Multiple Mental Health Problems Research Articles

Nurses' perceived barriers to the delivery of person-centred care to complex patients: A qualitative study using theoretical domains framework.

To determine nurses' perceived barriers to the delivery of person-centred care to complex patients with multiple chronic conditions in acute care settings. Complex patients have multiple physical and mental health problems, and their life is also greatly affected by sociocultural and economic determinants of health. These patients require person-centred care, but nurses often find it challenging to provide effective care to these patients due to their complex health needs. A descriptive qualitative design was used. The COREQ guidelines were followed for reporting. Semi-structured interviews were conducted with a purposive sample of 19 nurses in two hospitals. Data were analysed using deductive thematic analysis guided by the Theoretical Domains Framework, which entails 14 domains about factors affecting behaviours. The key barriers were identified under environmental context and resources, social influences, emotions, knowledge and skills domains. Deep-rooted social issues delay patients' health-seeking and nurses' abilities to understand patients' needs and discern appropriate care. Interpersonal hostility influenced nurse-patient-families interactions, and doctor-nurses conflicts affected collaborative efforts towards optimal care. Nurses' perceived barriers to care were intertwined with the deep-rooted social and cultural beliefs about nurses' image, patients' expectations and families' preference for home remedies over specialised nursing care. These barriers to person-centred care demonstrate an intricate interplay of personal, social and organisational issues and power struggles. Multifaceted implementation strategies targeting environmental context and resources, social influences, emotions, knowledge and skills domains may be beneficial to enable nurses to provide better person-centred care to complex patients. Designing implementation facilitation teams, organising person-centred care grand rounds, and allocation of stress management resources to address hostility, social-cultural influences, and organisational barriers is essential. Nurses could focus on their self-awareness and collaborative skills to address emotional and interprofessional conflicts.

Role of Telemental Health During the COVID-19 Pandemic: An Early Review

Context: The demand for remote psychologist services increased during the COVID-19 outbreak due to the emergence of multiple mental health problems. Many countries have applied telemental health approaches to managing and treating mental disorders. This review study aimed to investigate the role of information technology, especially telemental health, in managing psychological problems during the COVID-19 pandemic. Evidence Acquisition: This study was conducted in four phases: Identification, screening, eligibility, and inclusion. Keywords were selected from MeSH to search the principal medical databases. Finally, important information was extracted from nine selected papers, including the author names, study setting, purpose, technology, method, intervention, and results. Results: Some studies provided telepsychiatry to people whose mental problems developed during COVID-19. Another study explained the telepsychological service for patients with mental illness before the epidemic. Most articles signified the influential role of telehealth in screening and reducing social contacts. Besides, this technology played a significant role in providing mental health services. Conclusions: The study showed that telemental health and telepsychiatry approaches effectively promote the mental health and well-being of participants with various mental problems. In implementing these approaches, some items such as allocating sufficient funds, preparing appropriate infrastructure, providing training for users, defining suitable evaluation methods, and considering confidentiality and privacy need to be considered.

Unmet healthcare needs among middle-aged and older adults in China.

Unmet healthcare needs have increasingly been recognised as an indicator of equity of healthcare access and utilisation, having the potential to capture frailty of health and social protection systems. This study aimed to estimate the prevalence of unmet healthcare needs and its correlates among middle-aged and older adults in China. This study is based on analyses of the China Health and Retirement Longitudinal Study carried out in 2011 among Chinese adults aged 45years and above. Multivariable logistic regression models were conducted to examine associated factors, stratified by rural or urban residence. Reasons for having unmet needs for inpatient and outpatient services were also analysed. Among 14,774 participants, the prevalence of unmet healthcare needs was 13.0% (95% confidence interval 12.3-13.8%) and was higher in rural areas. The most prevalent reasons for unmet need for inpatient and outpatient care were 'not enough money' and 'illness is not serious, don't need treatment', respectively. The respondents who were unmarried, employed, had poor self-reported health, needed help with activities of daily living, reported lower life satisfaction, multiple chronic conditions and depressive symptoms had increased odds of unmet healthcare needs. This study suggests that unmet healthcare needs are more concentrated among people living with multiple health conditions and mental health problems in China. If universal health coverage goals and sustainable development goal 3 are to be met, it is essential that effective mechanisms for addressing unmet healthcare needs are identified.

