 Good evening everyone and welcome to this webinar on suicide prevention for LGBTIQA plus people and communities. I'd like to welcome all of the people who have joined us here this evening and also the people who are going to be watching this on recording. MHPM would like to acknowledge the traditional custodians of the land, seas and waterways across Australia upon which our webinar presenters and participants are located. We wish to pay our respect to the elders past and present for the memories, the traditions, the cultures and hopes of Aboriginal and Torres Strait Islander Australia. I'm Dr Damien Riggs. I'm a professor in psychology at Flinders University and I'm a psychotherapist who works with trans young people. Next slide please. Thank you. I would like to introduce our previous slides, sorry. I would like to introduce our panellists for this evening. The first panellist is Dr Atari Metcalf. Dr Atari, could you explain a little bit about your background coming into general practice? Sure. Thanks Damien and welcome everyone. So I'm a fairly new transplant to general practice just over a month into my first year as a registrar. So I've just finished my residency and internship. So prior to this was working predominantly in emergency and inpatient psychiatry settings. And prior to that I spent about 15 years before practicing medicine working in research and policy with a focus on youth mental health and suicide prevention program evaluation. And as part of that did quite a lot of work with LGBTQ populations and I identify as a trans masculine person. That's me. Thanks Atari. Next speaker is Emerson Osterberg. Emerson, would you like to tell me a little bit about how you came to be working with LGBTQIA plus young people and their families? Sure. Great to be here tonight. So I work in private practice and along my journey I saw a real need to be able to provide safe spaces for LGBTQIA plus young people and their families. And so that was one of the spaces that I made sure that we could provide that space and provide much needed support. Thank you Emerson. And our third speaker is Damien Botson. Damien, could you tell me a little bit about what motivated you to work in research in the area of suicide? Damien, you're muted. I'm muted. Hi. You have to be one. Hi. I'm just saying good evening everybody. I'm Damien. I'm an Abercromb child trying to gain man. I started working in suicide prevention in the Kimberley around 2011. I pivoted out of a social work double degree into suicideology after witnessing what was happening out in the community. There was a lot of programs that were being rolled out in the communities across the Kimberley, but they didn't seem to be working. So I have postgraduate qualification in suicideology because I wanted to understand what it is that we needed to do. I'm also the founder of Black Rainbow, which is more specifically around the prevention of suicide for the Aboriginal and Torres Strait Islander LGBTQIA community because there is a distinct lack of research, resources and evidence, and the prevention of suicide for our little community. Thanks Damien. Next slide please. So obviously, when we're working in groups, we want to be really mindful that we're being respectful of other people and respectful of us as panellists and facilitator. So what's going to happen this evening is we're going to, each of the panellists will give a short talk about what it looks like in their discipline to be working in this area, and then we're going to have Q&A at the end. So we just wanted to start off with just a few definitions, because for some people, some of these population groups that we're talking about today may be new to you or may be unfamiliar. So we're not trying to cover everything that people are going to be talking about today, but just to give a little snapshot of some sort of terms that you may not be aware of. So you would hopefully be very aware of the term trans or other people might use transgender. And we want to sort of note that is comparison with cisgender people or cis. So you might hear our speakers talking about that a lot this evening. So most people in society would say around 97%, 98% of people would be cisgender, and 2% to 3% of people would be trans. When it comes to sexuality, so a different topic here, shifting from gender, modality to sexuality, pansexual might be a new concept for some people. You may be more familiar with bisexual. Pansexual is a term that used to describe an attraction to people of a diversity of genders or all genders, which is not to say the same is the truth with bisexual people. But pans are more recent term to sort of use that more encompassing way of thinking about gender. And asexual again, is another sexual identity that we really want to be very clear is not pathologizing is not sort of thinking about people's some sort of problematic lack of interest in other people. But it describes a continuum of interest or desire in sexual activity. It doesn't necessarily mean no interest in intimacy, but it typically means no interest in sexual activity. So as I've already mentioned, when we're talking about population sizes, we have, you know, some information in Australia, but we have probably more robust information from overseas. And there's no reason to think why that wouldn't translate to Australia. So around 3% of people are likely to be trans or exploring their gender or thinking about what their gender means for them. About 1.7% of people are likely to be intersex. And around 3% of people age 18 or over are likely to identify as gay, lesbian or other, and that can include path sexual, it can include asexual. Just a few little numbers here that Atari put together for us from the private life study. Just to think about suicidal ideation, what it looks like in these populations that we're talking about today. So these very high numbers over three quarters of, oh, no, just three quarters of population report lifetime suicidal ideation and a little under half in the last 12 months. And if we look at this nice little sort of flow chart that Atari did, this is most likely to be the case for trans men followed by non-binary people, trans people, cis women and cis men when we're talking about gender, when we're talking about sexuality, it's most likely to be the case for pansexual people followed by queer, asexual, other, bi, lesbian and gay. So there's lots of different stats we could have thrown at you, but we just wanted to highlight these really high rates of suicidality including in the last 12 months for LGBTQIA plus people and to look at some of those points of difference who's more likely this is to be true for. And we also wanted to really note that we're working here today and we would encourage everyone else to work with the language of died by suicide. We know that there's other terms that gets used in the media that's sort of quite blaming of people who have died by suicide. So we want to really draw your attention to that language. Next slide, please. So as you will have already seen, these are the learning outcomes and we're going to be looking at these through each clinician's own experiences, but also talking for some people around the case study that we've sent through to you, the focus of Zankara, trans women and her own journey through self-harm and what that means in her relationships with other people, including her mental health professional. So I think that's enough from me. I think we'll start with the presentation so that we can get going and leave lots of time for questions. Atari, next slide, please. Thank you Damien. So as Damien explained, it's a very big topic so I'm obviously just going to focus more on the general practice set in and I'm going to focus quite a lot on our case study and try and draw that into my presentation, but there's certainly space in the Q&A to explore this more afterwards. So thinking about how we might come to engage with a person who's trans, gender diverse or LGB in general practice, well it might come to you for one of broadly three different things in terms of where it comes really relevant to think about gender and sexuality. So they might be exploring their sexual identity or their gender identity. It might be at different stages as they progress towards exploring coming out to others in their lives. They might be coming to you as a doctor to initiate gender affirmation through hormones or surgery or other pathways and really importantly they might just be coming to you for broader mental health support or medical support. It's really important to remember