Preventing transition "regret": An institutional ethnography of gender-affirming medical care assessment practices in Canada.

When a person openly "regrets" their gender transition or "detransitions" this bolsters within the medical community an impression that transgender and non-binary (trans) people require close scrutiny when seeking hormonal and surgical interventions. Despite the low prevalence of "regretful" patient experiences, and scant empirical research on "detransition", these rare transition outcomes profoundly organize the gender-affirming medical care enterprise. Informed by the tenets of institutional ethnography, we examined routine gender-affirming care clinical assessment practices in Canada. Between 2017 and 2018, we interviewed 11 clinicians, 2 administrators, and 9 trans patients (total n = 22), and reviewed 14 healthcare documents pertinent to gender-affirming care in Canada. Through our analysis, we uncovered pervasive regret prevention techniques, including requirements that trans patients undergo extensive psychosocial evaluations prior to transitioning. Clinicians leveraged psychiatric diagnoses as a proxy to predict transition regret, and in some cases delayed or denied medical treatments. We identified cases of patient dissatisfaction with surgical results, and a person who detransitioned. These accounts decouple transition regret and detransition, and no participants endorsed stricter clinical assessments. We traced the clinical work of preventing regret to cisnormativity and transnormativity in medicine which together construct regret as "life-ending", and in turn drives clinicians to apply strategies to mitigate the perceived risk of malpractice legal action when treating trans people, specifically. Yet, attempts to prevent these outcomes contrast with the material healthcare needs of trans people. We conclude that regret and detransitioning are unpredictable and unavoidable clinical phenomena, rarely appearing in "life-ending" forms. Critical research into the experiences of people who detransition is necessary to bolster comprehensive gender-affirming care that recognizes dynamic transition trajectories, and which can address clinicians' fears of legal action-cisgender anxieties projected onto trans patients who are seeking medical care.

Trans people's experiences with assisted reproduction services: a qualitative study.

STUDY QUESTION: What are the experiences of trans persons (i.e. those whose gender identity does not match the gender assigned to them at birth) who sought or accessed assisted reproduction (AR) services in Ontario, Canada, between 2007 and 2010? SUMMARY ANSWER: The majority of trans persons report negative experiences with AR service providers. WHAT IS KNOWN ALREADY: Apart from research examining desire to have children among trans people, most of the literature on this topic has debated the ethics of assisting trans persons to become parents. To-date, all of the published research concerning trans persons' experiences with AR services is solely from the perspective of service providers; no studies have examined the experiences of trans people themselves. STUDY DESIGN, SIZE, DURATION: Secondary qualitative research study of data from nine trans-identified people and their partners (total n = 11) collected as part of a community-based study of access to AR services for sexual and gender minority people between 2010 and 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: Trans-identified volunteers (and their partners, when applicable) who had used or attempted to access AR services since 2007 from across Ontario, Canada, participated in a 60-90 minute, semi-structured qualitative interview. Qualitative analysis was performed using a descriptive phenomenological approach. Emerging themes were continually checked against the data as part of an iterative process. MAIN RESULTS AND THE ROLE OF CHANCE: The data highlight barriers to accessing AR services for trans people. Participant recommendations for improving AR service provision to better meet the needs of this population are presented. These recommendations address the following areas: (i) AR service provider education and training; (ii) service provider and clinic practices and (iii) clinic environment. LIMITATIONS, REASONS FOR CAUTION: The majority of study participants were trans people who identified as men and who resided in major urban areas; those living in smaller communities may have different experiences that were not adequately captured in this analysis. WIDER IMPLICATIONS OF THE FINDINGS: While existing literature debates the ethics of assisting trans people to become parents through the use of AR, our study demonstrates that they are already accessing or attempting to access these services. This reality necessitates a shift toward exploring the ways in which AR services can be improved to better meet the needs of this population, from the perspectives of both service users and service providers. STUDY FUNDING/COMPETING INTERESTS: This project was supported by the Canadian Institutes of Health Research-Institute of Gender and Health, in partnership with the Assisted Human Reproduction Canada: Catalyst Grant: Psychosocial Issues Associated with Assisted Human Reproduction (FRN-103595). S.M. was supported by a Canada Graduate Scholarship from the Social Science and Humanities Research Council, as well as research funding from Osgoode Hall Law School, York University. S.J.-A. was supported by an Ontario Graduate Scholarship funded by the Province of Ontario and the University of Toronto. TRIAL REGISTRATION NUMBER: N/A.

Quality assessment of observational studies in psychiatry: an example from perinatal psychiatric research.

