Preventing suicide among

trans young people

A toolkit for nurses
Suicide prevention with trans young people

Acknowledgements
This toolkit is a collaboration between the Royal College of Nursing (RCN) and Public Health
England to support and develop the role of nurses in the prevention of suicide among trans
young people.
Public Health England exists to protect and improve the nation's health and wellbeing,
and reduce health inequalities. It does this through world-class science, knowledge and
intelligence, advocacy, partnerships and the delivery of specialist public health services.
PHE is an operationally autonomous executive agency of the Department of Health.
The Royal College of Nursing (RCN) is the voice of nursing across the United Kingdom and is
the largest professional union of nursing staff in the world. The RCN promotes the interest of
nurses and patients on a wide range of issues and helps shape healthcare policy by working
closely with the UK government and other national and international institutions, trade unions,
professional bodies and voluntary organisations. To join the RCN please call RCN Direct (24
hours) on 0845 772 6100 or visit our website at www.rcn.org.uk
Public Health England
Wellington House
133-155 Waterloo Road
London SE1 8UG
Tel: 020 7654 8000
www.gov.uk/phe
Twitter: @PHE_uk
Facebook: www.facebook.com/PublicHealthEngland

Prepared by: Colleen Dockerty, Luis Guerra.

The following people have helped to develop this document by sharing their expertise: Dr Justin Varney,
Dominic Walsh, Seamus Watson, Ian Hulatt, Joanne Bosanquet, Nuno Nodin (PACE), Dennis Carney,
Lily Makurah, Gaynor Aaltonen, Jay Stewart (Gendered Intelligence), Terry Reed OBE (Gender Identity
Research and Education Society), Bernard Reed OBE (Gender Identity Research and Education
Society), Susie Green (Mermaids), Sarah Grayer (Space Youth Project), Maeve Devine (All Sorts),
Kevin Mantle (Government Equalities Office).

For queries relating to this document, please contact: [email protected]

© Crown copyright 2015
You may re-use this information (excluding logos) free of charge in any format or
medium, under the terms of the Open Government Licence v2.0. To view this licence,
visit OGL or email [email protected]. Where we have identified any third
party copyright information you will need to obtain permission from the copyright holders
concerned.
Published March 2015. PHE publications gateway number: 2014801
2
Suicide prevention with trans young people

Contents
Acknowledgements ............................................................................................................... 2
Contents ................................................................................................................................ 3
Executive summary ............................................................................................................... 4
Definitions ............................................................................................................................. 6
Statistics and current landscape ............................................................................................ 8
What does the law say? ........................................................................................................ 9
Confirming and expressing a gender identity ......................................................................... 9
Discrimination and transphobia ........................................................................................... 10
Mental health of trans young people .................................................................................... 10
Suicide risk and protective factors ....................................................................................... 12
Other factors to consider ..................................................................................................... 13
Working with trans young people ......................................................................................... 14
Motivational interviewing techniques ................................................................................... 18
Effective communication ...................................................................................................... 19
Confidentiality and consent.................................................................................................. 22
Next steps ........................................................................................................................... 23
Resources for trans young people ....................................................................................... 24
Resources for you on mental health and suicide ................................................................. 26
Resources for you on trans health ....................................................................................... 27
Reflective checklist .............................................................................................................. 28
References .......................................................................................................................... 30

3
Suicide prevention with trans young people

Executive summary
Suicide often comes at the end point of a complex history of risk factors and distressing events.
Suicide prevention has to address this complexity. No suicide is ever inevitable, and this guide
provides a toolkit to support nurses working with young people who may be trans, to support
their distinct needs.

The National Suicide Prevention Strategy ‘Preventing suicide in England’ provides a national
approach to suicide prevention that recognises the contributions that can be made across all
sectors of our society. It draws on local experience, research evidence and the expertise from
members of the National Suicide Prevention Strategy Advisory Group, some of whom have
experienced the tragedy of a family suicide.

The national suicide prevention strategy supports a tailored approach to improve mental health
in specific groups including:

 children and young people

 people who are especially vulnerable due to social and economic circumstances
 lesbian, gay, bisexual and transgender people
 black, Asian and minority ethnic groups

Nurses play a crucial role in health care by providing compassionate and inclusive care to all.
As nurses, there is a duty to be constantly aware of those who may be vulnerable, regardless
of their demographic and the symptoms that they initially present with. Because most people
who take their own lives are not in touch with mental health services, the possibility that nurses
may come into contact with a suicidal person inside or outside of the health care arena is
significant.

The Royal College of Nursing Congress has highlighted the importance of addressing problems
affecting trans people, and the need to support nurses to work with them effectively. 1,2 At the
same time, the Department of Health has implemented a cross-government outcomes strategy
to prevent suicide in England.3 This toolkit is part of the broader effort to improve the support
and training for nurse when trying to avert suicide.

As trans young people’s sense of self develops, sometimes in an emotionally unsupportive

environment, trans young people’s fear of rejection from family, peers and society can creates
a sense of ‘otherness’. This can leave trans young people particularly vulnerable to depression
and suicidal thoughts.

One study in the UK found that 34.4% of trans adults had attempted suicide at least once and
almost 14% of trans adults had attempted suicide more than twice. 4 This higher risk of suicide
is related to experiences of discrimination, including stigma, transphobia and bullying. These
negative experiences occur in many trans individuals’ everyday lives, whether at home, work or

4
Suicide prevention with trans young people

school. This stigma and discrimination, and the fear of it happening, can make individuals in
this situation feel unable to reach out for help when they need it.

As nurses, we can help develop an inclusive clinical environment that makes it clear that we
welcome diversity and support young people, explicitly including trans youth. We can make
sure that we are not marginalising the people who most need our support at times of personal
crisis. We also have a duty to ensure that vulnerable people in our care are kept safe from
preventable harm. We need to be prepared to intervene quickly when someone is in distress or
in crisis, and this toolkit provides a basis for this potentially life-saving support.

Audience

This toolkit is designed primarily for nurses who work with children and young people, whether
in community or hospital settings, including school nurses, practice nurses and accident and
emergency nurses.

Aim

This toolkit helps you develop your skills and knowledge and recognise the wider context of
mental health in relation to trans young people and their identity. It provides a general outline
for health professionals looking to increase their skills and knowledge around suicide
prevention strategies with trans young people.

The national strategy recommends that frontline staff working with high-risk groups receive
training in the recognition, assessment and management of risk and fully understand their roles
and responsibilities. Our ambition is to have this toolkit integrated as a supporting document
within the national suicide prevention strategy.

Using the toolkit

Identifying suicidal individuals and responding appropriately can prove challenging. This toolkit
was developed with reference to the latest available research and published studies worldwide.
Suicide prevention strategies are most effective when combined with wider work addressing the
social and other determinants of poor health, wellbeing or illness.3 The toolkit is divided into two
main sections to help practitioners understand both the broader issues and practical skills and
tools.

What this toolkit does not include

This toolkit is does not replace training on mental health, equality and diversity or any other
training on trans communities. It does not replace clinical training on gender reassignment,
medical care or care pathways for trans people. Further resources and links to other useful
organisations can be found at the end of this document.

5
Suicide prevention with trans young people

Often trans young people are discussed within the larger context of lesbian, gay, bisexual
people. While some trans individuals may identify as lesbian, gay or bisexual, others identify as
heterosexual. Sexual orientation – who you are attracted to – is different from gender identity –
who you know yourself to be. Therefore, we have focused on gender identity as a distinct issue.
So while some topics in this toolkit are applicable to LGB communities, others are not. For
more information on LGB young people, see the companion document: Suicide Prevention with
LGB young people.

