Vector Volume 12 Issue 2 - 2018

V O L U M E 1 2 I S S U E 2 F O U N D E D 2 0 0 6
FEATURE: Manifesto à la
mode (p.2)
REVIEW: Pornography - the
psychological and
REVIEW: Pornography - the
neurobiological effects of a
psychological and neurobiological
$97 billion industry (p.14)
effects of a $97 billion industry (p.15)
FEATURE: Manifesto
à la mode (p.2)
ORIGINAL RESEARCH:
Comprehensive
healthcare interventions
ORIGINAL RESEARCH: Comprehensive
in Ethiopian STI clinics
healthcare interventions in Ethiopian 1 STI
(p.36)
clinics (p.33)

Advisory Board
The Advisory Board consists of academic mentors who provide guidance for the present and future
direction of Vector Journal.
Dr Claudia Turner
Consultant paediatrician and clinician scientist with the University of Oxford and chief executive officer
of Angkor Hospital for Children.
Professor David Hilmers
Professor in the Departments of Internal Medicine and Pediatrics, the Center for Global Initiatives, and
the Center for Space Medicine at the Baylor College of Medicine.
Associate Professor Nicodemus Tedla
Associate Professor in the School of Medical Sciences at the University of New South Wales.
Dr Nick Walsh
Medical doctor and regional advisor for viral hepatitis at the Pan American Health Organization / World
Health Organization Regional Office for the Americas.
Thank you to the peer-reviewers of Vector Journal 12 Issue 2:
Professor Michael Toole AM
Dr Rahul Gupta
Dr Paul Simpson
Associate Professor Nicodemus Tedla
Dr Stuart Wark
Dr Bridget Haire
Dr Renju Cherian
Vector Journal 2018 Committee
Editor-in-chief
Aidan Tan aidan.tan@amsa.org.au
Senior Editors
Nicholas Mattock
Associate Editors
Sophia Moshegov
Matthew Martin
Simran Dahiya
Tasmyn Soller
Koshy Mathew
Aimy Yan
Kyrollos Hanna
Tessa Tan
Nina Li
Publication Director
Nina Li
Promotion Director
Tessa Tan
Design and layout
© 2018, Vector Journal
vector.amsa.org.au
Content
© 2018, The Authors
Cover design image by Ryoji Iwata, accessed from https://unsplash.com/photos/_dVxl4eE1rk. Backpage design image by Cristian Newman, accessed
from https://unsplash.com/photos/wGKCaRbElmk.
Vector Journal is a peer-reviewed and student-run global health journal.
Responsibility for article content rests with the respective authors. Any views contained within articles are those of the authors and do not
necessarily reflect the views of the Vector Journal.
i

CONTENTS
Foreword 1
Aidan Tan
FEATURES
Manifesto à la mode 2
Aneka R Larsen
Exploring the ethics and legality of conducting clinical trials in developing nations 6
Rosemary B Kirk
The changing landscape of artificial neural stimulation and its introduction to the developing
world 10
Stephanie Kirkby
REVIEWS
Pornography: the psychological and neurobiological effects of a $97 billion industry 14
Bridie H Peters
Improving interactions between transgender and other gender-diverse persons and the healthcare
system 18
Meredith Grey & Imogen Janus
The public perception of major depressive disorder in South Asia: a literature review 24
Marisse Sonido
Guidelines for low birth weight: a literature review comparing national guidelines in Lao PDR with
WHO guidelines 28
Line M Pederson
ORIGINAL RESEARCH
The experience of Mekelle University in provision of comprehensive healthcare interventions at
STI clinics for FSWs in Ethiopia 36
Tesfay Gebregzabher Gebrehiwot
EDITORIAL
An open letter to our social media overlords 43
Nina Li
CONFERENCE REPORT
United Nations Climate Conference 46
Georgia Behrens & Katherine Middleton
BOOK REVIEW
There is No Me Without You 50
Juliana Wu
ii

Foreword
Aidan Tan
Once, standing ankle deep in the wet sand, I thought that I heard
the Pacific Ocean in a conch shell. The conch shell, I theorised, was
an Earth-bound black hole in thermal equilibrium, absorbing the
temper of the tide and emitting a lost Vivaldi, ‘The Four Seasons of
the Submerged’. Turns out, there are no oceans in conch shells, only
the attenuated frequencies of ambient noise in a calcium carbonate
cavity. I prefer the ocean.
Now, with an active imagination and origami instructions,
you can turn this issue of Vector Journal into your own conch
shell. If you listen carefully, you might just hear a call for ethical
fashion by medical students, debate on clinical trials in developing
nations, dialogue on developments in artificial neural stimulation,
discussion on the effects of internet pornography, report on
transgender and other gender-diverse persons, critique of South
Asian perceptions of depression, summary of low birth weight
in Laos, study of sexually transmitted infections in Ethiopia,
commentary on social media causing psychological distress, recount
of the United Nations Climate Conference, or review of a book on
AIDS in Africa. Whatever you hear, I hope it strikes a chord with you.
1

Manifesto à la mode
Feature article
Aneka R Larsen
Aneka R Larsen is a final year medical student at the University of Sydney
who spends far too much time thinking about clothes, and not enough
time studying.
Despite what your mother may have told you,
it’s not just what’s on the inside that counts. As
medical students, our external image matters
greatly. We dress to impress, to show patients
that we are capable and trustworthy. But how
would our patients feel if they knew who made
our clothes? Sustainable fashion is by no means
a new idea, and most people I know support
the idea, yet many of us still wear brands that
are known to engage in unethical practices.
Although we as medical students generally wish
to improve others’ quality of life, too often we
put ethics on the backburner as we convince
ourselves that we are too busy, too tired, too
whatever-it-happens-to-be that day, to think of
the consequences of our actions. If we were truly
compassionate, it would seem incongruent that
we would not also express this in choosing which
brands to support.
After becoming increasingly concerned, I
discussed the issue with a friend who told me
that given the opportunity, most people will
choose to do good. That is, most people don’t
want to benefit from the exploitation of others
but will unthinkingly ignore the reality of how
most clothes are made. Every day we are exposed
to marketing on billboards, bus stops, shop
windows, YouTube, Facebook, fashion blogs, and
Instagram feeds. Our first thought is not ‘who
made this?’, but ‘I want that’. It’s automatic, and
that’s why it works. I choose to believe that my
peers are not consciously deciding to fund a
harmful industry, and that instead their choices
simply reflect a lack of opportunity to consider
their purchases. Here is said opportunity. Think
carefully and buy ethically, so as to avoid a fashion
faux-pas that’s more than just embarrassing—
one that results in child slavery, abysmal wages
and factory collapses causing thousands of
deaths. If you would like to join me in protesting
an industry that fuels the maltreatment and
exploitation of others, then read on. This is my
manifesto to fashion, and all the illnesses, injuries
2

and deaths that it can cause when not held
accountable.
Do no harm
The famous, perhaps trite,
Hippocratic oath often comes to
mind when considering the part
that many medical students have
played in the illnesses inflicted on
sweatshop workers. It is a turn of
phrase strongly associated with
the medical profession, and one
that most doctors and medical
students take very seriously.
While much has changed since
the oath was created 2,500 years ago, human
nature is still very much the same. This oath is
important because it sets clear boundaries for
minimum decency. To paraphrase Hippocrates,
—‘Guys, I know you’re busy and all, but at least
don’t give Bangladeshi women gastric ulcers and
deprive them of food and sleep for days on end.’
Bangladeshi sweatshop workers receive one of
the lowest minimum wages in the world,[1] and
women often feel obliged to prostitute themselves
at work for extra money.[2] To help understand
how severely impoverished they are, let’s take into
account their average monthly wage, 3000 taka,
which is approximately $50 Australian Dollars.
Working 16 hours a day for 7 days a week, they
have made the shirt on your back for 10 cents an
hour. For an extra 7 cents an hour, they would
have enough to meet the “living wage”,[3] defined
as “the minimum required to provide a family with
shelter, food and education”.[3] If you add on the
other burdens associated with sweatshops; the
cramped living, lack of maternity care, and risk of
silicosis from all the sand blasting so your denim
can have that worn aesthetic, Hippocrates would
be turning in his grave.[4]
No cause justifies the deaths of innocent
people
Averting the deaths of innocent civilians
seems like another no-brainer, but in a globally
reported disaster in April 2013, an eight-story
sweatshop in Dhaka, Bangladesh, collapsed,
killing over a thousand people and injuring over
two thousand.[5] The sweatshop supplied clothes
to international brands such as Primark and H&M.
‘Our first
thought is not
who made this,
but I want that’
[5, 6] While this disaster was widely discussed, it is
one of many examples of the deaths inflicted on
Bangladeshi workers. Another 7 deadly accidents
were reported to have occurred in Bangladesh
between 2005 and 2015.[7] An
example of the response from
companies involved is the one
provided by H&M after the Rana
Plaza collapse. “It is important
to remember that this disaster
is an infrastructure problem in
Bangladesh and not a problem
specific to the textile industry”.
[8] This response shifts the blame
to a poverty-stricken country and
should not absolve them from
participating in the exploitation of Bangladeshi
workers. Although these disasters may seem far
away from our comparatively comfortable lives,
the deplorable crimes committed by the fashion
industry are being committed by the fashion
industry in our names. Many of the clothing
brands worn by my peers here in Australia
have been remonstrated for their manufacture
practices, including Tigerlily, UNIQLO, Gorman,
Ralph Lauren, Lacoste, Boohoo, and Dotti.[9]
Choosing which pretty dress or flash new suit to
buy for the next ball can seem like a life or death
situation, but instead of only stressing over which
looks best, also ask yourself where and how it
was made. There are actual lives at stake, not just
social ones, and they are lives that you can help to
save simply by asking the right questions.
Practice what you preach
Do what your favourite soul singer tells you to
do and “Practice What You Preach” (Barry White,
1994). How could you resist that deep baritone
anyway? Sustainable fashion is generally seen as
an ethical “thumbs up”, and yet so many people
don’t practice it. There are a range of reasons that
beliefs may not necessarily transfer to action, but
the difficulty in keeping track of which brands
treat their workers fairly seems to be a key one.
One way to combat this challenge is to refer to
an organisation that conveniently does it for you,
such as Ethical Clothing Australia (ECA), which
maps the local supply chain of brands to ensure
the fair treatment of clothing workers. It provides
a list of those brands which provide fair wages
and decent living conditions, and its website lists
A Kmart t-shirt‘s $3 price tag may be appealing to some, but
their supply chain is untraceable and the workers receive a
“minimum wage”, less than a “living wage”, the amount required
to meet basic costs of living.
3

these brands for your perusal. Some included
brands are Cue, Manning Cartell, Thurley, Scanlan
Theodore and Nobody.[10] As a general rule,
however, it helps to ask if the price tag on an item
really reflects the amount of work that went into
making it.[11] A Kmart t-shirt‘s $3 price tag may
be appealing to some, but their supply chain is
untraceable and the workers receive a “minimum
wage”, less than a “living wage”, the amount
required to meet basic costs of living.[11] When
considering price, it is obviously very important
to acknowledge that not everyone can afford to
pay for organic, handmade clothes. Some ways
to overcome this include participating in the
events run by charities like Fashion Revolution
that work at raising awareness, shopping secondhand
so that your money does not go directly to
exploitative companies, learning to make your
own clothes and writing to companies to put
pressure on them to subscribe to ethical practice.
[12] Go on, make Barry proud.
There are alternatives to supporting exploitative
fashion labels. Protesting the unethical choices
of the fashion industry doesn’t mean you have
to look like a hessian sack. Fashion is about
making you feel like your best self, which is hard
to accomplish when your new look endorses
an industry that is directly responsible for the
illnesses, injuries and deaths of women and
children from third world countries. Next time
you’re worried about committing a fashion fauxpas
at Med Ball, remember your commitment to
improving the lives of others. That commitment
shouldn’t just remain within the confines of the
hospital.
Acknowledgements
None
Photo credit
Ricardo Gomez Angel, accessed from https://
unsplash.com/photos/rNXy6ngoyQ0
Conflict of interest
None declared
Correspondence
alar9706@uni.sydney.edu.au
References
1. International Labour Organisation, Characteristics
of minimum wage setting system and minimum wage
levels, [Internet]. Available from: https://www.ilo.org/
wcmsp5/groups/public/---asia/---ro-bangkok/documents/
genericdocument/wcms_223988.pdf, (accessed 2 September
2018)
2. Inter Press Service News Agency, Women Suffer Most in
Garment Sweatshops in Bangladesh, [Internet], 1998. Available
from: http://www.ipsnews.net/1998/12/labour-bangladeshwomen-suffer-most-in-garment-sweatshops/,
(accessed 25
August 2018).
3. War on Want, Sweatshops in Bangladesh [Internet].
Available from: http://www.waronwant.org/sweatshopsbangladesh
(accessed 20 March 2017).
4. Akgun M, Araz O, Ucar EY, Karaman A, Alper F,
Gorguner M, et al. Silicosis Appears Inevitable Among Former
Denim Sandblasters: A 4-Year Follow-up Study. Chest.
2015;148(3):647-54.
5. The Independent, Bangladesh factory collapse: 41
charged over deadly Rana Plaza tragedy, [Internet], 2015.
Available from: http://www.independent.co.uk/news/world/
asia/bangladesh-factory-collapse-41-charged-over-deadlyrana-plaza-tragedy-a6781876.html,
(accessed 22 March 2016).
6. Clean Clothes Campaign, Evaluation of H&M
Compliance with Safety Action Plans for Strategic Suppliers
in Bangladesh, [Internet], 2015. Available from: https://
cleanclothes.org/resources/publications/hm-bangladeshseptember-2015.pdf,
(accessed 25 August 2018).
7. CBC, Timeline: Deadly factory accidents in Bangladesh,
[Internet]. Available from: http://www.cbc.ca/news2/
interactives/timeline-bangladesh/, (accessed 22 March 2016).
What you need to know:
• The fast fashion industry is responsible for illnesses,
injuries and deaths of sweatshop workers internationally.
• Workers live in cramped living conditions, do not have
access to maternity care, receive exploitative wages and are
exposed to occupational hazards ranging from silicosis to
factory collapses.
• The ubiquitous nature of fast fashion makes it particularly
difficult to forgo, however.
• This article aims to raise awareness of the issue and outline
some simple steps that we can take to minimise the amount
we each contribute to this harmful industry.
4

8. Business and Human Rights Resource Centre, Response by
H&M: Rana Plaza factory collapse in Bangladesh; over 1100 dead,
[Internet], 2013. Available from: https://business-humanrights.
org/sites/default/files/media/documents/company_responses/
h&m-response-re-bangladesh-building-collapse.pdf, (accessed
20 March 2017)
9. Baptist World Aid, The 2018 Ethical Fashion Report,
[Internet]. Available from: https://baptistworldaid.org.au/
resources/2018-ethical-fashion-report, (accessed 25 August 2018)
10. Ethical Clothing Australia, Brands, [Internet], 2016, http://
ethicalclothingaustralia.org.au/brands/, (accessed 20 March 2017)
11. Choice, Ethical clothing, [Internet], 2014. Available from:
https://www.choice.com.au/shopping/everyday-shopping/
clothing/articles/ethical-clothing#ethically, (accessed 22 March
2016).
12. Independent, Katharine Hamnett interview: How to shop
ethically on a student budget, [Internet], 2014. Available from:
www.independent.co.uk/student/student-life/katharine-hamnettinterview-how-to-shop-ethically-on-a-student-budget-9882406.
html, (accessed 22 March 2016).
5

Exploring the ethics and legality of conducting clinical
trials in developing nations
Feature article
Rosemary B Kirk
Rosemary B Kirk is a fourth year medical student at the University of New
South Wales. She has an interest in research and bioethics, and the point
where the two intersect.
Introduction
The number of clinical trials conducted in
developing countries has increased dramatically
in recent decades due to globalisation and
increased need for trial subjects. For example,
between 2002 and 2007 the number of United
States (US) sponsors conducting pharmaceutical
research abroad increased by 15% annually,
while US-based trials decreased by 5.5%.[1] All
trials involving human subjects require ethical
discussion, and this is of particular importance in
developing nations, where risk of exploitation is
high. In this article I will describe the legislation
surrounding these trials, summarise the benefits
of clinical trials to developing nations and
researchers, analyse the ethical issues raised
by this practice through a principles-based and
utilitarian lens, and discuss how future legislation
could align the potential benefits of these trials
with reality.
Legislation surrounding clinical trials
To understand why clinical trials in developing
countries are conducive to exploitation, the
issues with the legislation in place must first be
understood.
International
Numerous international bodies have created
documents outlining clinical trial guidelines. One
of the most commonly referenced documents
is the Declaration of Helsinki (DoH), developed
and regularly updated by the World Medical
Association. International guidelines such as this
are not legally binding, but are referred to in the
legislation of many countries.[2]
These international guidelines have
been criticised for being vague and thereby
allowing researchers to circumvent their
recommendations.[3] For example, the DoH
states that new interventions must be tested
against the current best intervention, that
researchers should make provisions for posttrial
access to their intervention, and that
medical research on a group is only justified if
6

it is responsive to their health needs.[4] However,
the DoH lists circumstances in which placebo use
is acceptable, does not specify the duration of
availability or price of the intervention post-trial,
and does not define how significant a health need
must be for a community to justify participation
in a trial.
Developed nations
Developed nations have regulations to
protect subjects in trials within their country that
are enforced by ethics committees. However,
depending on who is funding the research, such
regulations do not always have to be followed
when conducting research internationally.[5] It
can also be problematic to apply laws from one
culture to another. For example, in
the US, sponsors do not have to
compensate subjects for treatment
of research-related injuries, but
this cannot reasonably be applied
to nations where subjects cannot
afford treatment.[6]
Developing nations
Developing nations are less
likely to have established and
financially-supported clinical trial
regulation, and the increase in
clinical trials in developing nations
in recent years has overwhelmed
existing ethical review systems.[7]
This makes it easy for researchers
to avoid investigation, and a 2004
study found that 44% of studies in developing
nations did not undergo any review from the
country in which they took place.[8]
Arguments for clinical trials in developing
countries
For companies
The advantages for companies of conducting
clinical trials in developing countries are
numerous. Costs are significantly reduced as a
result of lower salaries, cheaper facilities, and less
time being required to receive approval for a trial.
[9] Participant recruitment is also easier, due to
the higher prevalence of diseases and paucity of
treatment options.[10] Finally, subjects are less
likely to have received prior treatment, increasing
result significance.[2]
For communities
While it can be easy to assume that clinical trials
in developing nations are inherently exploitative,
these trials are not without their benefits to local
communities. Trials provide pharmaceuticals
to people who may otherwise have extremely
limited access, and if the recommendations made
in the DoH are implemented, these communities
may have continued access to the drugs being
‘...44% of
studies in
developing
nations did not
undergo any
review from the
country in which
they took place’
tested.[11] Furthermore, through conducting
clinical trials, researchers can provide equipment
and knowledge to advance local research, and
can boost local economies.[12]
Ethical perspectives
If research is conducted ethically and following
international guidelines, it is possible for all of the
benefits described above to be realised. However,
as long as clinical trials in developing countries
are not properly policed, there are ethical issues
implicit in this practice and a risk of exploitation.
While there are countless ethical issues to be
considered in this area, I will focus on the issues of
informed consent, the dangers of trials, placebo
use, testing of interventions that
target health needs, and post-trial
availability of interventions. These
will be analysed using a principlesbased
and a utilitarian lens.
Autonomy
Autonomy describes a state
in which individuals are free to
make their own decisions; one
consequence of the principle of
autonomy is informed consent.
To make decisions, people must
be provided with the relevant
information in a form they can
understand.[13] Informed consent
has particular relevance for trials
in developing nations, because
gaining consent requires understanding local
languages and analogies, and obtaining written
consent can be difficult in the context of low
education rates.[14,15] Additionally, in many
communities it is essential to also obtain consent
from elders, religious leaders, or heads of families.
[16] Thus, in order for clinical trials in developing
countries to be considered ethical from the
perspective of autonomy, researchers must show
cultural awareness in acquiring informed consent.
Beneficence and non-maleficence
Non-maleficence is the principle that actions
should not expose individuals to unnecessary
harm, while beneficence describes acting in a
manner that benefits others.[13] In any clinical
trial there is potential for significant harm to
come to study subjects. This is particularly true
when clinical trials are poorly regulated. For
example, up to 2,644 people died in clinical
trials of 475 new drugs over a 7-year period in
India, with the majority of these trials being
conducted by international sponsors.[17] In the
context of murky international legislation and
the potential for negligent trial structure and
administration, such deaths can be considered
a violation of the principle of non-maleficence
by the researchers. Conversely, clinical trials can
7

