Experiences of gender incongruence and the relationship between social exclusion, psychological distress, and dysfunction among South African transgender adults: A field-study for ICD-11.

BACKGROUND: The classification of sexuality-related conditions and conditions relating to transgender identity has generated controversy. Growing evidence suggests that the distress and dysfunction reported by transgender individuals is more likely associated with social exclusion, stigmatization, and violence than as a result of gender incongruence per se. Our study aimed to explore the experiences of South African transgender individuals through: 1) their self-reported accounts of gender incongruence, and 2) associations between their experiences of social exclusion and violence, and their reports of psychological distress and dysfunction during adolescence. METHODS: Our sample of 57 South African transgender adults completed a structured interview, in English, including questions related to experiences of gender incongruence duration, distress, dysfunction, social exclusion, and violence. RESULTS: Many transgender individuals reported having experienced an intense desire to be a different gender, with all noting discomfort with several aspects of their bodies. Importantly, psychological distress and dysfunction were significantly associated with social exclusion (most commonly perpetuated by family and friends) and not with gender incongruence per se. CONCLUSIONS: This study adds to the growing evidence that experiences of social exclusion play a significant role in the psychological distress and dysfunction reported by transgender persons.

Proposals for Paraphilic Disorders in the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11).

The World Health Organization is currently developing the 11th revision of the International Classifications of Diseases and Related Health Problems (ICD-11), with approval of the ICD-11 by the World Health Assembly anticipated in 2018. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) was created and charged with reviewing and making recommendations for categories related to sexuality that are contained in the chapter of Mental and Behavioural Disorders in ICD-10 (World Health Organization 1992a). Among these categories was the ICD-10 grouping F65, Disorders of sexual preference, which describes conditions now widely referred to as Paraphilic Disorders. This article reviews the evidence base, rationale, and recommendations for the proposed revisions in this area for ICD-11 and compares them with DSM-5. The WGSDSH recommended that the grouping, Disorders of sexual preference, be renamed to Paraphilic Disorders and be limited to disorders that involve sexual arousal patterns that focus on non-consenting others or are associated with substantial distress or direct risk of injury or death. Consistent with this framework, the WGSDSH also recommended that the ICD-10 categories of Fetishism, Fetishistic Transvestism, and Sadomasochism be removed from the classification and new categories of Coercive Sexual Sadism Disorder, Frotteuristic Disorder, Other Paraphilic Disorder Involving Non-Consenting Individuals, and Other Paraphilic Disorder Involving Solitary Behaviour or Consenting Individuals be added. The WGSDSH's proposals for Paraphilic Disorders in ICD-11 are based on the WHO's role as a global public health agency and the ICD's function as a public health reporting tool.

Maladaptive coping mediates the influence of childhood trauma on depression and PTSD among pregnant women in South Africa.

Antenatal mental disorders compromise maternal and child health, and women who have experienced childhood trauma may be at increased risk for such disorders. One hypothesis is that early trauma leads to the development and use of maladaptive coping strategies as an adult, which in turn could predict mental health difficulties during stressful transitions such as pregnancy. To test this hypothesis, this study examined the relationship between childhood trauma and mental health (depression, PTSD) in a sample of 84 pregnant women seeking antenatal care in Cape Town, South Africa, and explored whether maladaptive coping mediated this relationship. The majority of women (62 %) met established criteria for antenatal depression and 30 % for antenatal PTSD; in addition, 40 % reported a history of childhood trauma. Childhood trauma, especially childhood sexual abuse and emotional abuse, was significantly associated with depression and PTSD. The relationships between childhood trauma and depression and PTSD were significantly mediated by maladaptive coping, even when adjusted for the woman's age, gestational age, and HIV status. Findings highlight the need for coping-based interventions to prevent and treat antenatal mental disorders among women with childhood trauma, particularly in high-trauma settings such as South Africa.

Proposed declassification of disease categories related to sexual orientation in the International Statistical Classification of Diseases and Related Health Problems (ICD-11).

The World Health Organization is developing the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), planned for publication in 2017. The Working Group on the Classification of Sexual Disorders and Sexual Health was charged with reviewing and making recommendations on disease categories related to sexuality in the chapter on mental and behavioural disorders in the 10th revision (ICD-10), published in 1990. This chapter includes categories for diagnoses based primarily on sexual orientation even though ICD-10 states that sexual orientation alone is not a disorder. This article reviews the scientific evidence and clinical rationale for continuing to include these categories in the ICD. A review of the evidence published since 1990 found little scientific interest in these categories. In addition, the Working Group found no evidence that they are clinically useful: they neither contribute to health service delivery or treatment selection nor provide essential information for public health surveillance. Moreover, use of these categories may create unnecessary harm by delaying accurate diagnosis and treatment. The Working Group recommends that these categories be deleted entirely from ICD-11. Health concerns related to sexual orientation can be better addressed using other ICD categories.

