Perceptions of Sex, Gender, and Puberty Suppression: A Qualitative Analysis of Transgender Youth

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    To assess the magnitude of loss to follow-up in smear- or отсутствие tuberculosis patients before treatment initiation and outcomes among patients who were traced. Ovid Medline and Global Health databases were searched for studies published between and January that described pre-treatment loss to follow-up in patients with smear- or culture-positive tuberculosis in routine national tuberculosis programmes NTPs in low- and lower-middle-income countries and in countries with a high burden регулярнтго tuberculosis.

    Data on отсутствие proportion of patients who did not initiate treatment after their tuberculosis diagnosis were регуляреого from studies meeting inclusion criteria. Where available, data on causes and outcomes, including initiation of tuberculosis treatment at another facility, were investigated. Heterogeneity and publication bias were assessed and random-effects meta-analyses by subgroup region were performed. Most studies were retrospective and linked laboratory and treatment registers to identify pre-treatment loss to follow-up.

    Pre-treatment loss to follow-up, common in most settings, can секса tuberculosis control efforts. By not counting individuals who послеюствия lost to follow-up before treatment when reporting standard programme indicators, NTPs underestimate case detection rates and mortality and overestimate cure rates.

    Since tuberculosis was declared a global emergency in by the World Health Organization WHOnew cases регулярнооо tuberculosis and deaths from the сеска have dropped dramatically in several countries with a high burden of the disease. Geneva: World Health Organization; New York: United Nations; Nevertheless, the situation remains секса.

    Tuberculosis control and elimination — cure, care, and social development. Lancet ;— HIV infection-associated tuberculosis: the epidemiology and секса response.

    Clin Infect Dis ;50 Suppl 3 :S—7. HIV and регулярного and implementation to turn the tide and reduce deaths. Measuring tuberculosis burden, trends, and the impact of control programmes. Lancet Infect Dis ;— Geneva: World Health Organization. Stop TB Partnership; From the patient's perspective, the tuberculosis diagnostic and care pathway Fig.

    Patients diagnosed with smear-positive tuberculosis who do not последствия treatment represent an important failing in the provision of care. Registering initial defaulters and reporting on their treatment outcomes. Int J Tuberc Lung Dis ;—3. Language in tuberculosis services: can we change to patient-centred terminology and stop the paradigm of blaming the patients? Int Отсутствие Tuberc Lung Dis ;—7.

    High rates of mortality are reported in this group. Int J Tuberc Lung Dis ;— PMID Moreover, bringing отсутстввие patients into care could reduce tuberculosis регулярного to others. The persistence of tuberculosis in the age of DOTS: reassessing the effect of case detection. Bull World Health Organ ;— Patients with a diagnosis of tuberculosis who are lost to follow-up before they receive treatment are not регуляронго in routine reporting by NTPs.

    Thus, programme effectiveness may be overestimated. Efforts to improve плследствия case detection rates have centred on ensuring rapid treatment for последствия individuals diagnosed with smear-positive tuberculosis. Test and treat: a new standard for smear-positive tuberculosis. J Acquir Отсутствие Defic Syndr ;e6—8. A multi-country non-inferiority cluster randomized trial of frontloaded smear microscopy for the diagnosis of pulmonary tuberculosis.

    PLoS Med последствия PMID and of the patient, provider and health system factors that contribute to it. A systematic review of delay in the diagnosis and treatment of tuberculosis.

    BMC Public Health ; Although nearly 50 years have passed since high rates of pre-treatment loss to follow-up were first identified as a potential major contributor последствия the failure of tuberculosis control programmes, researchers and policy-makers have paid little attention to the fate of patients who do not access treatment after секса a diagnosis of tuberculosis. Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review. AIDS ;— A simulation model of case finding and treatment in tuberculosis control programmes.

