On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.101 n.2 Cape Town Feb. 2011
Breaking down attitudes and ignorance about gender dysphoria
Not many doctors will have come across trans-gender patients, given the relatively low prevalence of gender dysphoria, itself a term hardly likely to have been included in their prescribed medical school textbooks. Yet those who have, with a few notable exceptions, have hardly covered themselves in compassionate glory,1 if you listen to those who've sought their help. In Izindaba, Chris Bateman explores this rare condition and what services exist to address it in South Africa while interviewing Lex Kirsten,2 whose openness about his journey from being born a girl to becoming a man is deeply courageous and educational.
Kirsten is a co-founder of Gender Dynamix, a human rights organisation promoting freedom of expression of gender identity and advocating for the rights of transgender, transsexual and gender non-conforming people and providing them with resources.
The catalyst for the reportage was a pioneering inaugural conference held in Hout Bay late last year where trans-gender men and women, health care providers and the national Department of Health met to establish a long-awaited research and policy agenda.
They called for the 'de-pathologisation' of the current transgender diagnosis from 'Gender Identity Disorder' to 'Gender Incongruence' in the Diagnostic and Statistical Manual of Mental Disorders (DSM5).
TB: control failure and prison effects
Control failure. South Africa's tuberculosis control has failed. Wood and colleagues explain the problem and explore ways of dealing with this.3
The TB programme has primarily focused on effective case management of passively presenting TB cases, and progress has been recorded towards international treatment targets. But while outcomes for notified cases of TB have improved, this strategy has failed to contain the TB epidemic. In South Africa (SA) TB notifications have increased fivefold over the past 20 years, and SA now has the third-highest TB burden after India and China. SA was responsible for approximately 25% of the global burden of HIV-associated TB cases in 2007. The 2009 Cape Town (population 3.4 million) notification of 31 095 cases represents double the number of TB cases reported in the USA (population >300 million). South Africa has the highest per capita annual risk of TB disease of comparably sized countries globally, and its communities have extremely high TB transmission rates. The TB rates of children and adolescents are now similar to those 100 years ago in Europe before the advent of chemotherapy.
High rates of HIV testing of HIV patients and use of other data allow analysis of TB notifications and a better idea of TB epidemiology. Improved understanding of the major drivers of the TB epidemic allows reasons for failure and new control strategies to be identified.
TB and the prison time bomb. Most citizens are unaware of the appalling circumstances that many prisoners in our prisons have to endure. While the ideal is to rehabilitate prisoners, they are often recruited into criminal gangs. O'Grady and colleagues, in their editorial on TB in sub-Saharan prisons,4 provide a stark reminder that prisons are also potentially a health time bomb.
The incidence of TB in sub-Saharan Africa (SSA) is very high at over 300 new cases of TB per 100 000 population in 2007. The incidence of multi-and extensively drug-resistant tuberculosis (MDR-TB and XDR-TB) is also increasing. The prevalence of TB in SSA prisons is estimated to be 6 -30 times higher than in the general population. Restricted and confined conditions for prisoners and prison staff, poor nutrition, poor ventilation, stress and inadequate prison health services are conducive to the emergence and transmission of drug-resistant TB, which can then spread in the community. Prisons in SSA have no proper isolation facilities to treat MDR/XDR-TB. Other serious infectious diseases are also rapidly transmitted in prisons, including HIV, respiratory and skin infections, and STDs.
To achieve TB control SSA governments must focus and take action on all aspects of the TB problem, including TB in confined institutions such as prisons.
Junior doctors: burnout and skills retention
Burnout is defined as the syndrome of emotional exhaustion, depersonalisation and reduced personal accomplishments. Stodel and Stewart-Smith5 evaluated the degree of burnout among junior doctors at Red Cross War Memorial Children's Hospital and its influence on skills retention in the hospital. They note that there has been an increase in the migration of medical doctors worldwide, with an exodus of doctors from South Africa. Along with the effects of HIV/AIDS, this places extra strain on those who remain.
The authors found a significantly high degree of emotional exhaustion and depersonalisation experienced by the junior doctors. Burnout resulting from high levels of stress at work can contribute to the exodus of health care workers. Recruitment, improved management and planning, increased support, mentorship and a more empathetic administration were some of the factors suggested to mitigate the burnout experienced by the junior doctors.
Research that led to human heart transplantation
Much experimental work over many decades preceded the first human heart transplant by Chris Barnard in 1967. Hassoulas6 provides a fascinating overview of this work, which ultimately resulted in fame for Barnard and South Africa.
1. Bateman C. Trans-gender patients sidelined by attitudes and labelling. S Afr Med J 2011;101:91-93. [ Links ]
2. Bateman C. Life on the inside; coming out - Lex's story. S Afr Med J 2011;101:94-95. [ Links ]
3. Wood R, Lawn SD, Johnstone-Robertson S, Bekker L-G. Tuberculosis control has failed in South Africa - time to reappraise strategy. S Afr Med J 2011;101:111-114. [ Links ]
4. O'Grady J, Mwaba P, Bates M, Kapata N, Zumla A. Tuberculosis in prisons in sub-Saharan Africa - a potential time bomb. S Afr Med J 2011;101:107-108. [ Links ]
5. Stodel JM, Stewart-Smith A. The influence of burnout on skills retention of junior doctors at Red Cross War Memorial Children's Hospital: A case study. S Afr Med J 2011;101:115-118. [ Links ]
6. Hassoulas J. Heart transplantation: Research that led to the first human transplant in 1967. S Afr Med J 2011;101:97-101. [ Links ]