L'Organisation mondiale de la Santé est en train de mettre au point la 11e révision de la Classification statistique internationale des maladies et des problèmes de santé connexes (CIM-11), dont la publication est prévue pour 2017. Le Groupe de travail sur la Classification des troubles sexuels et de la santé sexuelle a été chargé d'examiner et de faire des recommandations sur les catégories de maladies liées à la sexualité dans le chapitre sur les troubles mentaux et comportementaux de la 10e révision (CIM-10) qui a été publiée en 1990. Ce chapitre comprend les catégories des diagnostics basés principalement sur l'orientation sexuelle même si la CIM-10 stipule que l'orientation sexuelle seule n'est pas un trouble. Cet article examine les données scientifiques et les raisons cliniques pour continuer à inclure ces catégories dans la CIM. Un examen des données publiées depuis 1990 a révélé le peu d'intérêt scientifique pour ces catégories. En outre, le Groupe de travail n'a trouvé aucune preuve de leur utilité clinique: elles ne contribuent pas à la fourniture des services de soins ou à la sélection du traitement, et elles ne fournissent aucune information essentielle en matière de surveillance de la santé publique. Par ailleurs, l'utilisation de ces catégories peut créer des dommages inutiles en retardant le diagnostic précis et le traitement. Le Groupe de travail recommande que ces catégories soient entièrement supprimées de la CIM-11. Les problèmes de santé liés à l'orientation sexuelle peuvent être mieux traités en utilisant les autres catégories de la CIM.

La Organización Mundial de la Salud está desarrollando la undécima revisión de la Clasificación Estadística Internacional de Enfermedades y Problemas Relacionados con la Salud (CIE-11), cuya publicación está planeada para el 2017. El Grupo de Trabajo sobre la Clasificación de Trastornos Sexuales y Salud Sexual fue encargado de revisar y hacer recomendaciones sobre estas categorías de enfermedades relacionadas con la sexualidad en el capítulo sobre trastornos mentales y del comportamiento en la décima revisión (CIE-10), publicada en 1990. Este capítulo incluye categorías para diagnósticos basadas principalmente en la orientación sexual, a pesar de que la CIE-10 afirma que la orientación sexual en sí misma no es un trastorno. Este artículo revisa las pruebas científicas y los fundamentos clínicos para continuar incluyendo estas categorías en la CIE. Una revisión de las pruebas publicada desde 1990 encontró poco interés científico en estas categorías. Asimismo, el Grupo de Trabajo no encontró pruebas de que fueran útiles clínicamente: no contribuyen a la prestación de servicios sanitarios ni a la selección de tratamientos. Tampoco proporcionan información esencial para la vigilancia de la salud pública. Además, el empleo de estas categorías podría ocasionar un daño innecesario al retrasar los diagnósticos precisos y el tratamiento. El Grupo de Trabajo recomienda que se eliminen totalmente estas categorías de la CIE-11. Los problemas de salud relacionados con la orientación sexual se pueden abordar mejor utilizando otras categorías de la CIE.

A Supervision Framework for Task-Shared Mental Health Workers: Implications for Clinical Trials and Beyond.

The rise in task-shared interventions that address the mental health treatment gap in low- and middle-income countries (LMICs) has highlighted the need for additional support and supervision of nonspecialist mental health workers (NHWs). The supervision of NHWs in most resource-limited settings is still primarily disorganized, without clear guidelines that provide the necessary structure for supervision. The need for supervision is even greater for NHWs working in the context of trauma, not only to provide training and ensure adequate delivery of care but also to provide support to minimize the psychological impact of their work. In South Africa, women face intersecting epidemics of HIV, intimate partner violence, and sexual trauma. This syndemic highlights the importance of integrating mental health treatment in HIV care, especially in settings like South Africa, where mental health services are limited. In this context, our group developed and is evaluating the effectiveness of ImpACT+, a task-shared coping intervention to improve clinical and mental health outcomes among HIV-infected women with sexual trauma in South Africa. We describe the ImpACT+ supervision model that is currently being implemented in the context of a hybrid effectiveness-implementation clinical trial. Combining experiences from clinical psychology, task-shared interventions, and trauma-informed care, the supervision model integrates formal elements of clinical supervision into categories that are suitable for use in task-shared trauma interventions in low-resource settings. To the best of our knowledge, such a trauma-informed supervision approach has not been widely documented in the literature, particularly in task-shared interventions in LMICs. In this article, we describe the ImpACT+ intervention, provide an overview of the supervision model, and provide illustrative examples of how the supervision model has been implemented.

Proposed Declassification of Disease Categories Related to Sexual Orientation in the International Statistical Classification of Diseases and Related Health Problems (ICD-11).

(Reprinted with permission from the Bulletin of the World Health Organization).

"If He's Abusing You . . . the Baby Is Going to Be Affected": HIV-Positive Pregnant Women's Experiences of Intimate Partner Violence.

