Victorian Coroner finds that trans and gender-diverse people face discrimination in healthcare
Inquest into the death of ‘AS’ (a pseudonym) (COR2021/002415), Findings, Coroner Giles.
Content Warning: This case note discusses suicide, self-harm and gender identity discrimination. Readers may find it distressing. Support can be accessed through Lifeline and QLife. Information on other support services can be found on Transhub and ACON.
On 29 August 2024, the Coroner handed down her findings in the inquest into the death of AS.
AS died of sodium nitrite toxicity on 9 May 2021. She was at her home in Reservoir, Victoria on an online call to a friend in New South Wales (NSW) at the time she ingested the substance that caused her death.
AS faced several complex issues during her life, and had diagnoses of autism spectrum disorder, generalised anxiety disorder, major depressive disorder, oppositional defiant disorder, gender dysphoria, and gaming addiction in partial remission.
Her death was a ‘reportable death’ under the Coroners Act 2008 (Vic) because it occurred in Victoria and was considered unexpected, unnatural or to have resulted, directly or indirectly, from an accident or injury. While inquests into suicide are rare, shortly prior to and following AS’ death in May 2021, the Coroners Court of Victoria (Court) received reports of multiple suicides of transgender or gender diverse (TGD) people. These were not the only suicides of TGD people reported to the Court throughout this period, however there were multiple common features in relation to the circumstances of their deaths. These include that the deceased were all young people who had affirmed or were on a journey to affirming their identity as female; some were known to each other; they had all experienced mental ill health; some had been linked with service providers from a young age, and faced a degree of social isolation during the COVID-19 lockdown periods. On this basis, the cases were referred to the Coroners Prevention Unit for joint consideration and advice.
The coronial inquest proceeded on 27 - 29 November 2023 and 21 February 2024.
Key Findings by the Coroner
Determination as to intent
AS intentionally ended her own life in the context of multiple stressors and longstanding mental health issues and suicidal ideation.
Adequacy of health services engage by AS in the lead-up to her passing
No findings in relation to the adequacy of the clinical care provided to AS, although it was noted that there was no engagement with mental health or gender affirming services proximate to her passing.
Mental ill health and suicidality in the TGD community
Members of the TGD community face disproportionate rates of distress, mental ill health, and suicidality compared to the population as a whole. There are many reasons for this, which are frequently linked to the broader community’s responses to TGD people, such as discrimination, violence and exclusion.
Data on mental ill health, distress and suicidality amongst the TGD population is incomplete, including in relation to the incidence of completed suicides. Robust data is needed as a matter of priority to inform health, wellbeing and suicide prevention initiatives in the TGD community.
Provision of culturally appropriate gender-affirming care
Significant barriers exist for TGD people affirming their identities, particularly via a medical pathway. Further, delayed or denied access to treatment is linked to greater likelihood of suicidality compared to those whose treatment is timely and comprehensive. This demonstrates a clear need for improved access to gender-affirming healthcare and medical care.
Provision of suicide prevention and postvention supports
The provision of culturally-appropriate suicide prevention and postvention supports for the LGBTIQA+ community is particularly critical given the impacts of suicide contagion on and in TGD communities. Suicide contagion was a factor in at least three out of five suicides in the proceedings.
Provision of social and emotional wellbeing supports
Risks to the wellbeing of TGD patients from long waitlists for gender-affirming care, high costs, and ongoing workforce issues are compounded by the fact mainstream health services are often not genuinely accessible or culturally safe for many TGD people.
There is a clear need to devise and implement a statewide framework for the provision of culturally-appropriate care to TGD people in public hospitals and health services, including in rural and regional Victoria, with additional training on delivering culturally-appropriate care to TGD persons.
Culturally-appropriate supports for TGD people and their families are needed as a means to reduce social isolation, improve connectedness and wellbeing.
Further prevention opportunities
Cultural safety, visibility, dignity and respect to all deceased persons and their loved ones throughout Court processes is critical to the Court’s prevention function. Improvements to the Court’s processes in concert with entities such as Victoria Police will provide greater visibility of preventable deaths in the TGD community and more targeted strategies to reduce them.
Recommendations
The Assistant Minister for Mental Health and Suicide Prevention investigate, in conjunction with other appropriate Ministers, Departments and Agencies of the Commonwealth, ways to further restrict the online sale and distribution of sodium nitrite in Australia.
Victoria Police, in accordance with Priority Area 3 of ‘Pride in our future: Victoria’s LGBTIQA+ strategy 2022-32’ progress, as a matter of priority, steps to improve data collection in relation to TGD people to capture all gender identities.
The Victorian Department of Health as lead, in conjunction with the Department of Families, Fairness and Housing and any other relevant Victorian Government departments, consider urgently increasing resourcing to meet the growing demand for publicly funded health services delivering gender-affirming care to TGD patients, to reduce the current waitlists and to support and expand the existing health workforce delivering such care.
The Victorian Department of Health, under the guidance of experts from TGD communities, consider devising and implementing a statewide framework for the provision of culturally-appropriate care to TGD people in public hospitals and health services, including in rural and regional Victoria. This should include additional training to support staff delivering culturally-appropriate care to TGD patients.
The Victorian Department of Health, as lead, in conjunction with the Department of Families, Fairness and Housing and any other relevant Victorian Government departments, consider ongoing funding options available to ensure that TGD people and their families have appropriate access to culturally appropriate social and emotional wellbeing supports; and suicide prevention, postvention and bereavement supports.
The Royal Australian College of General Practitioners and Royal Australian and New Zealand College of Psychiatrists, under the guidance of experts from TGD communities, develop and offer training and support to all healthcare professionals under their remits, with the aim of ensuring cultural safety for TGD people accessing health services across these settings. This includes training on the factors that can contribute to the risk of suicide in these communities.
The State Coroner of the Coroners Court of Victoria, under the guidance of experts from TGD communities, consider introducing a LGTBIQA+ awareness training module, with a TGD-specific component, into the induction training for all staff and Coroners, specifically addressing the factors that can contribute to the risk of suicide in these communities.
Comments
The Equal Opportunity Act 2010 (Vic) precludes discrimination on the basis of gender identity, in the provision of services, including healthcare services, and contains a positive duty to eliminate discrimination.
Access to healthcare is also a fundamental human right under the International Covenant on Economic, Social and Cultural Rights (ICESCR) and United Nations Committee on Economic Social and Cultural Rights General Comment 14. However, Australia has not incorporated the ICESCR into domestic law. Further, the Charter of Human Rights and Responsibilities Act 2006 (Vic) does not explicitly include a right to healthcare.
The provision of healthcare also engages rights to autonomy and equality. This requires consideration of what constitutes ‘substantive’ over mere ‘formal’ equality. As noted by the Human Rights Committee in relation to article 18 of the International Covenant on Civil and Political Rights, “the enjoyment of rights and freedoms on an equal footing … does not mean identical treatment in every instance”. In the context of access to gender-affirming health care for TGD people, a substantive equality approach recognises that while the majority of the population does not require access to such care, access to gender-affirming care “may be essential for TGD people to achieve the highest attainable standard of physical and mental health”. This human rights framework should be borne in mind in resourcing, planning, and designing health services in Victoria.
If you are feelling distressed after reading this case note, you can access support through Lifeline and QLife.
Information on other support services for trans and gender-diverse people can be found on Transhub and ACON.