as I often recall the trans broken arm analogy which is that just because somebody's presented to you with a broken arm and they happen to be trans you don't have to always focus entirely on sexuality or gender, but it absolutely is very relevant and I think it's really important to acknowledge that many trans people have had really often quite scary experiences of accessing healthcare and quite negative experiences as others will expand on later in the presentation. And so it is absolutely relevant to be mindful and conscientious. And I guess when it comes to suicide specifically if you've got a patient in front of you they may be in acute crisis or it might come up through these conversations. For Kara there's a number of things that kind of stood out in the case study as sort of proximal stresses that might have precipitated her presenting for an acute, you know more of an acute crisis. So it's mentioned at the end of the case study that she's been thinking about self harm and worried that it might be escalating and transforming into perhaps suicidal ideation although it's not clearly stated and that's obviously something you'd need to explore but and there's a few reasons for that perhaps that are highlighted that are needed to be expanded on. So one is the recent relationship breakdown and there's some suggestion of possibly some domestic violence in that setting. She's socially isolated and feeling quite lonely and in the distant past she experienced a pretty significant parental projection, has a past experience of anxiety and has had a really negative experience of exploring her gender with a psychologist. So there's a lot to unpack there and it's really important as medical practitioners and as mental health practitioners not to fall into the trap of inadvertently pathologising someone's gender or sexuality when you're engaging them early on because that's something that many of us would be very sensitive to. Next slide. Thank you. So hopefully before Kara steps into your practice you've already had a look at your practice and considered what is safe or unsafe about this and I think you know looking at the people and the physical environment and your systems is really important. So have an audit of your organisation there's some fantastic resources we'll share at the end with sort of checklists that you can literally use to kind of assess your space but this means you know making sure your staff are competent including the trauma informed kind of approach to care signposting with literally signs or pronoun badges and then looking at your intake systems making sure you don't make assumptions about gender space for changing legal names and and preferred names those sorts of things. Next slide. And once you have someone like Kara in front of you it's really important as would be the case in all mental health practice to try and make sure you've got a nice quiet confidential space where you're not going to be interrupted so you can really sit down and explore things further. First up with all people not just trans people I think we really need to normalise the practice of just clarifying pronouns so I use he or they and as many of in the introductions stated that initially signposts to a trans person that you're thinking about gender and that you're inclusive but it's also worth clarifying are there any people that you use different pronouns with is there a different name using certain circumstances especially if they're not necessarily out to everyone or in different domains of their lives. I'm not going to go through the entire medical history because that's something that you'd be familiar with already but I'll just draw attention to a few important things for trans and gender diverse people and in particular when you're exploring the social connections understanding if they have a connection to the LGBTQ community and that includes online supports as well which can play a big role for these communities in supporting them and then in terms of their past mental health history exploring again gently what their experience has been like we know with Kara there's a number of things in her in her history that are quite protective so she's got a job in aged care which she loves but there's also some some tensions around family and I think it's important to explore if she has any chosen family which is a concept that will be expanded on further in the presentation but recognising that many trans and LDB people have lost connections with their traditional families and when you're exploring that past medical history or exploring self-harm behaviours recognising to the language around bodies is really important so be guided by what the person in front of you uses so recognising especially for trans people that they might direct self-harm towards particular anatomy that they're perhaps experiencing discordance with so for trans masculine people that might be using words like chest instead of breasts but really be guided by the patient themselves next slide and similarly for medical history there are I guess a few exceptional things to note so trans and gender diverse people may be taking hormones not all people will medically undergo affirmation therapies but but making sure you've got that documented really well and I think especially for GPs it's important to maintain that up-to-date list of you know medications for all your patients but recognising that hormone therapy is something that other practitioners may be less familiar with and so when making referrals it's really important to to have all of that down and anti-retro-rial therapies in terms of things like pre-exposure post-exposure and treatment for HIV might be important to note as I said before don't assume when exploring the developmental history that all suicidality or mental health difficulties arise from discordance with gender or sexuality and make sure you do a thorough broader history about about their background but do still consider gently exploring it with them and particularly how comfortable people are with themselves how they cope with transphobia and and homophobia because you know it's really quite common as we'll hear in further presentations just how almost universal it is so how is it that people bounce back from that what are the kinds of strategies they use to keep you know keep themselves feeling feeling good and affirmed next slide so as I said before there are a number of different acute stresses that can commonly present for patients who are suicidal in my experience and and these are not necessarily that specific to lgbt people but I do want to draw attention to the fact that insecure housing and and employment and food security are major problems particularly for trans people this isn't necessarily the case we don't know with car in this case study if this is going on but you definitely need to explore it there's extreme levels of discrimination in the workplace for trans populations and often that obviously creates cycles of difficulty in terms of accessing secure housing as well exploring identity documentation difficulties is also something that's been recognized in a number of studies that can precipitate suicidal crises in this population because that sets off another large chain of events and having to out themselves every time they are in the process of accessing any kind of government service or applying for a job and of course drug and alcohol use is is quite prevalent in the lgbt community it's not all necessary problematic use but you do need to take a thorough history and understand you know if if this is necessary if this is the contributing factor and we don't know actually with car that's not something we've explored yet in the in the case study next slide so once you've you've explored all of that and you've made you a sort of risk assessment with the person in front of you and you've explored the suicidal crisis if that's the case which I'm sort of focusing on really given given the case study you're obviously going to make your risk assessment and engage in some form of safety planning there's some really great generic tools out there but I would highlight that there is some fantastic resources through ACON's trans vitality e-learning which is a four-part module it's available through the link there and it'll be circulated later in and that's specifically around suicide prevention intervention skills for the trans community if you want to kind of use this as a springing stone there's I guess importantly for for trans folk if you're thinking you know what this person's really imminent risk