Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for t...

A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas

Background: Every person who seeks health care should be affirmed, respected, understood, and not judged. However, trans and gender diverse people have experienced significant marginalization and discrimination in health care settings. Health professionals are generally not adequately prepared by current curricula to provide appropriate healthcare to trans and gender diverse people. This strongly implies that health care students would benefit from curricula which facilitate learning about gender-affirming health care. Main body: Trans and gender diverse people have been pathologized by the medical profession, through classifications of mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD). Although this is changing in the new ICD-11, tension remains between depathologization discourses and access to gender-affirming health care. Trans and gender diverse people experience significant health disparities and an increased burden of disease, specifically in the areas of mental health, Human Immunodeficiency Virus, violence and victimisation. Many of these health disparities originate from discrimination and systemic biases that decrease access to care, as well as from health professional ignorance. This paper will outline gaps in health science curricula that have been described in different contexts, and specific educational interventions that have attempted to improve awareness, knowledge and skills related to genderaffirming health care. The education of primary care providers is critical, as in much of the world, specialist services for gender-affirming health care are not widely available. The ethics of the gatekeeping model, where service providers decide who can access care, will be discussed and contrasted with the informed-consent model that upholds autonomy by empowering patients to make their own health care decisions. Conclusion: There is an ethical imperative for health professionals to reduce health care disparities of trans and gender diverse people and practice within the health care values of social justice and cultural humility. As health science educators, we have an ethical duty to include gender-affirming health in health science curricula in order to prevent harm to the trans and gender diverse patients that our students will provide care for in the future.

No abstract available.

There is strong international evidence that students of rural origin, and those who intend to practise rural medicine, are more likely to practise in rural settings after graduation.2 The purpose of this study was to survey final-year medical students about their career plans and the influences on those plans, to ascertain implications for the future training of doctors in South Africa. MethodsFinal-year students at all 8 South African medical schools were asked to complete anonymous self-administered questionnaires during 2007 and 2008. Their geographical origin was defined as where they reportedly grew up. ResultsQuestionnaires were completed by 876 (67%) of the 1 306 students surveyed. Sixty per cent were women, the mean age was 24.7 years (SD 3.3 years), and 92% (N=797) were South African citizens. Of the 846 respondents who indicated their place of origin, 50% had grown up in a city, 30% in small towns, and 20% in rural areas.The majority (84%) planned to remain in the medical field as a career. Forty-one per cent (47% women v. 33% men; p<0.0001) of 849 respondents were not inclined to work overtime during most of their careers. Ten per cent planned to work part-time only, and a third (34% women v. 28% men; p=0.1) planned to take a few years' break (excluding maternity leave) from their careers.More than half (55%) of the 743 students of South African nationality planned to work abroad, either for a year or two (73%) or more (20%). The remaining 7% intended to relocate permanently. Between 47% (of 876 students) and 59% (of 700 who responded to the question) planned to work for a time in rural areas after specialising. Twice as many planned to work for most of their careers in the private rather than the public sector (28 -41% v. 14 -19%; p<0.0001).Those of rural or small-town origin (N=350) were less likely than those of city origin (N=376) to want to work abroad (p<0.001), were more likely to want to work in rural areas (p<0.0001), and were less likely to want to spend most of their career in the private sector (p<0.05). Among respondents planning to work abroad, those of non-urban origin were more likely to work there short-term than those of urban origin (p<0.001).Although only 47% of respondents had made a definite career choice, 93% nevertheless indicated their first choice of specialty. Internal medicine (including sub-specialties) was the leading choice overall (22%) and among women (21%). Surgery (including sub-specialties) was second overall (20%), the top choice of men, and the second-ranked choice of women (26% v. 16%; p<0.001). Paediatrics was the third-placed choice overall (12%). It was significantly more popular among women than men (16% v. 6%; p<0.001), as was obstetrics and gynaecology (11% v. 6%; p<0.05).

The findings indicate an association between the application of clinical audit and quality improvement in resource-limited settings. Co-interventions introduced after the baseline audit are likely to have contributed to improved outcomes. In addition, support from the relevant government health programmes and commitment of managers and frontline staff contributed to the audit's success.

Chronic conditions, particularly HIV, TB and non-communicable diseases, represented much of the disease profile in the internal medicine department. Of the comorbidities investigated, the greatest contributor to length of stay was HIV/TB co-infection. Factors such as HIV, TB and substance use that increase length of stay cannot be impacted upon by the district hospital staff in isolation. To improve the health of communities, we require partnerships between doctors, community health providers and patients with their families. Multimorbidity was widespread, suggesting the need to include an understanding of multimorbidity, including the patient perspective, in medical education and health system reform.

BackgroundIn Tanzania, a country of 42 million, access to oral morphine is rare.AimTo demonstrate the effectiveness of palliative care teams in reducing patients’ pain and in increasing other positive life qualities in the absence of morphine; and to document the psychological burden experienced by their clinical providers, trained in morphine delivery, as they observed their patients suffering and in extreme pain.SettingOne hundred and forty-five cancer patients were included from 13 rural hospitals spread across Tanzania.MethodA mixed method study beginning with a retrospective quantitative analysis of cancer patients who were administered the APCA African POS tool four times. Bivariate analyses of the scores at time one and four were compared across the domains. The qualitative arm included an analysis of interviews with six nurses, each with more than five years’ palliative care experience and no access to strong opioids.ResultsPatients and their family caregivers identified statistically significant (p < 0.001) improvements in all of the domains. Thematic analysis of nurse interviews described the patient and family benefits from palliative care but also their great distress when ‘bad cases’ arose who would likely benefit only from oral morphine.ConclusionPeople living with chronic cancer-related pain who receive palliative care experience profound physical, spiritual and emotional benefits even without oral morphine. These results demonstrate the need for continued advocacy to increase the availability of oral morphine in these settings in addition to palliative care services.