also be a force for beneficence in developing
nations through the provision of medication and
research infrastructure, as previously described.
It is thus important that the potential harms and
benefits of any trial to a community be carefully
considered in order to maximise both principles
of beneficence and non-maleficence.
A further ethical issue relating to beneficence
and non-maleficence is the use of placebos in
clinical trials, a pertinent case study being the
1994 African Zidovudine trials. These trials tested
Zidovudine as a means of preventing vertical
transmission of HIV, with comparison to control
groups who received a placebo.[18] During
the trial, many women in the control group
transmitted HIV to their offspring. This violates
the principle of beneficence, as researchers did
not act to benefit all trial subjects (which could
have been achieved by giving the control group
an existing intervention). Whether or not this
violates the principle of non-maleficence depends
on how harm is defined. If harm requires an
individual to be worse-off relative to a baseline,
then this placebo use could be considered ethical
in a nation where women otherwise receive
no treatment.[10,19] However, this creates a
double standard for developing countries, as
using a placebo when there is existing treatment
would be unethical in developed nations, as per
recommendations established in the DoH. Views
on placebos from this perspective, therefore, may
vary.
Justice
The principle of justice involves fair distribution
of scarce resources and respect for personal
rights and laws.[20] Trials in developing countries
are often for ailments primarily affecting
developed nations, such as overactive bladder
and allergic rhinitis, rather than for diseases that
disproportionately affect developing countries.
[1] People in developing nations are therefore
assuming the risks of research while receiving little
benefit. This practice is possible because there are
many health needs in developing nations and, as
previously stated, the DoH does not specify how
important a health need must be for it to be an
appropriate research target.[21] From a justice
perspective, in order for a trial to be ethical it
should target a health priority, not just a health
issue present in a community. If this principle is
followed, clinical trials may become a means of
combatting global healthcare inequalities; indeed,
as it stands today, 90% of the global healthcare
budget targets illnesses responsible for only 10%
of the global disease burden.[22]
Another issue pertaining to the principle
of justice is continued access to interventions
post-trial. Basic medications are often absent
or expensive in developing countries; therefore,
continuing to offer treatments after a trial ends
is one way of fighting this distributive injustice,
especially if the intervention is offered to a wider
community and the researchers are allied with
broader access programmes.[11]
Utilitarianism
Utilitarianism deems actions good if such
actions maximise the amount of good for
a maximum number of people.[13] Using a
utilitarian lens, it can be argued that since clinical
trials in developing countries are mutually
beneficial, imposing further constraints is not
justified.[23] For example, if placebo use was not
permitted in the African Zidovudine trials, the trial
may not have been conducted, meaning no one
would receive treatment.
In the context of extreme utilitarianism, it can
even be argued that all clinical trials in developing
countries are ethically justifiable because the
results can potentially help many more people
than might be harmed in the trial process.
Utilitarianism thus provides a very different
overall view of clinical trials in developing
countries than a principles-based perspective. In
practice, the views of most ethical theorists and
international guidelines align with a principlesbased
perspective, while some developed nations
follow the utilitarian perspective and favour
scientific arguments and economic advantages
over ethical concerns for people in developing
countries.[24]
Proposed future changes
It is evident that the current guidelines and
legislation surrounding international clinical
trials are inadequate to protect trial subjects
from exploitation. Because of deficiencies in
international legal capacity and infrastructure
in developing nations, the responsibility for
protecting subjects of clinical trials in developing
countries must fall to developed nations. Examples
of beneficial changes to current legislation
include adjusting laws to be culturally appropriate
for developing communities,[24] enforcing
governments to commit a portion of tax revenue
to research that is responsive to the health
priorities of developing countries,[21] and having
governments provide incentives to support health
policy improvement and appropriate research
practices in developing nations.[25] However,
such legislation is far from being realised, and is
unlikely to be implemented provided that current
legislation remains beneficial to developed
nations and wealthy researchers.
Conclusion
There are many layers of legislation to be
considered when conducting a clinical trial in a
8

developing nation, with considerable potential
for contradiction or legislative gaps. Trials can
therefore result in exploitation, and require
numerous ethical issues to be considered.
Exploring these issues using a principles-based
perspective reinforces the need for improved
legislation surrounding trials; conversely,
however, purely utilitarian perspectives support
maintenance of the current status quo. While
legislation is unlikely to change dramatically
in the near future, many ethicists agree that if
developed countries improve their legislation,
clinical trials in developing nations can become
a part of the solution to global health inequality,
rather than part of the problem.
Acknowledgements
None
Photo credit
Louis Reed, accessed from https://unsplash.
com/photos/pwcKF7L4-no
Conflict of interest
None declared
Correspondence
rosemary.kirk@unsw.edu.au
References
1. Glickman SW, McHutchison JG, Peterson ED, Cairns
CB, Harrington RA, Califf RM, et al. Ethical and scientific
implications of the globalization of clinical research. N Engl J
Med. 2009;360(8):816-23
2. Weigmann K. The ethics of global clinical trials. EMBO
Rep. 2015;16(5):566-70
3. Omonzejele PF. Is the codification of vulnerability in
international documents a sufficient mechanism of protection
in the clinical research ethics context?. Med Law. 2011;30:497-
515
4. World Medical Association. WMA Declaration of
Helsinki – Ethical Principles for Medical Research Involving
Human Subjects [Internet]. Geneva: The World Medical
Association; 2018 July 9 [cited 2018 Aug 10]. Available from:
https://www.wma.net/policies-post/wma-declaration-ofhelsinki-ethical-principles-for-medical-research-involvinghuman-subjects/
5. Schneider JL. Professional codes of ethics: Their role
and implications for international research. J Contemp Crim
Justice. 2006;22(2):173-92
6. Mamotte N, Wassenaar D, Singh N. Compensation for
research-related injury in NIH-sponsored HIV/AIDS clinical
trials in Africa. J Empir Res Hum Res Ethics. 2013;8(1):45-54
7. Simpson B, Khatri R, Ravindran D, Udalagama T.
Pharmaceuticalisation and ethical review in South Asia: Issues
of scope and authority for practitioners and policy makers. Soc
Sci Med. 2015;131:247-54
8. Hyder AA, Wali SA, Khan AN, Teoh NB, Kass NE, Dawson
L. Ethical review of research: A perspective from developing
country researchers. J Med Ethics. 2004;30(1):68-72
9. Alemayehu C, Mitchell G, Nikles J. Barriers for conducting
clinical trials in developing countries – a systematic review. Int
J Equity Health. 2018;17(1):37-47
10. Botha M, Zeier MD. Clinical trials in developing
countries: An overview. In: Stefan DC, editor. Cancer research
and clinical trials in developing countries. Cham: Springer;
2016. p.41-54
11. Okpechi IG, Swanepoel CR, Venter F. Access to
medications and conducting clinical trials in LMICs. Nat Rev
Nephrol. 2015;11(3):189-94
12. Lorenzo C, Garrafa V, Solbakk JH, Vidal S. Hidden risks
associated with clinical trials in developing countries. J Med
Ethics. 2010;36(20):111-5
13. McNeill P, Torda A, Little JM, Hewson L. Ethics Wheel.
Sydney: University of New South Wales. 2004.
14. Emanuel EJ, Wendler D, Killen J, Grady C. What
makes clinical research in developing countries ethical? The
benchmarks of ethical research. J Infect Dis. 2004;189(5):930-7
15. Diemert DJ, Lobato L, Styczynski A, Zumer M, Soares
A, Gazzinelli MF. A comparison of the quality of informed
consent for clinical trials of an experimental hookworm vaccine
conducted in developed and developing countries. PLoS Negl
Trop Dis. 2017;11(1):e0005327
16. Martellet L, Sow SO, Diallo A, Hodgson A, Kampmann B,
Hirve S, et al. Ethical challenges and lessons learned during the
clinical development of a group A meningococcal conjugate
vaccine. Clin Infect Dis. 2015;61(suppl 5):S422-7
17. Mahapatra D. 2,644 died during clinical trial of drugs in
7 years: Govt to SC. The Times of India. 2013 Apr 25 [cited 2018
Aug 11]. Available from: https://timesofindia.indiatimes.com/
india/2644-died-during-clinical-trial-of-drugs-in-7-years-
Govt-to-SC/articleshow/19719175.cms
18. Lavery JV, Grady C, Wahl ER, editors. Ethical issues in
international biomedical research: a casebook. Oxford: Oxford
University Press; 2007
19. Hawkins JS, Emanuel EJ, editors. Exploitation and
developing countries: The ethics of clinical research. Princeton:
Princeton University Press; 2008
20. Brizi AP, Filibeck U, Kangaspunta K, O’Neil AL.
Biomedical research in developing countries: The promotion
of ethics, human rights and justice. Italy: UNICRI; 2009
21. Hughes RC. Justifying community benefit requirements
in international research. Bioethics. 2012:28(8);397-404
22. Wertheimer A. Rethinking the ethics of clinical research:
widening the lens. Oxford: Oxford University Press; 2010
23. Mitra AG. Off-shoring clinical research: Exploitation and
the reciprocity constraint. Dev World Bioeth. 2012;13(3):111-8
24. Garrafa V, Lorenzo C. Moral imperialism and multicentric
clinical trials in peripheral countries. Cad Saude Publica.
2008;24(10):2219-26
25. Pratt B, Loff B. Health research systems:
Promoting health equity or economic competitiveness?
Bull World Health Organ. 2012;90(1):55-62
9

The changing landscape of artifical neural stimulation and
its introduction to the developing world
Feature article
Stephanie Kirkby
Stephanie Kirkby is a medical student at Deakin University. Stephanie has
previously completed a Bachelor of Science (Hons) at The University of
Melbourne, majoring in Neuroscience, where she completed an Honours
project with the National Vision Research Institute.
With Commentary from Professor Michael
Ibbotson
The artificial electrical stimulation of neurons
for the treatment of neurological disease and
impairment is a well-established field that is
undergoing rapid development in the treatment
of diseases such as Parkinson’s disease,[1]
obsessive compulsive disorder,[2] epilepsy,[3]
as well as auditory and visual impairments using
cochlear[4] and retinal implants.[5] The basic
principle underlying these treatments arises from
the inherent electrical excitability of all neurons
in the body. By using electrical impulses to
stimulate neurons, we can attempt to manipulate
their functions. Thus, if there is a dysfunction in
the firing of some neurons in the network, we can
seek to replace them using electrodes. Generally,
this is an area of research only being explored
in the context of the developed world, however,
particularly in the case of cochlear implants, there
may soon be an evolving role for artificial neural
stimulation in the developing world.
To appreciate the potential of artificial neural
stimulation, we must first appreciate the way
in which the neural network operates. The
communication between neurons within the
brain is the primary control point of all human
behaviours, ranging from the movement of our
limbs to the control of our deepest thoughts and
emotions. These neurons communicate via unique
patterns of electrical activity within synchronous
neuronal networks, which are composed
of billions of cells. Different sensations and
behaviours each depend upon a unique subset
of neurons within this synchronous network for
10

their function. For instance, the neurons recruited
for vision differ in appearance, location, electrical
signature, and distribution when compared
to those required for hearing. However, when
the health of these neurons is compromised,
so too is their ability to produce these complex
patterns of activity. Artificial neural stimulation
takes advantage of the electrical potential of
neurons, whose function is dependent upon
the flow of charge from one cell to the next. By
injecting such neurons with an electrical stimulus
using electrodes, we can artificially generate new
patterns of neuronal activity that can replace the
role of any dysfunctional cells in the network.
Bionic vision is still in its infancy but has made
significant strides in the treatment of retinitis
pigmentosa, the leading cause of inherited
blindness.[6] There are also plans
to utilise it for the treatment
of macular degeneration, the
leading cause of blindness
in the developed world.[7] A
United States Food and Drug
Administration (FDA) approved
model, developed by Second
Sight in the USA, has already
been implanted in hundreds of
patients for the treatment of
retinitis pigmentosa,[8] restoring
‘functional vision’ to its recipients.
Functional vision is significantly
different from normal vision and
relies on ‘phosphenes’ to produce
visual percepts of the surrounding
world.[9] Phosphenes are ‘spots’
within the visual field that can be
perceived as either light or dark,
such that a recipient may be able
to perceive a horizon, navigate a
dining room table, or see obstacles
on a street. Phosphene vision is
distinct from normal vision, being
unable to depict colour or fine detail, as well as
being limited by the number of phosphenes that
a patient can see. Each phosphene corresponds
to an electrode that has been placed on the
retina, so with more electrodes, the patient will
be able to perceive more sections of the visual
field distinctly. However, there are multiple
limitations to achieving higher visual acuity with
more electrodes within retinal prostheses such
that phosphene vision remains ‘functional’ but
rudimentary compared to normal human vision.
Michael Ibbotson, Director of the National
Vision Research Institute and Professor at The
University of Melbourne believes that “the sky
is the limit” when it comes to the potential of
artificial neural stimulation. “Two key factors have
driven the rapid expansion of bionics in recent
years; the improvement of surgical techniques for
‘Despite the difficulty
inherent in reading a
text with bionic vision,
patients would prefer
to utilise that sense,
which otherwise would
be lost to them, rather
than opt for an easier
means of reading such
as an audiobook.’
implantation and the increased biocompatibility
of the materials used. Recent advances have
made it possible to both record from and
stimulate neurons in different areas of the brain.
For instance, we could record sensory neural
information from one part of the brain and then
feed it back into motor neurons to emulate more
natural movements of the body.”
“However, in many cases although we do not
perfectly replicate the original neural network’s
function, there are still significant positive
outcomes for patients psychologically to have a
lost sense restored.[10, 11] Despite the difficulty
inherent in reading a text with bionic vision,
patients would prefer to utilise that sense, which
otherwise would be lost to them, rather than
opt for an easier means of reading such as an
audiobook.” What has been
restored for these patients
is much more than their
sight or their hearing, but
rather a restoration of their
sense of self.[11]
According to Professor
Ibbotson, it seems possible
that the future of bionics
may expand well beyond
the medical world, stating
that “once it becomes
normal within medicine, it
would not surprise me if
bionics became cosmetic”.
As the technology develops
and becomes normalised
as a treatment for various
impairments and diseases,
the public may eventually
see an opportunity
for self-improvement
through artificial neural
stimulation. For instance,
breast implantation was originally developed for
mastectomy patients before it became one of the
most popular cosmetic surgeries of the modern
world. [12] “If it were possible to improve memory
function by selectively stimulating memory
circuits at particular times, this could dramatically
change the way in which students approached
education, as well as in the treatment of memory
disorders”. Although it seems closer to science
fiction than reality, the cosmetic use of artificial
neural stimulation, if it were realised, would
have the potential to increase the profitability of
this technology. If this were the case, it may be
possible to fund its use in less developed regions,
where it is currently unavailable.
The expanding range of pathologies that can
be treated by neural stimulation is promising,
particularly for the developed world, but its
11

implementation in the developing world is far more
complex.[13] There are many obvious hurdles in
utilising this technology beyond high-income
countries. The first issue is the prioritisation of
resources to ensure the greatest possible impact
on public health outcomes. There are many other
competing health priorities that require attention
before advanced interventions to improve
neurological health can be implemented.[14, 15]
“The cochlear implant appears to be the
exception to the rule” according to Professor
Ibbotson. Since its initial clinical introduction
for patients in 1985, the cochlear implant has
undergone significant developments and is
now widely utilised in the treatment of hearing
impairment, particularly in paediatrics where its
impact is more dramatic in younger brains due
to increased neuroplasticity. The cochlear implant
has also seen recent introductions into low and
middle-income countries in South America,
Egypt, India and China, where it has faced multiple
ethical and practical challenges.[13] However,
recent studies have shown that its use can remain
cost-effective, even in regions where there is a
scarcity of health resources.[13] This is largely due
to both the use of low-cost materials and the high
health benefit associated with hearing restoration
in patients.
The health priorities of patients also need to be
aligned with access to neural implants, regardless
of the product’s availability. If patients do not
feel the need for such health interventions, then
such interventions are unlikely to be utilised. For
instance, the cochlear implant is still met with
some resistance in the deaf community due to the
fear of compromising their cultural identity. [16]
Visual impairment is one such example
where there is a significant variation between
the priorities of the developing world and the
developed world. In low-income countries,
cataracts are the leading cause of blindness, [17]
whilst in the developed world, the leading cause
of blindness is age-related macular degeneration.
[7] Naturally, there is a gap in the prioritisation of
treatment availability where surgical intervention
is a successful treatment for cataracts but remains
difficult to deliver to disadvantaged regions of
the world. The treatment of age-related macular
degeneration and other degenerative retinal
diseases has inspired the development of the
bionic eye, but is less likely to be considered a
treatment priority for the developing world until
it becomes far more affordable.
Global health priorities are consistently evolving
to reflect the needs of the wider population.
Although it may be in the distant future, the wider
utility of artificial neural stimulation will remain
unclear until the technology has sufficiently
advanced. It will be important for patients to
have an awareness and understanding of such
technology in the future, so that it is more likely
to be accepted as a potential treatment for future
health initiatives.
At a recent public forum, Professor Ibbotson
also reported that one of the primary concerns
of the public surrounding the use of neural
implants was the potential for ‘mind control’. This
demonstrates a significant gap in the public’s
understanding of what artificial neural stimulation
aims to achieve, as well as what it is capable of.
The potential for this type of neural control is wellbeyond
the capabilities of current technology,
which aims to stimulate otherwise inactive local
networks of the brain to restore a lost function
such as vision or hearing.[18] However, these
patient concerns are still important to consider if
such technology is ever to be widely implemented
in medicine in the future.
The human brain is infinitely complex and
research is only recently gaining significant
momentum in our understanding of its function.
The development of artificial neural stimulation
is an expanding field for the treatment of
degenerative neural diseases. Although this
technology is in its infancy, it has enormous
potential for public health outcomes in both the
developed and developing worlds, which are yet to
be fully realised. The range of pathologies treated
with artificial neural stimulation is expanding as
rapidly as our understanding of the brain itself,
making the development of this research an
important area to watch in the future of medicine.
‘Although it may be in the distant future, the
wider utility of artificial neural stimulation will
remain unclear until the technology has sufficiently
advanced. It will be important for patients to have an
awareness and understanding of such technology in
the future, so that it is more likely to be accepted as
a potential treatment for future health initiatives.’
12