and you collaborate with them around a plan to escalate to more acute care services such as emergency department or psychiatric support I would really strongly encourage you to call ahead and have a chat to the admitting officer and make sure that you flag with them any difficulties or foreseeing difficulties that this person might encounter particularly in relation to pronouns names legal discrepancies between legal name Medicare name those sorts of things just to create a smoother environment and not to reinforce that kind of trauma similarly in terms of access to hormones it can be a real challenge in the inpatient setting and I think it's important as GPs to advocate as best you can with with that kind of heads up similarly if it's you know maybe less acute support needed and you're looking at ongoing support as well there's a very large multidisciplinary team that you can kind of construct to support your your client or patient and on the right hand side of the screen you can see just it's not an exhaustive list but the kinds of people who are often involved in caring for trans and gender diverse people more broadly and there are a number of specific services are highlighted there which the links will be circulated in a resource I believe available later but that you know stands from other medical practitioners whether that's around hormones and endocrinologists or through to peer support services which play a really foundational role particularly for social support and mobilization of this community and there are a number of structured programs where you can link people to peers through ACON and other services in New South Wales the gender centre 2010 there's specific suicide prevention and mental health support lines like Q life and there are other supports as well in terms of advocacy so the University Legal Service provide a lot of support here in Sydney for trans people particularly around documentation and the legal challenges inherent so it's good to familiarize yourself in your local community with what's available and the resources that we'll share is a great source for that so I might leave it there and we can explore more in the in the Q&A and I'll hand it over to the next speaker. Thanks, that was wonderful someone has just asked a quick question if the slides will be available at the end they're actually available to you now on the link on the right hand side of the video that you're watching us on there's a link there to download a PDF of the slides. Emerson would you like to share with us your perspective as a clinical psychologist please? Great thank you so much so look today we're going to really be focusing on the fact that car is transgender and the fact that when we look at the most important factor that you need to do differently when working with people who identify as transgender is the fact that you need to provide gender affirming care that is a lot of the other the other ways to reduce suicidal ideation and overall mental health outcomes are very similar to other clients who work through through your walk through your doors but gender affirming care is is the most important factor and I'm going to be really focusing on that today. Next slide please so just a really quick point that I wanted to make is that on nearly every continent in all of recorded history we have seen that there's been more than two genders so this is not a new concept and and there is a lot of rhetoric at the moment about that well there is a lot more trans people and that comes down to a greater amount of visibility and the fact that our society is thankfully becoming safer for people to be trans so that is the reason why we're seeing higher numbers not for any other reason. Next slide please so why is gender affirming care just so important and why is it considered best practice so when we talk about gender affirming care we can see that as as Cara's experience she experienced a really negative response to being trans by a previous clinician and it's 42.1 percent of people who've reached doubt to practitioners don't understand or have not respected people who are trans or gender diverse 65.8 percent of people have experienced a lack of community or family support so we can see that when if you can't go somewhere that that says yes we're going to be gender affirming then no one's going to talk about their suicide with you you have to create safety first next slide please so we can see that 60 percent of young people don't even know that there's health professionals that specifically work in the area of gender identity we also know that one in five transgender people have experienced direct discrimination from mental health practitioners because of their gender status each week so again if we've got this large number of people constantly experiencing a lack of affirming care then that is going to increase the likelihood of suicidal ideation and intent and create unsafe spaces within a space that is actually meant to be protecting them and supporting them and this is why gender affirming care is just vital for this population next slide please so what does gender affirming care look like so when we're providing gender affirming care one of the things that we want to look at is that we place the person as the expert to their gender so we don't see ourselves as trying to determine or pathologize their gender what we are saying is if you come in and you tell me that you're a female then you're a female that that is what gender affirming care is we don't then try and work out how they got here or if there's enough evidence to say that this is where they're at they tell us that that's where they're at and we we use the pronouns that they would like to be referred by we use their chosen name we use affirming language that makes them feel like they're seen and heard just as you would anyone else we ask the person for information about words that might be triggering as Atari said that there might be maybe parts of a person's body that they don't like to use certain names so we clarify we we talk to them about things that that might be distressing and then we work to be able to fit in with what they need not what we need to feel comfortable within our session we support the person's choice in social affirmation and we also support the person's choice in medical affirmation and and sometimes that can mean for particularly for our young people that they go on puberty blockers for adolescents feminizing or masculizing hormones or surgery for auto clients and and again not all trans people will use any sort of medical intervention and and I think the other big thing is that that everyone's journey is different so you have to meet the person where they're at to be able to support them through that journey next slide please we can see that when people are supported with the psychological services to affirm their gender and the medical intervention to affirm their gender if that's what they choose to do then we know from this study as well as a couple of other studies that have recently been published that their mental health outcomes comparable to their peers now when you're looking at a comparison to those who do not receive the intervention or gender affirming care they're 13 times more likely to have suicidal ideations we can take that away by allowing them to be who they are why wouldn't we do that why wouldn't we provide services that allow these young people and these older people to to be their authentic self um next slide please and the biggest I guess one of the biggest messages I want to drill home is is that it can be really overwhelming when when you start working in in this population and I think as professionals we can be very well-meaninged but we can we can not know where we're at and one of the things that I would say is you've shown up today and so you know more information hopefully after this presentation then you knew at the beginning um and so your journey of understanding gender affirming care hopefully is increased but it's it's an idea that you started a particular phase and you're growing your development and being able to work out where you're at and the knowledge that you don't have and you still need is super important this isn't an area you can just wing it it is an area that you do need to understand the term of knowledge you do need to be able to practice using different pronouns you do need to know how to correct yourself when you make a mistake and if you can do that then you are actually going to provide such affirming care and reduce that person's suicidality just by showing