One of yesterday’s headlines was the national suicide data: each year the Chief Coroner releases numbers of suspected suicide deaths, and yesterday the numbers for 2021-22 were out. For the last couple of years, this number has been dropping, compared with the few years before where it had been increasing.
When I was in a role that responded to media about suicide, it was always impossible to know what to say about annual statistics. There are the population health angles in terms of trends and inequities, but most people don’t experience suicide as a population health issue. Always instead, it was a time where those who’d died over the last year were at the front of my mind.
For whānau, friends, and those who have lost people they loved, the data is often less about patterns and more of a marker. A collective gravestone, a never-adequate attempt at an explanation of their individual grief as part of a bigger social picture. Yesterday as always, I thought of people and stories I know among that number.
And I thought, as well, again, about the patterns missing from the population health story. I’ve written before about some of the many reasons rainbow communities are missing from this kind of story, the tricky epidemiology of such a complex issue.
So yesterday, some of my thoughts were about the three rainbow deaths I know of over the last year: one I heard about through work with a mental health service, one through social media, and one that was closer, someone I didn’t know but who was deeply loved by people I care about. They’re in that data, named by location and age and ethnicity, but their rainbow identities are held as community knowledge, not official statistics.
Thinking about our national data reminded me of an Australian initiative I heard about recently. Victoria’s Coroner’s Court has released a first-ever report of rainbow suicide data between 2012 and 2021. Like in New Zealand’s Coronial system, there aren’t official ways that rainbow identities are asked about in death, so this was a review looking backwards, at papers and investigation notes, to try and find who might have had an LGBTIQ+ identity. The report acknowledges that the numbers it’s reporting on are an undercount of LGBTIQ+ deaths for a range of reasons.
The report is just numbers, no stories (a Guardian article and a podcast start to unpack the issue in a more qualitative way), but is an important acknowledgement of the reality of rainbow suicide.
It’s a similar process to the Suicide Mortality Review Committee report I wrote about in the tricky epidemiology piece, which identified rainbow rangatahi Māori deaths between 2007 and 2011. Like the Victorian report, these people were identified through their paper trail – where issues related to their rainbow experiences might have contributed to their death. The researcher particularly chose to look for these aspects of people’s lives and report on them. Like the Victorian report, the specific numbers would have been an undercount of takatāpui Māori. But again, it was a place that named this reality as important.
I wonder what chances there might be to build on this kind of work over the coming years – to remember people in numbers and in stories. For now, I sit with aroha for everyone who knows the names of people among yesterday’s number.
To mark World Suicide Prevention Day this year, I held a free webinar presentation about rainbow suicide prevention, with two of my brilliant friends, colleagues and thesis research participants. You can watch the recording above – we’ll be adding closed captions to this video soon.
It was strange to reflect on what has changed since I started this work, around a decade ago, and what hasn’t. A couple of days before my webinar, I got an email from the national Suicide Prevention Office advertising an online live-stream of their national suicide prevention event, happening at the same time my webinar was planned. I hadn’t realised that there would be a timing clash because while I’m on their mailing list, I wasn’t on the invitation list for the event itself.
Now that I don’t work for an organisation that’s contracted to provide suicide prevention services, I’m not understood to be part of the sector, I guess, and I haven’t actively reached out to the government officials who are in those roles lately. Likewise, they haven’t reached back: as far as I can tell, the Suicide Prevention Office hasn’t done any work around building rainbow expertise or relationships, or advancing the couple of rainbow-related actions in the national action plan.
Scanning through the recording and transcript of that official World Suicide Prevention Day event now, I can see that rainbow suicide was acknowledged just once. In introducing a new evidence synthesis about suicide prevention in Aotearoa, Dr Sarah Fortune mentions rainbow communities as an example of a particular group that carries a particular burden of suicide, the kind of group where you might think about selective prevention initiatives. It’s a passing reference – she doesn’t go on to talk about evidence related to rainbow suicide prevention, or evidence gaps, or the fact that no selective prevention activities are being undertaken as part of the national suicide prevention strategy. A list of recommendations doesn’t include anything about rainbow communities.
I can’t find the document itself online – there might be other mentions in there. This isn’t a criticism of Dr Fortune. The rainbow population is just one group that needs to be considered as part of the national approach; rainbow evidence looks different and her project probably wouldn’t have been resourced or directed to include rainbow expertise; she did acknowledge us at least.
Watching the livestream got me thinking about the role of allyship in this sector. The event included lots of familiar faces – people I’ve worked with in various ways over the last decade. It isn’t any of their jobs, specifically, to think about rainbow suicide. They’re being contracted to think about the whole population, or to think about Māori or Pacific communities specifically. If they’re aware of the gaps around rainbow populations, they probably assume someone else is dealing with them. But more than likely, they aren’t seeing the gaps – they don’t live there.