Acknowledgements
Commentary and revisions provided by Professor
Michael Ibbotson.
Photo credits
Meo, accessed from https://www.pexels.
com/photo/photo-of-head-bust-printartwork-724994/
Conflict of interest
Stephanie Kirkby is currently working with the
National Vision Research Institute on a followup
project relating to her Honours research with
Professor Michael Ibbotson.
Correspondence
skirkby@deakin.edu.au
References
1. Aviles-Olmos I, Kefalopoulou Z, Tripoliti E, Candelario
J, Akram H, Martinez-Torres I, et al. Long-term outcome of
subthalamic nucleus deep brain stimulation for Parkinson’s
disease using an MRI-guided and MRI-verified approach. J Neurol
Neurosurg Psychiatry. 2014; 85: 1419-25
2. Alonso P, Cuadras D, Gabriëls L, Denys D, Goodman W,
Greenberg BD, et al. Deep brain stimulation for obsessivecompulsive
disorder: a meta-analysis of treatment outcome and
predictors of response. PloS one. 2015;10(7): e0133591
3. Cukiert A, Cukiert CM, Burattini JA, Lima AM. Seizure
outcome after hippocampal deep brain stimulation in a
prospective cohort of patients with refractory temporal lobe
epilepsy. Seizure. 2014;23(1):6-9.
4. Mäki-Torkko EM, Vestergren S, Harder H, Lyxell B. From
isolation and dependence to autonomy–expectations before and
experiences after cochlear implantation in adult cochlear implant
users and their significant others. Disability and rehabilitation.
2015;37(6):541-7.
5. Hadjinicolaou AE, Meffin H, Maturana MI, Cloherty SL,
Ibbotson MR. Prosthetic vision: devices, patient outcomes
and retinal research. Clinical & Experimental Optometry.
2015;98(5):395-410.
6. Hartong DT, Berson EL, Dryja TP. Retinitis pigmentosa.
2006;368(9549):1795-809.
7. Wong WL, Su X, Li X, Cheung CMG, Klein R, Cheng C-Y, et
al. Global prevalence of age-related macular degeneration and
disease burden projection for 2020 and 2040: a systematic review
and meta-analysis. The Lancet Global Health. 2014;2(2):106-116
8. Second Sight Announces Record Number of Argus II
Retinal Prosthesis Systems Implants and Completes First-in-
Human Orion Cortical Implant [press release]. California: Second
Sight 2018.
9. Pérez Fornos A, Sommerhalder J, da Cruz L, Sahel JA,
Mohand-Said S, Hafezi F, et al. Temporal properties of visual
perception on electrical stimulation of the retina. Investigative
Ophthalmology & Visual Science. 2012;53(6):2720-31.
10. Duncan JL, Richards TP, Arditi A, da Cruz L, Dagnelie G,
Dorn JD, et al. Improvements in vision related quality of life in
blind patients implanted with the Argus II Epiretinal Prosthesis.
Clinical and Experimental Optometry. 2017;100(2):144-50.
11. Da Cruz L, Coley BF, Dorn J, Merlini F, Filley E, Christopher
P, et al. The Argus II epiretinal prosthesis system allows letter and
word reading and long-term function in patients with profound
vision loss. British Journal of Ophthalmology. 2013;97:632-6
12. Champaneria MC, Wong WW, Hill ME, Gupta SC. The
evolution of breast reconstruction: a historical perspective. World
journal of surgery. 2012;36(4):730-42.
13. Fagan JJ, Tarabichi M. Cochlear implants in developing
countries: practical and ethical considerations. Current opinion in
otolaryngology & head and neck surgery. 2018;26(3):188-9.
14. Allegranzi B, Kilpatrick C, Storr J, Kelley E, Park BJ,
Donaldson L, et al. Global infection prevention and control
priorities 2018–22: a call for action. The Lancet Global Health.
2017;5(12):1178-80.
15. Chao TE, Sharma K, Mandigo M, Hagander L, Resch SC,
Weiser TG, et al. Cost-effectiveness of surgery and its policy
implications for global health: a systematic review and analysis.
The Lancet Global Health. 2014;2(6):334-45.
16. Goldblat E, Most T. Cultural Identity of Young Deaf Adults
with Cochlear Implants in Comparison to Deaf without Cochlear
Implants and Hard-of-Hearing Young Adults. The Journal of Deaf
Studies and Deaf Education. 2018;23(3):228-39.
17. Khairallah M, Kahloun R, Bourne R, Limburg H, Flaxman
SR, Jonas JB, et al. Number of people blind or visually impaired
by cataract worldwide and in world regions, 1990 to 2010.
Investigative ophthalmology & visual science. 2015;56(11):6762-
9.
18. Lebedev MA, Nicolelis MA. Brain-machine interfaces:
From basic science to neuroprostheses and neurorehabilitation.
Physiological reviews. 2017;97(2):767-837.
What you need to know:
• The artificial electrical stimulation of neurons for the treatment
of neurological disease and impairment is a well-established field
that is undergoing rapid development in the treatment of disease.
• The expanding range of pathologies that can be treated by
neural stimulation is promising, particularly for the developed
world, but its implementation in the developing world is far more
complex.
• According to Professor Michael Ibbotson of the National
Vision Research Institute, the future of bionics may expand beyond
the medical world and potentially be used cosmetically for selfimprovement.
• Although this technology is in its infancy, it has enormous
potential for public health outcomes in both the developed and
developing worlds, which are yet to be fully realised.
The
Lancet.
13

Pornography: the pyschological and neurological
effects of a $97 billion industry
Review article
Bridie H Peters
Bridie H Peters is a third year medical student at the University of New
England. She’s far from impartial to a chocolate dusting on cappuccinos,
a ripper sunset and some great evidence-based medicine.
“
Background
The proliferation of the Internet has fostered
a wild-fire growth of the pornography industry.
[1] Pornography is more accessible and widely
disseminated than ever before, accounting for
a quarter of all internet searches and 1.5% of all
websites.[2] However, this growth doesn’t come
without concern. The cultivation of sexual abuse,
misogyny and poor mental health are among some of
the startling accusations made against this industry.
[1,3,4] Given that 84% of Australian males and 23%
of females aged 16-25 years use this media daily
or weekly,[5] if these accusations hold water, they
may have significant and widespread impacts. The
following review aims to summarise the research on
the health effects of pornography on its users.
Compulsive pornography use and addiction
There is considerable debate as to whether
pornography has addictive potential and if it does,
whether it is comparable to those of other addiction
disorders (e.g. alcoholism, compulsive gambling).
[6] These well-established addiction disorders are
Abstract
Aims: This review aims to summarise the research exploring the health effects of internet pornography
on its users. It focuses on pornography’s addictive potential, impact on sexual behaviours and mental
health.
Methods: The relevant literature concerning the health effects of internet pornography was reviewed.
Resources were sourced from databases such as PubMed and JSTOR.
Results: This review finds significant evidence for the addictive potential of pornography, validating
the consideration of pornography addiction as a clinical diagnosis. Pornography may also cultivate
misogynistic beliefs, affect the sexual functioning of its users and have some role in promoting sexually
aggressive behaviours. Poor mental health and pornography appear to have a bi-directional association.
Conclusions: The potential health effects of pornography are extensive and well-established. Given
the ubiquitous nature of this media, there may be significant clinical implications for these findings.
”
characterised by several common thought and
behavioural patterns. These include but are not
limited to: (a) perceived lack of control over the
substance/ object of abuse; (b) adverse consequences
from is use (e.g. relationship, social, work or school
problems); (c) an inability to stop its use despite
these negative consequences; and (d) preoccupation
with the substance/ object of abuse.[7]
These symptoms are being increasingly reported
in patients who complain of pornography overuse. [6]
Pornography addiction is not at present a formallyrecognised
clinical disorder in the DSM-V or ICD-10,
however, the prevalence of these findings has led to
the widespread use of Compulsive Pornography Use
as a working clinical diagnosis. Many of the studies
mentioned in this paper have recruited patients
suspected to have this disorder. There is no consensus
on the definition of this disorder, but as with other
addictions, the aforementioned thought patterns are
characteristic[7]. The prevailing argument contesting
the recognition of Compulsive Pornography Use as a
clinical disorder is the thought that these symptoms
reflect a high sex drive in certain populations and are
not suggestive of a pathological addiction.[8]
14

The cultivation of sexual abuse, misogyny and poor mental
health are among some of the startling accusations made against
this industry.[1,3,4] Given that 84% of Australian males and
23% of females ages 16-25 use this media daily or weekly,[5]
if these accusations hold water, they may have significant and
widespread impacts.
Due to this debate, researchers have attempted
to draw direct comparisons between those with
suspected Compulsive Pornography Use and those
with addiction to substances where the disorder is
better defined and established (e.g. alcohol). One
of the hallmarks of a substance use disorder is an
increased desire for a substance without proportional
pleasure from its use.[6] On fMRI neuroimaging this
can be visualised as decreased striatal responsiveness
to dopamine as the brain becomes tolerant to its
effects.[9] Very similar findings have been found in
patients with suspected pornography addiction. Their
desire for this media far exceeds the pleasurable
effects it has on them[10] and fMRI changes
resemble those in patients with other substance
use disorders.[11] Studies have found reduced grey
matter volume in the right caudate and dampened
putamen activation in those who compulsively use
pornography.[12] These patients are also likely to
have escalating levels of pornography usage, which
supports the theory that a tolerance to pornography
can develop.[13]
A predominant counter to these findings is that
reduced striatal volume is a precondition for, not a
result of increased pornography use.[12] This model
argues that people with naturally lowered striatal
volume require additional stimuli for dopaminergic
responses. They are therefore more likely to consume
large amounts of pornography. With this model,
those with decreased striatal volume should be able
to achieve the full pleasurable effects of pornography,
even if more of it is needed.[12] However, there does
not seem to be this expected positive dose-effect
relationship between pornography use and pleasure.
[10] Additionally, laboratory fMRI studies have shown
that repeated viewing of sexual images can cause a
down-regulation of the brain’s reward pathways.[14]
This suggests pornography can play an active role
in down-regulating the striatum. The dose-response
relationship of this finding is yet to be established,
and it remains unclear whether these findings are
exclusive to high-volume users or those with other
risk factors for addiction.
Gender roles and sexual behaviour
Another charge made against pornography is
its potential to promote misogynistic attitudes and
behaviours, particularly in males. In a review of 135
studies on the topic, it was found that sexualised
media, of which pornography was included, was
directly associated with “sexist beliefs … and greater
tolerance of sexual violence toward women” in males.
[15] This media may play a role in cultivating views that
support female objectification, patriarchal ideologies
and permissiveness towards female harassment.
[1] This association is greatest when pornography
is accessed during early adolescence (12-14 years).
[16] Longitudinal research in this area is lacking,
therefore these findings may simply suggest that
people with these views consume greater amounts of
pornography as it reaffirms their beliefs. Additionally,
if pornography is to have a role in promoting sexist
attitudes, the extent to which these opinions go on
to influence interactions with others is unclear and
difficult to determine.
The research attempting to establish the impact of
pornography on sexual encounters is highly conflicted.
A prevalent thought is that the violence depicted in
its material desensitises viewers to sexual assault,
increasing their propensity to commit sexual crimes.
[17] This view is supported by findings that porn can
increase acceptance of rape and sexual assault in
males.[3,18] This influence on sexual violence seems
to be greatest and perhaps limited to males with
other risk factors for sexually aggressive behaviour.
[1] These include: a history of family violence, a
cultural upbringing promoting male dominance
and toughness, attitudes accepting of violence and
impersonal views of sex.[19] Pornography use in
these high-risk individuals has been associated with
an increased prevalence of forced vaginal, oral and
digital penetration, sexually aggressive remarks and
sex with animals.[1] This research challenges the
argument of a cathartic role for pornography – that
its usage can reduce the prevalence of sexual crimes
committed in males as these sexual impulses are
somewhat acted upon through pornography usage.
The active role of pornography usage in promoting
sexual assault is well-established in people with
other risk factors for sexual assault, however, the
causal link between pornography and sexual assault
in most users is less strongly established and highly
debated.[20] Therefore, pornography may play a role
in fostering and validating attitudes that predispose
some men to rape women, however, it may have little
to no impact in males with no other risk factors for
sexually aggressive behaviour.[1] There are many
15

arriers to research into this question, not least the
underreporting of sexual assault and the ubiquitous
nature of this media.
While pornography may have a limited role in
promoting sexually aggressive behaviour in most
men, lowered libido and erectile dysfunction are
widespread in pornography users.[21] In a study
of adolescent males, 16% of those who consumed
pornography more than once weekly reported
low sexual desire, compared to 0% of those who
did not.[22] Other sexual performance problems
associated with pornography use include difficulty
orgasming, decreased enjoyment of sexual intimacy,
less sexual and relationship satisfaction and a
preference for pornography over a sexual partner.
[23] Erectile dysfunction is also strongly associated
with pornography use and when present, often
occurs during intimate sexual relationships, but
not to sexually explicit material.[10] Males who use
pornography to stimulate sexual desire likely partially
account for these findings. However, cessation of
pornography use has on numerous accounts been
recorded as an effective treatment for patients with
sexual dysfunction, suggesting it does also play a
causal role in this condition.[24,25]
One longitudinal study has also found that
pornography usage has a statistically significant
role in predicting poor marital quality. Pornography
usage was found not only to be a product of
martial dissatisfaction, but a causal factor for such
dissatisfaction. This media was the second greatest
predictor of poor marital quality in the study,
following only marital quality at the commencement
of the study. These effects increase with frequency
of pornography use and seemed to only apply to
husbands who use pornography and not to wives.
[26]
Mental health
With our society’s increasing interest in mental
health, pornography’s impact in this area is being
heavily researched. Pornography usage is strongly
associated with mental health disorders, loneliness,
poor self-esteem and reduced quality of life.
[5,27,28,29] An Australian study of 914 adolescents
found that those who reported mental health
problems in the last 6 months were 52% more
likely to watch pornography at least once weekly
than those who did not.[5] Masturbation to internet
pornography has also been strongly associated
with dissatisfaction in offline life and feelings of
poor social support.[29] Pornography may play
a causal role in this relationship, but equally, it
may be a means by which adolescents aim to aid
feelings of loneliness. Exploring the causal nature of
this relationship, a study published earlier this year
found that intentional exposure to pornography in
adolescence was a predictive factor for depression
and low self-esteem in later life.[30] On the other
hand, a longitudinal study has also found that low
self-esteem and depressive feelings in adolescent
males are predictive of compulsive pornography
use.[31] The extent to which poor mental health and
pornography encourage each other is unclear. The
increasing ubiquity of this media makes controlled
longitudinal trials in this field difficult to conduct.
Additional research exploring the therapeutic
benefits of pornography cessation in patients with
mental health disorders would be of great clinical
benefit.
Conclusion
While much of the research exploring the health
impacts of pornography is still inconclusive, there is
still substantial and warranted concern surrounding
this media. This field would greatly benefit from
additional longitudinal studies which further clarify
the causal role of pornography in promoting the
health issues addressed above. The prolific use of this
media does serve as a barrier to controlled studies
in this field, but also stresses the need for further
research, given the extensive clinical implications
such findings may have. Additionally, this industry
has transformed substantially this century with the
proliferation of the internet, and the full impacts of
this may yet be apparent.
Acknowledgements
Koshy Matthew & Tim Hanna.
Conflicts of interest
None declared.
Correspondence
bpeters7@myune.edu.au
An Australian study of 914 adolescents found that
those who reported mental health problems in the last
6 months were 52% more likely to watch pornography
at least once weekly than those who did not.[5]
16

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17

Improving interactions between transgender and other
gender-diverse persons and the healthcare system
Review article
Meredith Grey & Imogen Janus
Meredith Grey is a third year medical student at the University of Sydney. She studied
public health in her undergraduate degree, and maintains a strong interest in health
justice.
Imogen Janus is a third year medical student at the University of Sydney who is
passionate about gender-diversity within medicine. She is hopeful for future cultural
change within medicine that will benefit people of all sexes, genders, and sexualities.
“
Abstract
Background: Individuals who do not identify with the normative gender identities experience
differences in access and treatment in the healthcare system as compared with their gender-binary
counterparts, both as patients and professionals. These disparities are hard to quantify due to a
paucity of specific and appropriate research to date.
Aims: To identify and explore the main barriers faced by gender-diverse individuals in accessing
appropriate healthcare, and by gender-diverse healthcare professionals in entering the health
workforce.
Methods: We reviewed the interactions between gender-diverse individuals and healthcare systems
by searching key databases including Google Scholar, EMBASE, and PubMed, as well as grey literature
from selected research bodies and peak community organisations. Search terms included: transgender,
transsexual, gender-diverse, gender dysphoria, health, healthcare, mental health, sex, and gender.
Results: Many large studies looking at gender-diverse healthcare do so under umbrella terms like
LGBTQI, and lack specific information about our target population. Some smaller international studies
and anecdotal reports highlight areas of focus for future research. From the available literature, it
appears that the primary barriers to care are a lack of knowledge about and erasure of the genderdiverse
experience, subsequent discrimination, inadequate and inappropriate healthcare, and a
consequent strained relationship between gender-diverse people and the mainstream healthcare
system.
Conclusions: Gender-diverse people experience barriers to healthcare at the individual, institutional
and societal level due to obvious challenges like discrimination and lack of understanding, and more
insidious issues like erasure, bureaucratic and financial barriers. Assessing the scope of these factors
with robust research and taking pragmatic steps towards increasing visibility, education and societal
support will go a long way to changing the healthcare landscape and the experience of genderdiverse
people within it.
Introduction
Individuals that do not identify with the
normative gender expectations set by society often
suffer significant negative health disparities when
compared with their binary counterparts. These
disparities are often hard to identify and quantify due
to a paucity of evidence specific to these individuals.
This article reviews current interactions between
gender-diverse individuals and healthcare systems
”
with reference to the available literature. The article
explores barriers faced by gender-diverse patients,
as well as gender-diverse healthcare professionals in
forming a part of the health workforce. We conclude
that the primary barrier is a lack of knowledge
about the gender-diverse experience, which leads
to discrimination, inadequate or even inappropriate
healthcare, and a consequent withdrawal from the
mainstream healthcare system. Structural factors
such as the binary description of gender used by
medical systems leads to a lack of visibility of these
18

individuals, both within healthcare organisations
and research. Further, for healthcare professionals,
there are actual or perceived potential professional
ramifications of expressing their gender-identity. We
propose that the identification and understanding
of these barriers will assist healthcare workers and
organisations in Australia to begin to address these
disparities.
Terminology
To accurately and respectfully
interact with issues about gender
and healthcare, it is important to use
terminology that is appropriate and
specific. Here we outline the terminology
most pertinent to this article. Cisgender
refers to people whose gender
identity is the same as the sex they
were assigned at birth. In this paper,
the choice to use the term ‘genderdiverse’
encompasses any and all
gender identities outside the cisgender the
‘male’ and ‘female’. This encompasses
transgender people, who often identify
as ‘male’ or ‘female’, but whose gender
differs from the sex they were assigned
at birth, as well as intersex, gender nonbinary
and gender-queer people whose
gender identity may not fall within the
categorical binary. These definitions are
not absolute nor comprehensive, and we
acknowledge that gender terminology
is an evolving and dynamic field. For
a more comprehensive explanation of
different terms used when regarding
sex and gender, we recommend the
University of Technology, Sydney’s LGBTIQ+ glossary:
Physical Sex, Sexuality, Gender Identity and Gender
Expression.[1]
Gender-diverse patients and the healthcare
system
Understanding the unique needs of Australia’s
gender-diverse community is a major public
health challenge. This is due to the lack of research
specifically aimed at addressing the health needs of
this community, the exclusion of non-binary gender
identities in research and policy, and the conflation
of sex, gender and sexuality in the data collected.
In Australia, there have not yet been any national
population-based data collected regarding gender
identity. Currently the Australian Bureau of Statistics
is reviewing its Sex Standard, which currently codes
only ‘male’ and ‘female’ in the census, but as yet
no new policies have been outlined.[2] Studies that
do look at health outcomes for gender-diverse
people often do so as part of umbrella-terms, such
as LGBTQI, encompassing various gender identities,
sexual orientations and sexual behaviours,[3] which
can fail to identify unique issues affecting these
diverse subgroups. Finally, health priorities and
‘In Australia, there
have not yet been any
national populationbased
data collected
regarding gender
identity. Currently
Australian
Bureau of Statistics
is reviewing its Sex
Standard, which
currently codes only
‘male’ and ‘female’ in
the census, but as yet
no new policies have
been outlined.[2]’
needs can and do differ within sub-groups – for
example, transgender men and transgender women
have different experiences within the healthcare
system and different specific needs as patients, which
can be overlooked when considering the health of
transgender people more broadly.
Recently, however, smaller-scale surveys and data
have been emerging parsing out health and wellbeing
outcomes specifically for gender-diverse people. This
research suggests that health outcomes are poorer
among trans-identifying people
than the wider population, as well
as other groups that are part of
the LGBTQI community. Patientreported
health outcomes such
as in Private Lives 2, a 2012
health survey of more than
3,000 gay, lesbian, bisexual
and transgender Australians,
demonstrated that transgender
men and women reported lower
levels of general health than both
the national average, and than
cis-gendered gay, lesbian and
bisexual respondents.[4] Specific
disparities faced by genderdiverse
people include reduced
engagement with cervical
cancer screening programs and
increased rates of smoking and
associated diseases.[5,6]
Mental health is a particular
area of disparity, with both
transgender men and women
averaging scores of 23.2 on
the Kessler Psychological Distress Scale, indicating
high psychological stress,[7] with more than half of
gender-diverse people experiencing a diagnosis of
depression in their adult lifetime.[6] Suicidality is of
particular concern, with transgender people 12 times
more likely to contemplate and 11 times more likely
to commit suicide than the general population in
Australia.[7] As well as high rates of depression and
anxiety, transgender individuals also report higher
than average rates of other psychiatric conditions,
with 23.4% of transgender men reporting such
conditions, compared to 3.2% of cis-gendered men.
[4] With this in mind, it is still difficult to confidently
quantify the particular health challenges faced by
gender-diverse populations, as these conclusions
come from small studies and/or studies looking more
broadly at LGBTQI groups.
There are a myriad of factors contributing to
the healthcare disparities experienced by genderdiverse
populations, and these issues range from
interpersonal challenges between patient and
practitioner, to hospital and institutional practices,
policies and structures and finally political and
societal context. It is important to note, as found
in research conducted by the Australian Research
19

