Psychosocial support interventions for children and adolescents experiencing gender dysphoria or incongruence: a systematic review.

BACKGROUND: National and international guidelines recommend that psychosocial support should be a key component of the care offered to children and adolescents experiencing gender dysphoria/incongruence. However, specific approaches or interventions are not recommended. AIM: To identify and summarise evidence on the outcomes of psychosocial support interventions for children and adolescents (age 0-18) experiencing gender dysphoria/incongruence. METHODS: Systematic review and narrative synthesis. Database searches (MEDLINE; EMBASE; CINAHL; PsycINFO; Web of Science) were performed in April 2022, with results assessed independently by two reviewers. Peer-reviewed articles reporting the results of studies measuring outcomes of psychosocial support interventions were included. Quality was assessed using the Mixed Methods Appraisal Tool. RESULTS: Ten studies were included. Half were conducted in the US, with others from Australia, Canada, New Zealand and the UK. Six were pre-post analyses or cohort studies, three were mixed methods, and one was a secondary analysis of intervention data from four trials. Most studies were of low quality. Most analyses of mental health and psychosocial outcomes showed either benefit or no change, with none indicating negative or adverse effects. CONCLUSIONS: The small number of low-quality studies limits conclusions about the effectiveness of psychosocial interventions for children/adolescents experiencing gender dysphoria/incongruence. Clarity on the intervention approach as well as the core outcomes would support the future aggregation of evidence. More robust methodology and reporting is required. PROSPERO REGISTRATION NUMBER: CRD42021289659.

Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: a systematic review.

BACKGROUND: Treatment to suppress or lessen effects of puberty are outlined in clinical guidelines for adolescents experiencing gender dysphoria/incongruence. Robust evidence concerning risks and benefits is lacking and there is a need to aggregate evidence as new studies are published. AIM: To identify and synthesise studies assessing the outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence. METHODS: A systematic review and narrative synthesis. Database searches (Medline, Embase, CINAHL, PsycINFO, Web of Science) were performed in April 2022, with results assessed independently by two reviewers. An adapted version of the Newcastle-Ottawa Scale for cohort studies was used to appraise study quality. Only moderate-quality and high-quality studies were synthesised. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were used. RESULTS: 11 cohort, 8 cross-sectional and 31 pre-post studies were included (n=50). One cross-sectional study was high quality, 25 studies were moderate quality (including 5 cohort studies) and 24 were low quality. Synthesis of moderate-quality and high-quality studies showed consistent evidence demonstrating efficacy for suppressing puberty. Height increased in multiple studies, although not in line with expected growth. Multiple studies reported reductions in bone density during treatment. Limited and/or inconsistent evidence was found in relation to gender dysphoria, psychological and psychosocial health, body satisfaction, cardiometabolic risk, cognitive development and fertility. CONCLUSIONS: There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment. More recent studies published since April 2022 until January 2024 also support the conclusions of this review. PROSPERO REGISTRATION NUMBER: CRD42021289659.

Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of guideline quality (part 1).

BACKGROUND: Increasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. There are various guidelines outlining approaches to the clinical care of these children and adolescents. AIM: To examine the quality and development of published guidelines or clinical guidance containing recommendations for managing gender dysphoria/incongruence in children and/or adolescents (age 0-18). A separate paper reports the synthesis of guideline recommendations. METHODS: A systematic review and narrative synthesis. Databases (Medline, Embase, CINAHL, PsycINFO, Web of Science) were searched to April 2022 and web-based searches and contact with international experts continued to December 2022, with results assessed independently by two reviewers. The Appraisal of Guidelines for Research and Evaluation tool was used to examine guideline quality. RESULTS: Twenty-three guidelines/clinical guidance publications (1998-2022) were identified (4 international, 3 regional and 16 national). The quality and methods reporting in these varied considerably. Few guidelines systematically reviewed empirical evidence, and links between evidence and recommendations were often unclear. Although most consulted with relevant stakeholders, including 10 which involved service users or user representatives, it was often unclear how this influenced recommendations and only two reported including children/adolescents and/or parents. Guidelines also lacked clarity about implementation. Two international guidelines (World Professional Association for Transgender Health and Endocrine Society) formed the basis for most other guidance, influencing their development and recommendations. CONCLUSIONS: Most clinical guidance for managing children/adolescents experiencing gender dysphoria/incongruence lacks an independent and evidence-based approach and information about how recommendations were developed. This should be considered when using these to inform service development and clinical practice. PROSPERO REGISTRATION NUMBER: CRD42021289659.

Gender services for children and adolescents across the EU-15+ countries: an online survey.