It’s been strange revisiting my thesis and realising how often I occupy those gaps, especially now. Operating from a rainbow-led community organisation, my work has become less legible to public health decision makers. Part of me feels guilty: I can see the gaps, and haven’t published journal papers from my thesis yet, so I haven’t given researchers an easy piece of evidence to synthesise. I haven’t written a briefing paper and pushed for meetings yet, so I haven’t talked to the current national leadership on this issue.
Another part of me feels deeply frustrated. I have tried, in various ways, for a decade. Despite various kinds of progress, rainbow communities are still leading largely-unfunded work to make the world safer and to look after our loved ones, and our national response still hasn’t included any real actions to address rainbow suicide. And when there’s a national conversation, like the World Suicide Prevention Day event, we’re not invited, and end up on a different corner of the internet, having a separate kōrero amongst ourselves.
I wrote about these feelings in my thesis – they’re things all of my research participants shared in one way or another: the frustration of sitting with the knowledge of community need, and of not being heard or understood by the decision makers who have paid responsibility for this kaupapa. I’m feeling that disconnect again today.
If you’re interested to hear me talk about my Masters research and thoughts about rainbow suicide prevention in Aotearoa, I’m talking about it in a webinar next Friday 9th Sep, 11am (NZ time).
I was letting people know about my graduation plans and realised that I hadn’t updated this space to say that my thesis research is finished! I submitted the thesis at the beginning of this year, and after various pandemic-related delays it was eventually marked, accepted and I’m graduating next week (in absentia – Auckland’s current COVID outbreak means that there can’t be an in-person ceremony).
“We hold the kaupapa”: Community-led rainbow suicide prevention in Aotearoa was co-supervised and informed by both public health and community leadership models. It writes into the gap between community expertise and public health decision makers, and explores the roles that rainbow community leaders currently play in suicide prevention across Aotearoa.
Through a series of interviews with people I’ve worked with on this kaupapa, it explores what the work of rainbow suicide prevention looks like in Aotearoa, how people conceptualise suicide prevention, their motivations for doing this work, and the factors that hinder and support this work.
It’s been a bit of a full-on year and I haven’t had a lot of space to work on sharing this research. So far I’ve presented at a couple of conferences (Queertopia at Northwestern University, INVOLVE, the IASP 31st World Congress), and I’m planning to work on a briefing paper and other written resources over the next little while.
If you’re keen to read the thesis and can’t access it through the University library link, get in touch and I can send you a copy.
Since I last wrote, I’ve been working with OUTLine to make a collective submission to the Health Select Committee, asking that rainbow people are specifically named in the Mental Health and Wellbeing Commission Bill.
Yesterday I spoke to the Select Committee (my presentation starts about 40:00 in). The Chair acknowledged the “phenomenal response” of our communities to this consultation, and stated a commitment to ensuring that rainbow mental health is addressed. She also spoke about the difficulty of balancing universal needs (the Commission needs to address mental health and wellbeing for the whole population) with selective approaches (focusing on the groups who face persistent inequities, and deciding which of these groups to specifically name). She has asked me to provide a supplementary submission considering how to recognise rainbow communities while ensuring a focus on the whole population.
So I’m working on that, but meanwhile I thought I’d share my speaking notes here:
—
OUTLine is a national support service for LGBTI+, takatāpui, rainbow, New Zealanders. We provide peer support and counselling to help rainbow people find support, information and a sense of community.
But I’m here today to speak not just for OUTLine. Our submission is supported by 506 individuals and 88 organisations from across Aotearoa. Our amazing OUTLine volunteers, along with key community leaders and rainbow support organisations, academic researchers, community groups from across the motu, some key organisations from the mental health, sexual violence prevention and youth development sectors, church ministers, companies, unions, whānau, friends.
So many people supported me to be here today because mental health and addictions are key concerns for our communities. We know from a wealth of research evidence that the rainbow population experiences much higher rates of distress, addiction, suicidality and social isolation than our peers.
We also know that this is because of the discrimination and exclusion that we face – that there are specific factors that contribute to rainbow mental health. We face the same kinds of risk factors that others do – poverty, family violence, trauma. Some of us face other kinds of exclusion related to other aspects of our identities – racism, xenophobia, inaccessible services and systems. But we also, as a rainbow population, face specific risk factors. Like whānau rejection and homophobic bullying, like not having access to gender-affirming healthcare, and like growing up learning we don’t fit social norms and don’t fully belong. These are detailed further in our written submission.
And while we’d benefit from more support around mental health and addictions, support that understands our contexts and cultures, we also experience barriers to the health system, including explicit discrimination and implicit bias. These systems which used to define our identities as illnesses have not really ever been supported to let go of that framing completely.
So we have specific needs when it comes to mental health and wellbeing. It’s complicated, but it’s all pretty achievable – we need systems to listen, learn and provide services where we feel welcome and understood. Our communities have expertise in this, we’ve been providing support systems to each other for years. OUTLine has been operating since 1972, long before New Zealand ever got around to Homosexual Law Reform. We can do this, we want to help the government do this.
