The end of a year is always a time of personal reflection, but this one feels like it requires more than previous years. Maybe because it’s the end of another decade (seriously, where did the last ten years go?!), or maybe because so much has happened in a relatively short amount of time.
I turned 40 this year; and I was ok with it. As opposed to the mini breakdown I had months before my 30th. I had set myself all of these arbitrary goals, probably similar goals that you have set yourself: have a partner, be on the way to owning property (i.e. have a mortgage), have a successful career, be happy. Turns out I had none of that at 29, hence that mini breakdown. My 30th came and went, I had an incredible night surrounded by many people near and dear to me, but those aches from unachieved goals lingered. I won’t bore you with a detailed summary of the last ten years, but I feel like a reflection of what I’ve come to know in that time might be useful for some of you. Yes, it’s personal and we should all live our life the way we want to, but some of these things might resonate with you:
You will continue to change and learn more about yourself every year: this is hard to digest as a twenty-something. I felt I knew what I was doing, where I was going, who and what mattered most. The simple fact is priorities change; what you once see as critical to your daily life pales into insignificance when your energy is diverted to new challenges, or new environments. I think there is some humanistic yearning for this ongoing discovery – I do not think we were designed to remain stagnant for all of our lives. This does not necessarily mean a life of constant travel or career changes – change and learning about yourself is as individual a process as you are and there is no blueprint for it. Even if you are convinced that where you are right now is where you will be in ten years, why close the door to any worthwhile opportunity that may present? So, instead of stressing about what next week, or next year is going to bring, try to pay more attention to here and now, and to those in your life who help you be the best you can be right now. And, a real goal of mine is to let people know that I appreciate them, care for them and thank them for any good they do for me. The world sure could use more appreciation and gratitude.
Do not spend too much time regretting decisions made: I think most decisions I have made along the way were the right decision at that time, and with different perspective or understanding, I may have decided differently, but how can you worry about something that you didn’t know at the time? I regularly look back at an opportunity I had nearly 20 years ago for a six-month exchange at McGill University in Montreal, Canada. Of course, things may have taken a different path if I had taken up that opportunity, but life circumstances at the time led me to decide against it. Initially, there was regret, but I have come to realise that this was the right decision for that time. It is probably something I would do differently now, but these decisions are always much easier in hindsight. So, instead of worrying about what could be, or what could have been, try to focus on what is and the possibilities that brings.
You will spend less time trying to be perfect and trying to be liked by everyone: this has been a tough lesson. It was always one of the things my ex partner (who remains a dear friend) would ask me – “why do you need everyone to like you?” I wish I knew the answer to this, but what I can say with some certainty is, you will begin to care less about being liked and care more about those relationships and connections that are genuine and offer each person mutual benefit. We are social creatures – we were not designed for isolation, so perhaps that plays some part in wanting to be liked, but the lack of genuine relationships and interactions is a recipe for loneliness, that I can assure you of. Quality over quantity is ever present.
This leads onto the next point, something I am only recently absorbing: know that actual interactions with actual people will always surpass online interactions. I freely admit that I am guilty of having too great of an online presence – I post numerous stories and updates, mostly photos these days, but nonetheless, most of you would have a fair idea of my habits simply from social media. Yet, I am as lonely today as I was at the start of this decade. That is possibly the reason for the posting – I am yearning for interaction, for connection, which for whatever reason, I have not been getting enough of in the physical world. But is all this online time taking away from the physical time? It is difficult to admit to this, but something I need to acknowledge. The only thing being connected online has brought me is more disconnection. Facebook has been in my life for 12 years and I wonder if it is a coincidence that these 12 years have been my toughest.
Happy place: a beach, hiking (Bushrangers Bay, near Cape Schanck, VIC, 2019)
Take that chance – generally, the worst that can happen is you learn some things along the way: a question I have been asked more times than I care to remember is “why do you keep changing career path?” Yeah, I’ve worked in retail, accounting, fitness, technology, even dabbled a little with writing and editing, and now I am less than three weeks away from commencing my nursing career. I have never been ashamed to seek something better – one of the greatest traps in life is to settle. This can apply to many situations, not just work life. Don’t settle – you are worth more than that. It might not be clear which path you want to take, but just seeking it is a good start. The alternative is the all-too-real realisation you will get one day of “what if?” and that’s something worth avoiding if you can. I know there are some situations in life where it is not always immediately possible to implement change – the realities of finances and dependants is ever present, but don’t let this lead to a dead end. You might reach a point where you want it bad enough that there is no alternative other than to make it happen. My last three years studying full time, working part time and completing unpaid clinical placements is a decent example – as tough as this was, I saw no other way than to push through it. It involves sacrificing things (such as my desire to travel frequently), but this is short term. Take that chance, at least you can say then that you tried, which is infinitely better than asking “what if?”
Happy place: a stunning sunset (one of my favourite moments of the decade, near Wreck Beach, Vancouver, Canada, 2017)
This decade has undeniably been the toughest of my life so far and I wouldn’t have it any other way. I have grown so much and learned many things about myself that could not be possible if everything was just swimming along. Adversity is a great teacher – you always have the option to tackle it, or ignore it. While it is difficult to see at the time (sometimes impossible), you will be able to look back and recognise how it helped you along your path and how you are a better person for coming out the other side. Know too that everyone struggles from time to time – this has been one of my most important lessons – and the best way to get through that is remind yourself of your purpose, your hopes and put yourself out there in a genuine sense. And for me, that means less time online and disconnected. Happy new year and I hope some of this helps, or at least resonates, as we all try to push on into a new decade. May it be what you need it to be.
Happy place: nature, especially when it shows off like this (somewhere along the Yarra River, Melbourne, VIC, 2018)
I am a gay male, yet I feel I am not fully aware of the diversity under the LGBTIQ+ umbrella. The issues gay males face now has some attention of the broader community and while there is still a long way to go, there is even more work to be done to bring transgender, gender diverse and non-binary individuals to the same status.
It is appropriate timing for this Friday (May 17) to be IDAHOBIT Day – the International Day Against Homophobia, Biphobia, Interphobia and Transphobia. Sadly, these types of awareness days are still so vital as LGBTIQ+ individuals continue to be significantly over-represented in poorer mental and physical health outcomes than the general population. It starts with compassion, empathy and education – and I hope the following helps with that.
To clarify terminology, transgender is an umbrella term used to describe a person whose gender differs from that assigned to them at birth and may not fit into the binary categories of male and female (Brady & Molloy, 2018). Gender non-conformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex (Coleman et al., 2012). It follows then that gender dysphoria refers to the distress caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (including the associated gender role and/or primary and secondary sex characteristics) (Coleman et al., 2012). It is important to note that not all gender non-conforming people will experience gender dysphoria, and that gender dysphoria can occur at various stages of life, although symptoms tend to heighten when secondary sexual characteristics develop during puberty (Atkinson & Russell, 2015).
Above: The Transgender Flag and Symbol. Credit: WeThePeople Clothing. Below: Pride March, Melbourne, 2017.
When this distress is significant enough to cause an impairment in functioning, and the person meets any two of six diagnostic criteria as set out in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) for at least six months, a diagnosis of gender dysphoria is made (Brady & Molloy, 2018).
Should gender dysphoria be considered a mental illness?
Consider the issue this raises – if a person’s expression of gender characteristics and identity does not match the cultural norm in a society and this causes them distress, should this be judged as a mental illness? Classing it this way attaches a pathological association (meaning that it is caused by a physical or mental disease), and this invariably leads to stigma and discrimination. Consider that homosexuality was treated in the same way and was only removed from the DSM in 1973 and the effect that this removal has had on changing social acceptance (although stigma and discrimination still exists). This stigma can result in prejudice and discrimination leading to minority stress, which is an additional stress minority groups can suffer on top of general stressors all people face, making them more vulnerable of developing mental health concerns like depression and anxiety (World Professional Association of Transgender Health (WPATH), 2010). It is important to recognise that these symptoms are generally the result of social stigma and exclusion and are not inherent to being transgender or gender non-conforming (WPATH, 2010). Please reflect on whether you think gender dysphoria should be classed as a mental illness, as it currently is in the DSM-5, as you read on.
One argument made for gender dysphoria remaining as a diagnosable condition is that it allows for access to health care and various treatment options (Coleman et al., 2012). When the DSM was updated in 2013, the term gender dysphoria replaced gender identity disorder (which was categorised as a sexual disorder), in an attempt to remove the pathological connection from being transgender (Brady & Molloy, 2018). The transgender community and their advocates remain unsatisfied with this assertion, feeling it perpetuates the implication of a mental illness and allows stigma and prejudice to continue. Furthermore, it remains necessary for transgender patients to be given a gender dysphoria diagnosis to access required health care, including hormone therapy and surgical specialists (Brady & Molloy, 2018).
Contrast this with the 2018 update to the World Health Organisation’s ICD-11 (International Statistical Classification of Diseases and Related Health Problems) – the term gender incongruence has been introduced to replace gender dysphoria, and importantly, it has been moved out of the mental disorders category, into a sexual health condition category (WHO, 2018). The WHO stated that their reason for doing so is that “while evidence is now clear that it is not a mental disorder, and indeed classifying it in this way can cause enormous stigma for people who are transgender, there remain significant health care needs that can best be met if the condition is coded under the ICD” (WHO, 2018). This change has delighted transgender advocates as it steps away from the mental illness assumption while still allowing medical and psychiatric treatment for a sexual health condition.