Definitions
The term ‘trans’ encompasses a diverse population and real individuals. The term ‘trans’ can
refer to anyone whose gender identity does not completely match the sex they were assigned
at birth. Gender identity may be innate and associated with neurobiological factors. 4 Gender
expression and gender role, however, are social constructs that vary with cultural setting. A
person’s gender expression may change over time.

While language is important, it is important to respect each individual. Assumptions should not
be made about a person’s gender based only on their presentation. At an individual level start
by asking a young person how they identify, and what terms they feel most comfortable with.
This is an important part of building trust and rapport with young people, demonstrating
respects and understanding how they view themselves.

The following is an overview of terms and related definitions to help us all better understand the
complexities of gender identity, gender expression and gender roles:

Sex: biologically determined, comprised of male or female, chromosomes, genes,

hormones, phenotype, anatomy and physiology.

Gender role and expression: socially constructed, this encompasses the roles, attitudes,
norms and behaviours ascribed to being a boy/man or a girl/woman; these roles are
learned and can change over time and differ between cultures. There can be pressure from
society to conform to the norms typically associated with the assigned sex. This can create
discomfort in those whose gender identity doesn’t match.

Gender identity: the sense of self; how individuals perceive themselves and what they call
themselves. Gender identity can be the same or different from the sex assigned at birth.

Transgender: broad term for those who do not conform to typical societal gender roles,
identities, behaviours and dress. This includes those who cross dress, people who wear a
mix of clothing, people who perform dressed in drag, people with a dual or no gender
identity, and transsexual people.

6
Suicide prevention with trans young people

Transsexual: someone whose gender identity is does not match the sex assigned at
birth, and who may therefore live permanently in the gender role that matches their
gender identity. They may seek gender reassignment. Although used in legislation, this
term is rejected by some as overmedicalising or pathologising.

Trans: an broad and inclusive term used in the UK for those who do not conform to
typical gender boundaries; viewed as a more respectful and inclusive than the terms
transgender or transsexual.

Intersex: someone who is born with atypical physical sex characteristics, including varied
chromosomal patterns, mixed development of sex-specific organs, ambiguous genitalia
and/or differences in the way sex hormones are either produced or metabolised. Intersex
individuals are assigned a sex at birth.

Gender fluid: some individuals do not identify as a boy or a girl, a man or a woman.
There are endless terms used to describe those who do not identify with a specific gender
role, including: agender, bigender, thirdgender, pangender, poly gendered, androgenous,
genderqueer, two spirit, gender-neutral and non-binary. They may use unusual pronouns,
such as per, zie, fey and titles such as Mx or Mz.

Cisgender: a cisgender person’s gender identity is the same as the sex assigned at birth,
ie, a non-trans person.

Trans man: a person who identifies as a man and was assigned the female sex at birth,
also known as FTM (female to male).

Trans woman: a person who identifies as a woman and was assigned male sex at birth,
also known as MTF (male to female).

Transphobia: an emotional disgust, irrational fear or hatred toward individuals who do

not conform to society’s gender expectations.90

Gender non-comforming: not conforming with society’s views of gender roles and
expression.

Passing: when a trans person is not visible as a trans person and is being perceived as
the gender they are presenting as. Those who do not ‘pass’ have some noticeable
features of their birth sex – which often means that other people may regard a trans
woman as a man; or a trans man as a woman.

Transition: the process of change in presentation between gender roles.

Gender reassignment: the intention to undergo, undergoing or having undergone

transition socially, which may include hormone treatment or and/or surgery to alter
physical characteristics to match one’s gender identity. Gender confirmation or gender-
affirming treatment are sometimes preferred terms.

7
Suicide prevention with trans young people

Be aware that language is dynamic and evolves over time. Terms, definitions, and how trans
individuals identify can vary. This is based upon a number of factors, including context,
geographic region, race/ethnicity, immigration background, culture, religion and socioeconomic
status. For example, some men or women who were assigned the opposite gender at birth and
have transitioned to living full time and permanently in a different gender do not identify as trans
men or trans women – but more simply as men or women. Again, it is most important to focus
on the individual, not make assumptions and ask what terms they want to use.

Statistics and current landscape

The real picture of the trans population is uncertain. Many national surveys do not ask about
gender identity and if asked, many individuals do not disclose due to fear of discrimination.
However, there is clear evidence that the number of trans people becoming visible is growing
very rapidly.5; 6

How many trans people are there in England?

There are no existing UK or England wide studies that give a full picture. What studies are
available measure different segments of the trans population and are not comparable.
However, the following provides estimates from government agencies and gender identity
organisations:

 in 2000, it was estimated there were 5000 trans people in the UK 4

 in 2006, 1,660 people had received a Gender Recognition Certificate4
 in 2009, an estimated 3500 people had gender reassignment surgery5
 approximately 1,200 people present to go through a gender transition per year 5
 in 2012, a survey estimated that one in 100 people experience a significant
degree of gender nonconformity7

How many trans young people are there?

The UK’s main gender identity service received 84 new referrals in 2009 and the number of
children and young people referred annually is growing rapidly.5,6 A study in New Zealand in
2014 found that in a cohort of 8,166 students, 1.2% reported being transgender, 2.5% reported
being not sure about their gender.8

Many people will not identify as trans until adulthood.4;5;9;10 However, the majority of trans
adults report having sensed that they identified with a different gender in childhood. 5;11;12 So
you should be sensitive to the needs of both trans young people and young people who are in a
process of questioning and exploring their gender identity.

Public Health England is working with partners to explore better ways to monitor gender
identity. Part of this work is supporting both nurses to feel more comfortable working with trans
people, which this toolkit aims to do.

8
Suicide prevention with trans young people

What does the law say?

The 2010 Equality Act13 makes ‘gender reassignment’ a protected characteristic. Anyone who
is, or is perceived to be, trans is protected from discrimination. This means that anybody with
this characteristic is protected from discrimination in various areas of life covered by the
Act. For example, any service provider, whether publically or privately funded, cannot
discriminate against, harass or victimise trans people. This means that refusing a young person
access to a service because they are trans could be unlawful unless there is an exception in
the Equality Act authorising this.

The Gender Recognition Act enables a trans person who meets its criteria to have a gender
recognition certificate (GRC), which qualifies them automatically for a new birth certificate, as
long as the birth was registered in the UK. The act states that: “It is an offence for a person who
has acquired protected information (about gender recognition) in an official capacity to disclose
the information to any other person.”14;15 This means that a nurse, or any other health care
professional, should not disclose that a trans individual is trans and/or that the gender they
identify with does not align with the sex they were assigned at birth. The permission of the
person should still be sought, before disclosure to another person, unless in medical
emergencies or directly relevant to clinical care.14;15 However, the Gender Recognition Act 2004
does not apply to under 18s. A young person seeking one would have to demonstrate that they
had lived in role for two years and had a diagnosis of gender dysphoria.

Under the Data Protection Act, information about a person’s gender nonconformity is regarded
as sensitive.

The Human Rights Act protects the rights of trans people to privacy. It works hand in hand with
the Equality Act, to ensure dignity, respect and autonomy.

Remember Gillick competence and Fraser guidelines apply to all children under 16. 16

Confirming and expressing a gender

identity
Confirming and expressing a gender identity should be a positive and empowering experience
for everyone; it is a normal part of growing up and finding our way in the world. Many young
people go through a journey of gender non-conformity, gender questioning and experiment with
gender expression. Young people should be supported in their journey of self-exploration and
realisation; some will go on to transition as adults. For those that do, the understanding of
themselves as not fitting cultural expectations should be a validating and empowering
experience, but it has the potentially added dimension of adverse judgement from peers, family
and friends.