One of the biggest barriers to progress has been the lack of space for a strategic conversation. The mental health system isn’t working well in this space, it’s a bit tricky for them to figure out where to start, so we’ve been stuck in the too-hard basket for a long time.
And so it was really exciting to see that this Bill’s purpose includes an intention to address health equity for rainbow communities. Across all of the background documents to this Bill, we’re named as a key population. We were specifically heard in last year’s Mental Health Inquiry. The Ministry of Health has recently reiterated in a letter to some of us that they consider rainbow communities a priority in their mental health response.
Many of us have been advocating for years for this kind of national recognition in mental health policy. Being named would be groundbreaking. It would make such a huge difference to our communities’ work to support our peers, and would mean our DHB services would finally be accountable to providing rainbow-competent practice.
The problem is, of course, that we’re not actually named.
The Bill’s explanatory note states an intention to contribute to improving equity for Māori, Pacific peoples, disabled people, rainbow communities, and other groups that experience poorer mental health and wellbeing outcomes.
The text of the Bill itself requires the Commission to engage with Māori, Pacific peoples, disabled people … and other groups that experience poorer mental health and wellbeing outcomes.
Why might this be? This omission isn’t explained. Five MP speeches in the first reading acknowledged rainbow communities – it seems like you all thought we were in there. It’s not at all clear how the Commission could improve health equity for rainbow communities without specifically engaging with us. Why we’re different from those other groups named, and if a different approach was intended, what that would be.
If we’re named, the new Commission would be required to talk to us – to partner with us perhaps – and to think about rainbow health equity alongside the work it does with other populations.
If we’re not named, there is no reason to think we’d be a priority. We haven’t been a priority for our national mental health policy response in the last decade. With the recent major investment into the mental health system, even though the Ministry of Health has said they are thinking about rainbow people as a priority, we have not been targeted in any of the investment to date.
It’s past time for rainbow mental health to be recognised as a critical health equity issue that deserves national attention. Naming us in this Bill is an essential step towards recognition.
I wrote recently about the need for rainbow mental health to be recognised as a public health priority, and the lack of national attention it receives.
Here is one opportunity to change this: I’m currently working on a submission to the Mental Health and Wellbeing Commission Bill from OUTLine, and on behalf of any rainbow community organisations, groups, leaders and friends who would like to sign on.
The Bill sets up a new Mental Health and Wellbeing Commission, and specifies some priority population groups that it is required to engage with. Even though all the background documents and speeches in Parliament mention rainbow communities, the text of the Bill itself folds us into a non-specific reference to “other population groups”.
Adding rainbow communities to the Bill would require the Commission to create mechanisms to hear rainbow voices – for example advisory groups or online consultations. Not adding rainbow communities would mean the Commission would not have a clear mandate or requirement to consider rainbow communities and our population-specific issues and needs.
Would you, or any organisations or groups you represent, like to add your name to this submission? You can review the draft submission here, including current signatories.
If you’d like to add your name, or the names of any organisations, groups or networks you represent, please fill in this form by the end of 10 December 2019.
If you’re making a submission of your own to this Bill, you could also help by making the recommendation to add rainbow people to subclause 13(1). Feel free to borrow language from our draft submission to support your point. Note that submissions are due on 11 December – you can find information about making a submission here.
Each year, the release of New Zealand’s suicide mortality statistics is a time to remember, to grieve and to reflect on what it means that so many of us die this way – what it would take to change this.
This understanding of epidemiology is used to guide our national and regional suicide prevention plans. We have a whole-population suicide prevention strategy, with specific investment in Māori and Pacific suicide prevention. We have a child and youth wellbeing strategy and specific Government commitments to reducing child poverty, which will address some of the major drivers of youth suicide.
I’ve recently joined the governance group for Auckland and Waitematā District Health Boards’ suicide prevention plan, and in the first meeting I attended we were shown a PowerPoint about “the stats” in our region. We all know them, we were told, but it’s important to be reminded. In this part of the country, as elsewhere, we see higher rates among Māori, men and people living in socioeconomic deprivation. We looked at differences between DHB regions, broke the data down by age, compared those who had recently connected with mental health services with those who hadn’t.
Rainbow deaths are not counted
When we count in these ways, one of the groups of New Zealanders at highest risk of suicidal behaviour is invisible. Rainbow suicide deaths are not counted directly, and aren’t separately listed in the stats. We can’t make graphs of them, track patterns, look at how they intersect with age, ethnicity and poverty data.
It’s not currently possible to calculate a rainbow suicide death rate. Rainbow identity markers (sexual orientation, gender identity and diversity of sex characteristics) are not routinely collected as part of the coronial investigation process into suspected suicide deaths, nor are they included in New Zealand’s Official Statistics System to enable calculation of suicide rates using clear population-level denominators.
Indirect data is also hard to find: sexuality, gender and sex characteristic diversity are not necessarily noted on medical records or other official documentation, and the population is not routinely counted as a demographic in research and surveys.