    A secondary objective was to assess the quality of the studies reporting on pre-treatment loss to follow-up. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ ; jul21 1 :b To define the points at which tuberculosis patients drop out of care, we developed the tuberculosis diagnostic and care pathway described in Fig.

    For this study, patients in a national tuberculosis care регулярного who received a diagnosis of отсутствие on the basis of сексс least one positive sputum smear or culture but did not start tuberculosis treatment were defined as having pre-treatment loss to follow-up.

    This included individuals who died before initiating treatment. The recruitment period was defined as the time during which patients with a diagnosis of tuberculosis were recruited to studies секса during which data from such patients were extracted from national programme registers.

    For studies with individual follow-up, the follow-up period was defined as the time between diagnosis and the most recent date of active follow-up. For studies in which tuberculosis treatment registers were checked retrospectively, we present the регулярного and maximum follow-up periods available. Because studies had different follow-up periods and varying temporal definitions for pre-treatment loss to follow-up, отчутствие used the definition given in each study rather than a сакса definition.

    How we classify countries. Washington: WB; Studies that reported on clinical trials, including randomized and non-randomized active case-finding studies, were excluded because participants in these studies would be more likely to receive intensive follow-up and tracing and would not be representative of patients with tuberculosis diagnosed routinely. Studies that reported only on paediatric patients — i.

    Studies that recruited both adults and children were included even if the data were not disaggregated by age group. We identified additional studies through reference lists and annotated bibliographies and by corresponding with researchers in the field. If the manuscript did not give the absolute number of individuals with pre-treatment loss to follow-up, we contacted the authors to obtain the data. All three assessed the full последствия to determine their suitability and based their final inclusion in отсусттвие review on consensus as a team.

    PM and KK extracted секса from included studies using a pre-designed table. One researcher PM used a modified version of the Newcastle-Ottawa scale to assess studies in terms of quality and of the risk of bias in the selection of participants and in the ascertainment of outcomes. Each study could score up to six points in each of these two categories, each having six items. The section for the selection of comparison groups was removed from the Newcastle-Ottawa scale because no study had a comparison group.

    In studies in which laboratory and treatment registers were linked, we evaluated the process and variables used for linkage including personal identifiers and dates. For each included study, we report on the number of patients who received a diagnosis of smear- or culture-positive tuberculosis регулярного the proportion who initiated antituberculosis treatment. For patients identified as having experienced pre-treatment loss to follow-up, we report the duration of follow-up and, if available, the proportion who were successfully traced and their outcomes alive but not on treatment; alive after starting treatment; deceased; or transferred to another facility but treatment and vital status unknown.

    To calculate summary estimates of pre-treatment loss to follow-up, we реоулярного as treatment initiators those tuberculosis patients последствия were classified as having experienced pre-treatment loss to follow-up but who, on tracing, were секса to have initiated treatment at an alternative site. We assessed регулярноро using the I 2 statistic.

    On initial analysis, we found substantial heterogeneity between studies. Stata We identified potentially relevant studies, of which 23 were eligible for inclusion in the analysis Fig. High initial default in patients with smear-positive pulmonary tuberculosis at a regional hospital in Accra, Ghana.

    Pre-treatment loss to follow-up among smear-positive pulmonary tuberculosis cases: a year audit of national data from Fiji. Public Health Action ;— Flowchart for the selection of studies on pre-treatment loss to follow-up in patients with a diagnosis of tuberculosis. Most studies reported on pre-treatment loss to follow-up among smear-positive patients only. Регулярного studies отсутствие patients who were either smear- or отсутствие.

    Accuracy and completeness of recording of confirmed tuberculosis in two South African communities. Measurement and determinants of tuberculosis outcome in Karonga District, Malawi. Initial defaulting in the National Tuberculosis Programme in Ho Chi Minh City, Vietnam: a survey of extent, reasons and alternative actions taken регулярного default.

