may worry that you’re making a judgement or assessment of themself or theirbody. and you’ll lose--absolutely lose opportunities to establish rapport. we also need to understandthat transgender people have typically been subjected to other people’s curiosity, prejudice,and, as michael said, violence. so keep in mind that the victims may be reluctant toreport the crime or consent to the exam, for many reasons, but for fear of being exposed,or inappropriate questions, or even abusive treatment. if the victim does consent to anexam, be especially careful to explain what you want to do and why, before each step.and i’m surely hoping that we do this anyway


with all of our patients, but specifically,respect their right to decline any portion of the exam. always refer to victims by theirpreferred name and pronoun, even when speaking to others. and remember, on rare occasions,a trans patient may be accompanied by someone who does not know their identity and history.in these cases, you should ask the patient privately how they would like you to referto them in that patient--in that person’s presence. and this brings up an importantplace to recall that patients should have the history-taking done in private, so thatthey’ll be free to talk about what’s happened to them, and i think that we all need to considerthat, when we’re in some places where there are no private areas, that you need to findone to be able to do your medical forensic


history-taking.so, an important reminder. and any patient who reports a sexual assault, remember, theyshould be referred to health care. this is for advocacy, law enforcement, whoever’slistening. there are long-term health consequences that a transgender person can have relatedto sexual assault, and anyone, and they always should be referred to medical to prevent thoselong-term health consequences that can be with them for the rest of their lives. andanother point here is the exam that we do, the medical forensic exam, is relative tothe anatomy that is present, rather than the perceived gender of the patient or affirmedgender of the patient. gender identity may include an internal sense of being male, female,bigender, multigender, pangender, two-spirit,


or any one of the more of hundreds of genderidentities. and i know that forge website has a research link--has a resource sheetwith a few of them--a few of the identity terms that people may use. always refer toand treat the patient socially as their preferred gender. be aware that transgender individualsmay have increased shame or even dissociation from their body, and michael brought thisup a little bit ago. and some are not. so it’s individualized. but some do use non-standardlabels for body parts, and others are unable to discuss sex-related body parts. reflectthe patient’s language when possible, and use alternative means of communication, suchas, you might be able to have the person draw or write down, if they can’t verbalize what’shappened to them. some transgender patients


may have extreme discomfort with their bodies,and may find elements of a physical exam traumatic. so the exam we are doing after a assault cancause further trauma. and to avoid this type of trauma, it’s important to take your timewith the patient. remember that establishing good rapport with any patient, especiallya sexual assault patient, is an essential component of the exam. it’s actually critical.allow the patient to establish the pace of the exam also, including frequent check-inswith them throughout the exam process. and here is where it’s critical to have reallystrong advocacy with you during the exam, because they often can be a gauge, when we’refocused on collecting samples and swabs and setting up the room, the advocate can be criticalto letting you know that the patient needs


some adjustment in the process.so specifically we’re going to talk about some considerations in transmasculine patients.remember, exams should always be done with sensitivity to the patient’s affirmed gender.always address a male-identified patient with masculine pronouns and his preferred name,even when undergoing a vaginal exam. so right here i’ve listed just basically four smallconsiderations that can be really large, and they’re very concerning for us as a forensicexaminer. some of those--the first one is hormone changes, and you’re going to seethis in both the transmasculine and transfeminine patient, but you can see a range of developmentin patients that may be undergoing hormone therapy. and i think we’ll point out thatsome people choose to do this, and some people


do not. so it’s important to note that notall trans men will have chosen to undergo hormone therapy. however, if they do, theymay have had--they may have beard growth, clitoromegaly (which is an enlarged clitoris),acne, and androgenic alopecia or hair loss. those who have bound their breasts for numerousyears may have a rash or yeast infection at the skin under the breast. for those individualsthat are taking testosterone, they can have vaginal atrophy or shrinking of the vaginaltissue, and the tissues become very un-elastic and fragile. transgender men who still haveovaries and a uterus can become pregnant, and this is a really important thing for usto remember as examiners. if there’s a uterus and ovaries present, they can become pregnant,even when they’re using testosterone, and


many of them don’t realize that, and/orhave not been menstruating. they think if they’re not menstruating, they can’t becomepregnant. and they still could be menstruating, also. so recognizing that pregnancy is a possibility,and offering and discussing in a really sensitive manner emergency contraception, is importantin this patient population. if the transgender male individual has not had a hysterectomy,he’s still within childbearing years, and the nature of the assault suggests that thepossibility of pregnancy should be discussed, even if he has not had a period. so emergencycontraception, again, should be offered, and that is a really important concept. transmen may also have concerns about using emergency contraception, because they may believe thatany estrogen- or progesterone-based medication


may undermine their masculinity. in this samecase, if the uterus and cervix are present, and this is the area of assault, a pelvicexam should be part of the clinical assessment. i will say it “needs to be”, but remember,as with any patient population, we always seek consent before we do any part of theexam as we’re proceeding. another point to make here is that the vagina, when it’sexposed to testosterone, especially in doses and over time, becomes more fragile, and itmay sustain injury more readily than the vagina that’s not been exposed to this hormone,and this also needs to be taken into consideration when preparing for the exam. for example,you may need to use a smaller-sized speculum, and that may be necessary if the tissues areatrophied and very fragile, which can often


