Deceased
Natalie Jade Wilson
Demographics
33y, female
Coroner
Coroner Ingrid Giles
Date of death
2020-09-02
Finding date
2024-08-29
Cause of death
neck compression and hanging
AI-generated summary
Natalie was a 33-year-old transgender woman with a long history of mental health conditions including severe social anxiety, agoraphobia, borderline personality disorder and PTSD, with suicidal ideation since age 17 and multiple suicide attempts. She died by hanging on 2 September 2020 after being offered voluntary hospital admission for high suicide risk but choosing to wait at home. While her GP and psychologist provided exemplary, trauma-informed care with appropriate crisis referrals, the inquest revealed systemic barriers facing transgender people: long gender clinic waitlists (2+ years), high medical costs, discrimination in healthcare settings, and lack of culturally-safe mental health services. The coroner emphasised that improved access to gender-affirming care, suicide prevention/postvention supports, and cultural safety training for healthcare providers are essential to reduce preventable deaths in the transgender community.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT COR 2020 004857 OF VICTORIA AT MELBOURNE FINDING INTO DEATH FOLLOWING INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Amended pursuant to Section 76 of the Coroners Act 2008 on 2 September 20241 Inquest into the death of Natalie Jade Wilson Findings of: Coroner Ingrid Giles Delivered on: 29 August 2024 Delivered at: Coroners Court of Victoria 65 Kavanagh Street, Southbank, Victoria, 3006 Hearing dates: 27-29 November 2023 21 February 2024 Appearances: Ms Gemma Cafarella, Counsel Assisting the Coroner, instructed by Ms George Carrington, Coroner’s Solicitor Mr Sebastian Reid on behalf of Austin Health, instructed by Lander & Rogers Ms Fiona Ellis on behalf of Monash Health, instructed by K&L Gates 1 This version is an amended version of the Finding into the Death of Natalie Wilson dated 29 August 2024, amended to insert an enhanced Table of Contents to improve navigability and to correct minor typographical errors.
Ms Erin Gardner on behalf of the Department of Health, instructed by the Department’s in-house lawyers Ms Amanda Dickens on behalf of the Chief Commissioner of Police, instructed by the Victorian Government Solicitor’s Office Ms Jasmine Still on behalf of Detective Senior Constable Garside, instructed by Hall & Wilcox Mr Christopher McDermott (27-29 November 2023) and Mr Chris Kais (21 February 2024) on behalf of Transgender Victoria, instructed by Allens Catchwords Suicide; transgender; gender diverse; LGBTIQA+; access to mental health services; access to gender-affirming care; cultural safety and wellbeing; postvention supports; missing persons; Victoria Police.
Readers are advised that this finding contains discussion of suicide. Readers are warned that there may be words and descriptions that may be distressing.
For help or support please contact:
• Switchboard and Rainbow Door on 1800 729 367 or text 0480 017 246 or email support@rainbowdoor.org.au
• Lifeline on 13 11 14 or text 0477 13 11 14
• Beyondblue on 1300 224 636
• Queerspace on 03 9663 6733
• Thorne Harbour Health on 1800 134 840
TABLE OF CONTENTS 3 - Mental ill health and suicidality in the trans and gender diverse (TGD) community22 Factors contributing to levels of distress, mental ill health, and suicidality in the TGD population
Access to gender-affirming medical care and impact on wellbeing of TGD adults, including those 5 – Provision of suicide prevention and postvention supports in the TGD community .. 66 Multidisciplinary approach to social and emotional wellbeing supports in TGD communities . 76
Issues associated with the ‘senior next of kin’ hierarchy under section 3 of the Coroners Act Other ways in which the Court has improved its approach to cultural safety and inclusivity .... 83
Natalie Jade Wilson (Natalie) was 33 years old when she was found deceased in circumstances consistent with suicide.
Natalie faced a number of mental health diagnoses during her life, including severe social anxiety, agoraphobia, borderline personality disorder and possible post-traumatic stress disorder. She had experienced suicidal ideation from the age of 17 and had a number of suicide attempts in the lead-up to her passing.
Natalie is remembered by her father as someone who was very intelligent, and who took a liking to computer games from an early age. While she struggled at times to leave the house, including due to her mental health issues, coupled with an intense fear of being discriminated against as a transgender person, she had periods of great fulfilment through community work, including volunteering at her local Op Shop.
Her father witnessed her growth in confidence when she affirmed her gender in 2017.2 THE CORONIAL INVESTIGATION Jurisdiction
Natalie’s death was a ‘reportable death’ under section 4 of the Coroners Act 2008 (Vic) (the Act), because it occurred in Victoria and was considered unexpected, unnatural or to have resulted, directly or indirectly, from an accident or injury.
Purpose of the Coronial Jurisdiction
3 Coroners Act 2008 (Vic) s 89(4).
circumstances in which the death occurred. The cause of death refers to the medical cause of death, incorporating where possible, the mode or mechanism of death.
The circumstances in which the death occurred refers to the context or background and surrounding circumstances of the death. It is confined to those circumstances that are sufficiently proximate and causally relevant to the death.
The broader purpose of coronial investigations is to contribute to a reduction in the number of preventable deaths, both through the observations made in the investigation findings and by the making of recommendations by coroners. This is generally referred to as the prevention role.
(a) report to the Attorney-General on a death;
(b) comment on any matter connected with the death they have investigated, including matters of public health or safety and the administration of justice; and
(c) make recommendations to any Minister or public statutory authority or entity on any matter connected with the death, including public health or safety or the administration of justice.
These powers are the vehicles by which the prevention role may be advanced.
They are not separate or distinct sources of power enabling a coroner to enquire for the sole or dominant reason of making comment or recommendation.4
5 Coroners Act 2008 (Vic) s 67(3).
It is not the role of the coroner to lay or apportion blame, but to establish the facts.6 It is important to stress that coroners are unable to determine civil or criminal liability arising from the investigation of a reportable death and are specifically prohibited from including in a Finding, a comment or any statement that a person is, or may be, guilty of an offence.7
Whilst it is sometimes necessary to examine whether a person’s conduct falls short of acceptable or normal standards, or was in breach of a recognised duty, this is only to ascertain whether it was a causal factor or background circumstance. That is, an act or omission will not usually be regarded as contributing to death unless it involves a departure from reasonable standards of behaviour or a recognised duty. If that were not the case, many perfectly innocuous preceding acts or omissions would be considered causative, even though on a common-sense basis they have not contributed to death.
It is also important to recognise the benefit of hindsight and to discount its influence on the determination of whether a person has acted appropriately.
Standard of Proof
All coronial findings must be made based on proof of relevant facts on the balance of probabilities.8 The strength of evidence necessary to prove relevant facts varies according to the nature of the facts and the circumstances in which they are sought to be proved.9
In determining these matters, I am guided by the principles enunciated in Briginshaw v Briginshaw.10 The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals or entities, unless the evidence provides a comfortable level of satisfaction that they caused or contributed to the death.
6 Keown v Khan (1999) 1 VR 69.
7 Coroners Act 2008 (Vic), s 69(1). However, a coroner may include a statement relating to a notification to the Director of Public Prosecutions if they believe an indictable offence may have been committed in connection with the death. See sections 69(2) and 49(1) of the Act.
8 Re State Coroner; ex parte Minister for Health (2009) 261 ALR 152.
9 Qantas Airways Limited v Gama (2008) 167 FCR 537 at [139] per Branson J (noting that His Honour was referring to the correct approach to the standard of proof in a civil proceeding in the Federal Court with reference to section 140 of the Evidence Act 1995 (Cth); Neat Holdings Pty Ltd v Karajan Holdings Pty Ltd (1992) 67 ALJR 170 at 170-171 per Mason CJ, Brennan, Deane and Gaudron JJ.
Proof of facts underpinning a finding that would, or may, have an extremely deleterious effect on a party’s character, reputation or employment prospects demand a weight of evidence commensurate with the gravity of the facts sought to be proved.11 Facts should not be considered to have been proven on the balance of probabilities by inexact proofs, indefinite testimony, or indirect inferences. Rather, such proof should be the result of clear, cogent, or strict proof in the context of a presumption of innocence.12 Coronial investigation and clustering of the proceedings
Deputy State Coroner Paresa Spanos (as she now is) initially held carriage of the investigation into Natalie’s death, followed by then-Deputy State Coroner Jacqui Hawkins.
In July 2023, I assumed carriage of the investigation for the purposes of conducting further investigations, holding an Inquest, and making Findings. Sergeant Jay McCarthy (Sgt McCarthy) was assigned as the Coroner’s Investigator and compiled the coronial brief in relation to Natalie’s death.13
Section 52(2) of the Act provides that it is mandatory for a coroner to hold an Inquest into a death if the death or cause of death occurred in Victoria and a coroner suspects the death was as a result of homicide, or the deceased was, immediately before death, a person placed in custody or care, or the identity of the deceased is unknown. The circumstances of Natalie’s death did not involve any such considerations; therefore, whether or not to hold an Inquest was a matter of discretion under section 52(1) of the Act.
Pursuant to this provision, coroners have absolute discretion as to whether to hold an Inquest.
However, a coroner must exercise the discretion in a manner consistent with the preamble and purposes of the Act.
11 Anderson v Blashki [1993] 2 VR 89, following Briginshaw v Briginshaw (1938) 60 CLR 336.
12 Briginshaw v Briginshaw (1938) 60 CLR 336 at pp 362-3 per Dixon J: ‘The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding, are considerations which must affect the answer to the question whether the issues had been proved to the reasonable satisfaction of the tribunal. In such matters “reasonable satisfaction” should not be produced by inexact proofs, indefinite testimony, or indirect inferences…’.
13 A second coronial brief called, referred to as the ‘Collated Brief’ was compiled by the Court in relation to the common issues in the cluster investigation. To accompany this brief, a statement of facts in relation to each deceased’s circumstances of passing was prepared following input being invited from Interested Parties.
In deciding whether to conduct an Inquest, a coroner should consider factors such as (although not limited to), whether there is such uncertainty or conflict of evidence as to justify the use of the judicial forensic process; whether there is a likelihood that an Inquest will uncover important systemic defects or risks not already known about and, the likelihood that an Inquest will assist to maintain public confidence in the administration of justice, health services or public agencies.
The convening of an Inquest into a suicide or suicides is rare. However, after Natalie’s death in late September 2020, the Coroners Court received reports of a number of suicides of transgender or gender diverse women, including:
• Bridget Flack (COR 2020 46727, who died between 30 November 2020 and 11 December 2020) (hereinafter, ‘Bridget’);
• Matt Byrne (COR 2021 1636, who died on 30 March 2021) (Matt);
• The person known by the pseudonym ‘AS’14 (COR 2021 2415, who died on 9 May
• Heather Pierard (COR 2021 2457, who died on 11 May 2021) (Heather).
14 This person is required to be referred to as ‘AS’ pursuant to a pseudonym order issued on 28 August 2023 in these proceedings – see explanation further below. Further persons referred to in this Finding (including H. Leigh) are not formally covered by the pseudonym order but are referred to by chosen names (see T-113, lines 6-16).
15 This definition will be further explored later in my Finding.
• Victorian Department of Health;
• The Office of the Chief Psychiatrist of Victoria;
• Monash Health Gender Clinic;
• Austin Health Gender Clinic;
• Thorne Harbour Health, which includes the Equinox Gender Diverse Health Centre;
• The Royal Children’s Hospital Melbourne;
• Royal Australian College of General Practitioners;
• Australian Psychological Society;
• Royal Australian and New Zealand College of Psychiatrists;
• Drummond Street Services;
• Victorian Commissioner for LGBTIQA+ Communities;
• Switchboard Victoria; and
• Transgender Victoria.
16 The CPU was established in 2008 to strengthen the prevention role of the coroner. The CPU assists the coroner with research in matters related to public health and safety and in relation to the formulation of prevention recommendations. CPU staff include health professionals with training in a range of areas including medicine, nursing, and mental health; as well as staff who support coroners through research, data and policy analysis.
The inquest proceeded on 27-29 November 2023 and 21 February 2024, over four days in total, with Ms Gemma Cafarella appointed as Counsel Assisting the Coroner, and the Chief Commissioner of Police (CCP), the Secretary to the Department of Health, Monash Health, Austin Health, DSC Garside, and Transgender Victoria all represented at Inquest.
Many members of the five deceased’s family, chosen family and friends were present during these proceedings, with some choosing to attend the courtroom, and others following the proceedings online.
Scope of Inquest
Although the coronial jurisdiction is inquisitorial rather than adversarial,17 it should operate in a fair and efficient manner.18 When exercising a function under the Act, coroners are to have regard, as far as possible in the circumstances, to the notion that unnecessarily lengthy or protracted coronial investigations may exacerbate the distress of family, friends and others affected by the death.19
In Harmsworth v The State Coroner,20 Nathan J considered the extent of coroners’ powers, noting they are not ‘free-ranging’ and must be restricted to issues sufficiently connected with the death being investigated. His Honour observed that if not so constrained, an inquest could become wide, prolix, and indeterminate. His Honour stated the Act does not provide a general mechanism for an open-ended enquiry into the merits or otherwise of the performance of government agencies, private institutions, or individuals. Significantly, he added: Such an inquest would never end, but worse it could never arrive at the coherent, let alone concise, findings required by the Act, which are the causes of death, etc.
Such an inquest could certainly provide material for much comment. Such discursive investigations are not envisaged nor empowered by the Act. They are not within jurisdictional power.21 17 Second Reading Speech, Legislative Assembly: 9 October 2008, Legislative Council: 13 November 2008.
18 Coroners Act 2008 (Vic), s 9.
19 Coroners Act 2008 (Vic), s 8(b).
21 Ibid.
In Lucas-Smith v Coroners Court of the Australian Capital Territory22 the limits to the scope of a coroner’s inquiry and the issues that may be considered at an inquest were also considered. As there is no rule that can be applied to clearly delineate those limits, ‘common sense’ should be applied. In this case, Chief Justice Higgins noted that: It may be difficult in some instances to draw a line between relevant evidence and that which is too remote from the proper scope of the inquiry ...[i]t may also be necessary for a Coroner to receive evidence in order to determine if it is relevant to or falls in or out of the proper scope of the inquiry.
Ultimately, however, the scope of each investigation must be decided on its facts and the authorities make it clear that there is no prescriptive standard that is universally applicable, beyond the general principles discussed above.23
Given the issues under consideration, the scope of the present Inquest was crafted to be systems-focused. Rather than examining the circumstances of death of each individual, which were sufficiently documented in the written evidence, the aim was to examine the broader systemic issues impacting TGD people and their experience in accessing health and other services. There were also two discrete scope items relating to Bridget and the missing persons search undertaken for her by Victoria Police.
A Directions Hearing was held on 13 October 2023 and Interested Parties were invited to provide submissions on the proposed scope. The settled scope of the inquest was as follows: Relating to the passing of Bridget Flack:
Approach of Victoria Police to the missing persons search for Bridget Flack, including by reference to relevant policies and procedures;
Victoria Police policies, procedures, training, and initiatives relating to the transgender and gender diverse (TGD) community; 22 [2009] ACTSC 40. See also the comments regarding the limits of a coroner’s inquiry, including that factual questions related to cause will generally be within the scope of the inquest.
23 See Ruling No.2 in the ‘Bourke Street’ Inquest into the deaths of Matthew Poh Chuan Si, Thalia Hakin, Yosuke Kanno, Jess Mudie, Zachary Matthew Bryant and Bhavita Patel (COR 2017 0325 and Ors), Coroner Hawkins, 23 August 2019, para. 55.
Relating to all deaths within the cluster:
The evidence base concerning the incidence of mental ill health and suicidality in the TGD community, including the reasons for this;
Availability of and issues concerning provision of culturally-appropriate genderaffirming care to TGD people in Victoria, including where there are intersecting mental health issues and diagnoses;
Availability of and issues concerning provision of culturally-appropriate suicide prevention and postvention supports to TGD people in Victoria;
Availability of and issues concerning provision of culturally-appropriate social and emotional wellbeing supports to TGD people in Victoria; and
Pseudonym order
Prior to a Directions Hearing in this matter being convened on 13 October 2023, on 28 August 2023, I issued a pseudonym order in this matter pursuant to section 55(2)(e) of the Act. The order required that, in order to assist the Court in referring to the deceased persons in a respectful and culturally appropriate manner in these proceedings, they should be referred to by the names that were in use prior to passing (even where not ‘legally changed’), and which had been chosen by the deceased to correspond with their gender identity (chosen names).
Further, I ordered that one of the deceased be referred to by the pseudonym ‘AS’, which I considered to be necessary to secure the proper administration of justice in this proceeding, including to ensure AS’s family’s capacity to participate in the Inquest and to limit trauma and the impacts of the proceeding on her family’s wellbeing.
On this basis, all deceased were referred to by what the evidence established to be their chosen name, or in the case of ‘AS’, a pseudonym. All deceased were referred to by ‘she/her’ pronouns, noting that, while their preferred pronouns may have changed over time, the evidence pointed to all five deceased using ‘she/her’ pronouns in the lead-up to passing.
Witnesses
(a) Elisabeth Lane, the Court’s lived experience expert;24
(b) Angela Pucci-Love, Bridget’s sister;
(c) Detective Senior Constable Garside, Coronial Investigator in Bridget’s case; and
(d) Deputy Commissioner Neil Paterson, Victoria Police.
(a) Professor Jeffrey Zajac, Austin Health Gender Clinic, medical practitioner and Head of Endocrinology Unit at Austin Health;
(b) Dr James Morandini, Australian Psychological Society, Clinical Psychologist;
(c) Mrs Bailey Nation-Ingle, Victorian Department of Health, State Suicide Prevention Response Adviser;
(d) Dr Gurvinder Kalra, Monash Health Gender Clinic, Consultant Psychiatrist;
(e) Dr Neil Coventry, Office of the Chief Psychiatrist, Chief Psychiatrist of Victoria (as he then was);
(f) Dr Peter Jenkins, Royal Australian and New Zealand College of Psychiatrists (RANZCP), Consultant Child and Adolescent Psychiatrist;
(g) Dr Mark Dalgleish, Royal Australian College of General Practitioners (RACGP), General Practitioner; 24 It is worth noting that a number of the other witnesses in this Inquest had their own lived experience as members of the TGD community.
(h) Dr Tram Nguyen, Royal Melbourne Children’s Hospital Gender Service, Psychiatrist; and
(i) Ms Carolyn Gillespie, Director of Services, Thorne Harbour Health.
(a) Mr Elliot McMahon, Drummond Street Services, Program Manager;
(b) Mr Joe Ball, Switchboard, Chief Executive Officer;
(c) Ms Anna Bernasochi, Switchboard, Suicide Prevention Manager;
(d) Dr Son Vivienne, Transgender Victoria, Chief Executive Officer;
(e) Ms Michelle McNamara, Transgender Victoria, Committee Board Member;
(f) Mx Vic Harden, Thorne Harbour, TGD Health Lead; and
(g) Dr Todd Fernando, Victorian Commissioner for LGBTIQ+ Communities (as he then was)
Closing submissions
Sources of Evidence
Natalie Wilson was born on 27 May 1987. She had three siblings. Natalie was assigned male at birth. She experienced gender dysphoria from a young age.
Natalie was reported to have had interests and tendencies that were regarded as stereotypically feminine. Because of this, Natalie was bullied at school. As a result, Natalie tried to suppress her feminine gender identity as a survival mechanism.
Natalie changed schools in year 10 to escape the bullying. She was not bullied at her new school but struggled to make friends. Natalie also reported experiencing family difficulties due to her gender identity, though reported being very well supported by some family members.27
From 17 years of age, Natalie suffered from depression, anxiety, and social isolation. She rarely left home and largely stayed in her bedroom.28 25 In the interests of certainty, this includes: (i) the Court file, inclusive of correspondence from Genspect; (ii) Coronial Brief compiled by Sgt McCarthy; (iii) Collated Brief version 4, dated 3 November 2023; (iv) Summary of Material Facts dated 16 November 2023; (v) Additional Materials 1-11; and (vi) Transcripts of evidence from 27-29 November 2023 and submissions hearing on 21 February 2024.
26 This section, and the section that follows, is derived from the ‘Summary of Material Facts’ in relation Natalie Wilson, dated 16 November 2023.
27 Statement of R. Berthelsen, CB, p. 52.
28 Statement of C. Wilson, CB p. 16.
In 2004, Natalie was hospitalised in a youth psychiatric ward for two weeks due to severe depression and suicidal ideation. Natalie later reportedly expressed that she had formed the impression that she felt that she had to deny her female gender identity to be able to leave the ward and she developed mistrust of hospitals and psychiatric intervention.29
In 2014, aged 26 years of age, Natalie commenced counselling with a psychologist, Ruth Berthelsen (Ms Berthelsen). Natalie had very low self-esteem and experienced anxiety, chronic lowered mood, and intermittent suicidal thoughts. Natalie was unemployed, had limited social contact outside her home, and feared being ridiculed or rejected in social settings.
From 2014 to 2015, Natalie’s mental health improved in the context of ongoing counselling.
She started to feel able to leave the family home. In 2016, Natalie took up a volunteer position at the Highett Community Centre.
In 2016, Natalie reported a decline in her mental health related to her ongoing unemployment and her gender dysphoria resurfaced. She reported thoughts of suicide. She was assessed by the Crisis Assessment and Treatment Team (CATT), who deemed her a low risk of suicide.
Over the 2016 Christmas period, Natalie commenced anti-depressant medication due to increased suicidal ideation.30
In 2017, she started to socially affirm her gender as female and changed her name to Natalie.