9
Suicide prevention with trans young people

Realising at a young age that you are ‘different’ from those around you can be isolating,
frightening and difficult. Society and institutions like schools, health services and youth groups
don’t always help, because they have just one vision of what ‘normal’ looks like. 17 While no
generalisations should be made about the overall experience of trans people, developing
confidence in expressing a gender identity where cisgender identity is the norm remains a
challenging experience, due to stigma and marginalisation.18;19;20

The emergence of an new identity may be a complex journey for an individual. It may also be
difficult or traumatic, especially if the reactions of peers, family and friends are negative.21 It
may involve changing names, documentation, taking hormones, and transitioning socially.
Some may choose to do all of these things; others may only disclose their gender identity
partly. This could mean for instance, being open with extremely close friends in certain social
circumstances, but continuing to live most of the time in the gender role that was expected of
them since birth. Regardless of how an individual presents, you should always refer to the trans
person with the names and pronouns they prefer.

Discrimination and transphobia

Experience of discrimination and transphobia can fluctuate throughout a trans person’s life. The
worst discrimination is often experienced during the early stages of transition or recently after.5

Hostility and harassment can be a real problem for trans young people. In the UK, trans people
experience high levels of harassment by strangers on the street, verbal abuse, assault with a
weapon, sexual assault and trauma, even as children and young people.4 In a study in the UK,
73% of trans people report harassment and 10% report experiencing threatening behaviour in
public spaces.4 Research in the US mirrors research in the UK. In a study in Boston,
Massachusetts, transgender young people reported more than double the experience of
perceived discrimination than cisgender young people.22 Another study in the US showed that
78% of trans people had experienced verbal harassment and 48% had been assaulted. 10

For young people who are going through a process of physical changes that conflict with the
gender identity can be extremely distressing. Harassment often starts or increases during
puberty for trans individuals.4 This often happens at school, an environment where one should
be learning, developing friendships, becoming more confident and developing an identity. In the
UK, 64% of young trans men and 44% of young trans women experienced harassment or
bullying at school and 25% of trans individuals experienced physical abuse at school. 4 Although
lesbian, gay and bisexual young people experience high levels of harassment and bullying in
school, these negative life experiences in trans young people experience are even higher.4
Bullying at school is linked to high levels of absenteeism and truancy,4 potentially affecting
educational attainment and employment potential in later life.

10
Suicide prevention with trans young people

Mental health of trans young people

Trans people experience significant inequalities relating to health, wellbeing and broader social
and economic circumstances, despite the significant recent improvement in social attitudes and
laws that protect13 and uphold their rights.23;24;25;26

A number of studies suggest that trans people are at higher risk of depression, self harm,
substance misuse, suicidal thoughts and behaviour, and suicide attempts than cisgender
people.22;27;28 All of which are reliable indicators of future suicide risk.29;30

Various studies highlight the high rates of depression and self harm among trans young people
and adults. In the UK, more than one in three trans young people have experienced major
depression.27 In a study in San Francisco, more than one in two trans adults reported
depression.28 In the UK at least one on two trans young people report self-harm.12;27 Trans
young people also have high rates of substance misuse, another risk factor for suicide. 31;32

There is a strong evidence base that demonstrates the negative impact of discrimination and
stigma on trans young people. The result is increased substance misuse, depression, self-harm
and suicide.22;33

Although it can be hard to play a role in preventing discrimination and stigma happening, you
can play an important role in mitigating its effects and helping trans young people. We will
explore some suggestions about how to do this later in the toolkit.

11
Suicide prevention with trans young people

Suicide risk and protective factors

The likelihood of a person taking their own life depends on several factors. Risk factors help
explain suicidal behaviour including past ideation and attempts. Protective factors make people
less likely to consider suicidal thoughts and behaviours.

Risk factors3;61 Protective factors3;61

 gender – men are three times as  access to effective care

likely to take their own life as  restricted access to lethal
women means
 mental illness  community support
 lack of social support  coping skills
 sense of isolation  strong family connections
 loss of a relationship
 alcohol and drug misuse
 treatment and care received after
making a suicide attempt
 physically disabling or painful
illnesses, including chronic pain
 suicide attempts by acquaintances

Identifying risk and protective factors and understanding their roles is central to preventing
suicides.34 Risk and protective factors can be biological, psychological or social, affecting the
individual, the family and environment.35 For many people, it is the combination of factors that is
important – rather than one single event. Stigma, prejudice, harassment and bullying can all
contribute to increasing an individual’s vulnerability to suicide.3;33

For trans young people

While most factors affecting suicide rates of trans young people are the same as those
affecting all young people36, there are some additional risk factors to consider. Psychosocial
stressors associated with being trans, including gender nonconformity, transphobia, lack of
support, dropping out of school, family problems, suicide attempts by acquaintances,
homelessness, substance abuse, and psychiatric disorders, elevate their risk of suicide. 35;37
Where protective factors are sufficiently strong, even the presence of several risk factors may
not create the conditions for suicidal ideation or behaviour.34

12
Suicide prevention with trans young people

Risk factors Protective factors

 psychosocial stressors associated  access to inclusive care

with gender nonconformity  community and school
 discrimination and transphobia support
 dropping out of school  strong relationship with family
 bullying and friends
 family problems  increase self-esteem levels
 homelessness
 psychiatric disorders

References: 34;35;61;95

Other factors to consider

Cyber-bullying
Young people who have experienced cyber-bullying are almost twice as likely to attempt
suicide compared to those who have not.38 Evidence shows that trans young people seek
accepting peer groups and social support through internet sites and related technologies to a
greater degree than their peers.39;40;41 This may be due to the need for privacy and anonymity
to access a supportive environment.41 In particular, social media sites have been embraced by
young trans individuals as spaces where they can explore their identity and interact with
others.42 However, cyber-bullying has become an increasing problem for all young people38
and young trans people may be particularly vulnerable in this space.

Young people who encounter cyber bullying can experience the same feelings of isolation,
powerlessness and hopelessness as if they were being bullied face-to-face. Because of the
nature of the technology, it can be hard for victims to escape the situation. They are reluctant to
disconnect from supportive friends or relations, via the internet and their phones.

In the majority of cases, online contacts decrease isolation and build positive relationships.
Further research is needed on how social networking and other internet applications can raise
– or lower – risks of suicide among trans and other young people.35

Ethnicity and cultural background

Research indicates that some cultural, ethnic and religious groups may be less welcoming and
accepting of trans young people.43 It is highly possible that young people who live within
13
Suicide prevention with trans young people

communities that strongly oppose trans groups can suffer from higher levels of stress, and that
can lead to increased risk of depression, anxiety, or thoughts of suicide.44

For asylum seekers language barriers, racism, and legal uncertainties can lead to depression
and social isolation, two of the most important risk factors for suicide. Some young people may
be asylum seekers because of their gender identity, following rejection and fear of persecution
in their country of origin.

Religion and faith

Religion and faith are important factors in suicidal behaviour. Faith can be a protective factor,
an important source of solace, support, reflection and renewal. Research shows a relationship
between low levels of suicide rates in religious groups where suicide is strictly forbidden. 45 At
the same time, faith and religions that believe in reincarnation are among those with the highest
rates of suicide.34 Young gender variant people within communities of faith where the religious
doctrine is not supportive may face significant additional stress and potential rejection from their
community.

While some religions and faith organisations remain unwelcoming of trans individuals, the UK
has a strong network of trans friendly faith-based organisations.46 More research needs to be
done in relation to religion and faith and suicide among young people.