happen. some of the surgical changes, if thepatient has had surgical intervention, you may see post-chest-surgery or mastectomy scar.the patient may have scar tissue consistent with a particular type of procedure that wasdone, including large nipples that may be present, or there maybe small grafted nipples,depending upon the surgical technique used. as there are several different options thatmay have been utilized for surgery on trans men, you may also find that they have hada neo-phallus, which is created from the release of an augmented clitoris and looks much likea small penis, or a grafted penis constructed by a phalloplasty which will be larger, comparableto the adult-sized penis but more flaccid than the natal male, unless of course thereis a prosthetic implanted in the penis. anticipate


the need for specialty consultation. as youcan see, many patients may have had surgical procedures done, and they may need a specialtysurgeon to come in to see them if there’s damage to the structures. individuals witha masculine identity may also sustain additional physical and emotional damage when vaginallyassaulted, and if they’re undergoing surgical procedures, like in the process of havingsurgery done, there may be a special need to have consultation done with specialty surgeon.you should definitely be prepared for that as an examiner program by knowing which surgicalstaff is prepared to care for these injuries, by gynecological staff or by plastic surgery,and have them as on-call. it’s probably good to meet with them ahead of time and discussthe possibilities, because you probably will


find some in your area that are willing tocome in and have experience of this nature. be sensitive to the evidentiary value of prostheticsand patient choices. now this is really an important point, because you may get the patientcoming in who uses prosthetic devices, and they can be very costly and difficult to replace,and they probably don’t have more than one, and they also can be more vulnerable abouttheir prosthetics. they may not want to part with them, such as penile prosthetics andbreast binders. for this--for reasons of safety and/or cost, in cases where the prostheticmay be of evidentiary value, we need to consider alternative ways to collect forensic samples,such as swabbing the prosthetic and collecting samples from the surface of it, rather thanactually bagging it up and sending it with


the kit. make sure, if the patient declinesto have it sent, that we do think of alternative methods for collection of forensic samples.also remember that victims’ compensation funds may be available for purchasing newitems, and this may help with concerns that the patient may have about the cost--the replacementcost--for these devices, these items. so as we move on to the trans woman patient,similarly, we should also address them--the female identified patient--with female pronounsand her preferred name. some of the hormone changes that we also may see--again, thisis patient dependent, whether or not they’re using hormones--they may have feminine breastshape and size, often with relatively underdeveloped nipples. the breast may appear fibrocysticin nature if there have been silicone injections.


and galactorrhea, or leaking from the breasts,is sometimes seen in trans women with high prolactin hormone levels, and that’s anotherhormone, especially those who are using breast pumps to stimulate development. injected siliconemay be common, and physical assault that may be involved in assault can dislodge that silicone,resulting in disfigurement, serious illness, or death, and we need to be aware of that,and be observing those areas and documenting any injury. there may be minimal body hairpresent, with variable facial hair, depending on the length of time they’re on hormones,and they may have had manual hair removal such as electrolysis. if testicles are present,they may be small and soft, with defects or hernias at the external anguinal ring areathat may be present due to the practice of


tucking the testicles up near or into theanguinal canal. so that would be another part of your evaluation, and also a part wherethey could be injured. some of the surgical changes that you may see in the trans womanis a surgically constructed vagina, which is generally created from the skin of theinverted penis, and it will be less resilient than the typical vagina, which stretches,and as we all know, that usually it can stretch to have a child come out, so very stretchy,and the surgically constructed one may not be--will not be--as well as, it’s not asdeep. using a shorter-billed or smaller speculum is probably going to be necessary, and shouldbe considered before you set up for your exam. you need to have your supplies ready. also,because of those factors, there is also an


increased likelihood of tearing and otherphysical damage during an assault, which, again, should raise our suspicion, becauseit raises the risk of hiv and stis. and trans women may place substantial emotional andfinancial value on their vaginas, and therefore be especially distraught if it is assaultedand/or damaged. so, again, this may anticipate a need for specialty consultation. you mayhave to call a surgeon in. the surgical construction may also require specialty consult if thesurface of the vagina is damaged. the walls may be thinner and may be perforated moreeasily. be prepared for that, knowing which surgical staff, again, is capable of caringfor these injuries. sometimes they may need to consult with their primary surgeon who’sdone the original procedure. and again, here


we come to the sensitive evidentiary valueof prosthetics and patient choices. as with trans men, a trans woman patient may be morevulnerable to safety concerns if they leave things like breasts or wigs or breastformsas evidence, since these items are often essential to publicly presenting as female. when possible,make sure that the trans woman has access to makeup and other items that will help themleave the facility presenting their gender in a way that will make them feel safe andcreate to the highest level of safety possible. as you all know, documentation is an essentialcomponent of the exam, and includes both the written and photographic record of the patientencounter. here are some specific recommendations--there are some specific recommendations for formsand body maps in the second edition of the


protocol. and you have a picture of the formup here, and you have a download on the forge website and on the safeta website for youto download and use. in terms of written documentation, i love the additional information given onthe handout from forge that includes informing the patient if you are using gender-conformingbody maps, because your program uses them, or your kit has that type of form, keep inmind the concept of “know and tell why”, to let the patient know that you’re notdisrespecting their gender by using a particular form. let them know why you used the formthat you did, affirming that it’s because you want to best record their injuries fromthe assault. when using photography to document, be sure to be sensitive as you do for allpatients. first, obtain consent for each photograph