Natalie became significantly happier and more confident and began to make friends. Her sleep improved, and she was positive about moving forward as Natalie. Her brother recalls that she started doing things she had never previously done in life, such as ‘making appointments, keeping appointments, making her own way and engaging with life’.31
30 Statement of R. Berthelsen, CB p. 55.
31 Statement of R. Wilson, CB, p. 38.
32 Statement of R. Berthelsen, CB p. 55.
significant deliberation, in April 2017 Natalie decided to go on the waiting list for the Monash Health Gender Clinic. She reported an increased sense of hope and happiness, and, having developed a more integrated sense of self, she ‘began to blossom’.33
However, Natalie’s fear of being discriminated against as a transgender person affected her mental health. Ms Berthelsen reports that Natalie’s fear of discrimination was a major barrier in Natalie being able to overcome her fear of being in public. Natalie also experienced significant distress around the impact her gender affirmation had on her family.
In 2017 to early 2018, having commenced seeing a psychologist through the Monash Health Gender Clinic, Natalie underwent a comprehensive assessment exploring her mental and physical health, sexual health and developmental history, and was approved for genderaffirming hormone treatment.34
In 2018, Natalie began making friends from transgender internet sites, which progressed to in-person friendships. Natalie reported having good mental health and feeling happy around this time. She commenced a voluntary role at the Pakenham Op Shop, which gave her an increased sense of purpose and self-worth. She also commenced an accounting course.
Nonetheless, Natalie remained anxious about being verbally or physically attacked in public.
In early 2019, Natalie began seeing General Practitioner (GP), Dr Danielle Dowman (Dr Dowman), who she trusted and felt well supported by.
In October 2019, having again been comprehensively assessed, Natalie underwent gender affirmation surgery (which she appears to have self-funded in part). Natalie was very happy about having surgery, reporting improved mood and denying suicidal ideation, though her engagement with the Monash Health Gender Clinic was interrupted by the COVID-19 pandemic.35
In January 2020, Natalie attended upon Dr Dowman and reported feeling depressed and experiencing panic attacks. Natalie’s lowered mood resulted from her fear of discrimination, 33 Statement of R. Berthelsen, CB p. 56.
34 Statement of Dr G. Kalra, Court file.
35 Statement of Dr G. Kalra, Court file.
which was heightened after surgery. She had also ended a relationship. Dr Dowman recommenced Natalie on anti-depressant medication and she showed initial improvement.36
In May 2020, Natalie reported a deterioration in her mental state and suicidal thoughts in the context of family conflict. Dr Dowman contacted Ms Berthelsen to report concerns about Natalie’s declining mental health and Ms Berthelsen contacted Natalie to offer her an earlier appointment and to check on her wellbeing.37
In June 2020, Natalie reported significant suicidal ideation to Dr Dowman. Natalie reported that she was unable to obtain her medication because of agoraphobia and had stopped taking it. Natalie told Dr Dowman that she did not want to undergo a hospital admission due to the distressing nature of her admission when she was a teenager. Dr Dowman made a referral to CATT and Monash Health Mental Health team. Natalie was assessed as high risk, and her anti-depressant medication was changed from fluoxetine to escitalopram.38
In June-July 2020, Natalie developed an infection following surgery that caused her significant pain. However, she refused to seek medical attention.
On 12 August 2020, Natalie reported an increase in suicidal thoughts. She had difficulty sleeping, and took an excessive amount of her anti-depressant medication on one occasion.
On 30 August 2020 at approximately 10:00 pm, Natalie attempted suicide via consuming hand sanitiser. On 31 August 2020, Natalie informed her father of her attempted suicide. Her father contacted the poisons hotline and Dr Dowman. Dr Dowman sought assistance for Natalie through Monash Health’s CATT.39
The CATT spoke to Natalie on 1 September 2020. She was offered and accepted an assessment appointment for 4pm on 2 September 2020.40 36 Statement of Dr D. Dowman, CB p. 47.
37 Statement of R. Berthelsen, CB p. 60.
38 Statement of Dr D. Dowman, CB p. 48.
39 Statement of Dr D Dowman, CB, p. 49.
40 Statement of L. Vere, Court file.
On 2 September 2020, Natalie had a telehealth session with Ms Berthelsen. Natalie presented with low mood. She was teary and distressed, stated that she wished she was dead, and felt alienated, angry, despairing and hopeless. She reported feeling ‘broken’ and not fit for the world. Ms Berthelsen assessed Natalie as an extremely high risk of suicide. Ms Berthelsen discussed a hospital admission with Natalie, who agreed this was necessary. Ms Berthelsen contacted Natalie’s father, Dr Dowman, and the Monash Health CATT.41 She provided Natalie with support via text after the session.
At 4pm on 2 September 2020, Natalie was assessed by the CATT. She was offered and accepted a plan for a voluntary admission to hospital however, a bed was not yet available, though it was hoped one would be available the following day. Natalie said that she would prefer to wait at home instead of attending the emergency department due to her social anxiety. A safety plan was discussed, and emergency contact numbers provided.42
Natalie was last seen alive at approximately 9:30pm on 2 September 2020 by her brother.
At approximately 10:45pm, her brother went to the garage and found Natalie suspended from the neck and non-responsive. Emergency services attended, and Natalie was pronounced dead at 11:39pm by Ambulance Victoria paramedics.
42 Statement of L. Vere, Court file.
Burke reviewed the post-mortem computed tomography (CT) scan and Victoria Police Report of Death Form 83, and provided a written report of his findings.
The post-mortem CT scan and external examination were unremarkable. Inspection revealed an abraded injury to the neck, beginning at the thyroid cartilage anteriorly, extending upwards on both sides of the neck into the hairline.
Toxicological analysis of post-mortem samples identified the presence of 0.1mg/L of citalopram (the metabolite of escitalopram).43
Dr Burke provided an opinion that the medical cause of death was 1 (a) neck compression and 1 (b) hanging. I accept Dr Burke’s opinion.
3 - Mental ill health and suicidality in the trans and gender diverse (TGD) community
The third item in the scope of inquest is ‘[t]he evidence base concerning the incidence of mental ill health and suicidality in the TGD community, including the reasons for this’.
I heard evidence in these proceedings that TGD people face disproportionate rates of mental ill health and suicidality compared to the population as a whole, as well as a higher rate of completed suicide.44 While there is some variation in specific findings and datasets (particularly where studies are drawn from clinical populations, as opposed to the TGD population more broadly), there is clear evidence that the TGD community reports and experiences higher rates of depression, anxiety, suicidality and self-harm than the population as a whole,45 with Dr Kalra of the Monash Health Gender Clinic stating that 50-75% of TGD people report having a mental health issue.46 43 Citalopram and escitalopram are selective serotonin reuptake inhibitors (SSRIs) that increase serotonin neurotransmitter action in the synapse.
44 Evidence of Dr P. Jenkins, RANZCP, T-211 line 28 to T-212 line 9.
45 See evidence of Dr P. Jenkins, RANZCP, T-212 lines 4-9.
46 See evidence of Dr G. Kalra, Monash Health Gender Clinic (MHGC), T-212 line 21 to T-213 line 6, referring to Ingrid Bretherton et al ‘'The Health and Well-Being of Transgender Australians: A National Community Survey' (2021) 8(1) LGBT Health 42 (Bretherton Survey). DOI: https://doi.org/10.1089/lgbt.2020.017 (Bretherton Survey) (I note that the transcript at T-212 line 27 refers to this as being authored by ‘Weatherton’ but the reference to ‘Bretherton’ is confirmed at T-214, line 10). The precise rate of mental ill health and suicidality in the TGD population varies according to the study cited and the specific mental illness being referred to – see for example T-213 lines 922
At Inquest, Professor Zajac of Austin Health noted that, in his experience of treating TGD patients (through a clinic treating approximately 600 TGD individuals), ‘virtually all […] report some kind of mental health problem. So it’s almost universal.’47 Bailey Nation-Ingle of the Victorian Department of Health (Department of Health) stated that TGD people are one of the most at-risk populations globally for suicidal ideation, suicide attempts and also death by suicide, with Carolyn Gillespie of Thorne Harbour Health noting that TGD people are also reported to experience the highest rates of distress out of the LGBTIQA+ population as a whole, with double or higher the rate of suicide attempts than cis-gendered participants.48
Despite this, both expert panels at Inquest emphasised that there is nothing inherent in being TGD that comprises or causes mental ill health or suicidality.49 The Chief Psychiatrist (as he then was), Dr Neil Coventry, noted in particular that contemporary approaches in the provision of healthcare to TGD people have moved away from pathologisation of gender identity, a phenomenon Ms Gillespie described as where ‘identity is seen as unwell or needing fixing or that there’s something wrong in you’.50
Dr Coventry emphasised that ‘pathologising gender identity really neglects the impact of complex psychosocial structural factors, the discrimination, trauma, marginalisation, family issues and also this can impede people getting access to care, certainly access to appropriate mental health specialist care’.51 In a similar vein, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) noted in its submission to the Court that ‘the discrimination and marginalisation experienced by LGBTIQ+ people increases the risk of
The Bretherton Survey involved 928 participants who reported high rates of co-occurring mental health issues, such as lifetime diagnoses of anxiety (67%) and depression (73%), as well as high rates of self-reported self-harm (63%) and attempted suicide (43%). In contrast, self-reported rates of depression, anxiety and suicide attempts for the general population are indicated at 11.6%, 26.3%, and 3.2% respectively – see LGBTIQ+ Health Australia, Snapshot of Mental Health and Suicide Prevention Statistics for LGBTIQ+ People. Sydney, Australia: LGBTIQ+ Health Australia (2021). Available at: https://www.lgbtiqhealth.org.au/statistics.
47 See evidence of Professor J. Zajac, Austin Health Gender Clinic (Endocrinology) (AHGC), T-214, lines 16-21.
48 See evidence of Mrs B. Nation-Ingle, Department of Health, T-216 line 28 to T-217 line 1 and Ms C. Gillespie, Thorne Harbour Health, T-214, line 24 to T-215, line 7. See further in this regard Adam Hill et al, ‘Private Lives 3: The Health and Wellbeing of LGBTIQ People in Australia’ (Research Paper, Monograph Series No. 122, ARCSHS, La Trobe University, 2020) 50-53 (Private Lives 3). ‘Cisgendered’ is used for someone whose gender identity aligns with their sex assigned at birth.
49 See for example the evidence of C. Gillespie, Thorne Harbour Health, T-222, lines 1-3.
50 Evidence of C. Gillespie, T-325, lines 1-3.
51 Evidence of Dr N. Coventry, Chief Psychiatrist, T-228 lines 14-23.
developing mental health conditions and creates barriers to accessing supportive services’.52 Factors contributing to levels of distress, mental ill health, and suicidality in the TGD population
Discrimination
53 See in this regard the evidence of Dr J. Morandini, RACGP, T-230 line 17 to T-231 line 17 and T-307 line 20 to T308 line 9; C. Gillespie, Thorne Harbour Health, T-254 line 15 to T-255 line 17 and T-309 line 28 to T-312 line 2; Dr T. Nguyen, RCH Gender Clinic, T-308 line 25 to T-309 line 18; Professor J. Zajac, AHGC, T-309 lines 20-26; Mr Ball of Switchboard, T-424 line 15 to T-426 line 6; Ms M. McNamara of TGV, T-426 line 30 to T-427 line 30; Commissioner Fernando, T-428 line 2 to T-429 line 9; Ms A. Bernasochi of Switchboard, T-430 lines 2-14; Mr E.
McMahon, Drummond Street Services, T-445 line 11 to T-447 line 9.
54 Evidence of Dr G. Kalra, T-308 lines 11-14. See in this regard Mill O’ Sull ‘Transgender People Face Casual Discrimination Up To 60 Times A Day’ Amnesty International (Web Page, 29 March 2017) <https://www.amnesty.org.au/transgender-people-face-casual-discrimination-up-to-60-times-aday/#:~:text='Transgender%20people%20face%20casual%20discrimination%20up%20to%2060%20times%20a%2 0day',Mill%20'O'Sull&text=Transgender%20rights%20have%20come%20under,Jennings%20and%20actress%20L averne%20Cox>.
ongoing there is a sense of anxiety, there’s a sense of hypervigilance, there’s poor selfesteem, a sense of self-shame. These all impact on a person’s mental health… those who experience discrimination have increased rates of depression, anxiety, suicidality, and selfharm’.55
Transgender Victoria highlighted in its submissions that, at times, the fear of experiencing discrimination can also cause TGD people to delay taking steps towards affirming their gender ‘until living in their birth gender becomes intolerable’.56 The point of gender affirmation can therefore be a period of particular vulnerability for TGD people, which MHGC noted in its submissions as a period that has been associated with an increase in suicide risk.57
Commissioner Fernando and Mr Elliot McMahon of Drummond Street Services also gave evidence about the compounding impacts of intersectionality on the experience of discrimination (for example, a person who is both transgender and Aboriginal may face 55 Evidence of Dr T. Nguyen, T-308 line 25 to T-309 line 12. Dr Nguyen’s evidence at Inquest echoes the written submissions of the RCH Gender Service, in which it was stated that the external factors faced by TGD people that lead to poorer mental health outcomes can be understood using a ‘minority stress framework’. A 2012 study described the ‘minority stress model’ in transgender people as ‘the stressors related to being a marginalised minority group, which in turn can lead to negative physical and psychosocial outcomes. External stressors or distal factors occur across a spectrum of severity, such as misgendering, social exclusion, bullying, discrimination, verbal harassment, physical and sexual assault. These can lead to proximal stressors or internal factors, such as concealment of transgender identity, hypervigilance, internalised transphobia and fear of rejection. Minority stressors may be chronic or acute and over time can lead to negative health outcomes and health disparities such as increased substance use (including smoking and alcohol), depressed mood, anxiety, self-harm and suicidality.’ – see Submission of RCH Gender Service, Collated Brief p. 286, referring to Michael Hendricks and Rylan Testa ‘A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model’ (2012) Professional Psychology: Research and Practice 43(5) 460. DOI: https://doi.org/10.1037/a0029597.
56 Submissions of Transgender Victoria, Collated Brief, p. 258. In this vein, Dr Kalra drew a comparison with Dr Abraham Twerski’s description of the way in which a lobster grows, and its period of vulnerability in discarding an outer shell that has grown restrictively around it (which requires it to shelter from prey), to a TGD person’s experience of affirming their gender and the vulnerability and stress that this can entail in the face of anti-trans sentiment - Evidence of Dr G. Kalra, T-315, line 18 to T-316 line 6. See also in this regard: JINSIDER, 'Rabbi Dr. Abraham Twerski on Responding to Stress' (YouTube, 26 February 2009) https://www.youtube.com/watch?v=3aDXM5HFuw.
57 Submission of Dr J. Erasmus, Collated brief, p. 90. See further in this regard Greta Bauer et al, ‘Suicidality among trans people in Ontario: Implications for social work and social justice’ (translated from original Québécoise French), Revue Service Sociale (2013) 59(1) 35. DOI: https://doi.org/10.7202/1017478ar. Cf evidence of Mr Elliot McMahon, T-437, lines 14-21: ‘For many transgender women it’s not the point of affirmation that is the most dangerous. I think that that danger often follows transgender women throughout their lives and of course that’s true for some non-binary people and trans men as well, but I really do want to acknowledge that trans women and transfeminine people tend to bear the brunt of that’.
heightened discrimination and a lower sense of wellbeing due to intersecting experiences of both transphobia and racism).58 Family violence and rejection
Mr McMahon gave evidence that, in a survey and subsequent report commissioned by Equality Australia in conjunction with Drummond Street Services, TGD respondents were found to be 2.7 times more likely to experience family violence over their lifetime than the population as a whole.59 Mr McMahon stated that Australian research into LGBTIQA+ experiences of family violence has found that recent experiences of suicidal ideation, suicide attempts, and high or very high psychological distress were associated with experiences of both family of origin violence and intimate partner violence.60
Mr McMahon also gave evidence in relation to the incidence of family rejection experienced by TGD people by virtue of their TGD status, which can include ‘increased arguments and conflicts, abuse and neglect, silence and avoidance, control and isolation and revoking housing. Familial exclusion in any of those categories to any degree is potentially psychologically damaging’.61
Ms Gillespie of Thorne Harbour Health noted that experience of violence or rejection from the family can ‘escalate at points of outwardly affirming gender’.62 Indeed, Ms Lane, the Court’s lived experience expert, noted that, in deciding to undergo her own gender affirmation process later in life, and in the lead-up to telling family, colleagues and friends, she ‘made the expectation to lose everyone’.63 58 Evidence of Commissioner Fernando and Mr E. McMahon of Drummond Street Services, T-417, line 5 to T-418, line 6.
59 Evidence of Mr E. McMahon, T-446 lines 2-7. See in this regard Madeline Gibson et al 'There's No Safe Place at Home: Domestic and family violence affecting LGBTIQ+ people' (Research Paper, Equality Australia: Sydney and Melbourne, Centre for Family Research and Evaluation and Drummond Street Services, 2020) 24.
60 Evidence of Mr E. McMahon, T-446 lines 8-19.
61 Evidence of Mr E. McMahon, T-445, lines 11-23.
62 Evidence of C. Gillespie, Thorne Harbour Health, T-282 lines 3-7.
63 Evidence of Ms E. Lane, T-25 lines 27-28.
Experience of violence in the community
Mr Joe Ball of Switchboard gave evidence that, through provision of its helpline services, Switchboard has become apprised of the unique experience by members of the TGD community (particularly transwomen) of violence who ‘fear going outside, fear going on public transport, fear basic things that people can do’. This can be heightened when one may be perceived as transgender in public, and be impacted by the degree to which one is seen to ‘pass’ in one’s affirmed gender.64
The submissions of Equinox outlined that experiencing physical assault correlated most highly with attempted suicide in the TGD community, referring to a study in which violence experienced due to being TGD was reported by 21% of participants, and which doubled the probability of a lifetime suicide attempt.65 Social exclusion
Mr McMahon of Drummond Street Services gave evidence of the impacts of social exclusion faced by TGD people, noting that ‘social exclusion for trans and gender diverse people impinges on our fundamental rights, among the types of social exclusion our community experiences are exclusion from income and protection. Exclusion from education. Poor work conditions including workplace discrimination. Lack of access to affordable healthcare of decent quality and lack of access to housing and basic amenities. [These are] some of the key social determinants of health and exclusion from access to them has long lasting material impacts on physical and mental health and well-being’.66
The effects of discrimination and social exclusion on TGD people were noted to be potentially long-lasting, with Dr Coventry, then-Chief Psychiatrist, giving evidence that ‘I 64 Evidence of Mr J. Ball, Switchboard, T-425, lines 13-25. See also evidence of Ms M. McNamara, T-426 line 23 to T-427 line 30. The notion of ‘passing’ was acknowledged by Mr Ball to be problematic, and the discussion of ‘passing’ was noted by Dr Vivienne to hinge on a ‘binary construct that we’re folded back into… the experiences of being not fitting are manifest from moment to moment on an ongoing basis when there’s not a bathroom door that you can walk through safely or there’s not a form that you can identify yourself in’.
65 Submissions of Equinox, Collated Brief, p. 78. See in this regard Sav Zwickl et al, ‘Factors associated with suicide attempts among Australian transgender adults’ (2021) 21 BMC Psychiatry 81. DOI: https://doi.org/10.1186/s12888021-03084-7.
66 Evidence of Mr E. McMahon, T-446 line 20 to T-447 line 2.
think it runs the significant risk that people lose the protective factors that are very helpful for mental health and wellbeing, particularly if we’re talking about children and young people that, with withdrawal from many other domains of their life, so thinking about young people that are already somewhat dislocated from education who drop out of education, they lose the opportunities for vocational training, tertiary education, all the other social impacts through this’.67 ‘Debate’ on TGD issues in the media
The Commissioner for LGBTIQA+ Communities, Commissioner Fernando (as he then was), noted in his submissions to the Court the deleterious impact on TGD people of ‘criticisms, hate speech and attacks upon trans people in the media and on social media’,68 an issue spoken to at Inquest by many witnesses, including those on the Medical Panel, such as Dr Nguyen of the RCH Gender Service69 and Professor Zajac of Austin Health.70 Significantly, Bailey Nation-Ingle of the Department of Health gave evidence that, following an ‘anti-trans rally’ held in March 2023 in Melbourne, the Department received many calls from service providers indicating a significant increase in the numbers of referrals to their services, including those supporting LGBTIQA+ people following a suicide attempt, suicidal ideation or self-harm. Mind Australia also reported a significant increase of referrals from TGD people at that time.71 The right to exist
At Inquest, Ms Gillespie described the ‘philosophical, ideological, religious objections to the existence of trans and gender diverse people’ that underpin the experience of discrimination and social exclusion of TGD people.72 Dr Mark Dalgleish gave evidence of the deleterious impact of such attitudes, insofar as the very existence, welfare and wellbeing 67 Evidence of Dr N. Coventry, Chief Psychiatrist, T-318 line 20 to T-319 line 2.
68 Submissions of the Commissioner for LGBTIQA+ Communities, Collated Brief, p. 122.
69 T-317 lines 13-26, referring to the stated impact on a young TGD patient of a former Prime Minister’s comments on ‘gender whispering’. This point was also raised by Ms M. McNamara of Transgender Victoria at T-434 lines 4-27.
70 T-317 line 28 to T-318 line 16, referring the impact of media commentary on sporting events in which TGD athletes are competing or seeking to compete.
