Identifying Training Needs of Health-Care Providers Related to Treatment and Care of Transgendered Patients: A Qualitative Needs Assessment Conducted in New England

SUMMARY

The Transgender Training Project of the New England AIDS Education and Training Center has been providing training on transgender-related issues to health-care providers in the New England region since 1999, having trained nearly 600 providers in that time. The Transgender Training Project embarked on a study during the 2001–2002 grant year to interview providers of HIV-related care and advocacy on their knowledge and experience with working with trans-gendered people and to assess training needs to increase their effectiveness with transgendered clients.

The methodology consisted of face-to-face interviews with 13 providers of HIV treatment and care who are affiliated with the New England AIDS Education and Training Center network to discuss clinical challenges in working with transgendered people.

In this exploratory study, we found that providers had:

1. Desire to treat transgendered patients respectfully but admitted discomfort and lack of tools for specific interviewing/assessments.

2. Experience with a range of transgendered patients, but lack of information on distinctions among transgendered experiences.

3. Restrictions based on time constraints that create an overarching barrier in building trusting relationships with clients, and trusting relationships are integral to quality care.

4. Concern and frustration with lack of information, studies and research.

5. Concern and frustration with lack of treatment guidelines, (or ability to access them), referral contacts and ways to advocate for transgender clients.

6. Belief that training by transgendered people themselves was an essential teaching element.

These results point to the need for the development and dissemination of specific training materials and resources for health-care providers serving transgendered people living with or at risk for HIV.     

On the ethical analysis of value issues in public decision-making

Abstract

The nature, methodology, importance and implications of an ethical analysis of value issues pertaining to public decision-making is not evident. In this paper I would like to address these issues by posing the following questions:

• Why is it important to focus on values in any process of public decision-making?

• What is the nature of an ethical analysis of the value issues involved?

• What is the basis, if any, for ethical analysis that moves beyond relativism and subjectivity?

• What difference can such an ethical analysis make to public decision-making?

During the course of discussing these issues, the question “What is ethics?” will be addressed in passing, as well as the usual objections against ethics and the consideration of value issues in public decision-making, namely that

• values cannot be analysed and discussed objectively

• values and ethics are relative to people and cultures

• value and ethical questions cannot be settled in a rational manner

• ethics cannot provide answers

• arguments about value and ethical issues move in circles, taking us nowhere

• values and ethics are so intertwined with emotions and biases that one cannot take them seriously in any process of public decision-making.

     

Seven things to consider when measuring religious identity

Measuring religious identity is complex. The author offers seven suggestions for those who wish to describe and understand religious identity using survey data:

• (1)?Definitions and measures of religious identity shape knowledge about religious groups;

• (2)?Variation in question wording leads to variation in responses;

• (3)?Comparing results across surveys provides valuable perspective;

• (4)?Incentives shape how respondents report their religious identity;

• (5)?Religious identity may be liminal;

• (6)?Salient identity categories are often unmeasured; and

• (7)?Religious identity and religious practice may not seem congruent.

This essay includes many examples to illustrate these measurement suggestions.     

Investigating the social integration and wellbeing of transgender individuals: A meta-synthesis

Introduction: There is growing literature about the experiences of social integration and wellbeing of transgender individuals. However, there has been no synthesis across this body of research. Accordingly, the aim of this review was to aggregate, interpret, and synthesize findings from qualitative studies pertaining to the social integration and wellbeing of transgender individuals.

Methods: This study synthesized findings from 18 qualitative and mixed method studies which had explored the social integration and wellbeing of transgender individuals, using Noblit and Hare's meta-ethnography method. The Critical Appraisal Skills Programme was also used to appraise the 18 included studies.

Results: Data from the included 18 individual studies ranged from moderate to strong in quality. Data analysis revealed five major themes which influenced transgender individuals' daily lives. These were gender transition and disclosing gender identity, health and self-isolation, living with stigma and discrimination: health care, leisure and work, the importance of relationships, and last, overcoming adversity: stories of what can work.

Conclusion: This meta-synthesis reinforces many preconceived notions about transgender individuals. These include being at high risk of social exclusion, experiencing discrimination and stigma across many social situations, and last, being at high risk of poor wellbeing. This study also found that there is further need for studies that investigate the self-isolation of transgender individuals as well as this group's relationship and experiences with health care professionals and providers.     

