Summary of Findings

Gloria Fraser

Victoria University of Wellington

TheRainbowMentalHealthSupportExperiencesStudy

In this report we use a few different umbrella terms to describe thepeople who’ve taken part in our research, including “rainbow communitymembers,” “sex, sexuality, and gender diverse people,” and “queer, trans,and intersex people.” We aim to be as inclusive as possible with our use of language, but acknowledge that not all of these terms work for

everyone.

Background

Project Overview and Methods

Participant Demographics

Gender and Sexual Orientation

Hauora/Wellbeing

Access to Mental Health Support

Helpfulness of Mental Health Professionals

Experiences of Discrimination

Experiences in Therapy

Creating Rainbow-Friendly Spaces

Gender-Affirming Healthcare

Strengths

Ngā Mihi

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International research shows that sex, sexuality, and gender diverse people around the world experience high rates of adverse mental health outcomes as a result of stress caused by stigma, violence, and discrimination. Research from Aotearoa – a country well-known for being at the forefront of social change – suggests that mental health disparities within rainbow communities reflect those seen overseas, but there is a current lack of research examining whether rainbow community members are receiving the support they need

from Aotearoa’s mental health system.

The aim of this study is to gain an in-depth understanding of the experiences and needs of queer, trans, and intersex people who access mental health support in New Zealand. Our hope is that this will highlight potential areas of improvement in New Zealand’s mental health service provision for queer, trans, and intersex clients. A second aim of the study is to consider ways in which these findings can inform the development of a resource to guide mental health professionals in their work with rainbow clients. The research questions for this study are as follows:

What are the experiences of rainbow community members who access mental health support in New Zealand?

What are the experiences of gender diverse people who undergo mental health assessments for gender-affirming healthcare in New Zealand?

How can these findings inform the provision of high quality and responsive mental health care for queer and trans people in New Zealand?

What are the experiences of rainbow community members who access

What are the experiences of gender diverse people who undergo mental

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The Rainbow Mental Health Support Experiences Study is a community-based research project led by Gloria Fraser from Victoria University of Wellington’s Youth Wellbeing Study, in partnership with Gender Minorities Aotearoa, InsideOUT, and Rainbow Youth. We also seek guidance and advice from other rainbow community organisations and leaders. Gloria is supervised by Professor Marc Wilson and Dr Anita Brady. As a research rōpu, we make decisions around research design, interview and survey questions, research recruitment, and analysis of findings.

The project is made up of three parts: interviews with rainbow community members, an online survey with rainbow community members, and the development of a resource for mental health professionals, to guide their work with rainbow clients. This report summarises findings from Study 2, the online survey. Due to space constraints we have not been able to report on all of our findings. If you’re interested in more detailed results, or have a question that is not answered here, you can contact us for more information (see the final page of this report for contact information). To see a summary of results for Study 1 (the set of interviews with 34 queer, trans, and intersex community members) visit http://tinyurl.com/study-1-summary. The resource based on Study 1 and 2 findings will be developed in early 2019, with a tentative launch data of July 2019.

The online survey was developed based on analysis of 34 interviews with queer, trans, and intersex community members about their experiences of accessing mental health support, past literature on rainbow mental health support experiences, and the advice of community leaders and organisations. After the survey was drafted we held a series of hui for feedback on the proposed survey, and made changes to the survey questions and design where needed. We also invited those we had previously interviewed to pilot the survey and provide final feedback on the design and questions. The survey was advertised through social media, asking community organisations to distribute our flyer through their networks, and posters in universities, cafes, and on community noticeboards.

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1%outside Aotearoa

were trans or nonbinarywere unsureand

were intersex or had a variation of sex characteristics

were unsureand

respondents were aged between

average age

different ethnic

affiliations

whakapapa connections to

iwi around Aotearoa

there were responses to the survey that we could use

gender- affirming healthcare

had accessed

are in the process of accessing

have not accessed but wish to access

1%outside Aotearoa

were intersex or were intersex or had a variation of had a variation of sex characteristicssex characteristics

