Issues – Words Not Numbers

What’s the T? An exploration into gender dysphoria and why it matters

Posted on May 14, 2019 by Steve Inguanti

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).

Trans Flag — 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):

https://www.rch.org.au/uploadedFiles/Main/Content/adolescent-medicine/australian-standards-of-care-and-treatment-guidelines-for-trans-and-gender-diverse-children-and-adolescents.pdf

(endorsed by ANZPATH, the Australian and New Zealand Professional Association for Transgender Health)

Gender Dysphoria Clinic – Melbourne

https://www.glhv.org.au/sites/default/files/gender_dysphoria_clinic.pdf

Minus18 – youth-driven support organisation, also provides training on supporting trans and gender diverse clients

https://www.minus18.org.au/index.php/workshops/adult-professional-training

In terms of hormone therapy medications available, NPS MedicineWise has a resource:

https://www.nps.org.au/australian-prescriber/articles/prescribing-for-transgender-patients

Educational resources:

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

https://www.anzpath.org/education

LGBTI National Health Alliance – includes many links to other LGBTIQ+ organisations

https://lgbtihealth.org.au/

https://lgbtihealth.org.au/trainingpackages/

Transgender Victoria

https://transgendervictoria.com/information/for-clinicians

Shine SA – Gender Wellbeing Service

https://www.shinesa.org.au/community-information/sexual-gender-diversity/gender-wellbeing/

Government resources:

Victorian Government – School policy on gender identity

https://www.education.vic.gov.au/school/principals/spag/health/Pages/genderidentity.aspx

South Australian Government, Dept of Education – Supporting students, Gender diversity and transgender (very detailed, includes health-related support info)

https://www.education.sa.gov.au/supporting-students/health-e-safety-and-wellbeing/health-support-planning/managing-health-education-and-care/neurodiversity/gender-diversity-and-transgender

Victorian Government, Dept of Health – report on Transgender and gender diverse health and wellbeing (2014)

https://www2.health.vic.gov.au/Api/downloadmedia/%7B3165C620-0649-4EA1-BBA1-4CA4CEF4F58A%7D

Services & Support:

National – Headspace – https://headspace.org.au/

Switchboard – http://www.switchboard.org.au/

Q-Life – https://qlife.org.au/

Support services:

A Gender Agenda – https://genderrights.org.au/

The Gender Centre – https://gendercentre.org.au/

Transhealth Australia – http://www.transhealthaustralia.org/

VIC Services:

The Royal Childrens’ Hospital Gender Service – https://www.rch.org.au/adolescent-medicine/gender-service/

Monash Health Gender Clinic – http://monashhealth.org/services/services-f-n/gender-clinic/

Support:

Transgender Victoria – https://transgendervictoria.com/

Seahorse Victoria – http://seahorsevic.com.au/main/

ButchFemmeTrans Melbourne – https://www.facebook.com/butchfemmetrans/

Rainbow Network Victoria – http://www.rainbownetwork.com.au/

PFLAG – http://pflagaustralia.org.au/about

References

Atkinson, S. R., & Russell, D. (2015). Gender dysphoria. Australian Family Physician, 44(11), 792-796. Retrieved from https://www.racgp.org.au/afp/2015/november/gender-dysphoria/

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

Brady, M., & Molloy, L. (2018). Mental health nursing for transgender people: Are we caring? (2018). Mental Health Practice (2014+), 21(05), 28-33. doi: http://dx.doi.org.ezproxy.lib.rmit.edu.au/10.7748/mhp.2018.e1223

Buzwell, S. (2018). Gender dysphoria. O&G Magazine: LGBTQIA, 20(4). Retrieved from https://www.ogmagazine.org.au/20/4-20/gender-dysphoria/

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

Wilson, D. (2019). Inclusive healthcare for members of the sexual and gender diverse community. Australian Nursing and Midwifery Journal, 26(5), 34. Retrieved from https://search-proquest-com.ezproxy.lib.rmit.edu.au/docview/2161599276?accountid=13552

World Health Organisation. (2018). ICD-11: Classifying disease to map the way we live and die. Retrieved from https://www.who.int/health-topics/international-classification-of-diseases

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

A Revolving Door

Posted on December 11, 2018 by Steve Inguanti

Sometimes, expectation and optimism does not match reality. That’s no reason to be pessimistic – just another opportunity to expand your viewpoint on previously held beliefs. This is how I have approached my third clinical placement, which is in a mental health facility in the suburbs of Melbourne. It is an area of nursing that holds great interest for me, hence my optimism. Halfway through this placement, the reality has been somewhat different to my expectation.

I have had to accept that, like with physical illness, not everyone recovers from mental illness. A myriad of factors may explain this – amotivated feelings about their condition (no desire to seek or engage in help), lack of participation in therapy, medication complications (this is its own set of issues, especially in relation to dependence), lack of access to programs or activities that can assist recovery, lack of a support network from family or friends, and medical personnel that are disengaged or victims of the health system, just to name a few.

What has surprised me at this early stage is the number of return patients. The overwhelming majority of patients are known to staff and are on their third, fourth, or even fifth admission. The facility does not accept high-risk patients, so I can only imagine how much worse this scenario is for facilities that do. Some patients only stay for a few weeks; others have been here close to three months. Some patients are being monitored for medication changes, while some patients are admitted for treatment that requires extended monitoring.