There are two significant factors which make clinical intervention important – the continuing over-representation of the LGBTIQ+ community in poor mental health statistics compared to the general population; as well as the positive results seen through treatment once it is commenced.
One study reported that 71 per cent of people with gender dysphoria will be diagnosed with another mental health condition during their lifetime (Buzwell, 2018). Depression (74.6 per cent) and anxiety (72.2 per cent) are most common, while post-traumatic stress disorder (23.1 per cent), personality disorder (20.1 per cent) and psychosis (16.2 per cent) are significant concerns (Buzwell, 2018). There have also been links found between gender dysphoria and autism and eating disorders, with further research being required to fully understand this (Buzwell, 2018).
Further studies show consistently high rates of mental health diagnoses in those with gender dysphoria: Telfer, Tollit, and Feldman (2015) reported that up to 50 per cent of young people with gender dysphoria have self harmed, and 28 per cent will attempt suicide. Brady and Molloy (2018) suggested even higher rates, where 84 per cent of participants had contemplated suicide and 48 per cent had attempted suicide in their lifetime. These studies showed that these alarmingly high rates of mental health issues are predominately caused by ongoing discrimination, stigma and transphobia, as opposed to being a result of being transgender (Brady & Molloy, 2018).
In relation to treatment outcomes, improvement is evident. Treatment may include a combination of psychotherapy, hormone therapy and surgery – meaning that the prognosis of gender dysphoria is generally positive (Atkinson & Russell, 2015), assuming treatment is sought and effectively managed. Successful treatment is individual – what may assist one person resolve their gender dysphoria could be very different to another person’s treatment, e.g. one person may be satisfied with a change in gender expression, while another person may wish to undergo body modifications (Coleman et al., 2012). Treatments are safe and effective in the long term and very few individuals that have chosen surgical reassignment have regretted their decision later in life (Atkinson & Russell, 2015).
Further evidence shows that the most vulnerable time for people with gender dysphoria is the time between when they decide to seek treatment to when they commence treatment. A study by Erasmus, Bagga and Harte (2015) showed that 28 per cent of gender dysphoria sufferers considering treatment had a past-year suicide attempt, compared to one per cent of those who had undertaken gender-affirmative treatment. This significantly heightened pre-treatment suicide risk was also found in another study by Telfer, Tollit & Feldman (2015), highlighting the critical need for timely access to health care support for this population.
Experiences in health care
Any meaningful therapeutic relationship will be based on openness and trust, yet, evidence shows that it is common for transgender patients to hide their gender identity from health professionals (Brady & Molloy, 2018). There remains a fear of discrimination, stigma and negativity, with various studies reinforcing this reality:
While one study stated some nurses have negative attitudes towards transgender people, another showed nurses are continuing to assume that all patients fit into a gender binary of either male or female, determined by their sex at birth. This results in transgender patients feeling invisible to nurses and less likely to garner a trusting relationship (Brady & Molloy, 2018).
This negativity and isolation extends to mental health services, where one study from Transgender Equality Network Ireland found 52 per cent of participants had a negative experience when they sought help from a mental health service, while other studies showed pronounced discrimination, blatant disgust and noticeable discomfort from mental health professionals when a patient revealed they were transgender (Brady & Molloy, 2018).
Other issues reported in studies (Puckett, Cleary, Rossman, Mustanski, & Newcomb, 2018) highlighted misgendering or being referred to as an inappropriate gender in public health care settings; unnecessary and invasive scrutiny into patient’s personal lives; denial of care; uninformed and/or intolerant medical providers; and being shamed by providers. Some patients reported bias and stigma from mental health providers, where their mental health was inappropriately used as rationale for denying care (Puckett et al., 2018).
There are also systems issues within medical and mental health settings: some patients felt that needing a letter from a therapist before treatment was unreasonable and unnecessary, while requiring a diagnosis also creates a barrier to accessing care (Puckett et al., 2018). Some patients reported feeling unsafe in a medical system that is not designed for them and that the fear of ridicule prevented them from seeking transition-related care. A lack of knowledge on gender-affirming care, including potential side effects, also causes barriers to effective support. Financial issues (cost of hormones, surgery and associated procedures), as well as insurance coverage difficulties provided yet further barriers for gender-affirming care (Puckett et al., 2018).
Stigma and bias can be explicit and implicit, where it is often unconscious and occurs despite the best of intentions. One large study of over 4,000 first-year heterosexual medical students found that almost half of the participants expressed some explicit bias while 81 per cent exhibited at least some implicit bias towards gay and lesbian individuals (Bidell & Stepleman, 2017). The experience of real or perceived stigma and discrimination in health care leads to many LGBTIQ+ individuals deciding to not disclose their true identity, or avoid accessing health care altogether. LGBTIQ+ patients report significantly lower satisfaction with their health care provider than heterosexual patients do (Bidell & Stepleman, 2017). This is one reason that I have attended an LGBTIQ+ friendly clinic for many years – I did not feel comfortable disclosing my identity or discussing my concerns in a standard clinic and I do not see myself changing that in the near future.
A critical factor of any therapeutic nursing relationship is to advocate for the patient in our care, and for that care to be person-centred. It should be a partnership that prioritises on the patient’s unique needs with compassion and dignity. There is a responsibility to care for each patient in a respectful and equitable way, regardless of their status. Mental health nurses in particular need to ensure they are providing an environment that is safe and welcoming to all, so that any person requiring care can feel comfortable to seek it. It is difficult to provide appropriate and individualised care if the patient does not feel comfortable to disclose their true identity and concerns.
The WPATH issued Standards of Care in 2011 for those seeking help with gender dysphoria, and these should be considered when we encounter a patient with this distress. The standards are:
Assess for a diagnosis of gender dysphoria
Provide information regarding options for gender identity and expression, and the possible medical interventions available
Assess and discuss treatment options for any co-existing mental health concerns
If applicable, assess eligibility for hormone therapy. Then prepare and refer the patient for treatment
If applicable, assess eligibility for surgery. Then prepare and refer the patient
If applicable, provide psychotherapy before hormone therapy or surgery (this is not a requirement). Psychotherapy can include counselling and support for changes in gender role, as well as family therapy and support for family members (WPATH, 2011)
Removing the barriers to care
A successful therapeutic relationship with a transgender patient will often mean needing to use gender neutral language. As gender identity is a spectrum, nurses cannot assume that ‘he’ or ‘she’ will be the appropriate pronoun to use. Often, transgender people do not identify as male or female, and may prefer ‘they’ – put simply though, the correct language and pronoun to use is that which is used by the person themselves, so we just need to ask them (Brady & Molloy, 2018). The use of gender inclusive forms is also imperative, especially ones that allow the person to write in their own gender identity, rather than a tick box set up. A lack of awareness of correct terminology can cause the health care experience to be negative, resulting in this population being less likely to seek help, or avoid it completely (Wilson, 2019). In a recent examination of health care organisation intake forms, 74 per cent included questions about gender and/or sex. Of these, 57 per cent were rated as using affirmative language for transgender and gender non-conforming people. Only 6 per cent of intake forms had free space for people to state their preferred pronouns and 18 per cent included an option to designate a chosen name where this differs from their legal name (Holt, Hope, Mocarski, & Woodruff, 2019).
The result of a specialised and inclusive service can be seen in patient findings from the Gender Dysphoria Clinic in Melbourne. 88 per cent of patients were satisfied with the services they received and this significantly reduced their perceived level of distress. They felt understood in a non-judgemental way and importantly, 70 per cent of patients now felt satisfied with their ability to handle their concerns that brought them to the clinic. This survey was conducted for one month and only included those seeking treatment, yet it still highlights the positive impact of person-centred care. A lengthy waiting list for appointments was the most concerning aspect from this survey (Erasmus, Bagga and Harte, 2015).
With the evidence unsurprisingly pointing to benefits of gender-affirming care, barriers to accessing this care must be eliminated. Ways in which this can be achieved include:
Being a professional who is culturally competent of all populations;
Exploring and challenging any biases towards minority groups;
Training for all staff to use patient’s requested names and gender pronouns;
Avoiding disrespectful language such as ‘biological’ or ‘real’, instead, using terms like ‘assigned at birth’ and using the patient’s terminology when possible;
Providers should explain why some potentially challenging questions are necessary in an assessment; and,
Avoid the use of some medical terminology for the body as they may be upsetting for transgender and gender non-conforming individuals, especially in relation to primary and secondary sex characteristics (Puckett et al., 2018).
It is also important to explore the extent of support the person is having with their interpersonal relationships. If they have family, friends or partners trying to stop them pursuing gender-affirmative care, additional support may be required from health care professionals. Post-treatment support should also be established (Puckett et al., 2018).
Education in practice
Numerous studies show a knowledge gap and lack of formal education among health professionals on transgender people. One study found a large majority of nurses had no understanding of the transgender spectrum and were unable to differentiate between sexual orientation and gender identity. Nursing staff also did not consider a person’s gender identity outside of being male or female as relevant to their nursing practice. This lack of awareness leads to unsatisfactory care (Brady & Molloy, 2018).
This study also reported on the lack of transgender education for nurses, where it was found that only 10 per cent of students had a basic level of care knowledge for transgender people; almost 40 per cent of students felt unprepared to work with transgender patients; 85 per cent felt their nursing education institution did not prepare them; alarmingly, 42 per cent believed a person’s gender identity only mattered sometimes while 13 per cent felt it did not matter at all. In further research of 375 health care organisations, most did not provide their staff with appropriate policies and guidelines for nursing care of transgender people and that only 19.8 per cent of nurses had undertaken any formal training on the topic (Brady & Molloy, 2018). Even a current Google search of transgender care information on hospital websites shows a lack of visibility – other than the Royal Children’s Hospital Gender Service, only the Royal Melbourne Hospital and Mercy Health appear to have specific and easily found transgender care information on their public websites. Some educational and government resources are listed at the end of this article if you wish to explore further.