Homeless young people

Being homeless is always associated with a higher suicide risk. Young homeless people have
higher rates of mental illness and are at higher risk of having suffered sexual abuse, violence
and substance abuse.47 For trans young people, the risk may be even higher. Although there is
limited research, evidence suggests that trans young people are more likely to experience
homelessness than their cisgender peers.48;49;50 This is often a result of actual or feared initial
rejection in the household when they first come out about their identity at home.50

Working with trans young people

Local responsibility for coordinating and implementing work on suicide prevention is an integral
part of local authorities’ new responsibilities for leading on local public health and health
improvement. Public Health England will also support local authorities, the NHS and their
partners across England to achieve improved outcomes for the public’s health and wellbeing,
including work on suicide prevention.

This toolkit looks to help build a trans-friendly practice that is welcoming and safe. However,
this process is not always simple, and some people might have concerns about working with
trans young people or might have some questions about why being trans-friendly is important.

Trans young people deserve respect and good quality healthcare in line with the commitments
made in the NHS Constitution.51 There is research to suggest that trans young people
14
Suicide prevention with trans young people

sometimes have difficulty disclosing their trans status to healthcare practitioners and have
concerns about their confidentiality being respected. In the UK some trans people have
reported encountering health care professionals who did not want to help, refused care, did not
approve of their gender variant identity. Some report feeling that being trans adversely affected
the way they were treated by health care professionals.4 Substantial proportions of trans young
people report experiencing negative interactions in accessing health services at a gender
identity clinic (62%), in general mental health services (63%) and in general health services
(65%).27

We do not expect everyone to become an expert in supporting trans young people after reading
this toolkit, but believe it is a good starting point in our wider efforts to prevent suicide and to
improve individual practice and care for young people.

15
Suicide prevention with trans young people

Practicalities: how to talk with and care for trans

young people
Does your gender identity match completely the sex you were registered at birth?

Have you gone through any part of a process, or do you intend to bring your physical sex
appearance, and/or your gender role, more in line with your gender identity?

6
Have you changed your name, your appearance and the way you dress?

Do you want to change the way you are living your life?

How would you like things to be different?

Are you happy with your assigned gender?

Have you told anyone else about your feelings?

Would you like to tell your family?

Do your friends know?

Are you scared to tell anyone? 52

If a trans young person is discussing their identity with you, here are some things you could say
to respond supportively:

It is very brave of you to come and talk to me, and I am really pleased that you felt able to do
that.

It’s not easy to live with a secret.

You know, although it might feel unusual, there are other young people who feel the same
way as you do, so we can make contact with them. You are not alone. 52

16
Suicide prevention with trans young people

Clear, non-judgmental, and confidential communication plays a critical role in building a safe
space for trans young people. Remember this might be the only time young people can be
open about their identity. Here are five simple tips to help you build rapport and make a
conversation easier.

Ensure confidentiality. Spend part of every visit with young people alone. By
asking them in private if they want their parent, partner, peer or other support
1 person involved in their care, they will be more likely to give you a more
. comfortable answer.

Begin by discussing confidentiality and its limits. This helps build trust and
explains the basis for mandated reporting. If you are unclear of the limits to
2 confidentiality, contact your practice child protective services for more
information. Note that an expression of gender nonconformity is not itself a
safeguarding issue and does not need to be communicated to others.

Use appropriate language. This language may be gender-neutral or guided by

the terms the trans youth prefers. Try using gender neutral terms like, young
3 people, people, parent, child, family member instead of he, she, boys, girls,
men, women, mother, father, daughter, son until you are certain of a young
persons preferred language.

Avoid complex terminology. Simple, straightforward language ensures

effective communication of important information. Check for mutual
4 understanding by asking open-ended questions, and clarifying slang in a non-
judgmental manner (eg, “I’ve never heard that term before, do you mind
explaining what ___ means?”).

Respect their experience and autonomy. Many young people feel that adults
and people in positions of authority discount their ideas, opinions and
5 experiences. Health care providers, perhaps together with parents, can help
young people make wise, healthier decisions.

Remember that many young people are still in the process of exploring their own gender
identity and many will not self-identify as trans. They may be gender variant, gender non-
conforming, genderqueer or uncertain. Just make sure to be welcoming to everyone and to
consider the five tips in order to better facilitate a conversation.

17
Suicide prevention with trans young people

Motivational interviewing techniques

Current research shows that motivational interviewing techniques can be an effective non-
invasive strategy to identify suicide risk factors. BATHE is one technique for conducting brief
assessments, exploring concerns during routine visits. The following table gives some
examples of questions you can use when talking to trans young people while trying to assess
suicide risk factors.

Example questions/comments Purpose

B Background
 What’s going on in your life? Invites young people to talk about the
 Tell me about a typical day for significant matters in their lives by
you using direct, open-ended questions.

A Affect
 How do you feel about that? Asks young people to recognize their
 That situation sounds very feelings and understand how
____. situations affect their emotions and
 Are you feeling___? behaviours.

T Troubling
 What troubles you the most
about problem, situation,
Aims to help young people determine
condition?
why and how significantly a situation
 How has this problem caused
troubles them and how it impacts
difficulties for you at home,
them.
school or anywhere else in
your life?

H Handling
 How are you dealing with
that?
Provides an opportunity to learn
 Could you respond to the
about and reinforce young person’s
situation differently?
own healthy coping strategies and
 What might help improve the suggest additional interventions.
situation or help you feel
better?

E Empathy
 That must be very difficult for Shows the young person’s response
you. to the situation is reasonable.
 Thank you for being so honest Demonstrates understanding for their
with me. position, feelings and perceptions.

18
Suicide prevention with trans young people

Effective communication
There is no perfect way to ask a difficult question. If you think a young person is at immediate
risk for suicide, self-harm or any other health related risk; you should always follow your local
risk protocol, regardless of gender identity.

While not an exclusive approach for trans young people, some components of effective
communication can help you be more inclusive and sensitive to their needs. The development
of a safe, non-judgemental environment that is supportive is always a good place to start. All
young people need to feel safe before discussing their feelings and behaviours, regardless of
gender identity.53 Building rapport, active listening and empathy are other important
components to keep in mind when working to establish effective communication.

Building
Rapport
Active
Listening

Empathy

Effective Communication

Building rapport, practising active listening and expressing empathy, are not always easy
strategies to implement; in particular when trying to identify suicide risk-factors. But there are
some small actions that we can take to have a bigger impact in our risk assessment.

19
Suicide prevention with trans young people

Building rapport
 design your working space to be welcoming to young people. Think about the visible
posters and signs, magazines and leaflets, if there is a waiting room
 begin the visit with an informal conversation. Explain what will happen during the visit
 help them recognize and appreciate their assets and strengths
 use terminology and expressions the young person will understand
 ask for their own input into treatment plans
 summarise findings, treatment plans, and next steps for the young person
 allow time for questions and provide information on community resources (if required)

Active listening
 pay attention to their concerns. Try to understand the young person perspective and
keep an open mind
 use gender-neutral terms when conversing with young people
 avoid interrupting
 minimise note-taking, particularly during sensitive questioning
 notice non-verbal cues such as eye contact, facial expressions, posture, and physical
movements
 ask open-ended questions in a non-judgemental manner

Empathy
 sense the emotion the young person is feeling, then state it back. "You seem tense.
Do you feel worried?"
 validate their feelings by letting them know you appreciate the possible reason for the
emotions
 educate them about mental health and substance use. Refer them to additional
resources and give out emergency contact information. Education helps to reduce
stigma
 highlight protective factors such as caring friends, supportive family, or coping
abilities
 reassure them that she/he is not alone
 honour their emotions and honesty with genuine remarks. Example: "It took a lot of
courage to talk about your feelings." "I am impressed with how well you are doing
under these circumstances"

20
Suicide prevention with trans young people

Sample questions for effective communication

The following are some examples of questions you can use when communicating with any
young person, including trans young people. These are examples and should be used
according to your understanding of the situation, and based on your comfort level. Remember
to be aware of the young person’s own response level. This will help you identify protective or
risk indicators in their answers.

