In Patch five, I will be using evidenced-based literature investigating 5 different research papers, critically analysing how they fall in line with my innovation. Additionally, I will be implementing the critical appraisal tool CASP to pick out three common themes within the evidenced-based literature that supports my change in practice which is providing training to nurses on gender dysphoria within children and adolescents.
When finding evidenced-based literature to support my innovation I wanted to follow the PICO table (Eriksen and Frandsen 2018) study highlights how the PICO table is a support to help refine a study question, promoting a more accurate clinical search. The PICO table is a widely used method, which breaks down a question as shown to get more accurate results, PICO stands for population, intervention, control, and outcomes. (Raich and Skelly 2013) However, there was a lack of academic journals on CINHAL in child and adolescence gender dysphoria, I only received 1 article. This shows even within the clinical journals there is a lack of research and clinical investigations in child and adolescent gender dysphoria. However, to discover further academic journals I searched the key words shown in the PICO table in google Scholar, this received many hits. I found 101 articles, when reducing the limitations to 2015-2021. In the end I got 5 articles which were appropriate therefore, I am going to focus on these as they link into my innovation.
The 5 academic articles I have selected that link into my innovation are:
- Psychosocial and Psychological Vulnerability in Adolescents with Gender Dysphoria: A ‘Proof of Principle’ Study' By (Bechard et al 2017)
- Taking the lid off the box': The value of extended clinical assessment for adolescents presenting with gender identity difficulties' By (Churcher Clarke and Spiliadis 2019)
- Autistic Symptoms in Children and Adolescents with Gender Dysphoria' By (Van der Miesen 2018)
- Trans People's Experiences of Mental Health and Gender Identity Services: A UK Study' By (Ellis, Bailey and McNeil 2015)
- Gender Dysphoria in looked after and adopted young people in a gender identity development service.' By (Matthews et al 2019)
As indicated my innovation is very challenging when finding effective academic evidenced-based research, Gender dysphoria is still not a widespread condition which is shown to have a lot of evidence and research as many health care professionals such as doctors and nurses do not get the adequate training in this condition, therefore there is lack of clinical investigations. To deal with the analysis of each 5 academic article I will follow the CASPS tool. (Long, French and Brooks 2020) presents how the CASP tool is key in the development of evidence-based practice, helping individuals to develop skills in understanding research evidence, and how to apply this into practice. Again, (Aveyard, 2019) indicates how the CASP tool contains 10 questions to appraise qualitative research, allowing it to be easier to understand the sample, data collection, data analysis and results from a study to be able to pick out the negatives and positives in a study comparing and contrasting throughout.
From all the articles gathered from the PICO search method (Bechard et al 2017) quantitative study considered the psychosocial and psychological vulnerability in adolescents with gender dysphoria, this study did take place in United States however it explored the mental health disorders adolescences face going through gender dysphoria. The quantitative methodology in this study was a case series conducted over a telephone interview with 15 different risk factor variables scored through a youth self-report form and child behaviour checklist. The results supported the literature in the psychosocial and psychological vulnerability in adolescences with gender dysphoria as over half of adolescences had suicidal intentions alongside with one quarter having at least one suicide attempt. (Bechard et al 2017) study had many strengths which linked into my innovation these were it provided an understanding into the importance of providing children and adolescences struggling with gender dysphoria with high quality care as adolescents who were referred to gender dysphoria services had an occurring history of psychological conditions. Additionally, the quantitative method was easy to analyse and link into current nursing practices however there was a limitation. As the study did not have a clinical controlled group of adolescents, results may not have been as accurate as shown nevertheless this study investigates the importance of support for children and adolescences going through gender dysphoria as they are more vulnerable to develop mental health conditions.
(Churcher Clarke and Spiliadis 2019) present a Qualitative study used over an 18-month period to identify young people who present to GIDs during their adolescence, who wish to purse medical interventions. When investigating the study using the CASPs tool, it is shown throughout the importance of psychosocial assessments before any medical interventions proceed. This qualitative study follows an appropriate case review methodology of 12 participants emerging with having gender dysphoria in their adolescence. Results concluded 7 out of 12 participants no longer felt the need of medical intervention, two case studies shown in the study expressed how two young individuals no longer felt the need to change their identity after psychosocial assessments and family support group sessions. The strength of (Churcher Clarke and Spiliadis 2019) qualitative research is it highlighted the importance of assessments in young people who struggle with their identity, providing a positive framework through results being consistent and pracised with literature. However, there were limitations with the study as providing a qualitative case study review through psychosocial assessment some young participants did not stay engaged due to distress in medical intervention. Linking this into my innovation for nurses to be able to be aware of the signs of gender dysphoria will help children and adolescents get the correct referrals and treatments, preventing them from any long-lasting consequences such as mental health disorders or irreversible changes to their gender.