One local study attempted to count rainbow suicide deaths. Individually reviewing each suicide death of rangatahi Māori between 2007 and 2011, the Suicide Mortality Review Committee was able to establish that issues related to sexuality were significant in at least 7.2% of deaths. While this was a significant finding, it is likely to under-represent the number of rainbow or Takatāpui deaths. For those who were able to be identified, issues related to their sexuality (for example homophobic bullying or social isolation) were noted in their records as potentially contributing to their death. However, sexuality, gender identity or diversity of sex characteristics are not necessarily directly salient to suicide attempts – there may have been no particular reason to mention a young person’s identity in their death records. As well, the details of young people’s rainbow identities are often not recorded in official documents held by the medical, educational or social services that connect with a young person.
It’s possible that rainbow deaths can’t be counted
In the case of suicide deaths, there are particular difficulties in counting. Identity is complex and may not be well understood by coroners or officials investigating a death. Rainbow is an umbrella term for people who have a range of identities, backgrounds and experiences. From a Western worldview, it includes three distinct and overlapping groups: sexual minorities (who might have attractions, behaviours or identities that aren’t heterosexual), gender minorities (whose gender identity or expression might differ from what’s socially expected) and intersex people (whose bodies don’t match standard understandings of male and female). Many Indigenous and non-Western cultures conceive of these concepts, and the differences or similarities between them, differently. Rainbow can also include people who don’t use specific words for their identity, people whose identity changes over time, and people who are in the process of understanding their own identity and may not have ‘come out’ to themselves or others. It can be complicated to decide who ‘counts’ as rainbow for statistical purposes.
Someone’s rainbow identity may not have been disclosed or known to friends or family members – indeed the person’s suicidality may have been related to fearing rejection, or perceiving the environment around them to be hostile. Rainbow identity may not have been accepted by the person’s birth family, who are usually those consulted by the coroner when trying to understand the cause of death. Often rainbow identity is not known by the medical professionals a person engages with – whether it is disclosed depends on whether the question is asked, how it’s asked, and whether there is a therapeutic relationship that supports the person to be open and trust that their information won’t be misused.
Rainbow identity may not even have been fully acknowledged or understood by the person who died. The Lavender Islands study, which looked at gay, lesbian and bisexual identity in New Zealand in the early 2000s, found that the average age where a young gay or bisexual man felt different was 11.2, whereas the average age that he came out to himself was 18.7. For women the ages were 14.3 and 23. I’d speculate that these ages may have lowered in recent years, but the point remains: there’s often a significant time period where someone might feel different, other people might treat them as though they’re different, but they don’t yet have a name for that difference.
Whatever the reason, when someone has died by suicide and has not left a formal record of themselves as a rainbow person, there may be no way for a coroner to know how they identified.
Regardless, we know that rainbow people are at higher risk of suicide
While there are fundamental methodological challenges in calculating suicide death rates, a large body of local and international research has consistently found that rainbow populations have higher lifetime risk for suicidal behaviour, self-harm and common mental health problems that are associated with suicidality including depression, anxiety, substance misuse and eating disorders. These inequities are connected with experiences of discrimination and exclusion. For example:
In the University of Auckland’s Youth2000 series looking at secondary school student wellbeing, young people who are attracted to the same or both sexes, and/or transgender, report the highest rates of suicide attempt of any demographic group. In the 2012 survey, 20% of rainbow students reported attempting suicide in the past year, compared with 4.5% of the overall sample (1,2).
Trans and non-binary New Zealanders surveyed in the recent Counting Ourselves research reported nine times higher rates of high or very high psychological distress compared with the general population.
The Christchurch Health and Development Study found in 2005 that predominantly-homosexual research participants had between 1.5 and 12 times the rate of mental health problems and suicidal behaviour compared with exclusively heterosexual men, including suicide attempts and suicidal ideation.
The New Zealand Mental Health Monitor started collecting identity data in 2016, and since then has found that rainbow participants have higher rates of depression, anxiety, psychological distress and lifetime mental illness than the general population.
Even though our data looks different, rainbow people should be recognised as a priority population
We may never have rainbow suicide death data. However, it’s clear that rainbow people are disproportionately affected by suicide and suicidal behaviour.
It’s important that as researchers, public health professionals and decision makers, we work out how to respectfully and effectively get more data and research on rainbow suicidality. However, what’s more important is learning from the research and needs assessments that have already been done.
We can’t let imperfect information and tricky epidemiology be an excuse not to act.
For a recent meeting with rainbow community leaders and politicians, I was asked to share a reflection on how our national mental health policy is responding to the needs of rainbow communities. If you’re here for the brief summary: not well enough, despite clear community consensus about needs and well-meaning policy makers who are tasked with doing things differently. I want to share some of my thoughts, to encourage those with a stake in this issue to think about how we can change this.
Here are my speaking notes:
I was at a national forum hosted by the Ministry of Health a couple of weeks ago. The event focused on equity in healthcare and wellbeing. It spanned two days, with 40 speakers and 450 attendees, including all of the Ministry’s senior management. It was really a coming together of the health sector to figure out what is needed for the future.
