Contraceptive counseling training experiences and behaviors among obstetrics and gynecology residents in California and Florida.

OBJECTIVE: To describe experiences with contraception counseling training and provision of obstetrics and gynecology residents training in California and Florida. STUDY DESIGN: We conducted a mixed-methods study of obstetrics and gynecology residents training across 19 programs (with approximately 428 residents) in California and Florida from September 2022 through February 2023. We asked participants how often they use tiered-effectiveness counseling, their satisfaction with contraception counseling practices, and experiences with witnessing and recognizing contraception coercion. We asked about personal disappointment when patients decline long-acting reversible contraception (LARC) and pressure from faculty to prescribe LARC. To further explore resident contraception counseling education and behaviors, we conducted semi-structured telephone interviews with a subset of 20 survey volunteers. RESULTS: We received survey responses from 155 (36.2%) participants. Most (n = 113 [76.4%]) often or always reported using tiered-effectiveness counseling. While few participants (n = 17 [11.3%]) reported feeling pressure from faculty to convince a patient to keep a LARC, some (n = 34 [22.1%]) reported they often or always feel disappointed when a patient chooses LARC removal, with more Florida participants reporting disappointment (n = 19 [37.3%]) compared to California (n = 15 [14.6%], p = 0.01). We identified two main themes from the telephone interviews. First, residents feel they have limited formal education on how to provide contraceptive counseling and commonly learn these practices by emulating supervising faculty or peer counseling styles. Second, residents are informally taught, through feedback and interactions with supervising faculty and peers, that successful contraception counseling is the ability to convince patients to use highly effective contraception. CONCLUSION: When residents lack formalized contraception counseling education, they adopt counseling behaviors that may not be patient centered. IMPLICATIONS: When obstetrics and gynecology residents lack formalized contraception counseling education, they learn practices that may lead to coercive counseling behaviors during training. Resident education should include recognition and mitigation of contraception coercion and patient-centered counseling both through a formalized curriculum and socialization of trainees during their medical education.

Compulsory Community Treatment Orders and health outcomes for Ma-ori in New Zealand.

BACKGROUND: We have previously analysed outcomes for all community treatment orders commenced during a 10-year period in New Zealand. Given Te Tiriti O Waitangi obligations to scrutinise health and consider equity for Maori, we completed this analysis to consider community treatment-order outcomes according to ethnicity. METHODS: Ministry of Health databases provided demographic, service use and medication dispensing data for community treatment-order recipients between 2009 and 2018. As non-Maori on community treatment orders are older, less deprived and less likely to be diagnosed with a Psychotic Disorder, data were categorised according to age (<35/⩾35 years), level of deprivation (New Zealand Dep levels ⩽3, 4-6 and ⩾7) and diagnosis (Psychotic Disorder/non-Psychotic Disorder). The incidences of key outcome measures (admissions, community care, medication dispensing) were calculated for periods on/off community treatment orders for Maori and non-Maori to consider the differential impact of community treatment orders according to ethnicity. RESULTS: Maori have high rates of community treatment order utilisation and are younger, more likely to be diagnosed with a Psychotic Disorder and spend longer receiving compulsory treatment than non-Maori. Non-Maori are more likely to receive more additional depot antipsychotic medication on-community treatment orders compared with periods off-community treatment order than Maori but other clear patterns of response distinguishing between Maori and non-Maori were not present. CONCLUSION: The differences between Maori and non-Maori for community treatment-order utilisation suggest the presence of structural inequity in underlying mental illness distribution and treatment provision. Maori cultural expertise at all levels of healthcare including healthcare planning and delivery is required to make advances and reduce disparity.

Beyond delinquency and drug use: Links of peer pressure to long-term adolescent psychosocial development.

This study examined the predictors and sequelae of exposure to peer pressure from close friends in adolescence. Adolescents (99 female; 85 male) were followed from age 13 to 24 utilizing peer, parent, and romantic partner reports and observational data. Participants who were exposed to high levels of peer pressure as teens were more likely to experience higher levels of coercive behavior from romantic partners (as reported by those partners), as well as lower levels of parent-reported functional independence. All findings held even after accounting for baseline levels of teen assertiveness. Adolescents at risk for increasing exposure to peer pressure were characterized by poor-quality parent and peer relationships, as well as baseline deficits in ability to assert autonomy. Results suggest that exposure to peer pressure, aside from its potential effects on deviant or risky behavior, may reflect a powerful threat to the autonomy development process as adolescents transition from parents to peers as primary sources of support and interaction.

