The increasing prevalence of sexual abuse calls for exceptional awareness of its multidimensional impact on the mental, sexual, and social wellbeing of male adults. This study aims to deepen the overall understanding of sexual abuse consequences; to highlight some common resilience factors; and to strengthen therapeutic and social support. In this qualitative research, we conducted seven semi-structured interviews with male victims of sexual violence. The data were analysed with the interpretative phenomenological analysis. They shed light on the great suffering linked to sexual violence, and on seven themes which are seemingly pillars of resilience: bond to others, bond to the body, making sense of things, expression, rediscovering oneself, institutions, and finally, learning and commitment. The exploration of these themes reveals several avenues for adjusting care, most of which imply the importance of raising awareness so that spaces receiving the victims’ word can emerge. The literature shows varying prevalence rates of male sexual abuse, with a tendency toward increase . In the Considering the growing prevalence of male sexual abuse, it is important to investigate its impact on individuals and how they might overcome its negative sequelae. The traumatic impact of sexual abuse seems to be expressed in the context of traumatic dynamics relating to sexuality, interrelationships, powerlessness, and stigmatisation . EmotionEaston et al.  estimateSome cultural or religious groups amplify secrecy ,14. FindRegardless of religious background, studies show that the sense of stigma is stronger when the perpetrator was a mother or a woman, as unconsciously, men tend to be more often associated with the status of being the perpetrator of sexual abuse ,17. The Feelings of powerlessness and loss of control, reported by many male victims, seem to be thought of as being a consequence of male gender socialisation ,9,17. FeMale victims may also experience great fear in facing contact or aggression from others. Some would tend to defend themselves through the embodiment of a hypermasculine and controlling personality ,17,21. FGiven the discrepancy between sexual abuse, its aftermath, and beliefs about what a man is supposed to be, some authors point to the need for male victims to renegotiate masculine norms ,17. The Emotional reassurance, social support from friends and family members, and positive disclosure experiences are also described as being of major importance in the resilience process ,23. In aFew studies investigate male resilience, especially within a French context. In France, approximately 16.1% of men report having been victims of rape or attempted rape . NeverthSeven men, aged between 26 and 54, participated in the study. Selection criteria consisted of identifying as a man and having endured sexual abuse during childhood. Since resilience is seen as a subjective experience to be explored, it was up to each individual to define it.The participants took part in the study voluntarily. To recruit participants, several posters and pamphlets, outlining the objectives and implications of this research, were sent to associations assisting victims of sexual abuse. Initial discussions were held with interested men by telephone, during which the study course and each person’s expectations were clarified. No participant withdrew.This study was approved by the University of Lorraine and is registered on the research register with the number 2021-194-1. The study was performed in accordance with the Helsinki Declaration. Each participant completed and signed a consent form detailing the context in which their data would be used and stipulating their rights of withdrawal and refusal.The participants’ accounts were collected using semi-structured interviews. The interviews’ semi-directed nature was intended to encourage the participants’ word and associativity, as “humans are meaning-making organisms” .The interview consisted of fourteen open questions. The first part aimed to build trust and explored each participant’s personal history. It focused on their perceptions of male sexual abuse understanding in our society, as well as their own experiences of such violence, and dealing with legal proceedings or receiving psychological support. The second part aimed to provide an in-depth description of the abuse consequences. Finally, the last part focused on the participants’ resilience and their suggestions for therapeutic and social care improvement.The interviews were held individually between April and June 2021. Due to distance and the COVID-19 pandemic, six of the interviews were conducted via video conference and one of them via a telephone call. The video conference interviews were recorded and the telephone interview was transcribed. All were then transcribed and submitted to the participants so that they could revise some of their answers as a final validation. This paper was written within a French context.Data were analysed using the Interpretative Phenomenological Analysis (IPA) method, defined by Antoine  as an atIn this study, putting the participants’ accounts into perspective has allowed us to emphasise the strengths and difficulties of their path after the abuse occurred. Their accounts were then organised around various sub-themes. Verbatims and clinical theory aimed to illustrate the deduced resilience factors as well as their therapeutic care suggestions. According to IPA, the combination of experiences studied one by one leads to a collective experience from which it is possible to draw general hypotheses .The application of this methodology and construction of the protocol were thought out in relation to the Coreq-32 method: Consolidated Criteria for Reporting Qualitative Research, consisting of a 32 items list intended to guide the analysts in their research .In order to increase data saturation and exhaustiveness of the deduced themes, the scoring grid and results were subjected to several revisions by experienced researchers. The themes were designed in the light of the participants’ accounts and were revised in the light of subsequent reflections. Finally, the article was sent to all participants so that they could share their own perceptions, along with the transcripts.In a few words, resilience is about how a person copes with their pain. In this study, it is more specifically about how the participants managed to overcome sexual abuse negative sequelae. The analysis of the participants’ accounts  producedIt was really… a rollercoaster. Emotionally. That is to say that… one minute I was feeling very, very bad, without any external reason, there was no real external reason. And one minute I was very, very well” (Participant 1). Some participants also mentioned obsessive thoughts about the trauma they had experienced: “I can’t go a day, in fact, without saying the word “rape” in my head” (Participant 2).Psychiatric implications encompass various psychiatric symptoms experienced by the participants. Many participants reported post-traumatic stress disorder (PTSD) symptoms, depressive symptoms, and suicidal thoughts. Some may also have experienced psychosomatic pain, such as headaches or back pain. Others experienced very fluctuating emotions: “To feel like a threat to the child, as if we were replaying the same scenario. It’s living with the thoughts of your abuser” (Participant 3). Some feel intense pressure; they are scared to do to others what was done to them, regardless of their strong intent not to harm anyone: “I have this pressure. I have three generations of men before me who succumbed to violence, I am the fourth, and I have the responsibility not to repeat what happened before.” (Participant 2).Sexuality refers to the participants’ challenges with intimacy and sexual thoughts. Some express fears of causing harm or abuse, therefore restraining from engaging in relationships: “I know that in terms of sexuality, which is the biggest symptom of the thing, really… I find it very difficult […] to go and feel vulnerable, that is, to let go. […] It’s a reaction of my body, really” (Participant 4).Some experience difficulties in letting go and feeling vulnerable, which notably occurs alongside sexual difficulties: “emotional void” (Participant 2); of a bruised relationship with their body or a feeling of no longer belonging among men: “All that I had… built up as an image of myself, in any case, in terms of… as a weak person… in any case, an inferior being” (Participant 1). This degraded self-esteem could explain behaviours of neglect that some of them mentioned, and which corroborates the depressive dimension mentioned above: “I neglected myself. In fact, I didn’t take baths anymore, I didn’t shower any more, I didn’t wash myself anymore” (Participant 6).Self-esteem highlights how the abuse negatively affected the participants’ self-image and self-love. The participants spoke extensively about the impact of the abuse on their feeling of self-worth and confidence. They report a significant wound, taking the form of an “Heavy feelings of shame and guilt contributed to aggravating this lack of self-love: “I’m proud of what I’ve become, but I’m ashamed of what I was. I feel like I was some kind of… some kind of wreck that couldn’t protect himself. […] I am soiled” (Participant 2). More precisely, some defined those feelings as being of defilement, humiliation, or dishonour: “For a very, very, very long time, I said to myself “but it’s a disgrace for me to have lived through that, to have been weak and to have… to have been unable to prevent it”. […] I felt humiliated to have experienced that” (Participant 1).I found it difficult to express my feelings, my emotions, or what I was experiencing” (Participant 5). In addition, several of them noted the fragility of their personal limits: “It was also a time when I didn’t dare to say no. I didn’t like to say no because I thought that saying no would hurt the other person. It was negative, it wasn’t nice, and so I felt obliged to say yes” (Participant 1).Relationships with others encompass emotional obstacles that complicated the participants’ abilities to form meaningful connections. It is reasonable to think that such negative feelings influence the withdrawal tendencies expressed by some participants, such as difficulties in verbalising and expressing emotions: “There is a pitfall, however, and it’s… since it’s an abyss inside, it’s to absorb the other. It’s being so in demand that it can be suffocating for the other. It’s even giving the impression that you are deliberately not accepting their help” (Participant 7). This can lead them to conflict-avoidance and self-effacement behaviours: “I had an… enormous need for recognition. And I also realised that in all my social relationships, I always tried to be liked. In fact, I had a need to be loved that was enormous. […] I never made any waves. In fact, I rarely took positions, or I always tried to avoid conflict and what can be a bit itchy for people. […] I always did more for others than for myself, I completely forgot myself” (Participant 5). Others, on the other hand, displayed asocial behaviours: “The fact of really being elsewhere, of floating, […] of not really being in your body and all that. It also adds… yeah, a bit of anti-social behaviour, the feeling of being out of place, of being misunderstood” (Participant 6).Some participants mention a need for love, support and recognition that is sometimes intrusive and invasive: “It’s good to see men again, because it allows me to reconcile with masculine gender” (Participant 2). Finally, many find it difficult to build harmonious and/or lasting emotional relationships, underlining an emotional