Marital Status and Gender Differences as Key Determinants of COVID-19 Impact on Wellbeing, Job Satisfaction and Resilience in Health Care Workers and Staff Working in Academia in the UK During the First Wave of the Pandemic.

Background: The COVID-19 pandemic is an unprecedented global public health crisis that continues to exert immense pressure on healthcare and related professional staff and services. The impact on staff wellbeing is likely to be influenced by a combination of modifiable and non-modifiable factors. Objectives: The aim of this study is to evaluate the effect of the COVID-19 pandemic on the self-reported wellbeing, resilience, and job satisfaction of National Health Service (NHS) and university staff working in the field of healthcare and medical research. Methods: We conducted a cross sectional survey of NHS and UK university staff throughout the COVID-19 pandemic between May-November 2020. The anonymous and voluntary survey was disseminated through social media platforms, and via e-mail to members of professional and medical bodies. The data was analyzed using descriptive and regression (R) statistics. Results: The enjoyment of work and satisfaction outside of work was significantly negatively impacted by the COVID-19 pandemic for all of staff groups independent of other variables. Furthermore, married women reporting significantly lower wellbeing than married men (P = 0.028). Additionally, the wellbeing of single females was significantly lower than both married women and men (P = 0.017 and P < 0.0001, respectively). Gender differences were also found in satisfaction outside of work, with women reporting higher satisfaction than men before the COVID-19 pandemic (P = 0.0002). Conclusion: Our study confirms that the enjoyment of work and general satisfaction of staff members has been significantly affected by the first wave of the COVID-19 pandemic. Interestingly, being married appears to be a protective factor for wellbeing and resilience but the effect may be reversed for life satisfaction outside work. Our survey highlights the critical need for further research to examine gender differences using a wider range of methods.

Relationship and sexual experiences in women with early-onset oestrogen deficiency: Comparison between women with Turner syndrome and premature ovarian insufficiency.

OBJECTIVE: Age at first date and sexual intercourse have been observed to be delayed in women with Turner syndrome (TS), with delayed puberty being the main factor. We sought to assess relationship and sexual experiences comparing women with TS and premature ovarian insufficiency (POI). DESIGN: Cross-sectional observational study. PATIENTS: 302 women with TS and 53 women with karyotypically normal POI (median age 33.0 [15.0-78.4] and 26.3 [17.8-52.3], respectively). MEASUREMENTS: A self-reporting questionnaire was used to collect data on relationship and sexual experiences. RESULTS: Women with TS were older than women with POI (P = .002). Compared to women with POI, a smaller proportion of women with TS had ever had vaginal sexual intercourse (VSI) (40 [78.4%] vs 169 [58.1%], respectively, P = .006) and women with TS exhibited a delay in the median age at first relationship and VSI (POI 19.3 ± 0.4 vs TS 22.2 ± 1.1, P = <.001). Start of oestrogen replacement therapy at ≤ 14 years of age compared with > 14 years did not result in earlier relationship and sexual debut. After adjusting for age and diagnosis, induction of puberty, as opposed to spontaneous puberty, was associated with a delay in the median age at first relationship and VSI and a reduced probability of having VSI (Hazard ratio = 0.44 [95% confidence interval: 0.32-0.60], P = <.001). CONCLUSIONS: Turner syndrome and induction of puberty are associated with a reduced likelihood and a delay in relationship and sexual experiences. Women needing puberty induction and women with TS more than POI have a delayed mean age at first VSI compared to the general population.

It is a problem and it is not a problem: Dilemmatic talk of the psychological effects of female genital cutting.

This qualitative study aimed to explore the psychological effects of female genital cutting in the United Kingdom within a systemic psychological framework. Semi-structured interviews were carried out with 13 women who had experienced female genital cutting. Four key themes emerged from thematic analysis of the data: (1) wholeness contested, (2) sexuality milestones and female genital cutting awareness, (3) salvaging family relationships and (4) for our own good. Findings highlight the importance of recognising the relational nature of how women perceive the psychological effects of female genital cutting and how these reactions are negotiated in their social sphere.