up for them in that way next slide please I think that might be the last one well I've got one more um um the other important point just to point out the end is is that the often one of the things that gets reflected to me is is that while while I work with a lot of young people who do have their family of origin I work with a lot of people who are out of out of that teenage years who who have a family of choice and a lot of the times our systems don't allow for that family of choice when they go to the hospital is next of kin it's not their best friend who because they don't have any family of origin should be the person who's called we have to know that that this is a very um assessing a person's family of choice is just as important as assessing the family of origin and is more likely to protect them in their safety planning to be able to provide that support because the family of origin can often be the ones who have perpetrated a lot of the trauma so making sure that we address that in in our planning is super important so thank you for for listening and I'll pass over to to Damian next speaker thanks for that wonderful comprehensive introduction to gender from in care and I'd love to just add in that we should also always think about animals as families of choice we know from the really growing body of research at the moment that animals are such an important buffer against stressors including being buffers against self harm so now I'd like to introduce our third speaker Damian Bonson to talk about his perspective on suicidality in indigenous communities from his perspective as a suicidologist good evening and thanks very much for the introduction just quickly I'm the one background at me I'm currently the only Aboriginal LGBTQJ plus person with a postgraduate qualification in suicidology I'm not a clinician so not speaking from the position of a clinician in the word that I've done over the years something that I have become quite apparent to me that's not necessarily discusses that suicide is actually quite a low frequency event and that I find that sometimes that that gets missed in the discussion so there is this catastrophization of suicide and what I find particularly when I've been working in the indigenous suicide prevention space is that it becomes highly emotive because of the very real impact of these of the lives that we look that are lost to suicide but the catastrophization of suicide can from my perspective can actually impede effective intervention we do need to unfortunately be a bit dry in the conversations and we need to look at the data and that includes you know qualitative data as well one of the key things that I say to people when I really just a short period of time and work with indigenous people is just don't be racist that's a really good starting point in terms of your interaction suicide is a behavior and it's not a mental illness that's something that became apparent to me throughout my studies as well and there's the I find that the conflation of mental illness with suicide is also obstructive to you know alternative prevention efforts that are out there we're definitely seeing a shift more globally I don't see none have recognized it really here in Australia but there is a shift out of the mental health space and actually into a suicide holiday understanding suicide of the human behavior rather than mental illness to come up with these preventative efforts suicide prevention is really about what we think will work there's actually no guarantee that the interventions that are put into place will actually work next slide please there's a few areas of you know some risk factors particularly in the context of car as life there and these are just really general and it's not exhaustive there are universal risk factors which every every person can be exposed to there are lgbqti specific ones and also there are indigenous specific ones but risk factors interact with people differently or people interact with the risk factors very differently and but also being exposed to a risk factor or risk factors does not equate someone to suicide or suicide ideation however there is a higher likelihood that their quality of life is an optimal and it really is to ask them what's going on and affecting them for someone like par who's um you know indigenous and trans all of these risk factors that could be happening could be happening for them or only parts of so these really important to ask next slide please I just wanted to reiterate the importance of gender affirming healthcare currently we don't have any uh anything really substantive around what that looks like for average on tish under transgender people um there's quite a portion of research or evidence based in indigenous queer suicide in general but um what I do know and from the conversations that I've been having with quite a number of indigenous trans people but also from the research that gender affirming care is really important plus there's some additional stuff there that I've added into the slide I also wanted to reiterate what Atari had said earlier that the use of inclusive language and inclusive environments will definitely go a long way in terms of your intervention and working with with a client one of the things I also say to people is that if you do have an indigenous crime do not automatically assume that culture is going to be what they require I personally don't buy into the mantra that culture will prevent suicide it hasn't for me being really unpacked as to how particularly in regional and remote areas where if we define culture as living on living on country speaking language you know engaging in you know custodial practices and law there's a lot of that going on but that's where we're seeing the higher rates of indigenous suicides in those areas so I'm not really sold on the idea that culture will prevent suicide in that context maybe in the city where there isn't as much of that and that's what they need but again ask the individual and find out what they need next slide please in 2015 there was a first ever national indigenous lgbti round table but I helped facilitate and get off the ground I was part of the average on tireshiner source of adventure evaluation project and here's a few of the themes that have emerged out of that round table unfortunately there hasn't been any further work done on this space this is despite the unknown quantum of millions upon millions of dollars that is in suicide prevention none of it has been directed not in a way that is commensurate with need in terms of preventing suicide average on tireshiner lgbti community and next slide please in 2000 also 2014 2015 I started some insider research because there was no literature there was in terms of that being that more specifically looked at indigenous lgbti suicide eventual suicidality so I crowdfunded about $25,000 and produced this report put voices from the black rainbow it was the first report has ever been done in suicide prevention particularly around the indigenous source indigenous queer community and has gone on to be a big background a background paper for quite a number of commonwealth policies however it doesn't it's apparently it's not academic enough to be picked up by queer researchers who are kind of sneaking into the indigenous queer suicide prevention space but it definitely has a footprint and it was a first next slide please the work that I've done over the years has led to three projects research projects and in the three first indigenous queer suicide prevention projects in the country this one's from WA could break in the silence this was based on a workshop that I delivered called inclusive practices which is around creating inclusive environments for suicide prevention mental health other social services to ensure that their services are inclusive into the abacom child child and queer folk can access them next slide please in terms of Cara I recommend that you draw on Cara's own strengths her connections engage Cara in the process and also some linkages including black rainbow and also indigenous and non-indigenous services next link please as black rainbow will be releasing our report in the next month or so with some of the first national data that speaks to mental health and suicide early plus some other baseline data around some of the social aspects that are going on for us as well thank you very much thanks for that wonderfully comprehensive overview we've now finished our three presentations so now it's time for the Q&A so we've had a few questions pop up but we and we'll start