STARC-SUD - Adaptation of a Transdiagnostic Intervention for Refugees With Substance Use Disorders.

Refugees often suffer from multiple mental health problems, which transdiagnostic interventions can address. STARC (Skills-Training of Affect Regulation - A Culture-sensitive Approach) is a culturally sensitive transdiagnostic group intervention that has been developed for refugees to improve affect regulation. In refugees with substance use disorders (SUD), the consideration of SUD-specific elements might improve the acceptance and effectiveness of such an intervention. We aimed to adapt the STARC program for refugees with SUD in a culturally sensitive way. The conceptual framework of Heim and Kohrt (2019) was used to culturally sensitively adapt the STARC program to the needs of Syrian refugees with SUD. The results of five focus group discussions with refugees on cultural concepts of SUD and their treatment informed the adaption. An expert group suggested adaptions and decided by consensus on their implementation. Two pilot groups were conducted with the adapted STARC-SUD program. Interviews with the therapists of these pilot groups informed further adaption. The concepts related to SUD identified in focus groups and therapists' interviews that differed from Western concepts were integrated into the STARC intervention. Further studies should assess the acceptance and effectiveness of the culturally sensitive STARC-SUD program for refugees with SUD.

Androgen abuse and the brain.

Purpose of reviewThe purpose of this review is to examine the recent evidence regarding the effects of exogenous androgens on the brain. Understanding these effects is of high importance, as the consequences of androgens on the reproductive and endocrine system are well documented, while fewer studies have focused on the neural and cerebral consequences of androgen use.Recent findingsSupraphysiological doses of androgens have been shown to contribute to neurodegeneration, decreased brain-derived neurotrophic factor, increased inflammation and decreased neuronal density in animal studies, which may correspond to changes in mood, cognition and aggression. Findings from human studies suggest that similar behavioural and cognitive deficits may occur as a result of prolonged use of androgens. Additional evidence suggests that androgen use, particularly in high doses, may contribute to brain ageing and cerebrovascular problems.SummaryFindings from recent human and animal studies indicate that androgen use likely contributes to brain alterations, which may cause the frequently observed deficits in cognitive and emotional functioning. Although exogenous testosterone in appropriate doses for therapeutic purposes likely have some neurobiological benefits for certain populations, supraphysiological doses may cause multiple mental and physical health problems, indicating a need for additional large-scale studies in humans.

General v. specific vulnerabilities: polygenic risk scores and higher-order psychopathology dimensions in the Adolescent Brain Cognitive Development (ABCD) Study.

Polygenic risk scores (PRSs) capture genetic vulnerability to psychiatric conditions. However, PRSs are often associated with multiple mental health problems in children, complicating their use in research and clinical practice. The current study is the first to systematically test which PRSs associate broadly with all forms of childhood psychopathology, and which PRSs are more specific to one or a handful of forms of psychopathology. The sample consisted of 4717 unrelated children (mean age = 9.92, s.d. = 0.62; 47.1% female; all European ancestry). Psychopathology was conceptualized hierarchically as empirically derived general factor (p-factor) and five specific factors: externalizing, internalizing, neurodevelopmental, somatoform, and detachment. Partial correlations explored associations between psychopathology factors and 22 psychopathology-related PRSs. Regressions tested which level of the psychopathology hierarchy was most strongly associated with each PRS. Thirteen PRSs were significantly associated with the general factor, most prominently Chronic Multisite Pain-PRS (r = 0.098), ADHD-PRS (r = 0.079), and Depression-PRS (r = 0.078). After adjusting for the general factor, Depression-PRS, Neuroticism-PRS, PTSD-PRS, Insomnia-PRS, Chronic Back Pain-PRS, and Autism-PRS were not associated with lower order factors. Conversely, several externalizing PRSs, including Adventurousness-PRS and Disinhibition-PRS, remained associated with the externalizing factor (|r| = 0.040-0.058). The ADHD-PRS remained uniquely associated with the neurodevelopmental factor (r = 062). PRSs developed to predict vulnerability to emotional difficulties and chronic pain generally captured genetic risk for all forms of childhood psychopathology. PRSs developed to predict vulnerability to externalizing difficulties, e.g. disinhibition, tended to be more specific in predicting behavioral problems. The results may inform translation of existing PRSs to pediatric research and future clinical practice.