It is imperative to remember that nurses are advocates and educators. The journey of nursing is an ever-evolving process, where continual learning is required to remain current on nursing practice and hospital policy and procedures for anyone under our care. Optimal care is given when compassion and respect for diversity is upheld, improving the health care outcomes for everyone, especially those in minority groups. This does not mean that any particular group requires special treatment above others, it simply means inclusive, respectful and individualised care based on the needs of the person in our care, with their voice always being heard (Wilson, 2019).
Promoting mental health
The Royal Children’s Hospital (RCH) in Melbourne has a multidisciplinary Gender Service, providing transgender children and adolescents care since 2003. Referral numbers have increased to the extent that the service had as many requests for care (more than 200 new referrals) in 2015 than it did combined for the previous 12 years (Telfer, Tollit & Feldman, 2015). The average age when presenting is 12.3 years, but most patients report gender concerns from the age of three or four. In contrast, the Gender Dysphoria Service at the Monash Medical Centre in Melbourne reports an average presentation age of 40 years, although most patients still report gender identity concerns from an early age (Telfer et al., 2015). Increases in awareness and social change will hopefully see the average age of presentation decrease.
The Victorian Government recognised the need to support these services when they announced $6 million in funding to the RCH Gender Service over four years. This will assist the service to fund adolescent physicians, child and adolescent psychiatrists, gynaecologists, an endocrinologist (for hormone therapy), psychologists and a social worker, as well as a speech therapy service for voice training. Services are regularly evaluated to assess treatment outcomes and inform future evidence-based practice (Telfer et al., 2015).
Australia currently has a unique legal barrier to treatment. Precedent from 2004 classified stage one and stage two treatment in adolescents under 18 years of age as ‘special medical procedures’ which necessitates Family Court of Australia approval before treatment can commence (Telfer et al., 2015). Stage one treatment involves puberty-blocking medication (via gonadotrophin-releasing hormone (GnRH) analogues) and this is entirely reversible. It allows the person to develop without experiencing the associated distress that the development of secondary sex characteristics can cause when that person feels it is not their true gender. Stage two treatment generally occurs around the age of 14 to 16 years, where testosterone or oestrogen is offered. This produces partially irreversible physical changes of the affirmed gender.
A legal challenge in 2013 resulted in the Family Court removing the need for legal approval for stage one treatment (as it is reversible) and also agreed that an adolescent who is ‘Gillick’ competent (medical legal test to determine whether a child under 16 years of age can consent to their own medical treatment without the need for parental permission or knowledge) could consent to stage two treatment (Telfer et al., 2015). However, it is the Court that decides whether the young person is competent and the opinion of medical-legal reports tends to determine competency. It is potentially another form of discrimination, where the court’s involvement is an intrusion into a decision which should ultimately be between the patient, their parents (if the patient wishes) and the health care team.
A reduction in anxiety and depression has been noted after the commencement of puberty-blocking medication, followed by hormone treatment. A follow-up Dutch study 15 years post-commencement of treatment (with some also accessing surgery) determined that the young trans-adults’ quality of life, educational and vocational outcomes matched those of the general population in the Netherlands (Telfer et al., 2015).
When a young person presents with gender dysphoria, it is important that the health care provider validates their gender-related distress. Allowing the person to choose their own path without influence or pressure reinforces individualised care. An ideal situation will cater for collaborative decision-making between the young person, their family or other supports and their care providers (Bonifacio, Maser, Stadelman & Palmert, 2019).
Guidance can be found in the WPATH Standards of Care for hormone therapy, with substantially different treatment regimens for adolescents than for adults (due to the different developmental stages at adolescence). The standards also recommend assessing for both gender dysphoria and other concurrent mental health concerns due to the likelihood of co-morbidity, and advises counselling, supportive psychotherapy or appropriate medications (Bonifacio et al., 2019).
Social transitioning
Social transitioning is the process where a person changes their gender expression to better match their gender identity (Buzwell, 2018). It is an important part of the journey and has been shown to reduce depression and anxiety while improving self-worth in transgender children aged 9-14 years (Bonifacio et al., 2019). Social transitioning can include a name change, choosing a preferred pronoun, altering clothing and/or hairstyle, hair removal or growth, use of a bathroom that matches the person’s desired gender, breast-binding or genital-tucking, and adopting new activities and mannerisms. A transition can include one, a few or all of these factors, gradually or altogether – a social transition is highly individual, as is the timing of it (Buzwell, 2018; Bonifacio et al., 2019). Trans children who have socially transitioned demonstrate comparable rates of depression, anxiety and self-worth as their cisgender peers (those whose birth gender matches their assigned gender) (Buzwell, 2018).
So, what’s the T?
Consider the many issues highlighted in the literature: transgender people face stigma and discrimination in society, but also in the health care system. The majority of health care professionals lack formal training on transgender issues and this leads to substandard care for this minority group. Transgender individuals (as well as other LGBTIQ+ individuals) are vulnerable, with consistently higher rates of depression, anxiety and suicidality compared with the general population. Even a basic understanding of conducting a consultation for gender dysphoria is important, as is identifying the level of support the person has around them (Atkinson & Russell, 2015).
Although identifying as transgender is not pathological, the ongoing inclusion of gender dysphoria in the DSM-5 implies this. Other mental health concerns should be assessed, such as body dysmorphic disorder (a preoccupation with an imagined or slight defect in appearance), borderline personality disorder (a disturbance in self-identity) or Asperger’s syndrome (being prone to obsessive preoccupations that could include gender dysphoria) (Atkinson & Russell, 2015).
Individualised treatment and care is as critical here as it is with anyone else. Some transgender people will be happy to live in their desired gender role, but one large Australian study found that 86 per cent of transgender individuals were either using, or intended to use hormone therapy. 39 per cent also had some form of surgery (Atkinson & Russell, 2015). Evidence shows that hormone therapy reduces distress without adverse psychological or physical effects, but with any medication, it is important to be fully informed of reversible and permanent side effects (Atkinson & Russell, 2015). Counselling with a mental health professional proficient in transgender health is recommended, especially in assisting diagnosis of co-morbid mental health conditions.
Changing legal documents is another affirmation of gender, with Federal Government guidelines issued in 2013 stating ‘sex reassignment surgery and/or hormone therapy are not prerequisites for the recognition of a change in gender in Australian Government records’ (Atkinson & Russell, 2015). This means that a letter from a registered medical practitioner or registered psychologist is all that is required to change gender on documents such as Medicare, passport, birth certificate, Centrelink, driver’s licence and Australian Tax Office records, and the forms to change documents are available to download from government websites.
Once patients have been on hormone therapy for at least one year and living in their desired role, surgical interventions are considered. These are often referred to as ‘top’ procedures (chest reconstruction or breast augmentation) and ‘bottom’ procedures (removal and creation of new genitalia). Surgical reassignment tends to occur overseas due to greater expertise and lower cost (Atkinson & Russell, 2015).
Consider that the objective of treatment is not to change how the person feels about their gender. Instead, it is to manage or resolve the distress being caused and support should be given if the individual wishes to make changes to align their external self with their internal gendered self. Remember that there is no correct way to transition and it should be guided by the individual, both in the degree of their wishes to transition, and the timing (Buzwell, 2018).
The following recommendations suggest methods to improve the health care experience for transgender and gender non-conforming people:
Health care organisation websites should mention, where applicable, expertise in working with this community;
Include links to suitable and professional resources and support groups;
Detail all services offered for transgender and gender non-conforming people;
List any memberships to professional organisations, such as WPATH;
Intake forms should ask for gender or gender identity, not sex;
Include free space for people to write in a response for preferred pronoun and/or name;
Ask for “I wish to be called…” so that staff are aware of these wishes during consultations (Holt, Hope, Mocarski, & Woodruff, 2019).
In following the WHO’s lead, the American Psychiatric Association should remove gender dysphoria from the next update of the DSM. In doing so, the hope is to reduce or remove the stigma attached to being transgender and the associated distress caused by this stigma, in the same way that removing homosexuality from the DSM was intended to do. The reality is that there is still a long way to go for all LGBTIQ+ individuals to be free of stigma and discrimination, but if the medical field is adding to the stigma (as is the case with gender dysphoria being listed as a pathological issue), the stark over-representation of poor mental health and physical health statistics in the LGBTIQ+ community will not improve.
The WHO’s move to rename gender dysphoria to gender incongruence in the latest ICD-11, and classify it as a condition relating to sexual health is intended to remove stigma and pathological assertions. An international transgender rights organisation, Global Action for Trans*Equality (GATE), is advocating for the complete removal of this category, and instead creating a ‘Z code’ specifically for transgender adults and children. Z codes are used by the WHO to describe non-disease states that can impact health in general and mental health care. Given they are for non-disease states, they are non-pathological in nature, assisting the removal of stigma attached to this issue (Bidell & Stepleman, 2017).