that you need, verbally, and allowing thepatient to decline. you need to recognize that many trans patients have had bad experiencesin the health care in general, and i know i’ve said that a couple times, but i can’temphasize it enough. we don’t want to cause further trauma. being sensitive to explainthe necessity of all photographic documentation is important, keeping the “know and tellwhy” in mind in this portion of the documentation also. another component when we are discussingdocumentation is to recognize that some transgender people, as well as other populations we see,may engage in self-harm or cutting as a coping mechanism, and i think we often see this inteen populations, of any patient population. however, recognize that cutting and genitalmutilation are also frequently a part of anti-transgender


hate crimes. with this in mind, it is importantto remain non-judgemental and careful not to make assumptions when documenting any scarsor even new injuries. i always ask the patient, if i see evidence of cutting, if the scarsare recent or older. most times, they share with you, if you’re not making any judgements,if you’re just asking about them. if they are a component of the crime, it should alsobe documented. so how can we make it better? what we wantto know is, how can we better serve the transgender patient? i thought this little girl with thebandaid was really good. how can we fix this? well, there’s several things that we canwork on process-wise that might help, and this is where kind of the rubber meets theroad. being victim centered. this is where


we started and this is where we end up. thismay be something you have never even looked at, as a sane program and as an individual,and i’m always for seeking out new kind of information on how to do it better. oneof the great things about webinars like this is, they offer great resources for us to useand practice. in fact, forge has created a fact sheet called “know and tell why”,which you can find on the website for more information on how to be more culturally sensitive,including how to distinguish between appropriate and inappropriate questions. because we’veall done it. we’ve all asked the wrong thing. and as soon as it comes out of your mouth,you want to pull it back, but you can’t. ensure safety. some victims, including transgenderpeople, may also fear assault or belittlement


by health care professionals’ and/or lawenforcement officials’ responses to their gender identity or expression and/or theirbody, and this may be different. this may be some treatment they have suffered in thepast. and remember that. treat the knowledge that the person is transgender as protectedmedical information, subject to all confidentiality and privacy rules. really important, especiallyremembering the companion of the patient may not even know their identity or orientationor sexual orientation. safety planning also includes assuring the patient has a safe placeto go. we know that as sanes, but we need to make sure there’s a safety plan in placefor all patients, and there also should be some sort of evaluation for suicidal ideationprior to discharge with every single patient.


i hope that you all are doing that. formsand body maps. we already spoke about this some. but take an opportunity, this is a greatopportunity to look at your intake forms and process, as well as your other documents thatyou use that ask about gender or sex. they should allow patients to write in a response,or include transgender and intersex options. make sure the questions appropriately distinguishbetween sexual orientation--which is the gender someone is attracted to, gender identity--theinternal sense of being a man, woman or gender non-conforming, and their sex. and dischargeplanning. some victims may want to talk about their perceptions of the role that their genderidentity may have played in making them vulnerable to an assault. because of their value in possibleprosecutions under anti-hate-crime laws, documenting


what they say may be helpful for them. otherwise,listen to their concerns as they’re discharged. assure them it was not their fault that theywere sexually assaulted. if needed, encourage follow-up discussion with counseling and advocacy.we do this with all of our patients. encourage follow-up with counseling and advocacy onthis issue. and another way to assure that you’re meeting the needs of these patientsis to include opportunities for trans patients to influence the development--include thepatients to influence the development of sensitive responses for sexual assault. and referrals.we’ve been talking about referrals throughout this; referrals for surgery, referrals toadvocates. ensure that the referrals that you give the victim, that they’ve been trainedor have experience with the special needs


of transgender survivors of sexual assault.recognize that you may have to connect with the patient’s primary md or primary physicianfor a consult, with permission, or with the surgeon who’s working with the patient.if there are referrals that need to be made to caregivers that are not familiar with thepatient, then remember that some transgender people may want your assistance in sharingtheir status with other providers. or some may not. it’s just individual, accordingto the patient. >> loree: kim, this is loree cook-daniels.i have a quick question for you. >> kim: sure.>> loree: someone has asked about the interaction between testosterone, and estrogen or progesteronehormones that are used for next-day contraception.


i’m thinking we don’t actually know howthey work together because we don’t have enough experience. but do you have a comment?do you know more than i do? >> kim: i’m going to say that if it’sa one-time dose of emergency contraception, they’re not going to be on it long-termlike they may be on the testosterone, it should not affect a one-time dose. it’s not likewe’re putting them on estrogen for 30 days or 60 days. it’s the one-time dose of emergencycontraceptive. >> loree: thank you. michael?>> kim: yep. >> michael: well, kim, thank you so much forsharing all of that just incredibly dense information.>> kim: [laughs] yeah, there’s a lot of


stuff.>> michael: [laughs] yeah, there’s a lot of stuff, which is really really great. andi know that you need to leave a little bit early. do you have some time to answer anyadditional questions that may come up right now, or....>> kim: i actually don’t right now-- >> michael: okay...>> kim: --but i’m happy to take email questions, and my email is right up on the slide, soi will be happy to answer any questions that i can.>> michael: that’s perfect. and so the people that are listening, we can--you can directlywrite kim, it sounds like? or you can-- >> kim: sure!>> michael: --you can feed them through us,


and we can send them off and, you know, maybeshare the answers with everybody, which would be probably more helpful to everybody that’sattending, so-- >> kim: great.>> michael: well, thank you very much-- >> kim: happy to do that, yep.>> michael: --thank you for being here. all right. i really appreciate the informationthat you shared, and i know that this was really very valuable to so many of us whoare not as familiar with forensic exams, and these very specific things that you talkedabout today, so thank you. [pause] we’re going to change pace a little bit, and i’mhoping that eric is on the line with us, and we’re going to skip ahead a little bit.we had a little bit of content that we were