71 Evidence of Mrs B. Nation-Ingle, T-313 lines 12-23.
72 Evidence of C. Gillespie, Thorne Harbour Health, T-315 lines 9-12.
of TGD people, which ought to be non-negotiable, are shifted ‘into spheres that are seen as being debatable or optional’.73 Dr Dalgleish opined that the questioning of gender identity necessarily entails questioning an intrinsic quality that underpins one’s very existence, noting that ‘gender, and to a large degree sexuality is embodied, it is deeply personal in their fullest sense because it is not just how we are operating in the world, it’s how we are in our very existence’.74
74 Evidence of Dr M. Dalgleish, T-250, lines 6-10. See also Submissions of Transgender Victoria, Collated Brief, p.
75 Evidence of Dr T. Nguyen, T-229 lines 16-26. Dr Kalra of the MHGC also provided a unique perspective of his work with the Indian Hijira community, a cultural group in India whose members do not align with a gender binary.
Dr Kalra noted that the sense of dysphoria and mental ill health in this community is not as prevalent as seen in the Western context, which he posits is due to the increased cultural acceptance for the Hijira community in India - Evidence of Dr G. Kalra, T-234 line 25 to T-235 line 10.
Classifications
The Coroners Prevention Unit (CPU), in providing advice to the Court on the cluster investigation, also emphasised that, while there are increased risks of suicidality, distress and mental ill health amongst TGD people, not conforming with a birth-assigned gender expectation is not itself a mental health ‘condition’.76 International Classification of Diseases and Related Health Problems
The CPU referred to the World Health Organization (WHO) International Classification of Diseases and Related Health Problems (ICD), which is used in Australia for classification of health-related conditions. According to the WHO, the 11th Edition of the ICD (ICD-11) which came into effect from 1 January 2022, redefined and replaced outdated diagnostic categories, including ‘transsexualism’ and ‘gender identity disorder in children’, with ‘gender incongruence of adolescence and adulthood’ and ‘gender incongruence of childhood’ respectively. Gender incongruence is defined in the ICD-11 as ‘characterised by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group’.77
In the ICD-11, gender incongruence has been moved from the ‘Mental and behavioural disorders’ chapter and into the new ‘Conditions related to sexual health’ chapter, to reflect current knowledge that TGD identities are not conditions of mental ill health, and that classifying them as such can cause enormous stigma. Transgender Victoria noted that this 76 See in this regard Coroners Prevention Unit Cluster Report (CPU Cluster Report), Collated Brief, pp. 10-11. See also in this regard the Submissions of Transgender Victoria, Collated brief, pp. 256-258.
77 See CPU Cluster Report, Collated Brief, pp. 10-11, referring to WHO, Gender incongruence and transgender health in the ICD, Available: https://www.who.int/standards/classifications/frequently-asked-questions/genderincongruence-and-transgender-health-in-theicd#:~:text=ICD%2D11%20has%20redefined%20gender,gender%20incongruence%20of%20childhood%E2%80%9 D%20. Extended definitions are included for gender incongruence in childhood and in adolescence/adulthood, with the latter described thusly: ‘Gender Incongruence of Adolescence and Adulthood is characterised by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual’s body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis’’.
revision was of great importance to TGD people ‘as it depathologises being transgender and more closely accords with TGD peoples’ understanding of themselves’.78 Diagnostic Statistical Manual
The CPU also noted that in 2013, the Diagnostic Statistical Manual (DSM-5), which is published by the American Psychiatric Association and is used by some clinicians as a classification of mental disorders in Australia, the diagnostic category of ‘gender identity disorder’ was changed to ‘gender dysphoria in adolescents and adults’ and ‘gender dysphoria in children’. The change is reflected in the revision published in March 2022 (DSM-5-TR) which focuses on the gender-related distress experienced by an individual, rather than the individual’s gender itself. Gender dysphoria in this context is defined as a ‘clinically significant distress or impairment related to gender incongruence, which may include desire to change primary and/or secondary sex characteristics’.79 I note that the DSM-5-TR and definitions therein are not used by all clinicians in providing genderaffirming treatment.80
As will be discussed in the next section, not all individuals who identify as TGD will experience psychological distress or meet the criteria for gender dysphoria, and some people can experience gender-related distress without identifying as TGD. In Australia, it is important to note that the presence of gender dysphoria is not required to access genderaffirming treatments. In its submissions to the Court, the RANZCP stated ‘gender dysphoria emerges in many different ways and is associated with significant distress for those who 78 Submissions of Transgender Victoria, Collated brief, pp. 255-258. In this connection, Transgender Victoria emphasised the need to avoid pathologisation of TGD identities through use of words such as ‘comorbidities’ to describe co-occurring mental health conditions in TGD people.
79 'What is Gender Dysphoria', American Psychiatric Association (Web Page, August 2022) https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria. An extended definition is included to guide diagnoses of gender dysphoria.
80 The classification of gender dysphoria under the DSM-5 is strongly resisted by some health care practitioners who are of the view that this continues to pathologise gender identity – see for example the approach of the MHGC outlined at ‘Frequently Asked Questions’, Monash Health (Web Page) https://monashhealth.org/services/genderclinic/questions/#assessments; and Dr T. Nguyen, RCH Gender Clinic, T-230, lines 2-12 – ‘I would also like to add to the comment around the DSM-5 classification that it is pathologising, it doesn’t speak to the trans experience, and it perpetuates binary gender stereotypes in terms of preferences and behaviours but in addition to this the real problem with it, it’s the perpetuation of its use. It’s used in spaces where it is required for medical affirmation, or it is required for surgical affirmation so there needs to be systemic changes not just within the DSM-5 and moving on to DSM-6 but within systems that continue to uphold it as a requirement’.
experience it. However, gender incongruence is not inherently pathological’.81 Dr Peter Jenkins on behalf of the RANZCP emphasised at Inquest that the RANZCP does not believe that being TGD is a mental health condition.82
Notwithstanding these changes to the DSM and ICD, their effect may still be somewhat ‘pathologising’.83 Dr Coventry noted the ongoing challenge that gender-related issues are still viewed through the prism of disease. He stated that ‘[t]he incongruence is actually from how our culture might be responding, so I find these labels very unhelpful because they are very unsophisticated, they focus on the individual… so I think while the World Health Organization as my colleague Peter Jenkins was mentioning is an improvement, I think it’s still talking about disease entities which creates barriers, I think, for people to be able to access care and it also creates barriers in terms of cultural sensitivity in terms of looking at the impact of stigma and discrimination on someone’s health and well-being rather than internally what’s going on’.84 Analysis Levels of distress, mental ill health and suicidality in the TGD population
I consider that the evidence at Inquest established unequivocally that those in the TGD community face disproportionate rates of distress, mental ill health, and suicidality compared to the population as a whole. The reasons for this are multifactorial, intersecting, and linked to extrinsic factors associated with the broader community’s responses to TGD people, which can include experience of discrimination, violence and exclusion that erode the TGD community’s wellbeing and contributes to mental ill health.
I have considered this evidence in light of the reported experience of the five deceased persons whose deaths I am investigating as part of the cluster. In respect of the issue of 81 Royal Australian and New Zealand College of Psychiatrists submission, Collated Brief, p. 99. It is noted that this part of the RANZCP’s submissions referenced Position Statement 103 which relates to the RANZCP’s position in working with TGD people in Australia and New Zealand and the role of psychiatrists in responding to their mental health needs. However, this aspect of the position statement remains unchanged.
82 Evidence of Dr P. Jenkins, RANZCP, T-231, lines 19-21.
83 Evidence of Dr T. Nguyen, RCH Gender Clinic, T-230, lines 2-12.
84 Evidence of Dr N. Coventry, Chief Psychiatrist, T-232 line 26 to T-233 line T-234 line 19.
discrimination, I note that Natalie’s fear of being discriminated against as a transgender person was described by her psychologist as something that deeply affected her mental health and led her to equivocate in relation to engaging with a gender clinic to affirm her identity as female, believing she would be ‘severely discriminated against by others due to being transgender’. This was described as a major barrier in her being able to overcome her fear of being in public and contributed to her increasing isolation.85
The experience of social isolation was also demonstrated in the evidence related to all five deaths in this cluster, and was amplified by COVID-19 lockdown conditions. For example, in the years after she finished high school, Matt was described as rarely leaving her bedroom due to anxiety and depression. Matt was also never able to secure a job, despite continuing to look and apply for work.86 I also heard evidence that AS and Matt lived isolated lives, often confining themselves to their bedrooms, and while Bridget was supported by Mx Leigh and her sister Angela following the COVID-19 lockdowns, she too reported becoming increasingly isolated in her small Flemington apartment, where she lived alone.87
The experience of family rejection was also evident amongst certain of the deceased whose deaths I am investigating as part of the cluster. For example, while she enjoyed support from other members of her family, including her father, AS’s mother told her on her sixteenth birthday that if she wished to pursue gender affirmation, she would not be welcome in the family home.88 This led AS to leave the family home which she described as an ‘involuntary’ act. Indeed, AS noted that she needed this understanding and support, and her experience of family rejection made her feel ‘more alone and vulnerable’.89
Finally, heightened fears of violence against TGD people were also reflected in evidence that, following Bridget going missing on 30 November 2020, many LGBTIQA+ community members feared she had been attacked, kidnapped, or murdered.90 85 Statement of R. Berthelsen, CB in the matter of Natalie Wilson, p. 55.
86 Statement of J. Byrne, CB in the matter of Matt Byrne, p. 23; Statement of R. Byrne, CB in the matter of Matt Byrne, p. 18.
87 Statement of H. Leigh, CB in the matter of Bridget Flack, p. 45.
88 Statement of S.T, CB in the matter of AS, p. 7 and also CB in the matter of AS, p. 54.
89 See CB in the matter of AS, p. 54.
90 Submissions of the Commissioner of LGBTIQA+ Communities, Collated Brief, pp. 122, 124, 130 and 136.
Impact of gender-affirming care on distress, mental ill health and suicidality
The evidence of Professor Zajac of Austin Health was that in general, mental health issues and distress experienced by TGD individuals is significantly reduced after commencing gender affirming treatment.91 This was echoed by Dr Kalra of MHGC,92 Dr James Morandini of the Australian Psychological Society,93 and Dr Tram Nguyen of the RCH Gender Service.94 Dr Mark Dalgleish also opined that the overall health of TGD people can improve when receiving gender-affirming care.95 The need for improved data regarding the TGD community
While noting that there is clear evidence of disproportionate mental ill health, distress and suicidality amongst the TGD population, the data on this issue is widely considered to be incomplete, including in relation to the incidence of completed suicides in the TGD community.
In Victoria, this has been attributed to ‘systemic issues around data collection’,96 insofar as entities such as Victoria Police, and until recently, the Coroners Court of Victoria and the Department of Health, have not had a comprehensive system for capturing and recording all gender identities (including transgender and non-binary identities), instead relying on the socalled traditional binary male/female designations.97 91 Statement of Dr J. Zajac, Collated Brief, p. 51, referring to Lucas Foster et al ‘Short-Term Effects of GenderAffirming Hormone Therapy on Dysphoria and Quality of Life in Transgender Individuals: A Prospective Controlled Study’ (2021) 29(12) Front Endocrinal (Lausanne). DOI: 10.3389/fendo.2021.717766.
92 Evidence of Dr G. Kalra, T-252 line 24 to T-253 line 5.
93 Evidence of Dr J. Morandini, T-256 line 12 to T0257 line 4.
94 Evidence of Dr T. Nguyen, T-259 line 27 to T-260, line 20.
95 Evidence of Dr M. Dalgleish, T-255, line 19 to T-256, line 6. I will return to this further below in analysing the evidence in relation to provision of culturally-appropriate gender-affirming care; its relevance to the present scope item is that for TGD people, affirming one’s gender may in fact reduce suicidal ideation and distress and lead to significantly improved mental health outcomes.
96 Evidence of Mrs Nation-Ingle, Department of Health, T-219, line 15.
97 This gives rise to the risk not only of failing to accurately record transgender identities but, as specifically noted by Dr Mark Dalgleish, it also gives rise to a risk that non-binary identities will not be recognised and recorded – see evidence of Dr M. Dalgleish, T-223 lines 13-16.
This is compounded by the fact that there is no population level data on the number of TGD people nationally or in Victoria.98 In a 2019 study, it was estimated that 0.1% - 2% of the population identify as TGD99 and that this cohort represents a sizeable and increasing proportion of the general population,100 with significant and growing numbers of people who are willing to publicly identify as TGD.101 However, the current data is likely to be a significant under-count of the numbers of TGD people in Australia.102
A report issued by the Coroners Court in 2022 entitled ‘Suicide among LGBTIQ+ people’ acknowledged the limitations in the available dataset on suicides amongst the LGBTIQA+ population in Victoria.103 Indeed, the report did not include data on deaths of TGD people as a discrete part of the LGBTIQA+ community due to concerns it may represent a significant undercount of the suicides in this cohort, and following concerns from community organisations on the impact of this. The report further recognised that ‘[i]ncomplete or inaccurate data may only offer limited insight into suicide among LGBTIQ+ communities and could potentially be unhelpful (and even damaging) to prevention efforts’.104
As noted in the above report, the lack of systems agility to accurately capture data has significant practical and policy implications. It is evident that accurate estimates of the proportion, distribution, and composition of the TGD population, as well as projections of resources required to adequately support health needs of TGD people, will ultimately depend 98 Evidence of Commissioner Fernando, T-397, lines 13-15. See also evidence of Mr Ball, Switchboard, T-397 line 24 to T-398 line 5.
99 See Ada Cheung et al ‘Position statement on the hormonal management of adult transgender and gender diverse individuals’ (2019) 211(3) Medical Journal of Australia 127. DOI: 10.5694/mja2.50259.
100 See Qi Zhang et al ‘Epidemiological considerations in transgender health: A systematic review with focus on higher quality’ (2020) 21(2) International Journal on Transgender Health (Zhang et al). DOI: 10.1080/26895269.2020.1753136.
101 Submissions of Transgender Victoria, Collated Brief, p. 254.
102 See evidence of Mr J. Ball, Switchboard, T-398 lines 27-29.
103 Evidence of Mrs Nation-Ingle, Department of Health, T-218 line 25 to T-219 line 2.
104 See ‘Suicide among LGBTIQ+ people’ (Report, Coroners Court of Victoria, 14 October 2022) <https://www.coronerscourt.vic.gov.au/sites/default/files/2022-10/Coroners%20Court%20of%20Victoria%20- %20Suicide%20among%20LGBTIQ%2B%20people.pdf>.
on the availability of systematically collected high-quality data,105 such as via the Australian census.106
In the context of accurately recording the rate of suicides in the TGD community in Victoria, I note that the Coroners Court has recently updated its own database to be capable of capturing all gender identities, which I will return to later in this Finding,
However, coroners investigating suicides may not be aware the subject of their investigation was a member of the TGD community unless this is documented in the coronial material: for example, by members of Victoria Police who submit the initial report of death (Form
106 See in this regard ‘2026 Census topic review: Phase two directions’ Australian Bureau of Statistics (Web Page, 12 December 2023) https://www.abs.gov.au/statistics/research/2026-census-topic-review-phase-two-directions and evidence of Ms M. McNamara, T-399 lines 12-22. However, as of 26 August 2024, the ABS has indicated that this will not occur in the 2026 census – ‘Changes to 2024 Census Testing Plans’ Australian Bureau of Statistics (Web Page, 26 August 2024) https://www.abs.gov.au/media-centre/media-statements/changes-2024-census-testingplans.
107 For a list of these, see Suicide among LGBTIQ+ people’ (Report, Coroners Court of Victoria, 14 October 2022) p 4 <https://www.coronerscourt.vic.gov.au/sites/default/files/2022-10/Coroners%20Court%20of%20Victoria%20- %20Suicide%20among%20LGBTIQ%2B%20people.pdf>.
See also in this regard the evidence of Commissioner Fernando, T-412 lines 16-23 – ‘I do note that there may be some sensitivities around police officers being able to ask the question of gender identity and/or sexuality on Form 83 to any parent or senior next of kin who may be at the scene, but nonetheless I think it is an important exercise for Victoria Police to do in regard to a cultural safety framework that the organisation should adopt’.
108 See in this regard the evidence of C. Gillespie, Thorne Harbour Health, T-225 line 18 to T-226 line 9.
the commitment under Priority Area 3 of ‘Pride in our future: Victoria’s LGBTIQA+ strategy 2022-32’.109 A pertinent recommendation will follow.
4 – Provision of culturally-appropriate gender-affirming care
Terminology
Prior to analysing the evidence received on the provision of culturally-appropriate genderaffirming care to TGD people in Victoria, I consider that it is worth briefly outlining the applicable terminology. Dr Mark Dalgleish gave evidence at Inquest of the importance of language to capture the breadth of experiences within the TGD community, stating that ‘when it comes to providing gender affirming healthcare we also want to be affirming in every aspect of what we are doing, and that means that we have to recognise a diverse – a diverse expression of identities, sexuality identities, gender identities, other identities that form the wholeness of who we are as humanity’.110 I have approached this task with Dr Dalgleish’s words in mind, noting that in relation to certain terminology, there are several available definitions.
As a broad starting point, I note that ‘gender’ is used to refer to the socially constructed roles, behaviours, expressions and identities of girls, women, boys, men, and gender diverse people. The World Health Organization (WHO), which is the agency of the United Nations responsible for, inter alia, providing leadership on global health matters, notes that gender interacts with but is different from ‘sex’, which refers to the different biological and physiological characteristics of females, males and intersex people, such as chromosomes, hormones, and reproductive organs.
Gender and sex are related to but different from ‘gender identity’, which is described by the WHO as a person’s internal and individual experience of gender, which may or may not 109 See in this regard evidence of Commissioner Fernando, T-411, lines 24-28.
110 Evidence of Dr M. Dalgleish, T-244 line 26 to T-245 line 8.
correspond to their sex at birth.111 Gender identity has also been described as ‘a person’s innermost concept of self as male, female, a blend of both or neither’.112
• Within the acronym ‘TGD’, a ‘transgender person’ is a person whose gender identity or expression is different from that assigned at birth or who sits outside the gender binary.
The terms male-to-female and female-to-male may be used to refer to individuals who are undergoing or have undergone a process of gender affirmation.
• ‘Gender diverse’ is a broad term that encompasses a diversity of gender identities and gender expressions including: bigender, trans, transgender, genderqueer, gender fluid, gender questioning, gender diverse, agender, and non-binary. Gender diverse refers to identities and expressions that reject the belief that gender is determined by the sex someone is assigned at birth.
• The term ‘non-binary’ is used to describe one whose gender is not exclusively male or female. Non-binary is both an identity and an umbrella term describing a range of people who exist outside societal expectations that gender is only a binary of male and female.114 111 ‘Gender’, Worth Health Organisation (Web Page) https://www.who.int/europe/health-topics/gender#tab=tab_1.
112 CPU Cluster Report, Collated Brief, p. 4. See further in this regard Charles Roselli ‘Neurobiology of gender identity and sexual orientation’ (2018) 30(7) Journal of Neuroendocrinology. DOI: 10.1111/jne.12562.
113 Eli Coleman et al ‘Standards of Care for the Health and Transgender and Gender Diverse People, Version 8’ (2022) 6(23) Journal of Transgender Health. (WPATH Standards 8). DOI: 10.1080/26895269.2022.2100644. Conversely, the term ‘cisgender’ is used for someone whose gender identity aligns with their sex assigned at birth. I have also used the acronym ‘LGBTIQA+’ in this Finding to refer to Lesbian, Gay, Bisexual, Trans and Gender diverse, Intersex, Queer, Questioning, and Asexual communities, being an inclusive umbrella abbreviation of diverse sexualities, genders, and sex characteristics (including TGD people). These definitions are used in the Victorian Government LGBTIQA+ Inclusive Language Guide, October 2023 (Web Page) https://www.vic.gov.au/sites/default/files/202310/LGBTIQA%2B-inclusive-language-guide.pdf.
114 See in this regard the Submissions of Equinox, Collated Brief, p. 72.
The process of ‘gender affirmation’ (also known as ‘transitioning’, though this is often not preferred terminology)115 will be outlined further below, and is described simply as ‘the personal process or processes a trans person determines is right for them in order to live as their defined gender and so society recognises this. This may involve social, medical, and/or legal steps that affirm a person’s gender’.116
Finally, as noted by Transgender Victoria, the WHO describes ‘gender-affirmative healthcare’ as including ‘any single or combination of a number of social, psychological, behavioural or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity’.117
I will explore further below what the term ‘culturally-appropriate’ means in the context of care and services provided to the TGD community. However, as a basic proposition and as noted by the CPU, referring to the submissions of Thorne Harbour Health, culturallyappropriate care of TGD people is that which is safe, accessible and welcoming insofar as it avoids the medicalisation or pathologisation of gender identity, avoids discrimination, is trauma-informed and holistic, and often involves peer workers and/or is peer-led; ‘if you can see yourself in a service, you can attend a service’.118
In the preceding section of this Finding, I have already noted basic definitions of ‘gender incongruence’ (a marked and persistent incongruence between an individual’s experienced gender and the assigned sex) and ‘gender dysphoria’ (clinically significant distress or 115 See in this regard Submissions of Equinox, Collated Brief, pp. 72-73: ‘Transitioning describes a TGD individual’s progress towards living their gender identity, either privately and/or publicly, when that identity is other than the gender identity presumed at birth. Transitioning in many cases (but by no means all) will involve some gender affirming medical or health care, however in nearly all cases the gender affirmation process will have begun well before this occurs. Throughout this response we refer to ‘affirmation’ rather than ‘transitioning’ as a truer representation of what TGD people experience’.
116 See CPU Cluster Report, Collated brief, p. 5, referring to ‘LGBTQIA+ glossary of common terms, Australian Institute of Family Studies (Web Page, February 2022) < https://aifs.gov.au/resources/resource-sheets/lgbtiqaglossary-common-terms>.
117 See Submission of Transgender Victoria, Collated Brief, p. 256, referring to ‘Gender Incongruence and transgender health in the ICD’. World Health Organization (Web Page) <Gender incongruence and transgender health in the ICD (who.int)>.