It is important to note that there is currently an even division in professional opinion as to whether gender incongruence should be a diagnosis in the ICD-11 at all (or gender dysphoria in DSM-5 for that matter). Those that believe it should be included mainly cite reasons that a diagnosis enables access to health care, provides a “protected status” to the transgender child and facilitates reimbursement (although the general lack of insurance coverage in this area is yet another barrier for those seeking treatment). Those that believe it should be removed commonly cite removing the pathology, stigma and discrimination associated with a disease assumption as their reasons (Bidell & Stepleman, 2017).
The concept of minority stress is now an important context of the increased prevalence of health and psychosocial problems among the LGBTIQ+ community. This highlights that the increased incidence of poor mental health here is caused by social forces (stress, prejudice, stigma, discrimination), not a pathological (disease) state. This change could not have occurred without the removal of disease classification of homosexuality and transgenderism, so it follows that gender dysphoria or gender incongruence should follow the same path.
These helpful resources are available if you need more information or just want some support:
Main healthcare support is the Royal Children’s Hospital Gender Service, which has published the Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents Version 1.1 (2018):
For primary health care staff – ANZPATH (Australia and New Zealand Professional Association of Transgender Health) has a free 60-minute online course to promote more inclusive and responsive services for transgender, gender diverse and non-binary people in primary health care settings
South Australian Government, Dept of Education – Supporting students, Gender diversity and transgender (very detailed, includes health-related support info)
Bidell, M. P., & Stepleman, L. M. (2017). An Interdisciplinary Approach to Lesbian, Gay, Bisexual, and Transgender Clinical Competence, Professional Training, and Ethical Care: Introduction to the Special Issue. Journal of Homosexuality, 64(10), 1305-1329. doi: https://doi-org.ezproxy.lib.rmit.edu.au/10.1080/00918369.2017.1321360
Bonifacio, J. H., Maser, C., Stadelman, K., & Palmert, M. (2019). Management of gender dysphoria in adolescents in primary care. Canadian Medical Association Journal, 191(3), E69-E75. doi: http://dx.doi.org.ezproxy.lib.rmit.edu.au/10.1503/cmaj.180672
Charter, R., Ussher, J. M., Perz, J., & Robinson, K. (2018). The transgender parent: Experiences and constructions of pregnancy and parenthood for transgender men in Australia. International Journal of Transgenderism, 19(1), 64-77. doi:https://doi-org.ezproxy.lib.rmit.edu.au/10.1080/15532739.2017.1399496
Cicero, E.C., & Wesp, L. M. (2017). Supporting the Health and Well-Being of Transgender Students. The Journal of School Nursing, 33(2), 95-108. doi: https://doi- org.ezproxy.lib.rmit.edu.au/10.1177/1059840516689705
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2012). Standards of care for the health of Transsexual, Transgender, and Gender-Nonconforming People: World Professional Association for Transgender Health (WPATH). International Journal of Transgenderism, 13(4), 165-232. doi: 10.1080/15532739.2011.700873
Erasmus, J., Bagga, H., & Harte, F. (2015). Assessing patient satisfaction with a multidisciplinary gender dysphoria clinic in Melbourne. Australasian Psychiatry, 23(2). doi: https://doi.org/10.1177/1039856214566829
Holt, N. R., Hope, D. A., Mocarski, R., & Woodruff, N. (2019). First impressions online: The inclusion of transgender and gender nonconforming identities and services in mental healthcare providers’ online materials in the USA. International Journal of Transgenderism, 20(1), 49-62. doi: https://doi- org.ezproxy.lib.rmit.edu.au/10.1080/15532739.2018.1428842
Puckett, J. A., Cleary, P., Rossman, K., Mustanski, B., & Newcomb. M. E. (2018). Barriers to gender-affirming care for transgender and gender nonconforming individuals. Sexuality Research and Social Policy, 15(1), 48-59. doi: 10.1007/s13178-017-0295-8
Telfer, M., Tollit, M., & Feldman, D. (2015). Transformation of health‐care and legal systems for the transgender population: The need for change in Australia. Journal of Paediatrics and Child Health, 51(11), 1051-1053. doi: doi.org/10.1111/jpc.12994
Wylie, K., Knudson, G., Khan, S. I., Bonierbale, M., Watanyusakul, S., & Baral, S. (2016). Serving transgender people: Clinical care considerations and service delivery models in transgender health. The Lancet, 388(10042), 401-411. doi:http://dx.doi.org.ezproxy.lib.rmit.edu.au/10.1016/S0140-6736(16)00682-6
Sometimes, expectation and optimism does not match reality. That’s no reason to be pessimistic – just another opportunity to expand your viewpoint on previously held beliefs. This is how I have approached my third clinical placement, which is in a mental health facility in the suburbs of Melbourne. It is an area of nursing that holds great interest for me, hence my optimism. Halfway through this placement, the reality has been somewhat different to my expectation.
I have had to accept that, like with physical illness, not everyone recovers from mental illness. A myriad of factors may explain this – amotivated feelings about their condition (no desire to seek or engage in help), lack of participation in therapy, medication complications (this is its own set of issues, especially in relation to dependence), lack of access to programs or activities that can assist recovery, lack of a support network from family or friends, and medical personnel that are disengaged or victims of the health system, just to name a few.
What has surprised me at this early stage is the number of return patients. The overwhelming majority of patients are known to staff and are on their third, fourth, or even fifth admission. The facility does not accept high-risk patients, so I can only imagine how much worse this scenario is for facilities that do. Some patients only stay for a few weeks; others have been here close to three months. Some patients are being monitored for medication changes, while some patients are admitted for treatment that requires extended monitoring.
One of these treatment options is Transcranial Magnetic Stimulation, or TMS. I was fortunate enough to accompany a patient during one of their TMS sessions, which afforded me a fascinating insight. This patient is currently going through their third round of TMS treatment, and each round has consisted of 30 sessions. The session I attended was their 24th of this third round. The patient does not feel that the TMS is making a difference to their outlook or thought processes, but they do not want to try the alternative treatment (Electroconvulsive Therapy, or ECT, which induces seizures to alter brain activity) because of the sometimes severe side effects of memory loss.
In contrast, TMS reportedly has little to no side effects and is not invasive. It involves using magnetic fields to activate specific areas of the brain – generally the pre-frontal cortex, which is the area of the brain that among other things, is associated with how we see ourselves (self-consciousness) and self-related mental processes. As depression can alter these thoughts and behaviours, TMS has been shown to improve self-perception in depressed patients by progressively altering brain activity in this area with repeated treatments. No anaesthesia is required (in contrast to ECT) and a patient can resume their usual daily routine once treatment has completed for the day, and some patients can even have two treatments in one day (one session takes around 40 minutes, depending on the severity of the patient’s depressive state). TMS is not a first-line course of treatment – it is generally prescribed when a patient continues to show depressive symptoms after at least one anti-depressant medication has been attempted. Interestingly, it is not currently covered by Medicare in Australia as further research on its long-term effectiveness is still ongoing. This results in an access issue, as it requires private health insurance and an inpatient admission or self-funding.
But how effective is this treatment when numerous patients are seemingly coming back for repeated rounds of therapy? Or is it more of a case of these patients not fully understanding their triggers and therefore relapsing? It could also be medication compliance or potentially new triggers. There is no obvious or simple answer, as we are not obvious or simple beings. Our brain exerts more control over us than we may ever give it credit for (side note: I recommend Afflicted, a truly fascinating series currently on Netflix to see some real examples of this). In this case, this patient is having their third round of treatment, reports that they do not see any improvement, yet, this patient is quite engaging, warm and reactive to conversation. They have a supportive family network and cannot specify any possible triggers for their continued admissions other than the feeling of hopelessness and helplessness that engulfs them. Consequently, they continue their treatment in the hope that it may eventually have an effect.
This is another important factor to highlight: it will not necessarily make sense that someone is suffering a mental illness. I was involved in a new patient admission recently – this patient has suffered depression for nine years (from the age of 12), an eating disorder for six years and has attempted suicide twice this year. They have no history of trauma or abuse, no family history of mental illness, no obvious triggers or explanations for why they feel the way they do. There is evidence of alcohol abuse, but not drugs. They have a good social network and a job. Prescribed medications have not had an effect and something just isn’t right, so they want to give ECT a chance to help them. This patient is warm, engaging and not visually distressed. They were studying at university until it became too difficult to manage with their illness. I can only hope that we can help them and not have them become one of the “frequent flyers”.
Naturally, I wonder why patients are returning at the rate that they are. It is clear from speaking with the staff at this facility that the system is letting some patients down. Medications are prescribed and dispensed, mental states are constantly assessed, as are current risk statuses. What might be a confronting question is asked – have you had any suicidal ideation recently, and if so, how do you plan to go through with it? Self-harm is also assessed and is more common than I thought it would be – one patient explained that they self-harm just so they can feel something. Sadly, some patients self-harm so they can be admitted, otherwise they might be turned away for a lack of available beds. There are clear cases of dependence to medications and these are managed as much as possible, but some of the return rate of patients might just sit at the hands of the patients themselves.
Patients need to understand the role they play in their own recovery. As someone who has suffered mental illness, I experienced two critical aspects: I was going nowhere until I acknowledged my illness; the next important step was to seek help and want to work at feeling better about myself and my life, instead of feeling embarrassed and ashamed of my predicament as I initially did. This is by no means an easy or simple step – this is the most difficult thing to do. To acknowledge and accept you are struggling is tough; to seek help and open up to someone that you are struggling and need help is even tougher.