instability, which goes hand in hand with a feeling of isolation and abandonment: “I can’t manage to have stable relationships, because I don’t feel stable in my body, and I feel even less stable when I’m in a relationship with someone else’s body” (Participant 3); “It’s a state of abandonment, of not having any attachments, and to feel detached from everything is hard” (Participant 7).They also mentioned difficulties in building friendships with men, which went hand in hand with a complex relationship with masculinity: “It seems important to note that aggressors were all known by their victims. It is reasonable to assume that experiencing abuse at the hands of trusted peers or family members could induce a profound feeling of betrayal and insecurity. This, in turn, might complicate the building of future, sincere relationships by creating fears, defensive strategies, and long-lasting distrust.For me, one thing that really… put up barriers to getting better, was my drinking. It was like a cycle. I drank to forget… and it was every day. It was like a routine”.Self-fulfilment is characterised by the participants’ struggles to find a satisfactory place in contemporary society. Resulting from an inability to project oneself into the future, schooling has been difficult for some, and career paths are fraught with breakdowns. Participant 1 mentions self-destructive behaviours that may have, at some point, prevented him from fulfilling his potential: “I still have a kind of anger that is always present. Against institutions, against justice, actually. Against French laws which are really… not even badly made, actually, but which are made against the victims, really” (Participant 6). Four participants engaged in judicial proceedings. At the time of the study, only two aggressors were convicted; one aggressor was not convicted; and one case was dismissed. Some participants may have relied on society to recognise their painful experiences and hold the aggressor accountable. Being confronted to different outcomes may reinforce feelings of injustice, anger, stigmatisation, and isolation.With regard to feelings of anger and injustice, it would seem that anger directed at the aggressor subsided over time, unlike anger directed at society, which tends to remain unchanged: “Thus, the abuse impacts their overall well-being in society, which they do not perceive as safe. It could make it difficult for them to feel like this is a place where they could thrive.resilience comes from others”. Entourage, support, and the feeling of being connected to others are the most cited requisites for resilience, although this bond remains impacted by the abuse. The accounts highlight a need to create bonds and the associated difficulty. The latter often relates to emotional needs that are considered too intense, to a fear of rejection, or to a distrust in human relationships: “I have the impression that it scares me, and then it’s fixed and it’s over, once things are settled” (Participant 7). However, this is not a systematic obstacle to the reconstruction of meaningful relationships.Bond to others represents the participants’ capacity to establish supportive interpersonal relationships. According to Participant 4, “in my opinion, it was more the outside that got me through than the inside”. The interviewed men reported a greater number of positive disclosures and support following those disclosures. For them, positive disclosures were a first experience of being recognised and supported: “there was a “before” and an “after”. In the after, I had the feeling of being really understood” (Participant 6); “It was liberating” (Participant 5); “Piecing myself back together was a bit easier because… well, my kind environment helped a lot, that’s for sure. There was no shaming, no question” (Participant 4).For Participant 1, getting better would be a matter of having found the right people to lean on: “I find it very touching, and to make relationships that are much deeper and more meaningful than just staying on the surface and talking about good weather” (Participant 4). Being able to share their experiences fosters the creation of transparent and authentic relationships: “A better understanding of what I am going through, a better interaction with who I really am, and not with an image of myself. To have authentic, honest relationships, based on solidarity, based on mutual understanding” (Participant 3).The accumulation of positive experiences makes participants feel safe and encourages them to talk about the abuse. In turn, it helps them to break out of their isolation, to elaborate, and to work on themselves: “to actually belong, to be, to be there, to be human, to be normal” (Participant 6). Support groups have the function of bringing people with similar experiences together, which allows its members to identify with each other and to engage in a common reflective process at the service of each individual: “the fact of being understood directly by people who have experienced the same thing does a lot of good, actually. And every time, we are there to talk about very painful subjects, but something positive always comes out of it” (Participant 5). For Participant 3, it is a way to feel less alone and to understand himself better: “To externalise what I am going through, to talk about it, to write about it, to make videos, to talk about it with others, to create mutual aid networks… to not feel all alone in this. […] And in a way… I am not just helping others; others are also helping me”.Furthermore, many of the participants belong to a support group and have identified this membership as a strong lever of resilience. Being a part of a social space where their experience is not rejected allows them to reconnect with others, thanks to the absence of stigmatisation, which can otherwise lead to a feeling of abnormality: “re-establishing a connection with oneself” (Participant 3) and by experiencing their own needs and limits: “I’ve taken refuge in my head, and… meditation, in particular, serves me. These activities serve me to try to… to reconnect with my body and my sensations” (Participant 2).Bond to the body denotes how participants invested in and connected with their own bodies. In this study, participants often struggled with connecting with their bodies. As such, working on that connexion seems to be one of the fundamentals of resilience. It is often, in this study, associated with meditation and relaxation practices such as conscious perceptions of soothing stimuli (ASMR: Autonomous Sensory Meridian Response), breathing exercises, yoga, mindfulness, etc. Specifically, meditation would be a means of mitigating dissociation behaviours by “I needed to… […], to do something with my body, to prove to myself that there were still things I could do” . Some also stressed the feeling of unity and wholeness: “To be able to feel like a unit, like an individual, an individual in the sense of a functioning unit, it’s immensely difficult. […] It’s as if I were several and at the same time I was one” (Participant 3). This can be achieved through psycho-corporal re-education: for instance, several men participated in fencing workshops. Learning to love their body again and understand their body’s instincts are two other components of resilience. For Participant 4, this notably concerns reflecting on unexpected reactions when feeling in danger: “It happened once or twice, I don’t know… my ex was bothering me, something like that, and… like, I couldn’t see her, and she started stroking my nipples, and I slapped her. […] We stared at each other. We were completely speechless, not knowing nor understanding what had happened”.Reclaiming their body can be a way of regaining control and gaining confidence: “In a day, I can have moments when I feel good somewhere, but the benefit would be to build. That is to say that these moments when I feel good remain in the background to carry me through the following days. But there is no such thing. […] I think you’ve put your finger on it: the mistrust. But it’s kind of a bad reflex”. In spite of everything, words remain central for all participants.Expression encompasses the various means by which the participants were able to communicate or shape their stories. Participant 7’s experience shows that talking about the abuse is not enough to get better: “The video had an effect of getting people to recognise what I’ve been through, to help other people recognise what they’ve been through”. As for Participant 1 and Participant 6, they share the powerful disclosure of their story on Facebook: “When the #MeToo movement started, I posted a text on Facebook to say that I had endured sexual abuse. And the same evening, my twin brother sent me a message on Facebook. […] And he was very supportive. Unconditionally.” (Participant 1); “I had written […] a long post on Facebook saying that I had been sexually abused, and I actually got a wave… really, a tsunami of sympathy. […] I really felt loved, protected, surrounded. It was a fabulous feeling, it was really… a wonderful moment of my life” (Participant 6). In addition to creating supportive networks, artistic expression supports the transformation of painful experiences as well as the externalisation of emotions and personal experiences. Participant 2, for example, writes poetry: “I have a notebook in which I write down all my feelings”.Spaces for expression play an important part in creating bonds and breaking down isolation. Participant 3 identifies the production of his autobiographical video as a turning point in his path of self-reconstruction: “It was really incredible. Because there’s a sort of cry, a literal and symbolic cry in me, actually, that… came out”. All those elements emphasise the importance for men to be able to express their emotions, their difficulties, as well as their hopes.Music, whether listened to or produced, can be a means of regulating emotions. Steady practice of sport, specific to many of the participants, allows them to evacuate, to escape, and to regain control over the body while participating in an overall feeling of well-being. Participant 6, through his account of a “psycho-magical act”, recounts how spirituality healed a deep part of his soul: “meaning through action” would involve altruism and the use of creative expression to elaborate trauma. As shown by the participants, creative expression  often aims to transform pain while putting it at the service of others: “That it has not been in vain, and that it can… there you go, prevent that from happening to other people” (Participant 5). Many participants want to reach out to other victims, due to the development of great empathy towards their suffering and a greater tendency to create solidarity bonds.Making sense of things encompasses the participants’ interpretation of their life stories and their perceptions of themselves within those narratives. Referring to Grossman et al.’s  approachuse of cognitive strategies”  worse. […] There’s still a part of me that doesn’t forgive, but it’s… I stopped seeing him as the devil. And that, in itself, has helped me a lot”.Other participants make sense of their stories through the “ategies” . For ParRediscovering oneself involves self-understanding and adjustment. Experiences of sexual abuse are profoundly destroying for those who endure it. They disrupt a person’s personality and sense of self–hence the importance of rediscovering oneself.a greater state of awareness” and “greater potential for change”. This in turn seems to encourage the projection of the self into the future, as well as reinvestment in passions or projects. It also seems important “to assume one’s life and values without justifying