Help-Seeking and Service Utilization Among Survivors of Intimate Partner Violence in Michigan During the COVID-19 Pandemic.

This study explores formal and informal intimate partner violence (IPV) service use among women and transgender/nonbinary individuals in the state of Michigan during the COVID-19 pandemic. A total of 14.8% (N = 173) of participants experienced IPV during this period, and 70% utilized at least one formal IPV service (13.3%). Up to 22% of survivors reported wanting to seek formal help but not doing so due to fear of partner reprisal, contracting COVID-19, or COVID-related service reductions. White, pregnant, and part-time-employed survivors were most likely to seek informal help. Older, higher-income, white, part-time-employed, pregnant, and non-essential worker survivors were most likely to seek formal help.

Power and control, resistance and survival: A systematic review and meta-synthesis of the qualitative literature on intimate partner violence against transgender individuals.

Transgender (trans) individuals experience intimate partner violence (IPV) at elevated levels compared to cisgender individuals. Traditional theoretical understandings of IPV as men's patriarchal domination of women, and later, broader theories in which IPV is conceptualized as the relatively privileged partner enacting domination over the relatively oppressed partner, do not fully capture the totality of IPV experiences, including how IPV is perpetrated against trans individuals. We conducted a systematic review and qualitative meta-synthesis of the qualitative and theoretical literatures on IPV against trans individuals (N = 37 articles and books) to generate novel IPV theory inclusive of trans individuals' experiences. We identified five major themes: (1) societal context of IPV, (2) IPV tactics and types, (3) help-seeking, (4) consequences of IPV, and (5) proposed interventions for victims. Synthesizing across themes, we offer a novel theoretical model that demonstrates how abusers can leverage structural discrimination and vulnerabilities against trans victims, regardless of the abuser's own identities. We identify individual power and control tactics abusers use, including identifying a category of IPV that we term leveraging vulnerability, which involves abusers weaponizing their own vulnerabilities to avoid accountability. Reducing IPV in trans communities requires expanding current IPV theory to include trans victims, recognition of a wider range of abuse tactics, and structural interventions that promote the respectful treatment of trans individuals. Our theoretical model of IPV "centers the margins" to make trans victims' experiences, and indeed all victims whose experiences fall outside normative scripts, more legible.

Toward the conceptualization and measurement of transphobia-driven intimate partner violence.

Transgender and gender expansive (trans) people face high rates of violence, including unique forms of abuse from intimate partners that specifically leverage transphobia. Past qualitative studies have explored trans-specific intimate partner violence (IPV) and transgender IPV; we propose a new term, transphobia-driven IPV, investigated in this paper. The goals of this study were two-fold: (1) to qualitatively identify the subdomains and boundaries of transphobia-driven IPV with the explicit intention of new scale development; and (2) to examine the degree to which existing trans-focused IPV measurement scales adequately assess the construct. We recruited US-based, English-speaking trans survivors of IPV, aged 18 years and older, online through community-based organizations and Facebook/Instagram advertising. Twenty people participated in the study, of which 60 percent were white, 55 percent were assigned female at birth, and 60 percent were nonbinary. Through thematic analysis of the 20 in-depth interviews, we identified four subdomains of transphobia-driven IPV: pressure to perform, disrupting gender affirmation, belittling gender identity, and intentional misgendering. When examining nine existing screening tools and measures that ask about IPV related to the survivor's trans identity, only one measure included questions related to all four subdomains. Further, the existing measures were either not psychometrically validated, only validated with a subpopulation of the trans community, or validated with a larger LGBTQ sample of which trans survivors comprised a small percentage. This study lays a foundation for new valid measures of transphobia-driven IPV that reflect the various ways in which transphobia can be leveraged by abusers and may be relevant across subpopulations of the trans community.

Risks of Severe Assault and Intimate Partner Homicide among Transgender and Gender Diverse Intimate Partner Violence Survivors: Preliminary Findings from Community Listening Sessions.