there were responses to the survey that we could use

Auckland 29.4%

11.1%Canterbury

6.4%Otago

Waikato 6%

3.9%Whanganui &

Manuwatu

2.5%Bay of Plenty

Taranaki 1.5%2.3%Hawke’s Bay

1.8%Nelson & Tasman

1.7%Southland

1.4%Northland

0.5%Gisbourne

0.9%Malborough0.7%

West Coast

28.9%Wellington

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Unlike most surveys, which ask about gender and sexual orientation using tick boxes, we asked our participants to describe their gender and sexual orientation using open boxes, meaning they could use as many terms as they liked. Survey respondents used a wide range of terms to describe their gender and sexual orientation. The word clouds on pages 7 and 8 visually represent responses to the gender and sexual orientation questions; the bigger the word, the more participants wrote it

into the open boxes.

These responses highlighted how complex and multifaceted gender and sexual orientation can be. Many participants told us how difficult it was to provide short responses to these questions, with some sharing that they may describe themselves in different ways depending on the context, or might simplify the words they use to help other people understand them. Survey respondents often noted that their gender and sexual orientation shifted over time, and others shared that they were unsure about their gender or sexual orientation, with some saying they didn’t think they were going to find out any time soon – and that this was fine with them!

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FemaleMalefemale

Non-binaryWoman

male

Nonbinary

Cis-female

Cis-woman

nonbinary

Agender

cis-female

Genderfluidwoman

non-binary

Cis-Female

Queer

Cisgender-female

GenderqueerNon-Binary

Gender-fluid

Trans-masculine

Trans-male

Cis-male

Man

Transgender-male

Cisgender-woman

genderfluid

Questioning

Cis-Woman

cis-

wom

an

agender

Girl

Make

Trans-Non-binary

Cisgender-Female

Transmasculine

trans-female

Gender-Fluid

trans-male

Cisfemale

Trans-m

an

Demiboy

unsure

Femail

Unsure

unknow

n-but-i

m-o

k-with

-going-a

long-with

-fem

ale.-mayb

e-like-fe

male-a

ligned-a

gender-but-i

-tend-to

-just-

say-

nb-fem

ale-for-e

ase

Technically,-MTF-transsexual-woman,-although-socially,-more-like,-woman-whose-medical-history-is-kept-private

Possibly-FTM-transgender-or-nonbinary,-although-I-am-AFAB-(assigned-female-at-birth

