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
Just feeling the need to put this out there. It’s a bit heavy, so feel free to skip it, which is partly what this is about.
Melbourne would not be alone these days in experiencing an ever-increasing and troubling homeless problem. And that is part of the problem – we can all see it, but most of us just keep on walking by. I have been one of those people too, so I’m certainly not trying to make you feel guilty as you read this. I simply want more of us to start thinking about this problem and what can be done about it. Are we ok with the fact that some people find themselves on the fringe of society and then get swept aside as if they don’t exist any longer?
Sometimes it takes a personal experience to make you evaluate your past behaviour. That happened to me tonight, as I was rushing between shifts at work. I only had 20 minutes to get something to eat and the local KFC comes in handy in these situations, so I made my way there to get a quick bite.
It was as busy and messy as it always is but I was still able to see a familiar face among the groups of mostly young and noisy people. A tired-looking man, who has an ever-increasing weathered face each time I see him. He is clearly homeless. He quietly sits in one corner of the KFC and waits for others to leave scraps of food behind. He isn’t picky – he can’t afford to be. He checks each bag left on the tables, lifts each drink cup to see if there’s any left, and yes, he rummages through the rubbish bins on a regular basis when there’s nothing left behind on the tables. But we all go about our lives and he just blends into the scene. Maybe we are so absorbed in our worlds that we don’t notice him, or maybe we just don’t want to notice him so we don’t have to think about it.
I have had a previous opportunity to help this man and for some unknown reason, I got nervous and didn’t do it. I wanted to buy him some food so he wouldn’t have to do what he usually does but I had a thought that he might not like me doing that. Maybe he would be too embarrassed to accept it, or maybe he would get upset? I sat there then for what seemed like a long time over-thinking the entire situation and then just got up and went home. I instantly felt guilty and wished I had acted differently.
So, when I saw him again tonight, I knew I had to act differently. I didn’t buy much for myself tonight but I did get an extra serve of chips. I walked up to him, smiled, and asked if he wanted them. He looked at me, smiled, and accepted the chips. He thanked me, and turned back to his collection of leftovers and mostly empty drink cups. He continues to look as if he is deteriorating, but I suppose that’s the way it is when you are homeless.
I didn’t do much, and it certainly didn’t cost me much, but I had to do something tonight. I was compelled. Anything to help has to be better than what homeless people usually see. It must be so hard to be ignored. We are social creatures and isolation is one of the toughest things to experience, yet this is what we are doing with homeless people.
I have no answers to this complex and troubling problem, but I have to believe that we can at least try to be doing something to help. It’s not realistic to say that you can help every single homeless person, but maybe if more of us started giving them an act of kindness, it could make a small difference. To not ignore them, to offer whatever help you can, it has to be better than what we’re doing right now.
Mahatma Gandhi is quoted as once saying “the true measure of any society can be found in how it treats its most vulnerable members”. We need to think about if we are happy to be that society that ignores its most vulnerable members.
“Take your broken heart, make it into art” – Meryl Streep quoting Carrie Fisher
It has been a rough few months again. I opened myself up and I was hurt. This time though, I did not see it coming. I was all in, but then without warning, it was all over.
Few things hurt as much as being rejected and not being told why.
Especially when it has happened more than once.
“The only closure you’ll get is that you won’t always get closure”
– a trusted friend
So when something like this happens to me, I do wonder whether I care too much and give too much of myself. And when someone is frivolous with my heart, I can fall hard. It is so easy to fall back into a negative head space and think that I will never experience these wonderful highs of connecting with someone on a beautiful level again. Or, whether I will be able to trust someone with my heart again. Or, whether I will open myself up to hurt again. It isn’t nice and it certainly isn’t easy, but sometimes things just don’t work out the way you want them to.
I retreat to nature and try to enjoy my own company. While the great outdoors always offers a recharge, sometimes my thoughts are too much even for nature to overcome. But it is still an important part of my life and one that I need to regularly experience.
An unforgettable sunset from near Wreck Beach, Vancouver, BC, Canada (July 2017)
Sometimes, the inevitable stage is withdrawal. It has happened before and it happened again here. I withdraw when people I really care for do me wrong. People that I trusted not to hurt me, but they did. This is when the negative thoughts can happen. And the restless nights. And I can feel very lonely when I am alone. Memories are everywhere and they remind me of the hurt. Thoughts are consumed with the confusion on not knowing what went wrong.
