We need better healthcare services for suicidal intersex, trans and gender diverse people

Dr Tracie O'Keefe, pictured, has written a new book titled Suicide in Intersex, Trans and Other Sex and/or Gender Diverse Groups: A Health Professional's Guide. Image: supplied.

Sex and Gender Education (SAGE) Australia has completed its three-year research project into suicide in sex and/or gender diverse (SGD) communities – and identified much-needed training and education for health professionals, writes Dr Tracie O’Keefe.

Sex variant people are much more common than those who warrant an official medical diagnosis of being intersex, as physical sex variations can take years to emerge or be discovered later in life.

Gender diversity takes in many groups who do not necessarily identify as trans but who are other than stereotypically presenting as male or female.

Research shows that suicidal thoughts in these groups can run at anything between 60-70 per cent, which is higher than any other group, more than 20 times the Australian national average. Other countries report similar figures.

SGD groups of people include those who are intersex, sex variant, sex non-specific, transsexual, transgender, cross-dressers, non-binary, neuter and those with cultural sex and gender differences. At SAGE, a campaigning group for the rights and dignity of all these groups, we have never discriminated between them.

“Ignorance in the health professions about sex and gender diversity is endemic. It is not well taught at medical school and universities.”

– Dr Tracie O’Keefe

When you say you are involved in research on suicide in intersex, trans, and other SGD groups, people smile, say ‘well done’ and look uncomfortable.

It’s a natural reaction because suicide frightens all of us and people are generally unsure what intersex or gender diversity is, even health professionals, so people generally try to be politically correct or in some cases not.

Ignorance in the health professions about sex and gender diversity is endemic. It is not well taught at medical school or universities mainly because lecturers for the most part only know what they have read in the newspapers and it is not on the curriculum. If an institution follows certain religious beliefs, discussion or teaching of SGD issues can even be banned.

When people from SGD groups go to the doctors and mention they are intersex or trans they can they be faced with confused clinicians who give responses like: “Why do you want to change your sex?”, “Have you ever considered seeing a psychiatrist?”, “Does your family know?”, “Maybe you should get tested”, “Try some antidepressants”, “Perhaps, you should stop taking any medications because I’m not a doctor who believes in those things”.

Faced with those responses, to even say that you are having suicidal thoughts can seem a dangerous step too far because you are not being offered help but instead having to negotiate the health professional’s ignorance.

You may even be referred on to gay services when you are not gay but the clinicians think gay services help everyone like you. Many people from SGD groups avoid having medical check-ups, screening or scans because they are afraid of the prejudice and discrimination they will face.

This is why at SAGE we thought it was important to embark on research in order to educate health professionals on how to handle suicide in people from SGD groups.

The result is my latest book Suicide in Intersex, Trans and Other Sex and/or Gender Diverse Groups: A Health Professional’s Guide.

The cover of Dr Tracie O’Keefe’s new book, Suicide in Intersex, Trans and Other Sex and/or Gender Diverse Groups. Image: supplied.

Suicide is a life-or-death issue so people often approach health professionals as their first port of call. As a health professional and researcher myself, I see that the majority of my colleagues locally and internationally do not have the skills to help people from SGD groups who are suicidal because they really don’t understand their issues.

So at SAGE, three years ago we started the Life Over Suicide Project of those who have overcome suicidal ideation.

The basis of the research was international. To look at the issues of suicide in SGD groups, we also needed to see how it happened in different cultures and what led to those suicidal thoughts. You cannot study human experience in isolation so you have to look at the wider environmental issues driving people to suicide.

Suicide is not a mental illness although some people with mental illnesses may be suicidal. Suicide in general is a stress reaction when a person perceives their personal circumstances are so bleak and daunting that suicide looks a better way froward. It appears to be an escape door when going on with life seems filled with unbearable, intolerable pain and anguish.

I am often asked when talking about the research, “What are the mental illnesses that lead to suicide in SGD groups?” It’s the wrong question asked from a presumption that people from SGD groups are mentally ill. The right question should be, “What are influences that drive people from SGD groups to suicide?”

“Many people from SGD groups live alone, have no contact with their families and find society too hostile … they feel deeply wounded by rejection.”