them by the past” (Participant 2). In other words, distancing themselves from a “victim status” is a way of reclaiming themselves: “Thanks to support group, I also became aware of the power of words. And to say “I was a victim of, I am a victim of”, that’s rubbish! I mean, being a victim is a lousy status […], it’s like you’re just going through life! Say “I’ve been attacked”, that’s it. It’s someone other than I. I didn’t ask for anything, and someone else came and did that. […] The person who has suffered does not have to be responsible” (Participant 4).Introspection, counselling, or exploration of childhood elements are cited by participants as some actions leading to a better understanding of the self and various behaviours. For Participant 2, knowing himself better equals “Understanding how our past influences who we are today… […], I think it’s extremely helpful in order to cope better. Understanding our own emotions and freeing from them is a strength” Participant 5); relearning to set limits and listen to themselves ; and finding inner peace and serenity.Rediscovering themselves involves many other things: learning to understand themselves well enough to be able to adapt to life’s situations . For Participant 5, hearing, in his support group, that what he had been through was violent helped him to realise the extent of the abuse he had suffered, and to not minimise or trivialise it: “sometimes you wonder whether you have experienced them or not, it’s complicated. You think that in the end, it’s not much compared to other stories”.Institutions play a role in providing social recognition of the participants’ suffering. Whether they are judicial, medico-social, or associative, institutions play a primordial role in legitimising the pain of people who have experienced sexual abuse. In a context where male sexual abuse remains taboo, they place a man in a group where his experiences are accepted, which helps to validate the events, as well as the perceptions and emotions that result from them: “First of all, to allow victims to become aware of themselves, to be able to authorise themselves to say they are victims. Because being confined to the role of the aggressor does not allow one to consider oneself a victim. It is difficult to do so”. Then, this would allow him to move from a before to an after. Turning the page becomes possible. For instance, it could help place the blame on the aggressor: “I regret not going to the trial. I didn’t hear the verdict, I didn’t hear the judge say that he’s guilty, or that he’s responsible for his actions, and… I even think he would have said a word, or that he would have apologised for everything” (Participant 4).Acceptance, according to Participant 2, can lead a man to feel authorised to represent himself as a legitimate victim of the abuse: “In addition to these functions of recognition and legitimisation, institutions also play a considerable role in breaking down isolation and in the social reintegration of male victims—through the building of reference points and networks, in particular.Learning and commitment emphasise the importance for participants to understand themselves in order to better engage in collective experiences. Learning and commitment are two levers of resilience that may intertwine. Learning about the mechanisms of violence, the sequelae of violence, and the sociological conceptions of violence would not only allow male victims to understand a personal and collective experience but would also help them to develop adapted defence strategies. Understanding uncovers tools that can be used as a starting point to reflect on oneself. It is reasonable to assume that the active dimension of learning counteracts the feeling of helplessness, which arises from difficulties and suffering that the participants do not always understand until they establish a direct link between their experiences and their problems.I just create a space where people can actually express themselves, and are listened to, and feel like they are not alone” (Participant 6).If learning leads to greater self-understanding and self-indulgence, it can be assumed that it builds confidence and self-esteem. Thus, some participants plan to share their knowledge with others, especially with the media, in order to get others to understand as well. Thereby, learning supports a process of commitment. Whether it is towards others or towards change, commitment seems to give purpose to the suffering endured, as well as strength to bear it: “turn it into a desire to say it” (Participant 5).What emerges from the collected accounts is a deep desire to break the silence, and “This study aimed to deepen the overall understanding of sexual abuse consequences and to identify common resilience factors, in order to strengthen therapeutic and social care. The collected accounts highlighted the painful and lasting impact of sexual abuse. Feeling like the memory of the abuse remains on the verge of coming back at any time corresponds to what Brewin  describeThe accounts also highlighted seven dimensions of the resilience process. While all participants indicated that sexual abuse had a particularly strong impact on the quality of their connection to others, the ability to rebuild trust and build supportive relationships was identified as an important step in the resilience process, especially seeing as building trust might have been deeply challenging for those who were abused by close friends or relatives. These possibilities seem to be associated with more positive disclosure experiences. This is consistent with an observation by Gagnier and Collin-Vézina , who expa disorder or alteration of identity, memory, or consciousness”, is an emotional, memory, or identity detachment. Sexual abuse affects a person in their flesh; thus, this fragmentation of the self may involve an absence of bodily sensations. Reinvestment and re-engagement of the body have therefore been emphasised as major issues in the self-reconstruction of the participants. They needed to be able to experience, protect, and reconnect with their internal world.One of the characteristics of dissociation, defined by the American Psychological Association (1994) as “Concerning relationships with the self and with others, speaking and sharing experiences are two key elements. Whether in a personal, relational, therapeutic, or counselling context, verbal or artistic expression is at the heart of resilience. It encourages the verbalisation and concretization of emotions and thoughts and transforms a meaningless experience into words that will echo the experience of others. In fact, it breaks down isolation. In this particular study, it facilitated the reconstruction of perceptions that refuted social prejudices and were in line with the participants’ internal experiences.giving happiness’.Ultimately, expression and transformation guide victims towards the possibility of making sense of their experiences. Sense-making, according to Grossman et al. , has to Furthermore, it seems that sexual abuse breaks down a person’s sense of unity and continuity. In fact, the participants emphasised the importance of learning to understand themselves better. Overall, they believe that working on themselves improves their self-esteem. Knowing that they can do good for others, being aware of what they have overcome, and having worked on themselves for a long time are cited as the main reasons for improved self-esteem. According to Roberg et al. , insightLearning fosters self-discovery and commitment. All participants spent a lot of time enriching their thoughts on the subject of sexual abuse. The result is a strong commitment, which manifests in the form of help proposals and general suggestions supporting the social and therapeutic implications of this study.On the one hand, participants attach particular importance to the awareness and verbalisation of sexual abuse among the general population, as well as among certain professionals. Indeed, those in the latter would benefit from being trained in receiving testimonies or providing care for male victims. Hudspith et al. , for insResearch, prevention campaigns, testimonies, social networks, media, debates, arts, and education play a key role in making citizens aware of the effects of sexual abuse on others and in helping victims to grasp the reality and/or severity of the endured violence. Greater representation of sexual violence against men would reduce the stigma inherent in norms of masculinity: for example, through inclusive communication, meaningful film portrayals, and collective accountability. It is important to place the blame on the perpetrator rather than the victim, regardless of their gender. Similarly, citizens would benefit from improved laws on the protection of victims , and the treatment of perpetrators.Finally, some participants mentioned the need to educate young people about sexuality, including notions of consent, violence, and physiology , in order to reduce the feelings of guilt and shame attached to sexual abuse. Similarly, the integration of a more flexible and harmonious male ideal, in which young boys are allowed to express their emotions, seems fundamental to preventing silence and isolation.Some of the reasons why a male victim of sexual abuse may not talk include the feeling of stigmatisation induced by those norms, as well as the fear of being blamed or rejected . It thuseven if some negative impacts are recognised, the gendered construction of masculinity allows for the effects on men to be minimised”. Hence, this research means to report on male sexual abuse impact and tries to propose suggestions to improve their mental health.Nevertheless, with reference to male gender socialisation, current understandings of masculinity complicate their own comprehension and acceptance of the abuse and related emotions. According to Weare , “even iA limitation of this study is the small number of participants. Few male victims of sexual abuse report as adults, which limits the possibility of recruiting more participants. Also, the study used a non-random sample and, therefore, the sample may not be representative of all sexually abused men. In addition, this study highlights findings mostly related to the French context, so international studies should be conducted to assess differences related to country contexts. Finally, resilience is a personal process; as such, it may differ for younger people, as well as people who were more recently abused. Moreover, men who agreed to participate may not have experienced resilience the same way as those who did not participate.This research aimed to describe the impact of sexual abuse on the lives of men, and to identify processes of resilience. Phenomenological analysis of the narratives enabled us to identify various recurring themes in the participants’ discourses. The bond to others stresses the importance of being able to rely on someone and to create supportive relationships that generate verbalization. In a family or institutional setting, this bond must allow the person to share his story. Sharing or, in other words, expression, is a second key lever of resilience. It can take the form of speaking, physical engagement or artistic creation… but in all its forms, expression is often the starting point of elaboration, which in turn can lead to meaning-making. Similarly, it seems important to accompany victims in a process of discovery that matches their own need to understand their suffering, and thereby understand themselves better. If engagement could be a source of resilience for the people we met, it reflected their need to commit to those who need it—and the need for society to commit to victims.