And at this
national conference on health equity, there was zero consideration of rainbow
populations. Almost zero – to be fair – the Minister of Health mentioned LGBTI
people as one of the groups most affected by suicide in his opening
address. But no-one was invited to consider, and no-one considered, what we
as a country are going to do about that.
None of
my rainbow friends were there – it was an expensive conference, largely invite-only,
and a lot of the key leaders doing work in this space aren’t seen as health
professionals, they’re seen as “communities” whose job is to be engaged with.
I decided my role for the two days was to try and make us visible, and ask people to think about us. We weren’t in anyone’s PowerPoints of statistics and success stories, we weren’t on the speaker list, and we weren’t in the frame that outlined the issue in the first place. In this conversation, as in so many others I’ve seen happening in Wellington lately, when people talk about equity they are thinking of Māori and Pacific people, people living rurally, and people in poverty. Sometimes other cultural groups, and sometimes disabled people. Not rainbow people – they’re too complicated, they’re not relevant, or we’ll get to them later.
So I
wrote some firm
tweets, and just went around observing to people that it’s really
interesting now that I’m working in a rainbow role, being in this kind of
space. How I’d noticed rainbow issues are really absent in these conversations,
even though we know there are significant health equity issues for our
population.
People
agreed, and they squirmed and changed the subject. Not necessarily out of
homophobia or transphobia, sometimes because they knew their service wasn’t
doing anything about rainbow competence and I was embodying their guilt.
People came out to me, and it was obvious they don’t get a lot of professional opportunities to bring their rainbow selves to their roles, as managers and CEOs and as people who are primarily seen as Māori or disabled in a system that doesn’t know how to let people be more than one thing at once.
People
agreed to meet me afterwards and keep talking.
There is
a lot of willingness in the mental health sector to think about changing, to
get things right. There is not a lot of connection with rainbow expertise, and there’s
not enough resourcing of that expertise to engage. The sector doesn’t know how
to change things and they can’t, or won’t, pay people who do.
And there’s so much to do – we know that the demand for specialist mental health services has massively increased in recent years and funding hasn’t kept pace, we know we have a system built around compulsory treatment and disregard of human rights that needs to be completely redesigned, our suicide rates, especially for rangatahi, are unacceptably high, the social drivers of mental distress including family violence and poverty are experienced by way too many people across the country. Among all the stats we have, Māori and Pacific communities are worse off and less likely to get support when they need it. Mental health in Aotearoa is a complex and complicated concern.
So of
course asking people to think about rainbow populations, without resourcing
them to do so, is going to be a challenge. It’s not hard to see why we are left
out of the frame, why we’re left in the too-hard basket.
But I
want to just wonder out loud: what will it take to change this?
Because we
know the stats, right? I don’t need to tell you that our young people in
secondary schools are fivetimes
as likely to have attempted suicide in the previous year than their peers. That
trans and non-binary New Zealanders have nine
times the rates of psychological distress compared with the general
population. That there are barriers to accessing caring, competent healthcare
that the Out
Loud report demonstrated so well last year.
And we
know the
issues, and the solutions. We know that there are particular drivers of
this distress that are different for rainbow people compared with other
populations – including discrimination, violence, family rejection, inadequate
access to gender affirming healthcare, medical system trauma particularly for
intersex people, more frequent experience of sexual assault, and being
instilled with a sense of something being wrong with us. We know that some of
us also face other drivers of distress, like poverty, racism, and the legacy of
colonisation.
And in theory, there should be mechanisms for change right now. The current Government is prioritising mental health, one of its first actions was to set up a broad-ranging Mental Health and Addictions Inquiry, and there’s just been a significant investment in the sector for the first time in years. There’s an obvious appetite for change. The Prime Minister and various other Ministers and MPs have mentioned rainbow people and mental health in speeches, often with a focus on young people.
The Inquiry specifically included rainbow people in its Terms of Reference. I was in the privileged position of being able to give feedback on that document, and advised them to – maybe they would have anyway. The process engaged directly with rainbow communities. A couple of us specifically invited them to meetings where they could hear rainbow voices, and kept inviting and insisting until they agreed to a couple of specific sessions. The panel heard from several of us through written submissions, including the Out Loud collection of people’s experiences with the system, and a collective submission I wrote. Members of the panel were receptive and really cared about what we were saying.
The
report that came from this process, He
Ara Oranga, mentioned that rainbow communities face particular challenges. But
crucially, it stopped short of recommending anything specific. It didn’t
specifically suggest any mechanisms for addressing equity, it just assumed that
if you were going to completely redevelop the country’s mental health system,
of course you would do it properly, involving all the relevant people
affected.
I think
the Ministry of Health is doing its best. There are people there who care, and
they’re on a massive learning curve and development journey as they try and get
their heads around how to develop a mental health system that works effectively
to improve people’s mental health. But they don’t have people who know about
rainbow populations, they’re too busy to engage expertise and not prepared to
pay for it, and they don’t see rainbow issues as a priority. They care, I think,
but asking people to think about rainbow populations, without resourcing them
to do so, necessarily leaves us in the too-hard basket.