going to share, and i think that loree andi will record it separately later, and then add that to the recordings that are availableonline. so, eric, are you on the line? >> eric: yes i am.>> michael: excellent. let me just forward-- >> eric: okay.>> michael: let me forward to your slide and--we’re really thrilled that you’re here with ustoo, and i know you’re calling in remotely and i’m wondering if you could share a littlebit about who you are and who you work for and then lead us into the couple of case examplesthat you’re going to share with us. >> eric: sure. thank you, michael. my name’seric stiles. i work for the national sexual violence resource center and i’m the ruralproject specialist. and what that means is,


i go around and i do a lot of training, ta--technicalassistance--around issues in rural communities, but i also work a lot with the lgbtqiah communitiesas well as men. previously though, prior to this work, i worked as an advocate in a ruralcommunity, and i just want to highlight that starting off working in a rural community,individuals think that you can’t possibly have worked with trans community. that’snot the case. trans folks are throughout all the communities. so the two case studies ihave today, both are experiences i have had, that i’m going to shield as much detailto keep everybody confidential, but i’d like to share them to give a little bit moreof the story behind what happens maybe after the fact of having sexual assault examinationsand it’s really important of how we interact


with survivors really plays a role in theirwell-being long-term. so, the first one that i’d like to talkabout is a young male--to actual sexual assault examination--contact--was referred to ouragency because they knew there was somebody there that could work with him, and he wasstruggling with follow-up. so as kim was talking about with having birth control, he had togo to an ob/gyn for follow-up to take care of what had taken place at the assault, tomake sure that rips and tears were taken care of. but a lot of our job as advocates wasworking with the post-ob/gyn visit and pre-ob/gyn visit because there was a lot of shame andguilt and confusion over gender, meaning that he felt that his gender had let him down;if he was more masculine, if he could pass


better, he wouldn’t have been assaulted,and that his own body parts betrayed him, because now he’s going to an ob/gyn, andso highlighting the body parts that he felt were not true to his being who he was. somy job as an advocate really got pushed beyond that initial, “oh, let’s go to an ob/gyn,”but also having session to help wrap up before he could go back in the community and socializeand interact. he felt like the way that he was perceived in the community was too feminine,so he was really concerned about his gender identity, and sexual violence took that tothe core of his being, and going to the sexual assault examination, as kim mentioned, canbe a very traumatizing experience in itself for highlighting those aspects of--that hedid not feel were appropriate and aligned


with his gender. so that’s the first one.and i know we’re in a place where we’re kind of tight on time, so i’ll go into thesecond one real quick, and then we’ll have some time for questions. and the second onedeals with--this is years down the road. a female was--i’m sorry--coming in becausethey were assaulted previously, they were drinking, they believed that something maybewas put in their drink when the assault took place, and when they came to after being beatup--also in the assault, the sexual violence assault--they came to without a wig on, withoutany bra, and they felt completely naked, and they were just--she was just totally mortifiedthat he or she woke up not feeling like herself, and then she had to walk out, and she feltlike she was this big joke, and that no one


took her seriously, and that was years andyears after this took place that i was meeting with her. so a lot of our time spent togetherwas working on how to deal with all of that trauma that took place in that actual examinationafter the assault, because everything was taken, and they kept referring to her as male.she felt very stripped down, very alone in the world, and [coughs] it consequently causeda lot of problems for her down the road, because she felt she couldn’t pass before, she feltlike she can’t pass now, and having all those things taken away from her that madeit so that in her mind she felt like she would be expressed as herself as a woman, that reallymade her journey to healing a lot more traumatic for her. so i address to you about both thoseexamples, but the key point to them, for advocates


on the phone right now on this webinar, andanyone working with survivors, is really slowing down and being present for everybody and beingin the moment. so being with the individual survivor in the moment and hearing what theirneeds are, and seeing them for their needs, and not kind of conforming to some sort ofform, conforming to the stated protocol. and like kim said, being very sensitive to theidea of how we address ourselves and how we make our appearances is extremely important,and taking away those things that make us a whole person can really cause problems forhow much trauma we’ve received from that examination. so really being present and listening,and seeking their guidance. with both survivors, i asked them what’s worked for them in thepast, and i asked them how they’ve gotten


through it, because they both had a lot ofresiliency, but i also asked them what type of support they needed. and at times theydidn’t know, so i just stayed around, and hearing my language now is “i just stayedaround”, i listened, i made times with them, until they came up with what they did need.so they might need more time going to the visit for ob/gyn and speaking with me afterwards,or they might need longer sessions because it’s the anniversary date of the hospitalcoming in. so, really taking into account every individual for where they’re at. and,michael, i know you might have some questions, but i think i made it in time for us.>> michael: you made it in super time! you could have taken a little bit more time, andi’m wondering if we could have--


