Readiness assessments for gender-affirming surgical treatments: A systematic scoping review of historical practices and changing ethical considerations.

Transgender and gender diverse (TGD) are terms that refer to individuals whose gender identity differs from sex assigned at birth. TGD individuals may choose any variety of modifications to their gender expression including, but not limited to changing their name, clothing, or hairstyle, starting hormones, or undergoing surgery. Starting in the 1950s, surgeons and endocrinologists began treating what was then known as transsexualism with cross sex hormones and a variety of surgical procedures collectively known as sex reassignment surgery (SRS). Soon after, Harry Benjamin began work to develop standards of care that could be applied to these patients with some uniformity. These guidelines, published by the World Professional Association for Transgender Health (WPATH), are in their 8th iteration. Through each iteration there has been a requirement that patients requesting gender-affirming hormones (GAH) or gender-affirming surgery (GAS) undergo one or more detailed evaluations by a mental health provider through which they must obtain a "letter of readiness," placing mental health providers in the role of gatekeeper. WPATH specifies eligibility criteria for gender-affirming treatments and general guidelines for the content of letters, but does not include specific details about what must be included, leading to a lack of uniformity in how mental health providers approach performing evaluations and writing letters. This manuscript aims to review practices related to evaluations and letters of readiness for GAS in adults over time as the standards of care have evolved via a scoping review of the literature. We will place a particular emphasis on changing ethical considerations over time and the evolution of the model of care from gatekeeping to informed consent. To this end, we did an extensive review of the literature. We identified a trend across successive iterations of the guidelines in both reducing stigma against TGD individuals and shift in ethical considerations from "do no harm" to the core principle of patient autonomy. This has helped reduce barriers to care and connect more people who desire it to gender affirming care (GAC), but in these authors' opinions does not go far enough in reducing barriers.

A Mobile Phone Application for Assessing Daily Variation in Pain Location and Pain Intensity in Patients with Urologic Chronic Pelvic Pain Syndrome: A MAPP Network Study.

Introduction: We created and tested a mobile app that facilitates the ecological momentary assessment of pain intensity and pain location and identifies heterogeneous patient pain phenotypes. Methods: A mobile app was created with patient, clinician and researcher input. A sample of 20 participants with urologic chronic pelvic pain syndrome were then asked to complete a 14-day pain assessment using the app. Data were analyzed to assess compliance, usability and the ability for the app to capture variation in pain intensity and pain location. Ecological momentary assessment pain data were then compared to end-of-week pain summary questions to determine construct validity. Results: Mean compliance was 70±8%, higher earlier in the study period (p <0.0005) and better in older individuals (p <0.0001). During the 14-day assessment, 90% of participants reported daily variation in pelvic pain intensity (SD 0.64-3.02; out of 10), 95% reported variation in their nonpelvic pain (SD 0.17-3.63; out of 10) and 100% reported variations in number of sites with pain (SD 0.22-1.44; out of 7). Pelvic pain and nonpelvic pain intensity, as determined by cumulative app scores, were associated with patient reported end-of-week scores; worst pain (r pelvic =0.67; r nonpelvic =0.53) and average pain (r pelvic =0.78; r nonpelvic =0.73). Conclusions: The easy-to-use app captured unique patterns of pain not fully captured by traditional end-of-day/week summary questions or by traditional in-office assessments. Mobile apps for assessing chronic conditions will become increasingly important as telehealth becomes more commonplace.

Pilot Study of an Online Self-Directed Learning Module for Medical Decision-Making Capacity.

OBJECTIVE: This study assessed the impact of an online, self-directed learning module on medical student knowledge and attitudes regarding decision-making capacity. METHODS: The authors created a 15-min didactic video on decision-making capacity and sorted medical students on the psychiatry clerkship to teaching as usual or teaching as usual plus watching the video. The authors assessed student knowledge about and attitudes toward decisional capacity assessment using a pre/posttest design. RESULTS: Thirty-eight students completed the study (24% of all psychiatry clerkship students in one academic year). Students who watched the video (n = 14) achieved higher scores on the posttest compared with students who did not watch the video (n = 24) (90% vs 84% on general knowledge and case examples), though this difference was small and not statistically significant. The degree of improvement from pretest to posttest was higher for students who watched the video but did not reach statistical significance. CONCLUSIONS: Overall, students found the online teaching module to be a helpful augmentation strategy for learning decisional capacity assessment. The authors incorporated student feedback and additional review to create an enhanced video, which is available on ADMSEP's Clinical Simulation Initiative website.

Understanding Assessment Systems for Clinical Competency Committee Decisions: Evidence from a Multisite Study of Psychiatry Residency Training Programs.