Centre in Sex, Health and Society between 2007 and
2014, that the poorer health outcomes experienced
by gender-diverse people in Australia are due to
these contextual factors like stigma and access, and
are not due to anything inherent to this identity.[6]
In the 2011 National Transgender Discrimination
Survey of more than 6000 transgender people in
the United States, large numbers of respondents
reported experiencing violence, harassment, and
discrimination when seeking medical care, with 23%
being denied care altogether.[8] These negative
interactions reportedly lead to individuals postponing
or avoiding medical care.[8]
Healthcare providers are also lacking in both
understanding the transgender experience and
delivering quality care to gender-diverse people
due to a lack of basic knowledge in these areas. This
begins with a failure to understand the continuums
of and differences between sex, gender, and
sexuality, and the tendency to conflate and confuse
these terms. It also relates to the lack of education
surrounding the specific healthcare needs of genderdiverse
people, including gender-affirming therapies
and their side effects, sexual health, and fertility.
The National Transgender Discrimination Survey
found that half of respondents reported having to
teach their healthcare providers about transgender
health.[8] While some specialties such as General
Practice have higher reported rates of positive
clinical experiences for gender-diverse people,
stigma and misunderstanding is present even
among those professions that are most likely to be
involved in providing care to gender-diverse people,
including psychiatrists, gynaecologists and paediatric
endocrinologists.[9–11]
There are also socio-political structures that
create barriers to healthcare access at an institutional
level.[6] Many of the healthcare disparities faced by
gender-diverse people in this setting relate to their
lack of visibility. Simply, most healthcare organisations
collect patient data about sex or gender - often used
interchangeably - as a binary of ‘male’ or ‘female’.
This method excludes those who do not identify
within the binary, while simultaneously rendering
transgender experience invisible, as it fails to capture
the difference between an individual’s sex-at-birth
and current gender identity. The purported aim of
collecting this information is two-fold: to identify
the sex-specific healthcare needs of a person, for
example, the likelihood of pregnancy, and to provide
gender-appropriate interactions, for example, the
appropriate use of pronouns. However, the method
of presenting patients as either ‘male’ or ‘female’ fails
to serve either of these aims in relation to genderdiverse
people.[12] In this binary system, transgender,
intersex and other gender-diverse people are
effectively invisible, a process termed ‘erasure’.[13]
The erasure that exists in health data collection
is mirrored in many bureaucratic contexts, which
themselves contribute to the substantial barrier to
care that gender-diverse people face. For example, a
large survey in the United States in 2015 found that
only 11% of gender-diverse respondents had their
accurate name and gender on all their official identity
documents, with reasons for not changing their
20

legal name including financial capacity and lack of
procedural knowledge.[14] In Australia, most states
and territories have significant barriers to correcting
gender markers on official documentation such as
being unmarried or having had surgery to alter their
reproductive organs.[6] If individuals are provided
avenues to change or correct their gender marker
within their medical record, these processes can be
insensitive, often requiring intrusive forms of ‘proof’,
and imposing significant administrative burden and
psychological distress on people seeking to do so.[6]
It is important to note that the inconsistent and
inappropriate use of gender markers extends beyond
clinical practice. This erasure exists across all levels
of data-gathering and makes collecting and locating
data about the health and wellbeing of genderdiverse
people difficult, which in turn makes it hard to
identify areas of need and action. Both demographic
information and data regarding cause and effects of
outcomes are necessary to create an evidence-based
approach to the healthcare of gender-diverse people.
Indeed, standardised tools have been created for
use at various levels from population to individual
clinic,[15] but large-scale implementation of these
standards are still required to fill gaps that exist in
our knowledge of both specific health challenges for
gender-diverse people and appropriate strategies to
address them. [15]
If and when basic issues of visibility can be
overcome, gender-diverse people face real pragmatic
barriers to care in the form of governmental
regulations and priorities. For example, the
financial burdens placed on transgender people
seeking gender-affirming therapies not currently
funded by public or private health insurance. In
recent years, there have been proposed changes
to governmental policy in an attempt to address
systemic barriers that gender-diverse people face in
the healthcare system. Access to many Medicare and
Pharmaceutical Benefits Scheme (PBS)-subsidised
items are dependent on patients’ Medicare gender
classification (either ‘male’ or ‘female’), making access
to certain procedures and medications difficult for
gender-diverse people. 6,000 such procedures and
treatments were proposed to be modified to remove
gender-dependent classifications, for example,
making cervical cancer screening available to anyone
with a cervix, as opposed to people whose marker
is ‘female’.[6] As of 2014, only 15 of the particular
Medical Benefits Scheme billing codes had been
changed.[6] Furthermore, some gender-affirming
management options are still classified as cosmetic
procedures and as such are not covered by Medicare.
These policy-related issues contribute both to the
significant barriers gender-diverse people face
generally in accessing care both for their well being,
and those faced by transgender people seeking
specific transition-related care.[6]
The Australian Medical Association (AMA)
recognises transgender, intersex and genderdiverse
people as a priority population in sexual and
reproductive health.[16] Their 2014 policy document
on sexual and reproductive health stresses the
importance of reducing stigma in the healthcare
setting, encouraging access to gender affirming
procedures and medications, and improving data
collection and research to identify gaps and improve
the experience that gender-diverse people have with
our healthcare system.[16]
Similarly, the Australian Medical Student
Association (AMSA) released a policy statement in
2016, echoing the sentiment of the AMA document,
as well as outlining specific recommendations for
government bodies, medical schools and student
societies to promote LGBTQI health and wellbeing.
[17] As well as presenting recommendations for the
provision of more competent healthcare to genderdiverse
patients, AMSA’s policy guidelines address
changing the professional culture and the roles
that medical schools and student societies play.
The document calls on medical schools to promote
visibility of LGBTQI health with integrated, accurate
and destigmatised curricula, as well as inviting the
participation of LGBTQI health care providers and
community members to be involved in teaching and
curriculum building. It also highlights the role of
student societies in protecting and promoting the
interests of LGBTQI students as well as raising the
quality of teaching around gender and sexuality.[17]
Gender-diverse healthcare professionals
While only a small amount of research is available
regarding gender-diverse patients, there is an even
greater paucity of data regarding gender-diverse
healthcare providers. However, with personal
accounts of gender-diverse people who have chosen
to write about their experience as medical students
and doctors, as well as some small studies and reports
of gender-diverse groups in the health workforce,
we can begin to build a picture of gender-diversity
among healthcare professionals.
Barriers for gender-diverse people in the
healthcare workforce can emerge early, as evidenced
by recent studies looking at how gender and
sexuality is addressed and taught in medical schools.
A 2015 survey conducted at Stanford Medical
School investigated the experience of LGBT-related
education by both LGBT and non-LGBT medical
students. One quarter of LGBT students and 8% of
non-LGBT students found the quality of their teaching
surrounding LGBT issues to be ‘very poor’, and the
discrepancy between these numbers highlights that
the LGBT students did not feel their experience was
represented appropriately.[18] Jai NicAllen, a British
medical student wrote of their experience as a transperson
in medical school in an article for the Student
British Medical Journal, noting challenges including
factually inaccurate information about gender and
health, and a generalised lack of knowledge among
peers and teachers.[19] Furthermore, while the
majority of medical schools provided at least 3 hours
21

of teaching on sexuality broadly, it is difficult to know
what and how gender is included in these curricula,
and many reported little to no information about
gender-diversity in their teaching.[20]
The potential result of the educational failures
suggested by these studies is a medical workforce
that lacks the confidence and capacity for caring
appropriately for gender-diverse patients, but it also
fosters an unwelcoming environment for genderdiverse
medical students and professionals. With
fear of discrimination from medical schools and
residency programs being the two most common
reasons among medical students for choosing not to
disclose gender-diverse gender identity or sexuality,
the failures of medical schools surrounding genderdiversity
teaching carry on into the workplace with
ongoing stigma and professional consequences
for gender-diverse doctors.[18] In the absence of
formalised information and support for genderdiverse
students and young doctors, informal peer
spaces like student forums and chat rooms provide
some of the only reliable and confidential aid in
navigating educational and career-related decisions.
Most LGBT
physicians continue
to work in settings
where they are
invisible”
The data available about gender-diverse doctors
and other healthcare providers paint a similar picture
of deficits and discrimination. A 2011 report put it
powerfully: “most LGBT physicians continue to work
in settings where they are invisible”.[20] Robust
policies surrounding gender-related issues in the
workplace including harassment and reporting,
pronoun use, dress codes, appropriate facilities,
and general employee education surrounding
gender identity are becoming more common and
exist in various guidelines.[21–23] However, there is
little adoption or creation of such guidelines in the
healthcare employment setting, and many genderdiverse
physicians are not even aware of their
workplace policies regarding gender and sexuality
both for patients and employees, with 28% of
respondents in the 2011 study noting they did not
know whether their employer’s non-discrimination
policy included gender identity at all.[20] Rates of
harassment and ostracisation of LGBT physicians
based on gender identity and sexuality have shown
improvement over the last 20 years, but still sit at
15% and 20% respectively in one reported study.
[20] These discriminatory experiences can be at the
hands of peers and bosses, but also patients, with
a 2007 national study in the United States reporting
that 30% of responders would change healthcare
providers upon learning theirs identified as LGBT.
[24] Finally, when considering reporting instances of
discrimination, gender-diverse healthcare workers
also have to consider how their identity and the
perception of it by their superiors could affect
their careers, for example regarding exclusion from
promotions or other opportunities.[20]
Conclusions
The lack of large scale and robust data
representing experiences of gender-diverse people
in the Australian health system speaks to their lack
of visibility, acceptance and representation within the
healthcare system both as patients and professionals.
Furthermore, the data and perspectives that are
available highlight that the erasure and inappropriate
treatment of gender-diverse people in healthcare is
not uncommon, nor is it uncommon knowledge.
The challenges that affect both the health outcomes
of gender-diverse people and their experience in
the healthcare industry are due to barriers that exist
at several levels. Individual factors in patient-carer
interactions including prejudice and lack of awareness
or confidence negatively influence gender-diverse
people’s access to and engagement with healthcare
professionals. Institutional factors such as the binary
description of gender used by medical systems leads
to a lack of visibility of gender-diverse individuals,
both within healthcare organisations and research.
Policy and structural considerations including
governmental focus, financial subsidies and public
policy define the context in which gender-diverse
people exist and interact with the healthcare system.
Finally, for healthcare professionals, there are real
workplace ramifications of expressing their genderidentity,
as well as associated fear or anxiety of
doing so. We propose that the identification and
understanding of these barriers will assist healthcare
workers and organisations in Australia to begin to
address these disparities.
Despite the perspectives of our large professional
bodies, as well as the growing body of data,
anecdotal experiences of gender-diverse people
and the availability of guidelines, templates and
recommendations both for gender-diverse patient
care and employee relations, healthcare institutions
in Australia are slow to change. In this case, the
resources are available, and many of the necessary
steps outlined in the relevant guidelines are
simple, inexpensive and quick to implement on an
institutional level. Reevaluating policy, practice and
attitudes relating to gender-diverse patients and
employees, and creating institution and industrywide
practical standards emphasising visibility,
education and appropriate structural supports for
gender-diverse people is possible and overdue.
Abbreviations
LGBTQI: Different studies referred to in this
paper use different umbrella or categorical terms
such as LGBT, LGBTQI and GLBT. With this in mind,
inconsistencies in the use of these terms may exist
22

in this review and are reflective of the terms used
in the specific studies or papers referenced.
Acknowledgements
This work is part of a larger research project
done on behalf of Level Medicine, an organisation
working towards gender equity in medicine.
If you have feedback about the contents of this
article or think that there are any particular
actions Level Medicine can take to improve
the experience of transgender and other genderdiverse
people within the healthcare system,
please contact the corresponding author.
Photo credits
Daniel Watson, accessed from https://unsplash.
com/photos/IEtUye-b28A
Conflicts of interest
The authors do not work for, consult, own
shares in or receive funding from any company
or organisation that would benefit from this
article, beyond an affiliation with Level Medicine.
Correspondence
mgre7512@uni.sydney.edu.a
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9. Vance SR Jr, Halpern-Felsher BL, Rosenthal SM. Health
care providers’ comfort with and barriers to care of transgender
youth. J Adolesc Health. 2015 Feb;56(2):251–3.
10. Unger CA. Care of the transgender patient: a survey of
gynecologists’ current knowledge and practice. J Womens
Health . 2015 Feb;24(2):114–8.
11. Riggs DW, Coleman K, Due C. Healthcare experiences of
gender diverse Australians: a mixed-methods, self-report survey.
BMC Public Health. 2014 Mar 6;14:230.
12. Bauer GR, Hammond R, Travers R, Kaay M, Hohenadel
KM, Boyce M. “I Don’t Think This Is Theoretical; This Is Our Lives”:
How Erasure Impacts Health Care for Transgender People. J
Assoc Nurses AIDS Care. 2009 Sep 1;20(5):348–61.
13. Namaste V. Invisible Lives: The Erasure of Transsexual and
Transgendered People. University of Chicago Press; 2000. 340 p.
14. James SE, Herman J. The Report of the 2015 US
Transgender Survey: Executive Summary. National Center for
Transgender Equality; 2017.
15. Reisner SL, Deutsch MB, Bhasin S, Bockting W, Brown
GR, Feldman J, et al. Advancing methods for US transgender
health research. Curr Opin Endocrinol Diabetes Obes. 2016
Apr;23(2):198–207.
16. Position Statement Reproductive Health And Reproductive
Technology [Internet]. Australian Medical Association; 2005.
Available from: https://ama.com.au/sites/default/files/
documents/Position_Satement_on_Reproductive_Health_And_
Reproductive_Technology_1998_revised_2005.pdf
17. Policy Document: Lesbian, Gay, Bisexual, Transgender,
Intersex, and Queer (LGBTIQ) Health Policy [Internet]. Australian
Medical Students’ Association; 2016. Available from: https://www.
amsa.org.au/sites/amsa.org.au/files/LGBTIQ%20Health%20
%282016%29.pdf
18. Stanford University School of Medicine Lesbian, Gay,
Bisexual, and Transgender Medical Education Research Group.
Lesbian, Gay, Bisexual, and Transgender Medical Student
Experiences: “Out” in Medical School and Perspectives on
Curricular Content [Internet]. 2015. Available from: https://myhs.
ucdmc.ucdavis.edu/documents/41620/0/
19. NicAllen J. The reality of being transgender in medicine.
Student BMJ [Internet]. 2016;23. Available from: http://student.
bmj.com/student/view-article.html?id=sbmj.h6648
20. Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay,
bisexual, and transgender (LGBT) physicians’ experiences in the
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21. Managing Gender Transition in the Workplace
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23. Model Transgender Employment Policy: Negotiating for
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7.
23

The public perception of major depressive disorder in
South Asia: a literature review
Review article
Marisse Sonido
Marisse Sonido is currently a 4th year medical student at the University of
New South Wales. She is both an aspiring doctor and writer and has recently
discovered, much to her excitement, that the two are not mutually exclusive.
“
Abstract
Aims: To understand: the perception of depression as an illness in South Asia and the language used
to describe it, its perceived aetiology, how individuals with depression are perceived by the community
and the beliefs in the community surrounding the treatment of depression.
Methods: Articles were found through a database search of MedLine, PSYCINFO, and GoogleScholar.
They were included if they discussed depression within the context of a South Asian culture.
Results: Depression is widely understood in South Asia as a disease with primarily somatic presentations
stemming from stresses associated with difficult socioeconomic circumstances. Those with depression
are often stigmatised but they are generally not excluded from the community. Alongside medical
intervention, assistance from family and the community are the most accepted methods of addressing
depression.
Conclusions: South Asian perceptions of depression accord with a psychosocial model of illness.
Incorporating these perceptions is essential to the success of interventions and educational programs
hoping to resonate with a general population and improve communication with health professionals.
Introduction
Depression, suffered by more than 300 million
people worldwide, represents the single greatest
contributor to global non-fatal health loss.[1, 2, 3] Its
impacts are not limited to the Western world. While
developed countries draw much of the research
focus, the South Asian prevalence of depression
was calculated at 26.3% based on primary care
presentations.[1] In India in 2004 it accounted for
a greater number of disability adjusted life years
per 100,000 people than both cancer and diabetes
mellitus combined.[1] Depression is particularly
under-recognised and undertreated in rural areas.[4]
The presentations, sequelae and understandings
of depression are known to depend on culture, a
relationship maintained in the South Asian context.
[5, 6, 7, 8] Existing research highlights significant
differences between developed and developing
world perspectives on the disease—the extent
to which depression is seen as somatic, the role
of socioeconomic factors in its aetiology and
community responsibilities in addressing it.[4] The
strict biomedical conception of depression favoured
by some health professionals may translate poorly
across cultures and pose obstacles to improving
recognition, treatment and education.[9]
This paper aims to discuss general perceptions
of depression in developing countries in South Asia.
It will identify community views on: (1) depression
as an illness, including the way it is described and
presents; (2) its aetiology; (3) opinions about
individuals with depression; and (4) beliefs about
treatment. In synthesising the trends and repeating
themes revealed by research, it hopes to provide a
foundation for tailoring clinical and public health
interventions to a South Asian cultural context.
Methods
”
Articles were found through a database search
of MedLine, PSYCINFO, and GoogleScholar using
the following keywords and MESH terms: Mental
Disorders OR Depression; Developing Countries OR
24

Asia OR Afghanistan OR India OR Sri Lanka OR Nepal
OR Bhutan OR Maldives OR Pakistan; and Stigma,
Public Perception, Understanding, OR Health Literacy.
Studies were excluded if they were not published
English language articles relating to depression in
South Asian cultures.
Results
Relevant studies were found about samples in
India (n = 3), Pakistan (n = 1), Afghanistan (n = 1),
Bangladesh (n = 1) and Sri Lanka (n = 1). The Afghan
sample reflected a migrant Afghan population. No
depression-specific articles were found about the
Maldives, Bhutan and Nepal.
Understanding of depression as a disease
Participants generally professed a poor medical
understanding of depression and other mental
illnesses. Many in the Liu et al. study (42.77%) could
not answer what the word ‘depression’ meant to
them.[4] In the Indian state of Maharashtra, 87.5%
of community members did not acknowledge
depression as a real medical illness.[10] However,
participant groups frequently employed locally
appropriate terminology when presented with a
depression case study or vignette. Bangladeshi
respondents referred to chinta rog or “worry illness”.
[5] The Dari language speaks of asfurgdadi, the low
mood and grief associated with hardships.[11] Using
tailored vocabulary greatly improved communication
between researchers and participants.[5]
Both participants with depression and communities
in general stressed the physical manifestations of the
disease.[4, 5, 6, 9] The most commonly identified
somatic symptoms associated with depression
included fatigue, pain, numbness, sleeplessness,
headache, breathlessness, and shaking.[5, 6, 9, 11]
While several psychological symptoms were also
listed,[5, 11] the physical aspects of the disease
dominated and were often the main reasons to seek
help.[6]
Aetiology of depression
An overwhelming majority of study participants
described depression through a psychosocial
understanding of its origins, emphasising the
suffering individual’s social context. In rural Indian
villages, depression is seen as an accumulation and
escalation of grief or stress.[4] Many studies identified
poverty and unemployment as major contributors to
these pressures.[5, 6, 9] In Bangladesh it is believed
that all tension rogs or “anxiety illnesses” are due
to obhab, a (typically material) need of some kind
caused by poverty.[5] Culturally specific financial
stressors included an inability to provide dowry
and education for all of one’s daughters.[5] Other
stressors ranged from female reproductive problems
and domestic violence to social inequality, injustice,
and trauma.[4, 6, 9, 11] Refugees interviewed by
Alemi et al. described language difficulties, family
separations and cultural clashes.[11]
A number of participants attributed depression to
religious, supernatural or spiritual factors. A vignette
about a woman with depression in Liu et al.’s
study prompted participant theories about divine
punishment and black magic.[4] Many raised the
possibility of spiritual possession.[4]
The Liu et al. study was an outlier in terms of
biological explanations for aetiology— 54% of
respondents linked depression to a disease of the
brain and 33.8% believed it was inheritable.[4] The
presentation of these options in a questionnaire,
as opposed to the open-ended interviews of other
studies, may have contributed to this divergence. But
some of the external causative factors identified by
participants, like “problems in the environment”[6]
and polluted air,[4] also hint at a biological
understanding of depression’s causes.
Perception of individuals with depression
Expressions of stigma were common. In two
of the Indian studies the majority of individuals
believed depression is a sign of weakness.[4, 10] In
the Kermode et al. study,[10] 40% of community
members concurred that people with depression
are dangerous, 52.1% said they are erratic and
42.5% believed they should be avoided. Similarly, a
large minority of respondents in the Liu et al. study
described those with depression as unpredictable
(43.8%), hard to talk with (40.5%), and a cause of
familial shame (45.1%).[4]
Despite this, most individuals expressed a
willingness to remain the neighbours, friends and
co-workers of someone with depression.[4, 10]
These opinions were more likely in respondents who
regarded depression as a “sign of weakness” instead
of a genetic or biological disease. However, only
60.8% of participants were willing to accept someone
with depression marrying into their family.[10]
Bangladeshi respondents echoed these doubts about
the marriage prospects of people with depression.[5]
Understandings of treatment
Most participants across the studies thought
depression would be difficult—if not impossible—to
remedy without assistance.[4, 10, 11]
Pharmaceutical treatments were often poorly
understood and warily regarded. Medication was
restricted to treating the physical symptoms of
depression.[9] Some participants were concerned
about the addictive potential of using drugs to treat
depression.[4] In Bangladesh, tablets were the option
of last resort, partly due to cost.[5] Bangladeshi
respondents instead prioritised poverty alleviation,
good health and positive family relations.[5]
Opinions of medical practitioners were generally
positive. The patients in the Naeem et al. study
professed a strong faith in doctors despite minimal
25

