In 2013, at one of the lowest points in her life, 44-year-old software engineer Greta Martela placed a call to the National Suicide Prevention Hotline. She had been hospitalized five times for being suicidal, starting at age 28, when she realized she was transgender. But she was still struggling with coming out to the wider world. When she disclosed to the counselor that she was transgender, he was confused about what that meant. Once she explained, “he got off the phone as quick as he could,” she said.

Martela went to the Berkeley, California, hospital he recommended, but the ER staff there was similarly ill prepared to work with transgender clients. “I had to argue with them about my gender pronouns,” she recalled. She was soon checked into a psychiatric hospital, where she waited for 24 hours to speak to a doctor. When she did, the psychiatrist spent less than 10 minutes with her.

“I actually did a Google search for ‘transgender suicide hotline,’ and nothing came up,” she said, recalling the experience. “I was surprised even then.”

As a Mormon teenager moving around California, Martela had run away from home and gotten involved in the Goth scene because of her parents’ issues with her gender presentation. After her experience in Berkeley, she decided to come out and begin her transition. Just a year later, she launched the first suicide and crisis counseling service created specifically by and for transgender and gender nonconforming people.

While research into transgender mental health issues is still scarce, what little there is suggests that her experience is common. Rates of attempted suicide are 35 percent higher for transgender people than among the general population, and medical services often pose additional obstacles to transgender people seeking care. According to a 2011 report based on the national transgender discrimination survey (a joint project of the National Gay and Lesbian Task Force and the National Center for Transgender Equality), 28 percent of respondents reported being harassed in medical settings, and 19 percent said they were refused care because of transphobia. Half the respondents said they had to explain to their medical provider what “transgender” meant.

“Being exposed to these further stressors when you’re at a point of crisis already can be really tragic,” said Ry Testa, an assistant professor of psychology at Rhodes College in Tennessee. “So a lot of transgender people may be leery to seek out those resources.”