'Botched labiaplasty': a content analysis of online advertising for revision labiaplasty.

A new development in female genital cosmetic surgery (FGCS) is the promotion of revision surgery for 'botched labiaplasty'. This content analysis study reviews the quality of information offered on websites specifically advertising revision labiaplasty. Twelve websites were identified through online searches and were examined for the quality of their clinical information. All sites defined botched labiaplasty as unsatisfactory appearance after labiaplasty. Four gave no further details and five listed asymmetry, irregular labial edges or removal of too much or too little tissue. Four websites described primary botched labiaplasty as 'mutilation'. Inadequacy of the primary surgeon was cited as the cause of botched labiaplasty in 11/12. Only two websites mentioned risks of surgery. Good outcomes were not defined and no website provided outcome data although guaranteed satisfaction was implied in two websites. This study highlights the existence and promotion of services for botched labiaplasty using non-specific and emotive descriptions. These findings suggest that unsatisfactory results from consumers' perspectives are far from uncommon. The same women whose expectations have not been met by primary surgery are now being targeted for repeat surgery with online advertising capitalising on their unchanged motivations.Impact StatementWhat is already known on this subject? Female genital cosmetic surgery (FGCS) is mainly advertised online with labiaplasty as the most commonly performed procedure. A market for labiaplasty revision to correct 'botched' primary procedures is developing. Academic literature and advertising materials are inconsistent when defining indications and determinants of success for labiaplasty or revision.What the results of this study add? A content analysis of websites specifically advertising revision labiaplasty describes the emotive and nonspecific terms used online to promote revision labiaplasty.What the implications are of these findings for clinical practice and/or further research? The existence of services for botched labiaplasty suggests dissatisfaction is common. Women whose expectations have not been met by primary surgery are targeted for repeat surgery through online advertising capitalising on their potentially unchanged motivations. This study demonstrates the need for clearer outcome data for labiaplasty and highlights the need for better advertising standards for FGCS promotion.

Clitoral surgery on minors: an interview study with clinical experts of differences of sex development.

OBJECTIVES: Clitoral surgery on minors diagnosed with differences of sex development is increasingly positioned as a violation of human rights. This qualitative study identified how health professionals (HPs) navigate the contentious issues as they offer care to affected families. DESIGN: Qualitative analysis of audio-recorded semistructured interviews with HPs. All of the interviews were transcribed verbatim for theoretical thematic analysis. SETTING: Twelve specialist multidisciplinary care centres for children, adolescents and adults diagnosed with a genetic condition associated with differences of sex development. PARTICIPANTS: Thirty-two medical, surgical, psychological and nursing professionals and clinical scientists in 12 specialist centres in Britain and Sweden formed the interview sample. RESULTS: All interviewees were aware of the controversial nature of clitoral surgery and perceived themselves and their teams as non-interventionist compared with other teams. Data analyses highlighted four strategies that the interviewees used to navigate their complex tasks: (1) engaging with new thinking, (2) holding on to historical assumptions, (3) reducing the burden of dilemmas and (4) being flexible. In response to recent reports and debates that challenge clitoral surgery on minors, HPs had revised some of their opinions. However, they struggled to reconcile their new knowledge with the incumbent norms in favour of intervention as they counsel care users with variable reactions and expectations. The flexible approach taken may reflect compromise, but the interviewees were often trapped by the contradictory values and assumptions. CONCLUSIONS: If the pathology-based vocabularies and narratives about genital diversity could be modified, and normative assumptions are questioned more often, clinicians may be more adept at integrating their new knowledge into a more coherent model of care to address the psychosocial concerns that genital surgery purports to overcome.

Sexual Experience before Treatment for Vaginal Agenesis: A Retrospective Review of 137 Women.