Characteristics of preschool-age children who engage in problematic sexual behaviors with siblings.

BACKGROUND: Problematic sexual behavior (PSB) between siblings can be a form of sibling sexual abuse (SSA). A notable gap in research are studies examining PSB among preschool-age children with siblings. OBJECTIVE: This study examined the impact of child maltreatment, exposure to family sexuality, and use of coercive sexual behavior on preschool-aged children PSB with siblings and with nonsiblings. PARTICIPANTS AND SETTING: All 284 children were ages 3-6 years with PSB who had siblings in the home (197 initiated PSB with siblings and 87 initiated PSB with non-siblings). METHODS: The two groups were compared on types of PSB, use of coercion, child maltreatment history, exposure to family sexuality, and caregiver attitudes. Caregiver report measures were the Child Sexual Behavior Inventory- Third Edition (CSBI-III), the Family Sexuality Index, and intake form on maltreatment experienced (i.e., physical abuse, sexual abuse, emotional abuse, neglect, exposure to domestic violence, caregiver drug use, and failure to protect). RESULTS: Maltreatment history was significant, t(258) = -3.36, p < .001; sibling initiators were associated with higher rates of sexual and physical abuse, and neglect than non-sibling. Exposure to family sexuality was significant with non-sibling initiators demonstrating greater exposure than the sibling group, t(282) = 2.66, p = .008. There was no significance between groups for types of PSB including use of coercion. CONCLUSIONS: Results illuminated unique dynamics of PSB with siblings of preschool-aged children. A developmental framework integrating child maltreatment, impulsivity, environmental factors, and capabilities are key considerations for conceptualization, prevention, and response that is distinct from SSA of adolescents.

Corrigendum: Expert opinions on improving coercion data collection across Europe: a concept mapping study.

[This corrects the article DOI: 10.3389/fpsyt.2024.1403094.].

Risk of adverse perinatal outcomes with violence in pregnancy.

PURPOSE: To examine the association between physical, sexual, or physiological harm in pregnancy and perinatal outcomes in a large, contemporary birth cohort. METHODS: This retrospective cohort study used California-linked vital statistics and hospital discharge data from 2016 to 2020. We included singleton, non-anomalous births with a gestational age of 23-42 weeks. Violence in pregnancy was identified using International Classification of Disease, Tenth Revision (ICD-10) codes. Chi-square tests and multivariable Poisson regression models were used to evaluate associations of violence in pregnancy with perinatal outcomes. RESULTS: A total of 1,728,478 pregnancies met inclusion criteria, of which 3,457 (0.2%) had reported violence in pregnancy. Compared to those without violence in pregnancy, individuals who experienced violence had an increased risk of non-severe hypertensive disorders (aRR = 1.36, 95% CI 1.22, 1.51), preeclampsia with severe features (aRR = 1.34; 95% CI 1.11, 1.61), chorioamnionitis (aRR = 1.68; 95% CI 1.48, 1.91), anemia (aRR = 1.59; 95% CI 1.50, 1.68), antepartum hemorrhage (aRR = 2.17; 95% CI 1.19, 3.95), and postpartum hemorrhage (aRR = 1.65; 95% CI 1.48, 1.85). Violence in pregnancy was also associated with increased risk of Apgar score < 7 at 5 min (aRR = 1.37; 95% CI 1.11, 1.71) and neonatal hypoglycemia (aRR = 1.26; 95% CI 1.07, 1.48). CONCLUSION: Violence experienced in pregnancy is associated with an increased risk of adverse perinatal outcomes. Understanding how universal screening and early recognition of violence in pregnancy may reduce disparities in maternal morbidity for this understudied population is critical.

Associations Between Sexualized Media Consumption, Sexual Double Standards, and Sexual Coercion Perpetration and Victimization in Late Adolescent Sexually Active Boys and Girls from The Netherlands.

This study examined associations between sexualized media consumption, sexual double standard (SDS) norms, and sexual coercion perpetration and victimization in late adolescence and whether these associations were moderated by gender. Participants were sexually active Dutch secondary school students aged 16-20 years (N = 255, 58.4% girls). Data were collected using a self-report questionnaire at a single time-point. Overall, more sexualized media consumption was associated with higher odds of both sexual coercion perpetration and victimization. These associations did not differ by gender. Specifically, viewing online pornography and sexually oriented reality television more frequently were associated with higher odds of sexual coercion perpetration, whereas viewing others' sexy social media posts more frequently was associated with higher odds of sexual coercion victimization. Finally, stronger endorsement of SDS norms was associated with lower odds of sexual coercion perpetration in girls, but with comparatively higher odds of sexual coercion perpetration in boys. Results indicate that consuming sexualized media and societal sexual double standards is associated with an increased risk of sexual coercion experiences in adolescence.