I sometimes think that I put too much of myself on the line, and that I am an easy target for those that don’t feel like I do. I don’t think that’s a part of one’s personality that can change though. And maybe it’s a part of one’s personality that shouldn’t change.
I know some things take time and that some people need more time than others to process difficult things. I have learned that there is no right or wrong way to process these feelings and that there is no timeline either. It isn’t helpful to expect that someone will just get over it like you might do and it definitely isn’t helpful to tell someone who is struggling to “just get over it”. There is always a time for empathy.
If you have someone special in your life, please do not take them for granted. Show them that you care, tell them that you care. You just don’t know if they’re always going to be there. Life is full of unknowns, and while that shouldn’t stop us from putting ourselves out there for both the good and the bad, the one sure thing I’ve learned is that things – and people – change.
Try to embrace the change. It is not always easy – in fact, sometimes it is the hardest thing to see – but each experience is a lesson. That’s why I will keep putting myself out there and why I will eventually feel confident about myself again. A positive mindset where you can see each experience, no matter how painful it is at the time, as a lesson, is more helpful than seeing things as a waste of time. I remember from previous struggles where I lacked a sense of purpose, it was a destructive mindset which works against any hope you have of feeling better about yourself and your life.
It is also okay to have a day here and there where you do not feel your best and when you just need to hide away. I can sense when I am feeling like this and I make sure that I acknowledge it and importantly, I try not to make myself feel bad about feeling like this. There are times when I feel like things are overwhelming and that there isn’t much to be happy about, but this is when I find it is most important to retreat and reset. It is human to feel happy and sad, and everything in between. Nothing, and no one, in this world is perfect, and it is worth remembering this when not feeling your best.
“There is no room in my heart for hate” – Sense8, Season 2, Episode 7
I think it is important to also be patient with each other. This is incredibly tough to do at times when you are hurting, as the natural reaction might be to get upset and say some things that you might later regret. I don’t see it as a weakness to be the person that understands that everyone has their struggles and sometimes, some people don’t behave the way that we think we would do in the same situation. You never really know this until you experience it for yourself. While it is easy (and tempting sometimes) to judge others for their behaviour, it is important to acknowledge that it might not be personal, so don’t take it that way.
The upshot of this is that I want to ask that we try to treat each other with a little more love and respect. I strongly believe that the increasing number of people suffering mental health deficits is related to the careless way some of us treat each other. We are unnecessarily frivolous with each other sometimes and forget that everyone has their own battles to fight. We don’t need to add to these stresses by being cruel to others. A little communication goes a long way, and sometimes it might be a difficult conversation, but just have it. So many things can be resolved by discussing the actual issues, rather than just walking away from them. I find hugs always help too.
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.
Those that know me well, know that I wear my heart on my sleeve. I find it difficult to hide my emotions, whether it is a good feeling or otherwise. This can be both a blessing and a curse.
Sleep is evading me tonight. My mind is far too active, even though my eyes are feeling as heavy as my heart. I can rarely pinpoint the cause of this, and trying to resolve that query only serves to extend the sleeplessness. Thoughts of the previous day are at the forefront, but so too are those moments from other days where unresolved matters play out in many different scenarios. It seems wearing your heart on your sleeve also means an over-active mind at the most unpredictable of times.
But, one event from yesterday is clearly troubling me. Yet another opportunity presented itself for Australia to join the many other developed nations of the world in treating a minority with respect and dignity. Once again, a fearful and ignorant few stood in the way of any progress.
Fairness, equality and compassion stand at the very centre of my being, and the continued toxic nature of the marriage equality debacle is taking a toll. I have previously written of the shockingly disproportionate mental health statistics of the LGBTIQ community, yet is it at all surprising when we continue to be told that we are not equal? Why is our love subject to an often hateful discourse, when heterosexual couples can merely go about their daily lives unquestioned, both in marriage and divorce? What impact does our love even have on anyone else’s? The world hasn’t imploded in any of the countries that have moved to protect the rights of all of its citizens, as opposed to just those that meet a religious criteria.