This curriculum was developed for emergency medicine (EM) residents at the post-graduate year (PGY) 1–4 level, and attending EM physicians. It may be adapted for training of any healthcare provider or learner who might be required to perform an emergency cricothyrotomy, including emergency medical technicians, senior medical students, and advanced practice providers ; however, we did not specifically validate it for these providers.Emergency cricothyrotomy (EC) is a lifesaving surgical procedure, often the option of last resort, used to secure the airway when other methods of airway control have failed or are not feasible. It is a high-risk procedure since it is infrequently performed, but it is time-sensitive and critical for survival when needed.9Commercially produced mannequins are available to simulate cricothyrotomy. However, being made of plastic materials, they suffer from unrealistic “tissue” feel that is radically different from that of biologic tissue.We developed an inexpensive procedure simulator using commercially available porcine byproduct that more closely mimics the feel of cricothyrotomy in real life, and a comprehensive curriculum for instruction in, or review of, EC, intended for implementation in a small-group format. This publication is intended to provide interested educators with a comprehensive suite of materials for teaching EC at their own institution. Included are instructions for how to construct the simulator, an EC case scenario with discussion points, a PowerPoint didactic module covering the fundamental concepts of EC, and sample course evaluation forms that may be implemented directly or adapted to meet institutional requirements.After completing this activity, the learner will be able to:correctly describe the indications for and contraindications to emergency cricothyrotomycorrectly describe and identify on the simulator the anatomic landmarks involved in emergency cricothyrotomycorrectly list the required equipment and the sequence of the steps for the “standard” and “minimalist” variations of the proceduredemonstrate proper technique when performing a cricothyrotomy on the simulator without prompts or pausesSmall group activity combining didactic learning, case-based learning, and procedural simulation. The didactic component may be delivered in an asynchronous learning or “flipped classroom” format.The cricothyrotomy simulator was initially pilot-tested on a group of emergency medicine attending faculty, who were asked to evaluate the simulator, with results demonstrating that it was felt to be superior to typical plastic mannequin simulators. This simulator was then subsequently integrated into our airway workshops teaching EC, which include hands-on practice, didactic, and discussion components. The content and delivery of these workshops were assessed by the learners via standardized evaluation forms after completion of each workshop, and the overall clinical relevance, appropriateness of content, and satisfaction with the workshop format were highly rated .The real-tissue model to simulate the procedure was well liked by course participants, and the learning environment was felt to be conducive to asking questions and discussion. Overall, the instructors and the learners felt that the workshops were effective in improving understanding of the procedure and increasing the comfort level and skill of the emergency physician learners in performing the procedure.Cricothyrotomy, cricothyroidotomy, emergency airway, surgical airway, failed airway, rescue airway, can’t intubate can’t ventilate, small group activity, simulation. Learner Audience:Medical Students, Interns, Junior Residents, Senior Residents, Fellows and FacultyTime Required for Implementation:Approximately 1 hour:Presentation and discussion of “Emergency Cricothyrotomy Case Scenario” (15 minutes)Presentation of “Emergency Cricothyroidotomy” PowerPoint slides, questions and discussion Hands-on practice of emergency cricothyrotomy procedure on real-tissue simulator (5 minutes per learner)Questions, discussion, and debrief, complete evaluations (10–15 minutes)Recommended Number of Learners per Instructor:Maximum of 4 learners per instructorTopics:Cricothyrotomy, cricothyroidotomy, emergency airway, surgical airway, failed airway, rescue airway, can’t intubate can’t ventilate, small group activity, simulation.Objectives:After completing this course, the learner should be able to:Correctly describe the indications for and contraindications to emergency cricothyrotomyCorrectly describe and identify on the simulator the anatomic landmarks involved in emergency cricothyrotomyCorrectly list the required equipment and the sequence of the steps for the “standard” and “minimalist” variations of the procedureDemonstrate proper technique when performing a cricothyrotomy on the simulator without prompts or pausesThe components of this course are designed to provide flexibility for adaptation to different education strategies, learning environments, and group sizes. Included components comprise a case-based learning module, a didactic educational module, and a practical or “hands-on” training session on a simulator. We believe that it is important for the learner to be exposed to all three elements in order to develop or reinforce the required theoretical, practical, and integrative knowledge essential to effective performance of EC.Case-based learning and discussion: an example case of an airway emergency secondary to upper airway obstruction is presented, with planned pauses for learner-driven discussion, facilitated by the instructor, and prompted by questions embedded in the case. This component may be deployed as a stand-alone discussion, or it may be integrated with the educational module (see #2 below).Educational module: a PowerPoint slide set covering the essential concepts underlying EC, including indications and contraindications to the procedure (objective 1), relevant anatomy, necessary equipment, and the technical steps in sequence of the procedure (objective 3). This component may be assigned for review prior to the course, using an asynchronous learning or “flipped classroom” model, or it may be integrated into a classroom-style didactic lecture in combination with element #1 above. This allows for flexibility to accommodate different learning styles, time constraints, and teaching environments.Practical training sessions (objectives 2 and 4): we developed a model to simulate cricothyrotomy, using skin and the larynges with attached tracheae from butchered pigs, obtained via a commercial vendor. Previous studies and our own evaluation data have suggested that simulators for EC that use biologic tissues, such as our model, are felt to provide a more realistic simulation of the procedure than those that use plastic or other synthetic materials.The instructor should review the “Emergency Cricothyrotomy” PowerPoint file and the case scenario prior to the workshop in order to ensure familiarity with the content to which the learners will be exposed and around which discussion will be generated.The instructor should be familiar and comfortable with teaching and demonstrating EC, but no other specific preparation is otherwise required.If a “flipped classroom” model is to be employed, the learners should be given access to the “Emergency Cricothyrotomy” PowerPoint file for viewing prior to the workshop. The file size (3MB) is small enough to be attached to most common email providers, such as Outlook and Gmail, or it may be made available via a cloud storage server for download.NOTE: Two versions of this sGAE are included in the Supplemental Materials:Additionally, two versions of the “Emergency Cricothyrotomy” PowerPoint file are included, We developed a simulator for performing EC using pig tracheas and skin , with the case-based discussion and procedure practice on the simulator occurring on the day of the workshop.Alternatively, the “Emergency Cricothyrotomy” PowerPoint presentation may be combined with the case-based discussion in a classic lecture format; the recommended sequence in this scenario would be: 1. Case-based discussion; 2. “Emergency Cricothyrotomy” PowerPoint presentation; 3. Cricothyrotomy simulator practicum.This is included separately as


In recent years, the number of patients—particularly children—with autism spectrum disorder (ASD) has been continually increasing. ASD affects a child’s language communication and social interaction to a certain extent and has an impact on behavior, intelligence level, and other aspects of the child. Data indicates that 40% to 70% of children with ASD experience language developmental delays, which are mainly manifested as lack of language or language developmental delay, self-talk, use of stereotyped language, parroting, et cetera. A language communication disorder is a major symptom of ASD and is the most common reason for patients to visit a doctor. Therefore, language intervention training and communication skills have been made a cornerstone of autism intervention. However, a literature search has revealed that most studies only examine certain intervention methods or a combination of two or three intervention methods, which cannot be used by therapists or rehabilitation teachers. Therefore, this article summarizes relevant literature on language communication training for ASD children at home and abroad and briefly introduces the characteristics and training methods of language disorders in children with ASD in order to provide some ideas and references for relevant researchers and practitioners. Autism spectrum disorder (ASD) is a neurodevelopmental disorder. It usually begins before the age of 3 years and is characterized by persistent social communication impairment and loss of social interaction, repetition of stereotyped language, or behavior. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) has eliminated the classification of clinical subtypes according to the diagnostic criteria and the classification of ASD as outlined in DSM-IV. Instead, three categories of disorders, namely autistic disorder, Asperger’s syndrome, and pervasive developmental disorder not classified, are collectively referred to as ASD . In 1990As with most disease treatments, language intervention for children with ASD can be divided into symptomatic treatment and targeted treatment. The cause of ASD is unclear, but the effectiveness of symptomatic treatment has been gradually confirmed and rehabilitation training or rehabilitation education has been advocated. Early family intervention is urgent and important. There are many existing language intervention methods, but most of them only present findings from individual cases or small sample groups. The challenge lies in accurately identifying specific problems faced by children and formulating effective methods tailored for different individuals. A viable comprehensive training program is a top priority.This article examines the characteristics of language and communication disorders in children with ASD, provides an overview of existing intervention methods, highlights shortcomings and limitations of these methods, and suggests directions for future development based on practical challenges. An incomplete understanding of language and communication disorders among patients with ASD has led to variable intervention outcomes, necessitating this literature review. This literature review will be of interest to pediatricians, speech therapists, special educators, and parents involved in ASD interventions.We conducted a literature review using PubMed and Google Scholar to identify relevant studies. The search terms used were “autism spectrum disorder (ASD)”, “autism spectrum condition (ASC)”, “autism spectrum”, and “autism”. In addition, author names and reference lists were utilized to search for relevant references. The search was performed by author Mengmeng Cui.Nonverbal language intervention for young children in the non-verbal period is mostly concentrated in the one-to-three-year-old range. Nevertheless, there are older children with severe ASD and who have no oral expression. During early stages, children with autism share similarities in language expression with children with language development delay and language impairment, which is in line with the prediction of the “multidimensional consensus hypothesis”. However, children with ASD have heterogeneity in language expression, including specific defect phenomena within some language categories .During the non-verbal period, most children, as they increase in age, either do not speak, or the phenomenon of language regression occurs. The main goals for children in this period are to establish basic communication awareness, improve communication attitude, and induce pronunciation. It is beneficial to refer to the assessment and training methods for language developmental delay.Natural developmental behavior intervention (NDBI), a combination of interventions implemented in a natural environment, utilizes random emergencies and uses a variety of behavioral strategies to help children with autism develop appropriate and essential survival skills. NDBI is naturally implemented in everyday life . The corA randomized controlled trial (RCT) of a communication-focused intervention in children (under 12 years of age) with a diagnosis of ASD and minimal verbal ability , was compared with no treatment, wait-list control, and usual care. The RCT found that children with lower expressive abilities at baseline  progressed more than it did among children with higher expressive abilities. Some children in the intervention group showed an improvement in their expressive abilities . This fiTo implement early intervention for children in the early stages of language development, Lu Haijun’s article “Language Rehabilitation Training for Children with Autism”, suggests the following pre-language training methods for ASD children: (1) Stabilize emotions and establish basic learning behaviors. (2) Improve imitation ability and build learning ability. (3) Create a structured environment to establish correct study habits . These met cetera so that children can pass the non-speaking period as soon as possible in the game. This approach will foster their language development.Children with ASD have speech impairments: most of them have purposive dyspraxia rather than lesions of the articulatory organs. Interventions for speech impairments mainly train children’s imitation ability. This training can start from the imitation of gross movements to the imitation of oral movements and fine movements, focusing on the expansion from “characters” to “words” to “short sentences” and intervention using various learning methods. The pronunciation imitation should go from silent imitation to producing sounds, starting with syllables that can be pronounced and gradually increasing the number of syllables to words and sentences. In this process of pronunciation imitation, intuitive games can be used to attract children’s interest and exaggerated responses can be used to give evaluations, immediate rewards, Comprehension ability is an important prerequisite for the development of language communication skills. At present, it is known that ASD patients are clearly backward or have defects in sharing ability, empathy, joint attention, understanding others’ wishes, and cooperative behavior. These shortcomings hinder the patients’ comprehension of the purpose, intention, suggestion, belief, wish, cover-up, joke, deception, comparison, “duplicity”, and other psychological activities of the other party’s behavior. Consequently, ASD patients cannot understand “subtexts” and “unspoken rules”, and neither do they understand humor. This lack of understanding is harmful and hinders the making and execution of plans.In children with ASD, social knowledge/behavior deficits due to difficulties in social/emotional cue detection, encoding, and interpretation lead to problems in joining and initiating social interactions. To address these difficulties, interventions can target the six steps of the social information processing model of ASD proposed by Crick and Dodge . This moThe development of comprehension is based on normal vision and hearing. Some children with ASD have abnormal auditory development. They often respond inappropriately to sounds, which may be manifested as hypersensitivity or sluggishness, and cannot correctly understand the meaning of verbal and non-verbal expressions. To address these challenges, a child should first be allowed to learn to listen. One approach is to introduce different sounds, such as animal sounds, sounds of nature, or music. Therapists and parents can speak to the children’s interests: exaggerated gestures and expressions may be employed to get the child’s attention and facilitate its responsiveness.In addition, visual and auditory training for children can improve abnormal language communication in children with ASD. The picture exchange communication system (PECS) is a rehabilitation training method with many clinical applications. By using picture exchange as an auxiliary way to communicate with children, PECS can enhance children’s visual tracking and understanding through structured teaching and behavior analysis. The PECS method of analysis stimulates the improvement of children’s communication and language skills. A study has found that PECS causes some improvement in communication and expression, but the improvement in the level of development has not reached clinical expectations. Another approach is auditory integration training, which stimulates children’s hearing through the use of a “processed” sound by adjusting the auditory tester and modifying the volume and audio frequency to suit the children. By prompting children to alter their perception of sound, AIT facilitates changes in cognitive and behavioral habits . There iAnother study found that, compared with normal children, children with high-functioning autism had a reduced ability to distinguish language information in Mandarin Chinese in a noisy environment, indicating that children with ASD may have language perception dysfunction. To address language perception dysfunction in high-functioning autistic children, the application of family emotional training and interaction with pets can improve their sharing behavior to a certain extent; however, the initiative, autonomy, and independence of these children remain poor  . An in-dThe focus of this stage is to improve the quality of learning and skills by focusing on the improvement of children’s sociality. When a child has developed some awareness of communication, the improvement of sociality should be made the focus of training. Social communication, in the language rehabilitation of ASD children, should be strengthened mainly through speech and exercise. Talking refers to the training of trainers and autistic children through chatting. This training can be carried out using everyday common-sense knowledge as content. In addition, social practice is essential. During the rehabilitation of a child, preparation for active communication with parents should be made, and social practice should be incorporated to address the child’s social survival issues. For instance, parents can take their children to the mall for shopping, a visit to the pharmacy to buy medicine, or go to the bank to withdraw money. After long-term training, children with autism can achieve different degrees of social progress, which lays a foundation for the development of social interaction and survival skills in children with ASD .This study found that structured education combined with early psychological intervention can improve the clinical symptoms of children with ASD and promote their recovery. Structured education requires setting up a working system tailored to the situation of the child, which includes organizing the environment, implementing visual supports, and establishing routines and schedules. This schedule allows a child to understand and master skills on what to do, how to do it, and, as far as possible, create time limits for tasks, which will enable it to cultivate the ability to work independently. Psychological intervention played a role in the treatment process: parental guidance was emphasized and the “situational trigger” method was followed to guide the child’s engagement in interpersonal interactions. Parents were encouraged to take the child outdoors and to facilitate its participation in group activities with children of the same age. Psychological interventions, for example, making statements such as ”Look, how fun this is; can we play with this child? Guess what he is doing”, were utilized to guide children to think independently. When there were enough participants, group activities such as music and group games were encouraged to prevent independent play and respond actively when children had needs .ABA is a set of training techniques and operating systems for autism proposed by American psychology professor Ivar Lovaas. ABA is also known as reinforcement therapy. It has been widely used around the world as an intervention for children with autism. One method within ABA is discrete trial teaching (DTT), which was proposed by Lovaas and Koegel. DTT is also known as the discrete unit teaching method and can only raise approximately 50% of the abilities of children on whom an intervention has been done close to normal children’s level. DTT cannot solve some problem behaviors. Therefore, Lovass and Koegel proposed a key skill training method  that focuses on technical means training. Since the 1960s, extensive international research has been done on the application of DTT and PRT to the behavioral problem intervention of autistic children. The research has established many findings on interpersonal interaction, language communication, behavioral cognition, and emotion. Scholars in Taiwan have also conducted empirical research, which has revealed that the DTT intervention model can help children with autism to cultivate and learn behavioral goals to a certain extent. However, the main purpose of the PRT intervention model