One of these treatment options is Transcranial Magnetic Stimulation, or TMS. I was fortunate enough to accompany a patient during one of their TMS sessions, which afforded me a fascinating insight. This patient is currently going through their third round of TMS treatment, and each round has consisted of 30 sessions. The session I attended was their 24^th of this third round. The patient does not feel that the TMS is making a difference to their outlook or thought processes, but they do not want to try the alternative treatment (Electroconvulsive Therapy, or ECT, which induces seizures to alter brain activity) because of the sometimes severe side effects of memory loss.

In contrast, TMS reportedly has little to no side effects and is not invasive. It involves using magnetic fields to activate specific areas of the brain – generally the pre-frontal cortex, which is the area of the brain that among other things, is associated with how we see ourselves (self-consciousness) and self-related mental processes. As depression can alter these thoughts and behaviours, TMS has been shown to improve self-perception in depressed patients by progressively altering brain activity in this area with repeated treatments. No anaesthesia is required (in contrast to ECT) and a patient can resume their usual daily routine once treatment has completed for the day, and some patients can even have two treatments in one day (one session takes around 40 minutes, depending on the severity of the patient’s depressive state). TMS is not a first-line course of treatment – it is generally prescribed when a patient continues to show depressive symptoms after at least one anti-depressant medication has been attempted. Interestingly, it is not currently covered by Medicare in Australia as further research on its long-term effectiveness is still ongoing. This results in an access issue, as it requires private health insurance and an inpatient admission or self-funding.

But how effective is this treatment when numerous patients are seemingly coming back for repeated rounds of therapy? Or is it more of a case of these patients not fully understanding their triggers and therefore relapsing? It could also be medication compliance or potentially new triggers. There is no obvious or simple answer, as we are not obvious or simple beings. Our brain exerts more control over us than we may ever give it credit for (side note: I recommend Afflicted, a truly fascinating series currently on Netflix to see some real examples of this). In this case, this patient is having their third round of treatment, reports that they do not see any improvement, yet, this patient is quite engaging, warm and reactive to conversation. They have a supportive family network and cannot specify any possible triggers for their continued admissions other than the feeling of hopelessness and helplessness that engulfs them. Consequently, they continue their treatment in the hope that it may eventually have an effect.

This is another important factor to highlight: it will not necessarily make sense that someone is suffering a mental illness. I was involved in a new patient admission recently – this patient has suffered depression for nine years (from the age of 12), an eating disorder for six years and has attempted suicide twice this year. They have no history of trauma or abuse, no family history of mental illness, no obvious triggers or explanations for why they feel the way they do. There is evidence of alcohol abuse, but not drugs. They have a good social network and a job. Prescribed medications have not had an effect and something just isn’t right, so they want to give ECT a chance to help them. This patient is warm, engaging and not visually distressed. They were studying at university until it became too difficult to manage with their illness. I can only hope that we can help them and not have them become one of the “frequent flyers”.

Naturally, I wonder why patients are returning at the rate that they are. It is clear from speaking with the staff at this facility that the system is letting some patients down. Medications are prescribed and dispensed, mental states are constantly assessed, as are current risk statuses. What might be a confronting question is asked – have you had any suicidal ideation recently, and if so, how do you plan to go through with it? Self-harm is also assessed and is more common than I thought it would be – one patient explained that they self-harm just so they can feel something. Sadly, some patients self-harm so they can be admitted, otherwise they might be turned away for a lack of available beds. There are clear cases of dependence to medications and these are managed as much as possible, but some of the return rate of patients might just sit at the hands of the patients themselves.

Patients need to understand the role they play in their own recovery. As someone who has suffered mental illness, I experienced two critical aspects: I was going nowhere until I acknowledged my illness; the next important step was to seek help and want to work at feeling better about myself and my life, instead of feeling embarrassed and ashamed of my predicament as I initially did. This is by no means an easy or simple step – this is the most difficult thing to do. To acknowledge and accept you are struggling is tough; to seek help and open up to someone that you are struggling and need help is even tougher.

The logical thought would be that the patients in a mental health facility have accepted these two aspects about themselves. Why then are they mostly returning for repeated admissions? Are they returning to past negative behaviours or thoughts? Are they disengaged with their treatment plans (not attending therapy groups or possibly non-compliant with medication)? I believe there is no obvious or logical answer – our complex brain can lead to many variations to mood, behaviour, thought, cognition, desire, as well as many other factors. This is where the nurse must be the patient’s advocate – each patient will bring their unique set of idiosyncrasies and one care plan that has succeeded with one patient might not work with another, just as one type of medication may assist one patient but not another. It is the system that lets patients down when it is assumed one treatment option is a best-fit for all, or indeed, that all patients will fully recover from their illness. It might just mean taking that little bit of extra time to sit down and talk, to listen and to care. Rapport and trust between the patient and the nurse is vital, as is the patient’s want to recover, or at least manage their condition.

This should extend to your network of family and friends – you do not have to wait until you can see an obvious sign of a friend or loved one struggling. Take that little bit of extra time to have a genuine conversation and know that some people are doing it tough, no matter the façade they put up. Try not to judge those who have the courage to admit that they are struggling and instead find ways to understand their struggle and offer ways out of it. There is no telling when or if someone will suffer from a mental illness, but showing that person that they are not alone and that someone cares about them will make the world of difference to them – and you don’t have to be a nurse to do that.

An Extra Serve of Chips

Posted on August 28, 2018 by Steve Inguanti

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.

The Problem with Gambling

Posted on July 3, 2018 by Steve Inguanti

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

spiraling-roulette — 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-web-image — 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.

