Warning: This story discusses suicide, self-harm and sexual violence.

Researchers say the first comprehensive study on the health and wellbeing of trans and non-binary New Zealanders reveals serious health inequities. Digital journalist Murphy reports.

Photo: The Gender Spectrum Collection

In New Zealand, trans and non-binary** people suffer from high or very high psychological distress at rates nine times higher than the general population. It's even higher for gender diverse youth and disabled people.

An even higher number of trans and non-binary people, 79 percent, have seriously contemplated suicide and two out of every five have deliberately self-harmed in the past 12 months.

They are statistics that have never before been available - in fact trans and non-binary people are rarely counted.

The New Zealand Health Survey doesn't collect information about gender diverse people in Aotearoa, and neither does the New Zealand General Social Survey or the Census.

Counting Ourselves was a chance to fill the gaps.

Surveying 1178 trans and non-binary people aged between 14 and 83, Counting Ourselves is the first comprehensive research project into the health and wellbeing of trans and non-binary people in New Zealand. It's trans-led research, funded by the Health Research Council with support from the Rule Foundation and the University of Waikato.

"This was a chance to have ourselves be counted," says Dr Jaimie Veale, the study's Principal Investigator and Senior Lecturer in psychology at the University of Waikato.

Counting Ourselves found 32 percent of trans and non-binary people have experienced sexual violence since the age of 13; rates two to three times higher than women in the general population and seven to 12 times higher than men in the general population. Forty-seven percent of trans and non-binary people reported that someone had tried to have sex with them against their will.

The statistics are sobering. The researchers say they reveal severe health inequities.

Those who also experience discrimination, harassment or violence because of racism and ableism were found to be even more likely to experience health inequities.

The World Health Organisation says there is ample evidence that social factors, including education, employment status, income level, gender and ethnicity have a marked influence on how healthy a person is.

Are systemic failures at play?

***

Gender was often enforced when Tāwhanga Nopera (Ngāti Wahiao, Ngāti Whakaue, Tuhourangi, Ngāti Tūwharetoa, Ngāi Tawake, Ngāti Amaru) was growing up in the '70s and '80s.

Māori uncles and fathers strictly policed it, though through no fault of their own, they had been conditioned to think about gender in a particular way, Tāwhanga says. In fact, before colonisation, traditional Māori society accepted there are people who aren't cisgender. Takatāpui have always been a valued part of Māori communities.

Tāwhanga's earliest memories were of going through mum's wardrobe and grabbing the prettiest things.

Society is stuck in really old ways of thinking about being, says Tāwhanga. Growing up meant not expressing a sense of self out of fear of getting beaten up.

"From a very early age I started drinking, I'd say from about 13…I definitely drank a lot and it wasn't until my 20s that I realised those were alcoholic behaviours… part of it was about gender but I experienced a lot of racism as a child too."

The compounding experiences of both racism and transphobic discrimination, and the way gender is racialised, really impacted on Tāwhanga's mental wellbeing.

***

The 2013-2016 government suicide prevention plan made no mention of trans and non-binary people.

In 2017, 84 organisations and community leaders, including the Mental Health Foundation, urged the government to make rainbow communities a priority group that requires specific resourcing and attention.

Two years on and the Counting Ourselves report reveals more than a third of trans and non-binary people in New Zealand (37 percent) have attempted suicide in their life.

The number of trans and non-binary suicides in New Zealand is not known as the data has never been collected.

The government's newly released suicide prevention strategy, Every Life Matters - He Tapu te Oranga o ia Tangata, mentions rainbow communities three times within its pages.

These include actions around developing inclusive practice guidelines, funding community organisations to run wellbeing programmes, and supporting communities after suicide loss.

While they are necessary and important steps, on their own they aren't sufficient, Counting Ourselves co-investigator and human rights researcher Jack Byrne says.

The Counting Ourselves report recommends trans and non-binary people, as well as the broader rainbow population, are named as a priority in the government's response to its 2018 Mental Health and Addiction Inquiry, including in national and regional mental health and addictions policies.

Even with a hat tip in the suicide prevention strategy, this recommendation remains necessary and crucial, Jack says.

"It took this Counting Ourselves research for the attempted suicide rates within trans and non-binary communities, across all ages, to finally be visible, he says. "Naming that pain should never have been the sole responsibility of our community.

"The responsibility to consistently name us a priority for action now rests with government."

***

As a young person, Tāwhanga engaged in really risky behaviours to mask what was really going on. "There was a lot of self-harm... but it wasn't overt. I would go and have really unsafe sex, I'd put myself in situations where the risk was really high and I'd probably get hurt somehow."

More than four out of 10 trans and non-binary people who filled out the Counting Ourselves survey had deliberately self-harmed in the last 12 months, with youth being the most likely to do so.