“I’m going to take a few minutes to ask you some sensitive questions. This information is
important and will help me provide better health care to you. Let’s first discuss what
information will be kept private and what information I might have to share with other
people”

Initial questions

 Some of patients I talk to are exploring what it means live as a man or a woman. Is
this something that you think about?
 What do you do when you feel stressed or overwhelmed?
 Do you ever feel very sad, tearful, bored, disconnected, depressed, or blue?
(choose a few, not all, for your question)
 Have you ever felt so sad that you feel life isn’t worth living?
 Do you think about hurting or killing yourself?
 Have you ever tried to hurt or kill yourself?
 Are you thinking about hurting/killing yourself now? Have you thought about it
recently?
 Do you know anyone who has tried to kill themselves, or has committed suicide?

Follow-up questions

 Who have you told about your gender identity, your feelings?
 What are your family’s reactions?
 Is there any adult that you can talk to if you feel depressed or suicidal (mirror youth
language, eg, sad, low, down)?
 Have you ever had counselling or therapy?
 What was that like for you?
 Have you ever been given any medications to affect your mood or behaviour?

Being trans is not itself a risk factor for suicide. However, we need to remember that for many
trans individuals there are higher risk indicators for suicide and self-harm. Keep an open eye for
the following signs in a young person’s responses. They should be an initial indicator for you to
continue further conversations to better assess their risk of suicide.
21
Suicide prevention with trans young people

Confidentiality and consent

Young people list confidentiality as one of the most important reasons for delaying or forgoing
medical care. During a visit, trans young people are more likely to disclose sensitive information
if consent and confidentiality is explained to them and they have time alone with a health care
provider. Nurses are in a privileged position when it comes to finding out a lot of information
about the client. It is possible that trans young people will speak about things with you, which
they have not discussed with their family or friends.

Breaching that trust by disclosing information about a client to someone who has no right to the
information is one of the most serious errors a health care worker can commit. It can lead to
disciplinary proceedings and, if the individual is a registered practitioner, to formal professional
misconduct hearings. More information can be found in the NMC: Guidance on professional
conduct.54

Consent is the means by which an individual authorises interventions in their own care.55
Nursing staff are used to this concept in relation to consent to treatment and records. For
consent to be effective, it must be informed. This means, before recording sexual orientation or
gender identity of a client, it is important to obtain consent and explain the purposes for which
the information is being recorded. If the young person refuses to give consent to record their
sexual orientation or gender identity, it is important to be respectful and mindful of their
decision. In children under 16, Gillick competence and Fraser guidelines apply.

Trusts and practices vary in their approaches to recording sexual orientation in clinical records
and are unlikely to collect data on gender identity. It may be useful to discuss with your team or
line manager what the local position is.

TIPS for better confidentiality and consent

 Be clear with young people up front about confidentiality and its limits. Be as
specific as possible, so that they know what to expect and do not feel betrayed if
something needs to be reported to a parent or child protective services.
 Explain that mandated reporting exists if a young person is at risk of abuse.
Though it can cause confusion at times, it is ultimately for their protection.
 Explain early on the importance of confidentiality between health care providers
and parents. Rather than adversaries, parents can be allies in the provision of
confidential health care for young people.68
 Nurses should never make a record of a client/patient’s sexual orientation or
gender identity without their prior permission.69

22
Suicide prevention with trans young people

Next steps
It is important when you are working with a young person that you think about how you finish
the consultation and leave them feeling safe, respected and with access to further support and
advice if they need it. If the young person has expressed clear suicidal wishes, it is crucial that
you refer them to a specialist service urgently.

There are lots of specialist services nationally and locally that can support young people in
terms of their sexual orientation and gender identity. The sections following have some
information on further resources and services.

It is important you talk to the young person about how they perceive their own situation, and
whether they would like to access any of these services. They may want to call one of the
helplines or access a website in your office or the clinic, where it is safer to do so without
someone seeing them. This is the kind of simple step that can really make a difference in a
young person’s life. Some areas may have a trans youth club or service and it’s a useful piece
of homework when you finish reading this toolkit to have a local look online, for example at
TranzWiki, or ask the Trust diversity lead for details.

If a young person is actively expressing suicidal thoughts and intent then it is crucial that you
follow the local procedures for a young person at high risk - and ensure they are referred for
immediate psychiatric assessment and care.

If they are not actively suicidal and you are happy that they are not at any immediate risk, then
try to end the consultation with some positive steps and actions. A clear agreed plan, whether
that be a further appointment with yourself or a plan to get help and support elsewhere, will
help to make them feel valued and cared for.

Some motivational interviewing questions may help draw the consultation to a positive close.

 How do you feel about things now?

 What would you like to do next? What might be useful?
 Would you like any information on local services? If it helps you could
call them/access the website from here?
 Would you like to come back to talk to me again?

If the consultation has left you feeling unsure about your practice then use your clinical
supervision with your line manager to reflect on the encounter, and consider how you can
improve your practice next time the opportunity arises.

23
Suicide prevention with trans young people

Resources for trans young people

The public health provider’s landscape is always changing, so it is possible that some local
services are no longer available or that their contact information has changed. If possible, we
encourage you to contact the organisation (being mindful of confidentiality) in advance of
referral, and make sure you are providing the right information – and request a contact name. It
makes the experience less intimidating for a vulnerable young person if you can let them know
that someone real is there, waiting to help them.

A guide for trans young people in the UK is a booklet that offers

information to trans and questioning young people.
http://www.east-ayrshire.gov.uk/Resources/PDF/L/LGBT-Guide-for-Young-
Transgender-People.pdf

Antidote offers information and support exclusively to LGBT people around drugs,
alcohol and addiction.
Telephone: 0207 833 1674
www.antidote-lgbt.com

ELOP are a London based LGBT mental health and wellbeing centre offering a holistic
approach, with free counselling and young people’s services.
Telephone: 020 8509 3898
www.elop.org

Gender Identity Development Service sees children and young people (up to the age
of 18) and their families who are experiencing difficulties in the development of their
gender identity. Includes a multidisciplinary team, with experts in child and adolescent
psychiatry, psychology, social work, psychotherapy and paediatrics
http://www.tavistockandportman.nhs.uk/care-and-treatment/information-parents-and-
carers/our-clinical-services/gender-identity-development

Gender Identity Research and Education Society offers information for trans people,
their families and the professionals who care for them
www.gires.org.uk

24
Suicide prevention with trans young people

Gendered Intelligence is a non-profit organisation that supports young trans people.