OBJECTIVE: This multisite study examines how clinical competency committees in Psychiatry synthesize resident assessments to inform milestones decisions to provide guidelines that support their use. METHODS: The study convened training directors and associate training directors from three psychiatry residency programs to examine decision-making processes of clinical competency committees. Annual resident assessments for one second year and one third year resident were used in a mock clinical competency committee format to assign milestones for two consecutive reporting periods. The committees reflected on the process and rated how the assessment tools impacted the assessment of milestones and evaluated the overall process. The authors compared reliability of assessment between the mock committees and examined both reliability of end of rotation assessments and their composite scores when combined with clinical skills evaluations. RESULTS: End of rotation evaluations were the most informative tool for assigning milestones and clarifying discrepancies in performance. In particular, the patient care and medical knowledge competencies were the easiest to rate, while the systems-based practice and practice-based learning and improvement were the most difficult. Reliability between committees was low although higher number of available evaluations improved reliability in decision-making. CONCLUSIONS: The results indicate that the medical knowledge and patient care competencies are the easiest to rate and informed most by end of rotation evaluations and clinical skills examinations. Other evaluation tools may better capture performance on specific sub-competencies beyond workplace-based assessment, or it may be helpful to reconsider the utility of how individual sub-competencies are evaluated.

Pain and Urinary Symptoms Should Not be Combined into a Single Score: Psychometric Findings from the MAPP Research Network.

PURPOSE: The purpose of this study was to create symptom indexes, that is scores derived from questionnaires to accurately and efficiently measure symptoms of interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome, collectively referred to as urological chronic pelvic pain syndromes. We created these indexes empirically by investigating the structure of symptoms using exploratory factor analysis. MATERIALS AND METHODS: As part of the MAPP (Multi-Disciplinary Approach to the Study of Chronic Pelvic Pain) Research Network 424 participants completed questionnaires, including GUPI (Genitourinary Pain Index), ICSI (Interstitial Cystitis Symptom Index) and ICPI (Interstitial Cystitis Problem Index). Individual items from questionnaires about bladder and pain symptoms were evaluated by principal component and exploratory factor analyses to identify indexes with fewer questions to comprehensively quantify symptom severity. Additional analyses included correlating symptom indexes with symptoms of depression, which is a known comorbidity of patients with pelvic pain. RESULTS AND CONCLUSIONS: Exploratory factor analyses suggested that the 2 factors pain severity and urinary severity provided the best psychometric description of items in GUPI, ICSI and ICPI. These factors were used to create 2 symptom indexes for pain and urinary symptoms. Pain, but not urinary symptoms, was associated with symptoms of depression on multiple regression analysis, suggesting that these symptoms may impact patients with urological chronic pelvic pain syndromes differently (B ± SE for pain severity = 0.24 ± 0.04, 95% CI 0.16-0.32, ß = 0.32, p <0.001). Our results suggest that pain and urinary symptoms should be assessed separately rather than combined into 1 total score. Total scores that combine the separate factors of pain and urinary symptoms into 1 score may be limited for clinical and research purposes.

The role of corticotropin-releasing hormone in the pathophysiology of depression: therapeutic implications.

Stress responses have been posited to be a key component of mental health and disease by playing essential roles both in normal adaptive processes and maladaptive physiological responses that in part underlie the pathogenesis of certain subtypes of mood and anxiety disorders. Early research focused on delineating the function of the hypothalamic-pituitary-adrenal (HPA) axis and subsequently examined its role in mediating the mammalian stress responses and its hyperactivity in depression. Much evidence now supports an important function of the biological mediators of this system in relation to not only depression, but also anxiety, substance abuse, and psychotic disorders, and implicates several components of this system as areas of intervention for novel pharmacotherapy. Perhaps the best studied central nervous system (CNS) component of this system is corticotropin-releasing factor (CRF), and considerable research has focused on its role in the HPA axis, as well in extrahypothalamic brain regions.

Choreoathetosis in the setting of lithium toxicity.

BACKGROUND: Lithium toxicity has been shown to cause lasting neurological sequelae in certain cases. OBJECTIVE: The authors present a case of choreoathetosis in the aftermath of a presumed episode of lithium toxic reaction. METHOD: The patient was treated by aggressive rehydration; lithium and, ultimately, all psychotropic medication was withheld for a period. RESULTS: The patient showed marked improvement in orientation and movement control; however, some of the choreoathetoid symptoms persisted. CONCLUSION: Patients on combination therapy with lithium and other psychotropics need to be closely monitored for the development of choreoathetoid and other symptoms of overmedication.