Specialized short term crisis intervention for patients with personality disorder: Effects on coercion and length of stay.

BACKGROUND: Acute crises in patients with personality disorders (PD) are often accompanied by suicidal and self-harming behavior. Their management is challenging, as both coercive measures and prolonged inpatient-treatment are known to be counterproductive. Only in crises that cannot be controlled by outpatient means, inpatient treatment is to be taken into account. This treatment should be time-limited and not involve coercion. AIMS: The aim of this study was to assess if the introduction of a specialized crisis intervention track is associated with a reduction of coercive measures as well as a shorter in-hospital stay in PD patients. METHODS: In this 8-year, hospital-wide, longitudinal, observational study, we investigated the frequency of coercive measures and the median length of in-hospital stay in 1,752 inpatient-cases with PD admitted to the Adult Psychiatry, UPK, Basel, Switzerland, between 01.01.2012 and 31.12.2019. By means of an interrupted-time-series analysis, we compared the period before and after the implementation of a specialized crisis intervention track for PD patients. RESULTS: Our data show a significant decrease in the median length of in-hospital stay and no significant reduction in the incidence rate of coercion among PD patients after the intervention. The latter is likely due to a floor effect, since there was a significant decrease in coercive measures over the entire observation period, already reaching very low rates before the intervention. CONCLUSIONS: Our study underlines the clinical importance of specialized short-term crisis management in PD, which comes along with shorter lengths of in-hospital stays and a stable low rate of coercive measure.

Legislation and policy for involuntary mental healthcare across countries in the FOSTREN network: rationale, development of mapping survey and protocol.

BACKGROUND: Several countries are currently revising or have already revised their mental health laws to align with the global movement to reduce the use of coercive care. No government has yet fully implemented the recommendation of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) to eliminate the use of coercion in mental healthcare. Consequently, the international field of mental health law and policy is in a degree of flux. AIMS: To describe the rationale, development and protocol for a project that will map and examine how mental health laws, policies and service capacity across European countries relate to the use of coercive measures, including involuntary admissions and treatment, restraints and seclusion. This will help to better understand the current situation and explore future directions of policies regarding coercive care. METHOD: The project is being carried out under the purview of the European Cooperation in Science and Technology (COST) action network, entitled FOSTREN (Fostering and Strengthening Approaches to Reducing Coercion in European Mental Health Services). A multidisciplinary group of experts developed a comprehensive survey assessing mental health laws, policies and service frameworks, based on World Health Organization and UNCRPD recommendations. The survey was piloted in three countries, revised and disseminated to 30 FOSTREN country representatives. The survey will provide data for three strands of work on legislation, policies and service-level context. A comprehensive evaluation will be conducted, drawing on findings from all work packages. CONCLUSIONS: The project could inform the development of strategies, interventions and legislation to address gaps and promote compliance with international standards.

Problematic Sexual Behavior in Children: The Influence of Transgressions of Interpersonal Boundaries and Family Adversity Across Generations.

Problematic sexual behavior (PSBs) in children have been linked to difficulties or challenges within the family environment. Despite this association, few studies have examined how interpersonal boundary transgressions influence children's PSBs. Based on a sample of 112 parent-child dyads recruited before undergoing PSB-focused psychotherapy, this study first aims to explore the concept of sexual, physical, and emotional boundary transgressions within the current family environment in relation to reported levels of PSBs. The study further investigates the connections between parents' current boundary transgressions and their past and present family environments. Bivariate analyses revealed a positive correlation between heightened levels of interpersonal boundary transgressions and increased PBS, alongside elevated externalized behaviors. Two hierarchical linear regression models were employed: one to predict children's PSB scores with boundary transgressions as a predictor, and another to predict current boundary transgressions within the family environment. Results showed that current boundary transgressions within the family predicted the level of PSBs. However, once the child's externalized behaviors were considered, boundary transgressions ceased to be significant. Regarding the parents, transgression of interpersonal boundaries within the current family environment was associated with exposure to higher levels of interpersonal boundary transgressions during their childhood, current socioeconomic status, and a higher level of parental psychological distress. Keywords: problematic sexual behavior, PSBs, transgression of interpersonal boundaries, conceptual model, victimization experiences, intergenerational cycle.