>> eric: [laughs] okay.>> michael: --we could have a little bit of a dialogue about it, because i think thatthese two cases are really--they’re really great examples of what people might be experiencingand what providers may, you know, see in their everyday work when a trans client is comingin. and, you know, i know you spoke at the end about that process of just--not just listening,but--listening, just, you know, spending time listening to what’s going on, and i’mwondering if you want to talk a little bit more about that in reference to both of thesecases, or in other situations that you may want to share.>> eric: yeah. i will definitely--we can talk about both these cases, but in general aswell. the first thing i think it takes to


listen is “thoughts make assumptions”.especially the communities that i’ve worked in, individuals have a variety of experienceof their gender expression, and also a lot of it came down to money. so if there’ssexual violence that took place--so both individuals were not going through surgery, both individualswere not transitioning, they were considering themselves and they do consider themselvesto be the gender they express--so to listen to someone’s story when they’re--whenyou have an outside culture that is surrounding them, kind of telling them they’re wrong,the hospital treats them like a different gender, really takes some balancing act, becausenow we’re listening at one part, but also kind of advocating in the second part. sowhen they express to you, “refer to me as


male,” you refer to them as male, of course,but when you go out into the community or you talk to an ob/gyn, and you’re helpingthem and you’re advocating, it’s taking that with you. and that one step that seemednatural at the moment for me, for example with the first individual, by telling thenurse or the ob/gyn center that his name is x, really meant a lot because it meant i listened,and i didn’t even take into account how much that meant to the survivor, but the survivorappreciated that i listened enough to take into account the pronouns being used and referringto him as who he was. so, we need to slow down, listen, and really take what they sayto heart. and what that means is being attentive, and not looking for the right answer. therewere lots of times i wanted to fix things,


meaning, the second individual, when she wouldtalk about how she was treated in the community and ridiculed and treated as she wasn’ta woman, i wanted to fix it. i wanted to go out and do all these things to change, buti couldn’t. but what i could do was be there in the moment and hear what she was expressingto get her feelings behind it. part of that active listening with individuals from anycommunity is, you have to take your time. it really is against my nature to rush throughthings like this, like this webinar, but in the moment with these survivors, you needto make that time, and working with trans survivors, sometimes that time takes longer.i did not hear the story from the second individual--i did not hear from her the complete story ofwhat happened to her in the hospital years


before until maybe 3 or 4 months, 5 months,into working with her, and then she expressed it because she needed to have that time forherself to figure out how to communicate with me. and there were missteps on my part, too,as well, that i did not necessarily think about. so it’s a combination of offeringtime, but also just being very, “well, you make mistakes.” and one of my mistakes withher--in my communication, i should say, not “with her”--in our communication was whenshe expressed very early on that the sexual assault examination that she went through--the“trip to the er”, as she put it--was very traumatic. i didn’t pick up on how traumatic,because i didn’t ask. i just let it go. i was like, “okay, i understand that,”and in my mind i understood that, so i thought


i understood, so i didn’t ask any more questionsor be supportive of that. so it took months to come back around to that, for her to findher space to bring that up. >> michael: yeah, that makes a lot of sense.and, you know, you kind of brought up some points that we continually kind of remindproviders around, about, with being patient and persistent and compassionate. and sometimesi think trans survivors really need--i don’t want to say more patience than other peopledo, but sometimes there’s a history of mistrust, and an uncertainty of how people are goingto respond, so it takes a little while for those stories to come out, and it sounds likethat’s what was happening with the second case, for you.>> eric: yes. and it takes--i don’t think


that trans survivors need more patience fromus. in my mind, i framed it over time as, it takes a very lot of--it takes a lot ofpatience for us to overcome the damage done by society.>> michael: yes. >> eric: it’s not them that need it. it’sthe damage that’s done that needs it. so there’s a lot more space that we need tocreate in our environments for them to have a space space, because so much space has beentaken from them in the communities they live in. so, it takes more time to build that space,and it takes more time to build all of that, and it’s not because of them individually.it’s because of what society has done, not because of them>> michael: exactly. do you have some comments


on how people can create that space?>> eric: one is very kind of fundamental space building, and that is, in our offices, ofcourse, having literature and information and being open and having trainings and receivingthings from something like forge, and other things on these concerns, starts creatingthat culture and creating that change in your agency. but it doesn’t stop there. it hasto be communicated to your hospital, to law enforcement. so you now become the advocatein the community before you ever see someone come in. and then beyond that is, when youstart creating that space and getting that time, being aware, if we’ve worked withchildren, for example--and i’m not comparing trans people to children--but advocates kindof get this niche, whether you’re adult


survivors, or you’re working with children,or you work with this community or that community, and we kind of get pigeonholed in that. butworking with trans survivors, they’re all different ages. so we have to look at it acrossthe life span. and we have to look at how does that play out its role, and how can wecreate more time? so if we go out to a school with a trans individual who’s being sexuallyharassed and bullied and has been sexually assaulted, what do we need to do to createthat space in that school, versus what do we need to do to create that space in thehospital setting? and then, in ourselves, we need to have somebody to go to to debrief,somebody to go to to bounce ideas off from, and we need to build a sense of real investmentin the community. it can’t be just lip service,


like “here’s a specialized populationto work with”. we need to make real allies within the community, and have real conversations,and at times those conversations can be very uncomfortable, because if you’re not fromthe community, you’re going to hear really solid and concrete truths. so you make partnerships.you find local agencies, whether that local agency is within the state, or a nationalagency, to start building some focus groups and some conferences. but we don’t justtake from the community. we give back. and as individually and as an advocate, we prepareourselves to have the ability to be more trauma-focused in all of our work, not just with trans, butto give ourselves time for each individual to have the time they need. so if they needtwo hours, we give two hours. if they need


