Shared care and gender identity support in Primary Care: The perspectives and experiences of parents/carers of young trans people.

This article addresses the complex issues surrounding trans youths' shared care perceived by parents in primary care settings in the UK. The analyses in this article draws on qualitative data derived from an online survey of 153 parents with trans children. Through the conceptual framework of healthcare assemblages, findings suggest that quality shared care for trans youth is based upon transient service relationships inherent in their healthcare-primary care, gender identity services, endocrinologists, and Adolescent Mental Health Services (CAHMS)-and, as such, this complexity must be understood better by GPs in order for quality shared care to be administered. We explored various blockages to quality shared care within primary care surgeries that produced limit situations, such as lack of knowledge, training, or experience with trans healthcare. One other key factor was that there were strong external forces that were limiting trans youths' quality shared care in the form of abject depictions from beyond the consultation, which all produced negative effects. Despite these blockages, we also demonstrate how and where quality shared care is received. For instance, we show that continuity of care or treatment after an initial diagnosis or assessment contributes to quality shared care as too does personalized care to those youths receiving it. Overall, this research provides insights into the complex perceptions of parents about what quality shared care is and ought to be for trans youth.

A Balancing Act: Agency and Constraints in University Students' Understanding of and Responses to Sexual Violence in the Night-Time Economy.

This article extends our understanding of how university students make sense of, and respond to, sexual violence in the night-time economy (NTE). Based on semi-structured interviews with 26 students in a city in England, we examine students' constructions of their experiences of sexual violence within the NTE, exploring their negotiations with, and resistance to, this violence. Building upon theories of postfeminism, we interrogate the possibilities for resistance within the gendered spaces of the NTE and propose a disaggregated conceptualization of agency to understand responses to sexual violence, thereby offering useful insights for challenging sexual violence in the NTE and in universities.

What Is Gender Dysphoria? A Critical Systematic Narrative Review.

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association has changed the diagnosis of gender identity disorder to gender dysphoria (GD). In this critical narrative review we ask: What is gender dysphoria? We report on some of the inconsistencies in the articles that foreground distress while obfuscating the fact that not all trans and intersex people suffer stress or impaired functioning, and the inappropriate referencing to intersex people in the diagnostic criterion, claims about the GD diagnosis contributing to the depathologization of and reducing stigma surrounding trans people, the conceptualizations of "gender dysphoric" research subjects, and finally we question the etiological approaches using GD as a conceptual framework. We further suggest that there are a number of methodological issues that need to be resolved to be able to claim that the GD diagnosis can be validated. To shed light on these paradoxes and methodological issues in the DSM-5, we report on the content validity of GD by reviewing research articles postdiagnostic inception. These findings will contribute to the debate about the validity of GD as a diagnosis for the 21st century for those people who need to live a different gender to that assigned at birth.

The DSM-5 and the Politics of Diagnosing Transpeople.

In the DSM-5, there has been a change in the diagnosis for transpeople of all ages from Gender Identity Disorder (GID) to Gender Dysphoria (GD), in part to better indicate the distress that transpeople may experience when their gender identity feels incongruent. The Workgroup for Sexual and Gender Identity Disorders, chaired by Kenneth J. Zucker, was employed by the American Psychiatric Association (APA) to update the DSM-5's GID diagnosis reflecting contemporary scientific knowledge. Additionally, in a pre-publication report to the APA, members of the Workgroup suggested that they would also be concerned with the destigmatization of transpeople while preserving a diagnosis that medical insurance companies would accept for issuing payments for transitioning treatments (Drescher, 2013). The aims of this article are, firstly, to question whether changing the diagnosis lessens the stigmatization of transpeople. I will suggest that the semantic change from GID to GD marks "inverted" gendered expressions as pathological and, thus, continues to stigmatize transpeople. Secondly, the article explores the development of the GD diagnosis, and illustrates how the scientific data this were founded on are contentious. The article then demonstrates how the trans anti-pathologization movement has challenged the perceived pathologizing effects of the DSM-5 classification of GD. The article examines a selection of Western transgender community advocates' websites, forums, and blogs. From these sources, the article then explores the different narratives of transpeople and political groups who offer details of their praxis, and evidences how the trans anti-pathologization advocates use the available science and human rights discourses to contest the role of psychiatry in the treatment of transpeople.

Patients' and clinicians' experiences and perceptions of the primary care management of insomnia: qualitative study.

BACKGROUND: Insomnia is common leading to patients with sleep problems often presenting to primary care services including general practice, community pharmacies and community mental health teams. Little is known about how health professionals in primary care respond to patients with insomnia. AIM: We aimed to explore health professionals' and patients' experiences and perceptions of the management of insomnia in primary care. DESIGN: We used a qualitative design and thematic approach. SETTING: Primary care in Nottinghamshire and Lincolnshire. METHOD: We undertook focus groups and one-to-one interviews with a purposive sample of health professionals and adults with insomnia. RESULTS: We interviewed 28 patients and 23 health professionals. Practitioners focused on treating the cause of insomnia rather than the insomnia itself. They described providing stepped care for insomnia, but this focused on sleep hygiene which patients often disregarded, rather than cognitive behavioural therapy for insomnia (CBT-I). Practitioners were ambivalent towards hypnotic drugs but often colluded with patients to prescribe to avoid confrontation or express empathy. Patients sometimes took hypnotics in ways that were not intended, for example together with over-the-counter medication. Practitioners and patients were sometimes but not always concerned about addiction. Practitioners sometimes prescribed despite these concerns but at other times withdrew hypnotics abruptly without treating insomnia. Both patients and practitioners wanted more options and better training for the management of insomnia in primary care. CONCLUSION: A better understanding of the current approaches and difficulties in the management of insomnia will help to inform more therapeutic options and health professional training.