In perinatal psychiatry, randomized controlled trials are often not feasible on ethical grounds. Many studies are observational in nature, while others employ large databases not designed primarily for research purposes. Quality assessment of the resulting research is complicated by a lack of standardized tools specifically for this purpose. The aim of this paper is to describe the Systematic Assessment of Quality in Observational Research (SAQOR), a quality assessment tool our team devised for a series of systematic reviews and meta-analyses of evidence-based literature regarding risks and benefits of antidepressant medication during pregnancy.

Bisexual people's experiences with mental health services: a qualitative investigation.

Bisexual people experience minority stress and social isolation as a result of their marginalized sexual identities, and likely due to this stigmatization, previous research has identified high rates of psychological distress, anxiety, depression, suicidality, alcohol misuse, and self-harming behaviour among bisexual populations. It is therefore important that mental health service providers are able to provide culturally competent care to bisexual people. This study used focus groups and interviews with 55 bisexual participants across the province of Ontario, Canada, to investigate their experiences with mental health care. Results suggest that bisexual people have both positive and negative experiences with mental health service providers. Specific provider practices which contribute to the perception of positive and negative experiences with mental heath services are described, and the implications for clinical practice discussed.

Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: a systematic review.

BACKGROUND: Although much is known about the risk factors for postpartum depression (PPD), the role of giving birth to a preterm or low-birth-weight infant has not been reviewed systematically. OBJECTIVE: To review systematically the prevalence and risk factors for PPD among women with preterm infants. SEARCH STRATEGY: Medline, CINAHL, EMBASE, PsycINFO and the Cochrane Library were searched from their start dates to August 2008 using keywords relevant to depression and prematurity. SELECTION CRITERIA: Peer-reviewed articles were eligible for inclusion if a standardised assessment of depression was administered between delivery and 52 weeks postpartum to mothers of preterm infants. DATA COLLECTION AND ANALYSIS: Data on either the prevalence of PPD or mean depression score in the target population and available comparison groups were extracted from the 26 articles included in the review. Risk factors for PPD were also extracted where reported. MAIN RESULTS: The rates of PPD were as high as 40% in the early postpartum period among women with premature infants. Sustained depression was associated with earlier gestational age, lower birth weight, ongoing infant illness/disability and perceived lack of social support. The main limitation was that most studies failed to consider depression in pregnancy as a confounding variable. AUTHOR'S CONCLUSIONS: Mothers of preterm infants are at higher risk of depression than mothers of term infants in the immediate postpartum period, with continued risk throughout the first postpartum year for mothers of very-low-birth-weight infants. Targeted clinical interventions to identify and prevent PPD in this vulnerable obstetric population are warranted.

Psychosocial and psychological interventions for treating antenatal depression.

BACKGROUND: Although pregnancy was once thought of as a time of emotional wellbeing for many women, conferring 'protection' against psychiatric disorders, a recent meta-analysis of 21 studies suggests the mean prevalence rate for depression across the antenatal period is 10.7%, ranging from 7.4% in the first trimester to a high of 12.8% in the second trimester. Due to maternal treatment preferences and potential concerns about fetal and infant health outcomes, non-pharmacological treatment options are needed. OBJECTIVES: The primary objective of this review is to assess the effects, on mothers and their families, of psychosocial and psychological interventions compared with usual antepartum care in the treatment of antenatal depression. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2006), the Cochrane Collaboration Depression Anxiety and Neurosis Group's Trials Registers (CCDANCTR-Studies and CCDANCTR-References) (July 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to July 2006), EMBASE (1980 to July 2006) and CINAHL (1982 to July 2006). We also scanned secondary references and contacted experts in the field to identify other published or unpublished trials. SELECTION CRITERIA: All published, unpublished and ongoing randomised controlled trials of preventive psychosocial or psychological interventions in which the primary or secondary aim is to treat antenatal depression. We excluded quasi-randomised trials (for example, those randomised by delivery date, or odd versus even medical record numbers) from the analysis. DATA COLLECTION AND ANALYSIS: All review authors participated in the evaluation of methodological quality and data extraction. Results are presented using relative risk for categorical data and weighted mean difference for continuous data. MAIN RESULTS: One US trial was included in this review, incorporating 38 outpatient antenatal women who met Diagnostic and Statistical Manual for Mental Disorders-IV criteria for major depression. Interpersonal psychotherapy, compared to a parenting education program, was associated with a reduction in the risk of depressive symptomatology immediately post-treatment using the Clinical Global Impression Scale (one trial, n = 38; relative risk (RR) 0.46, 95% confidence interval (CI) 0.26 to 0.83) and the Hamilton Rating Scale for Depression (one trial, n = 38; RR 0.82, 95% CI 0.65 to 1.03). AUTHORS' CONCLUSIONS: The evidence is inconclusive to allow us to make any recommendations for interpersonal psychotherapy for the treatment of antenatal depression. The one trial included was too small, with a non-generalisable sample, to make any recommendations.