BACKGROUND: Over the last 10-15 years, there has been an increase in the number of children and adolescents referred to gender services, particularly among adolescent birth-registered females. This population shows a higher prevalence of co-occurring mental health difficulties and neurodevelopmental conditions. Some countries have recently restricted access to medical treatments in recognition of the uncertain evidence base. AIM: To understand the current provision of gender services for children and adolescents across the EU-15+ countries that have comparable high-income healthcare systems, to inform service development in the UK. METHODS: An e-survey of paediatric gender services was conducted between September 2022 and April 2023. It covered service structure, care pathways, interventions and data collection. Data were described and compared to identify similarities and differences among participating services. RESULTS: 15 services in eight countries (Australia, Belgium, Denmark, Norway, Northern Ireland, The Netherlands, Spain and Finland) responded. While a multidisciplinary team was present in all services, its composition and organisation varied. Clinical practice was informed by international guidelines, with four countries following their own national guidelines. Differences were observed in referral criteria, care pathways for prepubertal children and those with co-occurring conditions. Eligibility criteria for medical interventions also varied. Psychosocial support and interventions were limited, and outcome data collection was scarce. CONCLUSIONS: This survey revealed both similarities and key variations in the clinical practice of paediatric gender services across eight different countries. The study emphasises the need for service development that both considers the management of co-occurring conditions and embeds routine data collection in practice.

Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of recommendations (part 2).

BACKGROUND: Increasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services and there are various published guidelines outlining approaches to clinical care. AIM: To examine the recommendations about the management of children and/or adolescents (age 0-18) experiencing gender dysphoria/incongruence in published guidelines or clinical guidance. A separate paper examines the quality and development of guidelines. METHODS: A systematic review and narrative synthesis. Databases (Medline, Embase, CINAHL, PsycINFO, Web of Science) were searched to April 2022 and web-based searches and contact with international experts continued to December 2022, with results assessed independently by two reviewers. The Appraisal of Guidelines for Research and Evaluation tool was used to examine guideline quality. RESULTS: 23 guidelines/clinical guidance publications (1998-2022) were identified (4 international, 3 regional, 16 national). Guidelines describe a similar care pathway starting with psychosocial care for prepubertal children, puberty suppressants followed by hormones for eligible adolescents and surgical interventions as these adolescents enter adulthood. In general, there is consensus that adolescents should receive a multidisciplinary assessment, although clear guidance about the purpose or approach is lacking. There are differing recommendations about when and on what basis psychological and medical interventions should be offered. There is limited guidance about what psychological care should be provided, about the management of prepubertal children or those with a non-binary gender identity, nor about pathways between specialist gender services and other providers. CONCLUSIONS: Published guidance describes a similar care pathway; however, there is no current consensus about the purpose and process of assessment for children or adolescents with gender dysphoria/incongruence, or about when psychological or hormonal interventions should be offered and on what basis. PROSPERO REGISTRATION NUMBER: CRD42021289659.

Impact of social transition in relation to gender for children and adolescents: a systematic review.

BACKGROUND: Increasing numbers of children and adolescents experiencing gender dysphoria or incongruence are being referred to specialist gender services. Historically, social transitioning prior to assessment was rare but it is becoming more common. AIM: To identify and synthesise studies assessing the outcomes of social transition for children and adolescents (under 18) experiencing gender dysphoria/incongruence. METHODS: A systematic review and narrative sythesis. Database searches (Medline, Embase, CINAHL, PsycINFO, Web of Science) were perfomed in April 2022. Studies reporting any outcome of social transition (full or partial) for children and adolescents experiencing gender dysphoria/incongruence were included. An adapted version of the Newcastle-Ottawa Scale for cohort studies was used to appraise study quality. RESULTS: Eleven studies were included (children (n=8) and adolescents (n=3)) and most were of low quality. The majority were from the US, featured community samples and cross-sectional analyses. Different comparator groups were used, and outcomes related to mental health and gender identity reported. Overall studies consistently reported no difference in mental health outcomes for children who socially transitioned across all comparators. Studies found mixed evidence for adolescents who socially transitioned. CONCLUSIONS: It is difficult to assess the impact of social transition on children/adolescents due to the small volume and low quality of research in this area. Importantly, there are no prospective longitudinal studies with appropriate comparator groups assessing the impact of social transition on mental health or gender-related outcomes for children/adolescents. Professionals working in the area of gender identity and those seeking support should be aware of the absence of robust evidence of the benefits or harms of social transition for children and adolescents. PROSPERO REGISTRATION NUMBER: CRD42021289659.

General practitioner well-being during the COVID-19 pandemic: a qualitative interview study.