Treatment outcomes in individuals diagnosed with comorbid opioid use disorder and Posttraumatic stress disorder: A review

ObjectivesOpioid use disorder (OUD) is a public health emergency. Evidence suggests that posttraumatic stress disorder (PTSD) is common among individuals with OUD; however, few studies evaluate whether concurrent diagnoses affect treatment outcomes. This review examines the impact of concurrent diagnoses of OUD and PTSD on treatment outcomes. MethodsA search was performed using articles identified through June 30, 2020 in PubMed, PsycINFO, and EMBASE. Included peer-reviewed articles evaluated individuals with OUD and a PTSD diagnosis via standardized assessment and/or medical record diagnoses, and reported relationships between diagnosis and treatment outcomes and/or other psychiatric conditions. ResultsOut of 412 articles, 17 studies met inclusion criteria for this review (from 13 databases). Articles included had a total of n = 2190 with OUD, with n = 79 non-OUD comparison participants. Studies examining individuals with OUD revealed comorbid PTSD was associated with more severe addiction, higher rates of depression, attempted suicide, and psychosocial problems. ConclusionsAmong individuals with OUD, presence of PTSD is associated with multiple mental health problems. The impact of PTSD on drug use is inconclusive. Although only 5 studies examined psychosocial PTSD treatment, all found PTSD-focused treatment to be effective for those with comorbid OUD. Overall, results suggest the need to better identify PTSD among those with OUD, and to develop and evaluate interventions that are brief, integrative, and easy to implement in clinical settings.

Sex differences in experiences of multiple traumas and mental health problems in the UK Biobank cohort

PurposeExperiences of reported trauma are common and are associated with a range of mental health problems. Sex differences in how reported traumas are experienced over the life course in relation to mental health require further exploration.Methods157,358 participants contributed data for the UK Biobank Mental Health Questionnaire (MHQ). Stratified Latent Class Analysis (LCA) was used to analyse combinations of reported traumatic experiences in males and females separately, and associations with mental health.ResultsIn females, five trauma classes were identified: a low-risk class (58.6%), a childhood trauma class (13.5%), an intimate partner violence class (12.9%), a sexual violence class (9.1%), and a high-risk class (5.9%). In males, a three-class solution was preferred: a low-risk class (72.6%), a physical and emotional trauma class (21.9%), and a sexual violence class (5.5%). In comparison to the low-risk class in each sex, all trauma classes were associated with increased odds of current depression, anxiety, and hazardous/harmful alcohol use after adjustment for covariates. The high-risk class in females and the sexual violence class in males produced significantly increased odds for recent psychotic experiences.ConclusionThere are sex differences in how reported traumatic experiences co-occur across a lifespan, with females at the greatest risk. However, reporting either sexual violence or multiple types of trauma was associated with increased odds of mental health problems for both males and females. Findings emphasise the public mental health importance of identifying and responding to both men and women’s experiences of trauma, including sexual violence.

Adults referred to a national ADHD clinic in Iceland: clinical characteristics and follow-up status

Objective Evaluate adults referred to a national ADHD clinic, by comparing those diagnosed with those who were not, and those who screened negative and to evaluate changes among those diagnosed at follow-up. Method Data obtained from 531 patients’ medical records (49.7% males). One hundred thirty-six screened negative, 395 positive and 305 met diagnostic criteria for ADHD. Eighty-three of them were contacted by phone at follow-up. Results ADHD diagnosis was associated with lower educational status and more concerns expressed by parents and teachers during childhood. Participants not diagnosed with ADHD more often met diagnostic criteria for dysthymia, agoraphobia and generalized anxiety, and were more likely to be diagnosed with two or more comorbid disorders. At follow-up, all reported a significant reduction of ADHD symptoms, irrespective of medication, but the medicated participants reported fewer symptoms of inattention and better functioning in daily life. Conclusion Adults referred to ADHD clinics may have multiple mental health problems, regardless of whether they receive ADHD diagnosis or not. This could have implications for differential diagnoses of ADHD in adults and emphasises the need to have appropriate treatment available for both groups. Psychoeducation about ADHD may be very helpful in decreasing anxiety and ADHD symptoms.

