Experiences of surgery readiness assessments in British Columbia

Abstract

Background: A surgical readiness assessment is a major step in the medical journey of trans people seeking gender-affirming surgery. Much of the peer-reviewed literature surrounding surgical readiness assessments emphasizes the perspectives of academics and clinicians, leaving the voices of trans and gender diverse patients largely unheard.

Aims: This paper foregrounds patient experiences with surgery readiness assessments to discuss the tensions, challenges and opportunities they generate.

Methods: We conducted a thematic analysis of 35 in-depth interviews with trans people who accessed or were seeking to access gender-affirming surgery in British Columbia.

Results: We developed three main themes to capture participants’ narratives of their surgical assessment experiences. The first, assessments as gatekeeping, explores the stories of people who described their assessments as outdated and even discriminatory processes. The second, assessments as a barrier to care, discusses the informational missteps, bureaucratic regulations, economic issues, and geographic concerns that made assessments difficult to access. The third, assessments as useful, includes positive stories about assessments that often involved feeling supported by an assessor and feeling prepared for the next steps.

Discussion: These narratives demonstrate how much variation exists among people’s experiences of readiness assessments for gender-affirming surgery. No matter how their actual assessment turned out, many participants approached their appointments with a great deal of anxiety and trepidation. We attributed this stress was to challenges ranging from lengthy wait times, arbitrary medical gatekeeping, a lack of access to knowledgeable and supportive providers, unclear or changing administrative processes, and insufficient communication. To address these challenges, it is crucial for the medical system to create more accessible pathways with centralized, up-to-date information for people trying to access assessments. Patients are best served by multi-disciplinary gender-affirming teams that provide individualized care.     

Psychological,social and physical environmental mediators of the SCORES intervention on physical activity among children living in low-income communities

ObjectivesThis study examined mediation effects of socio-ecological variables on accelerometer-determined physical activity among children in the Supporting Children's Outcomes using Rewards, Exercise and Skills (SCORES) intervention.DesignRandomized control trial mediation analysis.MethodsPrimary school children were randomly assigned the SCORES multi-component intervention or control group for the 12-month study. The outcome was accelerometer derived total moderate-to-vigorous physical activity (MVPA). Hypothesized mediators measured in children were physical activity enjoyment and perceived sport competence and social support. Hypothesized mediators measured in parents were family social support, access to physical activity facilities and equipment at home, and perceived access to physical activity opportunities in the local community. Mediation analyses were conducted using multi-level linear analysis in MPlus.ResultsThere were significant intervention effects for social support from teachers (A = 1.73, SE = 0.88, p = 0.048) and parental perceived access to physical opportunities in the local community (A = 2.69, SE = 1.12, p = 0.016). There were significant associations between changes in perceived sport competence (B = 0.48, SE = 0.36, p = 0.027), parental perceived access to physical activity opportunities in the local community (B = 0.60, SE = 0.26, p = 0.021), and changes in total MVPA. Parental perceived access to physical activity opportunities in the local community was found to have a significant mediating effect on total MVPA (AB = 1.61, 95% CI = 0.06 to 3.95, proportion 13%).ConclusionsParental perceived access to physical activity opportunities in the local community is a potential mechanism of behavior change for children and mediated the effect of the SCORES intervention on objectively measured physical activity.     

‘If they didn’t support me,I most likely wouldn’t be here’: Transgender young people and their parents negotiating medical treatment in Australia

Abstract

Background: It is increasingly recognized that transgender young people require affirming medical care, however the provision of such care may be mitigated by the availability of services and the views of parents.

Aims: This study aimed to explore the views of Australian transgender young people (aged 11–17) and their parents with regards to medical treatment.

Methods: Ten qualitative interviews were conducted with parent-child dyads in two Australian states. Thematic analysis was undertaken on responses to interview questions related to family relationships, views about medical treatment (specifically hormone blockers and hormones), and the relationship between medical treatment and sense of self.

Results: Themes developed focused on the importance of strong supportive parent-child relationships, the meaning of and access to hormone blockers, and the meaning of and access to hormones.

Discussion: The paper concludes by discussing the implications of the findings for clinical services, particularly in relation to supporting parents to be affirming of a transgender child, the need to prepare transgender young people and their parents for the passage of time in regards to medical treatment, and the need to focus on expectations in regards to sense of self in relation to medical treatment.     

Non-binary youth: Access to gender-affirming primary health care

ABSTRACT

Background: Transgender (trans) youth who identify outside the gender binary are a growing subpopulation. In this article, we document differences in access to gender-affirming health care between binary and non-binary identified trans youth and explore ways of meeting the health needs of non-binary youth within primary care settings.