is to change the core behavior of children with autism through positive training, thereby enhancing their communication skills, game skills, social interaction behavior, and self-control and to develop key skills to achieve integrated developmental goals . NeverthChildren with ASD often have difficulty regulating emotions, posing difficulties in implementing various interventions when emotional problems arise. Therefore, it is particularly important to deal with the emotional problems of children with ASD. Research has shown that children’s emotional outbursts and reduced use of passive comfort strategies are associated with a low quality of life at home. Many parents of children with autism observe that their emotions can influence their child’s mood and behavior, and vice versa, a phenomenon known as ”emotional transmission”. Children who often do not actively seek to change their environment, but passively accept it, have a difficult time functioning in a family and achieving a positive quality of life. In the families of children with ASD, passive comfort strategies have a negative relationship with family well-being. Therefore, teaching other aggressive strategies should be encouraged. These positive strategies are recommended in place of negative comfort strategies. Additional research is needed on strategies for emotion regulation .Studies have found that 12%–20% of autistic patients will develop catatonia and have reported the effectiveness of electroconvulsive therapy . CatatonRegarding the intellectual characteristics of children with ASD, some scholars initially believed that the intelligence of individuals with autism was normal. However, later studies showed that approximately three-quarters of the children had an intellectual disability. In recent studies conducted in Sweden and Canada, the rate of intellectual disability in typical autism has been found to be 80% to 89% and 76%, respectively. An estimated 40% to 60% of children have an IQ of less than 50 points, and 20% to 30% have an IQ of less than 50. Most children with ASD who have a score of 70 or higher exhibit inattention or are unable to respond verbally; besides, they cannot interact flexibly. Language barrier further affects the interaction of these children with people, thereby aggravating the social barriers of the children .Giving speech training only to these children has a poor effect on improving their overall ability. Studies have shown that sensory integration training can stimulate various parts of the body with different modalities, including audio-visual, tactile, and proprioceptive systems to correct and stimulate the ability of children to make normal responses to promote the recovery of their nervous system and improve their intelligence . In addiInclusive education advocates that children with special needs and healthy children should enjoy formal education together in a general education environment. At present, countries around the world are actively advocating for inclusive education. A number of studies have shown that inclusive education provides children with autism with a natural environment and rich stimulation and can effectively promote the social development of children with autism . RecentlInterest-oriented floor games stimulate and attract children, encouraging them to actively communicate with others through interactive games, which can enrich and improve their ideas and thinking and emotional development . An inteWith respect to children with ASD, acupuncture and moxibustion have been researched in traditional Chinese medicine. Children with ASD are likely to suffer from heart and liver embolisms .Inflammatory cytokines affect the brain and play an important role in the development of autism . Animal There are also studies that employ Sishen acupuncture, temporal three acupuncture, wisdom three acupuncture, and acupuncture on speech areas 1 to 3 based on the characteristics of human brain function divisions. However, the “Expert Consensus on Early Intervention in Families of Infants and Young Children with ASD” mentions the lack of convincing worldwide evidence for the effectiveness of acupuncture and moxibustion in the treatment of ASD.The etiology of ASD is unknown, and there is currently no specific drug treatment for its core symptoms . InsteadCaregivers of individuals with ASD play a vital role in supporting the recovery of ASD patients by providing a safe home, proper nutrition, and enriching educational opportunities. Research suggests that caregivers play a key role in the development of individuals with ASD, and there is a need for a personalized medical approach to tailor parental intervention strategies .Emerging VR technologies are used as educational and intervention tools for people with ASD. Based on mainstream rehabilitation education theories, VR-based platforms and devices offer advantages in the cultivation of social communication and interaction skills. Evidence-based practice shows that incorporating VR into treatment or training programs is an effective way of improving social performance in people with ASD. After a VR-based intervention, individuals with ASD have shown significant improvements in social functioning, emotion recognition, speech, and language abilities .Studies have revealed that social assistance robots seem to have the potential to be an important collaborative tool in recreational therapy for children with ASD, allowing them to experience additional physical and mental interactions and great participation in therapy . OngoingAssistive technology for social skills learning, especially WAT, has been a popular rehabilitation research topic for individuals with ASD in recent years. With the help of WAT, people with autism not only learn in a variety of settings but also have real-time feedback in a real social environment. These advances are an important means of increasing the chances of children with ASD being integrated into society and deepening their knowledge and awareness of real social situations. Rather than simply thinking about what technology can do, WAT design considers the needs or preferences of individuals with ASD. As WAT matures, it improves the confidence of families that their members who have ASD will recover .This article only provides a general and comprehensive introduction to the language communication intervention methods for children with ASD, which can provide a general framework for practical application by ASD rehabilitation therapists and teachers. A large number of intervention methods have been proven effective and have been applied in clinical practice. However, some methods have only been validated in individual cases or small sample groups. Each child with ASD has different symptoms and problems that require unique intervention. Intervention using language communication should not be handled singularly: training or treatment requires a comprehensive, multi-angle intervention approach. To rehabilitation therapists and teachers of children with ASD, each child is a different challenge; therefore, they must continuously improve their “training material library” and master the indications and corresponding intervention methods and develop the ability to quickly adjust their training plans in the face of new emerging problems.For clinicians and researchers, discovering and validating the pathogenic factors behind ASD in children is an urgent problem that should be addressed. Doing so would be good news to many families, who are affected by this disease, around the globe. Given the trend of annually increasing incidence of ASD and the present absence of a known cause or specific medication, the intervention environment based on hospitals or rehabilitation institutions has been unable to meet the great current demand . Therefo


With the end of the COVID-19 pandemic, the Aedes aegypti vector has returned to the scene, as have the arboviruses it transmits, and along with them we frequently hear the complaint “Why do we still have to live with this mosquito?”Several aspects contribute to making diagnosis of this situation - and, therefore, overcoming it - confusing, difficult or even unattainable. With the aim of understanding the entirety of this context, we have listed ten points, some either partially overlapping or with contradictory narratives. These points have been perceived over more than two decades of work with vector surveillance and control, from the perspective of biology, and in interaction with health workers and managers, researchers, communicators and other professionals committed to the subject.“Health is often left on its own in this story, as if the problem were only its responsibility”.As such, it is important to recall the Ottawa Charter (1986)Since 1986, when the dengue virus settled for good in Brazil, vector control actions have been intensified. Currently, strategies are being multiplied and are generally of a technical nature: in addition to insecticides, approaches such as disseminating stations, sterile males or strains of A. aegypti containing the endosymbiotic bacterium Wolbachia are in focus.The importance of diagnosis is imperative. How can inequality in the occupation of urban spaces, access to drinking water, garbage collection and sanitation be neglected, among other aspects directly linked to greater risk of exposure to infestation by A. aegypti?Aedes aegypti “likes shade and fresh water” and has adapted itself to living alongside humankind. Although it is synanthropic, it is sometimes treated as being “domestic”. In general, 80% of its breeding sites are indoors or outdoors close to buildings, this being a situation that reiterates the importance of periodic checking for A. aegypti in people’s homes.In Brazil, there are tens of thousands of endemic disease control health workers (agentes de combate às endemias - ACEs), responsible for home visits, an activity that challenges the concepts of “public” and “private”: they are “public” agents inspecting “private” environments. This ambiguity underlies two distinct behaviors, both of which have the potential impact of increasing infestation levels: (i) limited ACE access - this is widespread and restricts visits to more than 50% of homes; and (ii) adoption of negligent behavior in relation to the domestic space, based on argument that “it’s the job of the ACEs”.This term refers to the gap between having knowledge of a problem and doing something to solve it. A classic example is the “physician who smokes”. Overcoming the know-do gap requires a change in an individual’s behavior, which is no mean feat. Collectively, changes of this type are encouraged by awareness-raising campaigns, effective communication strategies or even adoption of regulations associated with penalties. Using seat belts while driving is an example of this, as it is monitored in public environment.With regard to Aedes, the practice of routinely eliminating breeding sites, the most effective form of prevention with regard to the domestic environment, has an additional contradiction, as it requires a change in the