Access to support systems is crucial for providing immediate assistance and treatment to children to counteract the long-term detrimental effects of various forms of violence. This study examines how adversity such as victimization of violence and self-injury behaviors among young people with their individual resilience is related to their access to support systems. The data used in our analysis are from two national youth surveys carried out in Norway in 2007 and 2015. We ask: To what degree do young people with experiences of violence gain access to support systems such as child welfare services, mental health services for children and youth, and pedagogical psychology services? Our results show that although not all young people who need help have gained access to support systems, victimization of violence and self-injury behavior significantly increase the likelihood of accessing these support systems. Our results also reveal a persistent effect of young people’s home socio-economic background on their unequal access to system support. More future research is needed on the subtle mechanisms and social–emotional implications of individual accessing system support from the macro-societal level and meso-system/family level.  The prevalence of children in high-income countries being exposed to adversities and the consequences of these experiences may indicate the proportion of children needing psychological and social support and interventions . Recent Research evidence shows that victimization of violence and abuse during childhood and adolescence has severe detrimental effects on the mental health of the victims such as anxiety, depression, self-harm, and impaired mental health ,6. Self-The prevalence of mental health problems among children and adolescents is around 14% ,12,13, oAccess to support systems is crucial for providing immediate assistance and treatment to children in need. To gain such access may also be an expression of resilience and contribute to building resilience. Resilience is understood as a personality trait inherent to an individual and as a process or phenomenon influenced by culture and context ,14,15. TResilience highlights that access to support systems may provide the resources that individuals need to cope, rather than the capacities of individuals themselves. The term implies how society facilitates access to support systems for young people. Previous research evidence shows that the most effective interventions for promoting resilience are those that address multiple systems ,14,15. RPrevious research evidence shows that the most effective interventions for promoting resilience are those that address multiple systems. Systemic influences matter as much as individual factors, at least in terms of positive outcomes ,14. TherUsing data from two national youth surveys in Norway on the victimization of violence and abuse from 2007  and 2015Traditionally working at separate levels of administration, three different types of support systems focus on helping children and youth living with adversity: child welfare services, mental health services for children and youth, and pedagogical psychology services. Professionals in frontline services have the important task of flagging up vulnerable children and have the possibility of preventing adversity, giving the child help, or referring them to a specialist service. It has become public knowledge that thousands of children who are victims of violence, abuse, and neglect do not receive timely or adequate protection and support . There hhttps://www.ssb.no/sosiale-forhold-og-kriminalitet/artikler-og-publikasjoner/4-av-5-i-det-kommunale-barnevernet-har-hoyere-utdanning, accessed on 20 April 2022). During the last century, child welfare services worked mostly on removing children from problematic homes where parents were drug addicts, violent and abusive, poor, or had low educational attainment. In recent years, some of these practices have been placed under serious criticism as being severely socially and racially biased; socioeconomic disadvantages and adversities follow both children in care and after care into adulthood [https://www.ssb.no/sosiale-forhold-og-kriminalitet/artikler-og-publikasjoner/4-av-5-i-det-kommunale-barnevernet-har-hoyere-utdanning, accessed on 20 April 2022).Upon being notified by a neighbor, a teacher, a child him/herself, or a family doctor about children aged 0–18 years old who may have a difficult life situation, the child welfare services at the municipality level have the duty to investigate this situation within 3 months and recommend how to help the child and the family in the best way possible for the child. Nearly 3% of Norwegian children receive interventions from child welfare services each year  are organized into interdisciplinary treatment teams consisting of doctors, psychologists, educators, social workers, and milieu personnel to treat children aged 0–18. The team is expected to provide a broad-spectrum approach, including the whole family as a target for the interventions. Unfortunately, services have been oriented more towards individual interventions, and a systemic approach has been difficult to apply due to a lack of available resources and professionals ,30. Servhttps://www.udir.no/kvalitet-og-kompetanse/samarbeid/pp-tjenesten/hva-gjor-pp-tjenesten, accessed on 24 April 2022).The pedagogical psychology service is the municipality’s advisory and expert body regarding children and young people’s needs for special pedagogical help in kindergarten and schools. Professionals working in this service often have several different areas of expertise , which separate them from other social workers in the field of child protection . Operatihttps://uni.oslomet.no/voldsprogrammet/ (accessed on 20 April 2022)). These survey data were stripped of several background variables before being made fully accessible without restriction. Therefore, as per our usual practice, data are safely stored and accessible from the NOVA—OsloMet Institutional Data Access/Ethics Committee, which grants researchers access if they meet the criteria to access confidential data.Data were obtained from two rounds of the Norwegian national youth survey on violence