The logical thought would be that the patients in a mental health facility have accepted these two aspects about themselves. Why then are they mostly returning for repeated admissions? Are they returning to past negative behaviours or thoughts? Are they disengaged with their treatment plans (not attending therapy groups or possibly non-compliant with medication)? I believe there is no obvious or logical answer – our complex brain can lead to many variations to mood, behaviour, thought, cognition, desire, as well as many other factors. This is where the nurse must be the patient’s advocate – each patient will bring their unique set of idiosyncrasies and one care plan that has succeeded with one patient might not work with another, just as one type of medication may assist one patient but not another. It is the system that lets patients down when it is assumed one treatment option is a best-fit for all, or indeed, that all patients will fully recover from their illness. It might just mean taking that little bit of extra time to sit down and talk, to listen and to care. Rapport and trust between the patient and the nurse is vital, as is the patient’s want to recover, or at least manage their condition.
This should extend to your network of family and friends – you do not have to wait until you can see an obvious sign of a friend or loved one struggling. Take that little bit of extra time to have a genuine conversation and know that some people are doing it tough, no matter the façade they put up. Try not to judge those who have the courage to admit that they are struggling and instead find ways to understand their struggle and offer ways out of it. There is no telling when or if someone will suffer from a mental illness, but showing that person that they are not alone and that someone cares about them will make the world of difference to them – and you don’t have to be a nurse to do that.
It might seem like a bit of harmless fun to most of us, but to some, gambling has become an overwhelming problem. The problem is compounded when mental health issues are combined with this addictive behaviour and further complicated when sufferers are directly targeted by gambling organisations that portray a fun and winning atmosphere, yet this is very far from the truth.
From when I was a tender and bright-eyed 18-year-old working at the main casino here, I knew something wasn’t right about the way gambling works. In fact, I only lasted three months working there as I couldn’t tolerate the misery I was seeing on a daily basis.
When does gambling become a problem?
The American Psychiatric Association (APA) defines gambling disorder as repeated problematic gambling behaviour that causes significant problems or distress. It becomes an addiction for some people, with the same effects as an alcoholic gets from alcohol – they can crave gambling the way someone craves alcohol or other substances. The compulsion to gamble can lead to problems with money, relationships, work and legal issues. It is also often a hidden behaviour, making diagnosis and treatment difficult.
To be diagnosed with a gambling disorder, at least four of the following behaviours need to be present in the past year (APA, 2018):
Need to gamble with increasing amount of money to achieve the desired excitement
Restless or irritable when trying to cut down or stop gambling
Repeated unsuccessful efforts to control, cut back on or stop gambling
Frequent thoughts about gambling (such as reliving past gambling experiences, planning the next gambling venture, thinking of ways to get money to gamble)
Often gambling when feeling distressed
After losing money gambling, often returning to get even (referred to as “chasing” one’s losses)
Lying to conceal gambling activity
Jeopardising or losing a significant relationship, job or educational/career opportunity because of gambling
Relying on others to help with money problems caused by gambling
Current research is showing that gambling disorder is similar to substance-related disorders in clinical expression, brain origin, comorbidity, physiology and treatment. Symptoms can subside but can then return with even stronger feelings. The disorder does tend to run in families but environmental factors may also contribute. Symptoms can begin as early as adolescence or as late as older adulthood. Men are more likely to begin at a younger age and women are more likely to begin later in life (APA, 2018).
Is it a big problem?
Various studies show that at any one time, 1% of the adult Australian population satisfy the clinical criteria for problem gambling. A further 4% are at a significant risk. This may not seem high, but the real issue is that problem gambling is markedly over-represented with other co-morbid psychological problems and 57.5% of problem gamblers in these studies were shown to have substance use disorders (Thomas, 2014). Younger men are over-represented as problem gamblers, as are people from Aboriginal and Torres Strait Islander backgrounds and those from lower income settings.
It has the potential to become a bigger problem as Australia has a high number of gambling venues and gambling opportunities. Australia has one electronic gaming machine (EGM) per 118 people, the UK has one per 404 and Switzerland has one per 1,796 people. If you ever watch sport, you will also know you cannot avoid betting talk and advertisements while watching the game, with some betting promotions now placed within the broadcast itself.
The Victorian Responsible Gambling Foundation (via a report issued by the Queensland Government) showed that in 2015-16:
total gambling expenditure in Australia increased from $22.734 billion in 2014–2015 to $23.648 billion in 2015–2016 (a 3.9% increase)
per adult gambling expenditure in Australia increased from $1,241.86 to $1,272.81
total electronic gaming machine expenditure in Australia increased from $11.589 billion to $12.074 billion (a 4.2% increase)
total sports betting expenditure in Australia increased from $815 million to $921 million (a 13.0% increase)
sports betting has more than doubled in expenditure from 2010-11 to 2015-16
Spiralling roulette. Credit: scottdmiller.com
Expect to lose! Gambling is irrational behaviour
Part of the issue with problem gamblers is that it is irrational behaviour. Most of us know that it’s unlikely we will win – the house always wins – but an addicted gambler will not consider this. To put this in perspective, here are some of the actual odds of winning in common scenarios, according to the Victorian Responsible Gambling Foundation (VRGF):
Winning top prize on a poker machine: 1 in 9,765,625 (typical prize $5,000)
Winning first division Tattslotto: 1 in 8,145,060 (typical prize $300,000 to $1m+)
Winning first division Powerball: 1 in 54,979,155 (typical prize $3m – $15m)
Winning single zero in casino roulette: 1 in 37 (typical prize $180)
Winning the joker on the casino big wheel: 1 in 52 (typical prize $240)
Compare this with the odds of some non-gaming related scenarios:
Dying of heart disease: 1 in 3 people
Having a back problem: 1 in 4.8 people
Having some form of cancer in the last 12 months: 1 in 6.3 people
Being stung or bitten by something in the last 4 weeks: 1 in 55 people (and that’s in a country like Australia where everything is trying to kill us!)
An Australian person dying in a terrorist attack: 1 in 333,333 people
Being killed by lightning: 1 in 1,603,250
Yes, you have a much higher chance of being killed by lightning than ever winning Tattslotto or top prize on a poker machine. But some people still do it. The bottom line is, no matter what type of gambling you’re doing, you should always expect to lose.
The advertising problem
Gambling advertising has a habit of normalising the behaviour, so it’s not seen as an issue to sit around with friends and talk about who’s favourite to win or if the underdog can win. According to the Standard Media Index, the gambling industry spent $234.5 million on advertising in Australia in 2016, up from $89.7 million in 2011. This excludes sponsorships and in-program content, such as during live sport broadcasts.
In Australia, advertisements for betting products are not permitted during TV programs classified G or lower from 6 to 8.30 am and 4 to 7 pm, or in programs directed at children between 5 am and 8.30 pm. However, these restrictions currently exclude news and sport broadcasts. Why is this relevant? A 2016 VRGF-funded study “Child and parent recall of gambling sponsorship in Australian sport” collected data from children and parents at community sporting venues in NSW and Victoria. They found:
75% of 8- to 16-year-olds interviewed could name at least one gambling brand, and 25% could name four or more.
Study participants were able to describe incentives offered by bookmakers, such as ‘bonus bet’ offers and ‘cash back’ deals, which likely contributed to their belief that you could not lose from gambling. This perception is not limited to young people. Incentives or inducements are a form of marketing used to attract new customers or to trigger further gambling. They can lead to people underestimating the risks they are taking.
Another 2016 study reported that 75% of 8- to 16-year-olds thought gambling was a normal or common part of sport.
Sports betting and advertising. Credit: Australian Institute of Family Studies
Why the issue with young people?
Research shows that gambling is one of the first ‘risky activities’ that adolescents engage in, even prior to experimenting with alcohol and drugs, or engaging in sexual behaviour. Those who start gambling earlier are more likely to develop severe gambling problems. Rossen et al. (2016) found that 24.2% of secondary school students had gambled in the last year and 4.8% had two or more indicators of unhealthy gambling. There were also socio-economic status (SES) impacts found here too where the lower the SES, the more likely it was that gambling was problematic.
Sagoe et al. (2017) states that being male, showing higher physical and verbal aggression and having more symptoms of depression were associated with greater odds of belonging to the risky and problem gambling class at age 17.
A Canadian study from Temcheff, Derevensky, St-Pierre, Gupta, & Martin (2014) revealed that problem gambling was viewed as the least serious adolescent risk behaviour by most professionals and few reported feeling confident in their abilities to deal with youth gambling problems – meaning it largely goes undetected and untreated. However, the majority of professionals felt they have a significant role to play in the prevention of youth gambling problems and many endorsed receiving continuing education of the issue. Parents and teachers also feel less concerned about gambling than they do about smoking or drinking. It appears that there needs to be greater awareness of the link between problem gambling and mental health issues.
Comorbidity
Comorbidity is defined as the co-occurrence of one or more disorders in the same person either at the same time or in some causal sequence (Department of Health, Australian Government, 2018). Comorbidity poses significant issues for the identification and treatment of problem gambling because of the high case complexity. Most people with problem gambling have one or more additional disorders that require intervention in their own right. For this reason, it has been proposed that people with problem gambling should be screened for other psychological disorders and vice versa. Many people with problem gambling are missed because their symptoms are masked by other disorders and often hidden from practitioners because of shame considerations. For example, the research that is available suggests that suicide risk is strongly elevated for problem gamblers. But there is a conflict of interest as the government collects licence fees and taxes from gambling revenue, while regulating the industry, operating treatment services and running public health interventions (Thomas, 2014). So, who can be relied upon to truly work at resolving these issues?
