Editor's note: If you or a loved one is in crisis, you can call the National Suicide Prevention Lifeline at 1-800-273-8255 (1-800-273-TALK).
FARGO — Katrina Koesterman is a leader in the local LGBTQ community, regularly giving others the kind of support she craved as an adolescent. But to get where she is now, it was a journey.
During the summer of 2016, she tried to take her own life as a patient at Prairie St. John's, a psychiatric hospital in Fargo.
Koesterman, a 33-year-old transgender woman, admitted herself due to thoughts of self-harm stemming from the trauma of a past abusive relationship. But she says that's not what spurred her suicide attempt.
When a nurse at the hospital did not use Koesterman's preferred pronouns and used her "dead name," a term describing a birth name that's been changed, this triggered Koesterman, already in crisis.
She went into her room and tried cutting her wrist, but a different nurse intervened.
After that episode, Koesterman legally changed her name and was re-baptized at a name-changing ceremony. And though her mental health is "an ongoing struggle," she’s since found doctors who respect her gender identity and preferred pronouns.
"Literally using someone's preferred pronouns and preferred name can save a life," she said. "Absolutely it can."
Koesterman is now president of Tri-State Transgender, a fellowship throughout the Red River Valley, and she volunteers on weekends at the Pride Collective and Community Center, an inclusive space that's existed in Fargo-Moorhead since 2000.
At this year's Fargo-Moorhead Pride Parade, Koesterman gave a speech in front of a crowd of hundreds. Reading from her smartphone and talking — sometimes shouting — into the microphone, the crowd applauded her call to action to save lives.
"We need to come together to fight for our most vulnerable family members," she told the crowd. "Look around you, your family needs you. They need your support, especially our youth and people of color. A member of our youth with just one supportive adult in their life is significantly less likely to die from suicide, and together we must stand up against violence befalling our family of color."
Koesterman grew up in Fergus Falls, Minn., with a supportive family. She lacked mentors, however, and said she didn’t talk to anyone about her gender identity and was "deeply closeted."
"It didn’t seem like a safe environment for me to come out," she told The Forum. "I was never popular in school because I was busy wrestling with my identity. The only friends I had were, at first, my brother, who introduced me to Dungeons and Dragons .... As I grew up, my friends were the type to sit in basements and play board games. So I’ve always been a huge nerd. And I’ve always felt sort of ostracized from society even before I came out."
Along with body image issues, Koesterman dealt with depression and suicidal ideation. But it wasn't until seeking care at Prairie St. John’s that she first tried to take her life. That attempt was four years after she came out as transgender in 2012 at the age of 26.
"When I first came out, they were confused," she said of her family. "And of course they were worried about me because they knew about the discrimination transgender people face. But they were as supportive as they could be."
Her only recourse, she said, was reading about transgender issues online. "That filled my niche for a while, but it became increasingly more difficult as I grew up to feel increasingly trapped in the wrong gender," she said.
"That’s an advantage I think this generation has. Being transgender isn’t as othered as it used to be," she said. "So people are able to come out earlier and explore their transition earlier in life. That’s an opportunity I simply didn't have, especially growing up in Fergus Falls."
Koesterman said LGBTQ youth still face barriers and discrimination today, but she recognizes some progress. She pointed to trans icons like actress Laverne Cox, and the increase in gender-neutral bathrooms.
'Honoring their wishes'
The American Foundation for Suicide Prevention notes that a large majority of LGBTQ people experiencing negative and stressful external factors do not become suicidal.
Suicide in LGBTQ populations is difficult data to track because death records don’t include a person’s sexual orientation or gender identity.
But studies in recent years are clear: There is a higher prevalence of suicide attempts among LGBTQ people. What’s also evident is their resilience.
The 2017-2020 North Dakota Suicide Prevention Plan says LGBTQ youth are 3.4 times more likely to attempt suicide than peers who identify with their birth sex, while transgender youth and adults are 10 times more likely to attempt suicide than the general population.
Major factors putting this group at risk include harassment, discrimination and rejection. LGBTQ teens not supported by their families are at more than eight times the risk for a suicide attempt, according to the prevention plan.