References

American Psychiatric Association. (2018). What is gambling disorder? Retrieved from https://www.psychiatry.org/patients-families/gambling-disorder/what-is-gambling- disorder

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

Sharman, V. (2014). Against all odds. Mental Health Practice, 17(7), 11. Doi: http://dx.doi.org.ezproxy.lib.rmit.edu.au/10.7748/mhp2014.04.17.7.11.s14

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

Thomas, S. (2014). Problem gambling. Australian Family Physician, 43(6), 362-4. Retrieved from https://search-proquest-com.ezproxy.lib.rmit.edu.au/docview/1539266785?accountid=13552

Victorian Responsible Gambling Foundation. (2014). Comorbid problem gambling in substance users seeking treatment. Retrieved from https://responsiblegambling.vic.gov.au/documents/79/Research-report-comorbid-problem-gambling-in-substance-users-seeking-treatment.pdf

Victorian Responsible Gambling Foundation. (2018). Gambling advertising. Retrieved from https://responsiblegambling.vic.gov.au/resources/gambling-victoria/gambling-advertising/

Victorian Responsible Gambling Foundation. (2018). How gambling works. Retrieved from https://responsiblegambling.vic.gov.au/getting-help/understanding-gambling/how- gambling-works

Victorian Responsible Gambling Foundation. (2018). Latest edition of the Australian gambling statistics. Retrieved from https://responsiblegambling.vic.gov.au/about-us/news-and-media/latest-edition-australian-gambling-statistics/

Vale Dolores O’Riordan

Posted on January 17, 2018 by Steve Inguanti

The soundtrack of my teens…

It seems this is a common reaction to news of the premature passing of Dolores O’Riordan, lead singer of Irish band The Cranberries. Dolores was only 46-years-old and is survived by her ex-husband and three children. Not to mention the legacy of her stunning voice and poignant lyrics.

This reaction mimics mine completely. The Cranberries came into my life at a time when things were very confusing and often troubling – my teens. Trying to figure myself out and my place in the world (an ongoing battle).

When I first heard Dolores’ distinctive vocals, it instantly got my attention. I wanted to hear more. My first taste of what was to come was the track Dreams, released in 1993 from their debut album Everybody Else Is Doing It, So Why Can’t We? Melodic rock, matched perfectly with warbling and haunting vocals. Without the benefit of online streaming in those days, it meant heading to the music store to seek out more. I found their album and did something I didn’t do all that often in those days – I bought the album instead of just the single. Something told me this was different. It sure was – all 12 tracks on the album did what only truly great music does – it took me on a journey of emotions through very relatable experiences, even at the tender age of 14 at the time. The Cranberries‘ music absolutely moved me, as cliched as that might sound.

The follow-up album, No Need To Argue, released one year later in 1994, took this so much further. 14 songs that truly helped me through some very emotional times, both then, and even to this very day. It wasn’t uncommon for me to choke back tears while listening to No Need To Argue and I also find myself doing the same today as I give these albums another spin. Partly for the sadness of losing a gifted musician far too soon, but also partly a reminder of everything this music helped me with. Truly the soundtrack of my teens and a constant refuge in other times of need since.

In memoriam, I thought I would compile a list of The Cranberries tracks that had the most impact on me:

#20 Twenty One (No Need To Argue, 1994) – a soothing, soulful track that ends with Dolores’ signature vocals. Always a favourite to sing along to when no one was around.

#19 Not Sorry (Everybody Else Is Doing It, So Why Can’t We?, 1993) – an exercise in defiance, something that has always been a personal struggle. Not apologising for walking away from a deceitful person is something we could all benefit from.

#18 Still Can’t… (Everybody Else Is Doing It, So Why Can’t We?, 1993) – an upbeat track that hides a more sinister narrative. “Still can’t recognise the way I feel, nothing you said to me was real”. Sadly an occurrence that still happens.

#17 When You’re Gone (To The Faithful Departed, 1996) – naturally, a death-themed album was never going to be easy listening. While this album did not hold up to the incredibly lofty expectations set from the first two, some tracks still had profound effects, such as this one. “I’ll miss you when you’re gone, and it’s time to carry on”. An appropriate song to remember those that have left us.

#16 Ode To My Family (No Need To Argue, 1994) – the opening track of the album that packed a vocal punch. I never could quite understand if this was a tribute to family, or the opposite. “Do you see me? Does anyone care?” contrasted with “My mother, my mother, she’d hold me, when I was out there”. Probably a very accurate reflection of family issues while growing up and trying to find your place.

#15 I Will Always (Everybody Else Is Doing It, So Why Can’t We?, 1993) – another soothing, soulful track that tells of devotion and letting go. “I will always go beside you”.

#14 Zombie (No Need To Argue, 1994) – I’m possibly being really unfair putting this here. Zombie was the song that put The Cranberries on the global scale and contains incredibly poignant, and sadly still too real lyrics. Music has long been used to voice opposition, political or otherwise. This is no exception and while I thoroughly love this song, all the songs below had more of an impact on me, but I do wonder if the message of this song will still be so relevant in another 24 years?

#13 Put Me Down (Everybody Else Is Doing It, So Why Can’t We?, 1993) – as someone that has always struggled with compliments and confidence, this song was so raw. A haunting chorus complementing relatable lyrics. A very powerful way to end an album.

#12 I Can’t Be With You (No Need To Argue, 1994) – “It’s bad and it’s sad, because I can’t be with you”. For all of the crushes and ones that got away, intentional or not, this continues to resonate.

#11 Pretty (Everybody Else Is Doing It, So Why Can’t We?, 1993) – how two minutes and 16 seconds of music can sum up so many emotions. “You’re so pretty the way you are, and you have no reason to be so insolent to me”.