addressing some of those but I would love you to send in some more using the question button at the bottom right hand side of your screen so a first question that we've got that I'm going to direct to Atari is someone from New South Wales has asked about in their understanding that we're not currently permitted to make name changes to medical records without Medicare proof how can we go about that what can we do to make that different yeah look I'd double check that based on the institution or the environment you're working within so I know that many hospitals can still provide an alternative name that's on on people it's you know hospital ID tags and ensures that certainly waiting rooms and that kind of thing that they're addressed by their name in the absence of Medicare proof or even a legal name change and it can still at the back end be linked to the legal name at least that's been my experience maybe it's more specific because I worked at some Vincent's which is its own sort of system it's a slightly different system to the wider New South Wales health but speaking to colleagues I'm aware that this is also possible in in hospitals like RPA when it comes to general practice depending on the system you have I know with best practice there is certainly in the latest updates an option to identify people's names as well as pronouns there's like boxes where you can tick those things and address those and that retrospectively applies the name so it doesn't necessarily require Medicare change if you are going to go down that road often in terms of Medicare change it does usually require a legal change of name certificate and if it comes down to gender you can also change that simply with a letter from a general practitioner and they can change that so that all Medicare purposes you can you can have the correct gender for your for your patient which is really important especially for things like accessing PBS subsidized medications and interventions thanks Atari we've had a question coming for Damian which is based on all the things you talked about in the lack of you know attention and giving to indigenous LGBTIQ people suicide and that includes the lack of attention sometimes to the work of Black Rambo what would you suggest can be done to advance indigenous LGBTQIA plus suicide prevention I support Black Rambo in the work that we do we are 100% volunteer run or un-waged we don't receive any funding we get by on donations we're kind of happy with so it allows us to focus on our own objectives and not others but yeah get behind us black rambo.org.au we've got quite a bit of research that we're ramping up later this year and into the future. Thanks Damian that's wonderful advice for everyone that everyone to follow and if you go to the Black Rambo website you certainly don't can donate to the wonderful work that they do so I would encourage everyone who's looking to make a donation to a great organization to do that we've had another question come in and this one I'm going to chuck your way Emerson someone's asked for those of us who work in a psychological diagnostic space how can we respectfully work with clients who may require a diagnosis of gender dysphoria to access gender affirming healthcare whilst it's not okay to pathologize trans people how can we approach the subject of a diagnosis that may not be experienced as affirming for the client but could help them in their transition journey. Thanks Damian a really great question because this this can be a really tricky one and I think the thing is most people we have access to the internet right so people know the state of the system to be able to get the care that they need so they're not going to be surprised that they have to jump through hoops to be able to get the medical medical intervention that they're seeking to affirm their gender I think one of the things that that you could do is whenever I have anyone come into my office or to my practice I always say I'm not here to I'm not here to be the gatekeeper I'm not here to tell you what to do I'm here to listen and be part of your journey and to be able to support you and there may be some things or some hoops that we have to jump through because the world hasn't caught up yet but we're going to provide support around getting you through those things so you end up being someone who is there to be able to support the person through those really tricky situations that are sometimes really pretty horrible and so have to continually tell people and convince people of your gender is something that cis people don't have to do and and I think we need to be able to just put it on the table that that you acknowledge that that's what has to happen to be able to get them the care but they don't actually you know you're playing your part in the system. Thanks Everson we've got a great follow-up question for Damien and that question is you spoke about suicide is a behavior and non-timental health issue could you break that down a little more please in in the real simplest terms is that you don't need to have a mental illness to be suicidal there there's a lot more that probably can be said in but they don't even have the time for that but yeah real simplest terms is that you don't need to have a mental illness to be suicidal or have suicide ideation. Thanks Damien that's really good and really clear point to make and other questions come through that I might direct to Everson who works with young people what I guess it's the question is what experience do you have working with non-binary preteens but I think the question is more around what resources do you direct people towards to support non-binary young people? Yeah look I think yeah as a non-binary person myself I think it's really clearly and it's well we're directing I think there's a few things if they're within a family structure I always say a little bit like the journey of the of the clinician and the fact that we're at different phases a lot of our non-binary young people when they tell their parents that they're non-binary that can really confuse some parents because they haven't grown up with this language so we need to get them access to language and a common and get them on the same level and so I always I've got a similar slide that that's a similar picture that has a transition of a family and I think one of the important things to know is that when we break it down until the young person that they're here and their parents are here or other parts of their their family are in different spots but we want to get them all up to speed and how we do that well part of that journey is is as the clinician your job is to educate and to inform and to provide the support and to lead them to organizations like trans hub and to 2010 and to minus 18 and to transcend there are brilliant organizations out there doing such fabulous work in this space and the more information and knowledge they have to normalize what they're seeing the better it's going to be. Thanks Alison there's a related question that's come through that I might put back to you again but I'll put in my own two cents where so the question is around how do we work with young trans people who are having suicidal ideation when their parents are refusing to be accepting including when they're continuing to use an old name and this person's raised the really important point that child protective services often don't see this as a protection concern which is something I've been speaking about for quite a number of years now that we need to everyone here in this space this evening and everyone beyond that to be working towards raising this in the context of child protection that these are actually child protection issues but I'll pass it over to MS now to add some extra words into that. I think the first thing that I try and do is see whether the parents are coming from I think I would say the majority of the parents that I have come through my door all have very similar fears they fear that we live in a society where their kids are going to get hurt and they want the best for their kids and they're absolutely petrified something's going to happen to them and so if if they that they don't want this to be true not because they don't want to necessarily support their child they want their child to have an easier life and and this signs them up for a harder life well what I would say is it not affirming your gender and not affirming that the identity that you have as a person who transitioned very like well what I would consider late in life compared to the young kids that I see who get