Victimization, including physical assault, sexual harassment, parental abuse and bullying, as well as lack of acceptance, results in increased risk of mental illness. But the prevention plan states this group is less likely to seek mental health services out of fear of being mistreated.
Officials with Sanford Health, Essentia Health and Prairie St. John’s said they have in recent years changed their patient intake forms to provide options for gender identity, sexual orientation and preferred pronouns. That information is then part of a patient’s online medical file so it’s shared among all staff.
"We as a health care organization deliver the best care when we understand who our patients are as people and make sure that we are honoring their wishes," Dr. Jamie Conniff, a family practice physician with Essentia, said in a statement.
Jeff Herman, Prairie St. John’s CEO, said the changes at the psychiatric hospital did not stem from Koesterman’s experience at the facility, but from "the ever-changing cultural perspective on health care" and "being more culturally aware."
Essentia and Sanford have transgender services with staff specializing in gender-affirming care.
Dr. Brianne Marion, a pediatric psychologist at Sanford, said she works with children and adolescents to figure out how to be the best version of themselves.
"What I want is my kids to thrive. And I think they’ll thrive when they can feel proud of who they are and they can show the world who they are and give everything that they have to offer," she said.
Marion said her gender-nonconforming patients are experiencing discrimination as early as day care and elementary school. "And this continues throughout their life," she said. "So yeah, people are going to get depressed if they're consistently mis-gendered, if they are mistreated."
Marion cited a 2018 study that found parents using the preferred name of gender-nonconforming youth significantly decreases depressive symptoms, including a 29% decrease in suicidal ideation and a 56% decrease in suicidal behavior.
Some research has demonstrated that parental support and acceptance of LGBTQ youth is associated with better mental health, including greater self-esteem, lower depression, higher sense of school belonging and lower risk of suicide.
Marion’s colleague at Sanford, Dr. Dan Sturgill, is a psychologist focused on gender-confirming psychotherapy for adults.
Sturgill said it's not a new idea that talking about suicide makes it less likely that someone will take their life. The same goes for talking about gender identity, he said.
"Sometimes I think families are fearful that if they are using the person's pronouns and their preferred name, that they're somehow going to make it confusing for them in figuring out their identity. And it's exactly the opposite," he said. "If we're allowing people the opportunity to talk about their gender experience, and we're affirming what they're telling us about their experience, that's going to help them to even more so understand who they are, and also help to decrease the chances of them taking their life."
Support and prevention
Every weekend, Koesterman opens the doors to the Pride Collective and Community Center.
"I like being here because it's a safe space for the entire community, whether it be youth or older adults who are just now coming out," she said. "It only takes one person to save a life."
A crucial component of the Pride Collective is its weekly youth support group, Kaleidoscope.
Adrienne MacDonald is a volunteer facilitator for the group. MacDonald recently asked the group how people can support LGBTQ youth.
What it boiled down to? "Don’t treat them differently than any other kid," MacDonald said.
"It's just a part of that person," MacDonald said of gender identity or sexual orientation. "There's a holistic person, they're into other things. There's other things that describe who they are. And so it's important to remember that it's just a part of who they are. It doesn't mean that that's all they are."
Five to 30 kids join the group each week, and MacDonald is mostly there to listen — to concerns or frustrations, to reactions to current events impacting LGBTQ people, to stories of resilience or celebrations, like someone using the correct pronouns.
"If we can validate their feelings and let them know that we are here for them, and they can come here, and they can be safe here, and they can make friends here, and they don't have to do this alone, I think that's what kids really benefit from hearing, and just being listened to," MacDonald said. "In general, I think a lot of the times they feel like they're not heard. They feel like nobody is there for them."
And all they need is a single person who cares.
LGBTQ youth with one supportive adult were 40% less likely to attempt suicide, according to The Trevor Project, a national organization providing crisis intervention and suicide prevention services to LGBTQ youth.
MacDonald said "having a social support does more power than we know."
"If you're highly victimized, just having one friend — and that goes for any kid — but one friend can help buffer the effects of victimization," MacDonald said.