an hour, we give them an hour. does that answersome of those questions for you, michael? >> michael: that’s perfect. that’s reallyreally perfect. i’m wondering if we should shift a little bit next to some take-homereminders and just reminders for folks about what other things forge can offer people,and then we’ll have some time for some questions. so, if people are thinking about questions,feel free to type that in that question area, and loree will sort through them. and, i think,eric, you and i are the only two left, and we’ll sort the other questions for kim andget those to her for her responses later on. so let me just bring us through a couple ofvery very brief take-home reminders. one is, i wanted to make sure that folks knowwhat we, forge, can offer you, and a lot of


you have seen this slide before if you’vebeen on our webinars, but we offer training and technical assistance for providers--victimservice providers--and some of what that involves is doing one-on-one support. we do an incrediblyhigh volume of one-on-one support. so you email us or call us with a question abouta trans client or a trans survivor or a situation that you’re thinking about, and we willwork through with you the best that we can to get to a solution that feels comfortableand right for you and/or for your clients. we obviously offer webinars just like thisone every month, and we’re really pleased that we have really a wide variety of topicsthat we’ve covered and that we will be covering, so please join us in the future on additionalwebinars. may is going to be another guest


speaker, rebecca dreke from the stalking resourcecenter, so we’ll talk about stalking in may. we also provide trainings across thecountry. i know eric is training across the country, too, right now. and yeah, i reallyenjoy traveling, and loree enjoys traveling, and so we’re at many of the conferencesacross the country and we’re pleased to do that. we also do some individualized trainingswhen we’re asked to come places, so we do that when we can, and we’re able to. andthe other thing that we offer for providers is a variety of different publications. kimreferenced a couple of them when she was speaking, and you can easily see them--when i send outthe follow-up, i’ll link to a couple of specific ones that you may be particularlyinterested in. and then we also offer support


directly to trans survivors, because a lotof times, trans survivors don’t get access to the healing services that they need, becausethey’re in places that don’t have a lot of trans support, or don’t have a lot ofproviders with trans knowledge. so we have listservs that are 24/7 where people can connectto other survivors and other loved ones. we do a lot of referrals, so if people don’tknow where to go or who to go to, and we can try to help get them connected in a placethat’s closer to them geographically to get the support that they need. we offer anonline writing to heal group, because a lot of times we’re finding that, trans survivorsare not able to access in-person support groups, so we’ve chosen to do writing to heal asour type of support group for folks, and it’s


a trauma-informed, writing based group, butit’s all online, so anybody can access it from anywhere in the country if they haveaccess to a library or public computer or private computer. and the fourth thing thatwe offer for survivors is a relatively new project called the espavo project, and thetwo photos that you saw in the slides when eric was talking are from the espavo project,so they’re professionally-taken photographs of people who want to be involved in thisproject, and the people are crafting statements of resilience, so it’s a really healingprocess to have an image that they feel really proud of and really good about, and then crafta statement that shows how they’ve survived and who they are as this current thrivingperson. so that’s a little bit about what


we can offer you.so a couple of take-home reminders about assumptions, and kim and eric both talked about a lot ofthese things, and so i’m just going to very quickly go through them, and we can do somequestions. so if you have assumptions, you know, check in with yourself about what gender-basedassumptions that you’re making, and try to leave them at home, or before you enterthat exam room or that office with somebody. another reminder is something that i don’tthink we think about very often, but to celebrate the limitless ways that bodies can be configured.we all have different bodies, and trans bodies are no different, in that, you know, we allhave different bodies, so let’s figure out how we can be celebratory and appreciativeof the differences in our bodies.


another reminder is to kind of keep calm andbe prepared. so we all need to be prepared to hear anything, and i know kim specificallytalked about, a lot of times we hear really difficult information when we’re talkingwith survivors, and when we’re talking with trans survivors, we may hear unexpected information.so we need to be prepared, and not show our surprise even if we feel a little bit surprised.another reminder is to “know and tell why”, and i know kim talked in much more detailthan i was expecting her to about “know and tell why”. so know why you need to aska question, and let your client or patient or survivor know why you’re asking, so theydon’t feel objectified or that they’re the object of your curiosity.another reminder is to think creatively to


find workable solutions. so, you know, sometimespeople do not fit into the service systems that we have. and so if they don’t fit intothose, what can we figure out about how to help them get the service and the care andthe healing that they deserve and need? so sometimes that’s really tricky, and sometimesit takes time, and sometimes it takes a lot of time. but i think that if we are patientenough, and persistent enough, that we can end up getting to a place that will do somethingto help the survivors that are in front of us.and i think all of us really know this last slide very well, but, you know, i think thatit’s really important to empower our clients with respect and compassion and informationand choices. and, you know, i think that all


of us who work with victims or survivors dothis, and i think sometimes it’s important just to have it be articulated and overtlystated, you know, that we keep that empowerment as a primary focus when we work with clients.and i think it’s especially true for trans people, who oftentimes feel disempowered,and then when they’re sexually assaulted, they feel disempowered around that as well.so those are the couple of take-home reminders, and i’d love to move on to questions, if,loree, you’ve collected some of them? >> loree: yes, i-->> michael: let’s do some questions. >> loree: yes, i have some questions. andone that i think both of you may want to address, we’ve had two people say, “what else shouldbe in our kits at the--in our sane kits to