A study by Maas (2016) shows mood and anxiety disorders to be strongly associated with gambling problem severity. It also shows that a person’s SES has a strong association with the degree of problem gambling – those with greater resources experience fewer problems as a result of their gambling participation. The findings also suggest that those with less education experience more problems with gambling.
A study from Manning et al. (2017) from eight outpatient mental health services in Victoria revealed that patients with drug-use disorder had over four times the risk of problem gambling. It also overlapped with other addictive behaviours, as problem gamblers exhibited significantly higher rates of nicotine and illicit drug dependence. Patients diagnosed with a psychotic disorder, bipolar or Borderline Personality Disorder (BPD) had double the risk of problem gambling.
Results from a 2014 Victorian Responsible Gambling Foundation study indicated a statistically significant association between gambling symptoms and lifetime major depression, and marginally significant links with lifetime panic disorder, specific phobia and Generalised Anxiety Disorder (GAD). There were also significant links between problem gambling and avoidant, antisocial, borderline, narcissistic and schizoid personality disorders. Substance users in treatment with any of these diagnoses reported up to four times the number of pathological gambling symptoms when compared to those without.
A study by Churchill & Farrell (2018) found that higher levels of gambling addiction are associated with greater levels of depression. Also, results suggest that online gambling poses a significant mental health risk compared to gambling in venues or outlets, where those that gambled online in the last 12 months, on average, reported higher levels of depression than those that did not.
Does problem gambling lead to mental health issues?
Hartmann & Blaszczynski (2018) found that psychiatric disorders can represent both a precursor and a consequence of problem gambling, and that there are underlying interactive factors, such as impulsivity, that can predict and drive both temporal sequences (happening over a sequence of time). Where co-morbid disorders are present before the onset of problem gambling, it could be that gambling was used as an emotional escape. Links between problem gambling and co-morbid conditions appear to be bidirectional for mood and anxiety disorders, substance use/dependence, alcohol use/dependence, and nicotine dependence in child, adolescent, young adult and adult populations.
Public stigma
Keeping a gambling problem hidden is common due to shame, embarrassment and fear of stigma, although this also hinders access to treatment, interventions and other support. A study from Hing, Russell, Gainsbury, & Nuske (2016) found that problem gambling attracts considerable public stigma, with deleterious effects on mental health and use of healthcare services amongst those affected. The issue of public stigma, or the perception of it, can stop people from ever seeking help. They can experience the mental health effects of diminished self-worth, withdraw from social support and reject treatment and other interventions. Stigma is the most cited reason for avoiding professional treatment for mental health problems, including problem gambling.
Self-stigma
The internalisation of stigma among individuals with gambling problems tends to work in a similar way as for those with alcohol or drug problems (Gavriel-Fried & Rabayov, 2017). Another study from Hing & Russell (2017) suggests that the self-stigma of problem gambling may be driven by similar mechanisms as the self-stigma of other mental health disorders and impact similarly on self-esteem and coping. They also found that self-stigma of problem gambling increased with females and older age groups, which were also associated with electronic gaming machine problems. Lowering self-stigma can not only increase coping skills but can foster a belief that recovery is possible, and that relapse isn’t a failure.
Clinical considerations
In many respects, problem gambling is a hidden disorder. Many sufferers choose to never seek help. In fact, less than 10% ever seek treatment (APA, 2018).
Psychological treatments have been shown to be effective for patients once they engage with it. This is important as many problem gamblers have co-morbid psychological disorders, as explained earlier. Improved detection of problem gambling may be as simple as adding a question into the standard health check screening – “have you or anyone in your family an issue with gambling?”. This can unblock a reluctance to discuss the topic without judgement and an appropriate referral may then take place (Thomas, 2014).
While many are too ashamed to speak of their addiction, many are not asked. Mental health nurses are well-placed to screen for signs of problem gambling and direct the person to appropriate treatment services. Some studies have shown that clinicians tend to focus on what they perceive as immediate risk, while problem gambling is often considered a longer-term concern, or even not related to mental health (Rodda, Manning, Dowling, Lee, & Lubman, 2018).
Signs of harm
Signs of harm can appear well before gambling becomes a problem and initial signs could be:
Having less time or money to spend on recreation and family
Reduced savings
Increased consumption of alcohol
Feelings of guilt or regret
Relationship conflict
Reduced work or study performance
Financial difficulties
Anger
Feelings of shame and hopelessness (VRGA, 2018)
How is it treated?
Gambling affects people in different ways and different approaches may work better for different people. Several different types of therapy are used to treat gambling disorder, including Cognitive Behaviour Therapy (CBT), psychodynamic therapy (focusses on unconscious processes as they are manifested in a person’s present behaviour), group therapy and family therapy (APA, 2018).
Current evidence-based treatment options indicate psychological therapy as being the front-line treatment option. CBT and motivational interviewing have some supporting evidence for their effectiveness with the strongest evidence base centred on CBT (Casey et al., 2017). This study also showed that Internet-based CBT may overcome barriers that prevent individuals from seeking face-to-face help, as preliminary evidence into the efficacy of internet-based delivery of CBT versus face-to-face shows similar results.
Various studies have examined a range of medications for treatment of problem gambling but there is insufficient evidence of their effectiveness. Some medications may be appropriate for other mental health issues associated with problem gambling but they are not indicated as the primary treatment for problem gambling.
One model to consider for the delivery of effective treatment for gambling disorders is a coordinated treatment program based on the application of mental health care plans, encouraging health care practitioners to view gambling problems in the wider context of other mental health conditions and manage those conditions as a whole (Harvey, 2013).
There is no simple solution to the problem of gambling but one thing is certain – it cannot be ignored in the hope that it will work itself out. It is an addiction for some people, just as alcohol and drugs are, and we do not expect those sufferers to just stop or work it out on their own. Problem gambling is the new tobacco – do we as a society want to do something to control its impact on those that are addicted and their friends and family, or do we just hope the government will step in? Forgive the gambling reference, but the odds of trusting the government to show leadership with this are less than favourable.
Casey, L. M., Oei, T., Raylu, N., Horrigan, K., Day, J., Ireland, M., & Clough, B. (2017). Internet-based delivery of cognitive behaviour therapy compared to monitoring, feedback and support for problem gambling: a randomised controlled trial. Journal of Gambling Studies, 33, 993-1010. Doi: 10.1007/s10899-016-9666-y
Churchill, S. A., & Farrell, L. (2018). The impact of gambling on depression: new evidence from England and Scotland. Economic Modelling, 68, 475-483. Doi: 10.1016/j.econmod.2017.08.021
Gavriel-Fried, B., & Rabayov, T. (2017). Similarities and differences between individuals seeking treatment for gambling problems vs. alcohol and substance use problems in relation to the progressive model of self-stigma. Frontiers in Psychology, 8(957), 1-8. Doi: 10.3389/fpsyg.2017.00957
Hartmann, M., & Blaszczynski, A. (2018). The longitudinal relationship between psychiatric disorders and gambling disorders. International Journal of Mental Health and Addiction, 16(1), 16-44. Doi: 10.1007/s11469-016-9705-z
Harvey, P. (2013). The provision of integrated care for people with gambling disorders and co-occurring mental health conditions. Australian and New Zealand Journal of Public Health, 37(6), 588. Doi: 10.1111/1753-6405.12125
Hing, N., & Russell, A. (2017). Psychological factors, sociodemographic characteristics, and coping mechanisms associated with the self-stigma of problem gambling. Journal of Behavioural Addictions, 6(3), 416-424. Doi: 10.1556/2006.6.2017.056
Hing, N., Russell, A., Gainsbury, S., & Nuske, E. (2016). The public stigma of problem gambling: its nature and relative intensity compared to other health conditions. Journal of Gambling Studies, 32, 847-864. Doi: 10.1007/s10899-015-9580-8
Maas, M. V. D. (2016). Problem gambling, anxiety and poverty: an examination of the relationship between poor mental health and gambling problems across socio-economic status. International Gambling Studies, 16(2), 281-295. Doi: 10.1080/14459795.2016.1172651
Manning, V., Dowling, N., Lee, S., Rodda, S., Garfield, J. B. B., Volberg, R., … Lubman, D. I (2017). Problem gambling and substance use in patients attending community mental health services. Journal of Behavioural Addictions, 6(4), 678-688. Doi: 10.1556/2006.6.2017.077
Okunna, N. C., Rodriguez-Monguio, R., Smelson, D. A., Poudel, K. C., & Volberg, R. (2016). Gambling involvement indicative of underlying behavioural and mental health disorders. The American Journal on Addictions, 25(2), 160-172. Doi: 10.1111/ajad.12345
Roberts, K., Smith, N., Bowden-Jones, H., & Cheeta, S. (2017). Gambling disorder and suicidality within the UK: an analysis investigating mental health and gambling severity as risk factors to suicidality. International Gambling Studies, 17(1), 51-64. Doi: 10.1080/14459795.2016.1257648
Rodda, S. N., Manning, V., Dowling, N. A., Lee, S. J., & Lubman, D. I. (2018). Barriers and facilitators of responding to problem gambling: perspectives from Australian mental health services. Journal of Gambling Studies, 34, 307-320. Doi: 10.1007/s10899-017-9713-3
Rossen, F.V., Clark, T., Denny, S.J., Fleming, T. M., Peiris-John, R., Robinson, E., & Lucassen, M. (2016). Unhealthy gambling amongst New Zealand secondary school students: an exploration of risk and protective factors. International Journal of Mental Health and Addiction, 14(1), 95-110. Doi: 10.1007/s11469-015-9562-1
Sagoe, D., Pallesen, S., Hanss, D., Leino, T., Molde, H., Mentzoni, R. A., & Torsheim, T. (2017). The relationships between mental health symptoms and gambling behaviour in the transition from adolescence to emerging adulthood. Frontiers in Psychology, 8(478), 1-8. Doi: 10.3389/fpsyg.2017.00478
Temcheff, C. E., Derevensky, J. L., St-Pierre, R. A., Gupta, R., & Martin, I. (2014). Beliefs and attitudes of mental health professionals with respect to gambling and other high-risk behaviours in schools. International Journal of Mental Health and Addiction, 12(6), 716-729. Doi: 10.1007/s11469-014-9499-9
A respected lecturer recently told me that it’s a privilege to be present as a new life begins, and to be present as a life ends. This is what nursing affords you – this privilege to be present at times of joy, grief and vulnerability. I saw this vulnerability in its rawest form while on my current placement in an acute care hospital in regional Victoria.