118 CPU Cluster Report, Collated brief, p. 16, referring to Equinox Submissions. Collated Brief. Ms M. McNamara of Transgender Victoria provided a helpful definition at Inquest of the related concept of ‘cultural safety’, noting ‘my simple definition would be that a cultural safety exists when a marginalised person for whom the cultural safety is being established, walks into a service and feels instantly at home and comfortable that they can - all their needs can be met … as a full person within that service’ – see T-525 lines 11-16.
impairment related to gender incongruence, which may include desire to change primary and/or secondary sex characteristics). In relation to these definitions, I acknowledge that some organisations do not use or support use of the definition and classification of ‘gender dysphoria’ under the DSM-5, and adopt the advice of the WHO’s ICD-11 which instead recommends using the term ‘gender incongruence’, including in a diagnostic context.119 The process of gender affirmation
I heard evidence at Inquest that gender affirmation can involve social, legal, and medical affirmation.120 Dr Nguyen of the RCH Gender Service noted that gender affirmation is ‘not a linear process’.121 A gender affirmation journey is unique to the individual – ‘there is no requirement for transgender people to undertake any form of affirmation; there is no prescribed order and there are as many trans-narratives as there are trans people’.122 Further, a gender affirmation process is not restricted to any particular timeframe and may be a lifelong process even where certain elements of affirmation are ceased, such as hormone treatment.123
Social affirmation may include use of chosen names, pronouns, online profiles, clothes, hair-style, grooming (hair removal, make-up), and clothing. Legal affirmation involves a formal change of name and gender markers on legal documents such as a birth certificate, passport, or Medicare card. Medical affirmation may include processes by which a person changes their physical sex characteristics via hormonal intervention and/or surgery 119 See in this regard ‘Frequently Asked Questions’, Monash Health (Web Page) https://monashhealth.org/services/gender-clinic/questions/#assessments. In this connection, Professor Zajac appeared to comment that the distinction may not be meaningful to some: ‘the surgeons usually insist on one or two psychiatrists or psychologists or somebody like me writing – writing, saying that the person has general incongruence or gender dysphoria, or whatever it is we’re calling it that day’ – T-243 lines 7-11.
120 I note that I received evidence of further forms of affirmation within these categories, to include familial affirmation as well as affirmation of gender in the workplace, professional associations, unions, and educational institutions – see in this regard the submissions of Transgender Victoria, Collated Brief, p. 258.
121 Evidence of Dr T. Nguyen, T-236, lines 11-12; reflected in submissions of Equinox, Collated Brief, p. 75.
122 Submissions of RCH Gender Service, Collated Brief, p. 279.
123 Evidence of Dr T. Nguyen, T-236, lines 20-23. See also T-244 lines 9-16 per Dr Nguyen – ‘just because someone stops hormones doesn’t mean that they have stopped their gender affirmation. An example of this is someone who might be happy with the permanent effects of testosterone and don’t feel they need to have it ongoing. That doesn’t mean their gender has changed, it just means that they feel affirmed in who they are in their body and don’t feel the ongoing requirement for hormone treatment’.
(including chest reconstructive surgery, breast augmentation, or genital surgery),124 and while this is the focus on many policy discussions in this space, medical affirmation is not the goal of all TGD people.
Dr Coventry, Chief Psychiatrist, noted the importance of gender-affirming care being individual-led and that it should not be assumed, for example, that ‘everyone wants medical affirmation in terms of your physical appearance matching your gender identity’. Culturallyappropriate gender-affirming care means ‘not challenging one’s sense of identity, showing shared respect, dignity, shared understanding and really intense listening and working together for people to be making appropriate decisions about their own health and their future. That’s the respect everyone is entitled to’.125 Standards, guidelines, assessment and access to care
The Australian Professional Association for Transgender Health (AusPATH) is Australia’s peak body for professionals involved in the health, rights and well-being of TGD people.126 AusPATH has endorsed the WPATH Standards127 to guide healthcare professionals on the process of medical gender affirmation in Australia, in conjunction with position statements and standards released separately by AusPATH.128 These standards include those addressing initiation of gender-affirming hormone therapy via the ‘informed consent’ model (AusPATH Informed Consent Standards), which build upon those previously developed and issued by Equinox Gender Diverse Health Centre (Equinox),129 which are also endorsed by AusPATH.
124 Submissions of RCH Gender Service, Collated Brief, p. 279. Gender affirming surgeries are currently not available in Victoria to people under 18 years of age.
125 Evidence of Dr N. Coventry, T-238 lines 15-20.
126 See in this regard the Submissions of Transgender Victoria, Collated Brief, p. 264.
127 WPATH Standards 8.
128 AusPATH notes on its website that it ‘recommends judicious use of the [WPATH] SOC 8 together with the Position Statements that AusPATH has released’ - ‘Standards of Care for the Health of Transgender and Gender Diverse People, Version 8’ AusPATH (Web Page, 1 September 2011 and updated in 2022) https://auspath.org.au/2011/09/01/world-professional-association-for-transgender-health-standards-of-care-version7/.
129 See AusPATH (2024). Australian Informed Consent Standards of Care for Gender Affirming Hormone Therapy.
Australia: Australian Professional Association for Trans Health. Version 1.1. (Web Page) ,https://auspath.org.au/wpcontent/uploads/2024/06/AusPATH_Informed-Consent-Guidelines_DIGI_2024_RLv01.pdf>.
Two potential models for medical affirmation
Different gender clinics and health practitioners offering gender-affirming care operate using different models. The first is the WPATH model. The Monash Health Gender Clinic (MHGC), which is publicly funded, operates using the WPATH model and requires a comprehensive mental health assessment to be conducted prior to any gender-affirming medical treatment commencing. While there have been significant changes made to the standards contained in WPATH-7 (issued in 2012) and WPATH-8 (issued in 2022), under these standards of care, a mental health assessment is still required to be conducted prior to gender-affirming medical treatment commencing,130 with any mental health symptoms that interfere with a person’s capacity to consent to gender-affirming treatment to be addressed before treatment is initiated.131 MHGC also assesses suicide risk as part of the mental health assessment and factors this into any treatment plan.132
The WPATH model is used at MHGC for the delivery of all gender-affirming care, including commencement of hormone treatment and surgeries, some of which are offered through MHGC or in partnership with private surgeons. The WPATH Standards require letter(s) of support from a mental health professional as a pre-condition for gender-affirming surgery,133 including to ensure the patient fulfils the WPATH criteria such as capacity to consent to the surgery, gender incongruence being marked and sustained, and assessment of any health conditions.134
The WPATH Standards are viewed by some as perpetuating a form of gatekeeping that limits access to gender-affirming care. However, proponents such as MHGC note that the WPATH 130 See summary of requirements at S256 - WPATH Standards 8.
131 Statement of Dr G. Kalra, Collated Brief, p. 327, referring to WPATH Standards 8 S172.
132 Statement of Dr J. Erasmus, Collated Brief, p. 92 (noting this statement was provided when WPATH-7 was still in place) ‘Frequently Asked Questions’, Monash Health (Web Page) https://monashhealth.org/services/genderclinic/questions/#assessments.
133 See WPATH Standards 8 S256.
134 See in this regard: https://www.healthdirect.gov.au/gender-affirming-surgery#what-is
Standards are applied flexibly, in a person-centred manner, and underscore the importance of a cautious approach to gender-affirming care.135
The second model for providing gender-affirming medical care is the ‘informed consent’ model or ‘shared decision-making pathway’, adopted by Austin Health Gender Clinic, Equinox,136 and other gender clinics, as well as individual GPs providing gender-affirming care outside of a gender clinic setting (usually at a patient’s own expense). Rather than being predicated on a mental health assessment, consent models of hormone-prescribing resist the notion that a doctor can determine the validity of a person’s gender, and instead centre the TGD person in the decision-making process, whilst ensuring that the patient understands and can consent to the potential impacts that gender-affirming hormone therapy may have on their body and life.137
Professor Zajac of Austin Health noted that, for his patients, first contact is made by a peer navigator, followed by a GP or endocrinologist to assess a patient for gender-affirming hormone therapy, with a psychiatrist also available if needed.138 Professor Zajac noted that, while a mental health assessment is not a precondition for delivery of gender-affirming treatment, he recommends all patients have ongoing mental health support when affirming their gender identity.139
Professor Zajac gave evidence at Inquest that ‘in terms of the models used, the WPATH - what you might call the mental health model – is gradually being replaced by the informed consent model’, opining however that those with significant mental health problems are 135 See in this regard Homewood et al ‘Urological focus on gender affirmation surgery’ (2024) 53(5) Australian Journal of General Practice DOI: 10.31128/AJGP-11-23-7044; ‘Frequently Asked Questions’, Monash Health (Web Page) https://monashhealth.org/services/gender-clinic/questions/#starting-at-clinic.
136 Carolyn Gillespie of Thorne Harbour Health (which Equinox forms a part of), gave evidence at Inquest that ‘the premise of the work of Equinox is an informed consent model which assumes that clients of the service know themselves and without any evidence otherwise we assume that they are in a position to make decisions in relation to their own body and their lives. So that’s directly to address some of the gatekeeping issues that people have in terms of historically having to get psychiatric assessments and psychological reports and whatnot in order to access gender affirming care’ - Evidence of Carolyn Gillespie, T-264, lines 8-16.
137 AusPATH Informed Consent Standards.
138 Submissions of Professor J. Zajac, Collated Brief, p. 53. Professor Zajac also noted that the gender-affirming services that Austin Health provides are delivered through the state-funded Trans and Gender Diverse in Community Health Initiative (TGDiCH), a consortium of Austin Health, Your Community Health (at PANCH in Preston), Ballarat Community Health and Thorne Harbour Health and includes endocrinologists, psychiatrists, GPs, peer workers and other support personnel – see Collated Brief p. 52.
139 Submissions of Professor J. Zajac, Austin Health Gender Clinic, pp. 51-53.
‘better off’ with the WPATH model.140 Dr Kalra of MHGC concurred that the WPATH model is more appropriate for those ‘with complex mental health issues or perhaps more than two or three mental health issues’, noting that those within this cohort ‘end up coming to the Monash Health Gender Clinic’.141 For MHGC, existence of serious mental illnesses is not a barrier to gender-affirming care per se, but the presence of illnesses such as schizophrenia and other major mental illnesses may warrant a longer period of assessment prior to any gender-related treatments commencing.142 The importance of gender-affirming care being culturally-appropriate for TGD people
Ms Gillespie gave evidence that Equinox, established in 2016, was the first service of its kind, designed to allow TGD people to ‘access a really culturally affirming general practice service, so what we offer is all aspects of GP care including hormone initiation, sexual health, mental health, vaccination, endocrinology, nursing support, secondary consultation to prison services…’.143
Equinox employs TGD-identifying nursing staff and peer workers as well as GPs who identify as members of the LGBTIQA+ community. Ms Gillespie described: ‘our community holds our community’,144 noting that TGD people are best-placed to determine what culturally-appropriate care looks like for them.
Ms Gillespie stated that, in terms of the relationship between Equinox and the TGD community, there is ‘genuine and meaningful inclusion around processes and decisions that get made. So when services and systems are built like Equinox was truly in partnership and led not just in partnership but led by trans and gender diverse people, it meant that we have 140 Evidence of Professor J. Zajac, Austin Health Gender Clinic, T-269, lines 17-26.
141 Evidence of Dr G. Kalra, T-271, lines 11-17.
142 ‘Frequently Asked Questions’, Monash Health (Web Page) https://monashhealth.org/services/genderclinic/questions/#starting-at-clinic.
143 Evidence of Ms C. Gillespie, Thorne Harbour Health, T-210 line 26 to T-211 line 15.
144 Evidence of Ms C. Gillespie, Thorne Harbour Health, T-284, lines 14-15.
a service that now sees thousands of people and supports them because it’s actually structured to meet those needs’.145
The benefit is that TGD people feel genuinely able to access the service and have their health needs met. This may also avoid the significant health risks which can arise where TGD people report delaying or avoiding needed medical treatment to avoid the risk of discrimination.146 The importance of multidisciplinary care
During my investigation, I received evidence that the importance of a multidisciplinary approach to gender-affirming care for TGD communities is underscored in both the WPATH and ‘informed consent’ models of care. WPATH promotes care from a multidisciplinary team as vital to the wellbeing of TGD people and considers this to be a key part of any assessment or treatment plan, with regular reviews between service providers, including importantly when there are indicators of risk.147 This approach is exemplified by gender clinics such as MHGC, which is staffed by a multidisciplinary team comprising consultant psychiatrists, clinical psychologists, a social worker, endocrinologists, peer support workers, a project worker, research assistant and administrative workers along with external private consultants in speech pathology and plastic surgery.148
Ms Gillespie of Equinox highlighted the importance of a multidisciplinary approach for those receiving gender-affirming medical care through an informed consent model, stating ‘I think from our perspective, having holistic integrated care is just good healthcare and it 145 Ms Gillespie also noted in this regard the Inquest process demonstrated cultural safety for TGD people through visible signs of inclusion, as well as consultation with people with lived experience prior to the convening of the hearing ‘to talk about how we could best make these structures and processes culturally safe for our trans and gender diverse community’ – See evidence of Ms C. Gillespie, Thorne Harbour Health, T-320, line 15 to T-321 line 7. To this end, Ms Lane noted, in assessing whether a space was safe for her to access as a transgender woman, and in referring to the courtroom, ‘Now, what I do is, I look for any signs of inclusion. Things like the flag you have here, or the flags here, show support and this is a really important thing for the community’ – T-32, lines 18-21.
146 Submissions of Equinox, Collated Brief, p. 84, referring to Lucille Kerr, Christopher Fisher and Tiffany Jones ‘TRANScending discrimination in health & cancer care: a study of trans & gender diverse Australians’ 2019 117 Australian Research Centre in Sex Health (Kerr et. al., 2019). DOI: 10.26181/5d3e1cc21a99c. This study found in relation to TGD people high levels of unmet healthcare needs, discomfort discussing their needs, feeling misunderstood, emergency department avoidance, barriers to care, numerous instances of poor treatment in the healthcare system and hesitancy to disclose their gender – see p. 6.
147 WPATH Standards 8.
148 See Statement of Dr G. Kalra, Collated Brief, p. 324.
doesn’t matter who it is that’s sitting in front of you but particularly for trans and gender diverse folk, when you provide a holistic integrated model, you can attend to all of the things that impact on someone’s mental health and their wellbeing. So for us we work within an organisation that can really be often a one stop shop’.149 This may include additional services such as culturally-safe alcohol and other drug support, support for family violence and other issues that may be faced by TGD persons seeking access to care, as well as providing a pathway to receipt of acute mental healthcare where needed.150
Professor Zajac of Austin Health lamented the deficiency in private practice in providing multidisciplinary gender-affirming care, where it is usually ‘just me and the GP, it’s hard to find at - for me to get access to the wide range of supports that are available at a place like Thorne Harbour and some of the other general practices who have an interest in this area’.151 Professor Zajac considered this was less than ideal where the potential mental health effects of gender-affirming hormones are required to be monitored, and in light of his recommended approach that all TGD persons undergoing gender-affirming hormone therapy have access to mental health support.152
This fragmentation of care can also be exacerbated where, as noted by Dr Nguyen in relation to care in the private sector, Medicare does not provide a billing item for case-conferencing in many circumstances, and different practitioners who liaise with each other in relation to a patient will often do so based on duty of care alone.153 149 Evidence of C. Gillespie, T-281, lines 19-26.
150 Evidence of C. Gillespie, T-286, lines 2-7.
151 Evidence of Professor J. Zajac, T-286 lines 11-17.
152 Submissions of Austin Health Gender Clinic, pp. 51-53.
153 Evidence of Dr T. Nguyen, T-287 line18 – T-288 line 2.
Access to gender-affirming medical care and impact on wellbeing of TGD adults, including those with co-existing mental health conditions
As noted earlier in this Finding, the evidence of Professor Zajac of Austin Health was that, generally, mental health issues and distress experienced by TGD individuals is reduced after commencing gender-affirming hormone treatment.154
Professor Zajac referred to a recent controlled study in which one group of TGD participants was taken off the waiting list at a gender clinic and provided gender-affirming hormone treatment (testosterone) immediately, while a second group of TGD participants at the gender clinic remained on the waitlist without hormone treatment (the waitlist being three months). A range of responses was sought from both groups during this period in relation to measures of wellbeing, mental health, and suicidality, with the study concluding that ‘immediate testosterone compared with no treatment significantly reduced gender dysphoria, depression, and suicidality in transgender and gender-diverse individuals desiring testosterone therapy’. Professor Zajac remarked that there is ‘clear evidence from this controlled study that even as short a period as three months can improve the wellbeing of individuals’.155
The improved mental wellbeing and reduced suicidality of TGD persons upon commencing gender-affirming treatment was echoed by Dr Kalra of MHGC, who gave evidence at Inquest that ‘we do see people who have embarked on the medical affirmation pathway and we follow up people who have started on hormones or have undergone surgery for one year, starting perhaps three months after their first appointment after they’ve started on hormones or undergone surgery and we do see that positive effect in the reduction of their distress, in almost disappearance of the suicidal thoughts that they were experiencing. So we do see that happening over a period of time once they have embarked on the pathway’.156 154 Statement of Dr J. Zajac, Collated Brief, p. 51, referring to Lucas Foster et al ‘Short-Term Effects of GenderAffirming Hormone Therapy on Dysphoria and Quality of Life in Transgender Individuals: A Prospective Controlled Study’ (2021) 29(12) Front Endocrinal (Lausanne), DOI: 10.3389/fendo.2021.717766.
155 Evidence of Professor J. Zajac, T-262 line 10 to T-263, line 16. See further in this regard Brendan Nolan ‘Early Access to Testosterone Therapy in Transgender and Gender-Diverse Adults Seeking Masculinisation: A Randomised Clinical Trial’ (2023) 6(9) JAMA Network Open, DOI: 10.1001/jamanetworkopen.2023.31919.
156 Evidence of Dr G. Kalra, T-252 line 24 to T-253 line 5.
Indeed, the benefit of improved mental wellbeing upon commencing of gender-affirming hormone therapy was noted in a number of the submissions provided to the Court, including those of the Royal Australian College of General Practitioners (RACGP),157 Equinox,158 and the Australian Psychological Society.159 While observing some limitations to the 2021 study he referred to, Dr Erasmus, formerly of MHGC, also noted that hormone therapy may improve quality of life and decrease depression and anxiety.160
Dr James Morandini of the Australian Psychological Society referred to a number of studies noting ‘modest improvements’ in psychological functioning following commencement of gender-affirming hormone treatments, with certain studies noting an improvement to wellbeing that is slightly stronger than most anti-depressant treatments would yield. Dr Morandini noted that ‘the standard of evidence is still needing to build, but certainly there is no evidence that suggests that these treatments on average have harmful effects for people’.161
In this connection, it is noted that each of the submitting organisations, prior to Inquest, was asked by CPU to address the existence of any risks or harmful effects associated with feminising and masculinising gender-affirming medical treatments. The known risks and side effects reported by these organisations were predominantly related to physical health (e.g. lower bone mineral density in transwomen following commencement of genderaffirming hormone therapy),162 but also included those that may also impact on TGD peoples’ mental health and wellbeing, such as the risk of mood swings or behavioural disturbance from hormone treatment (e.g. estrogen,163 progesterone,164 or cyproterone)165 157 See submissions of RACGP, Collated Brief, p. 109.
158 See submissions of Equinox, Collated Brief, pp. 77-78.
159 See submissions of Australian Psychological Society, Collated Brief, p. 58.
160 See submissions of Dr J. Erasmus, Collated Brief, p. 90, referring to Kellan Baker et al ‘Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review’ (2021) 5(4) Journal of the Endocrine Society. DOI: 10.1210/jendso/bvab011. Therein, it was noted that no studies had been found where quality of life scores decrease or depression and anxiety increase following commencement of gender-affirming hormone therapy.
The authors found there was insufficient evidence to draw a conclusion about the effect of hormone therapy on death by suicide (see Collated Brief, p. 78).
161 Evidence of Dr J. Morandini, T-256 line 12 to T-257 line 4.
162 Submission of Dr J. Erasmus, MHGC, Collated Brief, p. 91.
163 Submission of Dr J. Erasmus, MHGC, Collated Brief, p. 92.
164 Evidence of Professor J. Zajac, T-372 line 27 to T-373 line 2.
165 Submissions of RCH, Collated Brief, p. 282.
with RACGP noting in this context a risk of emotional lability and risk of depression/anxiety for those affirming male-to-female, and increased aggression and emotional lability for those affirming female-to-male.166
The implications are that those with a mental illness who are affirming their gender should have a comprehensive mental state examination where indicated, and be monitored for changes in mood, appropriateness of medication regimes, consideration of potential drug-todrug interactions, and assessment of any increased risk of suicidality,167 as is already provided for in both the WPATH Standards and informed consent model.168 The MHGC submission notes, for example, that given that estrogen can trigger mood swings, it is important that a person who has borderline personality disorder or a mood disorder has adequate control of their condition before commencing gender-affirming hormone treatment.169
Evidence was heard at Inquest that further long-term studies are needed to assess certain of the health impacts of gender-affirming care on the TGD population (an example given was an increased risk of heart disease or stroke in transwomen).170 However, Professor Zajac opined that, in the short-term ‘we know quite a lot’ and that these risks are explained in detail as a precondition to those seeking to commence gender-affirming hormone treatment.171
He also noted in response to questioning from Counsel for Transgender Victoria that his experience was that the proportion of people de-transitioning (namely, the act of stopping or reversing the social, medical, and/or legal changes achieved during a gender affirmation process) is very small, opining that ‘the material in some of the press about how common this is not based on any factual data’.172 166 Submissions of RAGCP, Collated Brief, p. 105.