Non-binary-/-Woman-/-Takatāpui.-I-am-AFAB-and-drift-in-and-out-of-womanhood

fem

ale

---unsure-a

s-whethe

r-I'm-co

mp

letely-fe

ma

le-o

r-if-I'm-g

end

er-fluid

I-dont-think-im-going-to-find-out-anytime-soon,-and-im-okay-with-that

Gender-nonconforming/-Nonbinary-(I'm-not-sure-which-word-is-best-yet

Bigender-(female-+-androgyne-are-the-2-genders-I-identify-with

I-am-not-sure,-I-am-somewhere-in-the-non-binary-area-tho

Cisgender-female-(but-potentially-questioning

Non-Binary-Transgender---maybe-Trans-Masc

Transmasculine-(male-adjacent-non-binary

genderfluid---third-gender-to-demiwoman

I-don't-have-a-gender-and-am-not-trans

Genderqueer-/-genderfluid-/-nonbinary

intersex-(i-consider-this-my-gender

Cis-female,-questioning-genderfluid

Agender-female--(pronoun-ambivalent

Male-(ftm-but-don't-like-to-use-it

Non-binary/-trans-guy/-genderqueer

agender/gender-in

differe

nt-fem

ale

Nonbinary/transmasc/genderqueer

gender-neutral;-male-presenting

some-sort-of-w

eird-girl-thing

Questioning,-probably-agender

Nonbinary,-femm

e-genderqueer

Non-binary-skewing-feminine

Male-(with-trans-experience

Transgender--female-to-malegender-non-confirming-woman

Genderfluid--Female-leaning

Non-binary-transgender-male

Whatever-i-feel-on-the-day

Non-binary-trans-masc/male

Questioning-but-not-female

Trans-masculine-non-binary

Man,-m

asculin

e-identify

ing

Male,-sometimes-genderflux

N/A

-(I-d

on't-

have

-a-g

end

er

Queer-(cis-female-on-paper

Non-binary/Female-leaning

Transmasculine-non-binary

genderqueer-and-nonbinary

I-am-female.-I-am-a-womanFemale-aligned-non-binary

Non-binary/transmasculine

Ira-tāngata-kōwhiri-kore

Non-binary-/-trans-woman

Female,-possibly-agender

Nonbinary-transmasculineGenderqueer-/-non-binary

Non-binary/-gender-queer

Non-binary/gender-queerGender-fluid/Non-binary

trans-fem-/-genderqueer

Gender-fluid/non-binary

sorta-a-girl,-sorta-not

Non-Binary/Gender-Queer

Genderqueer/Non-Binary

Non-binary-trans-femme

Genderfluid-or-dem

iboi

GenderQueer-Non-Binary

Masculine/questioning

Gender-Non-Confirming

Genderqueer-cis-woman

nonbinary/genderfluid

nonbinary-q

uestioning

Gender-non-conforming

Female-/-questioning

Female-/-Genderqueer

I-am-a-woman.-Female

Takatāpui,-cis-woman

Female/w

oman/she/her

incoherent-screaming

Involuntary-celibate

Trans-masc-Nonbinary

Nonbinary-trans-man

non-binary-transman

Cis-Gendered-Female

Transgender-demiboy

Gender-is-confusing

Demigirl/nonbinary

Agender/non-binary

Female-/-nonbinary

Non-binary/agender

transgender-female

trans-genderqueer

female/non-binary

Non-binary-/queer

Ge

nde

rque

er-W

om

an

transwoman-female

Transgender-Woman

Female,-Cisgender

Non-binary/female

Male-or-Neutrois

Transgender-Male

Non-binary-femme

Trans-non-binary

Fluid,-nonbinary

Male/questioning

Demigirl/Agender

Ge

nde

rflu

id-m

ale

non-binary,-afab

Male/Questioning

Gen

derfl

uid/

flux

cisgender-female

agender/demigirl

Nonbinary?-Maybe

Male-identifying

femme-/-agender

Mtf-transgender

Nonbinary-trans

Nonbinary-(AFAB

cis-femme-fluid

Cisgender-Woman

Cisgender-femle

Transgender-FTM

trans-masculine

Male/Non-binary

Male-and-female

Transgender-mtf

Intersex-Female

cisgender-woman

Trans-Masculine

transgender-man

Nonbinary/queer

Non-binary-AFAB

Woman/nonbinary

Male-expressing

Transgender-man

Cisgender-Male

Non-conforming

Female(I-guess

Ge

nde

r-Dive

rse

Not-applicable

Trans-masc/guy

Nonconforming

Female-binary

Female,-maybe

Dont-have-one

Man,-transman

Transfeminine

Cisgender-Man

Natal-female

I-don't-know

Trans-female

Trans-Female

gender-fluid

gender-queer

Gender-queer

Not-defined

Trans-femme

genderqueer

Trans-woman

mostly-male

GenderQueer

GenderFluid

tra

ns-w

om

en

Woman-(cis

Trans-masc

Transfemme

Transwoman

female-cis

Ma

le-(

AFA

B

Female-ish

Male-(FTM

Queer-ftm

Femaleish

Cis-women

Male-(Ftm

Trans-FTM

Mascfluid

Cisgender

takatāpui

CIS-w

oman

Demi-Girl

Trans-ftm

Takatapui

Male-(ftm

Female/NB

Neutrois

Male/Man

Bigender

bigender

feminine

Ciswoman

De

mig

irl

Transman

Male-CIS

Ftm-male

not-sure

ftm-/-nb

Not-s

ure

Blendeddemiboy

Femaile

Cis-guy

lesbian

Neutral

FTM-guy

Wahine

Zigzag

tāhine

fem

ail

queerFemle

Femal