Perinatal depressive symptomatology among lesbian and bisexual women.

Lesbian and bisexual women who were pregnant (N=16), biological (N=18) or non-biological (N=15) parents completed the Edinburgh Postnatal Depression Scale (EPDS), and scores were compared to a previously published heterosexual sample. Lesbian and bisexual biological mothers had significantly higher EPDS scores than the previously published sample of heterosexual women. Results suggest that perinatal depression is not less common and may be more common among lesbian and bisexual women relative to heterosexual women. Additional, longitudinal studies are needed.

Legal abortion for mental health indications.

Where legal systems allow therapeutic abortion to preserve women's mental health, practitioners often lack access to mental health professionals for making critical diagnoses or prognoses that pregnancy or childcare endangers patients' mental health. Practitioners themselves must then make clinical assessments of the impact on their patients of continued pregnancy or childcare. The law requires only that practitioners make assessments in good faith, and by credible criteria. Mental disorder includes psychological distress or mental suffering due to unwanted pregnancy and responsibility for childcare, or, for instance, anticipated serious fetal impairment. Account should be taken of factors that make patients vulnerable to distress, such as personal or family mental health history, factors that may precipitate mental distress, such as loss of personal relationships, and factors that may maintain distress, such as poor education and marginal social status. Some characteristics of patients may operate as both precipitating and maintaining factors, such as poverty and lack of social support.

Mood changes during pregnancy and the postpartum period: development of a biopsychosocial model.

OBJECTIVE: Women are vulnerable to mood changes during pregnancy and the postpartum period. We set out to empirically test the hypothesis that biological and psychosocial variables interact to result in this vulnerability. METHOD: Using structural equation modeling techniques, we developed an integrative model of perinatal mood changes from clinical, psychosocial, hormone and mood data collected from 150 women in late pregnancy and at 6-weeks postpartum. RESULTS: In the prenatal model, biological variables had no direct effect on depressive symptoms. However, they did act indirectly through their significant effects on psychosocial stressors and symptoms of anxiety. The same model did not fit the postpartum data, suggesting that different causal variables may be implicated in postpartum mood. CONCLUSION: This model demonstrates the importance of considering both biological and psychosocial variables in complex health conditions such as perinatal mood disorders.

Measurement issues in postpartum depression part 2: assessment of somatic symptoms using the Hamilton Rating Scale for Depression.

Assessment of the somatic symptoms of depression in perinatal women has been debated due to potential overlap with normal physical complaints of pregnancy and childbirth. We investigated the properties of the 17-item Hamilton Rating Scale for Depression (HAMD), which includes somatic items, between 36 weeks gestation and 16 weeks postpartum in 150 women. Scores on the HAMD were highly correlated with scores on measures that avoid somatic items. Scores on somatic items were not well correlated with the total HAMD score in pregnancy, but the correlations increased at 6 weeks postpartum. In contrast, scores on HAMD item 1 ("Depression") were less well correlated with the total score at 6 weeks postpartum than prenatally, suggesting that postpartum women may be less likely to articulate their difficulties as "depression", and more likely to describe somatic complaints such as low energy or insomnia. Implications for the assessment of depression in this population are discussed.

Measurement issues in postpartum depression part 1: anxiety as a feature of postpartum depression.

We investigated the contribution of anxiety symptoms to scores on the Edinburgh Postnatal Depression Scale (EPDS) between 36 weeks gestation and 16 weeks postpartum in 150 women. The 3-item anxiety subscale of the EPDS accounted for 47% of the total score in late pregnancy, and 38% of the total score in the postpartum period. Two categories of anxiety were common in the perinatal period: subsyndromal, situational anxiety (in particular during the last weeks of pregnancy); and clinically significant comorbid anxiety, which was experienced by nearly 50% of clinically depressed pregnant and postpartum women. The close relationship between anxiety and depression raises questions about whether symptoms of anxiety might be more common in the perinatal period than in other depressions. A strong role for anxiety symptoms in postpartum depression, and implications for its etiology and treatment, are discussed.