Intimate partner violence (IPV) is an epidemic among transgender and gender diverse (TGD) people. However, intimate partner homicide (IPH) among TGD people is under researched. Thus, thematic content analysis was used to describe and examine antecedents of severe assault and IPH among TGD adults who have experienced IPV (N = 13), via community listening sessions. While some themes resembled known severe assault and IPH risks among cisgender women, several themes were unique to TGD people and should be considered when safety planning with TGD individuals or adapting IPV screening tools for this population.

Digital-Assisted Self-interview of HIV or Sexually Transmitted Infection Risk Behaviors in Transmasculine Adults: Development and Field Testing of the Transmasculine Sexual Health Assessment.

BACKGROUND: The sexual health of transmasculine (TM) people-those who identify as male, men, or nonbinary and were assigned a female sex at birth-is understudied. One barrier to conducting HIV- and sexually transmitted infection (STI)-related research with this population is how to best capture sexual risk data in an acceptable, gender-affirming, and accurate manner. OBJECTIVE: This study aimed to report on the community-based process of developing, piloting, and refining a digitally deployed measure to assess self-reported sexual behaviors associated with HIV and STI transmission for research with TM adults. METHODS: A multicomponent process was used to develop a digital-assisted self-interview to assess HIV and STI risk in TM people: gathering input from a Community Task Force; working with an interdisciplinary team of content experts in transgender medicine, epidemiology, and infectious diseases; conducting web-based focus groups; and iteratively refining the measure. We field-tested the measure with 141 TM people in the greater Boston, Massachusetts area to assess HIV and STI risk. Descriptive statistics characterized the distribution of sexual behaviors and HIV and STI transmission risk by the gender identity of sexual partners. RESULTS: The Transmasculine Sexual Health Assessment (TM-SHA) measures the broad range of potential sexual behaviors TM people may engage in, including those which may confer risk for STIs and not just for HIV infection (ie, oral-genital contact); incorporates gender-affirming language (ie, genital or frontal vs vaginal); and asks sexual partnership characteristics (ie, partner gender). Among 141 individual participants (mean age 27, SD 5 years; range 21-29 years; n=21, 14.9% multiracial), 259 sexual partnerships and 15 sexual risk behaviors were reported. Participants engaged in a wide range of sexual behaviors, including fingering or fisting (receiving: n=170, 65.6%; performing: n=173, 66.8%), oral-genital sex (receiving: n=182, 70.3%; performing: n=216, 83.4%), anal-genital sex (receptive: n=31, 11.9%; insertive: n=9, 3.5%), frontal-genital sex (receptive: n=105, 40.5%; insertive: n=46, 17.8%), and sharing toys or prosthetics during insertive sex (n=62, 23.9%). Overall barrier use for each sexual behavior ranged from 10.9% (20/182) to 81% (25/31). Frontal receptive sex with genitals and no protective barrier was the highest (21/42, 50%) with cisgender male partners. In total, 14.9% (21/141) of participants reported a lifetime diagnosis of STI. The sexual history tool was highly acceptable to TM participants. CONCLUSIONS: The TM-SHA is one of the first digital sexual health risk measures developed specifically with and exclusively for TM people. TM-SHA successfully integrates gender-affirming language and branching logic to capture a wide array of sexual behaviors. The measure elicits sexual behavior information needed to assess HIV and STI transmission risk behaviors. A strength of the tool is that detailed partner-by-partner data can be used to model partnership-level characteristics, not just individual-level participant data, to inform HIV and STI interventions.

Factors Associated with Unsatisfactory Pap Tests Among Sexually Active Trans Masculine Adults.