Mental Health Among Children and Adolescents in Rural China: A Large-Scale Epidemiological Study

Background: Although children living in low-and middle-income countries (LMICs) account for 90% of the global population of children, mental health among children in LMICs has been understudied. This study examines the prevalence of depression and anxiety and their associations with biological and psychosocial factors among children across China, with a focus on rural areas. Methods: We conduct a large-scale epidemiological study among 53,421 elementary and junior high school-aged children across China’s rural areas. Findings: The results show that 20% are at risk for depression, 6% are at risk for generalized anxiety, and 68% are at risk for at least one type of anxiety. Girls and junior high school students show higher risk for mental health problems; socioeconomic status has varying associations to mental health. Our results also show robust correlations between mental health and cognition. Interpretation: These findings underscore the importance of identification, prevention, and treatment of youth mental health problems in underdeveloped areas. As China constitutes 15% of the global population of children under age 18, this study offers valuable information to the field of Global Mental Health, especially given its findings of high prevalence for multiple mental health problems and robust correlations between mental health and cognition. Funding Statement: This work was supported by the Enlight Foundation. Declaration of Interests: The authors have no conflicts of interest. Ethics Approval Statement: The six surveys conducted by the authors and their colleagues were approved by the Stanford University Institutional Review Board. Study permissions were also obtained from the Chinese government. In accordance with IRB requirements, all children involved in the surveys provided oral assent for the project, and the school principals – who serve as the children’s legal guardians while they are in school—also provided their written consent.

Mental Health Multimorbidity among Caregivers of Older Adults During the COVID-19 Epidemic

ObjectiveTo investigate mental health status and associated factors among caregivers of older adults during the COVID-19 epidemic in China.MethodsFrom March 1 to 31, 2020, 916 caregivers of older adults participated in an online cross-sectional survey on the prevalence of anxiety, depression, and sleep problems. The seven-item Generalized Anxiety Disorder Scale (GAD-7) was administered to measure anxiety symptoms, the two-item Patient Health Questionnaire (PHQ-2) was used to assess depressive symptoms, and a self-developed questionnaire was used to assess sleep quality and duration. Six questions about COVID-19-related experiences were used to assess community-level infection contact and the level of exposure to media information. The prevalence rates of anxiety, depression and sleep problems were computed. The Wald χ2 were applied to compare the differences between subgroups. Multiple logistic regression analyses were performed to investigate factors associated with anxiety, depression, sleep problems, and multimorbidity.ResultsThe prevalence rates of anxiety, depression, and sleep problems were 46.8%, 29.8%, and 10.8%, respectively. Approximately 263 participants (28.7%) presented with two or more mental health problems. Being female (OR, 2.254; 95% CI, 1.510–3.363), having community-level COVID-19 contact (OR, 1.856; 95% CI, 1.189–2.898), and having a mental disorder (OR, 3.610; 95% CI, 1.644–7.930) were associated with increased risk of multimorbidity among caregivers. Caregivers who preferred positive information (OR, 0.652; 95% CI, 0.472–0.899) had reduced risk of multimorbidity.ConclusionAnxiety and depression were common among caregivers of older adults during the COVID-19 epidemic. Being female and having community-level COVID-19 contact were independent risk factors for experiencing multiple mental health problems. Preexisting mental disorders increased the risk of multimorbidity among caregivers, while enhanced access to positive media information decreased the risk of multimorbidity.

Lost in Transition: Health Care Experiences of Adults Born Very Preterm-A Qualitative Approach.