and abuse from 2007 and 2015 [Overall, 7033 students responded to the 2007 survey, with a response rate of 77.3%; conversely, 4531 students responded to the 2015 survey, which provided a sufficient response rate of 66.2%. Previous analyses  comparinAccess to Support Systems: The surveys in both 2007 and 2015 included a question asking the young people “Have you ever been in contact with the following?” with “yes” or “no” responses on the three types of services providing support and help for children and youth living with adversity: child welfare services (Barnevernet), mental health services for children and youth (BUP), and the pedagogical psychology service (PPT). Unfortunately, as both surveys were cross-sectional and there were no follow-up questions on any details about contact with the support systems, we can only use these contacts to indicate young people’s access to them.Measure of Resilience: As a measure of resilience, we incorporated the 28-item READ scale used in both surveys. Responses range from 1 (completely disagree) to 5 (completely agree) on a five-point Likert scale. The READ scale has five dimensions of resilience, which were tested among Norwegian youth: “family cohesion”, “personal competence”, “social competence”, “social resources”, and “structured style” . OverallMental Health Problems: These were measured by a 12-item short version of the Hopkins Symptom Checklist (HSCL) , which iMeasures of Victimization: Both the 2007 and 2015 surveys used similar questions to obtained data on all types of offenses against children, from which we constructed a variable including all forms of victimization with five categories: 0 = never have had any victimization of violence, 1 = victimization of a single form of violence, 2 = victimization of two forms of violence, 3 = victimization of three forms of violence, and 4 = victimization of four forms of violence .Measures of Self-Harm: We included two categories of self-harm behavior: intentionally injuring oneself without intention to die (NSSI) and intentionally injuring oneself intending to die (SSI). NSSI is measured by counting responses of “yes, once” and “yes, more than once” to at least one of three questions: (1) “Have you at any time intentionally taken an overdose of pills or other medicine?”, (2) “Have you at any time tried to hurt yourself, e.g., cut yourself?” and (3) “Have you at any time ended up in the hospital due to an injury you have done to yourself intentionally?”. SSI is measured by counting responses of “yes, once” and “yes, more than once” to at least one of two questions: (1) “Have you at any time tried to kill yourself?” and (2) “Have you at any time ended up in hospital because you tried to kill yourself?”. We constructed a variable combining NSSI with SSI with three categories: 0 = never done self-injury, 1 = have done one of the two forms of self-injury, and 2 = have done both forms of self-injury.Background Variables: Besides gender, we also looked at several home background factors. “Parents live together” is measured by parents’ civil status, combining the categories of “married” and “cohabitating” as “1”, or as “0” if not falling under these two categories. “Both parents with higher education” is measured by educational attainment at tertiary level by both parents as “1” or as “0”. Home finance is a subjective measure determined by asking the correspondent, “Has your family been in a good or bad financial situation in the past two years?” on a six-point scale . “Family usually has good financial situation” is coded as “1” for responses “5” and “6” or as “0” for responses “1” to “4”. In both surveys, the respondent was asked to place the birth country of their father and mother among seven choices: Norway, another Nordic country, another European country, Asia, Africa, South America, and North America/Oceania. “Both parents are immigrants” is a combination of father’s and mother’s birthplace in countries other than Norway and any other Nordic country.We present our analysis in three steps, applying the concept of social resilience, which refers to a successful society that has the “institutional and cultural resources that groups and individuals mobilize to sustain their well-being” . We lookAs shown in Third, following a pattern similar to the one shown in Between the eight years, we see a slight decrease in reported adversity experiences of young people and a small increase in their access to support systems . When weYoung people living in homes with a good financial situation and those whose parents live together have a significantly lower likelihood of contact with all three types of support systems, particularly child welfare services. Having immigrant parents significantly increases the odds of contact with child welfare services: by 97% in 2007 and 78% in 2015; however, it reduces the likelihood of contact with mental health services for children and youth, and has no effect on the likelihood of young people accessing pedagogical psychology services.As expected, the odds ratios of accessing support systems doubled and tripled along with increases in victimization of violence. In particular, the odds ratio of access to child welfare services increases around three times for victims of two forms of violence, by four to six times for those victimized by three forms of violence, and by around eight times for victims of four forms of violence. For young people with any self-injury behavior, the odds ratio of contacting support systems also doubled. Meanwhile, for young people with both self-injury and suicide attempt history, from 2007 to 2015, there is a considerable increase in odds ratios of their access to child welfare services  and mental health services for children and youth . Similarly, we notice significant increases in odds ratios during the same years for victims of three or four forms of violence in relation to their access to child welfare services and mental health services.In line with previous studies, we find that young people with parents of higher education, parents who live together, and parents with good finances decrease the likelihood of contact with the support systems. One plausible explanation could be that all these