Purpose: Unsatisfactory collection of cells during Papanicolaou (Pap) tests prevents the detection of cervical cancer and dysplasia. Prior research found that trans masculine (TM) individuals are significantly more likely than cisgender women to have an unsatisfactory Pap test. The purpose of this study was to identify factors that place some TM individuals at greater risk for an unsatisfactory Pap test than others. Methods: Between 2015 and 2016, 150 TM adults were enrolled in a cross-sectional survey assessing demographics, health characteristics, health care experiences, trauma history, and unsatisfactory Pap test history. Bivariate and multivariable logistic regression analyses conducted in 2020 examined associations between age, length of time on testosterone, smoking history, having to educate a provider about transgender people to receive appropriate care, anticipated health care stigma, post-traumatic stress disorder (PTSD) symptoms, and lifetime history of unsatisfactory Pap tests. Results: Of all participants, 20.2% had an unsatisfactory test in their lifetime, age ranged from 21 to 50 years, 55.1% used testosterone for 1 year or more, and 41.3% had PTSD symptoms. In the multivariable model, older age (adjusted odds ratio [AOR] = 1.15; 95% confidence interval (CI) = 1.04-1.27; p < 0.01), 1 year or more lifetime testosterone use (AOR = 3.51; 95% CI = 1.02-12.08; p = 0.046), and PTSD symptoms (AOR = 3.48; 95% CI = 1.10-11.00, p = 0.03) were significantly associated with increased odds of having an unsatisfactory Pap test. Conclusions: Older age, testosterone use, and PTSD symptoms are associated with lifetime unsatisfactory Pap tests among TM adults. Clinicians should assess TM patients' trauma and testosterone use history before Pap tests and utilize trauma-informed practices that facilitate the collection of adequate Pap samples.

Perceptions of Partner Decarceration among Survivors of Intimate Partner Violence during the COVID-19 Pandemic.

The COVID-19 pandemic prompted the early release of thousands of incarcerated individuals, including those with histories of intimate partner violence (IPV) perpetration. Survivor advocates stress the importance of adequate supports for decarcerated individuals during re-entry, and notification and supports for their partners or ex-partners if there is a history of IPV. This survey assessed IPV survivors' expectations of and experiences with decarceration in the state of Michigan. Findings highlight that out of 42 survivors with recently decarcerated (ex-)partners, 64.3% reported helpful behavior on the part of their released partner. By contrast, out of 72 survivors with still-incarcerated (ex-)partners, the same percentage - 64.3% - expected harmful behavior from their partner if released. Decarceration efforts may distinguish between individuals who are likely to harm versus help (ex-)partners upon release. Nonetheless, survivors reported several unmet needs, indicating the need for better re-integration services for decarcerated individuals and their families.

Factors associated with transmasculine adults recently engaging in sexual behavior with partners of unknown STI and HIV status.

The sexual partnerships of transmasculine (TM) adults-those assigned female at birth who identify as transgender men or a masculine spectrum gender identity-and characteristics associated with STI/HIV risk behavior remains understudied. Participants in the current study were TM adults (n = 141) receiving care at a community health center in Boston, Massachusetts between March 2015 and September 2016. Using generalized estimating equations, we examined individual- and partnership-level factors associated with TM adults' odds of engaging in sexual behavior with a sexual partner of unknown STI/HIV status in the past 12 months. TM adults with casual sexual partnerships (vs. monogamous partnerships) and those in partnerships with cisgender men, other TM individuals, or transfeminine partners (vs. cisgender women) had statistically significantly higher odds of engaging in sexual behavior with a partner of unknown STI/HIV status in the past 12 months. Findings may inform future efforts to improve sexual health communication and STI/HIV disclosure between TM adults and their sexual partners.

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

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

Chest binding in context: stigma, fear, and lack of information drive negative outcomes.

Chest binding or 'binding' is a practice used by many trans and nonbinary people assigned a female sex at birth to achieve a flatter chest contour and affirm their gender. Binding allows individuals to affirm their gender in a temporary, reversible way. While many individuals who bind report negative physical symptoms, binding also often carries significant benefits for mental health and safety. In this commentary, we explain what the data do and do not say about the physical risks of binding and describe how decreasing stigma around binding will substantially reduce physical risks associated with binding and increase the benefits of the practice. As with any intervention, individuals should make an informed decision about the risks and benefits of binding. If negative physical symptoms arise, individuals can consider adjusting their binding practice or working with a healthcare provider to address these concerns.