167 Submissions of RAGCP, Collated Brief, p. 105.
168 See in this regard Australian Informed Consent Standards, p. 11 – ‘Complex mental health issues should be addressed, and the patient supported, prior to commencing hormone therapy’.
169 Submission of Dr J. Erasmus, MHGC, Collated Brief, p. 92.
170 Submission of Dr J. Erasmus, MHGC, Collated Brief, p. 91. See further the evidence of Professor J. Zajac, T-372 line 15 to T-373 line 12.
171 Evidence of Professor Zajac, T-372 lines 27-28.
172 Evidence of Professor Zajac, T-372 lines 8-15. This is consistent with studies noting the need for improved data on so-called ‘detransitioning’ to better-inform health responses - see for example Pablo Espósito-Campos et al ‘Gender detransition: A critical review of the literature’ (2023) 51(3) Actas Esp Psiquitar. PMID: 37489555.
Notwithstanding the gap in data on long-term physical health outcomes for TGD people undergoing gender-affirming treatment, I heard extensive evidence at Inquest, detailed in this section, supporting general outcomes of improved mental wellbeing and reduced suicidality amongst TGD people when they access gender-affirming medical treatment.
Further, Mrs Nation-Ingle, State Suicide Prevention and Response Adviser within the Department of Health, noted that ‘delayed or denied access to treatment among trans people pursuing medical transition was linked to a greater likelihood of suicidality compared to those whose treatment was timely and comprehensive’.173 This is supported by the previously-noted submission of MHGC, in which it was stated that the time between making a decision and then being able to access gender affirming care can be a particularly vulnerable period and has been associated with an increase in suicide risk, hence reinforcing the need to minimise barriers to accessing gender affirming care once a decision to affirm one’s gender has been made.174
The importance of timely access to gender-affirming care as a means to improved wellbeing for TGD people was also emphasised by those beyond the Medical Panel. Transgender Victoria stated that, while the decision to affirm one’s gender requires courage and may be delayed by the individual, access to gender-affirming care once the decision to affirm has been made is critical to reducing lack of congruence between gender identity and gender assumed at birth, and often ‘will ameliorate the ridicule, vilification, psychological and physical abuse and serious violence that TGD people suffer from’.175 173 Evidence of Mrs B. Nation-Ingle, T-259, lines 3-8, referring to Private Lives 3. It is noted that this was not expressly stated in Private Lives 3 but in a journal article subsequently produced by the Private Lives 3 Research team, namely Adam Hill et al, ‘Demographic and psychosocial factors associated with recent suicidal ideation and suicide attempts among trans and gender diverse people in Australia’ (2023) 53(2) Suicide and Life-Threatening Behaviour (Hill et al.
2023), DOI: https://doi.org/10.1111/sltb.12946 174 Submission of Dr J. Erasmus, Collated brief, p. 90. See further in this regard Greta Bauer et al, ‘Suicidality among trans people in Ontario: Implications for social work and social justice’ (translated from original Québécoise French), Revue Service Sociale (2013) 59(1) 35. DOI: https://doi.org/10.7202/1017478ar.
175 Submissions of Transgender Victoria, Collated brief, p. 248 and p. 260, referring to Hill et al. 2023 and ‘AusPATH: Public Statement of Gender Affirming Healthcare, including for Trans Youth’ AusPATH (Web Page, 26 June 2021) https://auspath.org.au/2021/06/26/auspath-public-statement-on-gender-affirming-healthcare-including-for-transyouth/.
Barriers to accessing gender-affirming care Waitlists and moral distress
Long waiting lists to access gender clinics were described at Inquest by Dr Nguyen as a great source of ‘moral distress’ for clinicians, who have substantially ‘more demand than we have capacity to see’.176 As of July 2024, MHGC’s wait-list was over two years, with MHGC currently booking appointments for clients whose referrals were received in June 2022.177 Austin Heath’s Gender Clinic waiting list was closed as of March 2024.178 Equinox’s waitlist, at the time of Inquest in November 2023, had been closed since April 2022, with some 1,500 clients already being treated at the clinic.179
Dr Morandini noted that the waitlists for gender-affirming surgeries can be ‘terrible’ and are ‘causing significant distress to folks in the community’. Dr Morandini noted that there are delays of up to two years to access surgeries such as vaginoplasty for transwomen.180
Dr Nguyen of RCH Gender Services gave evidence of an upward trend in demands for gender-affirming medical care, opining that in the future, she ‘would expect that we will then have more demand and increased waitlists. This is not something that will be ending soon’.181
In the context of extremely long waiting lists, choosing the right pathway may have critical impacts on the timing in which gender-affirming treatment is able to be received. The pathways for accessing gender-affirming care are quite different; one starts with a psychiatrist or psychologist (in the case of clinicians following the WPATH Standards of 176 See evidence of Dr T. Nguyen, T-297, lines 23-24. Dr Nguyen noted that, as of November 2023 at RCH Gender Clinic, ‘our current waiting list for the initial appointment is somewhere between four to six months and then after that into the full multidisciplinary team can be another six months to 18 months and at times people age out of the service. […]. We would like to provide more care and we would like to improve access’ – see T-297 line 26 to T-298 line 3.
177 ‘Frequently Asked Questions’, Monash Health (Web Page) https://monashhealth.org/services/genderclinic/questions/#assessments.
178 https://www.austin.org.au/gender-clinic/ ‘Gender Clinic (Endocrinology)’ Austin Health, Clinics & Services (Web Page) https://www.austin.org.au/gender-clinic/.
179 Evidence of C. Gillespie, T-294 lines 22-24. It is noted that at the time of issuing this Finding, this may have changed.
180 Evidence of Dr J. Morandini, T-290, lines 21-29.
181 Evidence of Dr T. Nguyen, T-300 lines 15-21 and T-303 lines 231-23.
Care, as at MHGC); the other starts with an endocrinologist or GP (in the case of clinicians following the informed consent model, as at Austin Health, Equinox or private GPs). Those seeking to affirm their gender must therefore have some idea as to which pathway they might be more suitable for and identify the appropriate waiting list to ‘join’. This may not always be clear for would-be clients.
Dr Kalra gave an example of where someone may be waitlisted for an informed consent pathway of medical affirmation, and the service provider eventually assesses them as being more appropriate for a WPATH pathway (due to the complexity of mental health issues, for example) and they are referred to MHGC for another 18-month wait. Evidence also indicates that Matt, for example, had appointments at multiple clinics for the purposes of being prescribed gender-affirming hormone therapy,182 and was later referred to Monash Health for assessment in relation to gender-affirming surgery.
This raises the critical issue as to how the wellbeing of TGD people on waiting lists for gender-affirming care is managed. Dr Kalra of MHGC noted that a social worker from MHGC will telephone those on the MHGC waitlist within a two-month period to do an intake assessment, assess their needs, and inform them of the alternative informed consent model as ‘many folks are not aware of the pathway’.183 During this ‘vulnerable period’, MHGC depends upon grassroots organisations such as Thorne Harbour Health to assist in providing social and emotional wellbeing supports to those on the MHGC waitlists.184 Ms Gillespie noted that, at Equinox (which is part of Thorne Harbour Health), for those on the waiting list, there is ‘a really robust peer network of support available for people which people may or may not choose to tap into […] the role of peers can’t be underestimated in supporting people’s wellbeing or even affirming how rubbish it is actually to have to wait’.185 182 See statement of A. Brownhill, CB in the matter of Matt Byrne, p. 49.
183 Evidence of Dr G. Kalra, T-292 lines 10-16.
184 Evidence of Dr G. Kalra, T-299 line 22 to T-300 line 11. However, MHGC will shortly trial a peer-run engagement group, namely a 5-week online program for people on its waitlist, as well as one-on-one peer support – see T-292 line 24 to T-293 line 13.
185 Evidence of C. Gillespie, T-301 lines 10-15 and 27-29.
Dr Dalgleish noted that for individual GPs providing gender-affirming treatment, there can be difficulties accessing psychologists for patients through the federally-funded Mental Health Care Plan system.186 Evidence of strategies to reduce waitlists
Professor Zajac made a suggestion in his submissions to the Court, endorsed by Dr Kalra, that to address the issue of long waitlists and the existence of two separate medical affirmation pathways, there should be a ‘central intake point, managed by peer navigators or gender clinic nurses responsible for triaging clients and referring them to either pathway.
[This] could be a means by which significant wait lists are reduced as well as limiting client distress. […] If this proposal was implemented, persons with gender incongruence seeking gender affirmation could be waitlisted to the most appropriate pathway dependent on their complexity of need. In this circumstance MHGC would be allocated clients who would likely, in accordance with the WPATH model, require psychiatric assessment’.187 This was described at Inquest by Dr Kalra as ‘a funnel model I would call it, wherein everybody joins one waitlist in the neck of the funnel’.188
Dr Kalra also emphasised the importance of availability for delivery of gender-affirming care to regional and rural patients, which was endorsed by Dr Coventry189 and Professor Zajac,190 and of the need to ensure a better process to manage waitlists.
While there was significant support for addressing waitlist issues and consolidating available options for TGD patients, other witnesses took a different view of the proposed ‘funnel model’. Ms Gillespie of Thorne Harbour Health expressed a concern that a central intake point would inadvertently replicate ‘gatekeeping’ of gender-affirming care and emphasised the importance of TGD people being involved in scoping any proposals to reduce waitlists.
Ms Gillespie opined that ‘the ultimate goal here is that it doesn’t matter what the touchpoint 186 Evidence of Dr M. Dalgleish, T-302, lines 9-21.
187 Submissions of Dr G. Kalra, Collated brief, p. 327, referring to submissions of Professor Zajac, Collated Brief, p.
188 Evidence of Dr G. Kalra, T-338 line 26 to T-339 line 1 (my emphasis).
189 Evidence of Dr N. Coventry, T-342 line15 to T-343 line 6.
190 Evidence of Professor Zajac, T-344 lines 11-14.
is, a trans and gender diverse person should get good universal healthcare wherever they are, just like any other member of the Victorian community’.191
Dr Dalgleish recognised the value of a central intake point while avoiding so-called ‘gatekeeping’, and proposed a central referral system telephone line which could ‘act almost as a centralised referral system without actually limiting direct community referrals, selfreferrals to other services as well’.192 Dr Nguyen also recognised the attraction of a ‘streamlined one stop shop’ though noted this may run counter to a vision in which genderaffirming care is ‘everybody’s business’ and could be delivered by GPs where a TGD person lives, and who is known to them longitudinally.193
Professor Zajac opined that whatever approach is adopted, it needs to be more streamlined, ‘but I think we need to give the system a shake because, well, I think more of the same is not going to get us anywhere’.194 Cost
Transgender Victoria, in its submissions to the Court, noted the cost, complexity and administrative burden on TGD people of affirming their gender, including legal affirmation (such as changing a name or record of sex on a birth certificate with Births, Deaths and Marriages Victoria, or doing so on a passport via the Australian Passport Office), for which Transgender Victoria provides funding (sourced from donations) to TGD Victorians seeking to legally affirm their gender so that cost is not a barrier to them doing so.195 Ms Lane, the Court’s lived experience expert, also noted at Inquest the costs to TGD people associated with social affirmation in changing wardrobe to clothing that affirms one’s identity.196 191 Evidence of C. Gillespie, T-340 line 16 to T-341 line 3.
192 Evidence of Dr M. Dalgleish, T-341, lines 23-26. They made the comparison with termination of pregnancy services where ‘the Royal Women’s Hospital have a telephone number that anyone can phone up and access and that telephone number can refer to different services…so it can act… almost as a centralised referral system without actually limiting direct community referrals, self-referrals to other services as well’.
193 Evidence of Dr T. Nguyen, T-342, lines 5-13.
194 Evidence of Professor J. Zajac, T-344 lines11-21.
195 Submission of Transgender Victoria, Collated Brief, p. 262. See also in this regard the evidence of Dr T. Nguyen, T-237, lines 18-26.
196 Evidence of Ms E. Lane, T-40 lines 28-30.
However, the biggest cost, for those TGD people going down that pathway, is usually that associated with medical affirmation. Unless one has access to a publicly-funded clinic such as MHGC (which currently has two-year wait times), Austin Health, or Equinox, which is funded through Medicare and other program funding (whose waitlist at the time of Inquest was closed), the costs of consultations for gender-affirming treatment are required to borne by the patient, or, as is the preferred terminology of Equinox, ‘client’. As noted by Transgender Victoria, this can result in ‘very large out of pocket costs for patients seeking treatment in private clinics which is often the only option available given the wait times and limited availability of public clinics’.197
Professor Zajac gave evidence that he bulk-billed his TGD patients, but there are still costs associated with treatment. In particular, he noted there was a lack of consistency as to the way prescriptions are issued and costs meted out (for example, to access testosterone via the Pharmaceutical Benefits Scheme, there is a requirement for TGD people to have hormones prescribed by an endocrinologist rather than a GP).198
Dr Dalgleish noted that Medicare bulk-billing for GP consultations is increasingly unsustainable, and does not allow easily for remunerable multidisciplinary conferencing, which is critical to comprehensive holistic care for TGD people. Dr Nguyen agreed, noting that current issues with bulk-billing will likely place additional demands on the public system in the future.199
There are also costs associated with the requirement for psychological or psychiatric support.
As Dr Dalgleish noted, even those with a mental healthcare plan are only entitled to a rebate from Medicare rather than the full cost of the session with a psychologist being covered.200 This is significant in light of the fact that, while those affirming their gender via an informed consent model may not require a mental health assessment in order to commence treatment, most are recommended to maintain mental health support throughout the affirmation process. There is also the added burden on TGD people of researching whether the services 197 Submission of Transgender Victoria, Collated Brief, p. 266.
198 Evidence of Professor J. Zajac, T-240, lines10-13.
199 Evidence of Dr M. Dalgleish, T-288, lines 5-12; Evidence of Dr T. Nguyen, T-303, lines 8-22.
200 Evidence of Dr M. Dalgleish, T-302, lines 9-21.
they seek to access are likely to be culturally safe,201 in a community that is already financially disadvantaged and often fearful of discrimination in healthcare settings.202
Finally, and significantly, the cost of gender-affirming surgery can be tens of thousands of dollars. Due to the lack of availability of certain surgeries in Australia, many TGD people are required to travel overseas to access such surgeries, which adds to the expense of the procedures themselves. Those without private health insurance will be further limited in available options.
Ms Lane, the Court’s lived experience expert, spoke openly at Inquest of the costs of her own gender-affirming surgery, which included facial feminisation surgery in Spain at the cost of approximately $30,000, as well as a number of surgeries in Australia and Thailand, totalling approximately $100,000.203 In her statement to the Court, Ms Lane noted that gender-affirming surgery ‘has a lot of costs associated and for me I had to sell my investment property to pay for them. It means my dream to retire at 60 are just that, a dream and I will be working until I am 70. Not everyone has the financial support for this and there is very limited Medicare to assist with the cost’.204 Workforce issues
A further barrier to accessing gender-affirming medical care is the fact that the pool of clinicians providing such care to the TGD population is relatively small, meaning that there is an insufficient number of gender-affirming clinicians to meet demand for their services.
201 See Collated brief, p. 227; ‘Understanding LGBTQA+SB suicidal behaviour and improving support: insight from intersectional lived experience’ (Research Paper, RMIT University, 2023). DOI: https://doi.org/10.25439/rmt.23640978.v1 202 Some examples of discrimination in a healthcare setting were provided at Inquest, including from Professor Zajac, who noted that he had ‘a patient, a young transman getting acne from his testosterone who went to see a dermatologist.
The dermatologist came out of his office and yelled at him and said, ‘Get out of my waiting room’, so if that’s not discrimination what is? And that person was scarred for years’ – see T-309 lines 20-26.
203 Evidence of Ms E. Lane, T-27, line 20 to T-28 line 26.
204 Statement of Ms E. Lane, Collated Brief, p. 43.
Professor Zajac noted that there is inadequate access to endocrine services as ‘it’s only a small percentage of endocrinologists who will see trans individuals. … some people feel they haven't had enough training, which is true, and some people just refuse’.205
Similarly, there are only a small number of GPs who deliver gender-affirming care outside of a gender clinic context,206 with Professor Zajac highlighting his experience where ‘one GP in a clinic is very enthusiastic and keen to treat trans individuals but the partners or the other GPs in that clinic are not, and that’s often the problem for the patient’.207 This was affirmed by Dr Dalgleish who noted that in being a GP offering gender-affirming care outside a gender clinic context ‘you’re often on your own’, and others in the clinic may not be supportive.208
Dr Nguyen gave evidence that the workforce issues in delivering gender-affirming care are rooted in discrimination and ‘hostility within the medical profession to the vision of gender affirming care amongst medical practitioners of all, of various sub-specialties, psychiatry in particular because that is my craft group, but also others….So what this means for trans people is that the access to care is limited because practitioners feel at risk’.209
Drs Nguyen and Dalgleish noted a clear need for capacity-building in mainstream health providers, further gender diversity and cultural safety training for clinicians, and a nondiscriminatory approach by medical indemnity insurers.210 This was echoed by Mx Harden of Thorne Harbour Health, who delivers training to GPs on TGD health, and who stated that a significant barrier faced by GPs ‘is that they don’t feel supported by their colleges or by their medico-legal insurance, and places like that. So having leadership from those organisations I think would help clinicians feel that they have someone behind them, they 205 Evidence of Professor J. Zajac, T-241, lines 23-29.
206 Evidence of Dr T. Nguyen, T-275 lines 15-16.
207 Evidence of Professor J. Zajac, T-276 lines 5-11.
208 Evidence of Dr M. Dalgleish, T-274, lines 4-5. Dr Dalgleish noted however that the RACGP has a special interest group for TGD health that offer GPs training through Thorne Harbour Health – see evidence of Dr M. Dalgleish, T326, lines 6-13. Mx Harden of Thorne Harbour Health also noted that this new interest group ‘sends a really clear signal that RACGP are invested in improving trans and gender diverse health…in the GP sphere’ – see in this regard T-459 lines 19-24.
209 Evidence of Dr T. Nguyen, T-274 line 21 to T-275 line12.
210 See generally T-274 line 21 to T-278 line 13.
have this organisation - you know, their college is supporting the work they’re doing’.211 They noted further that improved access to primary healthcare clinicians offering genderaffirming medical care would see a reduction in waitlist of gender clinics.212
Gender-affirming care for children and young people
In the course of my investigation, the Court received submissions from the Royal Children’s Hospital Gender Service (RCH Gender Service), which provides gender-affirming care for children and young people who are referred prior to their 16th birthday and who reside in Victoria. Dr Tram Nguyen, consultant psychiatrist and a co-director of the RCH Gender Service also gave evidence at Inquest as part of the Medical Panel.
I have not addressed children and young persons’ gender-affirming treatment pathway in detail in this Finding because, while there is evidence that AS received gender-affirming treatment as a young person in Queensland, the five deceased persons in this cluster inquest 211 Evidence of Mx V. Harden, Thorne Harbour Health, T-521 lines 15-29.
212 Evidence of Mx V. Harden, Thorne Harbour Health, T-524, lines 9-21 – ‘My solution is to have primary healthcare clinicians be able to provide gender affirming or medical gender affirmation services. If a trans person can go to their regular GP and discuss their gender identity with them and know that they won’t face discrimination, they won’t be refused care, that will reduce the wait lists at all of the specialist services, trans and gender diverse healthcare, gender affirming healthcare. Medical affirmation is not specialist care, and it doesn’t need to be held at specialist’s services’.
213 See for example in relation to GPs the evidence of Dr M. Dalgleish, T-352 lines 13-26.
214 Evidence of Dr T. Nguyen, T-342, lines 5-13.
215 Evidence of Dr N. Coventry, T-342 line 15 to T-343 line 6.
216 Evidence of Dr T. Nguyen, T-323 line 23 to T-324 line 8.
217 See in this regard the evidence of Mx V. Harden, Thorne Harbour Health, T-457 lines 7-12.
were all adults when they died, and their pathways to gender-affirming medical care (with the exception of AS, who then resided outside this jurisdiction), commenced in adulthood. I am thus limited in part by the scope of Inquest and the principles in Harmsworth.218
However, in light of the prevention role of the Court and the evidence of Dr Nguyen, it would be remiss of me not to briefly address the issue of care being provided to children and young people. In this connection, referring to two recent studies, Dr Nguyen gave evidence at Inquest that young people who were commenced on gender-affirming medical care in early adolescence had associated reduced depression and suicidality compared to those who were commenced later and those who were commenced in adulthood.219 She noted several hypotheses around this, including the greater congruence of physical appearance with experienced gender (based on not having developed secondary sex characteristics of the young person’s sex at birth) leading to a greater internal sense embodiment and lower chance of being discriminated against, as well as the possibility that having a supportive family facilitating the young person’s pathway was contributory to wellbeing outcomes.220
Dr Nguyen also gave evidence that for young people who are supported early in their gender identity pathway, such as through puberty suppression, their mental health outcomes are on par with their cisgendered peers, compared to those who have not had that early affirmation.221
The option of medical gender affirmation for children and young people therefore presents an opportunity for early intervention and prevention of distress, mental ill health, and suicidality that TGD people can face later in life.
218 Harmsworth v The State Coroner [1989] VR 989.
219 Evidence of Dr T. Nguyen, T-259 line 27 to T-260, line 7. See further in this regard Diane Chen et al ‘Psychosocial Functioning in Transgender Youth after 2 Years of Hormones’ (2023) 388(3) New England Journal of Medicine 240250. DOI: 10.1056/NEJMoa2206297 This 2-year study involving transgender and nonbinary youth found that genderaffirming hormones (GAH) improved appearance congruence and psychosocial functioning, and Jack Turban et al ‘Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults’ (2022) 17(1) PLOS One. DOI: https://doi.org/10.1371/journal.pone.0261039. which found that access to GAH during adolescence and adulthood is associated with favourable mental health outcomes compared to desiring but not accessing GAH.