They run youth group activities, deliver arts projects and mentoring for young trans,
non-binary and gender questioning people, support families and friends of trans young
people.
www.genderedintelligence.co.uk

Mermaids is a charity that supports gender nonconforming people and their families:
http://www.mermaidsuk.org.uk/

TranzWiki is a directory of support groups

www.TranzWiki.net

London Friend is a long-running LGBT charity that offers a telephone support

service, as well as many different drop-in counselling and support groups. It also runs
a specific befriending service and a carers’ support group. It is based in North London.
Helpline: 020 7837 3337 open Mondays, Tuesdays, Wednesdays and Fridays
7.30pm-9.30pm
www.londonfriend.org.uk

PACE offers specialised LGBT mental health and well-being services, including
advocacy, counselling, training, couples and family support, and also holds workshops
and produces publications. Based in London.
Telephone: 020 7700 1323
www.pacehealth.org.uk

Samaritans
While not an exclusively LGB&T organisations, it provides 24/7 confidential phone
support.
Telephone: 08457 90 90 90
www.samaritans.org

Stonewall Housing is a charity that specialises on lesbian, gay, bisexual and

transgender (LGBT) housing advice and support provider in England.
www.stonewallhousing.org

Young MINDS
www.youngminds.org.uk

25
Suicide prevention with trans young people

Resources for you on mental health and

suicide
This toolkit is not intended to replace any form of training. It is up to all of us to keep educating
ourselves to be the best health care providers that we can be. The following are some current
resources that could help you to better understand the complex mental health needs of trans
young people.

RCN toolkit on mental Health in children and young people

Royal College of Nursing
http://www.rcn.org.uk/__data/assets/pdf_file/0003/596451/RCNguidance_CYPmental_h
ealth_WEB.pdf

RCN toolkit for school nurses

Developing your practice to support children and young people in educational settings
http://www.rcn.org.uk/__data/assets/pdf_file/0012/201630/003223.pdf

RCN-accredited Sexual Health Skill e-learning course

University of Greenwich
www.gre.ac.uk/schools/health/current_publications

Royal College of Psychiatrists

Self-harm, suicide and risk: helping people who self-harm
http://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr158.aspx

Mind for Better Mental Health

www.mind.org.uk/

NICE Guidance on Self Harm

https://www.nice.org.uk/guidance/cg16

PACE – Project for Advocacy, Counselling and Education

Promoting lesbian and gay health
www.pacehealth.org.uk

Preventing suicide in England: A cross-government outcomes strategy to save

lives
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216928/P
reventing-Suicide-in-England-A-cross-government-outcomes-strategy-to-save-lives.pdf

Department of Health
You're Welcome - Quality criteria for young people friendly health services
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216350/d
h_127632.pdf

26
Suicide prevention with trans young people

Resources for you on trans health

To learn more about the health care needs of trans individuals and communities, you can use
the following online resources.

Caring for Gender Nonconforming Young People is an NHS e-learning resource,

funded by Health Education England, which provides a CPD facility:
http://www.nlmscontent.nesc.nhs.uk/sabp/gv/

Medical care for gender variant children and young people

http://www.gires.org.uk/assets/DOH-Assets/pdf/doh-children-and-adolescents.pdf

Mind Out: LGB&T mental health project

www.mindout.org.uk/

Trans: A Practical Guide for the NHS

Department of Health
http://www.gires.org.uk/assets/DOH-Assets/pdf/doh-trans-practical-guide.pdf

Transgender Action Plan

Government Equalities Office
https://www.gov.uk/government/publications/transgender-action-plan

Gendered Intelligence provides, trans awareness training and policy development

consultation for professionals, agencies and businesses
http://genderedintelligence.co.uk/

Gender Identity Research and Education Society offers information for trans people,
their families and the professionals who care for them
http://www.gires.org.uk/

Reducing health inequalities for lesbian, gay, bisexual and trans people - briefings
for health and social care staff
Department of Health
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Pu
blicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078347

Lesbian, gay, bisexual and transgender patients or clients

Royal College of Nursing Guidance for nursing staff on next of kin issues
www.rcn.org.uk/__data/assets/pdf_file/0015/520512/002017.pdf

Working with LGBT patients

NHS – National Health Service
www.healthwithpride.nhs.uk/miscellaneous/patients/

27
Suicide prevention with trans young people

Reflective checklist
Creating a safe, non-judgmental, and supportive environment can help young people feel more
comfortable sharing personal information. This toolkit can only provide an outline of best
practice when working with trans young people. Training for all staff and monitoring of
outcomes will be essential elements of any action plan and achieving good practice.

There are many things that can be done to ensure that your practice is trans friendly. Here is a
checklist64, with some points to consider as you work through developing a more welcoming
environment for all.

Are you prepared? Is your service prepared?

 I am aware of my own attitudes,  Our educational materials are
feelings and behaviours towards trans inclusive of a diverse audience
people and how my own experiences including trans young people.
shape my opinion towards trans young  Our confidentiality policies are
people. posted in areas that can be
 I am confident, comfortable, and non- viewed by both patients and their
judgemental when addressing young families.
people.  We use gender-inclusive
 I am prepared to take a strengths- language on intake/history forms
based approach when working with and questionnaires.
young people.  We have (and know how to
 I am aware of the implement) a general procedure
characteristics/features of positive for dealing with emergency and
adolescent development and crisis situations.
relationships.  We have a policy regarding
 I am ready to provide medically young people scheduling their
accurate information about adolescent own appointments
health.  We have policies regarding
 I am familiar with the legal and talking to young people alone
without their parent/caregiver.
confidentiality issues dealing with
adolescent’s health services.  Our clinic/practice attendance
hours are convenient for teens.
 I am aware of services for trans people
available in my community.  We have a network of referrals
for trans-friendly providers in the
area.

28
Suicide prevention with trans young people

Is your team ready?

 My team is friendly and welcoming toward trans patients.

 My team is knowledgeable about the laws of minor consent and confidentiality and
consistent in upholding those laws.
 My team is aware of privacy concerns when young people check in.
 My team is careful to avoid making assumptions about gender identity or sexual
orientation.
 My team is ready to maintain cultural sensitivity for the age, race, ethnicity,
transgender status, sexual orientation, disability, family structure, and lifestyle
choices of our patients and their loved ones.

If you realise there is some room for improvement in your practice, don’t worry. You have taken
the important step of identifying where there is an opportunity for you to take action.