Some of these aforementioned statistics bear repeating:
Same-sex attracted Australians have up to 14 times higher rates of suicide attempts than their heterosexual peers
Up to 50% of trans people have actually attempted suicide at least once in their lives
LGBTIQ people have the highest rates of suicidality of any population in Australia – 20% of trans Australians and 15.7% of lesbian, gay and bisexual Australians report current suicidal ideation (thoughts)
Lesbian, gay and bisexual Australians are twice as likely to have a high/very high level of psychological distress as their heterosexual peers (18.2% v. 9.2%). This makes them particularly vulnerable to mental health problems
The average age of a first suicide attempt is 16 years – often before ‘coming out’
Source: Rosenstreich, G. (2013) LGBTI People Mental Health and Suicide. Revised 2nd Edition. National LGBTI Health Alliance. Sydney, p 5.
Are we so short-sighted now that we can’t see the impact that this toxic discourse is having on the LGBTIQ community? Particularly those that are younger and still trying to figure out how to make their way through an already difficult time. The last thing any of us need is yet more ill-informed people preaching on a topic they know nothing about. How powerful a statement would it be to those who are currently unequal in the eyes of the government, to finally be treated as equal?
Humans are social creatures. Most of us crave love – some of us spend an awful lot of time thinking about love, both in its positive and not-so-positive forms. Marriage is one way that we express our love for another, and when a segment of the population continually get excluded from this, for no good reason other than tradition or religion, it really is no surprise that mental health issues swing wildly towards the LGBTIQ community. I am sick of having to justify my right to equality and I am sick of having to listen to hate and ignorance as an excuse for it. How dare some people think they have a right to vote on who I can choose to spend the rest of my life with! Did I get a vote on their choice?! The world needs so much more love, and yet, too many people are focussed on anything but love.
As tends to happen with these kind of things, important facts are ignored when they don’t suit the argument. When the Marriage Act was changed in 2004 by the then Prime Minister (to the current day definition of marriage being between a man and a woman only), it was simply done by an act of parliament – no plebiscite, no vicious hate campaigns, no fuss. It just happened. Apparently the same course of action to change it back simply cannot be done the same way, for the opponents are crying foul play, and that only a public vote should decide this – not an act of parliament. Trying to have it both ways without reference to facts that are inconvenient to their flaky argument.
In the meantime, I’ll just prepare myself for another round of bemusing (and probably hateful) commentary around why I’m not worthy of equality. I started wearing the “Live Proud” rainbow band on my wrist many years ago as a reminder to myself that I am equal, and I promised myself that I would wear it every day until I am an equal under the law. It appears we still have a very long way to go…
Ignorance in the name of national pride is still ignorance. And it’s ugly. Much in the same way that discrimination in the name of a religion makes no sense, using national pride as an excuse for celebrating Australia Day on January 26 makes no sense. A look into some history (of which every Australian should be aware, but it’s just not spoken of enough) of this issue should show you why:
Interestingly (and something I only recently learned), “the First Fleet, the group of ships which left England to create a penal colony abroad, actually arrived in Botany Bay somewhere between the 18th and 20th of January 1788. However, settlers decided to relocate on the 25th of January in the hopes of finding a more suitable area to construct their colony. They travelled to Sydney Cove and the next morning, on the 26th, Sir Arthur Phillip and a small entourage of marines and officers claimed the land in the name of King George III” (Pearson, L. and Verass, S., 10 Things You Should Know About January 26).
In case you’re thinking this is just another new outrage that the trendy leftists are onto, there have been Indigenous protests of Australia Day dating back to 1938, the 150th anniversary of the British invasion. “We, representing the Aborigines of Australia, assembled in conference at the Australian Hall, Sydney, on the 26th day of January, 1938, this being the 150th Anniversary of the Whiteman’s seizure of our country, hereby make protest against the callous treatment of our people by the whitemen during the past 150 years, and we appeal to the Australian nation of today to make new laws for the education and care of Aborigines, we ask for a new policy which will raise our people to full citizen status and equality within the community”. According to the National Museum of Australia, we even forced some Indigenous men to reenact events of the First Fleet landing at the 150th anniversary in 1938. Yes, at that time, and up until 1967 when a referendum was held to ensure that the First Australians were counted equally as citizens under section 127 of the Constitution, Indigenous communities were not regarded as citizens of the land they had lived on for more than 40,000 years. Incidentally, that referendum was a rare success, with more than 90 per cent of Australians voting ‘yes’ to delete two racially discriminatory references in the Constitution. Further work remains to recognise Indigenous people in the Constitution, with discussions ongoing for the last 20 years.