Methods: The Canadian Trans Youth Health Survey is a national online survey of trans youth, 14–25 years, conducted in 2013–2014. Among the 839 participants who responded to gender identity items in the survey, 41% identified as non-binary. We compared demographic, health outcome, and health care access responses between non-binary and binary (trans girls/women and trans boys/men) youth.

Results: Non-binary and binary youth were similar in most demographics, including age, geographic distribution, and ethnocultural backgrounds, however a larger proportion (82%) of non-binary youth were assigned female at birth. Older non-binary youth (aged 19–25) were significantly more likely to forego needed healthcare than older binary youth; no significant differences were found between younger (14–18) non-binary and binary youth in foregoing healthcare. Overall, non-binary youth (13%) were significantly less likely than binary youth (52%) to access hormone therapy, but they were more likely than binary youth to report experiencing barriers to accessing hormone therapy when needed.

Conclusions: Non-binary trans youth in Canada report challenges in accessing needed gender-affirming healthcare. Primary care providers are well-situated to integrate a broad range of gender-affirming care services into practice in order to address the unique needs of non-binary youth. Future research is warranted to explore experiences of non-binary youth related to barriers to care and to explore how services can be designed and delivered to better meet the needs of non-binary youth seeking gender-affirming primary care.     

The Scandal of Reason: A Critical Theory of Political Judgment

Abstract

Carruthers argues that knowledge of our own propositional attitudes is achieved by the same mechanism used to attain knowledge of other people’s minds. This seems incompatible with ‘privileged access’ – the idea that we have more reliable beliefs about our own mental states, regardless of the mechanism. At one point Carruthers seems to suggest he may be able to maintain privileged access, because we have additional sensory information in our own case. We raise a number of worries for this suggestion, concluding that Carruthers’s new theory cannot clearly preserve the superior reliability of our beliefs about our own attitudes.     

Considerations on medical training for gender-affirming care: Motivations and perspectives

Abstract

Background: Many transgender individuals lack access to needed medical care, partially due to a lack of providers with experience in gender-affirming healthcare.

Aims: The purpose of this study was to identify professional motivators for medical providers seeking out training in gender-affirming care and to define which training experiences were most beneficial to their career development. By identifying experienced providers’ recommendations on which training modalities are most relevant to their practice, we aim to suggest future directions for medical education initiatives to effectively expand the transgender care workforce.

Methods: A voluntary cross-sectional electronic survey was distributed through professional listservs and publicly-available referral lists to interdisciplinary providers who self-identified as having experience in providing care to transgender individuals.

Results: One hundred and fifty-three (n?=?153) physicians, physician assistants, or advance-practice nurses responded to the survey. The majority (96.7%) were located in the United States, representing 37 states. The two most common motivators for seeking out training in gender-affirming care were filling a need in the community (73.0%) and/or having met a transgender-identified person in a clinical setting who requested care (63.8%). While many providers gained skills independently (57.3%), the two most commonly-available training opportunities were professional conferences (57.3%) and mentorship (41.3%). Respondents were most likely to recommend that others in their field be trained via structured clinical experience (e.g., a rotation or longitudinal exposure during training), rather than additional didactic training.

Discussion: This study identifies key high-yield training methodologies which could improve access to quality gender-affirming healthcare. Through integration of structured clinical experiences during training, direct clinical mentorship, and professional development at conferences on gender-affirming care, the workforce of welcoming and prepared healthcare providers for transgender patients will increase. This will lead to a tremendous improvement on access to gender-affirming care in our communities.     

Treatment of grief and mourning through EMDR: Conceptual considerations and clinical guidelines

IntroductionEye Movement Desensitization and Reprocessing (EMDR) is an empirically-supported psychotherapeutic approach for treating trauma, which is also applicable to a wide range of other experientially-based clinical complaints. It is particularly useful in treating grief and mourning.Literature findingsEMDR is guided by the Adaptive Information Processing Model (AIP), which conceptualizes the effects of traumatic experiences in terms of dysfunctional memory networks in a physiologically-based information processing system. Numerous empirical studies have demonstrated EMDR's efficacy.DiscussionThe death of a loved one can be very distressing, with memories and experiences associated with the loss becoming dysfunctionally stored and preventing access to adaptive information, including positive memories of the deceased. EMDR can be utilized to integrate these distressing experiences and facilitate the assimilation and accommodation of the loss and movement through the mourning processes.ConclusionApplying the eight phases of EMDR to grief and mourning can yield potent clinical results in the aftermath of loss.     

Common barriers to healthcare for transgender people in the U.S. Southeast

Abstract

Background: Transgender and non-binary people are more likely to face barriers to healthcare than their cisgender counterparts. The majority of work in this area centers on the experiences of transgender people in northern cities and urban enclaves, yet over 500,000 transgender people live in the U.S. Southeast.