#10 Salvation (To The Faithful Departed, 1996) – probably one of The Cranberries‘ most “upbeat” songs, although it details the ongoing scourge of drug addiction. “To all the kids with heroin lines, don’t do it, it’s not what it seems”. From an album about death, it has always been a standout.

#9 The Icicle Melts (No Need To Argue, 1994) – hidden in the middle of the album is this stunning example of Dolores’ powerful vocals, mixed with tragically relevant lyrics of conflict and war. “There’s a place for the baby that died, and there’s a time for the mother who cried. She will hold him in her arms sometime, cos nine months is too long…”

#8 Linger (Everybody Else Is Doing It, So Why Can’t We?, 1993) – strings beautifully composed in the background with lyrics to match: “I’m in so deep. You know I’m such a fool for you. You got me wrapped around your finger, do you have to let it linger?” I can’t say the number of times I’ve leaned on this one.

#7 How (Everybody Else Is Doing It, So Why Can’t We?, 1993) – Dolores’ distinctive warble is all over this one, as is the usual meaningful words: “How? You said you’d never leave me alone”. Plenty of great bass guitar in this track just rounds out its edginess.

#6 Dreaming My Dreams (No Need To Argue, 1994) – an acoustic masterwork that has brought tears to my eyes countless times, including today as I listen with a heavy heart. “I’ll be dreaming my dreams with you. And there is no other place, that I’d lay down my face, I’ll be dreaming my dreams with you” – a lyric I’ve always wanted to sing to someone one day.

#5 Empty (No Need To Argue, 1994) – another masterwork accompanied by an utterly moving piano and string melody. This track always seemed to annoy my dad the most, where he’d always threaten to snap the CD if I didn’t turn it off (thankfully can’t do that with online streaming these days). I think this is possibly the best example of the power of Dolores’ voice, and as polarising as it may be, this song surely left me feeling empty after every listen. “My identity, has it been taken? Is my heart breaking? On me, oh my plans, fell through my hands. On me, all my dreams, it suddenly seems…empty”.

#4 No Need To Argue (No Need To Argue, 1994) – the title track and deservedly so. A resounding organ introduces the song, and continues throughout. “I knew, I’d lose you. You’ll always be, special to me. And I remember all the things we once shared, watching TV movies on the living room arm chair. But they say it’ll work out fine, was it all a waste of time? Cos I knew, I knew, I’d lose you. You’ll always be, special to me”. Indeed, a very special song.

#3 Ridiculous Thoughts (No Need To Argue, 1994) – “you’re going to have to hold on! Hold on! Hold on to me!” The bellowing brings further power to the line “I cried so hard, the ridiculous thoughts, oh”. Nothing like a constantly anxious mind to over-analyse every situation, over and over again to wear you out. This track seems to embody that perfectly.

#2 Daffodil Lament (No Need To Argue, 1994) – possibly a favourite for most fans of The Cranberries, and with every possible reason. It’s one of those rare, six-minute epic journeys that so few songs manage to transcend. It’s almost three songs in one – we start with a melodic relaxation, then Dolores kicks into overdrive with solid and dramatic music – “I can’t sleep, HERE!” It returns to a quiet intermission, flips into a more positive note – “…and the daffodils look lovely today, look lovely, look lovely”. And then one last haunting chant to round it out, complete with Dolores’ distinctive tones.

#1 Dreams (Everybody Else Is Doing It, So Why Can’t We?, 1993) – the song that started it all for me, and continues to be my standout. “Oh, my life, is changing every day. In every possible way. Oh, my dreams, it’s never quite as it seems. I know I’ve felt like this before, but now I’m feeling it even more, because it came from you”. Love, letting love in, being able to accept yourself, following dreams – it’s all in here and I knew from the first listen this would be a song I’d listen to for years. 25 years on, it still reminds me to dream my dreams and make them a reality. “You’re a dream to me”.

While speculation is unfortunately focussing on Dolores’ mental health battle over the last four or so years, the current information from London police is that nothing suspicious was found and the case has been referred to the coroner to determine the cause of death. I won’t add to the speculation, but I can only pass on my sincerest condolences to all of Dolores’ nearest and dearest. To Dolores herself, I can only feel eternally thankful to have had the privilege to listen to her music and know that it will live on with me, and millions of others, for a long time to come.

Vale Dolores O’Riordan. The daffodils don’t look so lovely today…

9334462-3x2-700x467 — Dolores O’Riordan (AP: Bruno Bebert, file)

An unequal, still

Posted on August 7, 2017August 8, 2017 by Steve Inguanti

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…

In the Wrong Place

Posted on July 15, 2017July 16, 2017 by Steve Inguanti

As I grow older, one thing is becoming more clear – I need to travel. The benefits of travel are too numerous to mention, but the happiness I feel while abroad is unmatched in my current home life. That might sound really obvious – something that isn’t routine is more enjoyable than something that is. But there’s more to it than that.

Travel has allowed me to grow as a person. I’ve had to fend for myself in unfamiliar situations, sometimes in foreign languages. I’ve met wonderful people by chance and had very memorable experiences listening to their stories. There’s been the odd scare or two as well, but that is part of the journey and it’s also something that my own city provides every now and then too.

There is one thing that my recent travel has shown me though – that I am in the wrong place. There has been an uneasy feeling over me for some years and my time in Canada has highlighted this further. I don’t feel I belong in Melbourne anymore, and if I’m brutally honest with myself, I’ve probably been feeling this for at least the last six years. Not previously having the courage to act on it meant that I festered away and went through the motions. Something inside me is not allowing this to happen anymore, and so I went exploring.