awareness of their role in depression management
and limited familiarity with non-pharmacological
treatments like psychotherapy.[6] Sri Lankan
undergraduate students who saw depression as a
mental illness had confidence in medical experts[12]
and refugees in Afghanistan also expressed faith in
psychiatrists.[11]
Opinions about traditional and religious healing
modalities were mixed across the studies. In India,
some respondents reported using herbal medicine
to treat depression’s somatic symptoms,[9] and
participants from Afghanistan sometimes consulted
a tabib or herbal specialist.[11] A minority in the
Indian, Bangladeshi, and Afghan samples identified
religious practices, mantras and amulets as possible
remedies.[5, 9, 11] Conversely, in another study,
63% of participants doubted traditional healers
could successfully remedy depression, with more
enthusiasm for their effectiveness only in conjunction
with medical treatment.[4] None of the participants
in the Pakistan study had visited a traditional healer,
though one participant did recite passages from
the Quran and perform the practice of do dum (or
blowing air) on themselves as a form of self-help.[6]
Several studies highlighted familial or social
support as a particularly popular treatment option.[4,
5, 9] Bangladeshi respondents typically approached
family members and close relatives before seeking
help from other sources. Many of these individuals
believed a community-based program would be the
ideal way to address depression.[5] Other suggested
treatments included involvement in communal
activities,[5, 9] internal dialogue[9]
and lifestyle changes such as eating
right and exercising.[11] In Alemi et al.,
cultural activities, such as listening to
Afghan music and visiting Afghanistan,
were also named.[11]
Discussion
The reviewed literature suggests
depression in South Asia is widely
understood as a stress-related
disease that emerges out of difficult
socioeconomic circumstances and has
primarily somatic manifestations. While
those with depression are still subject to
stigma, communal exclusion is rare.[4,
10] Familial and community assistance
are the most accepted treatments for depression with
medical intervention reserved for physical symptoms.
[4, 5]
South Asian respondents overwhelmingly
favoured a psychosocial model of depression’s
aetiology with minimal emphasis on biology.
Empathy and understanding seemed highest when
causal explanations of depression were linked to
relatable hardships. Education campaigns and anti-
stigma efforts may have more success if framed
through this understanding of the disease compared
to approaches rooted in biomedicine. In Kermode et
al., individuals who related depression to a personal
flaw (“weakness”) or extrinsic factors (e.g., family
and financial problems) were less likely to socially
distance themselves from people with depression
compared to those who believed in a biological
cause.[10] Biology may be seen to imply a lack of
agency and the possibility of hereditary transmission,
both of which negatively impact marriage prospects.
This aetiological understanding of depression
affects the acceptance of pharmacological
interventions. While Indian respondents used
pharmacological treatments for somatic symptoms,
and drugs are seen as a valid last resort in
Bangladesh,[5] the expense and arcane mechanisms
of action of antidepressants may compromise
adherence when they are prescribed. Nonpharmacological
methods might be more acceptable
despite remaining mostly unheard of in more rural
areas. A study on university students in Pakistan, for
example, found that cognitive behavioural therapy
could be successful in that population provided
interventions are tailored to South Asian cultural and
religious values.[13]
As depression is commonly attributed to external
socioeconomic factors, programs addressing these
wider social issues may reduce its prevalence. Studies
investigating poverty alleviation as an intervention
for depression have reported conflicting results in
Uganda and Mexico.[14, 15] The evidence suggests
depression interventions
demand a multi-faceted
approach.
‘... depression
in South Asia is
widely understood
as a stress-related
disease that emerges
out of difficult
socioeconomic
circumstances and
has primarily somatic
manifestations.’
The importance of family
and the community support
for individuals with depression
was a motif across the reviewed
studies. South Asian countries
are characterised by collectivistic
cultures emphasising close
family ties.[16] While family and
the community participation in
interventions can be extremely
beneficial, the isolation and
interpersonal conflict associated
with stigma can be especially
damaging. Communitybased
interventions were the ideal approach for
participants in the Selim et al. study.[5] Education
campaigns targeting the family and communities
around individuals with depression may be fruitful.
Limitations
Due to the limited body of research on this topic as
it relates to this region, not every South Asian country
could be represented in this review. The included
studies cannot be interpreted as reflecting universally
26

held beliefs within their respective countries. The
review also only included English-language studies,
narrowing its scope further and perhaps excluding
significant contributions from local research. It is
possible participants were reluctant to openly share
their traditional and religious beliefs with medical
professionals or as part of a scientific study, resulting
in their underrepresentation.[6]
Conclusion
This review aimed to present a general overview
of how depression is perceived in the developing
countries of South Asia. Considering these
synthesised findings may help shape future public
health efforts seeking greater success in improving
education about depression and its treatment and
prevention—in South Asia, and potentially in other
developing countries where depression is similarly
understood.
study in Sri Lanka. BMC Psychiatry. 2015;15(1):269.
13. Naeem F, Gobbi M, Ayub M, Kingdon D. University
students’ views about compatibility of cognitive behaviour therapy
(CBT) with their personal, social and religious values (a study from
Pakistan). Ment Health Relig Cult. 2009;12(8):847–55.
14. Ozer EJ, Fernald LCH, Weber A, Flynn EP, VanderWeele TJ.
Does alleviating poverty affect mothers’ depressive symptoms?
A quasi-experimental investigation of Mexico’s Oportunidades
programme. Int J Epidemiol. 2011;40(6):1565–76.
15. Green EP, Blattman C, Jamison J, Annan J. Does poverty
alleviation decrease depression symptoms in post-conflict
settings? A cluster-randomized trial of microenterprise assistance
in Northern Uganda. Glob Ment Health. 2016;3:e7.
16. Chadda RK, Deb KS. Indian family systems, collectivistic
society and psychotherapy. Indian J Psychiatry. 2013;55(Suppl
2):S299–S309.
Acknowledgments
None
Conflicts of Interest
None declared
Correspondence
marisse.sonido@gmail.com
References
1. Reddy R. Depression: the disorder and the burden. Indian J
Psychol Med. 2010;32(1):1–2.
2. World Health Organisation. Depression: World Health
Organisation; 2018 [cited 2018 Aug 16]. Available from: http://
www.who.int/news-room/fact-sheets/detail/depression
3. World Health Organisation. Depression and other common
mental disorders: global health estimates [Internet]. Geneva:
World Health Organisation; 2017 [cited 2018 Aug 16]. Available
from: http://apps.who.int/iris/bitstream/handle/10665/254610/
WHO-MSD-MER-2017.2-eng.pdf?sequence=1
4. Liu MC, Tirth S, Appasani R, Shah S, Katz CL. Knowledge and
attitudes toward depression among community members in rural
Gujarat, India. J Nerv Ment Dis. 2014;202(11):813–21.
5. Selim N. Cultural dimensions of depression in Bangladesh:
a qualitative study in two villages of Matlab. J Health, Popul Nutr.
2010;28(1):95–106.
6. Naeem F, Ayub M, Kingdon D, Gobbi M. Views of depressed
patients in Pakistan concerning their illness, its causes, and
treatments. Qual Health Res. 2012;22(8):1083–93.
7. Kleinman A. Anthropology and psychiatry: the role of
culture in cross-cultural research on illness. Br J Psychiatry.
1987;151(4):447–54.
8. McClelland A, Khanam S, Furnham A. Cultural and age
differences in beliefs about depression: British Bangladeshis vs.
British Whites. Ment Health Relig Cult. 2014;17(3):225–38.
9. Pereira B, Andrew G, Pednekar S, Pai R, Pelto P, Patel V.
The explanatory models of depression in low income countries:
listening to women in India. J Affect Disord. 2007;102(1):209–18.
10. Kermode M, Bowen K, Arole S, Pathare S, Jorm AF. Attitudes
to people with mental disorders: a mental health literacy survey
in a rural area of Maharashtra, India. Soc Psychiatry Psychiatr
Epidemiol. 2009;44(12):1087–96.
11. Alemi Q, Weller SC, Montgomery S, James S. Afghan refugee
explanatory models of depression: exploring core cultural beliefs
and gender variations. Med Anthropol Q. 2017;31(2):177–97.
12. Amarasuriya SD, Jorm AF, Reavley NJ. Quantifying and
predicting depression literacy of undergraduates: a cross sectional
27

Guidelines for low birth weight: a literature review
comparing national guidelines in Lao PDR with
WHO guidelines
Review article
Line M Pederson
Line M Pederson is an intern with the UN Refugee Agency in Copenhagen,
and soon to be working as a research assistant for the Danish Statens Serum
Institut in Guinea-Bissau. Her key interest and priority is to contribute to
building initiatives that ensure cultural and local appropriateness in health
development.
“
Abstract
Background: In Lao PDR (LPDR), the prevalence of low birth weight (LBW) is as high as 15%. Maternal
nutrition is one of the most crucial interventions in reducing the burden of LBW and its consequences
including perinatal and neonatal mortality, childhood stunting and increased risk of NCDs in
adulthood. Guidelines for LBW can be an important tool in prevention and care for LBW infants when
adapted to local contexts.
Objectives: To compare LPDRs and WHOs availability of guidelines for LBW, covering the period from
conception until 6 months postpartum, and to identify barriers for utilisation. This review also aims to
determine the appropriateness of these guidelines for reducing the LBW burden and consequences.
Methods: This literature review was conducted in three steps: identification of global and local risk
factors for LBW; retrieval and comparison of guidelines from WHO and Ministry of Health in LPDR
involving key informants from WHO regional and WHO LPDR office; and searching for barriers and
facilitators for implementation of guidelines. Databases (Pubmed, Proquest and Cochrane Library)
were searched using a combination of key terms: low birth weight, guidelines, Lao PDR, risk factors,
prevention and barriers.
Results: Guidelines were available and accessible by WHO and WHO LPDR office. Based on current
literature, various infrastructural, cultural and financial factors contributes to guidelines often not
being implemented nor accepted among health workers and mothers. Discrepancies between WHO
and local guidelines may have contributed to this, including the current non-aligned cut-off for
referral of LBW infants.
Conclusion: Despite guidelines being available, they were not always applied in LPDR. Inclusion of
vulnerable women in LPDR guidelines were inappropriate for reducing LBW and the risk of adverse
outcomes, but can be strengthened with the launch of guidelines for adolescent reproductive health.
Background
This study was prompted by the persisting
high prevalence of low birth weight (LBW) in Lao
PDR (LPDR), which reached 15% in 2012.[1] LBW
is defined as an infant weighing less than 2500g.
It is a leading cause of perinatal (22 weeks of
gestation to 7 days postpartum) and neonatal
(0-28 days) deaths globally.[2] It contributes
to 40-60% of newborn mortality.[2] LBW is
the most important criteria for determining
both immediate and long-term outcomes of
”
neonates and infants. Such outcomes include
chance of survival, healthy growth and freedom
from morbidities including infectious and
cardiovascular diseases and type 2 diabetes.[3-5]
Maternal nutrition has a major impact on LBW
and associated infant morbidity and mortality.
[6-8] Nutritional factors implicate biological
processes, which subsequently affect the foetal
and maternal physiology.[9, 10] The most
important maternal risk factors[11] increasing
LBW risk are; undernutrition and low BMI at
28

In Lao PDR (LPDR), the prevalence of low birth weight (LBW) is as high
as 15%. Maternal nutrition is one of the most crucial interventions in reducing
the burden of LBW and its consequences including perinatal and neonatal
mortality, childhood stunting and increased risk of NCDs in adulthood.
conception[8, 9, 12-15]; short stature[15, 16];
suboptimal gestational weight gain[11, 15, 17],
deficient intake of micronutrients (iron[18, 19]
and iodine[20]), maternal age (age35[27, 28]) and certain cultural food habits
and behaviours.[29-32]
Maternal and paediatric nutrition researchers
have found that adequate maternal pre-partum
health status, immediate care of the LBW infant
and exclusive breastfeeding (EBF) for 6 months
comprise a set of crucial activities for reducing
the burden of LBW.[33] Guidelines are important
as they act as a tool for quality assurance. This
seeks to improve the quality of care provided by
informed healthcare workers.[34] Evidence-based
and appropriate guidelines have the potential to
promote beneficial interventions and discourage
ineffective practice.[35] However, guidelines
function in the interplay between structural
factors and processes including economic, social
and political environments. This may affect a
guidelines’ desired effect.
Methods
A Quick Scoping Review was performed
to evaluate existing knowledge of LBW. This
involved a rapid review of literature on LBW
risk factors. Guidelines were obtained from the
WHO’s website, online and through formal email
correspondence with the WHO LPDR country
office and WHO Western Pacific Regional office
to ensure the newest updated guidelines were
included.
An extensive literature search was then
conducted to identify barriers for proper
implementation of LBW guidelines in LPDR.
Databases (Pubmed, ProQuest, Cochrane Library,
Google Scholar, WHO and UNICEF) were searched
using combinations of keywords including
low birth weight, guidelines, barriers, attitude,
beliefs, maternal health/nutrition, health services
utilisation, satisfaction and quality of care.
Additional articles were identified and retrieved
by reviewing references in relevant articles.
Further report materials from organisations and
governments were identified manually and found
online.
Only English papers published between 1990
and 2016 were included. Articles pertaining to
women with co-morbidities were excluded as a
separate set of guidelines exist for these mothers
and newborns. Besides the WHO’s guidelines,
only studies relating to LPDR were included.
Furthermore, only studies related to antenatal
care (ANC), perinatal care, postnatal care (PNC)
and breastfeeding (BF) practices with a focus on
LBW were included. The studies were critically
evaluated by looking at the study methodology,
perceived objectivity, study provenance, research
evidence and the contribution of the study to the
literature.
The review was conducted by one author from
February to June 2016 as part of a master thesis.
Subsequently, the LPDR Ministry of Health (MoH)
has launched The National Adolescent and Youth
Friendly Services (NAYFS) guidelines in February
2018, to strengthen the capacity for responding
to the needs of adolescent mothers. No significant
changes have been made in WHOs guidelines for
LBW.
Results
Variances between WHO guidelines and
national guidelines in Lao PDR
Variances between WHO’s guidelines and
national guidelines in LPDR are analysed to
see whether LPDR follow the evidence-based
guidelines proposed by WHO. As shown in table
1 below, national guidelines in LPDR are largely
in agreement with WHO guidelines. However,
significant disagreements still exist as highlighted
in the table.
Barriers to guideline adherence in Lao PDR
1. Health sector
Implementation of standard routines such as
weight recording and monitoring of newborn
care is low in LPDR.[1, 45-47] This poses a
significant challenge for effective implementation
of maternal, newborn and child health (MNCH)
services as data can help inform policy makers
about necessary and appropriate changes to
improve access and utilisation of high quality
services to achieve better maternal and LBW infant
outcomes. Duysburg et al. (2014) conducted
interviews with government officials, organisations
and MNCH care providers in LPDR who identified
several implementation barriers. This included the
29

current decentralisation of authority and
responsibilities of the health sector from national
to provincial, district and municipality level, as
well as limited MNCH management capacity and
skills which created confusion regarding roles and
Table 1. Guidelines for LBW in WHO and Lao PDR
WHO
Lao PDR[42-44]
Guidelines[36-41]
ANC
Perinatal
care
PNC
Particular
attention to
vulnerable
women
suffering
4 ANC visits (at
week: 8-12, 24-
26, 32, 36-38)
Maternal weight/
height
4 ANC visits (1 per
trimester, third visit
ideally at 36 weeks,
and 4th visit at 40
weeks/term)
Maternal weight
Fetal growth (uterine height)
Promoting
healthy lifestyle
and diet
Support on early
BF and EBF
Counselling on
nutrition
Counselling on BF
Skin-to-skin contact
Advice on early BF
Immediate identification of LBW
Cut-off for
referral -
1500/2000g
1st visit as early
as possible
within 24 hrs if at
home
Care for at least
24 hrs after birth
if in facility
(+) 3 PNC visits
(48 - 72 hr,
7-14d, 6 weeks)
Cut-off for referral -
2000g
1st visit within 24
hours if at home, 24
hrs later if in facility
(+2) PNC visits
(within 7d + 6
weeks)
Counselling on nutrition and EBF for 6
months
Poverty
Young age
Domestic or
gender-based
biolence
Women/
family-friendly
(respecting beliefs
and provision of
quality care)
responsibilities in practice.[46]
Inadequate facilities and equipment for MNCH
care have been reported in LPDR, e.g. lack of
hygiene facilities and weighing scales.[47-49]
Furthermore, lack of skilled health workers[47, 48,
50] has been identified as the highest risk factor for
under-5 mortality in LPDR.[48, 51] Health workers
have reported poor remuneration, insufficient
time, low status, weak technical supervision and
training contributing to low motivation and thus,
poor implementation of MNCH services.[45,
48, 49] Furthermore, guidelines do not propose
guidance in prioritising crucial components in case of
lacking equipment or staff-shortages – an additional
barrier of guideline adherence.
In LPDR, pre-service medical curricula fall under
the Ministry of Education whereas the MoH issues inservice
guidelines. Thus, national guidelines are likely
to be reflected only during in-services rather than preservice
training for health workers. A mixed-methods
study and three qualitative studies involving mothers
and MNCH care providers found a lack of awareness,
understanding, availability and adherence to some
key MNCH policies and guidelines.[46, 48, 49, 52]
An average consultation time of only 5 min was
reported.[49] This suggests that guidelines might be
used minimally or incorrectly due to time constraints
and/or availability. However, due to small sample
sizes generalisability of results might be limited.
2. Mothers and cultural factors
For most care procedures, coverage declines
with lower education status’ and wealth level.[50,
53-57] This explains the lower coverage in rural
areas compared to urban areas (Table 2).[1, 46, 58]
Additional barriers of MNCH care utilisation in such
socio-economic settings include infrastructural and
financial constraints such as transport time and costs.
[46-48, 50, 54, 56, 58-62]
Mothers with inadequate knowledge of healthy
pregnancy practices carry an eight-fold increased
risk of developing LBW infants in LPDR.[25] Reported
reasons for delaying or not receiving MNCH services
include a lack of time, feeling in sufficient health[56],
embarrassment[56, 60], reluctance towards male
nurses[47, 58, 59] and a lack of privacy during care.
[59, 63] Both mothers and health workers have
also reported ethnic discrimination, possibly due
to language barriers.[47, 48, 60] Other barriers for
MNCH care attendance found in the literature include
prolonged waiting times,[47, 56, 61] poor attitude
and quality of care provided by health workers’[57,
59] and misconceptions about ANC usefulness.[56]
Home births are still frequent in LPDR[50, 53, 54,
58, 61] due to the convenience of traditional practices
and lower costs.[48, 58, 59] However, traditional
practices can be unbeneficial and contribute to
delayed or under-utilisation of MNCH services.[48,
53, 54, 62, 64] Traditions include roasting, entailing
resting on a ‘hot bed’ or chair over a fire for up to 4
weeks[30, 31, 52, 61, 64], diet restrictions[29-31, 52,
61, 64], discarding colostrum[31], and complementary
feeding, e.g., rice, water and porridge.[30, 31, 52,
64-69] Interestingly, influence of the husband, and
female relatives[31, 48, 52, 57-60, 62, 63, 65, 70, 71]
have been found as both a threat and facilitator to
uptake and progress of evidence-based practices.
[48, 52, 72] However, most studies were conducted
in rural areas. Adaptation to modern practices seems
to be increasing and conducive for BF promotion in
some rural[69, 73] and urban areas.[47, 52] This has
been reinforced and facilitated by increased access to
health care[30, 52, 64, 65] and skilled health workers.
30