fluid

Trans

Fluid

Ze/it

Gurlnone

Null

girl

Dyke

Boy

gender7

BisexualLesbian

GayPansexual

Queer

Asex

ual Questioning

Demisexual

Homosexual

Takatāpui

Panstraight

Biromantic

Unsure

Panromantic

Heterosexual

Aromantic I-don't-know

AceHeteroflexible

not-sure

Maybe

Dem

i

Homorom

antic

Homoflexible

Grey-Asexual

Grey-ace

Female

Mostly

Male

Heteroromantic

I-like-people

Ho

mos

exua

lity

I-like-girls

Demiromantic

Polysexual

Omnisexual Greysexual

Same-sexPossibly

Identify

Females

I-think

Rainbow

Attracted-to-women-more-than-men

Still-trying-to-figure-it-out

not-comfortable-with-labels

Attracted-to-certain-people

Relationship-with-a-woman

Prefer-to-use-the-label

Unsure-how-to-describe

Define-my-orientation

Easier-to-tell-people

haven't-found-a-term

Explaining-is-tiring

Formerly-identified

not-completely-sure

Fictional-Character

not-100%-straight

Don't-use-a-label

Asexual-spectrum

Mostly-straight

leaning-towards

Male-attracted

Hard-to-define

Bisexual-past

Transmascbian

at-the-moment

Non-specific

kinsey-scalelithromantic

Greyromantic

Gay-leaning

Sam

e-ge

nder

Bisexuality

Androsexual

Com

plicated

all-genders

I-like-guys

Polya

mo

rous

Lesbianism

Preference

Gynesexual

Non-Binary

Interested

Transexual

Long-termOften-non

Bicurious

Undefined

Attached

Slightly

Evolving

Variable

Flexible

Oriented

Gay-ish

unknown

Curious

In-love

Prefer

People

Visual

Wom

an

sort

a

Fluid

Dyke

Poly

IDK

Cis

Aro

sexual orientation

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We based our questions about wellbeing on the Te Whare Tapa Wha framework, a Māori model for understanding holistic health. Results showed that, overall, participants’ strongest domains of wellbeing was taha whānau, or social wellbeing, and taha tinana, or physical health, while the weakest was taha

hinengaro, or mental health.

very poor

average

poor

good

very good

Spiritual wellbeing – taha wairua

1 2 3 4 5

Social wellbeing – taha whānau

1 2 3 4 5

Mental health - taha hinengaro

1 2 3 4 5 Physical health – taha tinana

1 2 3 4 5

Spiritual wellbeing taha wairua

Spiritual wellbeing – taha wairua

1 2 3 4 5

Social wellbeing – taha whānau

1 2 3 4 5

Mental health - taha hinengaro

1 2 3 4 5 Physical health – taha tinana

1 2 3 4 5

Social wellbeing taha whānau

Spiritual wellbeing – taha wairua

1 2 3 4 5

Social wellbeing – taha whānau

1 2 3 4 5

Mental health - taha hinengaro

1 2 3 4 5 Physical health – taha tinana

1 2 3 4 5Physical health

taha tinana

Spiritual wellbeing – taha wairua

1 2 3 4 5

Social wellbeing – taha whānau

1 2 3 4 5

Mental health - taha hinengaro

1 2 3 4 5 Physical health – taha tinana

1 2 3 4 5

Mental health taha hinengaro

/

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0% 20% 40% 60% 80% 100%

1

2

3

4

Chart Title

Series1 Series2 Series3 Series4

0% 20% 40% 60% 80% 100%

1

2

3

Chart Title

Series1 Series2 Series3

Lengthy waiting times made existing mental health difficulties a lot worse.

Some participants had been told by their GP that they were unlikely to receive publicly funded mental health support, due to high demand and lack of availability.

Some reported that they were only able to access help following a suicide attempt, or if they were considered to be high risk, while others noted that once they had told services they had no suicidal intent, they did not receive any follow up referral.

Several particiapnts had accessed care privately and noted that this was a privileged position – that to others having to pay for private care would be a significant barrier.

Although most feedback about waiting times was negative, some participants shared that they were seen very quickly by their mental health service.

35% 55.2% 9.8%

20.3% 39.5% 13.8% 15%

were seeing a mental health professional

were not seeing

were waiting

one week or less

between 2-5 weeks

6-8 weeks three monthsor more

How long did you wait to see a mental health professional?

10

mostly helpful

mostly unhelpful

neither helpful nor unhelpful

extremely helpful

extremely unhelpful

Thinking about all the mental health professionals you have seen - overall, how helpful have they been in

supporting your mental health?