Introduction: Adults Born Very Preterm (ABP) are an underperceived but steadily increasing patient population. It has been shown that they face multiple physical, mental and emotional health problems as they age. Very little is known about their specific health care needs beyond childhood and adolescence. This article focuses on their personal perspectives: it explores how they feel embedded in established health care structures and points to health care-related barriers they face.Methods: We conducted 20 individual in-depth interviews with adults born preterm aged 20–54 years with a gestational age (GA) below 33 weeks at birth and birth weights ranging from 870–1,950 g. Qualitative content analysis of the narrative interview data was conducted to identify themes related to self-perceived health, health care satisfaction, and social well-being.Results: The majority (85%) of the study participants reported that their former prematurity is still of concern in their everyday lives as adults. The prevalence of self-reported physical (65%) and mental (45%) long-term sequelae of prematurity was high. Most participants expressed dissatisfaction with health care services regarding their former prematurity. Lack of consideration for their prematurity status by adult health care providers and the invisibility of the often subtle impairments they face were named as main barriers to receiving adequate health care. Age and burden of disease were important factors influencing participants' perception of their own health and their health care satisfaction. All participants expressed great interest in the provision of specialized, custom-tailored health-care services, taking the individual history of prematurity into account.Discussion: Adults born preterm are a patient population underperceived by the health care system. Longterm effects of very preterm birth, affecting various domains of life, may become a substantial burden of disease in a subgroup of formerly preterm individuals and should therefore be taken into consideration by adult health care providers.

Implementing a transdiagnostic sleep and circadian intervention in a community mental health setting: A qualitative process evaluation with community stakeholders

The implementation of evidence-based psychological treatments (EBPTs) may be particularly challenging to accomplish in community mental health settings for individuals with severe mental illness (SMI). Transdiagnostic treatments, or treatments that target a mechanism that underpins multiple mental health problems, may be particularly well-suited to community mental health settings. This study examines community stakeholder perspectives (N = 22) of the Transdiagnostic Sleep and Circadian Intervention (TranS-C) implemented in a community mental health setting in the context of a randomized controlled trial of TranS-C for SMI. The present study aimed to identify barriers and facilitators to the implementation of TranS-C for SMI in a community mental health setting using (1) a deductive theory-based process based on the Framework for Dissemination in Health Services Intervention Research and (2) an inductive thematic analysis process. All deductive themes were identified as both barriers and facilitators to the implementation of EBPTs and TranS-C in this community mental health setting. Seven additional themes were identified through the inductive thematic analysis. A discussion of how the findings are related to prior research, other EBPT implementation, and future TranS-C implementation are included.

Cyber-victimisation and mental health in young people: a co-twin control study.

The rise of social media use in young people has sparked concern about the impact of cyber-victimisation on mental health. Although cyber-victimisation is associated with mental health problems, it is not known whether such associations reflect genetic and environmental confounding. We used the co-twin control design to test the direct association between cyber-victimisation and multiple domains of mental health in young people. Participants were 7708 twins drawn from the Twins Early Development Study, a UK-based population cohort followed from birth to age 22. Monozygotic twins exposed to greater levels of cyber-victimisation had more symptoms of internalising, externalising and psychotic disorders than their less victimised co-twins at age 22, even after accounting for face-to-face peer victimisation and prior mental health. However, effect sizes from the most stringent monozygotic co-twin control analyses were decreased by two thirds from associations at the individual level [pooled β across all mental health problems = 0.06 (95% CI 0.03-0.10) v. 0.17 (95% CI 0.15-0.19) in individual-level analyses]. Cyber-victimisation has a small direct association with multiple mental health problems in young people. However, a large part of the association between cyber-victimisation and mental health is due to pre-existing genetic and environmental vulnerabilities and co-occurring face-to-face victimisation. Therefore, preventative interventions should target cyber-victimisation in conjunction with pre-existing mental health vulnerabilities and other forms of victimisation.