Alcohol and workload as factors affecting the detection of angular acceleration.

INTRODUCTION: Previous findings have demonstrated that a low blood alcohol concentration (BAC) decreases subjects' ability to detect changes in angular motion and that this effect persists after the BAC returns to zero. METHODS: Angular motion thresholds of six alcohol and six placebo subjects holding pilots' certificates were obtained under both low and high task load conditions. The alcohol subjects were tested under double blind conditions in an enclosed simulator apparatus prior to drinking, after drinking (mean BAC = 0.038%), and at a time when the alcohol subjects' BACs had reached zero. RESULTS: Alcohol subjects' mean threshold values for the three threshold test sessions were 0.361, 0.512, and 0.465 degree.s-2 and 0.292, 0.422, and 0.379 degree.s-2 for the high and low task conditions, respectively. Corresponding values for placebo subjects were 0.364, 0.37, and 0.356 degree.s-2 for the high task load condition and 0.311, 0.317, and 0.312 degree.s-2 for the low task load condition. Statistical analyses showed significant task load and sessions effects (p < 0.025). Significant alcohol by test sessions interactions were found for both high and low task load conditions (p < 0.01) with subsequent t-tests showing no alcohol-placebo differences for the pre-alcohol test session, but significant alcohol-placebo differences for the alcohol test session and the test session conducted after the subjects' BACs returned to zero. CONCLUSIONS: The results indicate that the increased threshold for detecting changes in angular motion found after alcohol ingestion is relatively insensitive to task workload and, thus, it is unlikely that attentional changes underlie the threshold increase. These data together with the finding that an elevated threshold can persist after BAC reaches zero suggest that the threshold increase after alcohol ingestion reflects changes in vestibular functioning.

Design, synthesis, and biological activity of a potent inhibitor of the neuropeptidase N-acetylated alpha-linked acidic dipeptidase.

A series of substituted phosphonate derivatives were designed and synthesized in order to study the ability of these compounds to inhibit the neuropeptidase N-acetylated alpha-linked acidic dipeptidase (NAALADase). The molecules were shown to act as inhibitors of the enzyme, with the most potent (compound 3) having a Ki of 0.275 nM. The potency of this compound is more than 1000 times greater than that of previously reported inhibitors of the enzyme. NAALADase is responsible for the catabolism of the abundant neuropeptide N-acetyl-aspartylglutamate (NAAG) into N-acetylaspartate and glutamate. NAAG has been proposed to be a neurotransmitter at a subpopulation of glutamate receptors; alternatively, NAAG has been suggested to act as a storage form of synaptic glutamate. As a result, inhibition of NAALADase may show utility as a therapeutic intervention in diseases in which altered levels of glutamate are thought to be involved.

Effect of alcohol on the threshold for detecting angular acceleration.

We investigated the effects of a low blood alcohol level (mean BAC = 0.037%) on subjects' ability to detect acceleration and deceleration of angular motion. The angular motion thresholds of six alcohol and six placebo subjects, all of whom had private pilot certificates, were tested under double-blind conditions in an enclosed simulator apparatus prior to drinking, after drinking, and at a time when the BAC's of alcohol subjects had reached zero. Mean threshold values for the three threshold determination sessions were 0.282, 0.376, and 0.343 degrees.s-2 respectively for the alcohol subjects, and 0.263, 0.262, and 0.262 degrees.s-2 for placebo subjects. A significant alcohol x test-session interaction (p < 0.005) reflected the elevated thresholds shown by all alcohol subjects after consuming alcohol (p < 0.001). Of the six alcohol subjects, four continued to have elevated thresholds after their BAC's reached zero (p < 0.001). Alcohol and placebo subjects showed similar performance on the ancillary tasks of maintaining altitude and reporting a specified number when it appeared on a digital display. Both groups also reported that they had experienced similar levels of discomfort symptoms before and after drinking. The results indicate that a pilot's ability to detect angular motion can be compromised by low BAC levels, and this effect may continue for some pilots after their BAC reaches zero.

Professional pilots' views of alcohol use in aviation and the effectiveness of employee-assistance programs.

Pilots holding the Airline Transport Pilot certificate were surveyed about the seriousness of the alcohol problem in various areas of aviation and about the importance of a number of possible reasons why a pilot might drink and fly. They also rated a number of actions in terms of their potential effectiveness for reducing inappropriate alcohol use, and they evaluated a number of characteristics of employee-assistance programs. Respondents judged employee-assistance programs to be the best way to reduce problem drinking. They also identified areas in which currently available employee-assistance programs could be improved.