Aims: The purpose of this study is to explore barriers to healthcare among transgender people in the U.S. Southeast.

Methods: The research team conducted four 120-minute focus groups (eligibility criteria: 18?years or older, self-identify as transgender, live in the U.S. Southeast). Participants completed a demographic questionnaire prior to the start of the focus group. Each focus group explored access to and experiences of receiving basic healthcare as a transgender person in the U.S. Southeast. Established qualitative methods were used to conduct the focus groups and data analysis.

Results: Participants (n?=?48) ranged in age from 19 to 65, with the majority identifying as trans women (43.8%) and non-binary (33.3%). The sample was racially diverse: White (50%), Black (37.5%), and Latinx or Multiracial (12.5%). Multiple barriers to care were identified: (1) fear and mistrust of providers; (2) inconsistency in access to healthcare; (3) disrespect from providers; and, (4) mistreatment due to intersecting experiences of gender, race, class, and location.

Discussion: Transgender Southerners face barriers to care at the structural, cultural, and interpersonal levels. The study results have implications for researchers, as well as providers, practices, and health care systems throughout the region.     

The experiences of gender diverse and trans children and youth considering and initiating medical interventions in Canadian gender-affirming speciality clinics

Abstract

Background: Canadian specialty clinics offering gender-affirming care to trans and gender diverse children and youth have observed a significant increase in referrals in recent years, but there is a lack of information about the experiences of young people receiving care. Furthermore, treatment protocols governing access to gender-affirming medical interventions remain a topic of debate.

Aims: This qualitative research aims to develop a deeper understanding of experiences of trans youth seeking and receiving gender-affirming care at Canadian specialty clinics, including their goals in accessing care, feelings about care and medical interventions they have undergone, and whether they have any regrets about these interventions.

Methods: The study uses an adapted Grounded Theory methodology from social determinants of health perspective. Thirty-five trans and gender diverse young people aged 9 to 17?years were recruited to participate in semi-structured interviews through the specialty clinics where they had received or were waiting for gender-affirming medical interventions such as puberty blockers, hormone therapy, and surgery.

Results: Young people felt positively overall about the care they had received and the medical interventions they had undergone, with many recounting an improvement in their well-being since starting care. Most commonly shared frustrations concerned delays in accessing interventions due to clinic waiting lists or treatment protocols. Some youth described unwanted medication side-effects and others said they had questioned their transition trajectory at certain moments in the past, but none regretted their choice to undergo the interventions.

Discussion: The results suggest that trans youth and gender diverse children are benefiting from medical gender-affirming care they receive at specialty clinics, providing valuable insight into their decision-making processes in seeking care and specific interventions. Providers might consider adjusting aspects of treatment protocols (such as age restrictions, puberty stage, or mental health assessments) or applying them on a more flexible, case-by-case basis to reduce barriers to access.     

The Congruence of International Children's Rights and Feminist Principles as a Foundation for Therapy with Young People

SUMMARY

The United Nations Convention on the Rights of the Child, an international treaty that supports and protects humans under age eighteen, embodies several principles that are useful in guiding mental health treatment with young people. Here we summarize relevant tenets of the Convention and offer an analysis regarding its relevance to feminist therapy. Topics covered include participation and limited self-determination, privacy and autonomy, supportive community, access to information and care, least restrictive environment, and access to protection and recovery assistance. We then deconstruct the apparent assumptions underlying the Convention through a feminist, post-modern, social constructionist perspective. We conclude that the Convention offers a useful vision for work with children and is consistent in some ways with feminist-informed practice, although attention must be given to factors about which the Convention is silent, including gender, privilege, and assumptions regarding family, child, mental health, and human development.     

Fibred Security Language

We study access control policies based on the says operator by introducing a logical framework called Fibred Security Language (FSL) which is able to deal with features like joint responsibility between sets of principals and to identify them by means of first-order formulas. FSL is based on a multimodal logic methodology. We first discuss the main contributions from the expressiveness point of view, we give semantics for the language both for classical and intuitionistic fragment), we then prove that in order to express well-known properties like ‘speaks-for’ or ‘hand-off’, defined in terms of says, we do not need second-order logic (unlike previous approaches) but a decidable fragment of first-order logic suffices. We propose a model-driven study of the says axiomatization by constraining the Kripke models in order to respect desirable security properties, we study how existing access control logics can be translated into FSL and we give completeness for the logic.     

What's in a name? access to information from people's names

Abstract

The processing of people's names is contrasted with face recognition and word recognition. The effects of the familiarity of initial and surnames and frequency of surnames (the number of people with the same surname) were investigated in several tasks. It was found that the effects of name familiarity and surname frequency were analogous to the effects of word frequency in tasks which did not require access to memory for individuals (a nationality decision and naming latency). In tasks which do require access to memory for individuals (familiarity decision and a semantic classification), the effect of surname frequency was analogous to the effect of distinctive-ness in face recognition. The results are discussed in terms of a functional model of name processing in which name recognition units mediate between the output of word recognition units and access to identity-specific semantics.     