The relationship between early risk-taking behavior and mental health problems among a nationally representative sample of Australian youth

BackgroundEarlier engagement in risk-taking behaviors has been associated with more severe mental health problems across development. However, sex differences in risk-outcome relationships remain underexplored and mental health outcomes spanning both ends of the internalizing and externalizing spectra are rarely considered within the same sample. The present study examined associations between age at initiation of alcohol use, illicit drug use, and sexual intercourse, and symptoms of internalizing, externalizing, depression and self-harm, for males and females. MethodsThe present study analyzed self-report survey data from a nationally representative sample of Australian adolescents (N=2,950). Logistic regression models were conducted separately for males and females to test the association of early (age 15 or younger) and concurrent (age 16–17) initiation of alcohol use, illicit drug use and sexual behavior with symptoms of internalizing, externalizing, depression and self-harm at age 16–17. ResultsRisk-taking behaviors were associated with all mental health outcomes. Generally, earlier initiation of risk-taking behaviors demonstrated stronger associations with mental health outcomes than concurrent initiation. Associations between risk-taking behaviors and mental health outcomes varied by participant sex and mental health outcome. LimitationsMechanisms underlying the relationship between risk-taking behaviors and mental health problems were not tested and the sample had not yet reached early adulthood. ConclusionsRisk-taking behaviors, particularly when initiated early, share links with multiple mental health problems in adolescence. Public health strategies to delay the onset of risk-taking behaviors may therefore incur multiple benefits as might an integrated approach to mental health prevention programs for youth.

Research progress on current situation and preventive measures for the narcotic and psychotropic drugs abuse in the elderly

Both narcotic and psychotropic drugs are more often used to alleviate related multiple physical or mental health problems, but these drugs are very easily addicted to. With the aging of population, abuse of narcotic drugs and psychotropic drugs among the elderly are called for more attention. In this paper, harms caused by the abuse of anesthetic and psychotropic drugs, current situation and causes related to the abuse of anesthetic and psychotropic drugs as well as risk factors and preventive measures regarding the abuse of anesthetic and psychotropic drugs, among the elderly, are reviewed.

A critical review of current evidence on multiple types of discrimination and mental health.

Little is known about people who experience multiple types of discrimination (e.g., racism and heterosexism). While some work suggests that multiply discriminated groups are at higher risk for poor mental health, other studies propose that they may develop resilience against additional kinds of discrimination. We conducted a review of published studies on the relationship between multiple types of discrimination and mental health to critically examine evidence in support of broad risk and resilience models. Using PRISMA guidelines, we identified 40 studies that met our inclusion criteria. Typically, studies examined either whether experiencing multiple discrimination was related to poorer mental health, or whether one kind of discrimination was more predictive of poor mental health. Studies generally showed support for the risk model, with multiple forms of discrimination associated with higher risk for depression symptoms. Furthermore, both racism and heterosexism uniquely predicted symptoms of depression, although initial evidence suggested that only heterosexism predicted suicidality among lesbian, gay, bisexual, transgender, and queer (LGBTQ) racial/ethnic minorities. Findings on multiple discrimination and other mental health problems (e.g., anxiety, posttraumatic stress disorder [PTSD], distress, and substance use) were mixed. The current evidence suggests that multiply discriminated groups exhibit higher risk for some mental health problems, particularly depression symptoms. However, methodological problems abound in this literature (e.g., correspondence between study sample and types of discrimination assessed), which limits our ability to draw clear conclusions about multiple discrimination. We propose that to further our understanding of how multiple kinds of discrimination may affect mental health, studies must remedy these and other issues. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Intensive home treatment for adolescents in psychiatric crisis

BackgroundAdolescents with acute psychiatric disorders are typically treated with long-term clinical admission. However, long term admission may be associated with a variety of negative outcomes. This pilot study presents a new model of care, that is, the combined application of intensive home treatment and the possibility of short term stay at a psychiatric high & intensive care.MethodsIn total 112 referred adolescents with mixed diagnoses participated in this longitudinal observational design. Clinical outcome was measured by the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) which measures the severity of multiple mental health problems. The HoNOSCA was clinician-rated at intake, after two months and after four months at discharge. Change in HoNOSCA total score was analysed with paired t-tests. Outcome moderators were gender, age, primary diagnosis, clinical admission, home treatment-time, medication and additional therapies. Follow up data were completed for 62 patients after two months and for 53 after four months.ResultsParticipants aged between 11 and 18 years (M = 14.8 years, SD = 0.3; 52% female). Mean HoNOSCA total score at intake was 18.8 (SD = 5.2), after two months 13.0 (SD = 5.0); after four months resulting in a score of 9.3 (SD = 5.2). None of the moderators tested showed a significant effect on HoNOSCA scores. However, a control group could not be used because of the severe psychopathology and high risk for suicidality and the lack of an effective treatment intervention for a comparable study group.ConclusionWith a symptom decrease of over 50% within four months as measured by the HoNOSCA, including less risk for hospitalization, this new model appears promising and of clinical relevance. Nevertheless, further research regarding stability of treatment outcome is warranted and evaluation of long-term effects of this model in follow-up studies is needed.