STUDY OBJECTIVE: To summarize the self-reported sexual experiences of women with vaginal agenesis before treatment and discuss the clinical implications. DESIGN: A retrospective review of pretreatment baseline sexuality data and medical records of women with vaginal agenesis seeking vaginal construction. SETTING: A specialist multidisciplinary center for women with genital differences associated with diverse sex development. PARTICIPANTS: One hundred thirty-seven women with untreated vaginal agenesis associated with Mayer-Rokitansky-Küster-Hauser Syndrome and complete androgen insensitivity syndrome aged 15 to 41 years (mean age, 20 years). INTERVENTIONS: Gynecological examination and completion of questionnaires. MAIN OUTCOME MEASURES: (1) Sexual Experiences Questionnaire; (2) Multidimensional Sexuality Questionnaire; (3) Vaginal Self-Perceptions; and (4) vaginal length. RESULTS: A sizable proportion of women reported having had sexually intimate experiences before any medical intervention on the vagina. Vaginal length, which ranged from dimple to 7 cm and averaged 2.7 cm for the cohort, was unrelated to the range of sexual experiences. Most women perceived their vagina as being too small, but less than half believed that a sexual partner would notice this. Two-thirds of the cohort subsequently completed the dilation program, which was not predicted by pretreatment vaginal length or sexual experience. CONCLUSION: Contrary to the assumption that a vagina of certain dimensions is a prerequisite for women to "have sex," many women with Mayer-Rokitansky-Küster-Hauser syndrome and complete androgen insensitivity syndrome reported having experienced genital and nongenital sexual activities with no medical interventions. It is recommended that treatment providers affirm women's capacity for sexual intimacy, relationships, and enjoyment before they introduce the topic of vaginal construction as a non-urgent choice.

Vaginal Construction and Treatment Providers' Experiences: A Qualitative Analysis.

STUDY OBJECTIVE: To investigate specialist clinicians' experiences of treating vaginal agenesis. DESIGN: Semi-structured interviews. SETTING: Twelve hospitals in Britain and Sweden. PARTICIPANTS: Thirty-two health professionals connected to multidisciplinary teams (MDTs) including medical specialists and psychologists. INTERVENTIONS AND MAIN OUTCOME MEASURES: Theoretical thematic analysis of recorded verbatim data. RESULTS: The gynecologist and psychologist interviewees share certain observations including the importance of psychological readiness for and appropriate timing of treatment. Three overlapping themes are identified in our theoretical analysis of the MDT clinicians' talk: (1) the stigma of vaginal agenesis and the pressure to be "normal" can lead patients to minimize the time, effort, physical discomfort, and emotional cost inherent in treatment. (2) Under pressure, treatment might be presented to patients with insufficient attention to the potential psychological effect of the language used. Furthermore, the opportunity to question what is "normal" in sex is generally not taken up. It can be challenging to help the women to transcend their medicalized experiences to come to experiencing their bodies as sexual and enjoyable. (3) The reality of treatment demands, which are not always adequately processed before treatment, can lead to discontinuation and even disengagement with services. CONCLUSION: The MDT clinicians in this study emphasized the importance of psychological input in vaginal construction. However, such input should proactively question social norms about how women's genitalia should appear and function. Furthermore, rather than steering patients (back) to treatment, the entire MDT could more explicitly question social norms and help the women to do the same. By shifting the definition of success from anatomy to personal agency, the clinical focus is transformed from treatment to women.

Global Disorders of Sex Development Update since 2006: Perceptions, Approach and Care.

The goal of this update regarding the diagnosis and care of persons with disorders of sex development (DSDs) is to address changes in the clinical approach since the 2005 Consensus Conference, since knowledge and viewpoints change. An effort was made to include representatives from a broad perspective including support and advocacy groups. The goal of patient care is focused upon the best possible quality of life (QoL). The field of DSD is continuously developing. An update on the clinical evaluation of infants and older individuals with ambiguous genitalia including perceptions regarding male or female assignment is discussed. Topics include biochemical and genetic assessment, the risk of germ cell tumor development, approaches to psychosocial and psychosexual well-being and an update on support groups. Open and on-going communication with patients and parents must involve full disclosure, with the recognition that, while DSD conditions are life-long, enhancement of the best possible outcome improves QoL. The evolution of diagnosis and care continues, while it is still impossible to predict gender development in an individual case with certainty. Such decisions and decisions regarding surgery during infancy that alters external genital anatomy or removes germ cells continue to carry risk.