three background variables have a protective or resilient effect by lowering the need for young people from these families to be in contact with any of the support systems.As several variables in Our analysis finds that the exposure to serious adversities strongly increases the likelihood of access to support systems. This indicates that, in reality, severe self-injury is among the strongest indications to be picked up by support systems, although the likelihood of young people with polyvictimization accessing them is also high and increased from 2007 to 2015. This can be observed in the context of a society becoming more open and aware of young people struggling with mental health issues and the existing fact that many young people experience multiple forms of violence. It can be viewed as a positive trend that there is an increase in access to support systems, while the proportion of young people living with severe adversities in Norway is decreasing. Both conditions may contribute towards creating social resilience  for sociHowever, despite the small positive trend from 2007 to 2015, our analysis reveals three worrying aspects of unsuccessful system support for young people and children living with adversity in Norway: First, there is still a substantial proportion of young people who are victims of violence and abuse. Second, not all young people living with violence and self-harm have access to support systems. Third, access to support systems is still subtly “steered” by socioeconomic advantages. Moreover, due to data limitations, we cannot assume that access to support systems has helped with building resilience in young people and their families, as part of creating social resilience. Additionally, due to data limitations, our study is not able explain the alarming albeit small decreases in youth resilience dimensions of personal and social competences and social resources in Norwegian society from 2007 to 2015.What we discovered in this study is not unique—in fact, the lessons learned here may be related to studies from elsewhere. For example, family resilience can have a direct effect on child health and an indirect effect through mediating neighborhood resources ; multiplOverall, from 2007 to 2015, our analyses show a decrease in the prevalence of some forms of victimization of violence and a decrease in the number of young people as victims of multiple forms of violence. A decrease in self-harm prevalence is also demonstrated. At the same time, there is a small but significant increase in the proportion of young people with access to support systems such as child welfare services and mental health services for children and youth. An advantaged home background—indicated by parents having higher levels of education, healthy financial situation in the family, and parents living together—continue to reduce the likelihood of accessing any system support. In 2007 and 2015, migrant status increased the likelihood of being in contact with child welfare services, while the odds of accessing mental health services reduced. However, in both surveys, the likelihood of accessing all types of support systems doubled and tripled for all young people that experienced victimization of violence and self-harm. The odds even increased by up to 7 to 8 times in access to child welfare services for young victims of 3–4 forms of violence, and by up to 16 times in access to mental health service for young people who engaged in both forms of self-injury. However, our analysis reveals a continuous service provision gap between young people living with adversity and those who have had access to these systems as well as a persistent effect of socio-economic background showing social inequalities of access.In order to build social resilience, greater openness, transparent practice and close collaboration are necessary in policy, education and practice for all levels involved, from the government, support system operators, schools and families to individual children and young people. Future research should focus on the interlinkages between factors of the macro-, meso- and micro-levels, particularly both on the mechanisms and social–emotional implications of young people’s access to support systems, and on the process and quality of system support for those who have gained access.


This paper presents a critical examination of a vexed issue relating to how educational systems respond to diversity, inclusion, and social justice. Whilst there are unique factors specific to the various educational sectors; that is, to early years, schools, colleges, higher education and to the life‐long learning sector, this paper explores education and diversity in its broadest sense and recognizes that issues are as much cross‐sector as they are within‐sector. Further still, this paper shifts across disciplinary epistemic boundaries making use of Foucault's tools and the work of Deleuze and Guattari. Given this broader context, this paper primarily traverses the borders of schooling and higher education. It utilizes the notion of scales of justice and draws upon the work of Fraser and explores how this can offer insights into issues not only in relation to redistribution and recognition, but also to representation. It intentionally, draws upon  disability studies literature; and the often‐forgotten discrimination known as disability. It acknowledges the various paradigms and terminological descriptors associated with disabled people, how these are intentionally, I argue, produced and re‐produced, subject to a process of misframing, misrecognition and maldistribution through various territorialized and often segregated educational spaces. In response, this paper offers a reading of dis/ability which moves through theoretical and conceptual understandings and advances the notion of deterritorialization in order to escape, engage and identify larger patterns of inequality. It offers different insights, provides an alternative mapping that can raise different critical questions about disability, also to issues of diversity, inclusion, and social justice. Certainly, ending barriers experienced by disabled people is as much about making transparent territorialized boundaries between