Even if you’re looking for the tradition argument of celebrating Australia Day on January 26, it has only been consistently celebrated as a national holiday (in all states and territories) since 1994. Yes, only 23 years ago. It would hardly be an issue to find another date for a celebration that’s only been known in its current form for 23 years, especially for celebration of an event that dates much earlier than this.
Allow me to point out some further realities – for those that think the Indigenous community gets everything their way and has an advantage over us non-Indigenous – the Indigenous community, while only being about 3 per cent of overall population, make up 27 per cent of the national prison population. There is around a 10-year difference in life expectancy between Indigenous and non-Indigenous people (do I need to point out whose favour this is in?). The non-Indigenous community has a 12 per cent higher cancer survival rate. Indigenous children aged 0-4 years have a 1.9 times higher mortality rate than non-Indigenous.
In 2008, Australian Bureau of Statistics data showed non-Indigenous adults were more likely to have attained at least Year 10 or basic vocational qualifications (92 per cent) than Aboriginal and Torres Strait Islander adults (71 per cent), and were over four times as likely to have attained a Bachelor degree or higher (24 per cent compared with 5 per cent). What can education lead to? While it’s no guarantee of a self-sufficient life, it’s certainly a promising start. In fact, this ABS data shows that “while nationally, Indigenous adults are around half as likely to be in full-time employment as non-Indigenous adults, as educational attainment increases, the difference between the employment outcomes reduces”. Education levels also appear to impact the level of drinking habits with lower rates of acute risky/high risk alcohol consumption (binge drinking) being associated with higher rates of educational attainment (interestingly, the opposite is true for non-Indigenous people). And, education levels are also crucial in relation to housing status – nationally, Indigenous adults were over five times as likely to be living in an over-crowded dwelling as non-Indigenous adults, and less than half as likely to be living in an owned home (with or without a mortgage). At higher levels of educational attainment, these differences reduced. For example, Indigenous and non-Indigenous adults with a Bachelor degree were nearly equally as likely to be living in an owned home.
For those that think the Indigenous people needed our intervention, they seemed to exist successfully for 40,000 years before the British arrived (one of the world’s longest surviving cultures, if not the longest). It was only with our arrival (and the subsequent taking of their land and way of life) did they start to face the undeniable social issues they now face.
January 1: in 1901, the day six British self-governing colonies united to form the Commonwealth of Australia. In my opinion, not ideal as a new date.
February 13: in 2008, then-current Prime Minister of Australia, Kevin Rudd formally apologised to the Indigenous people who were forcibly removed as children from their homes and parents’ care and placed in Church missions or adoptive white family.
April 11: the day in 1973 that the “White Australia” immigration policy was abolished by the Gough Whitlam government.
May 27: the day in 1967 when the referendum asking whether Aboriginal people should be given the right to make laws and be accounted for under the Constitution occurred. The country voted with a resounding 90.77 per cent in favour of the changes. Until then, Aboriginal people were denied several rights, including the right to vote or to be counted within the human census. They were accounted for within the animal population until then.
June 3: Mabo Day. This perhaps has the strongest appeal as the alternative date. On 3 June 1992, the High Court of Australia ruled in favour of Eddie Mabo’s case which overturned the legal stance of “terra nullius” (a Latin term meaning “nobody’s land”) and acknowledged native Indigenous land rights. Though the day is already marked as a national holiday, it may fit better as a public holiday.
While the majority will still be celebrating Australia Day on January 26, I hope that we can at least advance the understanding of this issue without ignorance. I was recently told that we’re being over-sensitive about this and that it’s just another thing we all get too easily offended by. Of course, this is easy for us non-Indigenous people to say – we would hardly know or understand what the Indigenous community feels on this day – I’m not even going to suggest that I have the slightest understanding of what they go through when they see a nation celebrate on this day, but I’m prepared to educate myself on why they feel this way and then decide accordingly to join them in the call for change. Not as an offended citizen, but as one who seeks true unity and peace. That’s what this is about – bringing us all together in an all-too-divided world with educated and empathetic minds. I might be asking for too much, but if you don’t ask, you’ll never be answered.
Note: I have intentionally attempted to not use the term “Indigenous Australians” as I am aware that some of the Indigenous community do not use “Australia” to identify with, given that this is the name given to the land that they already lived on.
My Nonno Michele, or “Mick” as his Australian friends called him. Yes, that’s me on the right looking pretty excited to get into that cake (clearly the sugar obsession started at a young age), and yes, my Mum loved indoor plants and making big cakes.