Canada has always been a country of interest for me. I was offered an exchange when I was 20 to do one semester of university at McGill in Montréal. I didn’t take it, as I didn’t want to leave my Mum here on her own (she was going through some rough times, and my brother was also away travelling). Oh how I would do things differently now! Maybe it’s missed moments like these that fuel my desires to explore and not think of the reasons why I can’t do something. It’s more about why would I not do it?

So it comes as no surprise to me that my last two trips to Canada (luckily for me, these two trips have been in the last eight months) have had a profound effect. My time there has been overwhelmingly positive – stunning landscapes and cities, genuinely friendly people, a relaxed but proud attitude, a strong belief in diversity and acceptance – these are among the reasons that I feel I am in the wrong place.

Credit: Zack Singer. Stunning sunset at Wreck Beach, Vancouver, BC, Canada. July 2017

It’s also why it was so difficult to leave Canada on both of these occasions. As my first time in Canada was ending, I cried uncontrollably as I approached the airport. I tried to wipe away my tears before they were visible, but the sadness washing over me could not be contained. I was genuinely upset that I had to leave and make the long trek back “home”. I did not know when I would be able to return, and the prospect of returning to my lonely existence back in Melbourne was something I was not ready for. There were other issues at play at this time, only serving to compound my sadness about having to leave. These inevitably made the transition back to routine a very difficult one – in fact, the few months after returning to Melbourne have been the most challenging of my life thus far. I was lost and feeling hopeless about all of the major aspects of my life, so it should not come as a surprise that I found myself at the dreaded door of depression and anxiety. I would not wish these few months of my life on anyone – there are few feelings worse than feeling like there is no hope. Every day. Every night. It all becomes too hard and it is so much better to hide away, rather than risk someone you know or love seeing you like this. Then the worst part happens – all this alone time compounds all of the negativity. The voices in your head take over every moment, always reminding you of the failures and never letting up. Sleep becomes more difficult each night – the mind does not rest, forcing the body into this same restlessness. A tired mind only conjures further negative thought, adding more turbulence to an already bumpy ride. All of this makes it even more difficult to see a way out. To ask for help, or to feel comfortable enough to open up to someone seems far too risky. What will they think? Will they laugh at me and tell me to suck it up? Will they not even care? Will they use this information to their advantage somehow? All irrational thoughts find their way to become rational when your mind is so clouded by overwhelming hopelessness.

I got lucky. A few friends noticed my changed demeanour and offered their support. I cannot underestimate the importance of being present for someone suffering through their own mental demons. For me, being able to talk about it without fear of ridicule made an enormous difference. I also sought professional help – something not everyone is either able to do, or feel comfortable to do. But I knew I needed help to get through this. It had become too big for me to handle on my own. Each time I would start to rise back up, the slightest setback would send me straight back to bed. There were days when I just could not face the prospect of getting up. I knew I was bad company, so what was the point in going outside and participating in the world around me? Spontaneous bursts of tears further added to the risk of going outside – what if I just started bawling at the supermarket checkout? I could not risk it, so I stayed indoors most days.

Then, I got lucky again. The opportunity to study in a field that I’ve long admired presented itself and after speaking with some friends, I took this opportunity. I had something to be hopeful for, something to show me that I had a purpose. All did not feel lost now. It may have been a distraction to everything else, but it felt like things were changing. I wasn’t feeling sad all the time anymore. There were still ups and downs, but the ups seemed to be outweighing the downs now. Having a sense of purpose again was a fundamental shift in attitude and it was helping me recover.

Vieux Montreal (Old Montreal) – 375 years old this year. Montreal, Quebec, Canada, June 2017

The opportunity to travel back to Canada appeared and I seized it. It would be my reward of sorts for making it through my first challenging semester of nursing. And what a reward it was – my second visit to this beautiful country could not have been a more positive experience. Each city I visited had compelling reasons for me to stay, helped by the fact that I now have friends in these cities. But this has also led to the inevitable fall that I am currently feeling. I have been back “home” for three days and I am feeling more alone than ever. I was again very sad to leave Canada (no uncontrollable tears this time, but I got close while sitting at the airport) – partly because I am unsure when I will be able to go back for another visit, but more so, because I feel like I need to be there. I felt so happy, comfortable and so welcome in Canada, and I do not feel that here in Melbourne. It’s hard to explain the exact reasons, but it feels like I’m in the wrong place. And that is a strange feeling, especially when the prospect of being able to leave is years away. I am too old to move on a working holiday visa, and studying abroad is too cost-prohibitive, so my only option appears to be completing my studies in Melbourne and relocating with my new qualification. That is a three-year prospect. I don’t want to wish time away, but three years seems a long time to live somewhere when you don’t feel you belong. I know I need to find a way to make this work, but those voices of hopelessness are starting to nudge their way back in.

The Inukshak at another golden sunset, Vancouver, July 2017

I write this both as a coping mechanism and as a call out – life is feeling complicated and challenging again and I need to find a way to rise above it. For three years. If any of this is resonating with you, I hope these words can give you the strength to speak up, but more importantly, know that you are not alone. You might feel alone, like I do at times, but there are many others fighting these same battles. Some have been fighting them for a very long time, others are relatively new to the fight, but the more we talk about these issues, the more we can support each other through them. We are social beings and we are so much stronger when we are together. We are also better when we know we are valued, when we are seen, when we are heard. When we are relevant. When we are loved.

Change The Date

Posted on January 25, 2017 by Steve Inguanti

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.

1988-aboriginal-protests — Aboriginal protests on Sydney Harbour on Australia Day celebrations, 1988 (courtesy: 10 Things You Should Know About Australia Day)

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.