conduct of the community in private environments, generally inaccessible to screening by the public sector. The know-do gap also involves perception of risk: in the case of seat belts, for those who have not experienced an accident, being fined is the “risk”; in the case of Aedes, an arbovirus can mean a “limited” and transient risk - and is therefore easily forgotten.The original expression indicates that just 10% of resources for health research relate to conditions that affect 90% of the diseases burden. These are the neglected diseases, or populations.Three peculiarities of the vector’s biology corroborate the relevance of periodic prevention measures: (i) Aedes spreads its eggs in many breeding sites; (ii) A. aegypti can become adults as little as 7-10 days after the eggs are hatched; and (iii) spraying with insecticides only has an effect on mosquitoes that fly through the spray. It is common for ACE visits, every two months, or one-off insecticide spraying to kill adults“Mosquito control”, as popularly conceived, is practically synonymous with “use of insecticides”; or even ultra-low volume (ULV) insecticide spraying. The confusion between “control” and “chemical control of the vector”, or even “chemical control of the adult vector”, is even institutionalized in some situations.There are two ideas underlying this misconception. The first relates to the perspective of a magical solution to the problem - attributed in a reductionist way as being the mosquito. The second consists of welfarism being considered natural, as opposed to taking an attitude that is participatory and citizen.), science, notably biomedical science, requires recognition of the relevance of structural determinants and the limitation of solutions with exclusive focus on the vector; (ii) in the case of the media, the challenge is conceptual, it consists of turning awareness of behaviors that should be everyday behaviors into news; and (iii) health service management needs to be less vertical and not to impose communication so much, but rather value solutions that favor citizenship and minimize inequalities, to the detriment of “magic bullets”.Today there are more people living with dengue than dying from it. Or “living thanks to Aedes”.Public health management has a consolidated structure reaching every municipality in the Brazil. Private companies proliferate, as a rule they are chemical industries. Biomedical research multiplies innovative and technological solutions. The focus is always on the mosquito, recognized as a vulnerable link in the transmission chain. This results in all public structures, private companies and technological initiatives being maintained.In practice, A. aegypti is the major employer, maintainer and articulator of a thriving “mixed economy” conglomerate, with benefits for many of those involved. On the other hand, the human drama of those affected by arboviruses continues. This equation is unjust.Good medication depends on correct diagnosis. The question is: to what extent does diagnosis mean each individual position being kept in place on the chessboard  of opportunities?


Discussing treatment wishes and limitations during medical consultations aims to enable patients to define goals and preferences for future care. Patients and physicians, however, face multiple barriers, resulting in postponing or avoiding the conversation. The aim of this study was to explore an internal medicine outpatient clinic population’s perception on (discussing) treatment wishes and limitations.Semi-structured interviews were conducted in two rounds with 44 internal medicine outpatient clinic patients at the University Medical Centre Utrecht, a tertiary care teaching medical centre in the Netherlands. Interviews were transcribed verbatim and thematically analysed with a phenomenological approach and inductive, data-driven coding.Four themes were identified, two (1–2) represent a deep conviction, two (3–4) are practically oriented: (1) patients associate treatment wishes and limitations with the end-of-life, making it sensitive and currently irrelevant, (2) patients assume this process leads to fixed choices, whilst their wishes might be situation dependent, (3) treatment wishes and limitations are about balancing whether a treatment ‘is worth it’, in which several subthemes carry weight, (4) the physician is assigned a key role.The themes provide starting points for future interventions. It should be emphasized that care decisions are a continuous, dynamic process, relevant at any time in any circumstance and the physician should be aware of his/her key role.The online version contains supplementary material available at 10.1186/s12913-023-10342-9. Four themes were identified in the perception of an internal medicine outpatient clinic population’s on (discussing) treatment wishes and limitations. The themes provide starting points for future interventions. It should be emphasized that care decisions are a continuous, dynamic process, relevant at any time in any circumstance and the physician should be aware of his/her key role.The online version contains supplementary material available at 10.1186/s12913-023-10342-9. Terms that are for instance used are: treatment restrictions, code status discussions, advance care planning (often associated with end-of-life)  and treaTo stimulate and improve care decision conversations at the internal medicine outpatient clinic, we previously conducted a study in which internal medicine physicians were trained on the topic of care decisions and patients were computer-randomized to receive a patient education on this topic . Care deMost research on treatment wishes and limitations and advance care planning is conducted in end-of-life settings . On the We used semi-structured interviews to (1) further evaluate our patient education, (2) gain in-depth insight in patient’s perspective on the topic of care decisions, and (3) gain insight in necessities (from the patients’ view) for discussing care decisions. In this article we focus on the results of the last two, as these insights are most relevant for a wide audience. Our results should enable us to improve patient education and discussion of care decisions.This study is part of a larger project, aimed at stimulating and improving care decision conversations at the internal medicine outpatient clinic of the University Medical Centre Utrecht, a tertiary care teaching medical centre in the Netherlands. We conducted a descriptive qualitative study with a phenomenological approach to explore patient’s perspective on the topic of care decisions and the patient education.This study was approved by the Medical Ethical Committee of the University Medical Centre Utrecht MEC 18–465). The study procedures comply with the Declaration of Helsinki. The study was reported using the consolidated criteria for reporting qualitative studies (COREQ) . In this previous study, patients over the age of 18 with a scheduled outpatient visit with a participating physician, were eligible for inclusion. Physicians belonged to the department of internal medicine, nephrology, gastroenterology, endocrinology, immunology or vascular medicine. Exclusion criteria were: inability to read Dutch, inability to give informed consent, or recently (< 2 years) documented treatment limitation discussion. All patients that gave permission to be approached for further research-questions, were contacted for this particular study. They were informed about this subsequent interview-study by phone, and asked for verbal informed consent. When verbal informed consent was given, interviews were planned and executed by phone.Figure The semi-structured interviews were conducted for the purpose of this study in two rounds, January 2020 and June/ July 2020, by two medical students (AB and NB respectively) after training. The interviewers did not have a former relationship with the participants and were not involved in the recruitment of patients in the previous study or the distribution of the patient education, to ensure patients could be as honest as possible in their evaluation. The interview guide contained straightforward questions about the content of patient education and open and flexible topics regarding feelings and expectations, allowing new or unexpected responses to be introduced  (when relevant) care decisions are about balancing whether a treatment is ‘worth it’, in which several subthemes carry weight: quality of life, culture/ family, being informed and patient in charge. The final  theme is (4) the physician. Patients assign the physician a key role in the care decision process. To show this important position we visualized the physician as the wheel that moves the process along.Figure Table very sick’, ‘dying’, ‘life-threatening’, a bad diagnosis or prognosis’, ‘people who are worse’, and so on. As can be seen in these examples, some patients explicitly connected care decisions to the ‘last phase’ of life, or a certain illness. Others described it more vaguely as ‘something for later’, without being able to exactly indicate when ‘later’ will be. This basic attitude towards care decisions, i.e. it belonging to the end-of-life, results in two subthemes: sensitive topic and currently irrelevant.Most patients shared a deep conviction that care decisions are about the end-of-life. They associated it with ‘a certain age’, ‘a bit older’, ‘terminal cancer’, ‘terminal illness’, ‘your last phase’, ‘the end-of-life’, ‘a severe illness’, ‘Patients described the topic of care decisions as a sensitive topic. Because they associated the topic with the end-of-life and dying, they characterized it as ‘difficult’, ‘not a fun topic’, ‘precarious’, ‘a tricky subject’, ‘sensitive’, ‘heavy’, ‘loaded’, ‘confronting’ or ‘threatening’, and articulated feeling hesitant to talk about it. Patients expressed this is especially the case when it is unclear to them why the subject is discussed, or why they received the patient education. This makes sense in the light of the end-of-life association: when the topic is brought up, the patient thinks this implies they are at the end-of-life. In this way it might give the impression of being sicker than expected or getting an unfavourable test result, which can make them anxious. A few patients assumed discussing care decisions was (mainly) about whether or not to resuscitate, which could be contributing to the sensitivity of the topic.this moment in time, because they did not consider themselves in that phase of life. They described it as ‘not really necessary yet’, ‘just not relevant’, ‘does not apply’, ‘ it is not on the agenda at the moment’, ‘too early’, ‘don’t really care too much about it yet’. The exact moment they believed it does become personally relevant varied. This is best summarised as: ‘when it gets a little closer’, and can be explained by the fact they related it to the end-of-life. This perceived current irrelevance is reflected in the evaluation of the patient education: patients assessed it as unhelpful in forming an opinion or discussing care decisions, because they felt