Coercion Authorship: Ubiquitous and Preventable.

Coercion authorship (CA), typically enforced by principal investigators, has detrimental effects on graduate students, young researchers, and the entire scientific endeavor. Although CA is ubiquitous, its occurrence and major determinants have been mainly explored among graduate students and junior scientists in Sweden, Norway, and Denmark where the ratio of CA ranged from 13 to 40%. In addition to lacking comparable figures, developing countries usually lack institutional plans for promoting integrity and effective deterrents against CA and other malpractices. Hence, universities and research centers therein must publish their authorship policies and implement specific strategies to instruct graduate students, junior scientists, and experienced researchers on integrity, publishing ethics, and responsible authorship. Finally, I remark that the primary responsibility of principal researchers to promote fair authorship practices and discourage unfair ones is even greater when it comes to CA due to the asymmetrical power relationship between senior authors and novice scientists.

Pathways to experienced coercion during psychiatric admission: a network analysis.

BACKGROUND: In mental health care, experienced coercion, also known as perceived coercion, is defined as the patient's subjective experience of being submitted to coercion. Besides formal coercion, many other factors have been identified as potentially affecting the experience of being coerced. This study aimed to explore the interplay between these factors and to provide new insights into how they lead to experienced coercion. METHODS: Cross-sectional network analysis was performed on data collected from 225 patients admitted to six psychiatric hospitals. Thirteen variables were selected and included in the analyses. A Gaussian Graphical Model (GGM) using Spearman's rank-correlation method and EBICglasso regularisation was estimated. Centrality indices of strength and expected influence were computed. To evaluate the robustness of the estimated parameters, both edge-weight accuracy and centrality stability were investigated. RESULTS: The estimated network was densely connected. Formal coercion was only weakly associated with both experienced coercion at admission and during hospital stay. Experienced coercion at admission was most strongly associated with the patients' perceived level of implication in the decision-making process. Experienced humiliation and coercion during hospital stay, the most central node in the network, was found to be most strongly related to the interpersonal separation that patients perceived from staff, the level of coercion perceived upon admission and their satisfaction with the decision taken and the level of information received. CONCLUSIONS: Reducing formal coercion may not be sufficient to effectively reduce patients' feeling of being coerced. Different factors seemed indeed to come into play and affect experienced coercion at different stages of the hospitalisation process. Interventions aimed at reducing experienced coercion and its negative effects should take these stage-specific elements into account and propose tailored strategies to address them.

Coercion in psychiatry: psychometric validation of the Portuguese Staff Attitudes to Coercion Scale (SACS).

BACKGROUND: There is a growing recognition that staff attitudes toward coercion in mental health care may influence its application. This study presents the psychometric properties of the Portuguese version of the Staff Attitudes towards Coercion Scale (SACS) and describes mental health professionals' attitudes towards coercion in Portugal. METHODS: Mental health professionals working in five Portuguese mental health services in urban and rural regions of Portugal were invited to complete a questionnaire comprising the SACS and a socio-demographic form. Psychometric analyses including construct validity and internal consistency were carried out using R software. RESULTS: A total of 91 out of 119 questionnaires completed were valid for analysis. Fifty-seven (62.64%) respondents were female, with an age range of 24 to 69 years (M = 39.33; SD = 11.09). More than half of them were nurses (52.75%, n = 48), and a third were psychiatrists (36.26%, n = 33). A three-factor structure was confirmed and showed the best fit compared to previously proposed models with a cumulative explained variance of 59%. The Portuguese SACS exhibited adequate internal consistency for both the full-scale and subscales. The highest mean score was in the pragmatic attitude domain (20.60; SD = 3.37). A negative correlation was observed between the critical attitude domain and both age and years of experience (p < 0.05). CONCLUSION: A three-factor structure was confirmed and showed the best fit compared to previously proposed models. The Portuguese SACS showed excellent psychometric properties and is acceptable for assessing staff attitudes towards coercion.

A Scoping Review on Staff Attitudes towards the Use of Coercion in Mental Healthcare.