Systematic review of facilitators of, barriers to, and recommendations for healthcare services for child survivors of human trafficking globally

BackgroundChild trafficking is associated with multiple physical and mental health problems, yet relatively little is known about the factors that facilitate or hamper delivery of high-quality health care services to trafficked children. ObjectiveTo summarize information about identified facilitators of, barriers to, and recommendations for medical and mental health service provision to trafficked children. Participants and settingA systematic review was conducted of the English-language, peer-reviewed literature on medical and mental healthcare of trafficked children published since 2010. MethodsInclusion criteria were: (1) the study population or focus included, wholly or in part, individuals under the age of 18 years; (2) the study focus was clearly defined as human trafficking or commercial sexual exploitation; (3) a main focus included health services or barriers to care, and (4) the article contained original data. ResultsOf the 29 articles meeting inclusion criteria, 19 included facilitators of health service provision to trafficked populations, 22 included barriers to that provision, and 25 included explicit recommendations for service improvement. 45 distinct facilitators were identified a total of 140 times, 118 distinct barriers were identified a total of 174 times, and 52 distinct recommendations were identified a total of 100 times. The majority of facilitators, barriers, and recommendations fell under the locus of the healthcare provider and healthcare organization. ConclusionsExisting research reveals abundant areas of opportunity for healthcare professionals and healthcare administrators to improve access to, and quality of, medical and mental health care for trafficked children.

Is Gender Identity Discrimination a Religious Freedom Issue?

Currently, there are certain provisions in Australian law that exempt faith-based organisations from the operation of laws that prohibit discrimination on grounds of gender identity or 'being transgender'. This paper explores whether there is a religious basis for discrimination on the ground of gender identity, with particular reference to how faith-based schools make decisions about children and young people who seek to transition to a new gender identity – with or without parental agreement. While it has long been the case that a very small proportion of people, from early childhood right through to adulthood, identify as feeling they are of the opposite sex, there are reasons to be concerned about the number of adolescents who are now claiming to be 'transgender' – especially natal females. The research indicates that many of these children and young people have multiple mental health problems or are on the autism spectrum, and may have experienced abuse and other adverse life events. There is also some evidence for social contagion amongst friendship groups. The etiology of transgender identification remains poorly understood from a medical perspective. Identification with a gender identity different to natal sex is often accompanied by various beliefs that are incapable of either validation or falsification by science. These include that biological sex and gender are two different things; that gender is what you feel, that gender is fluid, and that it is possible to be “non-binary”. These beliefs conflict not only with religious understandings of the created order, but also with a mainstream understanding that gender is innate and people are not just 'assigned' a gender at birth. The Christian response to children or young people who are experiencing gender identity issues must be pastoral and compassionate, and focused on their best interests; but this does not mean agreeing with their beliefs. There is thus a basis for a religious exemption to prohibitions on discrimination based upon gender identity, if the law is understood to require that the person be accepted as the gender with which they now identify. However, if the law is understood as requiring only that a person should not engage in discriminatory conduct (for example refusing service in a restaurant), then there is no valid basis for a religious exemption. Beyond the issue of religious exemptions, there are compelling reasons not to legislate that any professional working with children or young people has to accept a young person’s self-identified gender identity against his or her professional judgment. Schools need to be free to adopt a pastoral approach, guided by appropriate health professionals, and based upon their assessment of what is in the best interests of the child or young person.