My first clinical placement in an acute care hospital setting had the obvious nerves and doubts running through my mind. Having never worked in a hospital before, I was unsure whether I could perform the necessary skills, especially injections and preparing medication solutions to deliver through IV lines. We haven’t had to do venipuncture yet, so that will be another doubt to cross in the near future. The communication aspect of the role does not trouble me though – I do enjoy interacting with people, especially when I can help them feel better about themselves or the situation that they have found themselves in.
My communication skills would be immediately tested though, when I first encountered a patient who had recently been told he had from three weeks to three months to live. It seemed all he heard was the three weeks part of that statement and he wanted to die. He was of sound mind and he was in pain. He initially looked scared and I can understand that – how do you process such a statement? We’re all guilty of wishing time away when we’re doing something we don’t necessarily like but what would go through your mind when someone tells you that your time left is so short? I watched as he seemingly went through phases – from the initial scare to the occasional cheeky smile and smart remark as we tried to lighten the mood for him, to the times when I just had to silently stand there and be with him.
One afternoon as I was walking down the hall of the ward, I noticed he was attempting to get out of bed, but wasn’t getting very far. By this stage, his pain had reached a level where the basic effort of moving his body was too much, but he was still determined to try. I walked into his room and asked what he was trying to do. “I need to piss”. He was clutching onto the side rails of the bed, trying to lift his frail body up. In this moment, I knew he probably shouldn’t have been trying to get out of bed, but his determination to move seemed more important. So, I lowered the bed and offered my hand to help him get up. It took some time and I could see how hard it was for him, but none of that mattered in this moment. He needed to do this. He needed to show that he was still capable of something, even if it was just the act of getting out of bed.
After the initial struggle of helping him out of bed, the next challenge was getting to the toilet. Yes, he could have just went in his bottle, but he didn’t want that. All I was thinking at this time was to maintain his dignity and independence, even though he couldn’t move without some support there. I held his right arm to prop him up as he slowly shuffled a few centimetres with each thrust. He kept apologising and I kept telling him he had nothing to apologise for. I was here to help him and we had all the time in the world (this won’t always be possible in the world of nursing, but I sure hope I’ll be able to be present whenever the need is there without having to rush off to the next patient).
We eventually reached the toilet and his pyjama pants had already fallen enough that he didn’t need to lower them. He was losing weight, which was another frustration for him. He started to go and mostly missed the bowl. Again, he apologised and sounded upset. Again, I reassured him that he had nothing to apologise for. I stood behind him, still holding onto his side. It sounded like it was a real effort to pee, but he managed to get a little out. He just stood there for what seemed a long pause as I continued to hold his side. “Well done mate, do you want to make your way back to bed?” He nodded and we started the slow shuffle back, with each move causing visible pain.
As we reached his bed, he slowly lowered himself onto the edge and sat there. I thought it was a good idea for him to sit up for a bit since he’d made the effort to get up. As he was sitting there, I asked if there was anything I could do: “get a knife”. He looked at me and his eyes were telling me he was serious. I have been a strong advocate of voluntary euthanasia laws for as long as I’ve been aware of the issue (I did my year 12 english essay on the topic, which shows how long this issue has been going here). This moment will sit with me as proof of when these laws should be acted upon. He was of sound mind, in immense pain, and he had had enough. He was losing his dignity and quality of life. I told him I would do as much as I could, but that I couldn’t do what he wanted. I said we were trying to make this time as comfortable for him as possible, but he replied “if I was a dog, I’d be put down already”. I couldn’t argue with that. Thankfully, Victoria will be legalising voluntary euthanasia as of mid-2019 with some of the most conservative laws in the world, but that didn’t help him in this moment.
Later that night, he was in bed and looked uncomfortable as I passed his room. I walked in and asked how he was: “shit, mate”. By this stage, he had been started on morphine for the pain, but it hadn’t taken effect yet. I walked up to his side and took his hand. With the little strength he had, he held my hand back and I just stood there. I didn’t say a word, I just held his hand and looked at him. I knew there wasn’t much else I could do, and all those times I’d been told of how communication is more about the non-verbal than the verbal came into my mind and rang true. I thought about my lecturer’s remark, of the privilege to be present at the end of a life, and that also rang true. And I continued to just stand there and hold his hand.
That was the last time I saw him. It was a Thursday night and my shifts meant that I wasn’t back in the ward until Tuesday morning. This is when I learned of his passing on the Sunday. It was bittersweet – I knew he wanted to go, but I was still sad that I wasn’t there. This will be a continual lesson for me to know that I won’t always be there at the end, but as long as I’m present when I can be, I will take that. It is indeed a privilege to be in this position and it is a privilege I hope to never forget, or take for granted. RIP dear man.
One year of my nursing journey has somehow already passed, and unsurprisingly, the last three weeks have been the most significant thus far. My first clinical placement experience was an important milestone – I needed to test my strengths and weaknesses and bring all of the knowledge taken in throughout the year into the real world. Just how real is where the experience became a critical one.
There were many moments over the three weeks that will remain in my mind as I reflect on my interactions, but three moments in particular had what I feel will be a lasting impact. As in all accounts of a medical and personal nature, no real names are used in these stories that follow.
PART III
On the Thursday of the second week, we were doing a late shift. There was typically less to do on these later shifts as the only meal was dinner and most of the residents settled after this, either watching TV in one of the lounges or staying in their rooms. After helping with dinner, I saw a young boy and his father sitting beside one of the residents. The young boy was playing with three balloons and having a wonderful time, so I decided to go join in. He was close to two-years-old but he already knew the different colours of the balloons and each time I’d hide one behind my back, he’d know which colour it was. I was so impressed and his father seemed pretty happy about it too.
This was when I met his grandmother, who I later learned was of sound mind and full mental capacity, but had a failing body courtesy of Parkinson’s Disease. I didn’t know this at the time, and I certainly didn’t know that this woman would leave a very lasting impact on me.
The next morning, I was there to help with breakfast and lunch. As I approached the dining area before lunch, I saw three people sitting beside the grandmother and overheard them: “What do you mean a male nurse? Huh?” Her daughter (as I later discovered) was trying to make out what her mother was saying, as the Parkinson’s had now taken hold of her throat muscles, making her speech very difficult to hear for us, and making it very tiresome for her to even muster up a few words. So I walked up to them and introduced myself, to which the daughter smiled and told me how much the grandmother appreciated me playing with her grandson the night before, and apparently she’d never mentioned any of the staff before, but she was very happy with what I had done. I didn’t even realise the grandmother was aware of what I was doing that night! This is when it occurred to me just how cruel Parkinson’s is. To be of sound mind, but not able to express it must be incredibly frustrating (to say the least). I won’t attempt to suggest one disease is favourable over another, but at least with dementia, you don’t know that you’ve forgotten things – Parkinson’s strips you of your most basic abilities and you know it’s happening.
Once I got talking with the family, I discovered that this grandmother had the same name as one of my grandmothers (not a common name), so I started to feel a connection. I made an effort to always be there to feed her from this point, and most times, we wouldn’t say much, as I didn’t want to make her have to struggle to talk, but we’d glance at each other and smile (as much as she could anyway), and I’d just occasionally talk about random things.
After a few days, I told her that she had the same name as my Nonna, but my Nonna had passed away many years ago. Through her strained tone, she asked:
“How old?”
“66”, I replied.
“Too young”, she whispered while shaking her head. Yes, far too young. But then, as she stared straight at me, the moment I’ll never forget:
“I want to pass in my bed”.
I couldn’t make out what she was saying, there was a lot of noise in the dining area this day. I asked her to repeat it as I leaned forward to have my ear right in front of her mouth, and each time, I struggled to put the words together as much as she struggled to get them out. I felt so guilty that I was making her repeat these words, but I just couldn’t piece together what she was saying at that time. It only occurred to me later what she had said – her daughter had told me that her Mum had mentioned numerous times that she wants to die. The daughter wasn’t surprised, but she also knew there was nothing she could do. Victoria has just passed voluntary euthanasia laws, but they don’t take effect until June 2019. We discussed this, and she wished this was an option for her Mum, but the sad reality was, that the only thing her Mum could do was not eat much and let nature take its course. She was apparently refusing food most days and had recently lost a lot of weight. Her daughter knows what she’s trying to do, but what are you supposed to say to someone who tells you they want to die? She really has no quality of life and is bound to her bed and chair all day. All of her food has to be cut into very small pieces and all liquids need thickener added to them to stop her from choking. She clearly doesn’t like the taste of the thickener either, as she would always wince as I offered her a drink (with a straw, as this was the only way she could get a drink down). Who are we to say that her wish shouldn’t be granted?