29
Suicide prevention with trans young people

References
1. Royal College of Nurses. Congress 2010 Agenda 3. Fair care for trans people (resolution). [Online] 2010.
http://www.rcn.org.uk/newsevents/congress/2010/congress_2010_resolutions_and_matters_for_discussion/3._fair
_care_for_trans_people.
2. Royal College of Nursing. RCN Congress Agenda 2014: 12 Suicide Prevention. [Online] 2014.
http://www.rcn.org.uk/newsevents/congress/2014/agenda/debates/12-suicide-prevention.
3. Department of Health. Preventing suicide in England: A cross-government outcomes strategy to save lives.
London : Department of Health, 2012.
4. Whittle, S., Turner, L. and Al-Alami, M. Engendered Penalties: Transgender and Transsexual People's
Experiences of Inequality and Discrimination: The Equalities Review, 2007.
5. Reed, B. et al. Gender Variance in the UK: Prevalence, Incidence, Growth and Geographic Distribution: Gender
Identity Research and Education Society, 2009.
6. Gender Identity Research and Education Society. Monitoring Gender Noncomformity - A quick guide. 2014.
7. Glen, F. and Hurrell, K. Technical note - Measuring Gender Identity: Equality and Human Rights Commission,
2012.
8. The health and wellbeing of transgender high school students: results from the New Zealand Adolescent Health
Survey (Youth'12). Clark, T. et al. 1, 2014, Journal of Adolescent Health, Vol. 55, pp. 93-99.
9. Empirical Data on Epidemiology and Application of the German Transsexuals' Act during its first ten years.
Weitze, C. and Osburg, S. 1998, International Journal of Transgenderism.
10. Genderpac. 1997. Waltham MA : Genderpac, The First National Survey on Trans Violence.
11. Transgender Children: More than a theoretical challenge. Kennedy, N. and Hellen, M. 2, 2010, Graduate
Journal of Social Science, Vol. 7.
12. METRO Centre: Youth Chances. The Experiences of LGBTQ young people in England. Youth Chances,
Summary of First Findings, METRO Centre. 2014. [Online] 2014. http://www.youthchances.org/wp-
content/uploads/2014/01/YC_REPORT_FirstFindings_2014.pdf.
13. UK Government. Equality Act 2010. Legislation.gov.uk. [Online] 2010.
http://www.legislation.gov.uk/ukpga/2010/15/contents.
14. House of Lords. Gender Recognition Bill . [Online] 2004.
http://www.publications.parliament.uk/pa/ld200304/ldbills/004/04004.6-10.html.
15. Department of Health. An introduction to working with Transgender people: Department of Health, 2007.
16. National Society for Prevention of Cruelty to Children. Gillick competency and Fraser guidelines: National
Society for Prevention of Cruelty to Children, 2012.
17. 'Coming out': Gender, (hetero)sexuality and the primary school. Renold, Emma. 12, 2000, Gender and
Education, Vol. 326, p. 309.
18. Straight Talking: Challenges in teaching and learning about sexuality and homophoia in Schools. Forrest, S.
2006, Education, Equality, and Human Rights: Issues of gender, 'race', sexuality, disability and social class., pp.
111-123.
19. Denton, M.J. The lived experiences of Lesbian/Gay/Bisexual/Transgender educational leaders. Minnessotta :
University of Minnesotta, 2009.
20. Jones-Redmond, S. Gay and Lesbian school administrators: negotiating personal and profesional identities
and profesional roles and responsabilities within heteronormative organizations. Illinois : Northern Illinois
University, 2007.
21. Identity development and sexual orientation: Toward a model of lesbian, gay, and bisexual development.
D'Augelli, Anthony R. 1994, Human diversity: Perspectives on people in context. The Jossey-Bass social and
behavioral science series, pp. 312-333.
22. Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation.
Almeida, J, et al., et al. 7, 2009, Journal of Youth and Adolescence, Vol. 38, pp. 1001-14.
23. UK Government. Sexual Offences (Amendment) Act 2000. [Online] 30 November 2000.
http://www.legislation.gov.uk/ukpga/2000/44/contents.
30
Suicide prevention with trans young people

24. —. Adoption and Children Act 2012. [Online] 2012. [Cited: 19 December 2014.]
http://www.legislation.gov.uk/ukpga/2002/38/contents.
25. —. Civil Partnership 2004. [Online] 2004. [Cited: 19 Decembe 2014.]
http://www.legislation.gov.uk/ukpga/2004/33/contents.
26. —. Marriage (Same Sex Couples) Act 2013. [Online] 2013. [Cited: 19 December 2014.]
http://www.legislation.gov.uk/ukpga/2013/30/contents/enacted/data.htm.
27. Nodin, N., Rivers, I., Peel, E. and Tyler, A. The RaRE Research Report - LGB&T mental health, risk and
resilience explored. s.l. : PACE (in press), 2015.
28. HIV prevalence, risk behaviours, health care use and mental health status of transgender persons:
Implications for public health intervention. Clements, K., Marx, R., Guzman, R. and Katz, M. 2001, American
Journal of Public Health, Vol. 91, pp. 915-921.
29. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: review and recommendations.
Haas AP, et al., et al. 1, 2011, Journal of Homosexuality, Vol. 58, pp. 10-51.
30. Risk factors for suicidie in individuals with depression: a systematic review. Hawton, K. et al. 1, 2013, Journal
of affective disorders, Vol. 147, pp. 17-28.
31. McNeil, J. et al. Trans Mental Health Study. s.l. : Scottish Transgender Alliance, TREC, TRAVERSE and
Sheffield Hallam University, 2012.
32. Transgender Primary Medical care. Feldman J, and Goldberg, J. 3-4, s.l. : International Journal of
Transgenderism, 2006, Vol. 9. 3-34.
33. Bullying and suicide: A review. Kim, Y. and Levanthal, B. 2, 2008, International Journal of Adolescent Medicine
and Health, Vol. 20, pp. 133-154.
34. WHO - World Health Organization. World Report on Violence and Health. Geneva : WHO, 2002.
35. Suicide Prevention Center. Suicide risk and Prevention for Lesbian, Gay, Bisexual, and Transgender Youth.
Newton, MA : Education Development Center Inc. , 2008.
36. Gay Adolescents and Suicide: Understanding the Association. Kitts, Robert Li. 159, San Diego, CA : Libra
Publisher, 2005, Adolescence, Vol. 40.
37. Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths’ health risk
behavior. Bontempo DE and D’Augelli AR. 5, 2002, Journal of Adolescent Health, Vol. 30, pp. 364-374.
38. Cyberbullying among Adolescents: Implications for Empirical Research. Patchin JW and Hinduja S. 53, 2013,
Journal of Adolescent Health, Vol. 4, pp. 431-432.
39. Your picture is your bait: Use and meaning of cyberspace among gay men. Brown G, Maycock B and Burns S.
1, s.l. : Journal of Sexual Research, 2005, Journal of Sexual Research,, Vol. 42, pp. 63-73.
40. Young adults on the Internet: Risk behaviors for sexually transmitted diseases and HIV. McFarlane M, Bull S
and Rietmeijer C. 1, 2002, Journal of Adolescent Health, Vol. 31, pp. 11-16.
41. Hillier, L, Kurdas C and Horsley P. “It's just easier”: The Internet as a safety-net for same sex attracted young
people. Melbourne : Australian Research Centre in Sex, Health, and Society, Latrobe University., 2001.
42. Exploring identities through the Internet: Youth experiences online. Maczewski, M. 2, 2002, Child and Youth
Care Forum, Vol. 31, pp. 111-129.
43. Family acceptance in adolescnece and the health of LGBT young adults. Ryan, C. et al. 4, s.l. : Journal of
Child and Adolescent Psychiatric Nursing, 2010, Vol. 23, pp. 205-213.
44. Social work practice with gay, lesbian, bisexual, and transgender adolescents. Morrow, D.F. 1, 2004, Families
in Society, Vol. 85, pp. 91-99.
45. A global perspective in the epidemiology of suicide. Bertolote, J. et al. 2, s.l. : Suicidology, 2002, Vol. 7, pp. 6-
8.
46. Changing Attitude's Guide to Welcoming and Open Congregations. [Online] Changing Attitude, 2014. [Cited:
19 December 2014.] http://changingattitude.org.uk/find-a-church.
47. Lesbian, gay, and bisexual homeless youth: An eight-city public health perspective. Van Leeuwen JM, et al., et
al. 2, 2006, Child Welfare Journal, Vol. 85, pp. 151-170.
48. Carolan, F. and Redmond, S. Research into the needs of young people in Norther Ireland who identify as
lesbian, gay, bisexual or transgender. Belfast : Youthnet, 2003.
49. Cull, M, Platzer, H and Balloch, S. Out on my own: experiences and needs of homeless lesbian, gay and
bisexual transgender youth. s.l. : University of Brighton, 2006.