So, what are the alternative dates we should use? There’s plenty to choose from and the debate should now focus on these (Sivasubramanian, S., Eight Alternative Days to Celebrate Australia Day That Are Not January 26):

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.

Why Going Vegetarian Isn’t Just About Animals – It’s About the Planet

Posted on December 28, 2016 by Steve Inguanti

From the day I visited a dairy farm in Year 8, I felt uneasy about eating meat. This day, I discovered what veal was and promptly decided that it wasn’t for me – it didn’t seem fair to me that a young calf barely got the chance to live a few weeks before ending up on a plate for us. This annoyed my Mum a little as she liked to cook with veal sometimes, but as I’d always been a fussy eater, this was just another hurdle for her to deal with.

I admit to the contradiction here of only eliminating veal – there is no difference to lamb, and chickens hardly get a chance to enjoy themselves either. But it wasn’t presented to me the way veal was – I didn’t see it at a farm, so it wasn’t real. I blissfully went about eating lamb and chicken through those years, but still to this day, have not knowingly eaten a single piece of veal since that farm visit.

I tried to go vegetarian some years ago and struggled through two arduous weeks before succumbing to a dodgy chicken roll from a fast-food chain. What an inglorious ending! I clearly wasn’t ready for it at that time and reconciled the theory that we needed the protein from meat to get adequate nutrition to avoid the guilt I felt about cutting out veal, but no other forms of meat.

Things started to click when I happened to stumble on a conference on food sustainability in late 2015 (Festival 21 – learn more at http://festival21.com.au/ if you’re interested). I sat there listening to various speakers all detailing the pressing need for us to think more about where our food is coming from and more critically, what it takes to produce it. Put simply, the way most food production currently occurs is not sustainable for years to come and is having such a significant impact on the environment, that animal agriculture is now said to be more of a contributor to greenhouse gas emissions (18%) than all forms of transportation (13%). Yes, more pollution from producing meat than planes, trains and automobiles produce. That fact astounded me and drove me to learn more.

I found more compelling evidence from the documentary movies Cowspiracy and later on from Food Choices – both currently available on Netflix, while Food Choices is also available online at http://www.foodchoicesmovie.com/.

Cowspiracy is a confronting, but fully-researched presentation of the many reasons why the current process in animal agriculture can’t continue without consequence. Some of the most surprising facts (to me) are (note: all of the following facts can be verified from http://www.cowspiracy.com/facts/ with full citations of the studies used. Further facts are listed at the end of this post):

Livestock is responsible for 65% of all human-related emissions of nitrous oxide – a greenhouse gas with 296 times the global warming potential of carbon dioxide, and which stays in the atmosphere for 150 years.
2,500 gallons (9,463 litres) of water are needed to produce 1 pound (453 grams) of beef.
Animal agriculture is responsible for 20%-33% of all fresh water consumption in the world today.
Livestock covers 45% of the earth’s total land.
75% of the world’s fisheries are exploited or depleted.
Animal agriculture is responsible for up to 91% of Amazon destruction.
World population in 1812: 1 billion; 1912: 1.5 billion; 2012: 7 billion. We are currently growing enough food to feed 10 billion people.
70 billion farmed animals are reared annually worldwide. More than 6 million animals are killed for food every hour.
Worldwide, at least 50% of grain is fed to livestock.
82% of starving children live in countries where food is fed to animals, and the animals are eaten by western countries.
Land required to feed 1 person for 1 year: Vegan: 1/6th acre; Vegetarian: 3x as much as a vegan; Meat Eater: 18x as much as a vegan.

Now, that’s a lot to digest (yes, the pun is intended). Each one of these facts is a significant issue in its own right, but when combined, it paints a troubling picture. I would strongly question why we need to be growing enough food for 10 billion people when the current global population is 7 billion (and it’s growing at an alarming rate compared to the previous 100 years). I’m also highly troubled by the fact that there are starving children in countries where food that could be fed to them is instead given to animals being produced for western consumption. The sheer waste of our most precious resource – water – is astounding to say the least. The destruction of land and rainforests to clear the way for yet more livestock is totally unnecessary, as is the fact that there are people on this planet who don’t have enough food to eat while we produce enough food for 3 billion more people that don’t actually exist.

So, I’ve gone vegetarian. I’m lucky that I love legumes, beans, chick peas and quinoa – all protein and fibre-rich foods. These are my meat replacements, along with increasing the types of vegetables I eat (it’s time to truly test my fussiness!). The transition will require some organisation and seeking out new recipes, while also getting a little creative with leftovers (like turning a lentil soup into veggie burgers for the next day). Protein shakes before the gym are also helping provide that extra push while my body transitions through this change.

I’m not going to demand that you stop eating meat, cheese and eggs, or that you stop drinking cow’s milk. These are choices you need to be comfortable with. Full disclosure here – I’m not about to give up milk or eggs just yet until I can satisfy myself that I’ll have adequate amounts of protein to maintain my current training regime without these two forms of animal protein. I’m fully aware that the process used to get cow’s milk is highly questionable from a moral standpoint and the confusion around what “free range” actually means in relation to eggs is a concern too, but unless you’re fully committed to eliminating foods from your diet, it won’t work. I wasn’t ready for vegetarianism all those years ago, but I’ve now gone three weeks without meat of any kind and feel driven to continue this momentum. I’ve been at two BBQs in this time, and also sat across from a friend eating what looked like an incredibly delicious chicken parma at the pub a few days ago, and I didn’t give in at any of these times. But I’m also not going to be silly enough to suggest that I’ll never eat meat again (seriously, that chicken parma looked so good!), so I think it’s important to allow yourself the flexibility to listen to your body if you decide to try this and don’t punish yourself for having some meat one day here and there, especially at a family gathering like a Christmas lunch. Any reduction you make to the global demand for meat can only be a good thing for our sustainability.