Attitudes of mental health professionals towards the use of coercion are highly relevant concerning its use coercion in mental healthcare, as mental health professionals have to weigh ethical arguments and decide within a legal frame in which situations to use coercion or not. Therefore, assessment of those attitudes is relevant for research in this field. A vital instrument to measure those attitudes towards the use of coercion is the Staff Attitude to Coercion Scale. This scoping review aims to provide a structured overview of the advantages and limitations in the assessment of attitudes toward coercion. We conducted a scoping review in Medline, PsycINFO, CINAHL, and Web of Science, based on the PRISMA-ScR. Inclusion criteria were empirical studies on the attitudes of mental health professionals. We included 80 studies and systematically mapped data about the main results and limitations in assessing attitudes toward coercion. The main results highlighted the relevance and increased interest in staff attitudes towards coercion in mental healthcare. Still, the majority of the included studies relied on a variety of different concepts and definitions concerning attitudes. The data further indicated difficulties in developing new and adapting existing assessment instruments because of the equivocal definitions of underlying concepts. To improve the research and knowledge in this area, future studies should be based on solid theoretical foundations. We identified the need for methodological changes and standardized procedures that take into account existing evidence from attitude research in social psychology, nursing science, and other relevant research fields. This would include an update of the Staff Attitude to Coercion Scale based on the limitations identified in this review.

Novel Approaches Needed: An Experimental Study with an Alternative to Mechanical Restraint.

Despite many calls to reduce or eliminate the use of mechanical restraint, it is still widely used in many countries. Studies using patient interviews have a very clear message: Patients experience mechanical restraint as the most humiliating intervention. There seems to be a lack of alternatives for violent patients if all other approaches to prevent the use of coercion have failed. We developed a method using 30 kg bags, originally designed for fitness purposes, to be attached to a patient's wrist or ankle under 1:1 supervision. The method was tested with 10 experienced nurses and de-escalation trainers. A video was made and presented to six outpatients who had previously experienced mechanical restraint. All participants were interviewed. Transcribed interviews were analysed using qualitative content analysis. All participants approved of the method as a milder and less humiliating alternative to mechanical restraint. The nurses' main concerns were the risk of falls and the use of the bags as weapons. The latter could be controlled by using an additional bag. Patients were generally positive, especially if there was a history of abuse. The method should be further developed to replace at least some mechanical restraints. As with all 'milder means', care should be taken to really replace restraint and not to introduce additional coercion.

Deep Vein Thrombosis in a 15-Year-Old Previously Restrained Psychiatric Patient: A Case Report.

Deep vein thrombosis is a condition in which a thrombus forms in one of the deep veins of the body, most often in the legs. It may manifest with pain, swelling, redness, or increased temperature of the limb, potentially leading to fatal complications such as pulmonary embolism. This is a case of a 15-year-old psychiatric patient diagnosed with deep vein thrombosis of the left lower limb of uncertain etiology. The patient presented few risk factors associated with venous thromboembolism disorder such as immobilization, antipsychotic treatment, and obesity. Even though psychiatry deals primarily with the mind of a patient, somatic complications occur very often and should not be underestimated. One of those complications is deep vein thrombosis, which is worth remembering, especially when applying procedures during which patients are immobilized for a long period.

Comprehension of English for-adverbials: The Nature of Lexical Meanings and the Neurocognitive Architecture of Language.

What is the nature of lexical meanings such that they can both compose with others and also appear boundless? We investigate this question by examining the compositional properties of for-time adverbial as in "Ana jumped for an hour." At issue is the source of the associated iterative reading which lacks overt morphophonological support, yet, the iteration is not disconnected from the lexical meanings in the sentence. This suggests an analysis whereby the iterative reading is the result of the interaction between lexical meanings under a specific compositional configuration. We test the predictions of two competing accounts: Mismatch-and-Repair and Partition-Measure. They differ in their assumptions about lexical meanings: assumptions that have implications for the possible compositional mechanisms that each can invoke. Mismatch-and-Repair assumes that lexical meaning representations are discrete, separate from the conceptual system from which they originally emerged and brought into sentence meaning through syntactic composition. Partition-Measure assumes that lexical meanings are contextually salient conceptual structures substantially indistinguishable from the conceptual system that they inhabit. During comprehension, lexical meanings construe a conceptual representation, in parallel, morphosyntactic and morphophonological composition as determined by the lexical items involved in the sentence. Whereas both hypotheses capture the observed cost in the punctual predicate plus for-time adverbial composition (e.g., jump (vs. swim) for an hour), their predictions differ regarding iteration with durative predicates; for example, swim for a year (vs. for an hour). Mismatch-and-Repair predicts contrasting processing profiles and nonoverlapping activation patterns along punctuality differences. Partition-Measure predicts overlapping processing and cortical distribution profiles, along the presence of iterativity. Results from a self-paced reading and an functional Magnetic Resonance Imaging (fMRI) studies bear out the predictions of the Partition-Measure account, supporting a view of linguistic meaning composition in line with an architecture of language whereby combinatoriality and generativity are distributed, carried out in parallel across linguistic and nonlinguistic subsystems.