Increases in Intimate Partner Violence During COVID-19: Prevalence and Correlates.

Measures to contain the global COVID-19 pandemic led to stay-at-home orders across the world, accompanied by fears of a global surge in intimate partner violence (IPV). We administered an online general-population survey to 1169 women and transgender/nonbinary individuals throughout the state of Michigan in June-August 2020 to assess changes in the prevalence, severity, and correlates of IPV during the COVID-19 pandemic. Quota sampling was used to match the racial/ethnic and urban/rural distribution of the state. More than one in seven (15.1%) participants reported physical, sexual, psychological, or technology-facilitated IPV since COVID, similar to the prevalence in the 3 months before COVID (16.2%). However, there were indications that IPV severity increased and that novel cases of IPV are occurring in relationships that previously had no abuse. A majority (64.2%) of individuals who experienced IPV since COVID reported that the IPV was new to the relationship (34.1%) or of increased severity during COVID-19 (26.6%), representing 9.7% of the overall sample. New or increased IPV was significantly more prevalent among those who were essential workers, pregnant, unable to afford rent, unemployed/underemployed or had recent changes to their job, had partners with recent changes to employment, and those who had gotten tested or tested positive for COVID-19. Urban residence, trans/nonbinary identity, and having a toddler were more strongly associated with IPV during COVID as compared to before COVID. While findings do not support significant changes in the overall prevalence of IPV, the majority of survivors reported incident IPV in relationships that had not previously been abusive, or IPV that became more severe since the start of the pandemic. Cases of new or increased IPV were more concentrated in marginalized groups. Potential touchpoints for outreach and services during future lockdowns include prenatal and pediatric settings, daycares, employers of essential workers, and COVID-19 testing centers. Policies providing rental, childcare, and unemployment support may mitigate increases in IPV during COVID-19.

The transgender-specific intimate partner violence scale for research and practice: Validation in a sample of transgender women.

STUDY/RESEARCH OBJECTIVE: To develop and validate a brief intimate partner violence (IPV) scale that screens for controlling behaviors and psychological abuse tactics directed toward transgender individuals. RATIONALE: Transgender individuals are at elevated risk of physical and sexual IPV compared to cisgender individuals. IPV often takes on unique dimensions against transgender individuals, such as when an abusive partner threatens to "out" the transgender person, or use other tactics that weaponize transphobia within the relationship. Standard IPV screeners do not assess this type of transgender-specific IPV (T-IPV). METHODS: Between March 2018 and October 2019, a T-IPV scale was tested in two samples (in-person and online) of transfeminine adults (i.e. assigned a male sex at birth and identify with femininity) from the eastern and southern U.S. Exploratory factor analysis (EFA) was conducted with the in-person sample (N = 661) to assess construct validity. Confirmatory factor analysis (CFA) was then used in an independent online sample (N = 481). Using the combined sample (N = 1137), convergent validity was assessed using correlations with other forms of victimization. Multivariable regression models were fit to estimate the relationship between T-IPV and health outcomes. RESULTS: Factor analyses yielded an 8-item unidimensional scale with moderate to good fit. Nearly half the sample (48.7%) experienced at least one scale item. Internal consistency reliability was strong (KR-20 = 0.827). Significant correlations with other forms of victimization indicated convergent validity. Lifetime T-IPV was significantly associated with psychological distress (adjusted prevalence ratio [aPR] = 1.32, 95% CI = 1.13, 1.53), PTSD (aPR = 1.50, 95%CI = 1.31, 1.72), alcohol abuse (aPR = 1.21, 95%CI = 1.01, 1.44), and drug use disorder (aPR = 1.30, 95%CI = 1.06, 2.59). CONCLUSIONS: This T-IPV scale is a reliable and unidimensional measure with strong construct validity. T-IPV is independently associated with mental health burden and substance use. Service providers working with transgender clients should screen for T-IPV to avoid missing cases of IPV, and refer to violence response services.

Gender-affirming care, mental health, and economic stability in the time of COVID-19: A multi-national, cross-sectional study of transgender and nonbinary people.