We also asked participants to rate the helpfulness of different types of mental health professionals. Psychologists and therapists were,

on average, rated as most helpful.

Participants also got support from those around them, like whānau, friends, partners, and rainbow organisations. On average, these sources of support were rated as

mostly or extremely helpful.

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A third of participants had heard stories of other queer, trans, and intersex folks having negative experiences with mental health professionals.

Almost half had experienced discrimination outside of mental health settings.

Over 20% had had negative experiences with other health professionals in the past.

Participants who had experienced discrimination outside of mental health settings, or had heard of others having negative experiences with mental health professionals:

Survey results showed that participants’ average number of positive experiences has increased over time.

The average number of negative experiences has stayed relatively stable over time, but there is some evidence to suggest that the kinds of negative experiences people have has changed over time:

The figure on the next page shows the proportion of people who had each experience, positive and negative, within the last five years.

felt less comfortable discussing their sex, sexual orientation, or gender with a new mental health professional, and

were more likely to worry that a new mental health professional would respond awkwardly or with discomfort when they came out.

far fewer participants reported that their mental health professional had tried to change their identity in the last five years than those who saw a mental health professional more than five years ago,

but the number of people who said their mental health professional required education about sex, sexuality, and gender diversity has increased.

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Refused to see you after you came out

Tried to change your identity

Refused to talk about your identity when you wanted to discuss it

Used your deadname

Implied your identity was a phase or not realMade insensitive or hurtful comments about your identityImplied your identity was caused by past trauma

Misgendered you

Blamed your difficulties on your identity

Focussed on your identity when it was not the issueSeemed surprised or uncomfortable when you came outRequired education about sex, sexuality, and gender diversity

Assumed you were straight or cis

Shared what pronouns they use

Checked what pronouns you use

Asked how you identify your sexuality and/or gender

Displayed visual signs of support, like rainbow flags and posters

Asked about your experiences of stigma and discrimination

Used inclusive language

Asked about your coming out experiences

Asked about your own understanding of your identity

Asked about the relationship between your identity and mental health

Affirmed and validated your identity

Was knowledgeable about sex, sexuality, and gender diversity

Focussed on topics you’d come to discuss

0% 20% 40% 60%

0%20%40%60%

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To explore how mental health services could be more rainbow-friendly, we provided participants with a list of different things mental health professionals could do, and asked them to rate how helpful each would be. All of our suggestions were, on average, rated as helpful by participants – though some more than others. In order of most to less helpful, they were:

Using inclusive language that doesn’t assume identity, e.g. “do you have a partner, or partners?” instead of “do you have a boyfriend/girlfriend?”

Displaying rainbow posters, flags, or other visual signs of support

Checking what pronouns clients use

Asking how clients identify their gender/sexuality as part of the initial assessment

Sharing what pronouns they (the mental health professional) use when introducing themselves

Asking how clients identify their gender/sexuality on a form

most helpful

less helpful

Overall, results from the mental health services section of the survey highlighted the need for:

Training for mental health professionals about gender, sex, and sexualityThe importance of following the client’s lead when it comes to discussing identityThe need for an affirmative approach, where all identities are seen as valid and potentially fluidConsideration of the impact of structural factors (like homophobia, transphobia, and intersex discrimination) on mental health and wellbeing

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In this study, we defined gender-affirming healthcare services as any services that affirms and validates a person’s gender, including support to talk about life stuff, and transition-related services like hormones or surgery. We focussed most of our questions on medical transition services, as there’s very little research on access to these services in Aotearoa, and an urgent need to improve public health provision of these services.

The most common gender-affirming healthcare service participants had accessed was hormone therapy, with 90% those who’d accessing gender-affirming healthcare accessing hormone therapy.

The most common reason for accessing care privately was because the waiting time was too long in the public system – over half of those that had gone private reported this as a reason for doing so.

Of those participants who’d accessed gender-affirming healthcare or were in the process of doing so, three quarters had seen a mental health professional for an assessment in order to access that care.