A new magna charta

In seeking an interpretation of the theory of Gestalt, the analysis revealed that the concept of Gestalt applies to processes and particularly to the way in which events or processes take place. The essential condition for the emergence of Gestalten or configurational properties was found to be—the ability of the parts or factors in the process to influence each other.

In considering first, the more dynamic or formative phase of processes, the significant factors which influence the reciprocity of influence between the parts or factors of the process were found to be

• (i) the properties of the individual parts or factors,

• (ii) the properties of the intervening medium,

• (iii) the ‘distance’ between the parts or factors,

• (vi) ‘factors of rigidity or constraint’.

It was emphasised that these factors operate relatively to one another. The concept of ‘wholeness’ was found to apply to both the dynamic and the more static phase of the process. The resultant or equilibrium position of the process derives some contribution from the whole matrix of interacting factors or influences which are responsible for the resultant being precisely what it is.

The recognition of the causal significance of even small contributions to an event or process is consistent with the concept of ‘wholeness’ and with the ‘matrix’ view of causal explanation. This view of causal explanation is the consistent implication of the theory of Gestalt and the many experimental results associated with this school.     

Parent–child interaction therapy (PCIT) in young children with autism spectrum disorder

Abstract

Parent–child interaction therapy (PCIT) is an evidence-based treatment for typically developing children with disruptive behavior. We conducted a randomized-controlled trial of PCIT versus wait-list control (WLC) with 23 children with ASD (3–7?years) and disruptive behavior. Over 16 treatment sessions, PCIT significantly predicted reductions in disruptive behavior over WLC and explained a significant variation in scores on the ECBI Intensity subscale. Additionally, parent skills improved significantly compared to WLC. However, no statistically significant group differences were found on child compliance rates, autism severity, or parental stress. Results support PCIT as an evidence-based treatment for disruptive behavior in ASD.

• Highlights

• Parent skills were significantly improved for those receiving PCIT

• Intensity of disruptive behaviors decreased significantly for those receiving PCIT

• Parental stress and autism severity did not significantly decrease with PCIT

     

Six Levels of Mentality

Abstract

Examination of recent debates about belief shows the need to distinguish:

• (a)?non–linguistic informational states in animal perception;

• (b)?the uncritical use of language, e.g. by children;

• (c)?adult humans' reasoned judgments.

If we also distinguish between mind-directed and object–directed mental states, we have: 1. Perceptual ‘beliefs’ of animals and infants about their material environment.

2. ‘Beliefs’ of animals and infants about the mental states of others.

3. Linguistically-expressible beliefs about the world, resulting from e.g. the uncritical tendency to believe what we are told.

4. Uncritically-formed beliefs about the mental states.

5. Beliefs about the material world arrived at by the weighing of evidence.

6. Beliefs about mental states formed by critical assessment.

     

Provider quality and barriers to care for transgender people: An analysis of data from the Wisconsin transgender community health assessment

Background: Transgender people in the United States often lack access to high-quality health care.

Methods: A group of researchers and transgender people came together in a community-based participatory research process to survey transgender Wisconsinites about their health care experiences. A multiple regression analysis of survey data was used to evaluate the association between barriers to health care, gender identity, and quality of medical and mental health care provider.

Results: Seventy-seven respondents were included in this analysis. Transmasculine respondents were more likely than transfeminine respondents to report barriers to high-quality health care, but having a high-quality medical or mental health care provider was associated with reporting fewer barriers to care across the entire sample.

Discussion: This community-based study suggests that health care providers play a key role in facilitating access to care for transgender Wisconsinites in the USA.     

Work function dependence on the thickness and substrate of carbon contamination layers by Kelvin probe force microscopy

The contact potential difference (CPD) between carbon contamination (CC) layers and the several substrates on which they were deposited has been measured as a function of the film thickness by means of Kelvin probe force microscopy (KPFM). The observed CPD trends may be divided into three categories:

2. an increase, or decrease, in CPD with thickness up to a saturation value with sign inversion with respect to the substrates (Al and Si);

3. an oscillation with no sign inversion (substrates, gold and platinum);

4. an oscillation through sign inversion (palladium substrate).