Where we are right now is not dissimilar to where we were before the Inquiry. We don’t have any policy directions, funds or strategy hooks to ensure rainbow mental health will be a priority. It’s up to community advocates to keep pushing for this, in every meeting and every setting. To get ourselves invited to things where people don’t necessarily want to see us. We’re starting to see a few small mentions in strategies – the new suicide prevention strategy, a new set of draft guidelines around the Mental Health Act. Under the last Government, these small mentions would have felt like wins.
But we’re
not seeing ourselves named in any of the major funding announcements recently –
Requests for Proposal aren’t asking service providers to prioritise rainbow
communities, and don’t have criteria which reward providers for engaging with
us or designing for our needs. And so they won’t – there is no structural
motivation for them to do so – why would a non-rainbow organisation incur the
additional cost and difficulty of designing services to meet the needs of a
group that their funder does not recognise as a legitimate priority?
I’m wondering: what will it take for this to be seen as a real health need for a real population? Not an activist issue, not a nice-to-have extra that only better-resourced providers in central city locations need to think about, not a side project that queer-identified mental health practitioners are allowed to develop in their spare time if they meet all their other objectives.
Last year,
I told the Inquiry that there were three main ways that our national response
to mental health could meet rainbow needs. I asked them to: name us in national policies and strategies, upskill
the system to provide inclusive support services, and resource rainbow
community leaders to develop solutions.
I still think those are the answers, and they’re not necessarily hard. But they do need investment and prioritisation. A tiny fraction of that $1.9 billion, and a national strategy that engages with community expertise, would go such a long way.
The one thing that reminded me that I was still myself, still me, still safe, was hearing my chosen name and pronouns. It acted as an anchor in uncertain waters, where you are reduced to a “patient,” where a chart held in place by a clipboard seemed to whisper “We’re watching you!” A chart that, for some godforsaken reason, told them where I should be at any given moment and what I should eat for lunch, but not the words they should use to speak about me.
Sam Dylan Finch’s recent story about his recovery after a suicide attempt is heartbreaking. His experience of being misgendered, disrespected and misunderstood by doctors is hard to read. It’s a thoughtful articulation of a dehumanising experience.
The days and weeks after surviving a suicide attempt can among be the hardest times for anyone to live through. Non-judgemental, caring human connection can be lifesaving and can help people start to reconnect with hope. Support at this time is a critical part of suicide prevention – people who have previously made suicide attempts are at significantly higher risk than others of attempting again, and of dying by suicide. (e.g. 1, 2, 3). (If you or someone you know is navigating this time & wants some advice, here is a resource I helped develop when I was working for the Mental Health Foundation).
Effective mental health care isn’t guaranteed for anyone, but for transgender people there are additional barriers related to the attitudes, understanding and competence of healthcare professionals and the systems they work within. Sam writes about some of these: his identity being ignored and disrespected, not being able to access gender-affirming clothing and medical treatments, professionals requiring him to educate them, having his identity pathologised as though it was the cause of his distress, being blamed for feeling distressed as a result of incompetent care.
“I wrote this because I deserved better,” he tweeted about this story. “But more importantly, because WE deserve better.”
Rainbow New Zealanders deserve better, too
It might be tempting to think this is just an American story, but we know from research and community stories that it’s not uncommon for transgender and other rainbow people in Aotearoa to have negative experiences with mental health services related to identity discrimination. As I wrote in a submission to last year’s Mental Health and Addictions Inquiry, “[mental health and addictions services] may offer unhelpful or unsafe service due to inadequate staff training, inappropriate policy settings, exclusionary environments or lack of availability of appropriate referral pathways.”
TheOut Loud project, also developed for the Inquiry, collected the stories and wishes of queer, gender diverse, intersex, takatāpui, MVPFAFF and rainbow communities around Aotearoa’s mental health and addiction services and system. Many of the stories echo Sam’s (“’You’re disrespecting my beliefs.’ That’s what my psychiatrist told me, when I asked him to correct the pronouns he had used for me in his notes.”). Others talk about privacy breaches, mental distress being used as a reason to gatekeep access to gender-affirming healthcare, religious attitudes contributing to poor practice, and racism and ableism adding additional layers of difficulty in accessing appropriate support.
In the recent Counting Ourselves study of trans and non-binary New Zealanders, less than half of respondents reported having GPs who consistently used the correct names and pronouns when referring to them, and a quarter had experienced a healthcare provider knowingly referring to them as the wrong gender, either in person or in a referral. Among those who had accessed mental health services, less than 30% of respondents who had been seen in a hospital ward or emergency department, or by a crisis mental health team, felt satisfied with their experience. Community-based mental health services, and especially Māori health services, were rated more highly, but for each service type less than 65% were satisfied with the care they received. By comparison, for the overall population of mental health service users in New Zealand, satisfaction with mental health services was rated at 83% in 2017.
