Zowie Davy

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

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.

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.

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

BackgroundPrevious 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.MethodsWe 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.ResultsWe 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.ConclusionsThis 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.

‘Sexing Up’ Bodily Aesthetics: Notes towards Theorizing Trans Sexuality

In this chapter we suggest that the organizing medical concept of ‘transsexuality’ either overtly represses and denies sexuality as a factor in trans experience, or explicitly understands transitioning as originating in a hypersexuality. We track this representation of trans embodiment as a form of excessive sexuality in the pornographic imagination, particularly with regard to the mythic figure of the ‘she-male’ that overshadows the ‘he-female’. Raven Kaldera and Hanne Blank suggest that the damaging impact of medical representations of hypersexuality on the cultural representation of transfolk, results in them being ‘pictured as cardboard cut-outs with improbable anatomy who will fuck and be fucked by anyone, anything, anytime, in any way’ (Blank and Kaldera, 2002: 7). Yet, until recently, erotic material featuring FtMs was non-existent, suggesting an apparent lack of sexual interest. At issue is the dearth of adequate erotic role models in sexually explicit representations as well as the lack of theoretical responsibility towards incorporating analyses of trans sexuality that begin from the transitioning body itself.

To be or not to be LGBT in primary health care: health care for lesbian, gay, bisexual, and transgender people

Lesbian, gay, bisexual, and transgender (LGBT) health care will, increasingly, be a feature of the primary care repertoire.1 Pride in Practice, which is supported by the Royal College of General Practitioners, provides a rating system that judges primary care surgeries on a welcoming environment, access, the GP, patient consultation, staff awareness and training, and health promotion for LGBT people. For those surgeries signed up to the initiative, plans to address shortfalls will be developed in consultation with the Lesbian and Gay Foundation. Another initiative, Transgender Awareness, is attempting to address matters that are important to a diverse group of transgender patients. While acknowledging these very positive developments, it is important to understand what we mean by ‘LGBT primary health care’. We will draw on the concept of LGBT health care to explore the benefits and potential harms that this term can engender, and on the different ways that the relatively sparse LGBT health literature has addressed and accounted for the different foci of LGBT health care over the years. In doing so, we will argue for a more nuanced approach to primary health care for these groups. Student teaching has tended to position heterosexuality and gender normativity — people conforming to social standards of what is ‘appropriate’ feminine and masculine behaviour — as the primary context in which health and illness is viewed. Models of health care that promote these views of sexuality and gender identity over others can create an environment in which gender stereotypes and heteronormativity — the cultural bias in favour of opposite-sex …

Democratising diagnoses? The role of the depathologisation perspective in constructing corporeal trans citizenship

In the scope of the current revision process of the diagnostic manuals Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases and Other Health Problems (ICD), an international trans depathologisation movement has emerged that demands, among other claims, the removal of a diagnostic classification of gender transition processes as a mental disorder. The call for submissions launched by the American Psychiatric Association (APA) and World Health Organization (WHO) seems to provide the opportunity for a participation of civil society in the DSM and ICD revision processes. These developments open up a number of questions for us that will be discussed in this article. We conducted a meta-narrative review to explore the trans depathologisation movement’s contribution to the DSM and ICD revision process, uncover evidence of a ‘democratised turn’ in the process and review depathologisation proposals implemented in trans healthcare practices, human rights frameworks and legal gender recognition processes. We argue that the trans depathologisation movement has had little impact on medical practices in trans healthcare. However, there is some movement in local health services towards an informed consent model for limited healthcare interventions. Within some European and South/Central American legal frameworks, the depathologisation movement’s demands to free legal gender recognition from medical interventions and examinations have, in different degrees, been incorporated into legal recommendations and enacted in some recent gender recognition laws.

Genderqueer(ing): "on this side of the world against which it protests"

Deconstructionism as a method in transgender studies has been useful to collapse concepts and ideas about (trans) gender and sexuality. In spite of the usefulness of undoing the gender and sexuality canon, by way of concentrating on transgender practices, the resulting deconstructions often leave us with no place to go. This article develops an analysis of transsexual and genderqueer people’s bodily aesthetic assemblages, challenging theorizations that exclusively pit transsexual people as subjugated and genderqueer people as subversive. Drawing on interview data from 23 transsexual and genderqueer people, this article argues that transsexual and genderqueer people, regardless of their desire for particular bodily aesthetic interventions and gender recognition, productively flee, elude, flow, leak and disappear from categorizing legal statutes and healthcare protocols. The article concludes by arguing that deconstructive work becomes divisive and unproductive for theorizing and understanding the bodily aesthetics and diverse connectivities and affectivities of transsexual and genderqueer people, all of whom become territorialized, deterritorialized and reterritorialized through polyvocal bodily aesthetic assemblages.

Introduction to the themed issue: Trans* policy, practice and lived experience within a European context:

This themed issue, ‘Trans* policy, practice and lived experience within a European context’, emerges at a time when global understandings of gender are rapidly changing across social, cultural, political, policy and legal spheres. The understanding of gender as the materialisation of the categories of male or female that are fixed at birth is in flux, and this issue speaks to these shifts at conceptual, procedural and empirical levels.