[31, 52, 55, 65, 70]
Traditionally, colostrum is discarded and
formula milk, water or pre-chewed rice are instead
fed the first days thus reducing early BF.[30,
31, 64-66] Though, Lee et al. (2013) found that
most urban first-time mothers recognized the
importance and low cost of colostrum compared
to infant formula.[52] Furthermore, this could be
facilitated by better access to health care.[30, 52,
64] Lack of EBF practice has been identified as the
second highest risk factor for under-5 mortality
in LPDR.[51] Based on national representative
Lao Social Indicator Survey data, two studies
found a significant association between Hmong
ethnicity, EBF for 6 months[65] and higher child
weight-for-height scores, all of which indicate
better nourishment amongst Hmong ethnicity.
[74] On the other hand, complementary feeding
before the age of 6 months is widespread and
varies in introduction and diversity among ethnic
groups. This is a prime factor for suboptimal
infant feeding practices, contributing to stunting.
[30, 31, 64, 70, 75-77] The caregivers’ ethnicity
therefore needs to be considered in provision of
nutrition/feeding counselling. A facilitating factor
for EBF for 6 months could be involvement and
Table 2. Coverage of interventions: early BF, EBF,
ANC, skilled birth attendants, iinstitutional delivery
and PNC
Lao PDR
Total Urban Rural
Early BF (within 1hr of birth), % 39.1 46.7 36.9
EBF for 6 months, % 40.4 39.2 41.0
Antenatal care (>4visits), % 36.9 70.6 27.2
Skilled attendant at birth, % 41.5 79.6 30.7
Institutional delivery, % 37.5 74.2 27.0
PNC for newborns within 2 7.4 12.6 5.9
days after delivery, %
Sourced from: Lao Social Indicator Survey 2011-2012.[1]
encouragement from the father.[70, 75]
3. Inconsistence/Confounding policies for LBW
prevention and care
Enforcement, monitoring and compliance with
the International Code of Marketing of Breastmilk
Substitutes (BMS)[78] is lacking and subsequently
undermining the promotion of EBF for 6 months in
LPDR,[75, 79-81] in particular, among low-literate
women.[82] Frequent and common violations of
the code are; BMS companies affiliating with health
workers[83], biased and misleading information
on labelling and systematic advertising and
promotion in public hospitals and health facilities.
[70, 75, 80]
Another confounding policy is the presence
of 3 months paid maternity leave. In case of
illness, women workers are entitled to 30 days
supplementary leave whereby approximately
50% of normal pay is provided.[84] Furthermore,
up until one year postpartum, women workers
are entitled daily one-hour breaks to care for the
child. However, some mothers have expressed a
lack of workplace support as a major barrier for
EBF.[52, 73] Thus, aligning current guidelines
with the International Labour Organisation’s
recommendation of 14 weeks maternity leave
could be conducive for promotion of EBF for
6 months and reducing LBW morbidity and
mortality.[80]
Discussion
As evident from this study, developing coherent
guidelines and aligning strategies preventing LBW
is difficult at national and international levels.
Even more challenging is implementation of such
guidelines where it is most needed, i.e. in countries
with high prevalence of LBW and neonatal
morbidity and mortality. A study conducted
in three central hospitals in LPDR suggested
some improvements of LBW care through the
implementation of the WHO Pocketbook of
Hospital Care for Children over a 1-year period.
[85] The appropriateness of current guidelines for
the prevention and management of LBW infants
in LPDR will be discussed, with emphasis on areas
of improvement if better coherence was present.
Appropriate cut-off for referral of LBW
Different cut-offs for referral of LBW infants
were found in two current WHO WPR documents:
a 2000g cut-off and a 1500g cut-off in the WHO
WPR Action Plan 2014-2020[39] and the WHO
WPR EENC guide (2014),[86, 87] respectively.
This demonstrates disparity within a pronounced
organisation. Due to low resources and poor
referral functions in LPDR, a higher cut-off for
referral (2000g) would not necessarily lead to
a better outcome in practice. However, LPDR
could consider introducing an alternative growth
assessment for when scales are not available,
in particular in rural areas. Measuring chest
circumference was in rural India found as the best
surrogate parameter for identifying LBW infants.
[88] Additionally, this could help strengthen
timely referral and avoid unnecessary referrals
burdening the referral centers.
Qualifying as a LBW infant might not necessarily
increase risk of mortality - known as the LBW
paradox.[89, 90] In LPDR, factors such as high
altitude may be a risk factor for LBW, but not
necessarily for mortality.[89, 90] Knowledge on
the predominant distribution (weight distribution
of term births) and the residual distribution
(percentage of small and preterm births) are hence
essential in gaining insight into the gestationalage
characteristics. Such epidemiological data is
necessary to provide a better basis to judge the
appropriateness of cut-off values.
31

Appropriate number and timing of ANC visits
Despite WHO recommending 4 ANC visits[37],
the exact timing of ANC visits has been debatable.
[91] The recommendation is based on a large WHO
ANC randomized trial comparing the standard
model of ANC (12 visits) with the new ANC model
(4 visits). No differences in maternal and perinatal
outcomes were found between the two models.[92]
A systematic review of studies from developed and
developing countries provided similar findings where
good perinatal outcomes persisted despite reduced
ANC visits.[93] However, it proposed that in a setting
of low ANC-coverage, visits should not be reduced
without close monitoring of foetal and neonatal
outcomes.[93]
The recommendation of 4 ANC visits might be
inappropriate for LPDR due to a lack of financial and
human resources. However, the unspecified timing of
ANC visits in LPDR might be appropriate, as it seems
unrealistic for mothers to adhere and attend ANC at
specific times due to the infrastructural and financial
constraints. However, recommending the 4th visit
at week 40/term might delay or miss detection and
management of LBW births as 44 % of neonatal deaths
are due to prematurity.[94] Conversely, reducing ANC
to 3 visits could reduce maternal satisfaction with
ANC which has been evident from the systematic
review comparing the two ANC models.[93] Declining
satisfaction can adversely influence ANC attendance
and thus, the burden of LBW.
A pre-requisite for appropriate ANC guidelines
is improvement in the quality of resources and
services at both structural levels (e.g., distribution of
guidelines and human resources), and in practice (e.g.,
education, training and adherence to guidelines).
Otherwise, a discussion of recommending 3 or 4
visits is unreasonable.
Appropriate number and timing of PNC visits
A Cochrane review conducted by Yonemoto et al
(2013), found no strong evidence associating frequency
and timing of home-visits with improvements in
neonatal and maternal mortality.[95] However,
this review found 4 studies providing evidence to
suggest that home visits may encourage women to
EBF. On the contrary, an association between home
visits and increased maternal satisfaction with PNC
was described. This suggests PNC is beneficial in
alleviating the burden of LBW. Unlike the WHO, the
MoH in LPDR does not recommend a PNC visit at
7-14 days. Considering the high neonatal mortality
within the first week of life,[96, 97] a PNC visit at
7-14 days might be inappropriate. Furthermore, the
current LPDR PNC schedule articulates well with the
Expanded Programme on Immunisation.[98] However,
due to the low rate of EBF and growing importance
of educating mothers in feeding practices for LBW
infants, a recommendation of PNC visit at 7-14 days
could be appropriate. Adding a PNC visit should
be considered only after evaluating availability of
resources and assessing morbidity and mortality risk
after the first week of life. Thus, the focus should be
on content and quality of care to facilitate optimal BF
practices as opposed to increasing PNC visits, which
carry costs towards the mother and society without
documented benefit.
Attention to vulnerable women
WHO guidelines[37] mention vulnerable women,
including adolescents, as a group that needs
special attention. Low maternal age (

eview suggested that structural factors including
culture, infrastructure and economy appeared to
be major barriers for adherence and acceptance of
guidelines.
In the context of barriers and facilitators for
implementation of LBW guidelines, appropriateness
of LBW guidelines needs further research. However,
4 ANC visits in LPDR were found appropriate due
to the risk of decreasing satisfaction and thus
utilisation of ANC if reduced to 3 ANC visits. In line
with recommendations by the WHO, BF and skinto-skin
contact were found appropriate for LPDR
given its potential to reduce the burden of LBW
morbidity and mortality in low-resource settings.
A recommendation is made on implementing
culturally acceptable maternity waiting homes due
to strong and widespread cultural practices in LPDR.
The internal institutional alignment and coherence
of guidelines, particularly the cut-off for referral of
LBW infants, should also be monitored to ensure
hard-working healthcare workers are appropriately
informed of appropriate practices and complications
of nonadherence. Further studies comparing
divergent WHO guidelines, local guidelines and local
cultural norms and traditions are recommended for
future studies.
Acknowledgments
None
Declarations
The materials used during the current study
are available from the corresponding author
on reasonable request. The author declares that
submissions are neither intentionally nor able to
be construed as defamatory or unfairly derogatory
of any persons or organisations.
Conflicts of Interest
None declared
Correspondence
linemp89@gmail.com
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35

“
The experience of Mekelle University in provision of
comprehensive healthcare interventions at STI clinics
for female sex workers in Ethiopia
Review article
Tesfay Gebregzabher Gebrehiwot
Dr. Gebregzabher Gebrehiwot has been working as a nurse and non physician
clinician. Additionally working in the zonal health department, district
health office and regional health bureau in the health system organization,
Dr Gebregzabher Gebrehiwot is currently working as Head of Public Health
at Mekelle University.
Abstract
Background: Evidence suggests that the presence of untreated sexually transmitted infections (STIs)
increases the chance of human immunodeficiency virus (HIV) transmission during unprotected sex.
In the Ethiopian context, many female sex workers live in poor conditions in rented slums and are
not typically known or recognised by local authorities, making them unable to access health facilities.
Methods: Data were obtained from a register of female sex workers recorded for purpose of service
provision at confidential STI clinics in Mekelle and Adigrat, Ethiopia, from May 2010 to August 2015
and from May 2011 to August 2015, respectively. A simple descriptive analysis of services delivered
to patients was performed.
Results: Among the 6288 patients included in this study, the prevalence of STIs was 23.4%. Of these,
12.9% (814/6288) of patients presented with vaginal discharge, 7.9% (490/6288) with genital ulcers
and 2.3% (158/6288) with lower abdominal pain (as per the World Health Organisation (WHO)
syndromic approach to STIs). Moreover, 180 cases of genital ulcer were tested for syphilis with the
Venereal Disease Research Laboratory (VDRL) test; 36 (20%) tested positive for active infection. The
HIV prevalence declined from 10% in 2010 to 1.1% in 2015. The frequency of STIs amongst repeat
patients was considerably lower than that in new presentations.
Conclusions: Clinic and workplace geography, hours of clinic operation, confidentiality and peer
outreach are important factors in the prevention and control of STI/HIV infection in key female sex
worker populations. A comprehensive clinic intervention enhances early diagnosis and treatment of
STIs and increases the proportion of female sex workers accessing HIV treatment services.
Introduction
Additonal authors: Dejen Yemane, Zerihun Abebe, Solomon Gmariam,
Yemane Ashebir, Afework Mebrat, Alemayehu Mekonen & Loko Abrham
Sexually transmitted infections (STIs) are
among the most common causes of illness in
the world, and have far-reaching health, social,
and economic consequences.[1, 2] STIs affect
the health and social wellbeing of women by
compromising their reproductive potential, with
women of reproductive age and adolescents
most affected. Women often feel uncomfortable
discussing issues regarding sexuality, potentially
resulting in further disempowerment in
developing countries. STIs create a significant
health and economic burden, especially for
developing countries, where they account for
17% of economic losses caused by ill-health.[3,
4]
Management of STIs in many developing
countries has been complicated by the lack of
simple and affordable diagnostic tests. STIs often
exist without symptoms; for example, up to 70%
of women with gonococcal and/or chlamydial
infections may be asymptomatic.[5, 6] human
immunodeficiency virus (HIV) remains one of
the most important STIs in developing countries,
in part due to high prevalence and associated
social, economic, and health burdens. It is wellestablished
that the concomitant presence
of non-HIV STIs increases the transmission of
”
36

HIV during unprotected sex.[5-8] Therefore,
effective prevention messages, treatment for
concomitant STIs, and promotion of condoms in
such populations can have a substantial impact
on HIV transmission.[8-10]
STIs and the Ethiopian context
STIs remain a major public health threat in
Ethiopia, with most cases affecting adolescents
and young adults.[11, 12] Indeed, STIs are
grossly underreported in Ethiopia, largely
because these infections have traditionally been
stigmatised, many infections are asymptomatic
and diagnostic and treatment facilities are
scarce. As a result, many patients with STIs
seek treatment in various settings, including
traditional healers, pharmacists, and informal
drug-vendors and marketplaces, none of which
report cases to the Ministry of Health. As with
many countries internationally, STIs in Ethiopia
have become a more complex issue in recent
years, in part reflecting changing attitudes with
respect to risk behaviours.[13, 14] Not only has
prostitution become more open and widespread,
but increasing poverty, postponement of
marriage, urbanisation, socio-cultural change,
and increasing youth unemployment have
contributed to earlier and often unprotected sex.
[7, 8, 11, 15-17]
Rationale for the intervention
Female sex workers (FSWs) are particularly
vulnerable to the changing sociocultural
environment in Ethiopia, due to ongoing
stigmatisation, economic disadvantage, and a
high rate of sexual partner turnover. Consequently,
FSWs pose a high risk of transmitting these
infections to their clients and other sexual
partners.[18] Although some reports indicate
that condom use by FSWs with paying clients
has increased in recent years, there remains
concern that condom use with non-paying
partners is low.[19, 20] This is a serious gap in
sexual health practices: non-paying partners can
transmit HIV and other STIs from FSWs to the
general population. Furthermore, the number of
FSWs in regional towns has increased. As a result,
the average age of FSWs has shifted towards
younger women, with a consequent decrease
in understanding and implementation of safe
sexual practices.[19, 21-24]
The majority of FSWs live in poor conditions
in rented slums, with limited access to services.
Even if they have access to health facilities, they
cannot afford to pay bills for drugs and diagnostic
services.[25-27] Improving access to STI clinics
in such areas can mitigate the socioeconomic
barriers faced by FSWs, thus increasing capacity
to treat STIs and prevent HIV transmission.[28,
29]
To address gaps in sexual health services
in these communities, the College of Health
Sciences at Mekelle University has entered into
a cooperative agreement with the Centers for
Disease Control and Prevention (CDC) Ethiopia/
Atlanta from 2009 to 2014.[30] The purpose
of this paper is to evaluate the outcome of
a comprehensive STI/HIV prevention and
treatment service, and to quantify STI/HIV cases
in FSWs visiting the confidential clinics in Adigrat
and Mekelle.
Methods
Data were collected from a register of FSWs
recorded for purpose of service provision at
confidential STI clinics in Mekelle and Adigrat,
Ethiopia, from May 2010 to August 2015 and
from May 2011 to August 2015, respectively.
Following consultation with authorities at
the Tigray Regional Health Bureau, the first
confidential STI clinic was established in Mekelle
in May 2010, functioning under the College of
Health Sciences, Mekelle University. The second
STI clinic was established in Adigrat town, where a
high number of FSWs reside, due to its proximity
to the Eritrean border and consequent military
population.
Typically, a client visiting the clinic is evaluated
according to her presenting complaint for
common STI syndromes, as per the WHO
syndromic approach to STIs. The syndromic
approach reduces the requirement for costly
and time-intensive diagnostic procedures by
assigning probabilistic STI diagnoses to patients
presenting with specific symptoms in the
context of high-risk behaviours. In particular, the
syndromes evaluated in this paper include vaginal
discharge syndrome (gonorrhoea/chlamydia,
and other genitourinary pathogens), genital
ulcer syndrome (syphilis), and lower abdominal
pain (presumed pelvic inflammatory disease).
Using this approach, patients receive treatment
according to the pathogens of greatest concern,
as listed above.
Owning to the unique nature of the clinic,
there is no sign for the confidential STI clinic;
FSWs visit the clinic only through peer referrals
made by specifically trained peer promoters
who are FSWs themselves. More than 250
trained FSWs educate their peers on STIs/HIV
and refer cases for treatment and care to the
clinic. Importantly, when needed, clients are
routinely provided with a range of contraceptive
options including condoms, targeted health
education and antibiotics, all free of charge.
Follow up appointments and consultations with
a dermato-venerologist are also made when
necessary for cases that require continuation
of care. Regulatory checks of equipment, drugs
and laboratory resources have been performed
to ensure standards of care are maintained, and
37

ongoing review is enabled by fortnightly meetings.
Data retrieval and analysis
Data pertaining to consultations and service
provision were obtained from a registration book
in the confidential STI clinic. New and repeat clients
were tabulated separately and categorised based on
the type of services provided. Thereafter, data were
recorded in an Excel sheet and a simple descriptive
analysis was performed. Data are presented as
frequency (percentage) unless otherwise stated.
This study received ethics approval from the
Mekelle University College of Health Sciences Ethics
Committee (approval number ERC0027/2011), who
waived the necessity for written informed consent
given the nature of the data presented.
Results
STI statistics - Mekelle
The Mekelle STI clinic provided sexual health
services to 2549 new clients during the 5-year study
period (2010-2015), of which 889 (34.9%) were
diagnosed with and treated for an STI. As per the
WHO syndromic approach to STIs, the most common
diagnosis was vaginal discharge syndrome (n = 445,
50.1%). Genital ulcers were noted in 381 women
(42.9%). Relatively few women were diagnosed
with lower abdominal pain (n = 63, 7.1%). Of note,
throughout the 5-year study period, only 15 repeat
clients presented with STI infection, suggesting that
the preventative practices promoted by the service
and peer workers were effective.
In the first year at Mekelle clinic, a total of 891 new
FSWs were examined from May 2010 to August 2011,
of which 302 (33.9%) were diagnosed with and treated
for an STI (Table 1). Most women were in the 15-29
age group (n = 710, 79.7%). Of the 302 cases with an
STI, 122 manifested with 1 of the 3 STI syndromes:
genital ulcer, 56 (45.9%); vaginal discharge, 54
(44.2%); and lower abdominal pain, 12 (9.8%).
Moreover, 180 cases were tested for syphilis with the
Venereal Disease Research Laboratory (VDRL) test, of
which 36 (20%) tested positive for active infection.
The remaining cases were managed empirically as
per the WHO syndromic approach. Unfortunately,
the true prevalence of active syphilis could not be
accurately assessed, due to a lack of VDRL reagents,
and a consequent lack of consistent testing amongst
clients. The prevalence of STIs rose significantly
during the second year of the project (2011-2012),
with 301 (76.9%) of all new clients screened (n =
391) found to have an STI. During the subsequent
years, the prevalence of STIs ranged from 29-34.8%.
In 2014-2015, the prevalence reduced rapidly from
30% to 17%; of 468 FSWs screened, only 80 STI cases
were diagnosed and treated (Table 2). The number
of FSWs (new and repeat clients) visiting the Mekelle
STI clinic increased considerably throughout the
study period; however, the number of new clients
remained relatively constant throughout the 5-year
study period.
STI statistics – Mekelle and Adigrat
As discussed above, the Adigrat clinic was not
established until the second year of the study. The
total number of screened cases among the 2 sites
was 6288, with 1462 STI cases diagnosed and treated.
The prevalence of STIs throughout the 5-year study
duration at both sites was 23.4%. Based on the WHO
syndromic approach, 814 (55.7%) patients were
diagnosed with vaginal discharge syndrome, 490
(33.5%) with genital ulcer syndrome, and 158 (10.8%)
with lower abdominal pain. Inferences regarding
the distribution of causative pathogens can be
made according to the WHO syndromic approach,
as discussed above. Of all diagnosed STIs, vaginal
discharge syndrome was present in more than half
of patients.
HIV counselling and testing service
From May 2010 to August 2011, of 598 women
who attended the Mekelle clinic, 55.7% (n = 333)
were provided HIV testing and counselling. Of FSWs
recruited for opportunistic screening, 48 (14.4%)
had positive HIV results. The remaining individuals
declined testing; many of these women claimed that
Table 1. Trends in STI presentations to Mekelle STI clinic from May 2010-August 2011
Age FSWs Treated STI syndromes
for STI Vaginal discharge Genital ulcer Lower abdominal pain
45 17 18 2 4 3
Total 891 302 54 56 12
FSWs, female sex workers; LAP, lower abdominal pain. *NB: Not all patients were diagnosed using the STI syndrome approach,
therefore, discrepancies may exist in frequency tallies.
38