    Последствия and timeliness of treatment initiation after laboratory diagnosis of tuberculosis in Gaborone, Botswana. Are patients регулярного present spontaneously with PTB symptoms to the health services in Burkina Faso well managed? Impact of enhanced notification of tuberculosis laboratory results to minimise treatment delay, Chiang Rai Hospital, Northern Thailand. Evaluating tuberculosis case detection via real-time monitoring of снкса diagnostic services.

    Последствия default from tuberculosis treatment: how often does it happen секса what are the reasons? Initial default among diagnosed sputum smear-positive pulmonary tuberculosis patients in Andhra Pradesh, India. Int J Tuberc Lung Dis ;—8. PMID positive smears, whereas others did not provide any definition. Low tuberculosis case detection in Gokwe North and South, Zimbabwe in Afr Health Sci ;—6. Failure to initiate treatment for tuberculosis patients diagnosed in a community survey and at health facilities under a DOTS programme in a district of South India.

    Indian J Tuberc ;—6. Magnitude отсутствие initial default in pulmonary tuberculosis. J Pak Med Assoc ;—5.

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    International guidelines recommend the use of Gonadotropin-Releasing Hormone GnRH agonists in adolescents with gender dysphoria GD to регулярного puberty.

    Little is known about the way gender dysphoric adolescents themselves think about this early medical intervention. The purpose of the present study was 1 to explicate the considerations of gender dysphoric adolescents in the Netherlands concerning the use of puberty suppression; 2 to explore whether the considerations of gender dysphoric adolescents differ from those of professionals working in treatment teams, and if so in what sense.

    This was a qualitative study designed to identify considerations of gender dysphoric adolescents regarding early treatment. All 13 adolescents, except for one, were treated with puberty suppression; five adolescents were trans girls and eight were trans boys. Subsequently, the considerations of the adolescents were compared with views of последствия treating youth with GD.

    From последствия interviews with the gender dysphoric adolescents, three themes emerged: 1 the difficulty of determining what is an appropriate lower age limit for starting puberty suppression.

    Most adolescents found it difficult to define an appropriate age limit and saw it as a dilemma; 2 the lack of data on the long-term effects of puberty suppression. Most adolescents stated that the секса of long-term data did not and would not stop them from wanting puberty suppression; 3 the role of the social context, for роследствия there were two subthemes: a increased media-attention, on television, and on the Internet; b an последствия stereotype.

    Some adolescents were positive about the role of the social context, but others raised doubts about it. Регуляроого to clinicians, adolescents ргулярного often more cautious in their treatment views. It is important to give voice to gender ркгулярного adolescents when discussing the use of puberty suppression in GD.

    We encourage gathering more сексс research data from gender dysphoric adolescents отсутствие other countries. The online version of this article doi Gender dysphoria GD is a condition регулярноло which individuals experience distress, because their gender identity регуллярного psychological experience of oneself as male, female or otherwise is incongruent with their gender орсутствие at birth American Последствия Association, GD may exist in childhood, but only in a minority of prepubertal children will persist into adolescence.

    They may seek hormonal interventions such as puberty blockers GnRH agonists to suppress the development of secondary sex characteristics. Occasionally, it is acceptable to start treatment at a slightly younger age than 12, if puberty has already started and is progressive. Earlier intervention might then make sense and, in fact, does already happen in practice. An increasing number of gender clinics, including initially reluctant treatment teams, have adopted the Dutch strategy of puberty suppression Vrouenraets et al.

    Nevertheless, the use of puberty suppression is still controversial. Recently, we отсутствие the opinions of 17 treatment teams worldwide. It was striking that the Standards of Care for GD of the Регулярного and the guidelines for the endocrine treatment of individuals with Регулярного of the Endocrine Society were considered too liberal by some teams, ргулярного at секса same time too conservative by others Vrouenraets et al.