help things like with the wigs?” [audiocuts out] “...some things that people may want to add to their kits?”>> michael: eric, would you like to start with these? i’d like to probably have youstart with most of the questions. >> eric: okay, sure. well, one thing you cando is, i know there’s some advocates in vermont that have caring carts where theyhave different items that they can have at the hospital or have at their center readyfor individuals to use. so makeup, wigs, bindings, items they can put--give to the survivorsso they can help address how they look before they leave the hospital. i know it takes alot of communication to get a hospital around to--i know a lot of times--just to have rapekits and extra clothing there, so having this


come up seems like a burden, but it’s reallynot. you can actually start pulling in, because some of these items don’t always go justto transgender folks in your community, because i’ve had makeup used at our hospital forindividuals who aren’t from the trans community. i’ve had wigs used from people who aren’t;i had a cancer survivor use a wig. so there are survivors--there are other purposes formost of these items, that you can just put that stuff at the hospital for them there.or, you can have them at your agency that someone can stop by and take to the hospitalwith them before going to the hospital accompanying them. the list--i would suggest--and michael,maybe you would know the individual i’m thinking from vermont. maybe she has a conciselist. i think she actually does, if memory


serves me right.>> michael: that would be really great if she did. i don’t know that she does. i knowwho you’re talking about, and i will contact her directly to see if she has a list. butlike you were saying, eric, i think that there’s a lot of things that are used by non-transpeople as well, like wigs for people who have cancer. things like ace bandages can be usedfor binding, but they can also be used for lots of other things. or scarves to coverheads. i mean, there’s lots of items that have dual purposes. i think, in particular,things like larger-size clothing. a lot of trans women are larger sized, but there’sa lot of larger-sized people who are not trans as well. so, you know, having some of thoseitems available, whether they’re on site


or at somebody’s agency, is very useful.we will try to-- >> loree: thank you. thank you. “how doyou balance the importance of getting the patient alone for the medical history withtheir desire to be accompanied by their support person if they don’t want that person tobe sent out of the room? what are the patient’s rights regarding having other people presentwith them during their medical visit?” [pause] >> eric: well, i know that in--i’ll speakto pennsylvania, and michael, i hope you can go to nationally, and i know something aboutother states. support people--i know that i sat behind curtains for survivors before.i’ve had other individuals, like, their family support that they had there--and isay “family” because they refer to them


as family--that’s really important to takeinto account what they signify others to mean--be there as well to show support for them, behindcurtains and in the room. >> michael: and we had some lovely noise inthere. sorry about that. did you have more to say, eric? it was hard to hear with thescreeching. >> eric: i think it’s a fire alarm in thebuilding. but it went off, so--no, that was it.>> michael: and i just wanted to add a little bit to that. one of the things we recommend,and i think others are starting to recommend as well, is it’s fairly--you can do a fairlyquick assessment of if somebody is accompanying with somebody who might be an abuser or tojust determine whether they are or not, or


what the level of comfort is with that person,and so that alone time can happen prior to the medical history, which a trans personor anybody may want to have somebody present. so i heard what kim said, and, you know, iwish she was still on the call, because i think there’s some variation around whenit’s important for people to have somebody in the room with them, and i think, you know,my primary concern tends to be around, we want to make sure that that other person,the accompanying person, is not the abuser or not the perpetrator. loree, are there otherquestions? >> loree: yes. “thank you for the case scenarios.really helpful advice. i am a rape crisis coordinator in an adolescent health center.i refer adolescents for the forensic exams


and for follow-up care. are there specificneeds to trans youth versus trans adults?” [pause]>> michael: eric, you’re probably going to have a much better answer for that thani will. [pause] >> loree: i wonder if we just lost eric.>> michael: we may have. [pause] well, let me start with the question, andhopefully eric will be able to get back on. so the question was around “are there specificconcerns or things to prepare for trans youth versus other youth?” was that the question?>> loree: no. trans youth versus trans adults. >> michael: trans youth versus trans adults.yeah, i think one of the primary concerns is going to be is that trans youth--out totheir family? what are some of the legal challenges


that they might be concerned about? they maybe worried about if their parents find out certain things. i think there’s a lot ofjust privacy concerns that trans youth might be experiencing, that trans adults could bettertake care of because they’re not dependent. >> eric: this is--can you hear me now?>> michael: yes. >> eric: great. i’m sorry. couple thingsto think about is the age group of trans youth. so youth are very young. often the parentsare very supportive, and they have identified that and can be around that. i’m not sayingoften, but they--parents often support, and buy their children the clothing for the children,so if they are below the age of 10, and this something has taken place, then parents mightbe one of the strongest advocates. so taking


into account, when the parents are there,if they’re strong advocates, helping them with the process. certainly with teens, likemichael said, there might be a disconnect between what parents know and don’t knowabout their youth, and that becomes the problem now, of how they identify themselves, especiallyafter the assault, in the emergency room, especially if they are called in. in our state,below a certain age, parents get called in, but they still might be [unclear] differentlyfrom what their parents think they should be [unclear]. so taking all that into account,the difference between youth and the adults would be really trying, as an advocate, toestablish where that relationship is, from the survivor, about the relationship to theirparents and support, and then going from there


and taking their lead.>> loree: thank you. i have another one. “i have heard from our sane nurses that whena trans individual does not reveal the bio parts, it is a waste of resources. for example,doing a pregnancy test on a trans woman. what are some responses i can have to their commentwhile advocating for the population in general?” [pause]>> eric: oh. okay. i’ve never been faced with that before, but off the top of my head,something i would come up with is, “pregnancy tests for a woman who might not be able toconceive a child, would that be a wasted test?” and if the person says “no, because howwould they know?”, that’s the same difference as to what response that we give. how wouldwe know? we treat individuals for who they