the test had been performed within the previous 3
months, however, several women also refused to be
tested due to the fear of stigma and discrimination
associated with a positive test. On subsequent
follow-up for those women who refused screening,
further opportunities for screening were offered,
as appropriate. All FSWs who received a positive
test result for HIV were referred to higher health
institutions for antiretroviral therapy (ART) and to
other organisations for related services.
When both clinics were included, a total of
5302 FSWs were tested for HIV over the 5-year
study duration, with 181 having positive results,
giving a prevalence of 3.4%; however, of those also
diagnosed with an STI (n = 1462), the prevalence was
12.4% (Table 3). This suggests that concomitant STI
infection is a risk factor for HIV infection. Notably,
the prevalence of HIV decreased from 10% in 2010
to 1.1% in 2015 (Table 4).
Discussion
This study aimed to describe the experience of 2
confidential sexual health clinics in northern Ethiopia,
and to quantify the prevalence of STIs and response
to education regarding preventative health activities.
The link between STI and HIV co-infection was
examined, with an increased rate of HIV infection
noted in those presenting for investigation of an STI
syndrome, as consistent with previous literature.
Establishing the clinic and peer outreach
In the first 2 months following establishment of the
clinic, the number of FSWs attending was minimal.
Subsequent efforts to educate peer promoters were
successful in increasing the number of FSWs accessing
services at the clinics. Furthermore, staff working
at the clinic also played a role in disseminating
key information to FSWs during outreach sessions.
During the 5-year period, different strategies were
implemented to mobilise FSWs for HIV testing and
counselling. Providing peer education, engaging
with bar and hotel owners, conducting forums with
various stakeholders, providing outreach services and
opening the STI clinics on weekends were among the
strategies used, with good effect.
The Mekelle STI clinic provided sexual health
services to 2549 new clients during the 5-year study
period (2010-2015), of which 889 (34.9%) were
Table 2. Provision of STI services at Mekelle STI clinic from 2010 to 2015
Screening STI syndromes Contraceptives and interventions
Year Total
visits
Screened VDS GUS LAP Condoms
provided
Depo OCP Pregnancy
test
New Rpt New Rpt New Rpt New Rpt Visits Condoms
2010 803 500 303 39 0 60 0 6 2 650 65,000 111 18 42
2011 4059 391 3668 148 2 126 0 27 1 3468 499,392 502 285 282
2012 5691 710 4981 126 1 68 0 13 1 4520 594,100 791 342 436
2013 5474 502 4972 53 1 77 2 10 1 4122 618,300 808 306 360
2014 2388 446 1942 79 2 50 1 7 1 3922 595,800 1153 388 526
2015 1229 468 761 52 0 26 0 2 0 1548 154,800 799 242 361
Total 18415 2549 15866 445 6 381 3 63 6 16682 2,372,592 3365 1339 1646
VDS, vaginal discharge syndrome; GUS, genital ulcer syndrome; LAP, lower abdominal pain; OCP, oral contraceptive pill;
Depo, Depo-Provera contraceptive injection.
Table 3. HIV testing and STI screening at Mekelle and Adigrat clinics
Screening STI syndromes Treated STIs HIV tested
Year Total Screened VDS GUS LAP New Rpt New 1 HIV+
visits New Rpt New Rpt New Rpt New Rpt
2010 803 500 303 39 0 60 0 6 2 650 65,000 111 18
2011 4619 951 3668 199 2 135 0 57 1 3468 499,392 502 285
2012 8003 2373 5630 229 1 102 0 57 1 4520 594,100 791 342
2013 7841 930 6911 127 1 92 2 18 1 4122 618,300 808 306
2014 4494 814 3680 146 2 66 1 14 1 3922 595,800 1153 388
2015 2165 720 1445 74 2 35 0 6 0 1548 154,800 799 242
Total 27925 6288 21637 814 8 490 3 158 6 16682 2,372,592 3365 1339
NB: 2010 refers to the Mekelle clinic alone, as Adigrat was not in operation until 2011. VDS, vaginal discharge syndrome;
GUS, genital ulcer syndrome; LAP, lower abdominal pain.
1. Only new patients receiving HIV tests have been included here.
39

Table 4. HIV prevalence among female sex workers
attending the STI clinics (Mekelle & Adigrat), 2010-
2015
Year
2010 2011 2012 2013 2014 2015
Number of FSWs 200 626 1514 1200 950 812
tested (HCT)
Positive cases 21 52 42 26 27 13
diagnosed with and treated for an STI. In general,
the number of consultations for FSWs, particularly
for repeat clients, grew throughout the study. The
overall STI positivity rate among FSWs who received
care at the STI clinics remained stable. Similar FSWspecific
STI clinics in Uganda have reported rates
of STIs approaching 70%.[31] This difference could
be explained by the study setting, in particular the
abovementioned clinics in Uganda were located
in major commercial centres, and lacked the peer
education component delivered in the Ethiopian
clinics. The prevalence of STIs throughout the 5-year
study duration at both sites (Mekelle and Adigrat) was
23.4%. This finding is consistent with other studies
conducted among FSWs in Finote Selam (Ethiopia)
and Malawi, where the prevalence of STIs were 20.6%
and 25%, respectively.[18, 24] However, STI rates in
Ethiopia vary considerably; for example, 47.9% of
FSWs were found to have an STI in Addis Ababa.[13]
Similar international FSW-specific clinics have
reported much lower rates of STI positivity, such as in
the Netherlands (9.5%).[32] A combined intervention
focusing on peer education, voluntary and
anonymous clinic attendance, condom promotion
and STI testing, as administered in this study, has
previously been successful in decreasing STI rates
in other African countries, such as Côte d’Ivoire and
Benin,[33, 34] and internationally in India.[27, 29]
HIV counselling and testing service
Of all FSWs who attended the Mekelle clinic in 2010
(n = 598), 333 (55.7%) were provided HIV testing and
counselling, with 48 (14.4%) returning positive HIV
results. The remaining individuals declined testing.
Sex workers face stigma and discrimination in
different forms; for example, it is common for FSWs
to be exposed to violence and social discrimination.
FSWs are highly vulnerable to HIV due to high risk
sexual behaviours; limited access to HIV prevention,
diagnosis, and treatment services; high-level stigma
associated with sex work; and social and economic
marginalization.[13, 26, 35] Despite growing efforts
to increase HIV testing and counselling services for
the most at-risk populations in Ethiopia, the uptake
of such services by FSWs remains poor. Previous
studies in Zambia and Ethiopia have shown that lack
of confidentiality is a major barrier to HIV testing.[35,
36]
Over the 5-year study period at both clinics, the
prevalence of HIV was 3.4%, with a concomitant
STI infection rate of 12.4%. The prevalence of HIV
exhibited a marked decline from 10% in 2010 to 1.1%
in 2015. This finding is lower than a previous baseline
survey in Ethiopia conducted from 1989 to 1990,
which reported a mean sero-prevalence of 17%.[23]
The current study observed a marked decline in HIV
prevalence. This is consistent with studies conducted
in Adama, Ethiopia.[26] Such a decline likely reflects
a number of factors, including increased accessibility
to ART, but also a decline in the prevalence of STIs
and condom promotion.
Lessons learned
Good connection and collaboration with the
community is required to mobilise services for
vulnerable populations. Furthermore, maintaining
confidentiality is crucial in building and maintaining
rapport. Whilst traditional services are typically
inaccessible for FSWs and similar vulnerable
populations, the model described in this paper
provides a realistic and reproducible approach to
preventative health for FSWs. Collaboration with
appropriate governmental and non-governmental
stakeholders is required to guarantee the
sustainability of such services.
Future directions
After establishment of the clinics, high service
demand was observed. Such demand requires
mapping and census of FSWs, with the view to
increase the number of confidential STI clinics in
areas with the greatest need. The preliminary results
observed in this study suggest that it is possible
to reduce the burden of STIs and HIV by provision
of targeted health interventions for vulnerable
populations, using a model that is cognisant of
the unique demands FSWs face. Further research
is needed to both confirm the results observed in
this study, and to explore aspects of stigma and
discrimination faced by FSWs when seeking medical
advice from traditional health providers.
Conclusion
The HIV prevalence declined from 10% in 2010 to
1.1% in 2015. Compared to new cases, the frequency
of STIs among repeat clients was extremely low,
suggesting that the cumulative effect of peer
promotion and preventative sexual health education
is effective in reducing the rates of STIs among
vulnerable populations. The clinic intervention
enhances early diagnosis and treatment of STIs, and
increases the proportion of FSWs linked with ART
services. Therefore, it is reasonable to suggest that
such an approach be encouraged in future models of
service provision.
Author contributions
TG was responsible for conception and design of
the project, completing grant applications,
overseeing project activities and reviewing
data compilation, analysis and composition of
the manuscript. DY was responsible for
coordinating part of the project and involved
40

in data retrieval and manuscript composition. ZA
was responsible for monitoring and evaluating
as a business official, supervising data retrieval
and manuscript composition. SG, YA, AM, AM, and
LK contributed equally in supervision of data
retrieval and manuscript composition.
Abbreviations
AIDS: Acquired immunodeficiency syndrome
CDC: Centers for Disease Control and Prevention
FSWs: Female sex workers
HIV: Human immunodeficiency virus
PEPFAR: President’s Emergency Plan for AIDS
Relief
STIs: Sexually transmitted infections
VDRL: Venereal Disease Research Laboratory
WHO: World Health Organization
Conflicts of interest
None declared
Correspondence
tesfig@gmail.com
Acknowledgments
Provision of sexual health services as discussed in
this manuscript would not have been possible
without funding granted by CDC/PEPFAR; the
authors wish to acknowledge the assistance of the
CDC/PEPFAR in enabling this service. The authors
also wish to acknowledge users of the service, in
particular peer educators who have been pivotal in
mobilizing beneficiaries. Further
acknowledgements go to the College of Health
Sciences at Mekelle University, Tigray Regional
Health Bureau and all project staff members,
in particular clinic staff. Finally, the authors wish
to acknowledge Dr. Belete Assefa (School of Public
Health, Mekelle University) for his support in
editing and reviewing the manuscript.
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2. Newman L, Rowley J, Hoorn SV, Wijesooriya NS, Unemo
M, Low N, et al. Global estimates of the prevalence and incidence
of four curable sexually transmitted infections in 2012 based on
systematic review and global reporting. PLoS ONE. 2015;10(12).
3. Mayaud P, Mabey D. Approaches to the control of sexually
transmitted infections in developing countries: old problems and
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4 Mullick S, Watson- JD, Beksinska M, Mabey D. Sexually
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5. WHO. Sexually transmitted infections (STIs). Fact sheet
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6. Celum N Celum, Gail B, Mellisa K, Karen C, Peter L, Cora
S, et al. Patients attending STD clinics in an evolving health care
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605.
7. HIV/AIDS Prevention and Control Office. Multi-sectoral
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8. HIV/AIDS Prevention and Control Office. National guidelines
for the management of STIs using syndromic approach. PEPFAR/
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9. Ngugi EN, Roth E, Mastin T, Nderitu MG, Yasmin S. Female
sex workers in Africa: Epidemiology overview, data gaps, ways
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Bull. 2001;58:129–53.
11. Central Statistical Agency (CSA). Ethiopia Demographic and
Health Survey 2016. Addis Ababa, Ethiopia: Ministry of Health CaI;
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12. Yohannes B, Gelibo T, Tarekegn M. Prevalence and
associated factors of sexually transmitted infections among
students of Wolaita Sodo University, Southern Ethiopia. Int J Sci
Tech Res. 2013;2(2):86-94.
13. Alem A, Kebede D, Mitike G, Enqusellase F, Lemma W.
Unprotected sex, sexually transmitted infections and problem
drinking among female sex workers in Ethiopia. Ethiop J Health
Dev. 2006;20(2):93-8.
14. Andualem H, Anteneh K, Astehun L, Atalay N, Tafesse
L. Knowledge, attitude and practice of risky sexual behavior
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15. Policy Plan Directorate FDRoE. Health and Health Related
Indicators. Ministry of Health, Ethiopia; 2010.
16. Kahsay AG, Daba F, Kelbore AG, Getachew S. Prevalence
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17. Tadesse G, Yakob B. Risky sexual behaviors among female
youth in Tiss Abay, a Semi-urban area of the Amhara Region,
Ethiopia. PLoS ONE 2015;10(3): e0119050.
18. Alamrew AZ, Amare AY, Molalign T. Sexually transmitted
diseases among female commercial sex workers in Finote Selam
town, northwest Ethiopia: A community-based cross-sectional
study. HIV/AIDS. 2017;9:43.
19. Berhane Y. Mekonnen Y, Seyum E, Gelmon L, Wilson D. HIV/
AIDS in Ethiopia: An epidemiological synthesis. Addis Ababa: HIV/
AIDS Prevention & Control Office and Global AIDS Monitoring &
Evaluation Team; 2008.
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and sexual behavior of female sex workers in Northwest Ethiopia:
A cross-sectional study. Pan Afr Med J. 2015;21:50.
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SZ, et al. Where do sex workers go for health care? A community
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29. Gurnani V, Beattie TS, Bhattacharjee P; CFAR Team, Mohan
41

HL, Maddur S, et al. An integrated structural intervention to reduce
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Health 2011;11(755).
30. Mekelle Univeristy College of Health Sciences.
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Emergency Plan for AIDS Relief (PEPFAR). Mekelle University; 2011.
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G, Kamali A, Guwatudde D. Acceptance of treatment of sexually
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Koedijk FDH, van Benthem BHB. Sexually Transmitted Infections
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34. Ghys PD, Diallo MO, Ettiègne-Traore V, Kalé K, Tawil O,
Caraël M, et al. Increase in condom use and decline in HIV and
sexually transmitted disease among female sex workers in Abidjan,
Cote d’Ivoire 1991-1998. AIDS. 2002;16(2):251-58.
35. Chanda MM, Perez-Brumer AG, Ortblad KF, Mwale M,
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ese- and sex-matched non-students.[4] Such a
finding
42

An open letter to our social media overlords
Editorial
Nina Li
Nina Li is a fourth year medical student at the University of New
South Wales. She is passionate about evidence-based medicine
and when she isn’t working with Vector Journal, she can be
found drawing instead of paying attention in lectures.
As I scrolled through my Facebook News Feed
on my millennial pink iPhone, I noticed a bitter tone
creeping into my thoughts. A friend was on a European
vacation in Santorini. #blessed. Another friend had
just completed a marathon run in a personal best
time. I’m not sure that I could complete a marathon
even if someone carried me to the finish line.
Someone else had posted an image of the kale and
quinoa power bowl they had consumed for lunch—
complete with cold-pressed juice accompaniment—
and affectionately captioned it “healthy habits”.
Silently stashing away my half-priced, greasy hot
chip lunch on a bus most definitely not in Europe,
I was overcome with feelings of inadequacy and
dissatisfaction. In my mind, none of my achievements
or positive attributes could hold a candle to what my
peers were accomplishing. It was all too easy to forget
the meticulous curation inherent in social media’s
highlights reel of life, complete with the option to
edit out any pesky sharp edges of reality.
I know I’m not alone in having these intrusive
thoughts. As of June 2018, Instagram has one billion
monthly active users.[1] Let us pause for a second and
consider what this number means. Not one million,
but one billion regular users. One billion individuals
routinely scrolling through images purposefully
presented to make you chuckle, elicit a tear, provide
inspiration, or perhaps trigger self-loathing. One
billion other individuals also stalking beauty gurus,
unintentionally consuming native advertising and
living vicariously through celebrities.
If my mortifying Emo phase has taught me anything,
it’s that adolescence and the turbulent transition
to young adulthood represents a critical time of
self-discovery and emotional maturation. Amidst
continually evolving technological advancement,
young adults come of age in an era where
communicating and expressing one’s individuality (or
lack thereof) on social media platforms is the norm.
[2] Young adults represent the highest proportion
of social media users, with 92% of Australians aged
16–17 years frequenting social media,[3] compared
to only 30% of individuals aged 65 and over.[4]
Considering the centrality of social media in
establishing connections, shaping self-identity and
providing access to a previously unimaginable wealth
of knowledge, its ties to psychological health are
inextricable. Facebook continues to reign supreme
over other user-generated social networking
platforms, which include Twitter, Google+, LinkedIn,
Pinterest, Instagram and Snapchat.[5] Despite its
43

ubiquity, we remain largely ignorant to the potential
mental health ramifications of navigating the social
media minefield.[2] The speed of change has only
widened the distinct generational gap between
the internet-indoctrinated millennials who face the
pressures of this novel online world firsthand and
the law-enforcers and policymakers attempting to
moderate and improve it.
It was all too easy to
forget the meticulous
curation inherent in
social media’s highlights
reel of life, complete
with the option to edit
out any pesky sharp
edges of reality.
Growing up as a so-called ‘digital native’,[6]
my relationship with social media was always
slightly dysfunctional (and occasionally bordering
on Stockholm Syndrome). Each brief jaunt to a
different social networking platform would spark
an uncontrollable spiral of comparison, envy and
self-loathing. Yet while I could rely on social media
to stir up negative emotions within me, it was also
an essential channel of communication for group
projects, organising events and simply chatting with
peers. Try as I might, social media’s utility made it
inescapable; the red notification icon acted like a
time-bomb, ticking upwards until I surrendered
and reopened the apps I had tried so hard to avoid.
Indeed, social media has been described by many
young adults as more addictive than smoking or
alcohol use.[7] In one study involving social media
habits,[8] 5% of young adult participants were
afflicted by social media addiction, fulfilling at least
five of nine DSM-V criterion also used to tentatively
diagnose Internet Gaming Disorder.[9]
common sentiment, known colloquially as FOMO
(Fear Of Missing Out), has alarming associations
with lower mood, greater anxiety and feelings of
inadequacy, and is strongly linked with higher levels
of social media engagement.[10]
Body image remains a significant issue for young
adults and adolescents, with 9 out of 10 girls citing
dissatisfaction regarding their figure.[11] Social
media provides an infinite pool of candidates to
compare oneself to online, all just a click or tap away.
With 80 million photographs uploaded to Instagram
daily,[12] young adults are continually bombarded
with heavily edited, meticulously staged images
presented as if they were “natural”. How often have
I found myself subconsciously assessing my worth
through superficial, appearance-based comparisons
using social media? Far more often than I will ever
admit to.
Inevitably, this has significant ramifications. Not
only has perusing Facebook been linked with higher
rates of body image concerns from women and girls,
but also an amplified desire for physical appearance
changes, which may be associated with the increasing
rates of cosmetic surgery in young adults.[2] The
mounting pressure to become this ‘perfect’ individual
can fuel feelings of inadequacy and low self-esteem,
potentially contributing to the rise of anxiety and
depression among young adults.[13] In studies by Lin
et al. (2015) and Sampasa-Kanyinga & Lewis (2015),
youths spending a disproportionate amount of time
(>2 hours) on social media platforms were more likely
to report poor mental health, psychological distress
and suicidal ideation.[14, 15] Researchers have even
coined the term ‘Facebook depression’ to describe
the growing evidence supporting the association
between the unattainable demands of the online
world and poor mental health.[16]
My attempted character assassination of
social media notwithstanding, the substantial
benefits of these novel communication platforms
deserve recognition. Social media have presented
revolutionary opportunities for young individuals
to express themselves and their beliefs. Established
The endless influx of photographic proof that my
friends were leading fulfilling, fun-filled lives made
my own situation feel mundane. Why was I lounging
at home in sweatpants instead of enjoying a night
out with friends? I burdened myself with unhealthy
expectations of matching what I was observing on
social media, lest I fail to live life to its fullest. But
achieving this seemed to demand even more attention,
more self-critical comparisons, more dedication to
the platforms perpetuating this destructive cycle. It
didn’t matter that I barely knew these people on my
social media—they simply provided a benchmark,
however unrealistic, to juxtapose my life against. This
44