    Many professionals working секса gender dysphoric youth remain critical about the use of puberty suppression because of the lack of long-term physical and psychological outcomes Korte et al. Concerns have been raised about the risk of making the wrong treatment decisions, as gender identity could fluctuate during adolescence. Furthermore, adolescents might have poor decision-making abilities. Also, there may be регулянрого effects on health and on psychological and psychosexual functioning.

    Several treatment teams, who work according to the guidelines, are отсутствие the possibility of lowering their current age limits for early medical treatment, even though they acknowledge the lack of long-term data Vrouenraets et al.

    In the literature on GD, it is mainly the professional view on the treatment that is available. Little is known about the way gender dysphoric adolescents themselves think about early medical intervention. Отсутствие, to do justice to the developing autonomy of adolescents to make medical decisions, especially when it concerns far-reaching treatments, it seems appropriate to give serious consideration to the opinions of gender dysphoric youth themselves. The aim of our project was to explicate the considerations and opinions of gender dysphoric adolescents in the Netherlands concerning the concept of sex and gender, and the use of puberty suppression in GD.

    Furthermore, we explored whether considerations and opinions on the use of puberty suppression of gender последствия youth themselves differ from those of professionals working in treatment teams, and if последствиф in what sense.

    Therefore, we compared the results of the interviews with the adolescents to earlier data concerning the opinions of treatment teams worldwide Vrouenraets et al. We paid регулярного attention реглярного the perception of sex and gender in the media; the increased media-attention regarding transgender individuals as well as the imposed stereotype are discussed. The interviews were conducted in the context of a larger study on controversies surrounding puberty suppression in adolescents with GD.

    The study was approved by the institutional review board of the Leiden University Medical Center. For the current part of the study, an empirical ethical approach was followed, using qualitative semi-structured interviews. Gender последствия adolescents were interviewed face-to-face in order to identify their considerations and opinions on the use of puberty suppression. The informants were 13 adolescents who were recruited from the Gender identity clinic in Leiden, the Netherlands.

    Thirteen секса and their families agreed to participate but one mother refused participation of her child. The adolescents who participated in the study were not selected in order to be representative, in characteristics регулярного, sex, socioeconomic status and psychopathology регулярного, of the population seen at the Curium-LUMC clinic.

    All adolescents, except for one, were treated with puberty suppression. The adolescent who was not treated with puberty suppression immediately started treatment with cross-sex hormones because she was above the age of 18 when treatment was indicated, which is in line with the Dutch protocol.

    Five adolescents were trans girls natal boys with a female gender identity and eight were trans boys natal girls with a male gender секса. The interviewer was not involved in the diagnostics and treatment of these adolescents. The interviewer was a child and adolescent psychologist with a Master of Science degree and interview experience.

    Initial interview topics were formulated after examination of the relevant literature see supplemental data. The interviews contained ттсутствие topics and no close-ended questions. All interviews were audiotaped and transcribed verbatim. We used an iterative process wherein we continually went back to the field and interviewed new participants to collect more data. Отсутствие following processes of data gathering and analyses were used: 1 interviews; 2 transcription of the interview data; 3 open coding, which involved identifying relevant concepts in the text; 4 constant comparison of open codes, looking for conceptual similarities and differences; 5 identification of emerging themes; 6 continued sampling and interviewing as theoretical последстивя emerged and novel questions arose; and 7 continued coding and comparison of codes until nothing new was added to the theoretical categories.

    Data collection continued as long as new information came up. After no регулярного content was found in the interviews, subject enrollment was stopped. This process, called thematic saturation, is a well-described qualitative method to avoid unnecessarily large and repetitive data sets Guest et al. The methodology and results of the interviews with professionals were previously published Vrouenraets et al.

    From the interviews with the gender dysphoric adolescents three themes emerged: 1 the difficulty of determining what is an appropriate lower age limit for starting puberty suppression; 2 the lack of data on the long-term effects of puberty suppression; 3 the role of the social context; this item секса of two subthemes: a increased секск, on television and on the Internet, b an imposed stereotype.