are coming in, and if they identify as. myconcern is about where that’s coming from, that question, if the nurses or the individuals,doctors who are asking this question about wasting resources is coming from, like, abigoted place, and also what type of conversation are they having with the individuals thatcome in that identify as trans but they don’t feel comfortable enough to share information,if there’s something--that there’s a breakdown between the way they provide services.>> loree: thank you, eric. i have someone else here, saying, “i have advocated fortrans men and women. since lea and sane were both very insensitive, i asked to speak tomy client first to ask permission to speak directly to lea and sane about how they weretreating my clients. one didn’t want me


to, so we discussed the treatment they receivedafter. eventually they gave me a release of info to speak with lea and sane. the otherclient was okay with me advocating for them. after speaking--” i just turned my thingoff. [laughs] i am sorry, i have lost the question.>> eric: okay. >> loree: “after speaking to lea....”[pause] [sighs] i really dislike how these come up. i’m sorry. [pause]>> michael: i’m looking for the question too, so.... [pause]>> loree: [sighs] >> michael: loree, do you want to go to thenext one while i look to see if i can find the original that you were reading?>> loree: okay. “i learned from our pharmacy


that some drugs are dosed based on parametersthat take into account the patient’s biologic sex. thankfully, none for sexual assault patientsdirectly, but maybe so if critical injury and admitted. how would hospitals handle that?the gender is a field that registration handles on arrival.” [pause]>> eric: i don’t really have an answer for that. do you, michael?>> michael: i don’t, because i’m multitasking, so maybe loree has an answer to that one.[laughs] >> loree: i think that when we start dealingwith the health care of transgender people and medical norms, there needs to be somecreative thinking about, what is it that the norms are set by? for instance, are they setby the average weight of men versus women?


are they set by the testosterone present orthe estrogen present? we need to--we may need to go back a little bit and think about “whyare there differences?” in order to figure out what would be appropriate ways to handlethat difference with regard to a person who is transgender. [pause]>> eric: thank you for that. [pause] >> michael: so i did find the original question,which is talking about working with trans men and trans women and lea and sane, andthe last part of that question was, “after speaking to lea and sane, interview and examwas more respectful and went a lot better. is there any other way that this could havebeen handled, the problem being lea and sanes don’t like being interrupted?” [pause]>> eric: i think that goes to, kind of--and


this is kind of my mindset, michael, and maybeyou have different points--is kind of getting ahead of the curve with this. i think themore we look at individuals as a whole being, and we know that there’s no cookie cutterfor any type of individuals, then that really pushes us as advocates to get out there andahead of the curve and really start advocating before we see a certain individual from acertain community come in, includes those who are trans. now i’m not saying we cando that, like, before any trans people have come in, but before we are faced with thatin the er. so we go out, we start talking to them about ways that we know. we can usetrainings, we can use resources from forge, definitely some from forge. helping the lawenforcement and nurses slow down their practice,


make room for more questions, like kim said,explain why they’re asking questions more, and really put that into practice. and throughdoing that advocacy work prior to someone coming in and seeing them in that crisis moment,you have more ability and resources and bridge to go back to them and say, “well, thisis a time for us to take a break or slow down,” and that might mean something you work inwhile you’re talking to these other agencies. >> michael: that’s a really great example--greatanswer to that question. i’m really aware of our time, too, that we’ve got a coupleminutes left, and i believe that there are more questions that we will feed out and sendby email to people or post on the web and send you the link to those questions and answers,because i’m hoping that eric would be willing


to participate in some more of those questionsoffline, and i know kim is as well. >> eric: sure.>> michael: i wanted just to--yeah, good, thank you! [laughs] i was hoping that wouldbe the answer. i really wanted to just remind folks of a couple things that we mentionedat the beginning. one is that we’ll be sending out the powerpoints tomorrow. you’ll getan email tomorrow. it’ll have link to the powerpoints and a link to the recording oftoday’s session. when the window closes today at the end of the webinar, there willbe a very short survey, and we really care about your feedback. it’s also another placethat you can ask questions, so feel to ask more questions in that brief survey, but wereally value your input, and we try to adjust


our webinars to meet your needs better. nextmonth’s topic is--i think i mentioned before--is on stalking, so may 8th, the webinar is alreadyopen for registration, and i hope that you will consider joining us next month. rebeccadreke with stalking resource center will be online with us. and i really wanted to thankkim and eric for being with us today and sharing their really amazing knowledge with us. it’sreally amazing to have guests, and guests who are so smart and bright and caring, sothank you very much. and thank you everybody for attending, and caring about trans survivorsand how to work better with the trans community. so thank you everybody.>> eric: thank you, michael, and thanks to


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forge for all the work that you do, and thanksto all the advocates and nurses out there


right now for all the work that you’re doing.and just take it easy, take time, and be patient with yourself and do this work. it’s allgrowing. thanks again. >> michael: thanks eric.>> loree: thank you.


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to simulate an erection: to transfer the fluidto the cylinders, locate the pump in the scrotum.


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squeeze the pump firmly a few times betweenthe thumb and fingers until an erection is achieved. to return to a flaccid state: fluidpressure in the cylinders is released with the patient momentary depresses the deflatevalve button to enable fluid to return to the reservoir thus returning the penis tothe flaccid state.


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