The recent Rainbow Mental Health Support Experiences Study (1, 2) found that respondents had faced a range of negative experiences in therapy, including misgendering, blaming difficulties on their rainbow identity, and even trying to change their identity. Other studies have reported similar experiences, including 2012’s Let’s Talk About Sex report on rainbow experiences in Auckland DHB’s mental health services.
I wrote an article for Like Minds, Like Mine earlier this year about how discrimination within mental health services can “create barriers to getting support for recovery, forming a positive sense of identity, and finding belonging within communities” in three ways. Rainbow-negative discrimination can impede access to mental health support. As well as this, discrimination related to mental distress can create barriers to transgender and non-binary people accessing gender-affirming healthcare like hormones and surgery. Thirdly, rainbow identities can be misunderstood as mental health problems, or as causes of distress.
We can do better
Making sure people can access effective mental health support is an essential part of suicide prevention. Mental health services are often in the position of supporting people when they’re living with suicidal ideation or recovering after making a suicide attempt. They also support when people’s situations are not so acute, and can help people gain skills and confidence to manage their distress.
Correspondingly, building mental health services’ capacity and confidence to work with rainbow people is an essential part of preventing rainbow suicide. Aotearoa’s mental health services need to develop so that they can support rainbow people effectively, and avoid being a site of discrimination and re-traumatisation.
We may see further local resources developed in the coming years – guidelines for rainbow-inclusive suicide prevention services are listed as an intended action in the new national Suicide Prevention Strategy.
Meanwhile, there is work to do for everyone connected with mental health services: recognising rainbow people as a priority population in strategies and service commissioning, developing inclusive and affirming environments, ensuring staff are supported to upskill and improve their practice, and holding people and systems accountable for doing better.
For the last four years, I’ve been an appointed member of Auckland Council’s Rainbow Communities Advisory Panel, which provides strategic advice to Council about improving rainbow communities’ wellbeing and quality of life, and building engagement between communities and Council.
There are lots of reasons to improve how local government works with rainbow communities, but one of those is to strengthen our population’s mental health and prevent suicide. In places that are safer and more inclusive, where rainbow identity is celebrated and affirmed, rainbow people experience fewer suicide risk factors related to discrimination, and are supported to develop protective factors. Leonard and Metcalf’s Going Upstream: a framework for promoting the mental health of LGBTI people is a good reference for understanding why developing rainbow-friendly communities is a key priority for mental health promotion.
This week, our Panel co-hosted a meeting for Council’s Community Development and Safety Committee on the topic of belonging and inclusion for rainbow Aucklanders. I had the opportunity to frame the topic, and I’ve shared my slides and speech notes below.
The meeting agenda gives a bit more context about the other people who presented. The Committee heard about Holding Our Own, a support network for parents of rainbow young people, Police diversity liaison officers, and about a range of work across Council:
I’m Moira Clunie. I’ve been a member of the Rainbow Communities Advisory Panel since its inception, I also work in the area of rainbow inclusion, wellbeing, mental health and suicide prevention. I am project lead of Te Ngākau Kahukura – a new initiative to equip the youth sector to provide safe and supportive environments for rainbow young people. I’m Chair of OUTLine, the national peer support and counselling service for LGBTIQ+ New Zealanders. I’m also undertaking Masters research on rainbow community leadership focusing on suicide prevention.
Our Panel includes people with a range of community
leadership roles and lived experiences, and we’ve worked with Council with a
range of ways over the years including a former elected representative (Bruce Kilmister).
Belonging and participation is key aspect of wellbeing for
everyone, and is one of the key outcomes of the Auckland
Plan. I want to frame why we chose belonging and participation for the meeting
today, and why it’s particularly important for rainbow people.
To start with definitions: when we say rainbow we’re talking about sexuality, gender and sex
characteristic minorities – including Takatāpui, lesbian, gay, bisexual,
transgender and intersex people. The term includes:
diverse
sexual orientation – which includes people who identify with labels like
lesbian, gay, bisexual, takatāpui, or queer.
people
whose gender identity or expression doesn’t match dominant norms – so they
might be transgender, fa’afafine, gender queer, leiti, akava’ine, non-binary or
many other identities
and
intersex people who are born with bodies that don’t match typical ideas of male or female.
Rainbow includes
people who don’t use any particular label, or who haven’t figured out which
labels fit. The ways people identify and understand themselves can change over
time too. So the term rainbow is complex and inclusive. Other words that mean
similar things are LGBTI+, ‘sex, sexuality and gender minorities’, or ‘queer,
trans and intersex’.
Research in this area can be a bit complicated. It’s tricky
to count who’s in or out of the group, and depends how you ask, who’s asking
and why. Estimates are that rainbow people are between 6
and 15% of NZ’s population.
We’re all over Auckland – across all communities. Rainbow
people exist across all age groups, and all ethnic and cultural groups. Some of
us are disabled, some are not. We’re of all political affiliations and socioeconomic
statuses, we’re urban and rural. We’re everywhere.