Today would have been my Nonno’s 90th birthday. He wasn’t a perfect man – none of us are. He was a selfless man and he’s the reason I’m here today. He’s also the reason many Italian migrants to northern suburbs Melbourne found their way in their distant new home.
Post-World War II Italy was not a prosperous place. Particularly in southern Italy, opportunity did not appear to be on the horizon. In much the same manner that I imagine current day asylum seekers make the impossibly tough decision to leave the relative surety of their homeland, my Nonno Michele Pizzichetta made that impossibly tough decision to get on a boat headed for a little-known country on the opposite side of the world. He left a small town, San Severo, in the Puglia region, for a 2-month boat trip. He did this on his own, leaving behind his wife and two very young children (my Mother being one of them). He arrived in Melbourne, Australia on 26 November 1952. Imagine that for a moment – a 25-year-old man, leaving behind his young family, to see if a better life existed in a mystery land so far away it took nearly two months to get there. It’s so difficult to comprehend as it’s so far away from the world in which I find myself in – a world that was made possible by his selfless move in 1952.
In his own words (intentionally left in his broken English), from an interview with the City of Whittlesea in 2001:
“I was in the army and I was look for the go out of Italy because in Italy not many jobs and I want to make some future to my family. Matter of fact I did my ideas come to, I did I come to Australia I like, I been a like it first since I come here. Another thing too I remember very well when I buy this block of land in Thomastown in the Poplar Street, corner Poplar Street and Boronia Street when I buy that I was a feel to be really own something in Australia in Thomastown and then I bring my wife and the children and look forward to build the house, I did build the house through the Building Society and I been paying the bank 1971. I work very hard because I used to work Saturday and Sunday one hour every change they do work and I saved a bit of money to pay the house off. When I pay the house off I went and see my Mother that’s after 18 years I been in Australia I went and seen my Mother because my Father died two years after I been in Australia, the first time I come. After I went seen my Mother I left money for the house I leave my wife money for food and children and went and seen my Mother. I take the time off from the job a bit of a holiday and went and seen my Mother. I stay in Italy the first time nine weeks it is a part of my holiday I been keeping that holiday for a few years they grow. Then when I come back I see everything the right way. I was worried my Mother not was well because was very old. Three years after my Mother died and I was happy I been to see. I been carry on some things you know I come back to Australia and work again and that’s my life I keep a go like that”.
It would be two long years before my Nonna, Mother and Uncle could make the journey to Melbourne to join him. He spent those two years doing whatever work he could to get by, while also buying a block of land with a bungalow in the developing northern suburbs of Melbourne and eventually building a house on it for the family to live in. They arrived on 11 November 1954. He learned enough English to get by from attending night school and from his various jobs – making materials for suits, and utilising the skills he learned in the Italian Army to work in maintenance and the metal trades.
In 1956, he began what would become a lifetime of community action. I am emotional to learn that he even helped raise funds for the construction of the hospital I was born in: “I been really myself live in my own country I was like you know I cared somebody else, some Italian anybody because in my own country I used to do the same you know, help the people how much I cared and that’s what I did here when I be in Australia. In fact, 1956 I was living in Thomastown I been collected some money to build the Preston Hospital, no can do because not enough money, that’s what you call Community Hospital. I been for years you know collecting big money from the trains, Thomastown and also raffle tickets through the Preston Council and sell that ticket in Cup Day and the profit it went to the hospital. I collect a bit of money door to door around Thomastown that time it used to be two shillings”. Sadly, that hospital is no longer there – it’s been turned into apartments. Another hospital was built further north which would become my birthplace’s replacement. My Nonno also played a role in the new Northern Hospital development and was on the Steering Committee that got it built. On this he said: “I be very happy I did that because I feel I believe that’s why you can help people. I been helping people for the pension for anything they come and ask for me. I used to do this sort of thing in my own country and I now a do here. All my difficulty to me the language that why I be doing a lot more than I doing I still feel happy I did and people all around this area respect me and they do the right thing. I never stop, I still do help them when I can”.