to live this spectacular life as you as young people and know no difference is is that it's a really hard road and and it is a much better space to be living your authentic life so I always try and get parents on board and and if I don't get them on board more times than not I do get them on board and it's slow steps and it's not vilifying the parents either it's not saying you just need to step up and change it's it's been able to be with them and break down what's going on for them because if you can do that with the parents they're going to get on board if you can find out what's preventing them they're going to get on board more times than not and then I think if you can't get them on board and the few ones that then you start to build up support networks without the parents involved so this is where you look at family of choice you look at friends you look at support networks you look at community you look at organizations like 2010 who have groups the gender center in Sydney has a trans group um transcend has support so there's lots of services that you can build support networks where these these people can get a different family to be able to support them through that thank them we've had a few questions come together that I'm going to sort of bunch together here and there are about questions about about supporting non-binary young people and particularly in schools which is great that we've got some educators here with us this evening I've shared with our mhpn organizer a link that she will share with everyone or the attendees this evening that is a module that provides ways to educate schools around how to facilitate non-binary inclusion how to educate staff how to educate families so that's a great sort of resource to start with in terms of how do we introduce this language how do we help people as Emerson said to understand something that may be really new to them we've also had a follow-up question for Damian that's quite a little bit similar to the previous one but hopefully means he can expand a bit more on that and the question is if I can find it is around how can we address the lack of culturally competent safe referral pathways for LGBTIQ people it really depends where you are to what's available and in terms of addressing it is really looking at you know using a combination of you know being both queer friendly and Indigenous and Aboriginal and Torres Strait Islander friendly and that's why at the beginning for me the the main thing is just don't be racist and also don't be afraid to actually engage with the Aboriginal and Torres Strait Islander community sometimes that the fear of making a mistake and also become problematic in terms of you know wanting to be able to respond to why people are there I'll refer back to the transbroken arm I think someone is coming in as an Indigenous person but they're also just a person so yeah the number one thing is to ultimately just don't be racist and but also being inquisitive in terms of that person's life as well and so you have a greater understanding of what their story is and where they've come from to get to get through your front door and get to you because if they've made that step and they've come to you they've come to you because if you they've identified yourself only somebody has has been someone that is there to assist them to be around ensuring that that space is um is is safe for them. Thanks Damian um someone asked a question which I think you know it's a challenging question but it's a useful question that maybe Atari might like to speak to which is can you help me understand why it is important to signal our pronouns as initially initially as a counsellor I minimise what I share about myself with my clients to keep the focus on the client. Yeah it's a great question um look I think the intention between behind that suggestion from where I was starting from is to say that it's about just normalising pronouns I think it's still a foreign concept for a lot of people and it's seen as as controversial as often thrown around in the media as has been an issue like it's going to somehow generate a whole new generation of trans people or it's somehow going to make it contagious which it doesn't we all have pronouns every single one of us and we use them all the time um and I think just it it's really to to step back and say I actually can't tell if you're trans or not because trans is a massive spectrum um and by by asking and by stating our own um it enables a dialogue around it um I don't think it it's it's really just about making something feel like a normal thing to do and to get comfortable with it um I relate to the point about not wanting to necessarily share all the time about yourself and and I um as a as a trans identified practitioner um haven't always disclosed my my trans status to to people I work with either and there's no way they can know I'm trans but but having that uh having a badge and saying that very immediately um sets up a dynamic where it doesn't have to fall back to them to feel safe to to disclose it just sort of makes it a safe space I think um so yeah thanks Tari um this is can I just add to that just for a second sure I think okay um I think the other thing to note on the pronouns is is that uh particularly um the pronouns can change and so if a client comes in and their pronouns are they them or their pronouns are he him or their pronouns are they him or or she heard it's just important to note that that you may have those pronouns you may have practiced for five weeks to get those pronouns right and they may come in and and want to alter them slightly and and you've got to relearn um and and normalizing that and knowing that that gender is a journey and is super super important sorry thanks so much thank you um there's a question here that you know I think I would direct people to the resources that are going to be available at the end of the webinar and the question was is there anywhere that lists gender affirming safe gps or medical professionals so I think Tari has given us some examples of that but he might want to elaborate that certainly here in South Australia we have the website transhealthsa.com that's run by trans people that lists people who have been vetted as being trans affirming yeah so in in New South Wales uh trans hub.org.au has a list of gender affirming gps and also OSPATH which is the Australian Professional Association for for trans healthcare they also maintain lists of not just gps but other allied health and other medical practitioners as well and that's a national database I believe there are similar things in victorian western Australia as well but those are those are probably the two that I'm most aware of thanks for Tari there's a really applied question here that I think I'll put out to whoever wants to ask it because I think the question itself is an interesting formulation so the person has shared that they work with a client who has a range of different social disabilities and I won't name what they are and that they're non-binary and that this person is often often states that they feel like people aren't helping them or the life would be better off without them other people's life would be better off without them so how do we help that person engage in self-care engage in domestic tasks engage in connecting with community I think the first thing is is finding out their interests because I think we have a lot of community like for instance in in Sydney um there's there's a lot of well not a lot but there's a few spaces that they can go just to engage with other people um and I can guarantee that that a lot I mean we know the stats on trans people and mental health um that there's people having similar experiences and and so if we can know their interests and know what they like then it's starting to look for activities that are within community and can help them to connect with other people having similar experiences and then they can broaden out I was going to say there are some formal peer support services too in most states of territory so depending on their age and stage but certainly here in Sydney again Trans Hub through ACON operates some peer support services there's also groups through 2010 as Emma mentioned before where they can link face to face for online Trans Pride Australia is a community driven organization which is an informal source of social support and they organize meet-ups online and offline and West Australia there's Freedom Center there's a whole range of different organizations and even Trans Folk WA and in certain health services