220 Evidence of Dr T. Nguyen, T-260, lines 8-20.
221 Evidence of Dr T Nguyen, T-261 line 29 to T-262 line 6.
The submissions of the RCH Gender Service provide a detailed overview of the clinical care pathway for children and young people being treated by the service, and emphasise the multidisciplinary nature of this care, the comprehensive ways in which any mental health issues are addressed, and that care is provided with regard to the WPATH Standards 8 and the Australian Standards of Care and Treatment Guidelines for TGD children and Adolescents.222 Dr Nguyen gave evidence that care is provided to children and young people presenting to the service through a family-focused, ‘holistic person-centred model’, the end point of which is not necessarily medical prescribing.223
I acknowledge that a divergence of opinion exists in the community in relation to how to best address and treat distress related to gender identity, particularly in children and young people. In this connection, I received correspondence following the close of evidence from an organisation named ‘Genspect’ seeking further evidence to be called at Inquest from clinicians who support, inter alia, a different approach to providing care for children and young people facing gender-related distress,224 and highlighting the outcomes of the final report authored by Dr Hilary Cass, which includes recommendations on ways in which to improve the United Kingdom’s National Health Service (NHS) funded gender identity services, and which was published in April 2024 (Cass Review).225
While I gave careful consideration to Genspect’s correspondence, I was conscious of the limits of the scope of the Inquest and considered that a detailed examination of the issues raised in Genspect’s correspondence would stray beyond the confines of the settled scope.
Further, at the time the correspondence from Genspect was received, the Inquest had already occurred, the coronial briefs had been tendered, and interested parties had already made 222 See submissions of RCH Gender Service, Collated Brief, pages 276-289.
223 Evidence of Dr T. Nguyen, T-268 lines 24-26.
224 Correspondence received from Genspect dated 20 March 2024, Court File, referring, inter alia, to what Genspect described as ‘mounting global concern amongst countless medical and allied health professionals about the efficacy and safety of GAC’ [gender-affirming care].
225 Correspondence received from Genspect dated 11 May 2024, Court File, referring to, inter alia, ‘Independent review of gender identity services for children and young people: Final report’ (Research Paper, Cass Review, April 2024) Accessible at: https://cass.independent-review.uk/wpcontent/uploads/2024/04/CassReview_Final.pdf. The Genspect correspondence highlights, inter alia, that ‘[i]n her report, Cass concludes that there is no clear evidentiary basis for medical gender affirmation interventions in children and confirms that the evidence for puberty suppression and cross-sex hormone treatment is of such poor quality that no foundation exists for clinical decisions and informed consent’.
closing submissions. It is also pertinent to note that Genspect had not sought to participate actively in the inquest by seeking standing as an interested party.226
Conversely, the positive impacts in providing gender-affirming care to this cohort were highlighted by a number of witnesses, including Mrs Bailey Nation-Ingle from the Department of Health.227
For completeness, I note that I considered Dr Nguyen to be an impressive witness. Her evidence was articulate, reasoned, and spoke of a doctor who cares deeply for her young patients and their families. While health services in other jurisdictions might be evaluating service models aimed at addressing gender-related distress in children and young people, including the United Kingdom’s NHS, the evidence at the Inquest demonstrates that the care provided by Dr Nguyen and her colleagues at the RCH Gender Service is multidisciplinary, holistic, individualised, and appropriately cautious. I consider that the relevance of any issues raised by the Cass Review will be a matter for the RCH Gender Service to consider in light of this existing approach.
In such circumstances, and having considered in detail the studies and reports referred to in correspondence by Genspect, I was not of the view that it was necessary or in the interests 226 See in this regard sections 56 and 66 of the Act. Further, Further, section 64 specifies that the witnesses to be called at Inquest, and the determination of the relevant issues for the purposes of the Inquest, are matters for the Coroner.
227 See for example Evidence of Mrs B. Nation-Ingle, T-259 lines 9-18.
of justice to call further evidence on this topic, and as a courtesy, the Court informed Genspect of the same earlier this month.
Analysis
Certain of these barriers have been attributed to ‘gatekeeping’ of gender-affirming medical care by medical practitioners, who in the past could decide when, where, and how TGD people were able to medically affirm their gender identity.228 The most recent WPATH Standards, while still viewed as a form of ‘gatekeeping’ by some, have lowered requirements for hormone treatment before surgical interventions, and removed requirements for living in desired gender role prior to receipt of gender-affirming care.229 In a further step towards supporting the self-determination of TGD people, the ‘informed consent’ model, the second pathway to gender affirmation in Victoria, is premised on the TGD person being in control of their own health, and explicitly rejects the notion of medical practitioners as ‘gatekeepers’ of gender-affirming care.230
229 See examples contained in ‘World Professional Association for Transgender Health Standards of Care for Transgender and Gender Diverse People, Version 8 Frequently Asked Questions (FAQs)’ (Web Page, WPATH) https://www.wpath.org/media/cms/Documents/SOC%20v8/SOC-8%20FAQs%20-%20WEBSITE2.pdf.
230 Ms C. Gillespie of Thorne Harbour Health (which Equinox forms a part of), gave evidence at Inquest that ‘the premise of the work of Equinox is an informed consent model which assumes that clients of the service know themselves and without any evidence otherwise we assume that they are in a position to make decisions in relation to their own body and their lives. So that’s directly to address some of the gatekeeping issues that people have in terms of historically having to get psychiatric assessments and psychological reports and whatnot in order to access gender affirming care’ – see T-264, lines 8-16.
231 See in this regard evidence of Dr T. Nguyen, T-303 lines 21-22.
232 Evidence of Mrs B. Nation-Ingle, T-259, lines 3-8, referring to Hill et al. 2023.
and attempts,233 I consider these ongoing barriers to gender-affirming care to raise serious concerns in relation to the health and wellbeing of TGD Victorians.
Strategies to improve access to gender-affirming care in Victoria
While there are three gender clinics that receive some form of public funding in Victoria for delivery of gender-affirming care to adults (MHGC, AHGC, and Equinox), these are the only publicly-funded options for those seeking access to gender-affirming care, and they simply cannot keep up with the demand for services.235 The RCH Gender Service is similarly-stretched.236
Ms Gillespie gave evidence that, at Equinox (which, at the time of Inquest, had a closed waitlist since April 2022, and had approximately 1,500 existing clients), when the waitlist is opened, it is opened for 175 people. ‘It takes us roughly two years to clear that waitlist and then we re-open it and it’s full within about 10 days of re-opening’.237 233 See evidence of Mrs B. Nation-Ingle, Department of Health, T-216 line 28 to T-217 line 1.
234 ED Discharge summary, Matt Byrne, p. 4/80, Court File. An orchiectomy or orchidectomy is the removal of testicles.
235 See evidence of Ms C. Gillespie, Thorne Harbour Health, T-295 lines 19-23.
236 See evidence of Dr T. Nguyen, T-297, line 23 to T-298 line 25.
237 See evidence of Ms C. Gillespie, Thorne Harbour Health, T-294 line 22 to T-295 line 5.
The pattern of increasing demand for gender-affirming care that far outstrips supply is a feature across all of the publicly-funded gender clinics, and calls into question the wellbeing of the individuals on the waitlists, who may have limited options for mental health support in the interim, at a point where they are often most vulnerable. The long waitlists also create moral distress for clinicians providing gender-affirming care, exacerbated by existing workforce issues faced by those delivering such care in an environment that is often marked by hostility and burnout. This situation is clearly untenable for patients and healthcare providers alike.
I therefore intend to make a recommendation, as a matter connected with the deaths I am investigating, to the Department of Health to consider immediately increasing resourcing to meet the growing demand for publicly-funded gender clinics delivering critical culturallyappropriate gender-affirming care to TGD patients. While noting, inter alia, that allocation of funding to services is subject to Victorian Government budgetary decisions, the Department has indicated in closing submissions that it agrees in principle with this proposition.238 Indeed, the Department’s witness provided clear, useful and cogent evidence at Inquest, underpinning the need for greater access to gender-affirming care as a means to ameliorate levels of distress and suicidality amongst TGD Victorians.239
The evidence from this Inquest has demonstrated that best practice care at such gender clinics (exemplified by existing approaches at clinics such as Equinox) is multidisciplinary, individualised, and culturally-safe through, inter alia, use of peer navigators and co-design with those from the TGD community, based on the maxim ‘nothing about us without us’.240
The Department may consider, as advocated by Transgender Victoria, that any additional resourcing for gender-affirming medical care is paired with revision of the existing framework for delivery of gender-affirming care to TGD Victorians, noting that the existing framework is now over six years old, in order to ensure the framework can keep up with current levels of demand. Transgender Victoria submits that any new framework emphasises 238 See in this regard Outline of Submissions of the Secretary to the Department of Health, 13 February 2024, Court File, pp. 1-2.
239 See in this regard, the evidence of Mrs B. Nation-Ingle, T-259, lines 3-8, referring to Hill et al. 2023.
240 See in this regard the evidence of Mx V. Harden, T-458, lines 18-26 – ‘As a trans person myself, I won't trust a service or a program that’s developed if there are no trans and gender diverse people involved’.
the provision of services not only through publicly-funded gender clinics but also through primary healthcare networks.241
In this connection, I heard substantial evidence inquest advocating for GPs and other primary health providers being trained to provide gender-affirming care to TGD people on the basis that such care is not required to be provided through a specialist service. I consider that the evidence at Inquest has indeed demonstrated the need for further training of healthcare professionals who may come into contact with or provide gender-affirming healthcare to TGD patients. I agree, as urged upon me by Counsel Assisting, that the RACGP and RANZCP, under the guidance of TGD experts, should develop and offer training and support to all healthcare professionals under their remits, including those who provide or wish to provide care to TGD people, with the aim of ensuring cultural safety for TGD people accessing services in these settings.
While not every GP or psychiatrist might feel equipped to deliver gender-affirming care to those in the TGD community, the expansion of existing training will ensure that appropriate referrals can be made and all TGD patients be cared for in a culturally-safe manner.
A note about the ‘funnel model’
242 Evidence of Dr T. Nguyen, T-342, lines 5-13.
was not broadly supported at Inquest, it is clear that, at a minimum, more information is required on the gender-affirming pathways available both for the benefit of the clinical community and for those who may seeking to join such a waiting list, which could be centrally available.243 5 – Provision of suicide prevention and postvention supports in the TGD community
The fifth item in the scope of inquest is ‘[t]he availability of and issues concerning provision of culturally-appropriate suicide prevention and postvention supports to TGD people in Victoria’.
Ms Bernasochi of Switchboard Victoria (Switchboard), which runs LGBTIQA+-specific suicide prevention, bereavement244 and postvention245 programs, gave evidence at Inquest that, in the past, there has been a lack of LGBTIQA+-specific, and in particular, TGDspecific, funding nationally for suicide prevention initiatives. While acknowledging that there are no reliable data on the number of TGD people in Victoria, Ms Bernasochi noted that ‘we do have consistent data about rates of suicidal distress among trans and gender diverse people. This data alone should be enough for us to see significant investment in trans and gender diverse suicide prevention’.246
Ms Bernasochi opined that, to be most effective, suicide prevention and postvention responses in the LGBTIQA+ communities need to be culturally-appropriate, communitycentred and peer-driven. Such supports need to be ‘particularly targeted for LGBTIQA+ people who have been bereaved or exposed to […] suicide. Unlike general postvention practices, these actions emphasise the cultural identities of those affected and seek to affirm, celebrate and connect with the LGBTIQA+ identification and communities’.247 The approach 243 Evidence of Dr G. Kalra, T-292 lines 10-16.
244 Defined by Switchboard as ‘[t]he period of grief, mourning, or sadness following deep loss, typically following the death of someone’ – see ‘LGBTIQA+ Suicide Postvention Response Plan: Preliminary Findings’, Collated brief, p.
245 Defined by Switchboard as ‘[a]ctivities and intervention related to supporting and helping people bereaved by suicide. This may include counselling, support groups, support from medical professionals etc. This aims to reduce the heightened risk of those bereaved by suicide and promote healing. – see ‘LGBTIQA+ Suicide Postvention Response Plan: Preliminary Findings’, Collated brief, p. 172.
246 Evidence of Ms A. Bernasochi, T-420 lines 2-6.
247 LGBTIQA+ Suicide Postvention Response Plan: Preliminary Findings, Switchboard, Collated brief, p. 178.
of Switchboard recognises that connectedness with the LGBTIQA+ community can moderate suicidality and that ‘narratives of sexual and gender diversity are key sources of strength which can reduce feelings of burdensomeness’.248 Addressing ‘suicide contagion’
The need for a culturally-appropriate response to suicide prevention is particularly borne out in addressing the risk of so-called ‘suicide contagion’ in LGBTIQA+ communities, which Ms Bernasochi describes as ‘an observable phenomenon that happens following a suicide death where people who are exposed to that suicide or bereaved by that suicide become a greater likelihood of experiencing suicidal distress themselves or going on to die by suicide’.249 Ms Bernasochi gave evidence at Inquest that suicide contagion is experienced differently in the LGBTIQA+ community to that of the population at large, due to the high rates of suicidal distress that exist ‘pervasively’ in these communities, and in particular for TGD communities, a perception from the outside that ‘a suicide is being blamed around identity for that person’s death’, as well as a perception from within that ‘being an at-risk population feeds into the perpetuation of contagion too’.250 Available suicide prevention initiatives aimed at LGBTIQA+ communities in Victoria
Switchboard is a peer-led organisation working nationally to provide culturally-appropriate suicide prevention programs for the LGBTIQA+ community, funded in the most part by the Department of Health. Amongst multiple other initiatives, Switchboard operates two sevenday-a-week helplines, one as the Victorian partner of ‘QLife’, which is the national helpline for the LGBTIQA+ community, the second being the State-wide ‘Rainbow Door’ helpline, being a family violence, mental health, and suicide prevention helpline that was established 248 Submission of Switchboard, Collated Brief, p. 159. Ms Bernasochi gave evidence at Inquest of what a culturallyappropriate postvention activity looks like, ‘[s]o what we might consider a postvention activity that is a social intervention, might be providing education to a bereaved community, it might be providing debriefing support, it could be working with key people in the community who are writing messaging around a loss, it could be around getting support pathways known to people, it could be facilitating a memorial’ – see T-499 lines 7-13. See further in this regard the evidence of Mr J. Ball, T-509 lines 11-21.
249 Evidence of Ms A. Bernasochi, Switchboard, T-496 lines 19-24. The term is, however, problematic when associated with LGBTIQA+ and more specifically, TGD identities, as it ‘is actually associated with homophobia and transphobia, as if our lives are somehow infectious or problematic’ – see T-496 lines 12-19.
250 Evidence of Ms A. Bernasochi, Switchboard, T-497 lines 13-19.
following the Royal Commission into Victoria’s Mental Health System (Royal Commission).251 Switchboard also designed and maintains the first-ever LGBTIQA+ suicide prevention hub, ‘CHARLEE’, an online resource containing information and support details for those impacted by suicide.252
• The new Victorian suicide prevention and response strategy (2024-2034) and initial two-year implementation plan (yet to be publicly released at the time of this Finding being delivered), which are being developed in close consultation with whole-ofgovernment partners and the Suicide Prevention and Response Expert Advisory Committee, which includes organisational representatives from Switchboard Victoria and Drummond Street Services, as well as lived and living experience representatives who identify as LGBTIQA+;
• The co-production of an LGBTIQA+-specific aftercare service, which is due for completion in 2024;253
• The expansion and enhancement of the Hospital Outreach Post-Suicidal Engagement (HOPE) program, through which Switchboard Victoria has been funded to deliver a LGBTIQA+ affirmative practice and suicide prevention training package to HOPE services in 2023-2024 to ensure HOPE staff have the most expansive learning 251 See evidence of Mr J. Ball, T-381 line 28 to T-382 line 13.
252 See in this regard ‘Charlee’ (Web Page) https://www.charlee.org.au/.
253 ‘Aftercare’ referring the care received by people following a suicide attempt, planning and/or intent, in light of the fact that an attempt is known to be the most significant risk factor for further suicidal behaviour and compassionate aftercare can reduce further suicide attempts and suicide deaths) – AM-4.
opportunity to improve their practice supporting LGBTIQA+ people experiencing suicidal distress; and
• As part of the existing Memorandum of Understanding between the Coroners Court and the Department, the Suicide Prevention and Response Office receives notification of suspected suicides among high priority communities, including LGBTIQA+ people, working with Switchboard, the Coroners Court and Standby Support After Suicide to monitor suspected suicides of TGD Victorians, including working to ensure that culturally-appropriate postvention takes place.254 Analysis
The Department has an increasing number of initiatives aimed at addressing the high rates of suicide in TGD communities, and in the LGBTIQA+ community more broadly. These initiatives are to be commended, and underpinned by the broader work of the Department in endorsing a new requirement for health services to report on ‘sex at birth’ and ‘gender’ as part of its annual changes process for key health services data collections, as part of the whole-of-government LGBTIQA+ strategy, ‘Pride in our future: Victoria’s LGBTIQA+ strategy 2022-32’.255 Such changes are paving the way for a clearer picture of the health needs and outcomes of the TGD community.
I consider that the evidence at Inquest demonstrates the critical importance of ensuring culturally-appropriate suicide prevention and postvention supports are available to the LGBTIQA+ community and in particular, the TGD community, given the high rates of selfharm, suicidality, and completed suicides in these communities. As noted earlier in this Finding, this need was clearly demonstrated in the enormous efforts of Switchboard and other community-based organisations to mobilise following Bridget’s death, to provide supports to community members, some of who knew Bridget personally, and some of whom 254 See in this regard the second Statement of Professor Euan Wallace, Secretary of the Department of Health dated 23 November 2023, AM-4.
255 Correspondence from the Department to the Court dated 5 March 2024, AM-11.
were impacted as members of the TGD and broader LGBTIQA+ community.256 The postvention supports that were required, and the risk of ‘suicide contagion’, was experienced in a way that was unique to the LGBTIQA+ community and required a culturally-appropriate response that was swift, tailored, community-specific and peer-led.257
I also consider that the evidence of ‘suicide contagion’ received during the coronial investigation demonstrates the importance of culturally-appropriate suicide prevention and postvention supports to the TGD community, and well as the need for early intervention. As detailed elsewhere in the Findings into these deaths, the available evidence indicates that at least three of the deceased persons (Matt, who died on 30 March 2021, AS who died on 9 May 2021, Heather who died two days later on 11 May 2021) knew directly at least one other person in the cluster. Given their means of suicide by way of ingesting sodium nitrite, it is likely that there was some discussion of this method of suicide amongst them (including with a fourth person in NSW, ‘E’, who died on 23 July 2021 after ingesting sodium nitrate).
Further to this point, the media coverage surrounding certain of the deaths, combined with online discussion about and deep concern regarding the deaths within local LGBTIQA+ communities, meant it was possible that some of the deceased persons knew about others’ deaths even if they were not personally acquainted, and that these concerns crossed borders into the LGBTIQA+ community in other states and territories. In relation to Bridget going missing and her subsequent death, Mr Ball noted ‘I think we still feel it today, that news – her going missing was shared in our major news outlets, this court case… when she was missing it was shared in Star Health, it was shared on Joy FM, it impacted so many people, 6000 plus’.258
As I have noted in the Findings into the deaths of Matt, AS, and Heather, these connections
257 See generally the evidence of Mr J. Ball and Ms A. Bernasochi, T-488, line 19 to T-493 line 16.
258 Evidence of Mr Ball, Switchboard, T-489, lines 14-20.
such suicides occurring in the future, and for the ongoing resourcing of culturallyappropriate postvention supports to TGD people.
6 – Social and emotional wellbeing supports
The sixth item in the scope of inquest is ‘[t]he availability of and issues concerning provision of culturally-appropriate social and emotional wellbeing supports to TGD people in Victoria’.
I heard evidence at Inquest that, over and above the barriers in accessing gender-affirming medical care for those who seek it, TGD people may also experience discrimination and poor treatment in accessing mental health and other services that may mean they avoid accessing those services.259 Mr McMahon noted in this connection that ‘poor quality of care is extraordinarily damaging to future help-seeking behaviour, not to mention the existential threat to the lives of trans and gender diverse people’.260
Mx Harden confirmed that the difficulties of TGD people in accessing health and other services do not just relate to gender-affirming care but that ‘we have difficulty accessing any kind of healthcare or support that affirms our gender’.261 In the same vein, Ms Bernasochi gave evidence that ‘not everyone who’s trans and gender diverse seeks medical affirmation and that if we’re actually thinking about preventing suicide it’s not just that around the supports for people who are seeking to medically affirm their gender’.262 Barriers for TGD people accessing mainstream mental health and other health services
At Inquest, Dr Coventry, Chief Psychiatrist, posited several reasons for TGD people facing such barriers in the context of accessing mental health services, which he noted to include:
(i) anticipation of discrimination based on past negative contact; (ii) the desire not to be a 259 See in this regard the evidence of Dr S. Vivienne, Transgender Victoria, T-468, line 27 to T-469, line 3; Mr E.
McMahon of Drummond Street Services, T-469 line 9 to T-470 line 14; Dr N. Coventry, Chief Psychiatrist, T-322 line 27 to T-323 line 18; and Commissioner Fernando, T-464 line 1 to T-465 line 18.