31
Suicide prevention with trans young people

50. Challenges faced by homeless sexual minorities: Comparison of gay, lesbian, bisexual and transgender
homeless adolescents with their heterosexual counterparts. Cochran, B. et al. 2002, American Journal of Public
Health, Vol. 92, pp. 773-777.
51. NHS. The NHS Constitution: the NHS belongs to us all. London : Department of Health, 2013.
52. Gender Identity Research and Education Society. Guidance on Combating Transphobic Bullying in Schools.
s.l. : Gender Identity Research and Education Society, Home Office, 2010.
53. Shalwitz, MD, Janet, Sang, Tina and Combs, Natalie. Behavioral Health. An Adolescent Provider Toolkit. San
Francisco, CA : Adolescent Health Working Group, 2010.
54. Nursing and Midwifery Council. The Code: Standards of conduct, performance and ethics for nurses and
midwives. [Online] http://www.nmc-uk.org/Publications/Standards/The-code/Introduction/.
55. Royal College of Nursing. Consent to create, amend, access and share eHealth records. London : Royal
College of Nursing, 2014.
56. —. Not 'just' a friend: best practice guidance on health care for lesbian, gay and bisexual service users and
their families. London : Royal College of Nursing and Unison Publication, 2005.
57. Stonewall. The School Report: The experiences of gay young people in Britain's schools in 2012. Cambridge :
University of Cambridge, 2012.
58. Sexuality: Behaviour versus Identity. Tracy, Daniel and Cataldo, Michelle. [ed.] Alex Chase. 2001, HIV
Counselor Perspectives.
59. Tracey, Daniel and Cataldo, Michelle. Sexuality: Behavior Versus Identity. San Francisco : Alliance Health
Project, 2001.
60. Guerra, Luis Eduardo. A phenomenological study of the sexual health benefits of having a gay identity among
gay men living in London. London : London School of Hygiene and Tropical Medicine, 2014.
61. U.S. Department of Health and Human Services. National strategy for suicide prevention: Goals and objectives
for action. Rockville, MD : U.S. Department of Health and Human Services, 2001.
62. Rethink Mental Illness. Lesbian gay and bisexual (LGB) issues and mental health. London : Rethink Mental
Illness, 2013.
63. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people.
King, Michael, et al., et al. 70, 2008, BMC Psychiatry, Vol. 8.
64. Sexual Orientation Discrimination in the Workplace: A Systematic Review of Literature. Ozeren, Emir. 2014,
Procedia - Social and Behavioral Sciences, Vol. 109, pp. 1203–1215.
65. Is Coming Out Always a "Good Thing"? Exploring the relations of autonomy, support, outness, and wellness
for Lesbian, Gay, and Bisexual individuals. Legate, Nicole, Ryan, Richard M. and Weinstein, Netta. 2, 2012, Social
Psychological and Personality Science, Vol. 3, pp. 145-152.
66. CWR University. Coming Out: Why Come Out? Risk and Benefits. [Online] 2011.
http://www.case.edu/lgbt/safezone/comingout.html.
67. Ageing towards 21 as a risk factor for Young Adult Suicide in the UK and Ireland: 'Many young men of twenty
said goodbye'. Malone, K. M., et al., et al. s.l. : Cambridge University Press, 2012, Epidemiology and Psychiatric
Sciences, pp. 1-5.
68. Changing Parental Opinions About Teen Privacy Through Education. Hutchinson, J. and Stafford, E. 116,
2005, Pediatrics, Vol. 4, pp. 966-971.
69. Evans, David T. Proud: Lesbian, gay, bisexual and transgender patients or clients. London : Royal College of
Nursing, 2012.
70. National Institute for Mental Health in England. Mental disorders, suicide, and deliberate self harm in lesbian,
gay and bisexual people. A systematic review. Leeds : NIMHE, 2007.
71. Royal College of Nursing. Defining staffing levels for children and young people's services: RCN Standards for
clinical professionals and service managers. London : The Royal College of Nursing, 2013.
72. Stonewall / Education for All. Everyone is Included. London : Stonewall, 2012.
73. Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the
National Surveys of Sexual Attitudes and Lifestyles (Natsal). Mercer, Catherin H., et al., et al. 9907, 2013, The
Lancet, Vol. 382, pp. 1781-1794.

32
Suicide prevention with trans young people

74. Sexual orientation identity in relation to smoking history and alcohol use at age 18/19: cross-sectional
associations from the Longitudinal Study of Young People in England (LSYPE). Hagger-Johnson, Gareth, et al., et
al. 8, 2013, British Medical Journal Open, Vol. 3.
75. Public Health England. HIV in the United Kingdom: 2014 report. London : Public Health England, 2014.
76. Nodin, Nuno, et al., et al. The RaRE Research Report – LGB&T mental health Risk and Resilience Explored.
London : PACE [in press], 2015.
77. Risk factors for attempted suicide in gay and bisexual youth. Remafedi, Gary, Farrow, James A. and Deisher,
Robert W. 87, 1991, Pediatrics, Vol. 6, pp. 869-875.
78. Stonewall Cymru. Toe in the water: The double jeopardy of race and sexual orientation in North Wales.
London : s.n., 2010.
79. Sexual Orientation and Risk Factors for Suicidal Ideation and Suicide Attempts Among Adolescents and
Young Adults. Silenzio VM, et al., et al. 11, 2007, American Journal Public Health, Vol. 97, pp. 2017-2019.
80. Sexual orientation and adolescent substance use: a meta-analysis and methodological review. MP, Marshal, et
al., et al. 4, 2008, Addiction, Vol. 103, pp. 546-56.
81. Culture, trauma and wellness: A comparison of heterosexual and LGB, and Two-Spirit Native Americans.
Balsam K, et al., et al. 3, 2004, Cultural Diversity and Ethnic Minority Psychology, Vol. 10, pp. 287-301.
82. Suicide among gay and lesbian adolescents and young adults: A review of the literature. Kulkin H, Chauvin E
and Percle G. 1, 2000, Journal of Homosexuality, Vol. 40, pp. 1-29.
83. Department of Health. Trans: A practical guide for the NHS. 2008.
85. Women and Equality Unit. Gender Reassignment - A Guide for Employers. 2005.
86. An epidemiological and demographic study of transsexuals in the Netherlands. Van Kesteren, P., Gooren, L.
and Megans, J. 6, 1996, Archives of Sexual Behaviour, Vol. 25, pp. 589-600.
87. Prevalence and demography of transsexualism in Belgium. De Cuypere, G. et al. 3, 2007, European
psychaitry, Vol. 22, pp. 137-141.
88. Prevalence of transsexualism among New Zealand passport holders. Veale, J. 10, 2008, Australasian
Psychiatry, Vol. 42, pp. 887-889.
89. The prevalence of gender dysphoria in Scotland: a primary care study. Wilson, P., Sharp, C. and Carr, S. 449,
1999, British Journal of General Practice, Vol. 49, pp. 991-992.
90. The development and validation of the genderism and transphobia scale. Hill, D. and Willoughby, B. 2005, Sex
Roles, pp. 531-544.
91. Fish, J. Reducing health inequalities for lesbian, gay, bisexual and trans people - briefings for health and social
care staff. s.l. : Department of Health, 2007.
92. Xavier, J. The Washington transgender needs assessment survey. 2000.
93. Transgender health: Findings from two needs assesssment studies in Philadephia. Kenagy, G. 19-26, 2005,
Health and social work, Vol. 1, p. 30.
94. Transgender youth and life-threatening behaviours. Grossman, A and D'Augelli, A. 5, 2007, Suicide and Life-
threatening Behavior, Vol. 37, pp. 527-537.
95. Centre for Suicide Prevention. Gay & Suicidal: Sexual and Gender Minorities and Suicide. Resource Toolkit.
Calgary, Alberta : Centre for Suicide Prevention, 2012.
96. Atypical Gender Development: a review. GIRES. 1, 2006, International Journal of Transgenderism, Vol. 9, pp.
29-44.

33