too if you're in a cute setting certainly I know back in St Vincent's we had peers and navigators we're really lucky to have them and included in that there were some trans identified people so kind of scout around the community and find some local ones and see if you can create a bit of a resource list for yourselves. Thanks Adrienne Emerson we've got a question for Damian which is what are your thoughts on the SEWB wheel as a tool for First Nations Queer Suicide Prevention? Just going to go back to the last one if I just can I had a depression for about three years and some of those symptoms that I had I share with the question that had before and what I found was consistent engagement with my psychologist and also with the use of medication helped me get off the couch and helped me become a lot more engaging but that was actually symptomatic of the mental illness that I had I'm not too sure if that's the case here and this person that I saw was female as well so I wasn't seeing an Aboriginal male and I wasn't seeing a gay person or a queer person as well I found that for myself what worked was on the engagement with the therapist for the social emotional wellbeing wheel it hasn't been unpacked in a queer context but also I haven't seen it really being robustly investigated as an effective tool for suicide prevention. I'm a bit of an outlier in suicide prevention particularly in the Indigenous suicide prevention space but I have a lot of questions and mainly because I really really want the evidence to be robust and I want to be able to the work that we do to prevent people from dying by suicide and at the moment I see that there is a lot of language that gets used in Indigenous suicide prevention that really doesn't have any meat on it and so in terms of the wheel I think it's a great tool in terms of in real practical sense in terms of identifying for Aboriginal and Torres Strait Islander what's important to them under those domains are well-being for them but it's never been investigated or about or about this robustly research in terms of how it applies or what needs to happen what are the queer elements of social emotional wellbeing what's our experiences in terms of how the interventions will look. Thanks Damien I just wanted to say you know I'm constantly looking at the questions and Scotland through them and you know we've had a lot of wonderful questions come in and we're not going to be able to get through them all because we've got about seven minutes or so left for questions so I do apologize if we don't get to your question and I'm sure there's ways we can you can follow up with us afterwards there's a question here that I would like to direct to everyone and maybe everyone wants to have a say I thought it was a wonderful question which is about as community members ourselves with lived experience how do you keep yourself safe and well when working with our peers other LGBTIQ plus people in suicide prevention when we all know either either know people or have experienced that distress ourselves. So I think one of the things is is our own community right so this community of clinicians is also supervision and being in groups where you are discussing some of the complexities and the challenges of working within your community and and some of the challenges are that the I guess knowing exactly the experiences that they have that people are having that are walking through your door and having you've had some of those similar experiences with you whether it's trauma medical settings or lack of affirmation from other psychologists or other doctors and and knowing what that does to you I think it makes it your better clinician because you're able to know a little bit about what works but also fight for for making sure that we can get change happening but definitely supervision and definitely your own support network and groups that you can talk through cases and and get the support you need. Let's start with exactly the same point which is reflective practice so and having different mechanisms for that I know in medicine it's not always very well structured so if you don't have it then make it and I certainly have done that. I'd say as is often the case put your own oxygen mask on first attend to your own well-being have a good GP have a good therapist as Emerson said find ways to nourish yourself socially and emotionally and physically for me it's swimming find the things that help you let off steam and and process for what you've experienced and know your boundaries I guess and and that extends to not just you know recognizing the signs of burnout or the signs because it can be a burden wearing the different hats and feeling that sense of experience you know the shared experience but but also to recognize that just because you come from this community doesn't mean that you know exactly what that person's going through as well because it is such a diverse experience and and try to step back as much as you can and use those clinical tools with that extra sprinkle of empathy that you'll have because of that shared experience may be my my suggestions thanks as I did Damien did you have something to add yeah but what I've learned through my experience of over a decade working in the field is that I needed to have interests outside of suicide ology and and suicide prevention to really have activities that I can gauge and I took up archery for something different to take my mind I think I'm also an avid reader but it was for myself within the space that we work it's not just around the loss of life that is traumatic and in observing and hearing about how the quality of life for some average and charged on a pure folks isn't optimal it's also the constant structural racism that we experience within the queer community and also the structural homophobia within the average and charged on a community so I find myself particularly you know as the founder of black rainbow and starting those conversations that I bear the brunt of quite a bit of the risk reaction from the non-indigenous queer community because suddenly I've just called them racist also the average and charged on a community because I've just called them homophobic the bottom line is that's the behavior when there is those structural barriers in place that actually affects the prevention of suicide average and charged on a queer folk so these are really tough conversations to have but that's something that has just come with the job now so from again myself I switch off I separate now even as an average and charged on a queer person working in average and charged on a queer suicide prevention really do what I can to disconnect from that body of work but I just wanted to share that as well so if you are you have average and charged on a queer colleagues that's also going on for them as well. Thanks Damian that's a great point so we are almost out of time for questions we've got a couple of minutes left and we've got quite a few left so I'm picking the last one and then again I think is a good opener for everyone to maybe comment on briefly is what should be the minimum criteria for an organization to be able to say they're truly an LGBTIQA plus affirming supportive service it's a gold question. I think it's about uh capacity building within the staff so the skill sets and knowledge of of the to everyone that's not just the clinicians it's also the reception staff especially the reception staff actually who are often the front facing experience that people have when they engage with the service and then it's looking at you know the physical environment that the the information systems your records your the way that you actually capture information about the people you work with I think that those would be the very bare minimum standards for me that they need to have done some accredited training and they and I think there is a set of minimum standards there's some in Victoria and here in New South Wales and the resources we've shared that you can use to literally tick yourself off against as an organization. Damian? My bare minimum is to ensure the environment that they're walking into is safe for them to engage again the services that you're offering potentially could be life-saving and so that person needs to feel comfortable within that space and also to not be fearful of making a mistake and if you do make a mistake only you've made the mistake and I just want to go back to something about the pronouns as a cisgendered gay man when I see other people using pronouns I know that they're that I'm going to be safe as a gay man or