260 Evidence of Mr E. McMahon, Drummond Street Services, T-25-28.
261 Evidence of Mx Harden, Thorne Harbor Health, T-455 line 24 to T-456 line 7.
262 Evidence of Ms A. Bernasochi, T-432, lines 6-12.
burden, described by Dr Coventry thusly, ‘there’s also a sense I think for many people when they’re in crisis in mental health that they don’t want to be seen as a bulk burden, it becomes their self-narrative that can block them accessing services’; (iii) a lack of awareness as to the crisis support services that are available before the requirement for an acute in-patient setting; and (iv) geographical barriers for those in rural and regional Victoria.263
Dr Nguyen noted that a perceived lack of cultural safety can also feed into TGD peoples’ experience of accessing mainstream health services, which is likely to occur ‘at the point where you’re most vulnerable and then to have experience of discrimination, misgendering, having to disclose your gender in public spaces, having intrusive or inappropriate physical examinations, and - so there is likely to be secondary to that an avoidance of services and not feeling safe’.264
Dr Nguyen referred to a study from Latrobe University which found that ‘the physical and mental health of TGD Australians continues to be poorer than the general population.
Accessing healthcare for our participants was highly problematic, with high levels of unmet healthcare needs, discomfort discussing their needs, feeling misunderstood, emergency department avoidance, barriers to care, numerous instances of poor treatment in the healthcare system and hesitancy to disclose their gender’.265
264 Evidence of Dr. T. Nguyen, RCH Gender Service, T-323 line 23 to T-324 line 8.
265 See evidence of Dr T. Nguyen, T-324, lines 4-8. See further in this regard Kerr et. al., 2019, p. 6 . Mx Harden also gave evidence on this point, noting that TGD people often delay accessing healthcare and that ‘health conditions that would benefit from early intervention are prolonged and then get to the point where emergency attention is needed’ – see T-456 lines 1-7.
266 Statement of C. Wilson, CB in the matter of Natalie Wilson pp. 16-17; Statement of R. Berthelsen, CB in the matter of Natalie Wilson p. 52.
267 Evidence of C. Gillespie, Thorne Harbour Health, T-324 line 19 to T-325 line 9.
health services but ‘the confidence in [the] trans and gender diverse community in coming out perhaps and seeking help has improved over time.’268
Commissioner Fernando noted that it is little more than four years since the World Health Organization stopped categorising being TGD as a mental health disorder, and opined that: ‘LGBTQIA+ people have been living in a world where we’re taught by many, including those in the professions supposed to help us, to be diseased, to be carriers of those diseases or potential carriers of those diseases but the health practitioners in those services I think we need to recognise were taught by a generation of teachers who were operating at a different standard – or under a different standard of care. But the point I think I’m trying to make is that there is a history because of that curriculum or because of that teaching or way of practice, that many in our communities don’t feel that they have trust in services’.269
Ms Michelle McNamara of Transgender Victoria emphasised the fatigue experienced by some TGD people associated with ‘trans broken arm syndrome’, where a TGD person might, for example, present at an emergency department in a mental health crisis, but have the presenting issue ignored, and instead the focus is on the person being TGD.270 Mx Harden of Thorne Harbour Health noted a further dimension to this fear on the part of TGD people accessing mainstream health services can also relate to the fear that their hormone medication may be ‘stopped or blamed for their mental health’.271
Commissioner Fernando noted the importance of CAT teams and other frontline mental health services undergoing proper TGD sensitivity training to ensure that TGD people presenting to health services in mental health crisis can receive culturally sensitive care.272 He also spoke of the need to ensure current models of mental health and suicide prevention 268 Evidence of Dr G. Kalra, T-325, lines 13-22.
269 Evidence of Commissioner Fernando, T-464 line 14 to T-465, line 3.
270 Evidence of Ms M. McNamara, Transgender Victoria, T-465 line 27 to T-466 line 8.
271 Evidence of Mx V. Harden, Thorne Harbour Health, T-468 lines 7-12.
272 Evidence of Commissioner Fernando, T-465 lines 4-18.
care for LGBTIQA+ communities are responsive to community needs, by, for example, embedding peer workers (who are connected with LGBTIQA+-led organisations) within mainstream health services.273
To this end, as noted in the preceding section, Ms Anna Bernasochi of Switchboard advocated for further cultural safety training of mainstream health practitioners and embedding of peer workers in hospital settings to improve the cultural safety of mainstream health services for LGBTIQA+ persons, using a model of care that aligns with the way in which LGBTIQA+ communities intervene and provide suicide prevention and mental healthcare within LGBTIQA+-specific services.274 Examples of the social and emotional wellbeing supports required by the TGD community Support for families to promote connection with family of origin
Evidence was heard at Inquest that providing support for families and parents of TGD people is critical to improving social and emotional wellbeing and reducing suicidality amongst the TGD population, on the basis that a supportive family of origin is considered a protective factor against suicide for TGD people, underscoring the importance of family cohesion.275
Mr McMahon gave evidence of the programs run by Drummond Street Services to promote the wellbeing of families, including provision of intensive supports to families in which there is Child Protection involvement and one of the family members is LGBTIQA+, as well as ‘The Village’, a seven-week program supporting parents of TGD children, structured around themes including anxiety, navigating educational settings, family dynamics and relationships.276 Ms McNamara noted the work of Transcend in working with parents of 273 Evidence of Commissioner Fernando, T-466 lines 19-24. This was endorsed by Ms A. Bernasochi – see T-511, lines 21-29.
274 Evidence of Ms A. Bernasochi, Switchboard, T-466, line 10 to T-468 line 2 (part of this appears to be misattributed to Commissioner Fernando in the transcript).
275 See evidence of Mr J. Ball, T-452, lines 17-29.
276 Evidence of Mr E. McMahon, T-450, line 27-T-451, line 25. See in this regard ‘The Village’ Queerspace (Web Page) https://www.queerspace.org.au/our-programs/the-village/.
TGD young people, as well as the work of Transfamily, which provides peer support to parents, siblings and other loved ones of TGD people.277
Mx Harden and Mr Ball also noted the need for ongoing support for parents and family members of TGD people who might be otherwise unfamiliar with even the concept of being TGD and who might be struggling to understand this in relation to a child or family member (with Mr Ball noting that for some parents ‘the first trans and gender diverse person they ever met was their child’), opining that support services for families ought also to be accessible and visible, and provided through mainstream services, GP clinics and community health settings.278 Supports for older TGD people
I heard evidence at Inquest from Mx Harden that a significant stressor for older TGD people is what will happen if they face a condition such as dementia, and the way in which that might impact their gender identity, including whether that gender identity will be denied in an aged care setting.279 The requirement for the social and emotional wellbeing needs of older TGD people to be catered to was also canvassed by Ms Bernasochi, who referred to Switchboard’s ‘Out and About’ program, where volunteers visit LGBTIQA+ older people who are living in care or on care packages as a means to stay connected and enjoy hobbies,280 and for which Ms McNamara is a volunteer. She gave evidence of her work with this program and emphasised the need for social and emotional wellbeing supports in the older cohort, noting, ‘I see isolated people and I go and visit isolated people and see them at risk of suicide through their ill-health and isolation’.281 277 Evidence of Ms M. McNamara, Transgender Victoria, T-461 line 10 to T-462 line 1. See in this regard ‘Transcend’ (Web Page) https://transcend.org.au/ and ‘Transfamily’ (Web Page) https://www.transfamily.org.au/.
278 Evidence of Mx Harden, Thorne Harbour Health, T-451 line 27 to T-452 line 15 and of Mr J. Ball of Switchboard, T-452 line 17 to T-453 line 24.
279 Evidence of Mx Harden, Thorne Harbour Health, T-471 line 19 to T-472 line 7.
280 Evidence of Ms A. Bernasochi, T-432, lines 17-20. See ‘Out and About’ Switchboard (Web Page) https://www.switchboard.org.au/out-and-about.
281 Evidence of Ms M. McNamara, T-484 lines 7-11.
Multidisciplinary approach to social and emotional wellbeing supports in TGD communities
Dr Vivienne of Transgender Victoria spoke of the role of peer navigation as a means of promoting social and emotional wellbeing in TGD people accessing health services and social and emotional wellbeing supports, by facilitating ‘the connection between care domains that are otherwise quite siloed’, for example, providing a peer support service to ‘join the dots’ between a gender clinic and an eating disorder clinic.282 Mx Harden of Thorne Harbour Health also noted that the care provided at Equinox is multidisciplinary in nature and that existing patients can and are connected to external counselling services (though the reverse route, from those counselling services back to Equinox, will entail traversing the already-described issues with the Equinox waitlist).283 Other factors related to the social and emotional wellbeing of the TGD population
Evidence was heard at Inquest that certain of the social and emotional wellbeing supports for the LGBTIQA+ community are not necessarily offered through services alone but through connection and participation in the broader community.
Mr Ball of Switchboard gave evidence that, in LGBTIQA+ communities, there are three commonly-accepted factors that protect against suicide: (i) a supportive family of origin; (ii) having a concept and vision of one’s future; and (iii) connection to community in the broader sense (that is, not just connection with the LGBTIQA+ community but being able to access opportunities in the community at large, such as sports, faith-based activities, and other spaces, without discrimination).284 Indeed, Ms Lane gave evidence of the joy and connection she experiences in attending ballet,285 and Ms McNamara gave evidence of the fulfilment she receives through singing in a TGD-specific choir and Buddhist women’s study group.286 282 Evidence of Dr S. Vivienne, T-472, lines 14-26.
283 Evidence of Mx Harden, T-475 lines 5-17.
284 Evidence of Mr J. Ball, T-440, line 23 to T-441-T-442, line 9.
285 Evidence of Ms E. Lane, T-29 lines 10-15.
286 Evidence of Ms M. McNamara, T-444, lines 2-14.
Commissioner Fernando noted the importance for Aboriginal people in the LGBTIQA+ community to be connected to Country as a key factor in reducing social exclusion.287 Analysis Improved access to mental and other healthcare services for TGD Victorians
I consider that the risks to the wellbeing of TGD patients from long waitlists for genderaffirming care, high costs, and ongoing workforce issues are compounded by the fact that mainstream health and mental health services may not be genuinely accessible or culturally safe for many in the TGD community. The Inquest heard evidence that TGD people face barriers in attending emergency departments when suicidal, due to fear of ridicule, discrimination or rejection, or based on a past experience of discrimination (as exemplified by Bridget avoiding an admission through the public mental health system in favour of a private mental health admission). The wellbeing of TGD people is thus placed at further risk by a public health system that at times, struggles to be responsive to the basic needs of some of its most vulnerable community members.
I consider that the evidence at Inquest has established 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 to support staff in delivering culturally-appropriate care to TGD persons. This will ensure that a cohort that has a higher risk of mental ill health, distress, and suicidality will have greater degree of safety in accessing mainstream services, including in crisis. This work will build upon the existing commendable efforts of the Department of Health to make mainstream health services more culturally-safe for TGD people including, since July 2024, collecting data that can accommodate where one’s identified gender differs from birth sex, with concomitant guidance for health practitioners collecting this data.
287 Evidence of Commissioner Fernando, T-444, line 16 to T-445, line 9. I note that Commissioner Fernando identifies as a queer cisgendered Wiradjuri man, descended from the Kalari Peoples.
Improved access to other culturally-appropriate social and emotional wellbeing supports
I consider that the evidence at Inquest demonstrated there is a need to ensure provision of culturally-appropriate supports for TGD people and their families as a means to reduce social isolation, improve connectedness and address wellbeing in the context of the community’s high rates of suicide, distress and mental ill health.
As noted earlier in this Finding, I received evidence during this investigation that AS and Matt lived isolated lives, often confining themselves to their bedrooms, with both reluctant to reach out to services for counselling and other wellbeing supports in the lead-up to their deaths.
Evidence at Inquest demonstrated that social and emotional wellbeing supports are required not just for TGD people but also for their loved ones. The need for support services for family of origin was demonstrated by the eloquent evidence at Inquest of Angela, Bridget’s sister, who noted that, in order to support Bridget in the process of affirming her gender (which she came to support, having found the process confronting at first), she tried to find a means to educate herself about the journey her sister was on, including via Google searches.
At that stage she was unaware of the support services that existed and ultimately never received any support for her own role as a family member of a TGD person on an affirmation pathway.288
See CIS of Rachel Byrne, p. 8, Court File.
funded by the Department of the Health and delivered by Transgender Victoria, and through which various social and emotional wellbeing are delivered.289
Transgender Victoria made submissions at Inquest that, in consultation with TGD people, a framework should be developed at state and federal level promoting access to professional social support services for TGD people. At Inquest, Ms McNamara noted the importance of programs to address social inclusion of TGD people as a means to promote social and emotional wellbeing. She referred to promoting inclusion of TGD people in ‘both their own communities, the LGBTIQA+ communities, but broadly their faith communities and other parts of their lives which intersect with their identities’, with the need for a comprehensive framework underpinning the same.290
As with all scope items, this raises the issue of improving data in relation to the number of TGD people in Victoria and recognising TGD status on data collection systems. As Dr Vivienne opined, ‘at every step along the way, if there’s no scope to be seen, then there’s no scope to be cared for’.291 This was also noted by Commissioner Fernando, who stated that ‘governments cannot resource what [they don’t] know about communities’.292
7 – Prevention opportunities
The seventh item in the scope of inquest is ‘[p]revention opportunities flowing from the above’.
The majority of prevention opportunities flowing from these proceedings have been canvassed and outlined throughout this Finding. However, there is a discrete set of issues related to the systems and practices of the Coroners Court that were raised prior to and during Inquest that I will detail in this section. As Counsel Assisting noted at the first Directions 289 See in this regard the second Statement of Professor Euan Wallace, Secretary of the Department of Health dated 23 November 2023, AM-4.
290 Evidence of Ms M. McNamara, T-448, lines 21-28.
291 Evidence of Dr S. Vivienne, T-486, lines 3-4.
292 Evidence of Commissioner Fernando, T-401 lines 3-4.
Hearing for this Inquest, ‘the Court will not shy away from reflecting on areas for its own improvement as a critical part of these proceedings’.293 Improved data collection to assist in identification of suicides in the TGD community
One of the resounding themes of the Inquest was the need for improved data collection in relation to: (i) the number of people who make up the TGD community itself; (ii) the systems that exist across government entities and their capacity to capture all gender identities; and (iii) the ways in which to capture better data on the incidence of TGD suicide. The Coroners Court has an important role in (ii) and (iii).
In May 2024, the Coroners Court implemented key changes to its internal database to give it the functionality to capture additional data, including ‘preferred name’, ‘sex at birth’ and ‘gender’ (the record of ‘gender’ being independent to that of ‘sex at birth’). Following a codesign process, these reforms will align with the new database being designed for the Victorian Institute of Forensic Medicine, which will be used by staff at Coronial Admissions and Enquiries who take reports of deaths on behalf of the Coroner. Accordingly, the Court’s systems are now well-placed to capture accurate data on the gender identities of those whose deaths reported to the Coroner.
Given that the initial report of a death is often actioned by police members, it is important that changes are made to Victoria Police systems and forms, including the Form 83 Report of Death for the Coroner, so that details such as preferred name and gender can be captured as early as possible in the coronial investigation .294 However, the updates to the Court’s internal database mean that it is capable of recording such details at any point of a coronial investigation. This means that, regardless of whether preferred names and gender are identified in a Form 83, Coroners and their staff will be able to record these details later in an investigation where applicable.
293 Transcript of Directions Hearing on 13 October 2023, T-21, lines 27-29.
294 The Coroners Court will receive a ‘Form 83 – Report of death for the Coroner’ for the vast majority of deaths even where these are reported by other persons, such as medical practitioners.
The role of the Court in postvention responses following the suicide of a TGD person
As noted in this Finding, as part of the existing Memorandum of Understanding between the Coroners Court and Department of Health, the Department’s Suicide Prevention and Response Office receives notification of suspected suicides among high priority communities, including LGBTIQA+ people. The Department works with the Court to monitor suspected suicides of TGD Victorians, including working to ensure that culturallyappropriate postvention takes place.295 This is done in conjunction with communitycontrolled organisations such as Switchboard.
It is recognised that these alerts, as they currently operate, may not be maximising opportunities for effective postvention. One issue the Court encounters, is that coroners do not always know about a deceased person’s LGBTIQA+ identity (or if applicable, TGD identity) when a suspected suicide is reported.296 Another issue is that sharing information about deaths under investigation involves a balancing of complex, sometimes competing considerations: for example, the deceased person and their loved ones’ right to privacy, versus the prevention imperative of identifying peers so they can be supported.
There are often further issues at a very early stage of an investigation in which an understanding of the deceased’s intent upon initial report of a death is based on only limited information and is subject to revision as the coroner’s investigation develops. All of these 295 See in this regard the second Statement of Professor Euan Wallace, Secretary of the Department of Health dated 23 November 2023, AM-4.
296 The reasons for this are explained in detail in Coroners Court of Victoria, Suicide among LGBTIQ+ people, published 14 October 2022, and include that: (i) witnesses may not wish to disclose information to police members and the Court about the deceased’s LGBTIQA+ identity, to protect the privacy of the deceased, especially for people who may be newly identifying as LGBTIQA+ or may not be ‘out’ to their families or work colleagues; (ii) family members and other witnesses with whom the coroner’s investigator engages, may not be aware or accepting of the deceased’s LGBTIQA+ identity, and therefore this information is not provided in their witness statements; (iii) police members writing reports for the coroner may omit information on the deceased’s LGBTIQA+ identity because they deem it not to be relevant; or may use broad terms and vague language which does not explicitly communicate the deceased’s LGBTIQA+ identity; (iv) consulting stakeholders have informed the Court that communicating with police and coroners following a suicide can be a deeply traumatic process due to negative historical interactions with police.
This might be a reason why the deceased’s LGBTIQA+ identity might not be disclosed to police; (v) when police attend the scene of a death to be reported to the Court, they are required to fill out a form titled Initial Report of Death to the Coroner. This initial report of death does not prompt the police member to ask any questions about the deceased’s gender and sexual identity; and (vi) there can be inconsistencies and ambiguities in the coronial material regarding the deceased person’s gender and sexual identity. Additionally, gender and sexual identity themselves are complex and deeply personal, such that the deceased's loved ones may struggle to express these in communications with police.
factors make information-sharing a complex (at times, fraught) exercise. The Court is very open to dialogue on these issues, including the ways in which it can best support suicide postvention efforts to reduce the likelihood that suicide contagion may occur.
Issues associated with the ‘senior next of kin’ hierarchy under section 3 of the Coroners Act 2008
I heard evidence at Inquest that the Court’s ‘senior next of kin’ hierarchy can raise complexities for the loved ones of a deceased where the deceased is a member of the LGBTIQA+ community. The ‘senior next of kin’ is defined in section 3 of the Act, which sets out a ‘cascading hierarchy’, or an ‘order of priority’ of persons, the first of whom will have certain rights and responsibilities in the coronial process (such as being able to make an objection to an autopsy direction, or apply for release of the deceased’s body).297 The Supreme Court has confirmed that there is no residual discretion for the Coroner to appoint someone as senior next of kin who is lower in the hierarchy,298 nor, in the context of a dispute between biological family members and ‘chosen family’ for release of a body under section 48(3) of the Act, to dispense with this hierarchy.299
Angela, Bridget’s sister, noted at Inquest that the ‘senior next of kin’ hierarchy raised significant issues for her family following Bridget’s death. She gave evidence that Bridget’s father was her ‘senior next of kin’ under the Coroners Act (a ‘parent’ coming before a ‘sibling’ under the hierarchy in the Act). However, Bridget’s father did not accept Bridget’s gender identity and Angela reported difficulties in the course of the death investigation process in ensuring it proceeded in accordance with Bridget’s affirmed identity, noting that ‘I, in the background, have had … a lot of stress to try and make sure that what I thought 297 For definition of ‘senior next of kin’, see 3(1), 3(2) and 3(3) of the Act, providing for the ‘senior next of kin’ to be a spouse or domestic partner, or if none available, a son or daughter of or over the age of 18 years, or if none available, a parent, or if none available, a sibling of or over the age of 18 years, or if none available, a person named in the will as an executor, or if none available, a person who, immediately before the death, was a personal representative of the deceased person, or if none available, a person determined to be the ‘senior next of kin’ by a Coroner because of the closeness of the person’s relationship with the deceased person immediately before the death. For the right to object to autopsy, see section 26(2) of the Act; for release of body, see section 48 of the Act.
298 Trinh v Coroners Court of Victoria [2019] VSC 133, [5]; Lawrence v Coroners Court of Victoria [2013] VSC 77, [15].
299 In commenting upon the ‘mandatory hierarchy’ imposed by section 48(3) of the Act (within which the ‘senior next of kin’ hierarchy is replicated by virtue of section 48(3)(b) of the Act), her Honour Justice Forbes in Vallianos v Coroners Court (Vic) (2023) 69 VR 276 noted at [87] that this ‘may not assist those who are estranged from some or all of their family and who develop other close relationships in its place. I accept that the hierarchy may well be based upon assumptions that are less likely to hold true for groups including those who identify as LGBTQI’.
was respectful to Bridget as a transgender woman happened and I had to fight our father for that on her behalf’.300 Angela noted that LGBTIQA+ people may be estranged from their biological family and ‘more likely to have chosen family’, and ‘if there’s any way of taking that into consideration it would again vastly improve an already really stressful situation’ when someone dies in reportable circumstances.301
This may have particular resonance where those to whom the deceased’s body is released will be making funeral arrangements, as is usually the case. Commissioner Fernando noted that ‘the former Commissioner [for LGBTIQA+ Communities] recalls going to funerals of young LGBTI people and families didn’t know that they were queer or trans or gender diverse.’302 contributing to a further lack of visibility of members of this cohort.
I consider that the evidence at Inquest established that the ‘senior next of kin’ hierarchy under section 3(1) of the Act may create hurdles and undue distress for the loved ones of LGBTIQA+ Victorians who die in reportable circumstances. A pertinent recommendation will follow.