I feel ready to be a vegetarian now and I feel compelled to do this – both from a moral view and an environmental sustainability view. Morals are personal, so you really need to want to do this for it to work long-term. I understand that this isn’t for everyone, but if this makes you at least think about your food and its impact on the planet, and you maybe cut back one piece of meat each week, it’s a small win.

Further facts from Cowspiracy:

Emissions for agriculture are projected to increase 80% by 2050, while energy related emissions are expected to increase 20% by 2040.
Californians use 1,500 gallons (5,678 litres) of water per person per day. Close to half is associated with meat and dairy products.
477 gallons (1,805 litres) of water are required to produce 1 pound (453 grams) of eggs.
Almost 900 gallons (3,407 litres) of water are needed for 1 pound of cheese.
1,000 gallons (3,785 litres) of water are required to produce 1 gallon (3.79 litres) of milk.
5% of water consumed in the US is by private homes. 55% of water consumed in the US is for animal agriculture.
For every 1 pound (453 grams) of fish caught, up to 5 pounds (2,268 grams) of unintended marine species are caught and discarded as by-kill.
As many as 40% (63 billion pounds) of fish caught globally every year are discarded.
Scientists estimate as many as 650,000 whales, dolphins and seals are killed every year by fishing vessels.
1-2 acres of rainforest are cleared every second. The leading causes of rainforest destruction are livestock and feed crops.
5 acres can produce 37,000 pounds (16,783 kg) of plant-based food.
5 acres can produce 375 pounds (170 kg) of meat.
A person who follows a vegan diet produces the equivalent of 50% less carbon dioxide, uses 1/11th oil, 1/13th water, and 1/18th land compared to a meat-lover for their food.

The Favourite

Posted on February 16, 2016 by Steve Inguanti

If you watch sport, chances are you have seen sports gambling promotions. You have probably also noticed that the people in these promotions are usually male and they are usually smiling and winning. Like most promotional material though, the reality of the situation is a little different.

The reality is that if you watch sport on television, you will not avoid sports betting marketing. The value of sports betting advertising quadrupled between 2010 and 2012 (Hing, N. (2014). Sports Betting and Advertising (AGRC Discussion Paper No. 4). Melbourne: Australian Gambling Research Centre). In 2012, 3,069 individual sports betting advertisements were relayed over all forms of media, excluding social media. This included 528 individual sports betting advertisements, which were collectively played over 20,000 times on free-to-air TV and more frequently on pay TV (Hing, N. 2014). It is getting more prolific each year – over ten weeks from 30 August to 7 November 2014, the six main wagering providers collectively spent $12 million, running a total of 13,000 advertisements. Sportsbet spent the most during this time (over $5.5 million), while Tom Waterhouse paid for the most expensive individual advertisement, which cost $461,000 and was screened on television 347 times (Sproston, K., Hanley, C., Brook, K. (ORC International), Hing, N., Gainsbury, S. (2015). Study on Marketing of Sports Betting and Racing. Melbourne: Gambling Research Australia).

What does all this advertising do? Sports betting is the only gambling form for which participation rates have increased during the last decade (Gainsbury et al., 2014). Approximately one in seven (13%) adult Australians now gambles on sport (Hing, Gainsbury et al., 2014). Half of all sports betting is now conducted online (Hing, N., 2014) due to the 24/7 access via mobile apps and betting websites, as well as mobile wagering vans located at some sporting events. Yes, just in case you missed the many opportunities to gamble on your way to the game, you can rely on the mobile wagering van sitting outside the ground – useful if you don’t have a smartphone or access to the Internet, where you will also find many opportunities to gamble. Live coverage is streamed on some mobile betting apps, further incentivising sports enthusiasts into using this readily available medium.

Many sporting events, teams and stadiums have entered into commercial marketing arrangements with corporate bookmakers. This is most prominent in the two largest Australian sports, the Australian Football League (AFL) and the National Rugby League (NRL). These sports attract about half of all sports betting in Australia, with a doubling of turnover expected within five years from $750 million to $1.5 billion on the NRL and from $900 million to $1.8 billion for the AFL (Hing, N., 2014). As the sporting bodies receive marketing and product fees based on betting revenues, there is no incentive for them to reduce betting activity in the foreseeable future.

Sport is now used as a marketing platform to deploy huge investments of money by sports betting operators to recruit and retain customers. Particular concerns are that this marketing can encourage consumers to consider gambling as a sport, and that young people are learning about gambling through sport programming and merchandising, which can normalise and legitimise gambling uptake at a young age (Hing, N., 2014).

The embedding of sports betting promotions into live and televised sports is possibly the most controversial aspect of their marketing strategies, as it is mostly unavoidable for the viewing audience – many of which are likely to be children and young adults. I recall sitting at football games at the Melbourne Cricket Ground (MCG) seeing live betting odds splashed across the big screens while being announced to the crowd as a bit of harmless fun to talk about and follow throughout the game. Any number of live score apps come with betting odds right there next to the score, just in case you hadn’t seen those odds elsewhere. Even tipping websites (yes, footy tipping is considered harmless fun even though it’s usually a competition with a monetary prize) have live betting odds prominently displayed as well, presumably to help with deciding who you’re going to tip to win. Less subtle examples are when Tom Waterhouse was employed as a “special comments” analyst by Channel Nine during live broadcasts of NRL games, only to spruik the odds available at his betting agency. Or the financial market type newsflash segment, usually performed by an attractive female to get the target young male audience’s attention. This still occurs on subscription TV, as they cross to whichever betting agency has paid enough to get the slot and promote all those last minute options you have before the game starts, or during the game too. They usually wrap up these segments with a brief mention to gamble responsibly, after they have just saturated the TV viewing experience with their marketing strategies (more on this aspect later).