Effects (ii) and (iii) seem to be typical of CC, since they have not been observed for other materials, including evaporated carbon. Several possible causes of the above two effects are examined, but a satisfactory interpretation has not been found yet. The sensitivity of KPFM is such that CC layers 10 nm thick are easily visible, whereas they are hardly detectable by topography.     

The Internal Problem of Dreaming: Detection and Epistemic Risk

Abstract

There are two epistemological problems connected with dreaming, which are of different kinds and require different treatment. The internal problem is best seen as a problem of rational consistency, of how we can maintain all of:

1. Dreams are experiences we have during sleep.

2. Dream‐experiences are sufficiently similar to waking experiences for the subject to be able to mistake them for waking experiences.

3. We can tell that we are awake.

(1)–(3) threaten to violate a requirement on discrimination: that we can only tell Xs from Ys if there is some detectable difference between Xs and Ys. Attempts to solve the problem by Descartes and Williams are considered. It is suggested that if we take account of levels of epistemic risk, we can use Descartes’s criterion of lack of coherence, at least with hindsight – which is the time when we need to use it.     

Consensus and Cognitivism in Habermas’s Discourse Ethics

Abstract

Habermas asserts that his discourse ethics rests on two main commitments:

1. Moral judgements have cognitive content analogous to truth value; and

2. moral justification requires real-life discourse. Habermas elaborates on the second claim by making actual consensus a necessary condition of normative validity. I argue that Habermas’s two commitments sit uneasily together. The second entails that his cognitivism is revisionist in the sense that it must reject the law of the excluded middle. Moreover, Habermas’s argument in defence of the need for real-life discourse is unconvincing and his derivation of the principle which requires consensus is fallacious.

     

Enlarged Range of Free Flaps for Phalloplasty in Transsexual Reassignment Surgery

ABSTRACT

Our concept for complete phalloplasty which we applied in 66 female-to-male transsexuals, using free prelaminated osteofasciocutaneous fibula or fasciocutaneous forearm flaps, consisted of the following three operative stages:

1. mastectomy, ovariohysterectomy, urethra lengthening, colpectomy, and neourethra prelamination

2. after 3–6 months, neophallus creation with free sensate and prelaminated osteofasciocutaneous fibula (n = 41) or radial forearm flaps (n = 25)

3. 3–6 months later, urethral connection, neoscrotum formation and testicle prosthesis implantation.

Results: After mastectomy 2 hematoma had to be removed, and twice colpectomy revision was needed because of hematoma. No complications occurred after ovariohysterectomy. Partial flap necrosis took place in 1 patient of the forearm group and total necrosis in 2 patients of the fibula group. Eleven patients presented urethral stricture, and 9 a fistula. In 7 patients an operative stricture expansion was required, and in 6 patients surgical closure of the fistula. Overall patients' satisfaction was excellent.

Conclusions: The applied results demonstrates the effectiveness of such a multistage and interdisciplinary approach for female-to-male transsexual and it shows, that the fibula flap is an equal routine method extending the therapeutical range of gender assignment operations in female-to-male transsexuals.     

Toward a Theory of Progressive Evolution (Large-Scale Stages of Evolutionary Progress)

Here I discuss the basic elements, major stages, and completion of progressive evolution. The cosmic world of self-realization is based on extensive self-development within a closed contour: temporal counter-transitions of spatial counter-elements (energy bonds and media and, basically, substance structures) form of local worlds within it through evolution of informational structures.

• The organic world of reproduction develops through the open informational path: the initial substance, through energy exchange and metabolism, reproduces similar substance; the latter interacts with the environment and, subsequently, reproduces its like, and so on.

• The animal world of self-regulation builds up a closed informational contour in the environment through the informational input and command output.

• The human world of self-cognition forms the intensive type of development within the internal closed informational contour of cognition. Counter-transitions of ideal images and signs relate to their real prototypes. In the course of cognition, abstractive thinking develops and brings man to the possibility of reflection of the initial world in its integrity (thus, elevates man to the infinite, by Hegel).