Stonewalling Emotion.

This commentary is an exploration of emotion by a therapist. It focuses on how emotion is managed in the stories of growing up and living with atypical sex anatomies--how (much) is emotion (not) discussed, and what are the effects of forestalling emotive dialogue. Emotion care in the narratives is often sidelined in favor of medical doings. Rather than creating a haven to keep normative pressures at bay, so as to enable the affected parents, adolecents and adults to process their situations, some of the storytellers reveal how medicine has concentrated its efforts on the erasure and silencing of their bodily differences. The most frequently mentioned emotion management strategy is 'stonewalling', as some of the affected children and adults were silently left to take in what was reflected in the eyes of the large number of people inspecting their naked bodies. Emotional suffering continued for many years for some individuals. An apology might ease suffering but is rarely bestowed. Learning to become more comfortable with emotion may open up more possibilities for helpful conversations between care users and providers and within families. Feelings of joy became more available to the storytellers who as adults learned to embrace their differences and connected with like-minded people.

Will the introduction of non-invasive prenatal testing for Down's syndrome undermine informed choice?

OBJECTIVE: To investigate whether the introduction of non-invasive pre-natal testing for Down's syndrome (DS) has the potential to undermine informed choice. PARTICIPANTS: Three hundred and ninety-three health professionals; 523 pregnant women. METHODS: A cross-sectional questionnaire study across nine maternity units and three conferences in the UK designed to assess opinions regarding test delivery and how information should be communicated to women when offered Down's syndrome screening (DSS) or diagnosis using invasive (IDT) or non-invasive testing (NIPT). RESULTS: Both pregnant women and health professionals in the NIPT and DSS groups were less likely than the IDT group to consider that testing should take place at a return visit or that obtaining written consent was necessary, and more likely to think testing should be carried out routinely. Compared to health professionals, pregnant women expressed a stronger preference for testing to occur on the same day as pre-test counselling (P = 0.000) and for invasive testing to be offered routinely (P = 0.000). They were also more likely to indicate written consent as necessary for DSS (P = 0.000) and NIPT (P < 0.05). CONCLUSIONS: Health professionals and pregnant women view the consenting process differently across antenatal test types. These differences suggest that informed choice may be undermined with the introduction of NIPT for DS into clinical practice. To maintain high standards of care, effective professional training programmes and practice guidelines are needed which prioritize informed consent and take into account the views and needs of service users.

Sexual function and health-related quality of life in women with classic bladder exstrophy.

OBJECTIVE: To investigate sexual function and quality of life in adolescent and adult women with classic bladder exstrophy (BE). MATERIALS AND METHODS: A two-part observational cross-sectional study with a questionnaire arm and a retrospective case review arm was performed. The study was undertaken in a centre providing a tertiary referral gynaecology and urology service. Outcomes were sexual function and quality-of-life scores. RESULTS: A total of 44 patients with BE were identified from departmental databases and included in the study, of whom 28 (64%) completed postal questionnaires. Sexual function scores and quality-of-life visual analogue scales were significantly poorer compared with normative data. CONCLUSIONS: Bladder exstrophy has a detrimental psychological impact on women. In future, methodical multidisciplinary paediatric follow-up research will help to identify predictors of better and worse adolescent and adult outcomes. Development and evaluation of cost-effective psychological interventions to target specific problems is also warranted.

Practice changes in childhood surgery for ambiguous genitalia?