sectors as well as within sectors and across disciplinary fields. Indeed, as Paasi  which often shape understandings of equality, social justice and by association notions of diversity, and social mobility; also matters. In unison to this and within the context of higher education this includes notions of widening participation. For example, Reay , with rerelational advantage” and little if any “consideration to the fate of others”. Of course, this middle‐class “relational advantage” is out of reach for many (disabled and non‐disabled) parents of disabled children . This associated policy context is laden with ableist and disablist rhetoric—coercive, perpetuating and privileging notions of ableism, normalcy, the “ideal, normal and the mean or default”  and macro (the institution) level contexts that are themselves subject to sociohistorical forces  experienced by disabled people and simultaneously advances an affirmative model aligned with a broader disability arts movement and an assertion of identity politics. Although, as argued by Fraser  by an individual deficit medical model of disability, Fraser, , p. 70.  Fraser,  “Disabily Fraser , p. 29; d Barnes  have beeIs Higher Education Fair?”  is typically “additional” to or to “fix” later in some way.In Weber's , and not just for students treatment.  embody a different kind of territorialized and segregated world, in which students conform to educational norms in a coercive and aggressive higher education institutional culture.Definitions of disability being medical, biological, psychological, legal, educational, pseudo‐scientific and others abound; Foucault's , p. 11 “4sic] to actively promote equality for disabled people have all contributed to this changing reterritorialized educational landscape. Relatedly, Ahmed's , as a metaphor, specifically:The institution, in being imagined as an organic body, is understood as a singular entity made of multiple interrelated parts, all of which contribute to the health or well‐being of that body. Indeed, organic and mechanical metaphors are used simultaneously as ways of describing the institution. Both metaphors work to convey an entity that is made up of parts, where the communication between parts is essential to an overall performance. , the Special Educational Needs and Disability Act (2001), UK government recognition of British Sign Language as a language in 2003, the Disability Equality Duty (2006), and the Equality Act  requirin Ahmed's , p. 26 winstitutional racism becomes part of the institutional language”, and that the institution becomes the “sick person who can be helped by receiving the appropriate treatment” framing and labeling, operating “… by the determination of degrees of deviance …” framing of SEN and disability it should be no surprise that debates about the place of disabled young people within mainstream or “special” provision are circular, and as argued elsewhere, has an intentionally strong resistance to closure  …” . For sure, the history of academic disciplines, can be written in terms of “violent” paradigmatic shifts  turnstile for higher education and the skilled and profession‐based workforce. The requirements of the unskilled labour market, together with domestic family service for girls and a segregated system of special [sic] education have colluded with schools to disguise the extent of educational failure.  The persistence of a dual education system that segregates children with disabilities, in special schools, including based on parental choice; (b), the increasing number of children with disabilities in segregated education environments; (c) The fact that the education is not equipped to respond to the requirements of high‐quality inclusive education, particularly reports of school authorities refusing to enrol a student with disabilities who is deemed to be “disruptive to other classmates”; (d) The fact that the education and training of teachers in inclusion competences does not reflect the requirements of inclusive education. UNCRPD, , n.pAbsolutely, schools continue to have this role, and of course needless to say this is an inaccessible credentialing turnstile for higher education. Arguably, in terms of overcoming injustice, recent examination chaos in the UK, and dismantling institutional and political obstacles, scrutiny also involves an investigation of professional values, those who perpetuate the use of and principally define the “needs” of disabled people including those labeled as having “SEN”. In a recent United Nations concluding observation of the UK on the Convention on the Rights of Persons with Disabilities, with regards to Education (Article 24) reported that the committee is concerned at:[t]he emphasis should be on the language of entitlements rather than that of needs”, and similarly by Morgan, who in the context of higher education, noted:… the support required by a student is often referred to as “needs”, which is a negative term and suggests that an institution is having to provide extra support to help them succeed. In fact, the support they require is an entitlement, and it is a university's duty and responsibility to provide the support required by a student to enable them to thrive and be successful in their studies. Morgan, , p. 8For sure, disabled people whether children or adults should be part of the decision‐making process (participatory parity), to inform and respond to requirements of inclusive education. Far from this, and moreover, the so‐called “helping” and “well‐being” professions have shifted from explicit forms of terror and punishment to more subtle forms of coercive control and self‐regulation  ignored, silenced and erased. Indeed, as Davis , p. 1 haf Fraser , 2008, w