Other ways in which the Court has improved its approach to cultural safety and inclusivity
301 Evidence of A. Pucci-Love, T-84 lines 11-14.
302 Evidence of Commissioner Fernando, T-416, lines 23-25.
• Offered workshops to coroners and staff on Trans and Gender Diverse Awareness, to enhance cultural safety and promote awareness of the particular issues faced by the TGD community;
• Circulated for whole-of-Court use the ‘Inclusive Language and Communication Guide’, released by Court Services Victoria in May 2024; and
• Placed the details of ‘Rainbow Door’, the free specialist LGBTIQA+ helpline providing information, support, and referral to all LGBTIQA+ Victorians (run by Switchboard), on the Support Services page on the Coroners Court website.303
Finally, the State Coroner has sought to enhance the cultural safety and respect for participants within Court proceedings across a number of priority groups through issuing, under section 107 of the Act, ‘Practice Note 1 of 2024 - Pronunciation of Names and Forms of Address in Coronial Proceedings’ to (i) provide guidance on expectations for the correct pronunciation of names and forms of address in coronial proceedings; and (ii) facilitate a simple process by which families, interested parties and legal representatives can provide, and the Court can seek, clarification on correct pronunciation of names and appropriate forms of address (including pronouns and honorifics).304 Analysis
It is crucial that the Coroners Court processes accord cultural safety, visibility, dignity and respect to all deceased persons and their loved ones. This is not only required as a function of section 8 of the Act but also, as this Inquest has demonstrated, it is a critical pillar in the Court’s prevention function.
We cannot comprehensively identify appropriate initiatives aimed at reducing preventable deaths in the TGD community if we do not have the systems visibility to capture the identities of those whose deaths we are investigating. Therefore, improvements to the 303 See in this regard ‘Grief & bereavement counselling & support services’ Coroners Court of Victoria (Web Page) https://www.coronerscourt.vic.gov.au/families/supports-and-resources/services/grief-bereavement-counsellingsupport-services and Proposed Recommendations of the Commissioner for LGBTIQA+ Communities, p. 2, Court File.
304 See ‘Practice Note 1 of 2024 – Pronunciation of Names and Forms of Address in Coronial Proceedings’, issued on 17 June 2024 by his Honour State Coroner Judge John Cain.
Court’s processes, when occurring in concert with other entities such as Victoria Police, will allow for greater visibility of preventable deaths in the TGD community and more targeted strategies to reduce them.
(a) that the identity of the deceased was Natalie Jade Wilson, born on 27 May 1987;
(b) that Natalie Jade Wilson died at the family home in Pakenham on 2 September 2020 from 1 (a) neck compression and 1 (b) hanging;
(c) in the circumstances described above.
Adequacy of mental health services engaged by Natalie in lead-up to her passing
Assessment and Treatment Team (CATT), and supported appropriate safety planning for Natalie, including by keeping her family (and each other) apprised when the risks she faced had escalated. The support provided to Natalie was comprehensive, trauma-informed and speaks of two professionals who cared deeply for their patient.
The care provided to Natalie by Monash Health on 2 September 2020, the day of her passing, was also appropriate and comprehensive. Natalie was assessed by the CATT and was offered and accepted a plan for a voluntary admission to hospital. Given that a bed was not yet available, Natalie was advised to remain in the Emergency Department until such time as that occurred. Natalie did not meet the requirements for an involuntary admission under the Mental Health Act 2014 (Vic) (as then applied), on the basis that she had agreed to treatment, and she went home with family support and appropriate safety planning, including the provision of emergency contact numbers.
Once Natalie decided she would wait at home rather than in the Emergency Department, I find that there was little the CATT could do other than offer intensive support until a bed became available, which they did. The care provided and plan devised was therefore appropriate, despite the tragic outcome.
However, the evidence points to the fact that Natalie faced agoraphobia, a mistrust of public hospitals and an intense fear of discrimination based on her status as a transgender woman.
Therefore, while I consider that the mental health treatment offered and provided to Natalie in the lead-up to her passing was appropriate, this brings into sharp relief the broader importance of public health services being responsive to the specific needs of trans and gender diverse patients, and offering spaces in which trans and gender diverse patients can feel welcomed and safe.
Determination as to intent
she had a plethora of mental health issues, a recent relationship breakdown and increasing isolation from her community, a deep fear of discrimination based on her TGD status, and chronic suicidality, including multiple suicide attempts in the lead-up to 2 September 2020.
Further, I find that Natalie was using her recently prescribed antidepressant prior to death, which was apparent upon examination of the toxicological results. At the time of her passing, she was also prescribed gender-affirming hormones, alprazolam and diazepam for use on a daily basis. While these medications may have side effects in some individuals, there is an insufficient cogency of evidence to make any finding as to whether, or how, any of these prescribed medications may have affected her state of mind. Natalie’s decision to take her life was preceded by a long history of mental ill health and a number of stressors.
As a result of this constellation of factors, I find that, while Natalie was actively help-seeking and well-supported by her GP, psychologist and certain of her family members, she intentionally took her own life on the evening of 2 September 2020 by way of hanging.
Mental ill health and suicidality in the trans and gender diverse community
The expert evidence at Inquest demonstrated that those in the TGD community face disproportionate rates of distress, mental ill health, and suicidality compared to the population as a whole. The reasons for this are multifactorial, intersecting, and are frequently linked to extrinsic factors associated with the broader community’s responses to TGD people, which can include discrimination, violence and exclusion, that erode the TGD community’s wellbeing and can contribute to mental ill health and suicidality.
There is nothing inherent in being TGD that comprises or causes mental ill health or suicidality.
While noting that there is clear evidence of disproportionate mental ill health, distress and suicidality amongst the TGD population, the data on this issue is widely considered to be incomplete, including in relation to the incidence of completed suicides. Robust data (including population level data on the number of TGD people in Victoria) 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
The expert evidence at Inquest demonstrated that significant barriers still exist for TGD people affirming their identities, particularly via a medical pathway, including due to issues of cost, access and long waitlists in the face of increasing demand for access to genderaffirming care.
Given the evidence I heard that delayed or denied access to treatment among trans people pursuing medical transition was linked to a greater likelihood of suicidality compared to those whose treatment was timely and comprehensive, I consider these ongoing barriers to gender-affirming care to raise serious and unacceptable concerns in relation to the health and wellbeing of TGD Victorians.
I find there is a clear need for improved access to gender-affirming healthcare, including gender-affirming medical care, to TGD people in the state of Victoria.
Provision of suicide prevention and postvention supports
The expert evidence at Inquest demonstrated the critical importance of ensuring culturallyappropriate suicide prevention and postvention supports are available to the LGBTIQA+ community and in particular, the TGD community, given the high rates of self-harm and suicidality in these communities.
I find this to be 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 present cluster proceedings.
Provision of social and emotional wellbeing supports
I find that the 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 that mainstream health services are often not genuinely accessible or culturally safe for many in the TGD community.
I find that the evidence at Inquest has established 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 to support staff in delivering culturally-appropriate care to TGD persons. This is critical to ensuring that mainstream services are genuinely accessible for TGD people, including those presenting in crisis.
I find there is also a need to ensure provision of culturally-appropriate supports for TGD people and their families as a means to reduce social isolation, improve connectedness and address wellbeing in the context of the community’s high rates of suicide, distress and mental ill health.
Further prevention opportunities
It is crucial that the Coroners Court processes accord cultural safety, visibility, dignity and respect to all deceased persons and their loved ones. This is not only required as a function of section 8 of the Act but also, as this Inquest has demonstrated, it is a critical pillar in the Court’s prevention function.
Improvements to the Court’s processes, when occurring in concert with other entities such as Victoria Police, will allow for greater visibility of preventable deaths in the TGD community and more targeted strategies to reduce them.
COMMENTS I make the following comments connected with the deaths under section 67(3) of the Act:
has the right to the enjoyment of the highest attainable standard of physical and mental health.305
In 2000, the United Nations Committee on Economic, Social and Cultural Rights issued General Comment 14, stating that the right to health ‘must be understood as a right to the enjoyment of a variety of facilities, goods, services and conditions necessary for the realization of the highest attainable standard of health’, which should be accessible ‘without discrimination’. Paragraph 43(a) then sets out a core obligation of non-discrimination on the part of States Parties (including Australia) to ensure ‘the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups’.306
While Australia has not incorporated the ICESCR into domestic law, and the Victorian Charter of Human Rights and Responsibilities Act 2006 (Vic) (the Charter) does not explicitly include a right to healthcare, the Equal Opportunity Act 2010 (Vic) precludes discrimination on the basis of certain attributes (including gender identity) in the provision of services (including health services), and contains a positive duty to eliminate discrimination.307 There exists, therefore, a duty on the part of health service providers to prevent discrimination from occurring in the provision of those services.
Further, a human-rights based approach to healthcare for the TGD community requires ‘availability, accessibility, acceptability, participation, non-discrimination, transparency and accountability’.308 The rights to autonomy and equality are thus engaged in provision of healthcare, which necessitates consideration of what may constitute ‘substantive’ over mere 305 See International Covenant on Economic, Social and Cultural Rights, opened for signature 16 December 1966, 993 UNTS 3 (entered int force 3 January 1976) art 12(1). Accessible at https://www.ohchr.org/en/instrumentsmechanisms/instruments/international-covenant-economic-social-and-cultural-rights. See generally in this regard Ronli Sifris and Paula Gerber ‘Sexual and Reproductive Health Care For Trans and Gender Diverse People: Imagining a Human Rights Based Approach’ (2013) 48(3) Alternative Law Journal 159-165. (Sifris and Gerber 2023). DOI: https://doi.org/10.1177/1037969X231188066.
306 See Committee on Economic, Social and Cultural Rights, General Comment No 14 (2000): The Right to the Highest Attainable Standard of Health (Article 12 of the International Covenant on Economic, Social and Cultural Rights), UN ESCOR, 22nd sess, Agenda Item 3, UN Doc E/C.12/2000/4 (11 August 2000) [9], [12b] and [43a]. Accessible at: https://www.refworld.org/legal/general/cescr/2000/en/36991.
307 See in this regard Equal Opportunity Act 2010 (Vic) s 6(d), Part 3.
308 Sifris and Gerber 2023 p 161, referring to Sofia Gruskin, Dina Bogechi, Laura Ferguson ‘“Rights-based approaches” to health policies and programs: articulations, ambiguities, and assessment’ (2010) 31(2) Journal of Public Health Policy 124-145. DOI: 10.1057/jphp.2010.7.
‘formal’ equality. Substantive equality is ‘premised on the basis that rights, entitlements, opportunities and access are not equally distributed throughout society and that a one size fits all approach will not achieve equality’.309
In this connection, in its General Comment on article 18 of the International Covenant on Civil and Political Rights (ICCPR) (which enshrines the principle of non-discrimination and upon which the right to equality in section 8 of the Charter is based),310 the Human Rights Committee stated that ‘[t]he enjoyment of rights and freedoms on an equal footing, however, 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 would entail recognition 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’.311
I consider that this human rights framework ought to be borne in mind in resourcing, planning, and designing health services in Victoria, including in actively ensuring that such services are culturally safe, accessible, and inclusive, and not directly or indirectly discriminating against TGD people.
Indeed, the evidence at Inquest has demonstrated that the rights of TGD people in Victoria are often imperilled in a healthcare setting.
I heard evidence from Professor Zajac of the experience of a young transman who was ‘scarred for years’ after being yelled at to ‘get out’ of a dermatologist’s waiting room.312 I heard from Ms Elisabeth Lane, the Court’s lived experience expert, that, when her regular GP went on leave in 2016, she explicitly directed Ms Lane not to approach two other GPs at the clinic, and circled the names of those who would be safe for Ms Lane to see.313 In relation 309 Sifris and Geber 2023 referring to Australian Law Reform Commission, Pathways to Justice: Inquiry into the Incarceration Rate of Aboriginal and Torres Strait Islander Peoples (Report 133, 9 January 2018) Executive Summary.
310 Explanatory Memorandum, Charter of Human Rights and Responsibilities Bill 2006 (Vic) 2.
311 Sifris and Geber 2023 referring to Human Rights Committee, CCPR General Comment No 18: NonDiscrimination, 37th sess, CCPR/C/21/Rev.1/Add.1 (10 November1989) [8].
312 Evidence of Professor Zajc, Austin Health, T-309 lines 20-26.
313 Evidence of Ms E. Lane, T-31 line 23 to T-32, line 6.
to the other GPs, Ms Lane stated ‘She told me, do not see them… they will not look after you’.314
They can understand that the community has extra barriers’.315 In her view, and as has been demonstrated by multiple witnesses at Inquest in relation to access to healthcare, ‘the community has been explicitly excluded and you have to explicitly include them, so they know it’s safe.316
I consider that, in 2024, it is wholly unacceptable that a TGD person should have to consider which clinicians are ‘safe’ and which are ‘unsafe’ to consult with. As a TGD person, you should not, as Mr Elliot McMahon stated, ‘feel profound fear and dread’ at the thought of encountering ‘a doctor or a person who’s in a position of power [who] looks at you and says “You don’t know who you are, I do”’.317 There should not be a ‘myriad of horror stories that circulate in [the TGD] community about what can happen if you go through the wrong door to get support.318
In 2024, there must be ‘no wrong door’ for TGD people to receive healthcare or referrals to healthcare that affirm their identity, dignity and personhood. This is the right of every TGD person attending upon a GP or any other clinician in Victoria, and I intend to make a series of recommendations on this front.
On the subject of recommendations, pursuant to section 72(2) of the Act, I note that I am only empowered to make recommendations that are ‘connected with a death or deaths’. I received an abundance of proposed recommendations from Counsel Assisting, Interested Parties and submitting organisations in the lead-up to and at closing submissions – by my 314 Evidence of Ms E. Lane, T-34 lines 12-14.
315 Evidence of Ms E. Lane, T-35 lines 21-23.
316 Evidence of Ms E. Lane, T-34 line 30 to T-35 line 3.
317 Evidence of Mr E. McMahon, Drummond Street Services, T-469, lines 9-29.
318 Evidence of Mr E. McMahon, Drummond Street Services, T-469 lines 27-29.
count, a total of 65 proposed recommendations were sought – some of which overlapped in subject matter, aims and intention, some of which include specific resourcing proposals, and not all of which I am empowered to make.
Nevertheless, I consider that the evidence at Inquest and concomitant recommendations sought by Interested Parties and organisations contain invaluable guidance on the ways in which gender-affirming healthcare, mental health and social and emotional wellbeing supports for TGD people could be strengthened in Victoria. As noted by Mr Ball of Switchboard, a form of ‘needs analysis’319 was conducted through the unfolding of this evidence that I strongly believe should be reviewed by the Department of Health (whose approach to these proceedings has been commendable) and other entities in considering the operationalisation of the coronial recommendations I intend to make.
I make one final comment in relation to the five TGD people whose deaths I have investigated as part of this cluster, and of the impact of gender-affirming care in the context of the ultimate decision each made to take their own lives. It is worth recalling that I received evidence of improved mental wellbeing and/or increased happiness upon commencing a gender affirmation process in four out of the five people in the cluster.320
However, as cautioned by Switchboard, the provision of gender-affirming medical care is not the ‘full picture’ when it comes to providing affirming care to TGD people who may be suicidal: Gender affirming care helps people live affirming lives. However – and this is imperative in understanding trans and gender diverse suicide prevention – for people already experiencing suicidal distress, gender affirming care can significantly help mental health and well-being – it does not prevent suicide.
319 Evidence of Mr J. Ball, Switchboard, ‘[The evidence of the Medical Panel at Inquest] was a needs analysis that took place like I’ve never seen before with that panel of experts who identified needs and gaps…. So I think – I just want to say that there was one done yesterday, I feel, and I would like…[that] to be used hopefully in the future by the Victorian government’ – see T-405 line 25 to T-406 line 4. This is in part why I have elected to draft the finding in such granular detail.
320 In relation to Bridget; see statement of H. Leigh, CB, p. 39 and evidence of A. Pucci-Love, T-55 line 10-11; in relation to Natalie; see statement of C. Wilson, CB, pp. 16-18; in relation to Heather, see CIS of K. Pierard, Court file; in relation to Matt, see statement of Dr P. Wong, CB, p.42. There is a dearth of evidence in relation to the positive experience of ‘AS’ upon commencing her gender affirmation process, noting this occurred in Queensland.
It can deeply help and support trans people experiencing suicidality – but significantly – hormones alone do not create protection against suicidality.
People who have medically affirmed their gender may still experience suicidal distress. What is needed is affirming culture around their gender.321
I consider this throws into sharp relief the need for a broad conception of care that is affirming of all gender identities – inclusive of mental healthcare, and social and emotional wellbeing supports – and of a broader recognition of the impacts of discrimination, isolation and violence on TGD people’s wellbeing. I make this comment acknowledging that this is – or should be – a very basic proposition that is already recognised as such within TGD communities and those who deliver services to them.
Ultimately, the way in which members of our TGD communities in Victoria are engaged with through health services and by the community at large is a measure of our respect for human rights, dignity, and our collective humanity. As noted very simply by Dr Nguyen at Inquest, ‘being trans and gender diverse is a wonderful part of human diversity, to be celebrated’.
RECOMMENDATIONS I make the following recommendations connected with the death under section 72(2) of the Act:
That 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, by amending the Law Enforcement Assistance Program (LEAP) or as otherwise deemed appropriate. This should include amending the Form 83 ‘Police Report of Death for the Coroner’ to include fields to capture all gender identities, to assist in improving the accuracy of data on deaths in the TGD communities, and specify a timeframe for this to be carried out.
That the Victorian Department of Health as lead, in conjunction with the Department of Families, Fairness and Housing and any other relevant Victorian Government 321 Submissions of Switchboard, Collated Brief, p. 158.
departments, consider urgently increasing resourcing to meet the growing demand for publicly funded health services delivering gender-affirming care to TGD patients, in order to reduce the current waitlists and to support and expand the existing health workforce delivering such care. The Department may consider whether this should involve revision of the existing framework for delivery of gender-affirming healthcare and supports to TGD Victorians.
That 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, with additional training to support staff in delivering culturally-appropriate care to TGD patients.
That 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: (i) social and emotional wellbeing supports; and (ii) suicide prevention, postvention and bereavement supports, as a means by which to address the high levels of suicidality, social exclusion and mental ill health in the TGD community.322
That the Royal Australian College of General Practitioners (RACGP) and Royal Australian and New Zealand College of Psychiatrists (RANZCP), under the guidance of experts from TGD communities, develop and offer training and support to all healthcare professionals under their remits, including those who provide or want to provide care to TGD people, with the aim of ensuring cultural safety for TGD people accessing health services across these settings and which includes training on the factors that can contribute to the risk of suicide in these communities.
322 To assist in identifying culturally-appropriate TGD-led strategies to achieve this, the Victorian Department of Health should consider its very helpful ‘Table of Proposed Recommendations’ contained at Annexure 1 of the Department of Health’s ‘Outline of Submissions of the Secretary to the Department of Health’, dated 13 February 2024, which contains a summary of all proposed recommendations made by Interested Parties and communitycontrolled organisations following this Inquest.
ACKNOWLEDGEMENTS I convey my sincerest sympathy to Natalie’s family, chosen family, friends and community. I acknowledge the grief and devastation that you have endured as a result of your loss, and I recognise the great difficulty of these proceedings unfolding so long after Natalie’s passing. I also thank the Family Liaison Officers for supporting Natalie’s family with dedication over the past years.
I thank Counsel Assisting, Ms Cafarella, and the counsel and solicitors who represented the interested parties for their assistance, comprehensive submissions and collegial approach to these proceedings. I also acknowledge and thank George Carrington, Janet Lee, Kajhal McIntyre and Olivia Collings at the Coroners Court for their invaluable assistance in this investigation, and for striving to ensure that these proceedings could be as culturally safe as possible for the members of the LGBTIQA+ community in attendance.
I also acknowledge the work of my colleagues who previously had carriage of this investigation and who worked tirelessly to progress it long before I assumed carriage of these proceedings. I thank the CPU for its excellent ongoing assistance, including for obtaining the statements and submissions that formed the backbone of the Inquest. In this connection, I also wish to thank each and every witness who provided statements and/or came to give evidence at Inquest, and who shared their personal and professional experiences for the purposes of assisting the Court’s understanding of the issues.
ORDERS AND DIRECTIONS I order that a copy of this finding be published on the Coroners Court of Victoria website in accordance with the Coroners Court Rules 2019.
I further direct that a copy of this Finding be provided to: Charles and Lorraine Wilson Chief Commissioner of Police, c/o Victorian Government Solicitor’s Office Victorian Department of Health, c/o Department’s in-house lawyers Monash Health, c/o K&L Gates Austin Health, c/o Lander & Rogers Transgender Victoria, c/o Allens Sergeant Jay McCarthy Elisabeth Lane The Office of the Chief Psychiatrist of Victoria Thorne Harbour Health The Royal Children’s Hospital Melbourne Royal Australian College of General Practitioners Australian Psychological Society Royal Australian and New Zealand College of Psychiatrists Drummond Street Services Victorian Commissioner for LGBTIQA+ Communities Switchboard Victoria Australian Bureau of Statistics Dr Danielle Dowman, c/o Avant Law Ruth Berthelsen Those to whom recommendations are directed (and who are not already on the distribution list): Department of Families, Fairness and Housing State Coroner of the Coroners Court of Victoria, Judge John Cain
Findings in relation to the other deaths investigated as part of this cluster inquest are available on the Coroners Court website at https://www.coronerscourt.vic.gov.au/inquests-findings/findings.
Signature: ___________________________________
INGRID GILES Coroner Date: 29 August 2024 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an inquest. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.
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