Over the last few days of placement, I’d always seek her out and speak the very few Italian words I knew to her. I wanted her to feel seen, and to feel like she actually still had something to live for, even though I knew she was ready to go. And on the final day, just after I had finished feeding her lunch, with the little strength she had, she took hold of my hand, looked me in the eyes and simply said: “I’m very happy. You make me very happy”. I was speechless, yet so incredibly humbled at the same time. I wasn’t doing any of this for any other reason than to make her happy, and when she said those words, I knew this is my true calling in life. No other work I have ever done has given me this feeling and it’s quite difficult to put into words, but after she said this, I just smiled (trying not to break down into tears) and I said how happy I was that she was happy, and that it was an absolute pleasure to spend time with her. I thanked her for allowing me to care for her and then gently released my hand from hers and walked away. I can still picture this entire scene in my mind so clearly and I know this is going to stay with me for as long as my mind is willing and able.
While this placement presented many confronting situations, it also offered many highlights and uplifting moments. I have detailed some of the more challenging aspects but it just motivates me to continue learning and to look forward to my next clinical placement, which is less than two months away in a rural hospital. As there is in life, there will undoubtedly be more challenges to reflect on.
One year of my nursing journey has somehow already passed, and unsurprisingly, the last three weeks have been the most significant thus far. My first clinical placement experience was an important milestone – I needed to test my strengths and weaknesses and bring all of the knowledge taken in throughout the year into the real world. Just how real is where the experience became a critical one.
There were many moments over the three weeks that will remain in my mind as I reflect on my interactions, but three moments in particular had what I feel will be a lasting impact. As in all accounts of a medical and personal nature, no real names are used in these stories that follow.
PART II
The second week of placement had a new challenge – feeding residents with varying levels of care requirements. This offered many insights, one of which was a gentle reminder to not take the simple things in life for granted.
There were three residents that I had to assist with their meals and each one presented a very different set of challenges. The first, a gentleman who had speech issues and also struggled to lift a spoon to his mouth, took me a couple of feeds to learn his quirks. One thing I kept reminding myself of was that this was a person deserving of the exact same treatment that any of us would expect – just because he had issues feeding himself did not render him useless or not worthy of my time or respect.
He was hard to read – at times, he would reply to my questions of what he wanted to eat next with a nod or a little smile, at other times he would just stare off into the distance. I didn’t just want to assume that he would eat whatever I put to his mouth. He really seemed to enjoy his beans and carrots, but his breakfast, not so much. Breakfast never really looked that appealing, so I could understand his lack of excitement for it. He would raise his empty fingers to his mouth, as if he thought he was feeding himself, so sometimes, I’d let him pick up his food with his fingers and eat that way. Sometimes though, I’d just raise the fork to his mouth and he would eat without hesitation.
After a few feeds, I was feeling more comfortable with him. So I was shocked when one of the carers (a loose term to use for this particular person) decided to walk up and take the spoon from me and force it to his mouth. “You have to feed him! You have to tell him what he wants. He doesn’t know”. I was so taken aback at their utter lack of care for this man that I didn’t know what to say. It seemed that my way of feeding was working just fine, but this was clearly a very bad habit of this carer. I did notice this person also doing some other things that did not please me, and I know they are under time pressure to get tasks done, but when you lose sight of the fact that each person under your care deserves respect and dignity, it’s time you find another job. Sadly, I did see and hear of other events that trouble me in relation to a lack of care from some staff – one morning while walking past a resident’s room, I saw a carer eating the resident’s toast. When they noticed that I had seen this, they offered an excuse: “she wasn’t going to eat it anyway”. I didn’t think it was my place as a student to say anything, so I just gave a disapproving look and kept walking.
The next resident I was assigned to feed was a dementia sufferer, and this presented much different challenges. She was so sweet, yet so frail. She would regularly fall asleep at the table, either before or during the meal. I’d ask which food she wanted and she would reply that she didn’t know. Everything appeared to be so tiring for her, even just trying to answer a question. Within the space of a few seconds, she would say she didn’t like chicken, but then proceed to eat it the very next time I asked. The only constant for her was ice cream – there was never any confusion about whether she liked ice cream! She would gaze at me with her troubled eyes and sometimes attempt a smile, but at other times, I could sense she was so confused about everything that was happening, and it was quite confronting to see.
Dementia is a cruel way to spend your final years – just imagine not knowing if you like a particular food or not, or what it is you’re actually sitting at the table for. It was heartbreaking. We all did our best to make her smile and took our time with her. She even said to me one day, “Hello RMIT”. She could see the logo on my uniform and obviously thought it was my name, and I just smiled and said hello back to her. I understand that she doesn’t know that she’s forgotten some of the basics, but it was still hard to accept that this is the way some people live out their lives. Seeing her sing along at the various events the facility put on made me smile, she was good with the lyrics to plenty of the classics, but it was the simple task of eating that seemed to provide her the most troubling test.
To finish this thought on a positive note (it wasn’t all doom and gloom after all), it just needs to be said: do not, I repeat, do not underestimate how seriously residents take their bingo! I learned very quickly as I was calling out the numbers one day just how serious it is (to the point where one resident was cheating, and one of the other residents discovered this and made quite the scene about it!). One of them even “shooshed” me a couple of times as I was trying to have some fun with it. And if you don’t shuffle the numbers properly after every game, you’ll definitely hear about it too! Also make sure you know what to say with each number, such as “legs eleven” or “two little ducks” for 22 (followed by a “quack quack!”) – thanks to Google for helping out with that part. The daily activity time really was wonderful to see and the staff involved should be congratulated for their efforts to put smiles on the residents’ faces each and every day.
One year of my nursing journey has somehow already passed, and unsurprisingly, the last three weeks have been the most significant thus far. My first clinical placement experience was an important milestone – I needed to test my strengths and weaknesses and bring all of the knowledge taken in throughout the year into the real world. Just how real it was is where the experience became a critical one.
There were many moments over the three weeks that will remain in my mind as I reflect on my interactions, but three moments in particular had what I feel will be a lasting impact. As in all accounts of a medical and personal nature, no real names are used in these stories that follow.
PART I
In the days leading up to the start of my clinical placement, I was thinking about the challenges that lay ahead. One challenge that I knew I would be tested on was my ability to separate the emotional attachment from the task of caring for a person in need. Little did I know that this test would present itself in the very first week.
We were each assigned one resident to assist, and it would be a “simple” resident for now – one that did not require a high level of care with their daily activities (or ADLs, Activities of Daily Living, as we like to call it). I was assigned a friendly but reserved gentleman, who just one month on from his 94th birthday, had found himself admitted into residential care due to a complication with his eye sight after suffering a three-month pneumonia battle. He was otherwise mobile and independent, even though he used a walking aide. I only needed to assist with the trickier parts of a shower, and keeping an eye on a sore he had on one of his toes. Otherwise, I found my main assistance to him was just being there for a chat and we had a rapport right from the start. He was still processing the fact that he was now a resident in a care facility, something that was both unexpected and a little uncomfortable for him. It was the little things that were making a big difference to his transition, such as the lack of honey that was available at breakfast time for his toast (and of course, I set about trying to stash some honey away for him once I learned this).
After the second day, he said we made a good team, and that gave me a sense of satisfaction I’ve rarely felt in any work I’ve ever done. I was genuinely enjoying our chats – learning about his history as a merchant shipper, and the many fascinating places he had sailed to. I learned about his wife, who had passed two years earlier, and of the way he would spend his time down at the local stores with his neighbours. He told me of his three daughters and how proud he was of them. I had the pleasure of meeting one of them and I could see why he was a proud father.
Then, on the Friday, I knocked on his door as I always did and entered his room. I saw him sitting on his bed, quietly staring out the window, with all of his belongings packed beside him. This startled me, and it was almost like he read my reaction, as he started to tell me what was happening before I even had a chance to ask. He was being transferred to another facility, as this was only supposed to be for respite care. He wasn’t sure when he was leaving, but I said I would be there to say a proper goodbye. I thanked him for the opportunity to assist him and I told him how much I enjoyed our very brief time together learning about his story. I had some other tasks to attend to and then went back to his room about an hour later.
The room was empty. My heart sank. My throat felt heavy. He was gone and I wasn’t there like I said I would be. I instantly felt like I had let him down and I was so disappointed in myself.
I went back to our meeting room that we used to debrief and told my educator and fellow placement buddies what had just happened. My educator had a look on her face, almost like she knew this was coming. I had mentioned to her at the start of placement that I thought I might struggle with the emotional side of things and here we were – on day five, already facing this test. But they rallied around me (something that I hope will continue to happen throughout my nursing journey) and reminded me of the reality of the situation – yes, I said I would be there to say goodbye, but this isn’t always possible. I was there when he needed me throughout the week, and then he needed to move to his next phase. I suggested that I would go visit him in his new facility, to say a proper goodbye, but my educator stepped up again: “Are you doing this for him, or are you doing this for you?” It was a powerful question, one that instantly highlighted to me that I had become too emotionally attached to the first resident I interacted with and proved this would be a real challenge for me to work on. People in need will come and go and I won’t always be there to say goodbye – things will rarely be that perfect or organised. There is a fine line between being the empathetic, caring nurse and the nurse that doesn’t protect themselves emotionally. I was already too close to this line and I had to back away.
Words Not Numbers 