– Dr Tracie O’Keefe

There are multiple answers including a lack of or poor medical services, intersex children being operated on to change their genitals without their permission, encountering unempathic clinicians, prejudice, discrimination, bullying, inability to get proper legal documents that match their identities, exclusion from families, religions, work, education and social spaces, poverty and homelessness.

When you are an excluded and oppressed minority your future can seem like an insurmountable, unsurpassable wall that is impossible to climb.

What also comes into play is the isolation factor where you become so far removed from others that your self-esteem plummets to such a low level you think it’s not worth living.

Many people from SGD groups live alone, have no contact with their families and find society too hostile, so do not mix with many people; they feel deeply wounded by rejection.

Far-right groups, religious and other institutions and the media are constantly making outrageous false claims that you do not have a right to exist, are evil and a danger to society. The bombardment of those message, thousands of them, can lead you to begin to believe what your oppressors say about you.

One of the clearest things to emerge from the research and my own clinical practice is the level of post-traumatic stress disorder (PTSD) suffered by people from SGD groups. It’s not occasional or even intermittent but to be expected in these groups because of the trials and tribulations they have experienced in life.

“When research reports suicidal thoughts in SGD groups of up to 70 per cent, and children are killing themselves, we have an epidemic.”

– Dr Tracie O’Keefe

The new book teaches health professionals, doctors, nurses, psychologists, psychotherapists, counsellors, social workers, naturopaths, project managers and policy makers about the world in which people from SGD groups live.

It teaches them how to secure funding for clients, screen for suicide and what treatments may be effective to restore the will to live.

I also talk considerably about community participation in suicide prevention. I always think that if you have been fortunate enough to get through what many of us from SGD groups have endured, it’s important to hold out your hand and help someone else. 

I believe the public services and the voluntary sector should be working together more. The government can never provide all the help needed but government-funded organisations often exclude valuable voluntary groups under the pretence they have no idea what they are doing, which is not true and often the opposite.

As an intersex and trans woman myself in the community, I have seen so many lives saved from suicide by people simply reaching out to help others with no expectations of a wage or personal gain. 

We live in a world that’s obsessed with personal gain which leaves many needy people alone isolated and suicidal. In my own clinic at the moment, I am seeing so many people who were traumatised and became deeply depressed during the long Covid lockdowns.

During the three-year research project SAGE was still lobbying parliament for human rights, fighting the Latham Education Amendments, the Religious Freedom Bill and others.

I have spent 50 years working in the field of suicide in SGD groups in the voluntary, state and private sectors but it took many people to make this project happen including those who were willing to tell their stories.

Dr Tracie O’Keefe, pictured, has spent five decades working in the field of suicide in SGD groups. Image: supplied.

Suicide is never an easy subject to raise, but it is an even more dangerous subject to avoid when it leads to death or a lifetime of depressed pre-suicidal thoughts that leave people unable to work or interact with others.

Many people of my generation from SGD groups took their own lives, turned to drugs or alcohol and are not alive today. Time may have passed and we may have more rights but we also now have more emboldened and aggressive oppressors.

When research reports suicidal thoughts in SGD groups of up to 70 per cent, and children are killing themselves, we have an epidemic.

People can overcome suicidal thoughts, emotions and attempts with the right kind of care and attention. At the point of the heightened suicidal thoughts, it may seem there is no life ahead for the suicidal individual. That too can pass when someone is willing to be helped. However, it depends on the availability of specialist SGD help which at the moment is sparse.

As an intersex and trans child in the 1960s, I was locked in a 2 x 4 metre cell in a mental institution with iron bars on the window for years because a court decided children like me were a danger to the public.

I attempted suicide more than once but what saved me was the kindness of people who helped me, at times at risk to their own careers. Then there were the people I discovered as friends in my teenage years, many of whom are my friends today, who were kind, non-judgmental, helped me and restored my faith in human nature.

It doesn’t always take letters after your name to save a life.

Suicide in Intersex, Trans and Other Sex and/or Gender Diverse Groups: A Health Professional’s Guide is available book retailers.

If you want to get involved as a volunteer in SAGE’s Life Over Suicide Project or have SEO skills and can help, email us at sageaustraliateam [at] gmail [dotcom].

Dr Tracie O’Keefe DCH, BHSc, ND is a sexologist, PACFA-registered clinical psychotherapist, mental health professional and specialist in sex, gender and sexuality.