Mental health care for trans and gender diverse youth from culturally and linguistically diverse (CALD) backgrounds: Reflections from communities of practice

Figures & data

Table 1. Practical actions to support trans and gender diverse CALD youth in mental health and suicidal distress.

Trust and rapport	Allow for time to build trust and rapport; Due to fear of rejection and ostracizing, trans and gender diverse CALD youth need time to reduce their perception of risk and feel safe. Work to create a psychologically safe space for youth to tell their story as a strategy for trust and rapport. Explore contact with services and acknowledge the young person’s feelings of unfamiliarity and uncertainty. Communicate that you can discuss and make a shared decisions on what can be discussed with family or other professionals. Start a conversation on knowing and respecting preferred names and pronouns. Decide with the young person which names and pronouns to use to encourage agency, decision-making and psychological safety. Consider the need to communicate specificities of name and pronouns use to service administrative and reception staff. Advise non-clinical staff that some family members may be unaware of the young person’s gender identity and use of personal pronouns. Prioritize – whenever safe and possible to do so - care delivery in the absence of an interpreter. This may be necessary to create safety for the young person to trust and engage with the service, their right to privacy and safety in the community.
Strategies to reduce inequality	Unpacking the young person’s experience and taking the time to listen is a therapeutical strategy per se. The clinician might be the first person to whom the young person is disclosing their distress. “Bearing witness” means to move beyond the need to interpret the young person’s experience based on the practitioner’s own point of reference, as a form of active open listening. “Bearing witness” is also a way to reduce the power imbalance in the therapeutic relationship as the practitioner becomes aware of their own potential biases and leans in to listen to the young person’s experience. Cultivate “open curiosity” about the young person’s experience of their own gender. Explore meaning(s) attributed to identifying as trans or gender diverse. Acknowledge the implicit risk of stigmatizing the experience of patients by inflexibly adhering to protocols. Rigidity in how assessment and intervention is conducted by a practitioner or service can amplify feelings of inequality and stigma experienced by this group in varied contexts.
Encouraging culturally meaningful expression of distress	Show willingness to appreciate diverse understandings of mental health and suicidal distress. Mental health workers need to constantly reflect on the power dynamics associated with delivering care to populations of diverse backgrounds. Invite the young person to guide you in understanding their distress and what perspectives they bring into the conversation. Explore in a culturally meaningful way. Explore young person’s expectations around involvement with family and community and how much they feel included in their cultural context. Questions might include: What does your family expect of a young person such as yourself? What is the most difficult part in trying to participate in family life? What is the easiest part of it? It can be helpful to explore nuances of their experience from a culturally and linguistic-diverse perspective and the way they perceive the experience of peers from other backgrounds. Questions might include: What does your family believe [use the young person’s own/ preferred terminology] should be like? Is that different from what you see as the experience of your peers? Be conscious of words and actions to safely discuss concerns and strengths related to gender diversity. It is important to facilitate a conversation that is not characterized by the presence of forced choices; allow for the young person to decide how much they want to disclose. Understanding of distress may involve engagement between stakeholders, ways of knowing brought by each person and the diversity within and between understanding. Be open to new insights linked to cultural, religious, and spiritual concepts and explanatory models used when discussing gender diversity.
Promote flexibility, choice, shared decision making	Clarify limits to confidentiality, emphasizing psychological safety as a priority. Communicate it in a way that is encouraging of trust, power, and autonomy. Mental health workers communicate to the young person that they are not alone in their distress. Examples might include: “Generally, I would discuss it with you first if I am concerned about your safety. Then we can discuss who else we might need to talk to.” When assessing drivers of suicidal distress, be open to potential issues that might require priority attention. Although it can be a driver for suicidal distress, questions around gender identity might not be pressing for some young people. Involve the young person in deciding priorities, what to disclose to family members and what support is needed. Assess and facilitate options on disclosing sensitive information that can increase distress and subsequent risk. Acknowledge that suicide ideation/risk fluctuates. The young person may seek a personalized safety plan or crisis plan.
Engaging family in promoting safety	Explore cultural understanding of mental health distress and suicidal ideation; avoid clinical jargon and be open to other conceptualisations of health and wellbeing. Questions might Include: Within your family and community, how do people express their distress? What is acceptable, what is not? When people express their suffering, distress or struggles what they are expecting other people’s response to be? If you were in your home country, what supports would you have/who could you turn to in case you needed help? Identify caregiver’s concerns and validate distress What are your major concerns for your child? When did you first start being concerned? It sounds like you might be scared about what can happen to your child. As a parent, what is important to you for your child? Engage a future-oriented discussion around wellbeing. Questions might Include: What sort of support do you think you can provide for your child at present? What can you do to promote your child’s safety at this time? What supports would you need to increase their safety? What life has been like for you since you arrived in Australia? What did you want for your child when you arrived in Australia? What are your hopes and dreams for yourself, your family, and your child now? When discussing safety planning, acknowledge that for families with a refugee background conception of safety might be restricted to fear of racial persecution and concerns for physical safety. Caregivers might not consider the young person to be at risk. Explore caregivers’ understanding of safety when trying to engage them in promoting the young person’s wellbeing.
Identifying supports in and outside the family system with the young person	Identify aspects of the distress the young person feels they can share with other family members. Explore what information they feel they can discuss with a family member and what they need to keep private. Questions might Include: Is there anyone in your family you can talk to about this? What aspects do you feel you can share, and which others do you need to keep private? Do you know of anyone in the family with a similar experience to yours? Identify supportive systems outside of the immediate family – e.g., education, friendship, peer support; school counselors; online communities’ support. Review potential barriers to accessing support and explore alternative pathways. In cases where there is support from family and caregivers, identify preferred ways to communicate gender within a cultural context.

Whilst there is no straightforward or linear action plan, these guidelines can contribute in formulating the individual care response to trans and gender diverse CALD youth. The fluctuating nature and rapid intensification of suicide related distress can make a care response dynamic. Regular team discussion, individual supervision and self-care are important.

Ethics statement

Ethics committee clearance is not applicable to this article as no datasets were generated or analysed during the writing of the paper.

Data availability statement

The original data contributions presented in the paper are included in the article material, further inquiries can be directed to the corresponding author.