BACKGROUND: Transgender and nonbinary people are disproportionately affected by structural barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) crisis and subsequent control measures on gender-affirming care, mental health, and economic stability among transgender and nonbinary people in multiple countries. METHODS: We collected multi-national, cross-sectional data from 964 transgender and nonbinary adult users of the Hornet and Her apps from April to August 2020 to characterize changes in gender-affirming care, mental health, and economic stability as a result of COVID-19. We conducted Poisson regression models to assess if access to gender-affirming care and ability to live according to one's gender were related to depressive symptoms, anxiety, and changes in suicidal ideation. RESULTS: Individuals resided in 76 countries, including Turkey (27.4%, n = 264) and Thailand (20.6%, n = 205). A majority were nonbinary (66.8%, n = 644) or transfeminine (29.4%, n = 283). Due to COVID-19, 55.0% (n = 320/582) reported reduced access to gender-affirming resources, and 38.0% (n = 327/860) reported reduced time lived according to their gender. About half screened positive for depression (50.4%,442/877) and anxiety (45.8%, n = 392/856). One in six (17.0%, n = 112/659) expected losses of health insurance, and 77.0% (n = 724/940) expected income reductions. The prevalence of depressive symptoms, anxiety, and increased suicidal ideation were 1.63 (95% CI: 1.36-1.97), 1.61 (95% CI: 1.31-1.97), and 1.74 (95% CI: 1.07-2.82) times higher for individuals whose access to gender-affirming resources was reduced versus not. DISCUSSION: The COVID-19 crisis is associated with reduced access to gender-affirming resources and the ability of transgender and nonbinary people to live according to their gender worldwide. These reductions may drive the increased depressive symptoms, anxiety, and suicidal ideation reported in this sample. To improve health of transgender and nonbinary communities, increased access to gender-affirming resources should be prioritized through policies (e.g., digital prescriptions), flexible interventions (e.g., telehealth), and support for existing transgender health initiatives.

Preliminary findings for adverse childhood experiences and associations with negative physical and mental health and victimization in transmasculine adults.

INTRODUCTION: Studies highlight the impact of adverse childhood experiences (ACEs) on risk for negative health outcomes in adulthood, including cancer, cardiovascular disease, substance use, and mental health. Lesbian, gay, bisexual, and transgender (LGBT) people report higher rates of ACEs than non-LGBT people, with transgender people at greatest risk. OBJECTIVE: This study aims to comprehensively assess the prevalence of ACEs and association with health outcomes among transmasculine individuals. PARTICIPANTS AND SETTING: A sample of 131 transmasculine individuals enrolled in a clinical trial on preventive cervical cancer screening between March 2015 and September 2016 in the United States were surveyed about ACEs and health outcomes. METHODS: Pearson's chi-squared tests and logistic regression models were used to examine associations between self-reported ACEs prior to age 18 and the risk of various negative health outcomes in adulthood. ACEs were categorized as 0-1 ACEs, 2-3 ACEs, and 4+ ACEs. RESULTS: Over 90% of the sample (120/131) reported at least 1 ACE; 45% (59/131) reported 4+ ACEs. Report of 4 or more ACEs increased risk for negative health outcomes and risk factors compared to 0-1 ACEs, including: depression (AOR = 5.3, 95%CI = 1.7, 16.2), suicidality (AOR = 5.2, 95%CI = 1.4, 18.8), post-traumatic stress disorder (AOR = 6.0, 95%CI (1.6, 22.8)), intimate partner violence (AOR = 5.3, 95%CI = 1.4, 18.8), and obesity (AOR = 8.2, 95%CI = 1.8, 37.2). Report of 2-3 ACEs was also significantly associated with obesity (AOR = 5.9, 95%CI = 1.3, 26.2). CONCLUSIONS: ACEs are highly prevalent in this sample, and more attention is needed for research and intervention. This exploratory study is the first to comprehensively highlight patterns of physical and mental health risk and victimization associated with report of ACEs among transmasculine individuals. Trauma-informed screening and intervention efforts tailored to the unique needs of this population are needed to provide appropriate and effective care. Clinicians should consider routinely screening for ACEs among transmasculine youth and engage in prevention strategies to reduce health disparities. Further research is warranted to validate these findings among larger, more representative samples to better reflect the diversity of experiences and identities of transmasculine individuals and produce more reliable findings.