This embedded advertising can be particularly powerful because very little can be avoided, other than not watching the broadcast at all, or not attending the event. It is also likely to evoke an emotional response, rather than a rational one (Milner et al., 2013). Promotions occur at critical points when audiences are at their most attentive (e.g., when points are scored). Fixed advertising signs are all over stadiums, and some team uniforms. An audit of four live AFL matches held at two major stadiums in 2011 showed promotion of nine wagering brands during an average of 59 marketing communications (Milner et al., 2013; Thomas, Lewis, Duong et al., 2012).

The proliferation of sports betting advertising did result in community concern, especially in relation to the exposure to children and young adults. Some of the concern centred around the potential to normalise gambling among young viewers and potentially grooming a new generation of problem gamblers (Hing, Vitartas, & Lamont, 2013, 2014; Hunt, 2013; Lamont et al., 2011; McMullan, 2011).

“This “gamblification” of sport may transfer images associated with sport to promote gambling as healthy, harmless fun that, like sport, relies primarily on skill (Hing, Vitartas, & Lamont, 2014; Lamont et al., 2011; McMullan, 2011). Sports betting is becoming culturally embedded among young males, who report that peer discussions now include betting odds and that they feel pressured to gamble to fit in with their peers (Thomas, Lewis, McLeod et al., 2012). These promotions also undermine responsible gambling messages targeting young men, who are also the most at-risk group for gambling problems (Delfabbro, 2012)”.

Some evidence is showing that the proliferation of sports betting advertising is also negatively affecting problem gamblers. The University of Sydney Gambling Treatment Clinic has found that “the proportion of clients with sports betting-related problems increased fourfold between 2006-07 and 2010-11, with sports-embedded promotions reported as contributing substantially to these clients’ problems and relapses” (University of Sydney Gambling Treatment Clinic, 2011).

The extent of community concern in relation to sports betting advertising led to three separate government inquiries during the period between 2011 and 2013. “Following community concerns raised in these inquiries, Australian government pressure led to amendments to broadcast advertising codes from August 2013 to stop in-match commentary and on-screen displays of betting odds. Other promotional practices continue, including live odds promotions before match commencement. Ironically, airing of the statutory message to “gamble responsibly” has decreased with curtailment of live odds messages” (Hing, Vitartas, & Lamont, 2014). This is where a large part of the issue lies. If you watch live sport, you simply cannot avoid sports gambling messages. Whether it’s the casual mention of favourites through commentary, or the market style betting update before a game commences, or the copious number of sports betting advertisements throughout each broadcast, you won’t be able to avoid a reminder that you can easily go and throw some money at the game you’re watching. Seemingly, the only way to avoid it is to not watch the broadcast at all, nor read a newspaper, nor check your favourite sporting app, nor go anywhere near a computer with an Internet connection. How likely is any of this if you like to watch sport either regularly, or even occasionally? There’s also concern that it took three government inquiries before the industry finally acted, and even then, they only went a very small way towards removing the constant signals they give sports followers to go and gamble. It shows they cannot be trusted to self-regulate and will only act when pressured to do so. To further highlight the lack of self-regulation in the industry, an audit of sports betting advertising conducted in 2014 found that “responsible gambling messages were not commonly seen in either the televised or live sports or racing events observed. They were not displayed in many advertisements included in the content analysis and there were generally problems with legibility whenever they were present” (ORC International), Hing, N., Gainsbury, S. (2015). Study on Marketing of Sports Betting and Racing. Melbourne: Gambling Research Australia).

It has been found that gambling advertising can have particularly negative impact on problem gamblers. They report gambling advertisements as being a greater stimulation to gamble, a larger influence on spending than intended, and an encouragement for them to think that they will win. They also report that these advertisements can remind them about gambling, trigger gambling urges and undermine attempts to moderate their gambling. Bonus offers for sports betting, such as money-back guarantees and “free” bets that require matching deposits appear to particularly increase Internet gambling among problem gamblers. While gambling advertising has to date not been found to motivate many people to commence gambling, it has been shown to increase gambling among existing gamblers (Hing, N. 2014).

As research into the impact of sports betting advertising is still relatively new and ongoing, lessons could be learned from the advertising of other potentially harmful products in sport. Research has indicated that exposure to alcohol, tobacco and junk food advertising contributes to their uptake and consumption, especially among adolescents (Hing, N. (2014). Sports Betting and Advertising (AGRC Discussion Paper No. 4). Melbourne: Australian Gambling Research Centre). In fact, tobacco advertising at sporting events in Australia was banned some years ago, even though this caused a great controversy with particular international events such as the Formula One Grand Prix. As research continues on the sports betting industry, it will be interesting to see if a similar ban on sports betting advertising at sports events and on sports broadcasts ever eventuates. Given the amount of money being made through royalties and commissions to sporting bodies, this move might not be very likely.

There is a need for updated research into the impact that sports betting marketing is having on the community, particularly problem gamblers and the target markets of these companies (predominately young males). The trends from existing research are not going in a favourable direction for anyone other than the sports betting companies and the sports bodies themselves and I am reasonably sure we don’t need to put any odds on where current trends are heading. If my viewing of sport is anything to go by, this issue has become much more problematic than it was three or four years ago.

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