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

Posted on 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.

melb pride

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

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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

 

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A Revolving Door

Posted on 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 24th of this third round. The patient does not feel that the TMS is making a difference to their outlook or thought processes, but they do not want to try the alternative treatment (Electroconvulsive Therapy, or ECT, which induces seizures to alter brain activity) because of the sometimes severe side effects of memory loss.

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

depressed woman pic

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”.

park bench pic

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.

The Problem with Gambling

Posted on 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/

The Privilege

Posted on by Steve Inguanti

A respected lecturer recently told me that it’s a privilege to be present as a new life begins, and to be present as a life ends. This is what nursing affords you – this privilege to be present at times of joy, grief and vulnerability. I saw this vulnerability in its rawest form while on my current placement in an acute care hospital in regional Victoria.

My first clinical placement in an acute care hospital setting had the obvious nerves and doubts running through my mind. Having never worked in a hospital before, I was unsure whether I could perform the necessary skills, especially injections and preparing medication solutions to deliver through IV lines. We haven’t had to do venipuncture yet, so that will be another doubt to cross in the near future. The communication aspect of the role does not trouble me though – I do enjoy interacting with people, especially when I can help them feel better about themselves or the situation that they have found themselves in.

My communication skills would be immediately tested though, when I first encountered a patient who had recently been told he had from three weeks to three months to live. It seemed all he heard was the three weeks part of that statement and he wanted to die. He was of sound mind and he was in pain. He initially looked scared and I can understand that – how do you process such a statement? We’re all guilty of wishing time away when we’re doing something we don’t necessarily like but what would go through your mind when someone tells you that your time left is so short? I watched as he seemingly went through phases – from the initial scare to the occasional cheeky smile and smart remark as we tried to lighten the mood for him, to the times when I just had to silently stand there and be with him.

One afternoon as I was walking down the hall of the ward, I noticed he was attempting to get out of bed, but wasn’t getting very far. By this stage, his pain had reached a level where the basic effort of moving his body was too much, but he was still determined to try. I walked into his room and asked what he was trying to do. “I need to piss”. He was clutching onto the side rails of the bed, trying to lift his frail body up. In this moment, I knew he probably shouldn’t have been trying to get out of bed, but his determination to move seemed more important. So, I lowered the bed and offered my hand to help him get up. It took some time and I could see how hard it was for him, but none of that mattered in this moment. He needed to do this. He needed to show that he was still capable of something, even if it was just the act of getting out of bed.

After the initial struggle of helping him out of bed, the next challenge was getting to the toilet. Yes, he could have just went in his bottle, but he didn’t want that. All I was thinking at this time was to maintain his dignity and independence, even though he couldn’t move without some support there. I held his right arm to prop him up as he slowly shuffled a few centimetres with each thrust. He kept apologising and I kept telling him he had nothing to apologise for. I was here to help him and we had all the time in the world (this won’t always be possible in the world of nursing, but I sure hope I’ll be able to be present whenever the need is there without having to rush off to the next patient).

We eventually reached the toilet and his pyjama pants had already fallen enough that he didn’t need to lower them. He was losing weight, which was another frustration for him. He started to go and mostly missed the bowl. Again, he apologised and sounded upset. Again, I reassured him that he had nothing to apologise for. I stood behind him, still holding onto his side. It sounded like it was a real effort to pee, but he managed to get a little out. He just stood there for what seemed a long pause as I continued to hold his side. “Well done mate, do you want to make your way back to bed?” He nodded and we started the slow shuffle back, with each move causing visible pain.

As we reached his bed, he slowly lowered himself onto the edge and sat there. I thought it was a good idea for him to sit up for a bit since he’d made the effort to get up. As he was sitting there, I asked if there was anything I could do: “get a knife”. He looked at me and his eyes were telling me he was serious. I have been a strong advocate of voluntary euthanasia laws for as long as I’ve been aware of the issue (I did my year 12 english essay on the topic, which shows how long this issue has been going here). This moment will sit with me as proof of when these laws should be acted upon. He was of sound mind, in immense pain, and he had had enough. He was losing his dignity and quality of life. I told him I would do as much as I could, but that I couldn’t do what he wanted. I said we were trying to make this time as comfortable for him as possible, but he replied “if I was a dog, I’d be put down already”. I couldn’t argue with that. Thankfully, Victoria will be legalising voluntary euthanasia as of mid-2019 with some of the most conservative laws in the world, but that didn’t help him in this moment.

Later that night, he was in bed and looked uncomfortable as I passed his room. I walked in and asked how he was: “shit, mate”. By this stage, he had been started on morphine for the pain, but it hadn’t taken effect yet. I walked up to his side and took his hand. With the little strength he had, he held my hand back and I just stood there. I didn’t say a word, I just held his hand and looked at him. I knew there wasn’t much else I could do, and all those times I’d been told of how communication is more about the non-verbal than the verbal came into my mind and rang true. I thought about my lecturer’s remark, of the privilege to be present at the end of a life, and that also rang true. And I continued to just stand there and hold his hand.

holding hands

That was the last time I saw him. It was a Thursday night and my shifts meant that I wasn’t back in the ward until Tuesday morning. This is when I learned of his passing on the Sunday. It was bittersweet – I knew he wanted to go, but I was still sad that I wasn’t there. This will be a continual lesson for me to know that I won’t always be there at the end, but as long as I’m present when I can be, I will take that. It is indeed a privilege to be in this position and it is a privilege I hope to never forget, or take for granted. RIP dear man.