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On the other hand, another study which is important when associated to my innovation is (Lehmann et al 2020) qualitative study of examining the autistic traits which are shown within adults and adolescents accessing gender-affirming treatments in Northern Ireland. Appropriate methodology was used with 123 participants 38 adolescents and 69 adults who attend specialist gender services. The strengths within this study are it recognises the purpose of the literature and the problems within health services in not providing the correct pathways for gender dysphoria individuals who show significant social and communication difficulties. (Lehmann et al 2020) Highlighted the likelihood of individuals seeking gender-affirming interventions in the future present with autism traits. Weaknesses within the study is it did not have a comparison group so researchers cannot be certain whether higher rates of autism traits are only apparent in those seeking gender interventions. This study helps back up the importance in my innovation in providing nurses training in child and adolescent gender dysphoria as nurses can consider autistic traits and symptoms when assessing and treating a child or adolescent with gender dysphoria.
(Ellis, Bailey and McNeil 2015) shown a UK mixed method survey examining the mental health of trans people alongside with their experiences of being trans in two health care setting which are: mental health services and gender identity clinics. The mixed method research shown is a methodology survey for conducting research that involves fixed and open qualitive responses around trans-gender experiences in health settings, transphobia, current past mental health, and social support. Through much critical reflection there are weaknesses in mixed-method studies shown by (Noyes et al 2019) these are it is more time-consuming and relays on more researchers to be involved. Nonetheless, Strength within (Ellis, Bailey and McNeil 2015) survey is it matched the purpose of the study as results shown all together participants felt health professionals lacked knowledge around trans issues and experiences failing to provide support when needed, this backs up my innovation expressing the importance of providing training to nurses on gender dysphoria as they will be able to effectively communicate with children and adolescence struggling with their identify alongside with understanding the issues they face within society. Overall, the study expressed how much trans individuals mental health can be deuterated through ineffective support, unreasonable waiting time for referrals and stereotypical beliefs.
(Matthews et al 2019) quantitative study investigates the frequency of looked-after and adopted young people within referrals to GIDS to recognise if there is a higher-than-expected referral compared to the general population. The methodology is a quantitative descriptive research taken over two years following different variables, results shown out of 185 young people referred to GIDS for intervention, 4.9% were looked-after young people and 3.8% were adopted making up 8.6% of referrals. The strengths within this study are it provides a framework with outcomes that supports the presented literature, investigating how abuse and neglect has shown to be a common background in looked-after and adopted young people, so childhood trauma can be associated with difficulties in young people identifying their gender. (Matthews et al 2019) One key limitation that is shown is data results could lack information as they were taken from referral letters and clinical notes. Implementing this study into my innovation, paediatric nurses will have a better understanding of the links between gender identity issues and looked-after children, could also give nurses an insight to safeguard children and adolescences who are adopted or looked after as they are greater risk of emotional distress and negative outcomes.
Mental health
In the majority of the 5 studies, it was apparent that there was a common theme of children and adolescences having a risk of developing mental health disorders in gender dysphoria. (Ellis, Bailey and McNeil 2015) highlighted how in the trans community individuals fear to speak out about mental health as it will be perceived as a symptom of being trans. Critical appraisal from (Bechard et al 2017) and (Churcher Clarke and Spiliadis 2019) studies express fears that children and adolescences have high exposure to transphobic trauma which can leader to a future of mental disorders. Additionally, gender dysphoria is a concept still overlooked within society even now when social media playing a role in educating individuals, this still can be overshadowed by discrimination and stereotypical beliefs. Again (Matthews et al 2019) qualitative study shows a theme of neglect causing mental health problems by health practitioners as they do not have an adequate understanding in gender dysphoria and the daily struggles, they face promoting poor communication and ineffective referral treatments. Therefore, my innovation is vital as it will give paediatric nurses the competence in providing effective care for children and adolescences going through gender dysphoria.
Autism
An alternative key theme throughout the different studies was the relationship between autism traits and gender dysphoria in children and adolescences. (Lehmann et al 2020) presents how adults and adolescences show social and communication difficulties, which can be linked to autism traits. (Bechard et al 2017) study results also links to autism traits as one young participant who was newly diagnosed in gender dysphoria had a long-standing history of social difficulties particularly with girls in her school, this could be a motivation in wanting to change gender as she could not communicate with her own gender progressing into questioning her own gender identity. (Lehmann et al 2020) and (Matthews et al 2019) studies likewise signifies if health practitioners had a better understanding in gender dysphoria and the relationship with autism, more effective care would be promoted, with the combination of screening tools to identify autism quick providing positive pathways in gender medical interventions.
Childhood Trauma
When exploring the 5 studies, it is clear to see how childhood trauma plays a role in the confusion of child and adolescence gender dysphoria. (Matthews et al 2019) explores how early experiences of trauma impacts on gender identify development as looked-after and adopted young people may express their hard experiences through the difficulty of comprehending their gender identity. Consequently, young people with early experiences of trauma in their childhood may struggle having discussions about what their future holds and what gender they would prefer to be as they do not understand who they will become. (Matthews et al 2019) Critical analysis from (Churcher Clarke and Spiliadis 2019) and (Bechard et al 2017) studies indicate childhood trauma can also be developed from bullying in school when one adolescence openly speaks out about their sexual identity and gender but are knocked back by holistic approaches in peers, triggering detachment from social interaction proceeding in questioning their gender identity. The importance in my innovation will allow nurses to understand If a child or adolescence has experienced trauma which has triggered them to question their gender identity, be able to act on this getting them referred to GID for psychosocial assessments as (Churcher Clarke and Spiliadis) Study has shown some adolescences do not want to change their identify but open about past experiences.
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