The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England.

BACKGROUND: Previous studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke. We aimed to evaluate the effectiveness of implementing a Quality Improvement Collaborative (QIC) for improving ambulance care for AMI and stroke. METHODS: We used an interrupted time series design to investigate the effect of a national QIC on change in delivery of care bundles for AMI (aspirin, glyceryl trinitrate [GTN], pain assessment and analgesia) and stroke (face-arm-speech test, blood pressure and blood glucose recording) in all English ambulance services between January 2010 and February 2012. Key strategies for change included local quality improvement (QI) teams in each ambulance service supported by a national coordinating expert group that conducted workshops educating staff in QI methods to improve AMI and stroke care. Expertise and ideas were shared between QI teams who met together at three national workshops, between QI leads through monthly teleconferences, and between the expert group and participants. Feedback was provided to services using annotated control charts. RESULTS: We analyzed change over time using logistic regression with three predictor variables: time, gender, and age. There were statistically significant improvements in care bundles in nine (of 12) participating trusts for AMI (OR 1.04, 95% CI 1.04, 1.04), nine for stroke (OR 1.06, 95% CI 1.05, 1.07), 11 for either AMI or stroke, and seven for both conditions. Overall care bundle performance for AMI increased in England from 43 to 79% and for stroke from 83 to 96%. Successful services all introduced provider prompts and individualized or team feedback. Other determinants of success included engagement with front-line clinicians, feedback using annotated control charts, expert support, and shared learning between participants and organizations. CONCLUSIONS: This first national prehospital QIC led to significant improvements in ambulance care for AMI and stroke in England. The use of care bundles as measures, clinical engagement, application of quality improvement methods, provider prompts, individualized feedback and opportunities for learning and interaction within and across organizations helped the collaborative to achieve its aims.

Patients' and ambulance service clinicians' experiences of prehospital care for acute myocardial infarction and stroke: a qualitative study.

BACKGROUND: Patients with suspected acute myocardial infarction (AMI) and stroke commonly present first to the ambulance service. Little is known about experiences of prehospital care which are important for measuring the quality of services for patients with AMI or stroke. AIM: We explored experiences of patients, who had accessed the ambulance service for AMI or stroke, and clinicians regularly treating patients for these conditions in the prehospital setting. METHOD: A qualitative research design was employed to obtain rich and detailed data to explore and compare participants' experiences of emergency prehospital care for AMI and stroke. RESULTS: We conducted 33 semistructured interviews with service users and clinicians and one focus group with five clinicians. Four main themes emerged: communication, professionalism, treatment of condition and the transition from home to hospital. Patients focused on both personal and technical skills. Technical knowledge and relational skills together contributed to a perception of professionalism in ambulance personnel. Patients' experience was enhanced when physical, emotional and social needs were attended to and they emphasised effective communication within the clinician-patient relationship to be the key. However, we found a discrepancy between paramedics' perceptions of patients' expectations and patients' lack of knowledge of the paramedic role. CONCLUSIONS: Factors that contribute to better patient experience are not necessarily understood in the same way by patients and clinicians. Our findings can contribute to the development of patient experience measures for prehospital care.

Integrating online communities and social networks with computerised treatment for insomnia: a qualitative study.

BACKGROUND: Insomnia is a common psychological complaint. Cognitive behavioural therapy for insomnia (CBT-I), although effective, is little used because of lack of trained providers. Computerised CBT-I (CCBT-I) may be a solution to this shortfall in access. AIM: To explore patient and health professional perspectives and the role of social networking, to develop a novel CCBT-I programme to increase access to this form of intervention. DESIGN AND SETTING: Qualitative methods underpinned by the theory of planned behaviour in primary care in Lincolnshire and Nottinghamshire. METHOD: Semi-structured interviews and focus groups with a purposive sample of health professionals and adults with insomnia. RESULTS: A total of 23 health professionals and 28 patients were interviewed. Features designed to engender trust and improve functionality were perceived to improve uptake and adherence to CCBT-I. Trust lay in programme accreditation; for professionals, trust derived from evidence of effectiveness; for patients, trust depended on the doctor-patient relationship, professional support, the quality of online peer support, and perceptions of risk. Patients wanted mobile applications; access in short periods; self-assessment; interactive, personalised information on sleep; and moderated contact with other users. Patients and practitioners differed over whether useful information could be distinguished from less useful or potentially incorrect information. CONCLUSION: Improving uptake and adherence to online programmes for insomnia requires design features focusing on trust and functionality. Enabling greater patient control and interaction with other users and professionals may stimulate positive experiences of online therapy. CCBT-I would enable greater access to treatment but is limited by lack of online access or poor computer literacy.