For these numerous selfless acts, my Nonno Michele was awarded the Citizen of the Year. But in his typical benevolent way, he said “I not ask, they give it to me. Yes, I did a lot of things. Many time I try to push the Council at Whittlesea to get road built. Because the children used to go on the school in the winter you have no roads to the children not to the school to go along water and mud. I was feeling very sorry for the children, and I did push the Council that time. I not afraid to knock on the door and ask for the benefit to the people, benefit to the area, benefit I see to this area, no discrimination. I like to see that why because this very good area, you see the people come from different countries I seen never been discrimination for long time. I like to see that way because that’s what should be in every area, every place in Australia”. Wise words from a man lacking a formal education but absolutely not lacking compassion. Although these words were spoken in 2001, they could not be more relevant to the society we find ourselves in now, 16 years later.
He was also actively involved in social groups and events. A member of one of the very few Italian/Australian clubs at the time (meeting in Lygon Street, Carlton, which is still the main Italian area of Melbourne). “I was the Treasurer. You see, around this area, I build two pensioner clubs, the Bocci (an Italian lawn bowls game) club. 22 years ago, City of Whittlesea give a piece of land to make the Bocci club they give all the land and the fence around it – it still there. Us build the row for playing Bocci and it built 22 years ago and now I look after the welfare, Italian welfare in Whittlesea, I look after, I am the President. Before that I build Eastern Thomastown Bocci. Before this, I build the others and the Councillors helped me a lot for build all these citizen clubs in Thomastown. They said 12 years ago start Italian Women Groups. Why I started that Women Groups because I see the woman by themselves. They have nowhere to go, nobody to talk to and my idea, I got the Pensioner Club, I got the Bocci Club, now I gonna start something for the woman, that’s what I did. When I started there were five to six women now there be 200-300, maybe more. They have good fun, they play together, the Bingo, have a talk, have a dance. Many times I go there myself and you have a good time, food together, very good. I like it because I see I do something good for them and now there are too many people there and the place where they are not big enough – I tell them I gonna ask Council to build a bigger place for you”.
My Nonno Michele was the one other migrants to the area would go see when they needed help. He was referred to as the “Welfare Italian” and he said “the Council give me one place where I can meet the people with the problem every Friday from 10 o’clock in the morning to 4 o’clock in the afternoon. And they are very good and happy for that and the fact that people come there for ask for help, they come to pass the time too, play cards, or have lunch together, or some bit of music and play Bingo like that for the Italians. No obligation – the only fee for one year $3 for membership and that’s very good because I want to keep as low as possible, because all that come there are pensioners and the ladies and not rich people, that’s a working class people. Sorry I say that, because in this area they are all a working class, because I remember the rich people never come to this area because the rich people go to Toorak or South Yarra, but here all the friends all working, all get on well together”.
His community action also extended to political activism – he was a member of FILEF, or the Federazione Italiana Lavoratori Emigrati e Famiglie (Italian Federation of Migrant Workers and Their Families), a group that existed from the 1970s in Melbourne. It is said that “not only has FILEF been the launching pad for the professional careers of some of its members, but at a smaller scale it forged the political consciousness of rank-and-file activists and ordinary members who through their activism or presence in FILEF were able to retain, express and foster their political culture, whether communist, Labor or broadly left-wing” (pg xiii, http://www.academia.edu/11331631/Immigrants_turned_Activists_Italians_in_1970s_Melbourne). He is pictured below at some of their meetings (pictures courtesy of the article linked above).
Even my Nonna (Pina Pizzichetta, 2nd from the left below) got involved in the political action, pictured here at a PCI meeting, which was the Partito Comunista Italiano (Italian Communist Party), later renamed the Partito Democratico della Sinistra (Democratic Party of the Left) in 1991 and Democratici di Sinistra (Democrats of the Left) in 1998.
When asked what Italian people hope for, he replied “Italian people not only here but everywhere, they are very good for the family. They look after family and in fact the ladies, the Italian ladies, the grandmother, always look after the grandchildren, they do everything for them, cooking, buy them some suit, shoes or some socks, they grow the grandchildren more than they grow their own children”.
It’s really no wonder that I continue to develop a strong desire to be socially minded and to be actively involved with social programs that assist those less fortunate than myself. I have it in my blood, and I owe it to both of my grandparents who fought for equality and access to basic rights for all, regardless of position or background. They did this with very little wealth of their own, but did it anyway. I’m so incredibly sad that I did not know this story when my grandparents were still here, but maybe I was too young to understand it anyway. So many things I need to say thanks for, but I know that the best way I can say thanks is to continue their legacy. Happy 90th birthday Nonno, I miss you so much (and you too Nonna). I hope I can make you proud one day as I try to contribute to the world around me, much in the way you did.
Words Not Numbers 