The average waiting time between participants first requesting hormone therapy and getting their first injection was 47 weeks – far too long when considering that long waiting times increase distress and exacerbate mental health difficulties.

of participants had accessed care through the public system

through the private system

through a mix of the public and private system

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Over a quarter of participants who tried to access gender-affirming healthcare had been denied it. The most common reason they were given for this was that they needed to be more mentally well to access care. This was followed by being told they needed to think about it for longer, and needed to lower their BMI or lose weight.

reported that the person doing the assessment had respected and validated their gender, but 62% said they felt pressure to conform to a dominant narrative during their assessment, e.g. having a binary identity, knowing they were trans from an early age, or feeling “trapped in the wrong body”. This suggests that though many individual professionals providing good support to their clients, professionals must still ask outdated questions because of systemic demands.

Overall, results from the gender-affirming healthcare section of the survey highlighted the need for:

An increase in availability for gender-affirming services

Shorter waiting times for gender-affirming services

Clear pathways and information about accessing gender-affirming services

Implementing an informed consent model, rather than a gatekeeping model, for gender-affirming service provision

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The ability to fall in love with the best parts in anyone.

It opens your eyes to not accepting a lot of other bullshit we're taught about relationships, sexuality, gender, and gender roles. There's a lot of cool community stuff to be part of. You get to help other people. Being

queer can prompt you to get a better understanding of politics, society, and the world we live in and why we need to change it.

Love, freedom, creativity, not having to conform, being able to integrate all of yourself together, compassion for others who are stigmatised,

realising everyone has something painful about themselves and feeling connected, healing shame by learning to trust and connect, having a

amazing broad family, being able to create your own family.

My identity taught me strength, resilience and perseverance more so than any other experience in my life.

You meet so many lovely understanding and open people.

It's liberating resisting toxic gender stereotypes, and I have met the most amazing non-judgmental people along my journey. I feel my transness is something to be celebrated, and love wearing T-shirts which make

my gender diversity known to the world. I have an appreciation for how people of all genders experience the world because of the bodies they

inhabit. I just wish everyone else felt the same about how cool being trans is!

Te whakawhanaungatanga me te manaakitanga o mātou ki a mātou anō. Ka tū māia mātou i ētahi wā i te mea kei te mōhio mātou ko wai

mātou.

Because research often focusses on the negative experiences of sex, sexuality, and gender diverse people, we asked participants at the end of the survey what they thought is amazing about being queer, trans, and intersex. For the most part, responses emphasised the opportunities to find community, see the world from

different perspectives, and love freely:

“ ”

”

”

””

”

”

“

“

“

““

“

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This study wouldn’t have been possible without the help and support of hundreds of people who gave feedback on our study design, helped to spread the word about the study, and filled out the online survey. From the bottom of our hearts,

ngā mihi nui ki a koutou.

We would like to give special thanks to Toni Duder, Aych McArdle, Joey Macdonald, Jelly O’Shea, Ahi Wi-Hongi, Tabby Besley, Lucy Cowie, Dasha Fedchuk, and Jaimie Veale for looking over our survey questions. Thanks to Kealagh Robinson, Kate McLeod, Kylie Sutcliffe, and the other Youth Wellbeing Study team members for your aroha and support. A big thank you to Jordan Curtis for your beautiful design

work on our research flyer, and on this resource.

Last, but certainly not least, we would like to thank all our furry (and not so furry) friends who helped us advertise for our study. Thank you Poppy, Artemis, Percy, Ghost, Ziggy, Ollie, Nala, Merlin, Ariel, Banjo, and an unidentified, yet curious,

Wellington-based kereru.

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For any questions, whakaaro, or feedback of any kind on this report or our wider project, please email Gloria.Fraser@vuw.ac.nz

Watch out for the last part of our project our resource for mental health professionals

launching mid !

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The Rainbow Mental Health Support Experiences Study is presented by:

Thank you to the Rule Foundation, the Oakley Mental Health Foundation, and Graduate Women New Zealand

for providing funding to support this project.

This work uses the Gilbert font family which was designed for striking headlines and statements on banners for rallies and protests. A preview version of Gilbert is available on http://www.typewithpride.com. This use of the Gilbert font family is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License https://creativecommons.org/licenses/by-sa/4.0/deed.en. Some minor modifications have been made to this font. This design and its elements are otherwise the exclusive intellectual property of Jordan Curtis. For more information please contact jordancur@gmail.com.

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