Participants who had been discriminated against for being trans or non-binary were more likely to have very high psychological distress (54 percent) than those who hadn't been, and they were also twice as likely to have attempted suicide in the past year.

Assumptions about gender spill over into the healthcare system, says Tāwhanga, now a kaupapa Māori academic and performance artist.

"If you're a transgender person, or between genders…and you enter into a clinical space and straight away a clinician is trying to break you into pieces, how are you ever going to communicate to that person who you really are and the things you actually mean?

"We're really out of balance, you can see it in our health, our bodies are out of balance."

For trans people to be well the world needs to change how it thinks about gender, Tāwhanga says.

"We're not the issue. The health system needs to realise it's the issue and do the work."

We don't think about healthcare services as having a responsibility to keep us well, Tāwhanga says, but Māori services do things differently.

"There's already an acknowledgment that you're related... that there's a way of talking and there are a set of values that are collective, that we're on the same kaupapa. Māori services know how to talk to us, we know how to talk to Māori services... we start from whakapapa, we start from what we know, start from that big picture stuff."

A research project is under way to investigate the life experiences of Takatāpui to gain insight into understandings of health and wellbeing. The Honour Project investigates issues of access, provision and appropriateness of the healthcare services to this specific Māori community.

The Counting Ourselves report found that of those who had ever used mental health services, people were most satisfied with Māori health services.

But there's a lot of work to be done and Tāwhanga says the Ministry of Health needs to take the lead.

"My ancestors weren't really interested in who did the work, they were more interested in the work getting done."

Photo: Supplied / Phil Twyford's office

Phylesha Brown-Acton has faced severe discrimination in life because the gender she was assigned at birth did not align with who she is.

"For many years they would label me as a young gay boy, which I knew I wasn't, that was not my reality.

"I struggled with that for quite some time, right through school to the point that I left school very early, I ended up working kitchen-hand jobs just to pay my rent and to get by, left home at the age of 16 and ended up on the streets as a sex-worker. [I was]...trying to find peace within myself but also work out what it was I needed and the tools, the information, the go-to people that I needed to support me through what I was dealing with internally, not just physically, but mentally and spiritually."

The constant discrimination and being labelled and defined by others led her to self-harm and contemplate suicide.

This year, Phylesha was recognised in the Queen's Birthday Honours, receiving the New Zealand Order of Merit for services to Pacific and LGBTQI peoples.

"It's taken this long to get to the point that I am but that would not have been possible if I was not pro-active...lobbying and advocating for support because there was nothing out there for us."

She's now the director of F'INE, a Pacific LGBTQI focused community-led service, providing Whānau Ora navigational services for people and their fanau.

When a Pasifika trans or non-binary person walks through the doors of a service provider their needs are not very different from anyone else's, Phylesha says, but they're faced with layers of discrimination.

"They might present as fakafifine or leiti or fa'afafine and automatically that comes with its own sort of stigma attached to it." As does being labeled as trans, she says. Add to this assumptions about employment, where they live, whether their family is supportive, lack of understanding about their culture and professionals just think it's all too hard to deal with. "They kind of just get shifted from one person to another to the point where they just don't get the support that they require."

But it's not just about cultural competency, Phylesha says racism and stigma are at the forefront of mainstream services.

She can see how beaten down the youth of today are. For every positive story there is about a trans or non-binary person, there's a story about trans people being murdered, she says.

"I fear for what's ahead of us for the future, it's not getting any better, our people in our trans and non-binary communities, [we] are finding it harder to cope as a result of other people creating so many things that work against us."

***

Experiencing discrimination in one area of life makes it harder for people to access other areas as well, says Ahi Wi Hongi.

"If somebody's experiencing employment discrimination or they've been bullied at work or they've had to leave their job, or they simply can't get a job, then it's much more likely that they have a really low income so they're living in poverty, maybe it's very difficult for them to get housing as well... then it's really hard for them to be in stable housing which makes it difficult for them to have a GP, makes it difficult for them to access regular healthcare, it means that they can't plan their future in the same way as as a cisgender person and if they had a more stable situation."

Ahi was part of the Counting Ourselves community advisory group and is the national coordinator for Gender Minorities Aotearoa; a nationwide organisation, run by trans people for trans people providing information support and advocacy. It relies on fundraising and international grants to carry out its work.

Ahi says the Counting Ourselves findings show what people who are in the community doing the work already know.

"It's been very, very hard for trans people to advocate for their needs because there hasn't been research that backs up what we know is happening," says Ahi. "Having this study which shows evidence that trans people are experiencing really high rates of discrimination, especially in healthcare, it's a really huge step for pushing for change."

Photo: Supplied / Ahi Wi-Hongi

Until now, there has never been data and statistics that represent the experiences of trans and non-binary disabled people in New Zealand.