     

Foreign accents reduce false recognition rates in the DRM paradigm

ABSTRACT

More cognitive resources are required to comprehend foreign-accented than native speech. Focusing these cognitive resources on resolving the acoustic mismatch between the foreign-accented input and listeners’ stored representations of spoken words can affect other cognitive processes. Across two studies, we explored whether processing foreign-accented speech reduces the activation of semantic information. This was achieved using the DRM paradigm, in which participants study word lists and typically falsely remember non-studied words (i.e. critical lures) semantically associated with the studied words. In two experiments, participants were presented with word lists spoken both by a native and a foreign-accented speaker. In both experiments we observed lower false recognition rates for the critical lures associated with word lists presented in a foreign accent, compared to native speech. In addition, participants freely recalled more studied words when they had been presented in a native, compared to a foreign, accent, although this difference only emerged in Experiment 2, where the foreign speaker had a very strong accent. These observations suggest that processing foreign-accented speech modulates the activation of semantic information.

Highlights

• The DRM paradigm was used to explore whether semantic activation is reduced when processing foreign-accented speech.

• Across two experiments, false recognition of non-studied semantic associates was lower when word lists were presented in a foreign accent, compared to native speech.

• The above results suggest semantic activation may be reduced when processing foreign-accented speech.

• Additionally, it was found that when the foreign speaker had a mild accent, correct recall of studied words was uninfluenced. If the foreign speaker had a strong accent, however, correct recall of studied words was reduced.

     

“Beyond Frontiers of Traditional Project Management”: The Concept of “Project Management Second Order (PM-2)” as an Approach of Evolutionary Management

Fundamental changes in sciences offer new perspectives for the management of complexity. Increased complexity in society, economics, and technology requires a new and suitable organization and management. What are the consequences and results for project management? That is the theme of this article. First of all it will given a short introduction to project management, which will be later called “traditional project management” or “project management 1st order (PM-1).” Then, the challenges by the fundamental changes in sciences and the increased complexity in society, economics, and technology will be discussed. It will state that traditional project management cannot solve these challenges. The widespread working-themes and results of the research program “Beyond Frontiers of Traditional Project Management” as an answer to these challenges will be presented at a glance. Subsequently, it will discuss some selected results of the research program:

• The principle-definition and foundation of “Evolution of 1st and 2nd Order.”

• The Evolution of 1st Order and the impact on Project Management methods and processes.

• Evolution of 2nd Order and the Grand Evolutionary Systems Theory (GEST) of E. Laszlo as also the impact on Project Management methods and processes.

• Management of crisis: turn a change to advantage or risk-assurance?

Thereafter, the concept of “Project Management Second Order (PM-2)” is presented as a highlighted result of the research program, as a new paradigm in project management, and as an answer to the challenges, described earlier will be explained in detail. Finally, a real example of transfer evolutionary and self-organizational management principles in a real project life will be demonstrated.     

Supporting Transgender and Sex Reassignment Issues

SUMMARY

For the care provider unfamiliar with supporting transsexual and transgender persons, as well as their partners, it becomes an imperative to be able to identify this population's unique needs, transition concerns and relationship dynamics. New challenges arise as transgender clients become more prevalent within the GLBT community and contact community clinical resources. These include distinguishing between sexual orientation and the complexities of gender identity; differentiating actual transgender issues and ordinary relationship concerns; and recognizing characteristics of strong relationships versus those doomed to fail when one or both partner's needs can no longer get met.

This article reviews an abundance of stereotypes adversely affecting transgender individuals, relationships and which can taint the treatment environment. At a core level, there exists the need for care providers to recognize when having a transgender identity stops being a disorder, such as when the client is no longer gender dysphoric, and where the care provider needs to advocate the individual's right of self-determination. This includes recognizing when situational depression or anxiety and social discrimination are the actual root of ongoing individual and relationship concerns. With basic transgender knowledge, effectively supporting transgender persons and their relationships is possible for cross-specialty providers, and is recommended.     

Care of the transgender or gender-nonconforming patient undergoing in vitro fertilization

Background: Assisted reproductive technologies, including in vitro fertilization (IVF), can be utilized for fertility preservation and family building in the transgender and gender-nonconforming population.

Methods: This is a retrospective case series from an academic tertiary care center.

Results: We present three couples with a transgender or gender-nonconforming member who pursued IVF to build their families. The first case involves a transgender man who suspends hormone therapy to undergo IVF. The second involves a transgender woman who uses her previously banked sperm to undergo IVF with her wife. The third involves a gender nonbinary patient and their cisgender wife who create and transfer embryos from both partners.

Conclusion: IVF can provide unique family-building opportunities to transgender and gender-nonconforming patients, and providers should seek to broaden their clinical experience with this population.