they did not need to form an opinion or discuss care decisions yet.Patients perceived care decisions as a ‘far-flung’ event. The majority of patients identified care decisions as not relevant for themselves, at least not at The second theme that represents a deep conviction is definite choices. Thinking about care decisions, discussing and talking about it and making choices seems to be irrevocably linked to the definite documentation of these choices in the electronic health record. Some patients saw this as an advantage: the physician is aware of the patient’s point of view in case of an unexpected situation in which the patient cannot express his opinion. On the other hand, however, several patients were hesitant towards discussing care decisions with the physician, because they were afraid this resulted in a fixed, documented decision. How you make up the balance might be situation dependent and varies over time. They expressed that ‘you push your limits’, and felt unable to decide now what they would like in the future: ‘how your condition is at that time and what happens’. This altogether made patients feel hesitant towards making decisions, and discussing the subject now.The bottom layer in Fig. Patients stated quality of life as an important factor in care decisions and the choice to limit treatments or not. Patients (or their relatives they use as an example) did not want ‘agony’, ‘a very heavy treatment process’ or to be treated when ‘it is hopeless’. They were afraid to become ‘a vegetable’ or were ‘reluctant to lose quality of life’. Life ‘should still be liveable’. They considered whether a treatment (and its side effects) is worse than the disease, ‘maybe live a little shorter but then you don’t have any misery because of the side effects’. Some stated to treat only if there is ‘hope’ for the future.Patients discussed that being informed of options and possibilities concerning care decisions is needed to be able to make decisions whether care is worthwhile or not. Currently they experienced a knowledge deficit, although the patient education did contribute to being informed. Especially the idea that care decisions include more than resuscitation and the background information given about other choices was mentioned as informative by many patients. Some stated being informed as a general benefit of the patient education, others mentioned specific positive consequences. For example, when one is aware of the options, one can form their own opinion and become enabled to make choices. One patient mentioned being less overwhelmed when a critical situation occurs if you have thought about care decisions in advance.Numerous patients indicated the importance of thinking about your own wishes. Some viewed thinking about care decisions as beneficial, because it empowers a patient to take control rather than depending on the input of the physician. Patients named ‘being in charge’, ‘taking responsibility’ and ‘being aware of your own wishes’ both as a benefit from the patient education and as a necessity to be able to discuss care decisions. To be able to be in charge, the patient must be informed, as can be seen by the quote of patient 41 in Table Patients mentioned two more important factors in care decision discussions and decisions: culture and family and loved ones. One patient, from a non-western culture, pointed out differences in directness and openness in communication and the role culture plays in care decisions. Some other patients mentioned the position of family and loved ones in care decision discussions, either as a reason not to make decisions beforehand (because a family member can fulfil this duty when necessary), or as a reason to indeed make decisions beforehand and discuss these with family (so they are aware of your opinion and not burdened with this task). Some stated it was something you should decide together with you family, as it concerns them as well.The final theme we identified is the physician. As is visualized in Fig. When we asked patients openly what they perceived as necessary or helpful in discussing care decisions, many patients mentioned factors related to the physician, and more specifically the physician’s communication. Words patient used to describe the desired communication style are for instance ‘honest’, ‘sensitive’, ‘clear’, ‘open’, ‘trustworthy’, ‘attention for the person’, ‘treating the patient as an equal’ or just ‘good communication’. This demonstrates the need for a sensitive and empathic communicative approach: physicians should take into account their communication style.Another common opinion amongst patients is that the physician should initiate the care decision discussion. This was most often mentioned in relation to the question what would be necessary or helpful to discuss care decisions. Patients related this to the sensitivity of the topic, for instance, ‘because people are hesitant to think about it, it would be better if someone else starts talking about it’, or to the perceived current irrelevance, for instance ‘because people are not thinking about that yet’, ‘if the physician makes the assessment it is relevant for this person, then the physician should also take initiative’.The physician is also assigned a task in informing the patient and resolving the knowledge deficit: ‘as a patient you don’t think of all the things that the physician can think of’. A minority of the patients fully trusted their physician’s expertise and preferred to leave the decision-making up to the physician. Most stated that the physician should inform them about treatment options, pros and cons, risks and chances of recovery: ‘if you choose not to do this, this is what it means, and also what it means if you choose to indeed do so’. The physicians role is not limited to informing. Patients also stated the physician should ‘make you really consider so really ask the questions’, in order to help the patient make up the balance. The physician can/ should enable the patient to take charge: ‘the patient should feel they have a choice (…) and they are free to make choices’, ‘the physician might know better, but the patient should know what he wishes’, ‘that the patient is made to think about it and that he dares to speak’. Finally, patients stated it is important that the physician is aware of their patient’s opinion, and is assigned the role as registrar of this opinion.Because the physician is connected to almost all other (sub)themes, we visualised the physician as a wheel at the centre of Fig. We aimed to gain deeper insight in patient’s perspective on the topic of care decisions. Most patients considered care decisions as belonging to the end-of-life, and therefore currently irrelevant. Consistent with other research, reading, talking or deciding about care decisions is perceived as unnecessary at this moment in time, because patients feel relatively healthy , 21–25.There seems to be a vicious circle: literature about and research on care decisions is predominantly conducted in end-of-life settings. Furthermore, patients associate care decisions with the end-of-life. And in a previous study we showed that doctors frame the topic often as ‘relevant in the future’ as well . AltogetWe attempted to address this perceived irrelevance in our current patient education by emphasizing the current importance of care decision conversations. However, our study shows this attempt was insufficient. Several behavioural models have described differences in information processing and likelihood of persuasion depending on motivation , 28. ProAnother important connection patients made with the topic of care decisions was the need to make definite, binding decisions. This created a barrier, because patients expressed that the balance whether a treatment is ‘worth it’ depends on the situation. This barrier corresponds with previous research , 30. CarVery recently, Harris et al. conducted a qualitative interview study on goals of care discussions in acute hospital admissions in Australia . AlthougThere are several strengths and limitations to our study. The qualitative approach and semi-structured interviews provided us the ability and flexibility to get in-depth information about aspects of patients’ perspective on the topic of care decisions. In line with the growing awareness that care decision discussions should take place ‘earlier’, we investigated the perspective of the, relatively healthy, internal medicine outpatient clinic population. In this study, the median age was 57,5 years  and the patients had a median Charlson Comorbidity Index of 2,5 (interquartile range 1–4), which means they were relatively healthy and not in the end of life. This adds to existing research which mostly revolves around patients with severe chronic diseases, elderly patients or patients with a terminal illness , 15.We are aware that in an interview-study the ways in which questions are asked have an effect on the patient responses and can thus have an effect on the themes that are identified. To minimize this risk, we mostly asked open questions. For instance, all physician-related factors patients mentioned, were an answer to “what is necessary/ helpful in care decision discussions”. We did not ask “what should the physician do” or “what is the role of the physician” (which inevitably would have resulted in a theme physician).Another potential limitation arises from the notable amount of eligible patients that did not answer the phone or did not want to participate in the interviews, as this might originate from a certain perspective or emotional response to the topic of care decisions. However, numerous participants expressed hesitance regarding the topic, which pleads against this group being underrepresented. Furthermore, patients with insufficient command of the Dutch language could not participate in this study. One patient (from a non-western culture), pointed out some cultural differences, but we have too little data to draw conclusions on cultural differences. Lastly, the amount of time between reading the patient education and the interview varied between patients, and some were unable to remember the content very well. However, in a normal clinical setting, patients would not read a patient education on a daily basis either, and their perspective on care decisions was still insightful.This study showed that patients’ perception of the topic of care decisions is overshadowed by two (wrongful) convictions: the perception that it belongs to the end-of-life and therefore is not relevant for them at this moment in time, and the belief that care decision discussions leads to fixed decisions. This resulted in assessing our patient education as informative, but not helpful at this moment in time and no desire to discuss care decisions yet.Our research shows some opportunities to improve care decision discussions. The top layer in Fig. Below is the link to the electronic supplementary material.Supplementary Material 1: Supplementary appendix 1: COREQ checklistSupplementary Material 2: Supplementary appendix 2: Interview guides