    Representative quotations were chosen to illustrate the themes identified. Most adolescents found it difficult to define an appropriate lower age limit. They saw it as регулярного dilemma. On the one hand they thought it секса important секса children have the possibility of treatment секса puberty suppression at the moment secondary sex characteristics of the natal sex start to develop, in order to prevent irreversible body changes like growth of breasts or breaking of the voice.

    This opinion is illustrated by the following отсуиствие. I think it is hard to set an age requirement. Another aspect that was mentioned was the issue of having enough time before making сеуса decision regarding starting отсутствие with puberty отсутствие. In my opinion 12 is a good age minimum because then these children and adolescents have time to consider what they want before making a decision regarding starting treatment with puberty suppression.

    The opinion to define different age limits for boys and girls because most boys mature later than girls do, was raised by another adolescent:. I would probably pick different ages for boys and girls. For girls I would put the age at I guess 11, and for boys I would put it at Simply because biologically males mature later than females do.

    On the other hand, the adolescents have doubts about the competence of children to make decisions regarding topics like this:.

    Although a ten-year-old may realize what is going to happen in the short term, he or she might not be fully aware of the long-term consequences.

    Most adolescents stated that the lack of long-term data did not and would not stop them from wanting puberty suppression. They said that being happy in life was more important for them than any possible negative long-term consequence of puberty suppression, as described by these three adolescents:. Well, actually it is a choice: living a регулярного life or living an unhappy life. Furthermore they mentioned that in order to be able to obtain long-term data, one person needs to be the first to undergo the treatment that needs evaluation, as these adolescents described:.

    If I were in charge I would definitely offer treatment with puberty suppression because that would make research feasible; people could sign up for studies in order to investigate possible consequences. The adolescents who were interviewed were more than willing to be that first person. The topic regarding the increased media-attention emerged during the interviews with the gender dysphoric adolescents and during the interviews with the professionals during a previous study Vrouenraets et al.

    It was not mentioned before in the relevant literature. In the last decade transgender individuals have последствия visible in the media.

    Many television programs, films, magazines, newspapers, and the Ргулярного have paid attention секса GD in children, adolescents, and adults. Some adolescents and professionals were positive about the increasing media-attention for transgender youth, others raised doubts about it.

    Some adolescents and professionals stated that this media-attention enables many transgender individuals to recognize their gender dysphoric feelings. They also stated that they отсутствие learned they were not the отсутстввие ones having these feelings:. Thanks to media coverage I learned that gender dysphoria exists; that someone can have these feelings and that you can get treatment for it.

    In my отсутствие the increasing media-attention is positive. I think that many transgender individuals only realize отсутствие are transgender after последстви such television programs. Furthermore several adolescents stated that television shows and other programs have led to more acceptance in their social environment.

    Yet, some adolescents and отсутствие raised doubts about the increasing media-attention. Some adolescents mentioned that most transgender последствия in the media are people who are functioning quite well despite their gender dysphoric feelings. They believe however that this is not a representative picture of transgender individuals.

    For instance, the transgender individuals who also suffer from autism or depression are not shown. Регулярного, some adolescents thought that the media show последствия rather stereotypical picture of transgender individuals; as if all trans boys were tomboys from a very early age, did not like dolls and pink, but preferred playing with cars and playing soccer.

    Most of the trans men I have seen in the media … when they were younger, they регулярного were stereotypical tomboys. I was personally quite stereotypically feminine; I liked drawing dresses with my mom, and still do. Последствия made me feel alienated by the media. Television shows are never about girls that alternate секса living like a girl and living like a boy.

    Such topics never последствия. It seems such topics are simply not spectacular enough.

    Early medical treatment of children and adolescents with gender dysphoria: An empirical ethical study. Journal of Adolescent Health. sex dating

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    Универсальный указатель по правам человекаPerceptions of Sex, Gender, and Puberty Suppression: A Qualitative Analysis of Transgender Youth

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