Développement et validation de l’Inventaire francophone de l’Épuisement Professionnel (IFEP)

IntroductionThe prevention of burnout is a major issue for companies. However, they do not always have access to tools adapted to the implementation of prevention policies.ObjectiveThis study is part of a project to create a questionnaire adapted to employees’ needs in the field of burnout measurement.MethodThe survey was distributed online to French-speakers workers (N = 680).ResultsThe results of the exploratory and confirmatory factor analyses indicated two dimensions (exhaustion and interpersonal stress) with high internal consistency. This factorial structure was confirmed for men and women as well as for French and Belgian workers by means of measurement invariance analyses. Criterion validity was verified regarding the relationships between the scores on the IFEP dimensions and those obtained with the MBI-GS, the measure of the intent to quit, the subjective health scale and the number of days of sick.ConclusionThe overall results of the analyses performed in this study show satisfactory psychometric qualities of the French Burnout Inventory (IFEP), a new measure of burnout that can be used in many French-speakers work contexts.     

Child Access and Visitation Following Divorce: A Growth Area for Marriage and Family Therapy

Recent federal legislation encourages states to increase noncustodial parents' access and visitation with their children following separation or divorce. The State of Iowa Department of Human Services Bureau of Collections commissioned a pilot study to provide a beginning picture of how parents and professionals experience the child access and visitation process. Two midsized urban centers and a rural community were studied. A total of 14 divorced parents and 16 professionals who work with divorced individuals were interviewed using a 2-hour focus group format. Study findings identified problematic themes regarding child access and visitation, potential solutions, and suggested services to address these problems. The services suggested by the study all fall within the professional expertise of marriage and family therapists. A primary finding of the study was the need for therapy and mediation focused on relational issues.     

Collaboration of Churches and Service Providers: Meeting the Needs of Older African Americans

ABSTRACT

This article describes a community outreach volunteer project designed to reach frail community-based older adults. The project is an example of church and secular agency collaboration in which the church provides leadership in volunteer recruitment and the agency provides training and outreach activity monitoring. The church's role in this project illustrates that small and medium-size African American churches can play an important role in mobilizing volunteer resources and can perform a linking role in helping secular agencies to gain access to frail, hard-to-reach, low-income older adults.     

Conversion Symptoms and Psychoanalysis in a Second Language

Abstract

Conversion symptoms involve a regression, where the patient appears to have lost access to previously available modes of verbal expression. Instead movements, sensations, postures, gestures, and visceral processes express emotions and unconscious wishes directly. Patients who are analyzed in a language other than their mother tongue, without access to the language of their early years, may rely on the body to express powerful affect and fantasies. A patient who displayed pseudoseizures on the couch is presented, looking specifically at how this man's conversion reaction may relate to the fact that the language of the analysis is not his mother tongue.     

Profiles of dyadic adjustment for advanced prostate cancer to inform couple-based intervention

Objective: The purpose of the study is to describe from a relational perspective, partners’ psychological adjustment, coping and support needs for advanced prostate cancer.

Design: A mixed methods design was adopted, employing triangulation of qualitative and quantitative data, to produce dyadic profiles of adjustment for six couples recruited from the urology clinics of local hospitals in Tasmania, Australia.

Methods: Dyads completed a video-taped communication task, semi-structured interview and standardised self-report questionnaires.

Results: Themes identified were associated with the dyadic challenges of the disease experience (e.g. relationship intimacy, disease progression and carer burden). Couples with poor psychological adjustment profiles had both clinical and global locus of distress, treatment side-effects, carer burden and poor general health. Resilient couples demonstrated relationship closeness and adaptive cognitive and behavioural coping strategies. The themes informed the adaption of an effective program for couples coping with women’s cancers (CanCOPE, to create a program for couples facing advanced prostate cancer (ProCOPE-Adv).

Conclusion: Mixed method results inform the development of psychological therapy components for couples coping with advanced prostate cancer. The concomitance of co-morbid health problems may have implications for access and engagement for older adult populations in face-to-face intervention.     

Motherloss: An Adult Daughter's Depth Perspective

Abstract

This writing brings consciousness to the experience of Motherloss from an adult daughter's perspective. Death is an issue of soul. It is not a problem to be understood and resolved but, rather, a mystery to be experienced. To face death and have a soulful relationship to the experience of Motherloss, one must have access to a feminine consciousness, a dimension of reality deeply forgotten and lost in modern Western culture.