in the aftermath of the 2018 Marjory Stoneman
Douglas High School shooting, The Never Again
MSD Movement’s gun control advocacy is a prime
example of social media’s ability to amplify the voices
of young adults in a world where attempting to do so
by conventional means presents difficulties. For many,
social media has revitalized dormant relationships,
strengthened existing friendships and helped form
online support networks that overcome geographical
separation. The ability to connect with like-minded
peers and receive emotional support, especially for
individuals belonging to real-world minority groups,
remains invaluable.
‘How often have
I found myself
subconsciously
assessing my worth
through superficial,
appearance-based
comparisons using
social media? Far more
often than I will ever
admit to.’
Nearly half of all Australians (45%) will experience
a mental illness during their lifetime,[17] with
prevalence remaining the highest amongst Australian
aged 18-24 years (21.2% of all Australians within
this age group).[18] Clearly, these are not paltry
numbers. While research remains sparse, there is
increasing evidence that social media usage may
contribute to psychological distress and poorer
mental health. Since social media services are not
destined for obsolescence anytime soon, a thorough
consideration of their lasting psychological impacts
grows ever more imperative, especially for young
adults and adolescents.
Acknowledgements
None
Photo credits
Image 1: Pixabay, accessed from https://
www.pexels.com/photo/facebook-applicationicon-147413/
Image 2: Thought Catalog, accessed from https://
unsplash.com/photos/xVRdDDe6M1A
Conflicts of interest
None declared
References
1. Christine, J. Instagram hits 1 billion monthly users, up from
800M in September [Internet]. San Francisco US: TechCrunch; 2018
[updated 2018 June 20; cited 2012 Nov 20]. Available from: https://
techcrunch.com/2018/06/20/instagram-1-billion-users/
2. Keracher M. #StatusOfMind. London UK: Royal Society
for Public Health; 2017. pp. 5, 10, 24-26. Available from: https://
www.rsph.org.uk/uploads/assets/uploaded/62be270a-a55f-4719-
ad668c2ec7a74c2a.pdf
3. Newspoll Market and Social Resources. Like, post, share:
Young Australians’ experience of social media. Canberra ACT:
Australian Communications and Media Authority; 2013. p. 8.
Available from: https://www.acma.gov.au/-/media/mediacomms/
Report/pdf/Like-post-share-Young-Australians-experience-ofsocial-media-Quantitative-research-report.pdf?la=en
4. Australian Bureau of Statistics. Older persons internet use –
2012 – 2013 Multipurpose Household survey [Internet]. Canberra
ACT: Australian Bureau of Statistics; 2014 [updated 2016 February
17; cited 2012 Nov 20]. Available from: http://www.abs.gov.au/
ausstats/abs@.nsf/Lookup/
5. Sensis. Sensis Social Media Report 2017. Melbourne
VIC: Sensis; 2017. Chapter 1. Available from: https://irp-cdn.
multiscreensite.com/535ef142/files/uploaded/Sensis-Social-
Media-Report-2017.pdf
6. VanSlyke T. Digital natives, digital immigrants: some
thoughts from the Generation Gap. The Technology Source
[Internet]. 2003 May/June [cited 2018 Nov 20]. Available from:
http://technologysource.org/article/digital_natives_digital_
immigrants/social media addiction 5% - 3
7. Hofmann W, Vohs KD, Baumeister RF. What people desire,
feel conflicted about, and try to resist in everyday life. Psychological
Science. 2012 Jun [cited 2018 Nov 20];23(6):582-8.
8. Jenner F. At least 5% of young people suffer symptoms of
social media addiction [Internet]. Brussels BEL: Horizon: the EU
Research & Innovation Magazine; 2015 [updated 2015 April 29;
cited 2018 Nov 20]. Available from:
9. https://horizon-magazine.eu/article/least-5-youngpeople-suffer-symptoms-social-media-addiction_en.html
10. van den Eijnden RJ, Lemmens JS, Valkenburg PM. The social
media disorder scale. Computers in Human Behavior. 2016 Aug
[cited 2018 Nov 20] 1;61:478-87.
11. Dossey L. FOMO, digital dementia, and our dangerous
experiment. Explore: The Journal of Science and Healing. 2014 Mar
1 [cited 2018 Nov 20];10(2):69-73.
12. Lamb B. 2015. Human diversity: Its nature, extent, causes
and effects on people [Internet]. Singapore: World Scientific
Publishing; 2015.
13. Smith K. 41 incredible Instagram statistics [Internet].
Brighton UK: BrandWatch; 2015 [updated 2018 April 25; cited
2018 Nov 20]. Available from: https://www.brandwatch.com/blog/
instagram-stats/
14. Primack BA, Shensa A, Escobar-Viera CG, Barrett EL, Sidani
JE, Colditz JB, James AE. Use of multiple social media platforms and
symptoms of depression and anxiety: A nationally-representative
study among US young adults. 2017 April 1 [cited 2018 Nov 20];
69:1-9.
15. Lin LY, Sidani JE, Shensa A, Radovic A, Miller E, Colditz JB,
Hoffman BL, Giles LM, Primack BA. Association between social
media use and depression among US young adults. Depression
and anxiety. 2016 Apr [cited 2018 Nov 20];33(4):323-31.
16. Sampasa-Kanyinga H, Lewis RF. Frequent use of social
networking sites is associated with poor psychological functioning
among children and adolescents. Cyberpsychology, Behavior, and
Social Networking. 2015 Jul 1 [cited 2018 Nov 20];18(7):380-5.
17. O’Keeffe GS, Clarke-Pearson K. Clinical report—the impact
of social media on children, adolescents, and families. Pediatrics.
2011 Mar 22 [cited 2018 Nov 20]:peds-2011.
18. Australian Bureau of Statistics. National Survey of Mental
health and Wellbeing: summary of results, 4326.0, 2007 [Internet].
Canberra ACT: Australian Bureau of Statistics; 2007. Available
from http://www.ausstats.abs.gov.au/Ausstats/subscriber.
Correspondence
nina.li@student.unsw.edu.au
45

United Nations Climate Conference
Conference report
Georgia Behrens & Katherine Middleton
Georgia Behrens and Katherine Middleton are second-year medical students
at the University of Notre Dame and the University of Western Australia
respectively. They are the 2018 Project Coordinators for AMSA Code Green,
and the 2019 National Student Rep-Elect for Doctors for the Environment
Australia.
Who are you, and what is AMSA Code
Green?
We are Katherine Middleton and Georgia
Behrens, second-year medical students with a
passion for the environment and health. With
a national team, we run AMSA Code Green,
which is AMSA’s climate change and health
project. We provide a platform for Australian
medical students to respond to our planet’s
health emergency - educating, engaging and
advocating on the health challenges posed by
climate change.
In May 2018, we joined the International
Federation of Medical Students’ Associations
(IFMSA) delegation to the United Nations (UN)
Climate Conference in Bonn, Germany. We spent
two weeks watching, learning, sightseeing, and
doing a bit of casual international environmental
activism.
What is the UN Climate Conference?
The UN Climate Conference is an international
meeting of diplomats, policy-makers, scientists,
academics and non-governmental organisations,
all working together to confront the challenges
posed by climate change.[1] This meeting occurs
every year in Bonn, Germany, and focuses on
continual implementation of the Paris Agreement.
The Paris Agreement, which came into force in
late 2016, unites countries around the world to
take action on climate change. 178 countries
are currently signed up as parties to the Paris
Agreement, and are thus committed to acting
for climate change mitigation and adaptation.
The Paris Agreement commits nations to actively
prevent increases in global temperatures to well
below 2 o C.
The key aim of this year’s UN Climate
Conference was to develop the operating
manual for the implementation of the Paris
Agreement, also known as the “Paris Agreement
46

Rulebook”. This rulebook will be a guide for all
involved countries as to how they should go
about conducting climate change mitigation and
adaptation activities in the upcoming years.[2]
The rulebook is due to be finalised at the end of
2018 at the 24th Conference of Parties (COP24) in
Katowice, Poland. The significance of COP24 has
earned its name “Paris 2.0” (COP21 was where the
Paris Agreement was signed).
Why do medical students go?
At every UN Climate Conference, hundreds of
people from around the world
come as “observers” to watch,
learn and contribute to the UN
Climate process, even though
they are not parties to the Paris
Agreement. Youth observers
(‘YOUNGOs’) are a particularly
important group at every
conference, as the UN “recognizes
the key role that youth play in
tackling climate change”.[3]
The IFMSA has been sending
youth observers to UN Climate
Conferences for a number of
years. This is because the IFMSA
believes that climate change is an immense
global health issue, an issue which future medical
doctors should be working hard to address as a
matter of urgency.
The preamble of the Paris Agreement
acknowledges “climate change is a common
concern of humankind” and states that climate
action must respect “obligations on human rights
[including] the right to health”.[4] Over the past
few years, IFMSA delegates have been working
hard at UN Climate Conferences to ensure that
parties to the Paris Agreement remember that
climate change is a significant health issue.
‘... the IFMSA believes
that climate change
is an immense global
health issue, an issue
which future medical
doctors should be
working hard to
address as a matter of
urgency.’
What did we do there?
We did so many wonderful things while
attending the conference. First and foremost,
we had the opportunity to meet amazing people
from around the world, all working incredibly
hard to fight climate change and ensure the
ongoing health of our planet. These included
other globally-minded medical students and
youth environmental activists from a wide variety
of countries. We also had the privilege to interact
with representatives from the World Health
Organisation (WHO), and the Executive Secretary
of the UN’s main climate change
organisation, the United Nations
Framework Convention on Climate
Change (UNFCCC).
We sat in on the international
negotiation sessions between
different countries about the
Paris Rulebook, which was an
incredible experience. Getting to
see how the UN works in reality
is a fascinating (if sometimes
bewildering) experience. Alongside
the negotiations, we were able to
attend a range of presentations and
workshops that were being run at the conference.
This included the WHO’s talk regarding health
impacts of air pollution; a legal team aiding a group
of Swiss grandparents in their action of suing the
government for a lack of action towards climate
change; and many presentations addressing the
need to empower women and youth to lead the
charge on climate activism.
Finally, we got involved in a bit of activism to
help remind all the delegates of the urgent health
issues posed by climate change. In both weeks
of the conference, the IFMSA delegation held a
little “action” in the main lobby where we dressed
up in lab coats, stethoscopes and more. We were
47

extremely appreciative at how well-received we
were, and the never-ending interest of others
regarding climate change and health.
about the following questions with regards to
climate change: Where are we? Where do we
want to go? How do we get there?
What did we learn?
There is a tremendous amount of bureaucracy.
At first, it seemed a bit overwhelming and
sometimes even counterproductive. But as the
week progressed, its purpose became evident.
The complexity of climate action on a global scale
is such that a one-size-fits-all approach to climate
mitigation is not feasible. Discussions within the
conference were at times tense for this reason.
A phrase we heard time and time again was the
need for a “just transition” towards a
more renewable future. It taught us
that at a global level, climate action
needs to be well considered and
carefully planned, which is the key to
the UNFCCC process. Climate action
can seem complex in a developed
country such as Australia, and global
climate action is no different.
However, young people are
playing a key role in shaping climate
action. The voices of YOUNGOs
are surprisingly being listened to,
especially as the youth are increasingly
contributing to UN processes. We
also learnt that Pacific nations, in
particular Fiji, are leading the way in the climate
change conversation. The Fijian COP23 President
called for an international dialogue, whereby
party delegates and stakeholders levelled to
share stories and take stock of collective efforts to
achieve targets of Paris Agreement. A Talanoa is a
traditional word used in Fiji to describe a process
of sharing ideas, skills and experiences through
storytelling.[5] We were fortunate enough to join
with other YOUNGOs in our own Talanoa, where
youth from all around the world shared stories
‘... climate
change cannot be
approached from
only one discipline.
It needs to become
integrated into all
aspects of public
policy.’
From this sharing of stories we came to realise
that globally, we are all in a similar place in terms
of climate change, but it is manifesting differently
across nations. We all think that education, in a
way that people can understand and relate to
their own lives, is of utmost importance moving
forward. However, climate change cannot be
approached from only one discipline. It needs
to become integrated into all aspects of public
policy. These stories from our peers were
inspiring and invigorating. We
learnt about the current state
of affairs around the world, and
became hopeful that if we work
together we can figure out how
to effectively tackle climate
change.
Acknowledgements
None
Photo credits
Georgia Behrens & Katherine
Middleton
Conflicts of interest
None declared
Correspondence
georgia.behrens@amsa.org.au
katherine.middleton@amsa.org.au
References
1. United Nations Framework Convention on Climate
Change (UNFCCC). What are United Nations Climate Change
Conferences? [Internet]. New York City, US: UNFCCC; 2018
[updated n.d.; cited 2018 Oct 5]. Available from: https://unfccc.
int/process/conferences/what-are-united-nations-climatechange-conferences
2. United Nations Framework Convention on Climate
48

Change (UNFCCC). Understanding the UN Climate Change
Regime [Internet]. New York City, US: UNFCCC; 2018 [updated
n.d.; cited 2018 Oct 5]. Available from: https://bigpicture.
unfccc.int/
3. United Nations Framework Convention on Climate
Change (UNFCCC). Partnerships [Internet]. New York City,
US: UNFCCC; 2018 [updated n.d.; cited 2018 Oct 5]. Available
from: https://unfccc.int/topics/education-and-outreach/
workstreams/youth-engagement/partnerships
4. United Nations Framework Convention on Climate
Change (UNFCCC). The Paris Agreement [Internet]. New York
City, US: UNFCCC; 2018 [updated n.d.; cited 2018 Oct 5].
Available from: https://unfccc.int/sites/default/files/english_
paris_agreement.pdf
5. United Nations Framework Convention on Climate
Change (UNFCCC). 2018 Talanoa Dialogue Platform [Internet].
UNFCCC. New York City, US: UNFCCC; 2018 [updated n.d.; cited
2018 Oct 5]. Available from: https://unfccc.int/topics/2018-
talanoa-dialogue-platform.
What you need to know:
• In May, AMSA Code Green Project Coordinators attended
the UN Climate Conference in Bonn, Germany. At the
conference, politicians, NGO representatives and citizens from
around the world met to discuss the implementation of the
Paris Agreement, in order to limit global temperature rises to
well below 2.0 degrees celsius.
• The AMSA Code Green Project Coordinators joined a
delegation of medical stduents advocating for the consideration
of the health impacts of climate change in the Paris Agreement
implementation process.
49

There is No Me Without You
Book review
Juliana Wu
Juliana Wu is a first year medical student at the University of
Melbourne.
There is No Me Without You: One Woman’s
Odyssey to Rescue Africa’s Children.
Melissa Fay Greene’s traveller’s account,
There is No Me Without You, is the story of
Haregewoin Tefarra, a middle-class Ethiopian
widow, who opens up her dwelling as a refuge
for hundreds of children orphaned by acquired
immunodeficiency syndrome (AIDS). The book
presents a stark image of the AIDS crisis in Africa
and its decimating effects on Ethiopia. Against
prevailing stigmas and the blind eye taken by
the international community in its denial of the
humanitarian crisis taking place in Ethiopia,
Haregewoin’s selfless acts shine as a joyous
counterpoint to the bleak reality that continues
to consume large parts of Africa.
Greene’s book is an overdue reminder that
our humanity is the key ingredient in combating
the global fight against AIDS. By illustrating each
child’s haunting story of becoming an orphan,
Greene not only addresses, but confronts,
many paradigms in popular culture. Specifically,
she tackles the widespread suggestion that
promiscuity and hypersexual behaviours are to
blame for the continuation of the AIDS epidemic
in Africa. Her stories render this stigma as unfair
and over-simplified. Instead, a prevailing feeling
of defeat and a distinct lack of alternatives
dominate the stories. One woman contracted
AIDS from a man who had “lied in saying he
would marry her” and fled when he found out
she had the disease.[1] The inexorable shame
and guilt she felt in bringing a baby into this
world without the capacity to support it became
a driving factor behind the mother’s decision
to abandon the child. Her story is a testament
to the helplessness of those under the pressure
of extreme marginalisation. Others in the book
would come to feel the force of unimaginable
accusations and violence after being infected
with human immunodeficiency virus (HIV) by
a single unsterile injection.[1] Thus, the book
exemplifies the dangerous stigma towards
those who contract the “unspeakable” disease,
and although Greene does not explicitly state it,
she certainly alludes to the systemic failure of both
domestic and international governments in allowing
the crisis to escalate and social stigmas to linger.[1]
Although the social, economic and political
insufficiencies of Ethiopian governance are all too
obvious throughout the book – for instance, Greene
mentions that Ethiopia ranked 170th out of 177
nations for its Human Development Index, and 134th
out of 140 nations for its gender inequality-related
development index – one cannot help but sympathise
with the Ethiopian context.[1] The so-called “free-fall”
of health and happiness in Ethiopia is the result of a
multiplicity of domestic issues, including border wars,
50

a history of weak and irresponsive leadership, and
the lasting effects of colonisation and international
oppression. Moreover, the onset of social collapse
has been hastened by international politics and
imposition. First world trade policies, which forced
African countries to assimilate and compete against
the global market in the name of “economic
modernisation”, with a climate that heavily favoured
Western economies, meant that African countries
were becoming increasingly dependent on foreign
food imports whilst their exports rapidly declined in
value. This, in combination with stringent conditions
associated with developmental loans, eventually
required the slashing of vital public sectors such
as health and education as a means of reducing
government expenditure. Despite this, Greene is
careful not to lay the blame purely on international
delinquency in the domains of political, economic
and social governance. She notes that instances of
governmental failure and corruption in Ethiopia’s
history, including concealment of famine, vastly
excessive military expenditure, and ongoing ethnic
tensions, have all contributed to the rampant state of
HIV/AIDS in Ethiopia.
Yet one could argue that by the time the AIDS
epidemic had hit Ethiopia, the sustained stagnation
of the Ethiopian economy and international
impositions had rendered it almost impossible
for Ethiopia to properly handle the crisis without
international intervention. It follows then, that the
AIDS epidemic is a blatant example of deliberate
ignorance by the Western world. In a country where
two-thirds of school-age children are not in school,
only 41% of adults can read, and 81% of people live
on less than two dollars a day, the country is simply
not equipped with the resources and administration
it needs to win the war against AIDS.[1] Indeed, it
could be argued that the delay in the provision of
antiretroviral treatments is an issue of international
irresponsibility rather than domestic governance.
For instance, Greene mentions that the Unites States
government stood against mass-producing cheap
drugs as a method of protecting the profits of
American multinational pharmaceutical corporations.
This was done at the expense of some millions of
people in Africa dying of AIDS under the illusory
pretence of “public health realism”.[1] Without lifesaving
antiretroviral treatment, the helplessness
and impossibility of resurrecting the AIDS situation
is made manifest by the character, Dr Rick Hodes.
Although he was an American doctor, he knew that
“without the antiretroviral medication, he couldn’t
save a single life”.[1] Arguably then, Ethiopians,
especially those who contracted HIV, fell victim
to misallocated resources and the neglect of the
international community.
However, this argument is limited in many ways, a
point that Greene is quick to emphasise. In the age
of the AIDS pandemic, there were those both within
Ethiopia, such as Haregewoin, and those outside
the borders of the country, such as Dr. Rick Hodes,
who worked tirelessly to suppress the epidemic
that had infiltrated the country. More specifically,
Greene emphasises families from foreign countries
who provided lifelines to orphaned children through
adoption. In direct opposition to the widespread
negligence of the West in failing to provide lifesaving
medication to Ethiopia, the adoption of
unwanted, psychologically traumatised, and at times
deathly sick orphans by otherwise well-off families is
a testament to the fortitude and love of the human
spirit. Thus, just as Ethiopia may be considered
a victim of international immobility, it was also
arguably the recipient of an altruistic salvation by the
international community.
In conclusion, the book discusses the African AIDS
crisis in a powerful yet sensitive manner. Greene
does well in addressing the multiple facets of the
AIDS pandemic: the relentless social stigmas, lack
of treatment options, international neglect and the
burgeoning number of families destroyed by the
pandemic. Although the book itself brims with grief,
it also stands as a testament to what a single human
being or family can do for others “in a place with no
people”.
‘Against prevailing stigmas
and the blind eye taken by the
international community in
its denial of the humanitarian
crisis taking place in Ethiopia,
Haregewoin’s selfless acts shine
as a joyous counterpoint to the
bleak reality that continues to
consume large parts of Africa.’
Acknowledgements
None
Photo credits
There is No Me Without You: One Woman’s
Odyssey to Rescue Africa’s Children Melissa Fay
Greene]. Bloomsbury USA. 2016 [cited 5 October
2018]. Available from: https://www.
bloomsbury.com/uk/there-is-no-me-withoutyou-9781596912939/
Conflicts of interest
None declared
Correspondence
julianaw@student.unimelb.edu.au
References
1. Greene, M. (2006). There is No Me Without You [Book]. New
York: Bloomsbury [cited 2018 Sept 17].
51

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