Appendix B: Trauma-Informed Care as A Model to Increase Access and Quality of Care

The principles of Trauma-Informed Care are fundamental when working with sexual and gender minority (SGM) patients.[1],[2] Practitioners of Trauma-Informed Care acknowledge that many people have experienced one traumatic event (i.e., a distressing life event that threatens one’s emotional or physical safety) or more. Such experiences can shape subsequent interactions with other individuals and systems, including health care. In response to this knowledge, practitioners of Trauma-Informed Care assert that patient care should reflect the awareness of the impact of trauma on patients and offer a setting conducive for recovery from exposure to trauma (e.g., safe and welcoming environment). Put succinctly, “Trauma-Informed Care is a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.[3] When patients feel validated, safe, and heard, they are more likely to return to care and feel empowered in their healthcare decision-making. Trauma-Informed Care comprises four steps guided by six principles. The four steps are:
  1. Realize the prevalence of trauma and take a universal trauma precautions position;
  2. Recognize how trauma affects all individuals involved with the program, clinic, or system, including its workforce;
  3. Respond by putting this knowledge into practice; and
  4. Resist re-traumatization.
Universal trauma precautions include patient-centered care strategies guided by cultural humility and mutual respect and ensuring that all clinic members understand the insidious impact of trauma on health. In addition, the precautions entail understanding how trauma may manifest during interpersonal and organizational interactions, such as individual tendencies toward fight, flight, or freeze when faced with a potentially threatening event (e.g., being misgendered or discriminated against). The guiding principles of Trauma-Informed Care are:
  1. Safety: Throughout the clinic, staff and the people they serve of all ages feel physically and psychologically safe. Specifically, the physical setting must be safe and interpersonal interactions should promote a sense of safety.
  2. Trustworthiness and Transparency: The clinic’s operations and decisions are conducted with transparency to build and maintain trust among patients, family members, staff, and others involved with the clinic.
  3. Peer Support: The clinic promotes opportunities for exchanges of mutual support between peers (i.e., individual patients, family members, or caregivers of children with lived experiences of trauma) in ways that establish safety, build trust, enhance collaboration, and maximize a sense of empowerment.
  4. Collaboration and mutuality: Partnering and leveling power differences among clinic personnel (providers, frontline staff, and administrative), patients, and families, helps support meaningful sharing of authority and decision-making. The clinic recognizes that everyone has a role to play in a trauma-informed approach, such that “one does not have to be a therapist to be therapeutic.” As a consequence, people are empowered in their professional roles, as well as in their healthcare interactions and choices.
  5. Empowerment, Voice, and Choice: Throughout the clinic and among patients, the strengths and experiences of individuals are recognized and built on, having a voice and choice is validated, and new skills are developed. By building on strengths rather than focusing on perceived deficits, the clinic fosters a belief in resilience and in the ability of individuals, organizations, and communities to heal and promotes recovery from trauma.
  6. Cultural, Historical, and Gender Factors: Members of the clinic actively engage with and challenge cultural stereotypes and biases, their own and those of others. Whether they are prejudicial beliefs based on assumptions about race, ethnicity, gender, identity, sexual orientation, age, or geography, staff works together to recognize influences of bias on patient and family interactions and clinical decision making. Moreover, when working with communities with profound historical experiences of historical trauma and medical mistrust (such as American Indian communities), staff must recognize those histories, work to respect cultural differences, and understand the value of traditional cultural connections.
[1] Huang, L. N., Sharp, C. S., & Gunther, T. (2013). It’s just good medicine: Trauma-informed primary care [Webinar]. [2] Substance Abuse and Mental Health Services Administration. (2014).  SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration. [3] Hopper, E.K., L Bassuk, E.L., & Olivet, J. (2010). Shelter from the storm: Trauma-informed care in homelessness services settings. The Open Health Services and Policy Journal, 3(1).