Pilot performance with blood alcohol concentrations below 0.04%.

The effects of a low (less than 0.04%) BAC on pilot performance were investigated in a series of four experiments in which pilots flew a light aircraft simulator under alcohol and placebo conditions. The mean BACs of subjects when starting and finishing the test sessions were 0.037% and 0.028%, respectively. Two of the experiments involved demanding flight tasks under instrument meteorological conditions: complicated departure, holding, and approach procedures in one case; and VOR-use intersection problems in the other. The other two experiments involved ILS approaches under turbulence, cross wind, and simulated wind shear conditions that imposed heavy control-task loads on the pilots. Significant alcohol effects were found, but only under the heaviest workload conditions. During posttest interviews 75% of the pilots reported physical and/or mental effects due to alcohol.

Professional pilots' evaluation of the extent, causes, and reduction of alcohol use in aviation.

Pilots holding the ATP rating were surveyed to obtain judgments concerning the seriousness of the alcohol problem in various areas of aviation, the reasons for alcohol use, and the probable effectiveness of strategies intended to reduce alcohol use in aviation. Alcohol use was judged to be a more serious problem in general aviation than in corporate, charter, regional, and major airline activities. Respondents identified the individual's inability to control alcohol use as a primary reason for drinking and flying, and they endorsed remedies that are directed toward those individuals who are seen as the source of the problem. Other factors considered important causes of drinking and flying included pilots' beliefs that they can compensate for alcohol's effects and their lack of knowledge about the rate of decrease in blood alcohol concentration (BAC) that occurs as a function of time and amount consumed.

A modeling analysis of young drivers' judgments of accident risk due to alcohol use and other driving conditions.

Male (60) and female (60) college students who were under the legal drinking age completed a personal driving experience questionnaire and judged the probability of an accident occurring in 100 driving scenarios, half involving an intoxicated male driver and half a sober male driver. The scenarios also varied in terms of the safety levels of five other driving factors. Mathematical models derived from the probability judgments permitted measurement of the influence of the various driving factors on perceived risk. The driving factors in order of their influence on the accident probability judgments were driver intoxication-nonintoxication, vehicle speed, road conditions, driver mood and driving experience, which did not significantly differ, and the driver's experience with alcohol use. Accident probability estimates of the alcohol scenarios increased as an additive function of the other driving factors, whereas increased risk of an accident in the no-alcohol scenarios was more dependent upon multiple unsafe factors. Female students judged the probability of an accident higher overall than did male students. Subject drinking classification (abstain-light, moderate or heavy) was not related to accident probability estimates.

Young drivers' evaluation of driving impairment due to alcohol.

Ninety-six college students, 18-20 years of age, were selected from three drinking categories (abstain-light, moderate, and heavy) based on their self-reported drinking habits. Subjects rated the relative importance of three driving components (attention, control/maneuvering, and emergency responses) for safe driving and the impairment each component and overall driving ability would sustain after driver drinking. Impairment ratings were made of the effects of drinking the number of drinks that would have resulted in the rater having blood alcohol concentrations (BACs) of .05%, .10%, and .15%. Subjects also estimated the number of drinks that they could consume in one hour and then safely drive after after different time periods, the time they should wait before driving after drinking various amounts of alcohol, and the number of beer, wine, wine cooler, and whiskey drinks that would cause them to reach a .10% BAC. While the driving components were rated to be of approximately equal importance for safe driving, the emergency responses component was judged to be more impaired following alcohol consumption than any of the other components, or overall driving ability. Heavy drinkers judged that there was significantly less driving impairment due to alcohol than did light or moderate drinkers in the case of overall driving ability and all of the driving components except emergency responses. Heavy drinkers also judged it safe to consume a number of drinks before driving that would result in higher mean BACs than those of light and moderate drinkers. Both drinking category and gender differences were found in the estimated BAC values that would have occurred at the time of driving after waiting periods judged by subjects to be sufficient for safe driving.

Naturally occurring retirement communities: a multiattribute examination of desirability factors.

This study investigated the factors important in older individuals' attraction to and satisfaction with apartment complexes that become naturally occurring retirement communities (NORCs). Quantitative measures examining the relative importance of various apartment complex attributes in attracting older and younger people to apartments that have and have not become NORCs were obtained by using a multiattribute scaling procedure. Results are presented from two main perspectives: a comparison of the factors attracting older residents to NORCs and non-NORCs; and a comparison of the factors attracting older and younger residents to NORCs.