Counting Ourselves found disabled gender diverse people experience increased levels of hardship, discrimination, violence and isolation. Nine out of ten experienced high or very high psychological distress over a four-week period, two thirds had deliberately self-harmed in the last 12 months.

Disabled participants were more likely to have experienced discrimination in the last 12 months, either on the street/in a public place, in a shop or restaurant, or when seeking medical care.

They were twice as likely to report sexual violence - a rate seven times that of the overall New Zealand population.

They had lower median incomes and higher levels of material hardship.

These statistics don't surprise Jasper*, who says inaccessibility to community and support increases social isolation.

"When you have multiple minority identities it can be difficult to find any service that feels inclusive - which is why intersectional services and community building is so important."

Jasper says his experience navigating the healthcare system was a privileged one. Being a Pākehā trans-macsuline person who can advocate for himself, and whose disability isn't very visible, he was able to access community support and information independently.

Medical professionals often perceive trans and non-binary disabled people's transition related care as too complex or too risky because of disability, and question their ability to consent, he says.

"Healthcare services have historically pathologised disability and gender diversity, so disabled trans and non-binary people may be hesitant to engage. Mainstream services need to ensure that they respect people's right to self-determination. They need to ensure their physical space is accessible and they are providing information in a variety of formats, allowing time for people to ask questions without feeling rushed.

"It is important that everyone working in the service receives training around disability responsiveness cultural competency and working with gender diverse communities. It's important that they feel heard and respected."

GP visit: Ann's story

Ann* puffs away on a cigarette in front of her block of units in one of Auckland's leafy suburbs - she's nervous about today's GP visit.

Her battered station wagon is filled to the brim with gear she needs for a job later today - she was going to just drive the car until it died but now she's now hoping it holds out a little longer. Work is irregular and she's currently living off savings.

On the short drive into the city the nerves are getting the better of her. "Sorry, I'm driving on autopilot," she says after taking the wrong exit.

She's been with her medical practice for a decade or so, but they've only known about her gender identity for the past few, since she decided to start on hormones. Ann's used to changing the way she presents and avoiding a places when she doesn't feel comfortable, or she fears for her safety.

She knew that she needed a designated GP to manage the transition process. "All she's had to do is write me a prescription every three months, but she's friendly, she's supportive...she doesn't really know that much but I assume she's done enough homework to know what to expect and in any case, I've done enough homework to know what to expect."

Now in her 60s, Ann has been on hormones for two years.

A week ago Ann needed to see a doctor after urinating blood, she couldn't wait until her GP was free. The experience left her feeling stressed and uncomfortable. This wasn't the first time she'd felt this way after seeing a new doctor.

On this weekday morning the receptionists greet her without hesitation, Ann tells me they've always been pretty good here, as if it's not something to be assumed when you're trans.

The waiting room is full with families waiting to be seen, Ann and I sit around the corner.

In the GP's office Ann explains that she's worried something is seriously wrong - she'd been told she need to have an ultrasound.

Her doctor begins to draw a diagram, explaining why she's called Ann in today but stumbles on the correct terminology for trans people. There's nothing to be worried about, she continues, before making an inappropriate joke under her breath. It cuts the air as soon as it leaves her mouth.

Ann's had to teach her GP a number of things about trans healthcare and today is no different, this time it's the effects of hormone blockers. "Hormones have never been my niche," the doctor says, thanking Ann before asking if she needs to renew her prescription.

Outside the clinic, as the wind whips past her Ann turns to me; "She doesn't always get it right".

Photo: The Gender Spectrum Collection

Transcend: Soul's story

Soul Mehlhopt grounds himself in Rongotea, a small farming village in the Manawatū region.

At the 2013 census, 594 people lived there. The majority of them, like Soul, were Pākehā - including families who settled on the Carnavon block after it was sold by the Crown in the late 1860s, he says.

In the late 1800s the town was the centre of a religious revival, earning it the title 'the Holy City'.

Rongotea's very much a typical rural village, Soul says; it's got the necessities of a 4 Square, a chippie and a garage. "It's best known for its butter chicken pies and the Guy Fawkes display the volunteer firefighters put on."

Small towns like Rongotea aren't always the easiest places for trans and non-binary people to live.

Soul sees his gender identity as being tied to the wairua of who he is and so there isn't really one term that encapsulates that for him. Sometimes he'll use the terms trans, masc or non-binary to help people understand his identity a little more.

About five years ago he and a few mates realised there wasn't a space for trans and non-binary people in the area, so they created one; Transcend. The peer-led organisation runs a mixed bag of groups and community events offering information, support and education in Palmerston North and wider Manawatū area. It's a common story; gender diverse communities with no resources being forced to create the services they desperately need.

Transcend knows how hard it is to find that one person in healthcare that can champion and awhi a gender diverse person the whole way through their journey.