OBJECTIVES: The COVID-19 pandemic presented new challenges for general practitioners' (GPs') mental health and well-being, with growing international evidence of its negative impact. While there has been a wide UK commentary on this topic, research evidence from a UK setting is lacking. This study sought to explore the lived experience of UK GPs during COVID-19, and the pandemic's impact on their psychological well-being. DESIGN AND SETTING: In-depth qualitative interviews, conducted remotely by telephone or video call, with UK National Health Service GPs. PARTICIPANTS: GPs were sampled purposively across three career stages (early career, established and late career or retired GPs) with variation in other key demographics. A comprehensive recruitment strategy used multiple channels. Data were analysed thematically using Framework Analysis. RESULTS: We interviewed 40 GPs; most described generally negative sentiment and many displayed signs of psychological distress and burnout. Causes of stress and anxiety related to personal risk, workload, practice changes, public perceptions and leadership, team working and wider collaboration and personal challenges. GPs described potential facilitators of their well-being, including sources of support and plans to reduce clinical hours or change career path, and some described the pandemic as offering a catalyst for positive change. CONCLUSIONS: A range of factors detrimentally affected the well-being of GPs during the pandemic and we highlight the potential impact of this on workforce retention and quality of care. As the pandemic progresses and general practice faces continued challenges, urgent policy measures are now needed.

General practitioners' wellbeing during the COVID-19 pandemic: Novel methods with social media data.

BACKGROUND: It is difficult to engage busy healthcare professionals in research. Yet during the COVID-19 pandemic, gaining their perspectives has never been more important. OBJECTIVE: To explore social media data for insights into the wellbeing of UK General Practitioners (GPs) during the Covid-19 pandemic. METHODS: We used a combination of search approaches to identify 381 practising UK NHS GPs on Twitter. Using a two stage social media analysis, we firstly searched for key themes from 91,034 retrieved tweets (before and during the pandemic). Following this we used qualitative content analysis to provide in-depth insights from 7145 tweets related to wellbeing. RESULTS: Social media proved a useful tool to identify a cohort of UK GPs; following their tweets longitudinally to explore key themes and trends in issues related to GP wellbeing during the pandemic. These predominately related to support, resources and public perceptions and fluctuations were identified at key timepoints during the pandemic, all achieved without burdening busy GPs. CONCLUSION: Social media data can be searched to identify a cohort of GPs to explore their wellbeing and changes over time.

GP wellbeing during the COVID-19 pandemic: a systematic review.

BACKGROUND: Doctors' organisations in the UK have reported worrying levels of work-related stress and burnout in the GP workforce for some time, and the COVID-19 pandemic has presented clear new challenges. AIM: To synthesise international evidence exploring the impact of COVID-19 on primary care doctors' mental health and wellbeing, and identify risk factors associated with their psychological wellbeing during this time. DESIGN AND SETTING: Mixed-methods systematic review. METHOD: Six bibliographic databases, Google Scholar, and MedRxiv were searched on 19 November 2020 and 3 June 2021 to identify studies of GP psychological wellbeing during the pandemic. Reference checking was also conducted. Two reviewers selected studies, extracted data, and assessed the quality of studies using standardised tools. Heterogeneity in outcomes, setting, and design prohibited statistical pooling; studies were combined using a convergent integrated thematic synthesis. RESULTS: Thirty-one studies were included. Multiple sources of stress were identified including changed working practices; risk, exposure, and inadequate personal protective equipment (PPE); information overload; pandemic preparedness; and cohesion across sectors. Studies demonstrated an impact on psychological wellbeing, with some GPs experiencing stress, burnout, anxiety, depression, fear of COVID-19, lower job satisfaction, and physical symptoms. Studies reported gender and age differences: women GPs had poorer psychological outcomes across all domains, and older GPs reported greater stress and burnout. Use of outcome measures and reporting practice varied greatly. CONCLUSION: This review of international evidence demonstrates that the COVID-19 pandemic has adversely affected GPs' wellbeing around the world. Further research could explore gender and age differences, identifying interventions targeted to these groups.

Professional experience guides opioid prescribing for chronic joint pain in primary care.

BACKGROUND: Chronic joint pain is common and is a leading cause of disability. Most chronic joint pain is managed in primary care. Opioid pain medication is one option for pain management, but research suggests that its use by general practitioners (GPs) may be suboptimal. There is a widespread perception that doctors' concerns about misuse and addiction limit use of opioids. OBJECTIVES: To explore GPs' opinions about opioids and decision-making processes when prescribing 'strong' opioids for chronic joint pain. METHODS: Qualitative semi-structured interviews were conducted with 27 GPs. Using thematic analysis methods, the data were coded and grouped into themes. RESULTS: GPs described a variety of prescribing habits for chronic joint pain. Opioids engendered strong opinions. GPs said that decisions about prescribing were based on careful assessment of patients' needs and their personal views about the management of adverse effects. Although addiction and misuse were discussed, there was limited concern about these issues. The overarching influence on prescribing decisions was GPs' previous experience, including previous outcomes and exposure to palliative care settings. CONCLUSIONS: GPs' prescribing decisions are primarily influenced by previous professional experience of opioids. Much existing literature stresses that opioids are not prescribed due to concerns about addiction or misuse, but our study indicates otherwise. Augmenting GPs' exposure to and experience of opioids may be key to providing better pain management for patients.