But we don’t necessarily belong everywhere – or feel a sense
of belonging across all communities.
Research tells us rainbow populations in New Zealand
experience significantly higher lifetime risk for suicidal behaviour, self-harm
and depression, anxiety, substance misuse and eating disorders, homelessness
and social isolation. Community experience backs this up too.
Without
getting too far into studies – I can provide those if you need them and the
slide shows a few reports (1,
2,
3)
– just one example is the Youth2000
series from the University of Auckland that suggests sexual
and gender
minority young people have four or five times higher risk of suicidal behaviour
than their peers – the highest identified risk of any demographic group.
The Panel undertook an engagement piece, 3
Questions, with Auckland’s rainbow communities that asked:
What are
your dreams for Auckland?
How can
Council help achieve this?
If you
could change one thing about Auckland tomorrow, what would it be?
This identified
a range of challenges around housing and homelessness, transport safety,
visibility, Auckland Council’s international leadership role, inclusive spaces,
events & venues, access to healthcare, and safety.
It’s important to emphasise: research is also clear that
rainbow identity or
experiences are not the cause of these challenges, or of distress and
suicidality. There’s nothing harmful or pathological about being gay, lesbian,
bisexual, transgender, intersex or any of those other identity terms I’ve talked
about. Rather, these health and social outcomes we see are caused by discrimination
and exclusion as key determinants of health.
That might
seem obvious to say but it’s within living memory that homosexuality was
treated as an illness in New Zealand, it was only in the 70s that this
officially changed. And it was only last year that the World Health Organization
declassified
transgender identities as mental illnesses.
Rainbow
people have the same potential to flourish and live beautiful lives as everyone
else. A disproportionate number go through a hard time, but simply having these
identities doesn’t determine negative outcomes, discrimination does.
Discrimination and exclusion happens at multiple levels. A
few of these are: internalised discrimination and a sense of failure to meet
social norms, physical and sexual violence, isolation from whānau, legal
discrimination, and inadequate access to health and mental health care. The combined effect of these kinds
of factors is often talked about as minority
stress, that is the idea of chronic stress related to being part of a
stigmatised minority group.
Research has also found the opposite to be true. Experiences
of inclusion, belonging and acceptance within families, friend groups, schools
and communities have been found to be protective against negative health and
social outcomes. One local
study found that young gay and bisexual men
are five times less likely to attempt suicide when they attend a school that is
considered to be supportive of sexual diversity.
And a recent
US study found that transgender young people who had their identity
affirmed in interpersonal relationships by being able to use their chosen name
in school, work, home or friend groups experienced 71% fewer symptoms of severe
depression and 65% fewer suicide attempts.
So creating space for people to feel like they belong is
hugely important for their wellbeing. We can address so many of the challenges
I’ve talked about by promoting social inclusion and acceptance, and reducing
interpersonal discrimination, social exclusion and harmful norms
Three key things I think Council can do are:
1. Name and prioritise rainbow populations in
strategies, policies and research as a priority population
Auckland Council has made some progress on this, but there
is still little specific recognition in policy documents. When decision makers think
about social inclusion, there can be a tendency to focus on poverty, rather
than – for example – embracing tikanga Māori to make environments more inclusive,
addressing accessibility for disabled people, or challenging homophobia and
transphobia to reduce barriers for rainbow people.
Council can
work on respectfully and effectively getting more data & research – the Auckland
Homeless Count was a good example of this. But more importantly, Council can learn
from the needs assessments and research that have already been done, and listen
to community experts. It’s important not to use imperfect information and
tricky statistics as an excuse not to act.
2. Develop inclusive
services and spaces with confident, competent staff
Council can
develop inclusive environments that affirm people’s identities, with staff who
are competent and confident to work with rainbow people. People who understand
that gender and sexuality are not problems, and that sometimes treating
everyone ‘the same’ isn’t quite the right approach if your systems use language
that isn’t inclusive, or your environments don’t have bathrooms that are safe
for gender minorities to use, for example.
3. Involve and resource rainbow community
leaders to develop solutions
Council can
engage with rainbow community leaders, and include rainbow clients and
ratepayers, in planning, policy and service design and evaluation. We have a
lot of the answers, they’re not hard. They’re often just about building
understanding, empathy and human relationships. So take the time to connect.
Create mechanisms to get decision makers to include and listen to rainbow
expertise. Resource our community organisations, which are mostly volunteer-run
and extremely stretched, so they can participate in these processes.
Council’s support of the homelessness work at RainbowYOUTH
is a great example of this. Another example is the Northern DHBs’ recent contract
with RainbowYOUTH and OUTLine to develop transgender peer support services that
complement their clinical services.
There are plenty of specific things that can be done, but if
we can get some of this basic infrastructure in place we can start to build
solutions. There are many opportunities to improve, and there are amazing,
passionate and dedicated people working in this space. And we’ll hear from some of them next!
Rainbow suicide prevention 