Effectiveness of the Addressing Reproductive Coercion in Health Settings (ARCHES) intervention among abortion clients in Bangladesh: a cluster-randomized controlled trial.

Background: The Addressing Reproductive Coercion in Health Settings (ARCHES) intervention trains existing providers to address reproductive coercion (RC) and intimate partner violence (IPV) within routine family planning counseling. This study evaluated the effectiveness of a single ARCHES counseling session as adapted for use with abortion clients in Bangladesh. Methods: In this cluster-randomized controlled trial conducted between January 2019 and January 2021, health facilities with an abortion clinic with infrastructure for private counseling and onsite violence support services were eligible. Six facilities in Bangladesh met inclusion criteria, and matched pairs randomization with parallel assignment and a 1:1 allocation ratio was used to randomize three facilities to ARCHES and three facilities to control, which implemented standard counseling. Blinding was not possible as providers in intervention facilities participated in a three-day ARCHES training. Participants were abortion clients aged 18-49 years who could provide safe recontact information and be interviewed privately. The primary outcome was past three-month modern contraceptive use without interruption or interference. The trial was registered on clinicaltrials.gov (NCT03539315) on 29 May 2018. Findings: A total of 1492 intervention participants and 1237 control participants were enrolled. Available data were analyzed at each follow-up period: 1331 intervention and 1069 control participants at the three-month follow-up, and 1269 intervention and 1050 control participants at the twelve-month follow-up. ARCHES was associated with higher likelihood of modern contraceptive use at the three-month follow-up (adjusted RR = 1.08, 95% CI: 1.06-1.10) and the twelve-month follow-up (adjusted RR = 1.06, 95% CI: 1.02-1.10). ARCHES was also associated with decreased incident pregnancy, decreased IPV, and increased knowledge of IPV support services. Interpretation: The ARCHES intervention is effective in increasing post-abortion modern contraceptive use and decreasing incident pregnancy and IPV among abortion clients in Bangladesh. Implementation of ARCHES should be considered in facilities with sufficient privacy for counseling. Funding: Society of Family Planning (#SFPRF11-07) and Ipas.

Mothering in the Aftermath of Reproductive Coercion and Abuse.

A partner's reproductive coercion and abuse (RCA) can significantly undermine women's physical health and psychological wellbeing. Yet little research has explored how RCA affects experiences of mothering and relationships with children. Based on an analysis of interviews with 30 Australian mothers, we found that RCA affected mothering in complex ways. Many struggled with feeling detached, resentful, and guilty toward their children, while some found mothering an emotionally and morally restorative experience after the RCA. All felt compelled to conceal their abuse from their children and others. The findings have implications for how healthcare practitioners can support mothers in the aftermath of RCA.

Lev Tolstoy, A Founder of Democratic Education.

In this philosophical-theoretical study of Lev Tolstoy's pedagogical legacy of his Yasnaya Polyana school in the Russian Empire (1859-1862), I raised three major questions: (1) was Lev Tolstoy a democratic educator, and if so, why can one claim that, (2) if so, what kind of a democratic educator was he, and (3) what kind of limitations to his democratic education have I observe and what were the sources of these limitations? My answer to the first question was unequivocally positive. I argue that Tolstoy was the conceptual founder of democratic non-coercive education and the first known practitioner of democratic education for children. In my view, his democratic education was based on educational offerings provided by the teachers. His democratic educational philosophy was based on non-coercion, naturalism, anarchism, liveliness, pragmatism, pedagogical experimentation, student responses, pedagogical self-reflection, and dialogism. At the same time, his democratic education was limited to his uncritical acceptance of conventionalism. Tolstoy's attraction to Progressive Education was facilitated by ignoring his enormous powers, both explicit and implicit, that he manifested exercised in the school and enacted through his "pervasive informality." In my judgment, Tolstoy overemphasized pedagogy over self-education and did not distinguish learning from education. Still, Tolstoy's pioneering work in democratic education, both in theory and practice, remains mostly unacknowledged and unanalyzed while continuing to be highly relevant and potentially influential.