It can be really difficult to access gender-affirming healthcare in the region, Soul says, and misinformation makes the process even more stressful. "The information doesn't get dispersed, so quite often we're left in isolation, stressing out and dealing with all of these things, trying to figure it out. You just get stuck in a box in the dark for a while."

Being misgendered, dead-named and insulted by a healthcare provider isn't uncommon for trans and non-binary people, the Counting Ourselves report found.

It's also not uncommon to have to teach a doctor the basics, Soul says. In fact, Counting Ourselves found that when trying to access healthcare, almost half of all trans or non-binary people had to teach someone about their gender identity in order to get appropriate care.

Health professionals have told 27 percent of gender diverse people they didn't know enough about gender-affirming care to even provide it.

In 2018, the community filled a gap in healthcare by releasing guidelines for gender-affirming healthcare in Aotearoa.

Soul grew up with his grandparents, but his gender identity wasn't something he opened up to them about.

As a teenager without a licence, when he had appointments that meant having to come up with reasons why he'd need to be driven to Palmerston North so frequently. They were always really good about it though, he says.

Sometimes he'd crash at a mate's house in town to get to an appointment. At other times his only choice was to miss school. "You start to prioritise; school or your happiness and wellbeing."

Cost is a real barrier to accessing healthcare too, six out of every ten trans and non-binary people simply can't afford to visit a GP.

But for trans and non-binary people, finding work can be stressful.

"You get the standard anxiety about whether your workplace is going to be accepting; are you going to have to fight to have the name you prefer on your badge, are they even going to accept your application and call you up?"

In the Manawatū region, there's a few safe places, Soul says. "Like New World's epic, if you're going to work that's where you're going to go but," with a chuckle he quips; "not everyone can work at New World."

Sometimes the only other option is farm work. But for people who wear a binder, it's unsafe to work such a physical job.

"When someone can't engage with school or engage with work, because of whatever transitioning looks like for them, it becomes a barrier and they can't engage with society."

***

Counting Ourselves data shows that the unemployment rate for trans and non-binary people is more than double that of the general population.

Almost three quarters of trans and non-binary people in employment don't disclose their gender identity because they fear being discriminated against. The Counting Ourselves researchers say this is understandable, as many participants reported negative experiences when co-workers were aware of their gender.

The annual median income for trans and non-binary people is $15,001- $20,000 which is far below that of the general population whose median income according to the 2016/17 NZ Health Survey is $35,001 - $40,000.

***

"Being in a community that hasn't been counted before, we can't underestimate the importance of this research because for the first time ever, we'll be able to put numbers behind the experiences of trans and non-binary people in Aotearoa," says Jack Bryne.

"We hope that these numbers will mean people will take the issue seriously and that it's a wakeup call about the need for action."

The recommendations

Create clear pathways for gender-affirming healthcare, including training, resources and culturally appropriate services

Ensure health services respect gender diversity

Improve trans and non-binary people's mental health and wellbeing, as a named priority in mental health and addiction policies

Support schools to be safe and inclusive for trans and non-binary students

Better protect trans and non-binary people from discrimination

Protect trans and non-binary people from violence, as a priority in sexual and domestic violence work

Simplify processes for trans and non-binary people to have accurate health records and identification documents

Support health and wellbeing initiatives led by trans and non-binary communities.

* Names have been changed

** Trans and non-binary are used as umbrella terms for people whose gender/gender expression is different to their gender/sex assigned at birth, while acknowledging that these are Pākehā terms that cannot fully describe the meaning of genders that come from other languages or cultures.

Where to get help:

Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.

Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.

OUTLine: 0800 688 5463

Rainbow Youth: (09) 376 4155

Gender Minorities Aotearoa

Lifeline: 0800 543 354 or text HELP to 4357

Depression Helpline: 0800 111 757 (24/7) or text 4202

Samaritans: 0800 726 666 (24/7)

Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email talk@youthline.co.nz

What's Up: online chat (3pm-10pm) or 0800 WHATSUP / 0800 9428 787 helpline (12pm-10pm weekdays, 3pm-11pm weekends)

Kidsline (ages 5-18): 0800 543 754 (24/7)

Rural Support Trust Helpline: 0800 787 254

Healthline: 0800 611 116

Sexual Violence:

NZ Police

Victim Support 0800 842 846

Rape Crisis 0800 88 33 00

Rape Prevention Education

HELP Call 24/7 (Auckland): 09 623 1700, (Wellington): be 04 801 6655 - 0

Safe to talk: a 24/7 confidential helpline for survivors, support people and those with harmful sexual behaviour

Shakti 0800 742 584 Domestic violence intervention services for women of Asian, African or Middle Eastern origin

If it is an emergency and you feel like you or someone else is at risk, call 111.