OBJECTIVE: In 2001, this team published an observational study of the clinical outcomes of a cohort of adolescent girls born with ambiguous genitalia. The poor outcomes observed represented a major scientific challenge to the standard practice of childhood feminising genital surgery. That publication was one of several contributing to a call for change in surgical practice, which culminated in the publication of the Chicago Consensus Document in 2006. The aim of this current study was to repeat the same evaluation of clinical outcomes on a recent cohort of adolescent girls and compare the two cohorts to identify differences in adolescent outcomes which may indicate a change in paediatric surgical practice. METHODS: This was an observational study of a current cohort of adolescent girls treated in childhood for ambiguous genitalia and referred to a specialist adolescent disorders of sex development (DSD) service for assessment. Data were collected on surgical history, genital examination findings and treatment recommendations for 30 consecutive adolescents over a 5-year period. Findings were compared with those of a similar cohort of adolescent girls published over a decade previously. RESULTS: Clitoral surgery remained common (93% vs 100%, current cohort vs historical cohort). However, concomitant vaginoplasty was performed less frequently (80 vs 100% current vs historical). Vaginoplasty revision surgery was also less commonly required (65 vs 81%), although 24% of the recent cohort still required major revision surgery prior to intercourse. There was some improvement to the cosmetic outcomes as deemed by the surgical team using the same criteria as the previous report. CONCLUSIONS: This study provides some slight evidence of recent practice change. There was a small reduction in the number of vaginoplasties performed in childhood and an improvement in vaginoplasty outcomes and cosmesis. However, there was no identifiable change in management of clitoromegaly and the numbers of clitoral reduction operations remained high. This is surprising given the clear evidence of a detrimental impact of surgery on clitoral sensation and sexual function.

Improving self-esteem in women diagnosed with Turner syndrome: results of a pilot intervention.

STUDY OBJECTIVE: To evaluate a brief intervention to improve the self esteem of women diagnosed with Turner syndrome (TS). DESIGN: Prospective observational study. SETTING: Turner Syndrome Support Society, UK. PARTICIPANTS: 30 women aged 18-60 years. INTERVENTION: A 1-day psychology workshop targeting problems of self-esteem in women diagnosed with TS. The workshop drew on cognitive-behavioral therapy and narrative therapy skills and emphasized increased self-awareness of interpersonal difficulties and improved capacity for self-management. MAIN OUTCOME MEASURES: Rosenberg Self-esteem Scale (RSS); Hospital Anxiety and Depression Scale (HADS); bespoke user experiences questionnaire. RESULTS: All 30 women provided baseline data, 27/30 provided immediate post-intervention data and 22/30 provided follow-up data at 3 months. The intervention improved RSS and HADS scores at 3 months. CONCLUSION: Generic skills-based psychological interventions have the potential to be adapted to provide brief and low-cost interventions to improve self-esteem and reduce psychological distress in women diagnosed with TS.

An analysis of the content and clinical implications of online advertisements for female genital cosmetic surgery.

OBJECTIVES: Women who are contemplating any form of female genital cosmetic surgery (FGCS) are likely to seek information from provider websites. The aim of this study is to examine the breadth, depth and quality of clinical information communicated to women on 10 popular sites and to discuss the implications of the results. METHODS: The content of online advertisement from 10 private providers that offer FGCS procedures was examined according to 16 information categories relating to indications for surgery, types of procedure, risks and benefits. RESULTS: FGCS procedures were presented on all of the provider websites as an effective treatment for genital appearance concerns. No explanation for presenting clinical complaints was found. There was scanty reference to appearance diversity. Only minimal scientific information on outcomes or risks could be identified. There was no mention of potential alternative ways for managing appearance concerns or body dissatisfaction. CONCLUSIONS: The quality and quantity of clinical information in FGCS provider sites is poor, with erroneous information in some instances. Impeccable professionalism and ethical integrity is crucial for this controversial practice. Clear and detailed guidelines on how to raise the standard of information to women on all aspects of FGCS are urgently needed.