Pregnancy represents a time of increased risk for intimate partner violence (IPV), and an HIV diagnosis further increases the vulnerability of this at-risk group. This study explores experiences of recent IPV using qualitative interviews with N = 12 HIV-positive pregnant women recruited from a clinical setting in South Africa, a location with a high global prevalence of IPV and HIV. Partner dynamics around IPV resulted in HIV shame and stigma and adversely affected engagement in HIV care and HIV treatment behaviors. The results highlight the challenges women face in navigating disclosure of both IPV and HIV, accessing necessary support, and engaging in both HIV-related and pregnancy-related care in the context of an abusive relationship.

Substance abuse and behavioral correlates of sexual assault among South African adolescents.

OBJECTIVE: The aim of this article is twofold: first, to examine the prevalence of being the victim of actual and attempted rape among a large representative sample of Cape Town high school students; and second, to identify the correlates of sexual assault for both boys and girls, including alcohol, tobacco and other drug use, behavioral problems, and suicidality. METHOD: Data for this study were derived from the 1997 South African Community Epidemiology Network on Drug Use (SACENDU) school survey. A stratified sampling procedure was used to select students in Grades 8 and 11 at non-private high schools in Cape Town. A total of 2,946 students completed a survey consisting of socio-demographic questions and items about substance abuse, sexual activity, and other adolescent health risk behaviors. A subsample of 939 was randomly selected to complete items about sexual violence. RESULTS: The results revealed that 8.4% of respondents were victims of attempted rape, while 5.8% were victims of actual rape. Ordinal logistic regression showed that girls were 3.9 times more likely than boys to have been victims of sexual abuse. Family structure was also significantly related to rape as persons who lived with a single parent (OR = 1.74, CI = 1.00-3.04) and those who resided with one biological parent and one step parent (OR = 2.59, CI = 1.34-5.01) were more likely to have been have been victims of sexual abuse than those living with both biological parents. Alcohol use (OR = 2.0, CI = 1.10-3.62), anti-social behavior (stolen property, caused physical damage to property, bullied others, or been in physical fights) (OR = 1.44, CI = 1.12-1.86), suicidal dialogue (OR = 2.48, CI = 1.19-5.19), and suicidal attempts (OR = 3.2, CI = 1.65-6.30) were also significant predictors of sexual abuse victimization. Racially classified social groups (RCSG), age, drug use, and cigarette smoking were not significant predictors of sexual abuse victimization, while socioeconomic status was found to be marginally significant. CONCLUSION: This study reinforces the importance of multiple factors including alcohol use, anti-social behavior, suicidal thoughts and actions, and family structure with respect to sexual assault of adolescents in South Africa. Establishing and strengthening intervention programs, school based child protective protocols, professional education of teachers and school personnel, community prevention programs, and initiatives could help prevent adolescent sexual violence and reduce the sequelae associated with this problem.

Relationships, trust, decision-making and quality of care in a paediatric intensive care unit.

OBJECTIVE: To assess the care-giving practices of health-care practitioners in the paediatric intensive care unit (PICU) through their qualitative insights, reflections and experience in participatory action research. DESIGN AND METHODS: Qualitative research in the form of 'participatory action research' was used to gather data from three sources within the unit: focus groups within disciplines, observations within the PICU, and semi-structured interviews. All staff members were active collaborators and equal stakeholders in the decision-making process, research and feedback. SETTING: The paediatric intensive care unit (PICU) of the Red Cross War Memorial Children's Hospital (RCWMCH). PARTICIPANTS: All staff members from various disciplines working in the PICU. RESULTS: Staff members described problems with respect to relationships, trust and decision-making within care-giving practices. CONCLUSION: The study qualitatively describes how poor communication amongst staff members in respect of relationships and decision-making impacted on trust and how this tended to compromise care-giving practices in the PICU. The data suggested that this was more evident in informal rather than formal clinical decision-making procedures. The strength of the study was that the participatory action design in the research allowed staff members to address the very dynamics that they themselves cited as problematic.

Childhood trauma in obsessive-compulsive disorder, trichotillomania, and controls.

There is relatively little data on the link between childhood trauma and obsessive-compulsive/putative obsessive-compulsive spectrum disorders. The revised Childhood Trauma Questionnaire (CTQ), which assesses physical, emotional, and sexual abuse as well as physical and emotional neglect, was administered to female patients with obsessive-compulsive disorder (OCD; n = 74; age: 36.1 plus minus 16.3), TTM (n = 36; age: 31.8 plus minus 12.3), and a group of normal controls (n = 31; age: 21.5 plus minus 1.0). The findings showed a significantly greater severity of childhood trauma in general, and emotional neglect specifically, in the patient groups compared to the controls. Although various factors may play a role in the etiology of both OCD and trichotillomania (TTM), this study is consistent with some evidence from previous studies suggesting that childhood trauma may play a role in the development of these disorders.