there's going to be a level of safety because I've gone to that that extra bit of the step I'm currently working with a large cohort of people at the moment and I'm the only one with pronouns in my Zoom and it's online and we're about to have a in-person meet up in a few weeks and I'm like I don't know what the level of safety is so those small things the signs and the symbols I think are really important can't be understated in terms of I'm accredited training there's I've not seen anything or come across anything that's had a particular Indigenous queer lens put over it to ensure that it is looking at the intersectionality of being both Indigenous and queer. Emerson any quick one minute comments? Yeah one minute comment would be that that you know I'd really encourage everyone to to do their own gender journey just because your cis doesn't mean that you don't get to break down gender and work out your own gender and so don't feel that this is exclusive for trans people and that would actually make your practice a whole lot better and and make practices a whole lot safer. So that might have already been a neat way to wrap things up in a way but I would like to turn it back to our panelists again and ask do you have any last-minute things that you'd like to say from your own perspective from your own work in a minute or two that sort of really summarizes your take on the topic this evening. Let's start with Atari. Well first I just want to say thanks to everyone who showed up tonight because I think that's already a great sign that you are self-aware of you know wanting to develop your skills in this space and I really appreciate it and I also want to extend a thanks to the fellow panelists who were absolutely fantastic. I think in terms of the key things I think be a human I think is the point that Damian has made a number of times tonight. You don't have to get a hundred percent right you won't it's not possible that's okay and just commit to learning from those experiences and doing the best you can. Pay attention to language, learn the language and there are lots of resources to help you with that and then practice those skills over and over and maintain that practice because I guarantee the language will change. It has in my lifetime experience and keep a sort of forward thinking approach at all times. Thanks Atari. Any other thoughts? The final comments I'd like to make is that the burden education should be on the clinicians not on the people who are presenting to you in crisis. Go and get educated and we need you. We need more people educated and willing to work in this space and that is what's going to save lives and that's what's going to normalize things within community and allow people just to live and be their authentic self. And for myself I feel really privileged and then that I've had this opportunity to learn from both Atari and Emerson over this short little bit this evening but also in preparation for and I'm really going to wave the general firming flag here I think that it's really is essential not just at a clinician level but also the societal level I think that families need to have access to this information. I think there's a lot of families out there with young children who require gender affirming care and parents don't know what that is or don't know how to ask for it and young people don't know how to ask for it and that that's really upsetting to me so that's the flag that I'm going to wave for this evening is around you know get into this gender affirming care find out what it is and and not just at the clinicians level also around educating for families because they need it and also the young people need it especially. I'd be really sneaky and add one more thing because David just just did inspire me to remind myself to say this too which is to not let it end at your own on one work and to recognize that working in this space you have a lot of power from the positions that you all occupy and you can do a great deal of work in terms of helping to change structures as we've heard from everyone tonight that the structural issues are really significant so I encourage you to advocate and that extends to thinking about where and how you vote and and petitions and be vocal as you can in supporting these communities trans people have really borne the brunt of some extraordinarily damaging public debate recently without any trans people being able to participate in them very few and we really do need allies so I just want to advocate for advocacy so thank you thanks for towering thanks Amazon and thanks Damian so we've had quite a few questions coming that obviously we couldn't address and many than were about resources so we do have a wonderful resource that's going to be that is available to you to download that has lots of links and references and resources and information about all the reports that Damian's done for example and websites but we I can already see and I'm sure mhpn can see as well that there have been some questions that have come through that maybe we haven't included enough resources around so certainly we will continue this conversation between ourselves and we will work with mhpn to update that list of resources as needed certainly there was a question that came in at the very end around the intersections of suicidality and domestic violence for lgbtiq plus people so I know I can certainly speak and I'm sure Terry would as well to a wonderful resource from acorn that there's really fantastic information around domestic violence for lgbtiq iq plus people that includes you know a locate yourself and where's the nearest service for you in it so we'll add some of these extra resources into our existing resources we already have up there for you in the coming days to make sure that the extra questions we were asked about around you know the inclusion of non-binary young people in schools and the legislative issues that some people may be facing around the inclusion of lgbtiq people in hospitals and in other medical services questions around domestic violence so we want you to know that we've heard those questions um we couldn't get to all of them this evening but many of them for me were around resource information so we will make sure those resources are added in to the resources we've already got there for you so I'd like to wrap up by starting by giving my genuine heartfelt thanks to our three panelists for saying such amazing things and I already knew it though I was going to say that even what they said was amazing to hear again and extra things that added in that I didn't know was going to be added in was just amazing there's extra sort of thoughts and comments that they're shared with us I think are really inspiring for why we all do this work I would like to ask all the attendees to take a moment to do the feedback survey this it's so important for mhpn to learn about what we do well and what we could do better both as panelists but also as an organization and if you don't have time to do that this evening don't have time to click on the link then you'll get follow-up information from mhpn to encourage you to do that survey which is really really important the next slide please so there's just a few bits of pieces of housekeeping to remind you around what's coming up so there's a number of webinars coming up in the coming weeks there's one on assessment and engagement with infants and children that you're welcome to register for there is other ones coming up around the more information will be coming out soon so we encourage you to keep an eye on that information and to register for things that may be interested to you and to go back to what all the panelists said to ensure that this information is going through your network so we had you know 1500 or people here this evening but we want you to get that word out to people beyond all of you and to keep this sort of momentum happening for people to understand the work that mhpn does so in summary mhpn's networking program supports practitioners to meet a network with others from their local community there are more than 350 across the country visit the mhpn website mhpn.org.au to find your nearest if you're interested in starting one contact by email mhpn or and they'll provide you details or you can ask us in your feedback survey for more information about how you make that contact so in conclusion i'd like to note i'd like to really acknowledge the lived experience of people and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present thank you to everyone for your participation this evening