Addendum to: Development and Validation of a Scale to Measure Intimate Partner Violence Among Transgender and Gender Diverse Populations: Protocol for a Linear Three-Phase Study (Project Empower).

[This corrects the article DOI: 10.2196/23819.].

Time to First Onset of Chest Binding-Related Symptoms in Transgender Youth.

BACKGROUND AND OBJECTIVES: Most transgender individuals assigned female at birth use chest binding (ie, wearing a tight garment to flatten chest tissue for the purpose of gender expression), often beginning in adolescence, to explore their gender identity. Although binding is often critical for mental health, negative physical side effects, ranging from chronic pain to rib fractures, are common. Time to first onset of symptoms is unknown. METHODS: A community-engaged, online, cross-sectional survey ("The Binding Health Project") enrolled 1800 assigned female at birth or intersex individuals who had ever used chest binding. Lifetime prevalence of 27 pain, musculoskeletal, neurologic, gastrointestinal, generalized, respiratory, and skin or soft tissue symptoms related to binding was assessed. Nonparametric likelihood estimation methods were used to estimate survival curves. RESULTS: More than one-half (56%) of participants had begun binding by age 21, and 30% had begun by age 18. In 18 of 27 symptoms, the majority of people who go on to experience the event will do so within the first binding-year, but several skin-related and rare but serious outcomes (eg, rib fracture) took longer to occur. Pain presents rapidly but continues to rise in intensity over time, peaking at >5 years of binding. CONCLUSIONS: Although many symptoms emerge quickly, others can take years to develop. Individuals and their clinicians can use this information to make informed decisions on how to structure binding practices and top surgery timing while meeting goals related to gender expression and mental health. Access to puberty blockers may delay initiation of binding, preventing binding-related symptoms in youth.

Polyvictimization Among Russian Sex Workers: Intimate Partner, Police, and Pimp Violence Cluster With Client Violence.

Female sex workers (FSW) are a key population in the HIV epidemic and face high levels of violence. While women globally are predominantly at risk of intimate partner violence (IPV), FSW are additionally vulnerable to violence from clients, police, and pimps associated with their occupation. FSW are therefore at risk of cumulative trauma from polyvictimization, or violence from multiple types of perpetrators. Polyvictimization is a driver of morbidity and mortality in numerous populations, but there has been little research on how multiple types of victimization are related to one another in FSW. A cross-sectional survey was conducted among 754 FSW from three cities in the Russian Federation. Surveys assessed lifetime experiences of client, police, intimate partner, and pimp violence. Multivariate log-binomial and Poisson regression were used to test associations between these types of violence. Forty-five percent experienced any type of violence, including 31.7% from clients, 16.0% from police, 15.7% from intimate partners, and 11.4% from pimps. One fifth (20.4%) experienced polyvictimization. Client violence was central to polyvictimization: Only 5.9% of polyvictimization occurs without client violence. When client violence was not present, police, pimp, or IPV co-occurred significantly less than would be expected under an assumption that these types of violence occur independently (p < .001). However, they co-occurred more than would be expected when client violence is present. After adjusting for other types of violence experienced and demographic factors, experiencing client violence was independently associated with police violence (adjusted relative risk [ARR] = 2.77, 95% confidence interval [CI] [1.67, 4.59]), IPV (ARR = 3.67, 95% CI [1.95, 6.89]), and pimp violence (ARR = 5.26, 95% CI [2.80, 9.86]). Client violence may drive exposure to other types of violence and enable polyvictimization in a way that other types of violence do not in this setting. Violence prevention interventions may achieve maximal effect in reducing multiple types of violence by focusing on client violence.