This study aimed to identify instruments that may assist organizations with implementing an integrated approach to workplace mental health using three activities from the knowledge to action (KTA) framework. A scoping review of published and grey literature, supported by stakeholder (business end-user and researcher) consultation, identified work-specific instruments that were relevant to at least one of the three domains of an integrated approach to workplace mental health: ‘prevent harm’, ‘promote the positive’, and ‘respond to problems’. A total of 207 instruments were located, and 109 instruments met eligibility criteria. 10 instruments were located that were relevant to multiple domains, however most instruments (n = 72) were relevant to the ‘prevent harm’ domain. Instruments relevant to the ‘promote the positive’ (n = 14) and ‘respond to problems’ (n = 13) domains were limited. Most instruments found were suitable for the ‘monitor, review and improve’ KTA activity. Further development of instruments that can assist with ‘promote the positive’ and ‘respond to problems’ strategies are required, specifically those instruments that can assist organizations with the ‘identify gaps and opportunities’ and ‘identify priorities and design new/enhanced interventions’ KTA activities. Mental health concerns are common in the working population . An estiAn integrated approach to workplace mental health is a principles-based, evidence informed framework that guides the protection and promotion of worker mental health through three overlapping domains of action see : ‘prevenThe ‘prevent harm’ domain is largely based on principles and evidence from the fields of public health and organizational psychology ,7. The mAn integrated approach to workplace mental health provides a framework that organizations can follow to create a mentally healthy workplace. However, there is no single ‘recipe’ for implementing an integrated approach as each organization is unique and will require a strategy that is tailored and context appropriate ,7. DetaiKnowledge translation guidance in this area outlines a framework that organizations can take when implementing an integrated approach to workplace mental health. An unpublished knowledge translation guide, developed by Beyond Blue, outlines six activities that organizations can take when implementing an integrated approach . The BeyThree of the six activities contained within Beyond Blue’s KTA framework relate to ‘identifying gaps and opportunities’ (activity 3), ‘identifying priorities, and designing new/enhanced interventions’ (activity 4), and creating a system to ‘monitor, review and improve’ (activity 6). To assist organizations seeking to implement an integrated approach to workplace mental health, the current study aimed to locate and catalogue extant instruments that can support these three KTA activities.An integrated approach to workplace mental health is still an emerging area of research, thus, the present study poses an exploratory research question:“What instruments are available to assist organizations with the process of implementing an integrated approach to workplace mental health?”https://osf.io/pe9zx/ accessed on 28 July 2021). Due to our research methods being complex, and consisting of multiple phases within different steps, our methods have been summarized in A scoping review methodology was selected as the body of literature and resources under inspection are large and heterogenous . A scopiThe literature under review was complex and significant, requiring a broad search methodology. A scoping review was considered useful in mapping the existing literature and determining the boundaries of what instruments were available to assist organizations with the process of implementing an integrated approach to workplace mental health .For the purposes of this paper, the word ‘instrument’ will be used when referring to measures, scales, questionnaires, tests, and inventories, among other related measurement terms . The worThe details of how a ‘workplace mental health instrument’ was operationalized, how that instrument was assessed against one or more of three KTA activities, and what was required for an instrument to be assessed as providing development resources is explained further in To address the research question, we took a two-fold approach. First, the data were recorded in the data charting form and presented in two tables; the first, a list of the included instruments as they sat against the domains of an integrated approach to workplace mental health, the author and year, the country of origin, and a brief description of the instrument. Second, to provide an overall picture, we summarized the number of instruments that were mapped to one or more domains of an integrated approach, the KTA activities, and that included development resources. Taken together, this provided a catalogue of instruments as well as an overall view of what was available for assisting with the process of implementing an integrated approach to workplace mental health.The inclusion and exclusion criteria utilized throughout the scoping review are detailed in Before commencing the review, an initial search of Google and Google Scholar was completed to identify relevant literature to refine the search strategy. The key words located in several of the relevant research articles were then used to formulate a search string for the formal review. These included “Job Stress”, “Psychosocial Risk”, “Mental Health”, “Psychological Health”, “Risk Assessment”, and “Surveys and Questionnaires”. This approach was in keeping with scoping review guidelines that recommend text words and index terms are reviewed after completing a limited search of relevant databases . A threeSearches were initially completed between December 2020 and June 2021 by A.N. (first author). However, this search was later expanded from June 2021 until September 2022, yielding an additional 11 instruments for inclusion. The first phase of the search was a comprehensive review of relevant databases . The search terms are recorded in Each database search string was updated after a review of the text and index terms found in the key words section of each article that were included for title and abstract screening purposes. The first 1250 entries in each database were reviewed, with a total of 5000 articles reviewed across the four scientific databases to reach data saturation. The decision was made to limit the Google Scholar search, having noted the lack of relevant entries in the initial search of Google Scholar, to the first 200 entries. The reference lists of papers provided for screening were then hand searched to identify additional relevant articles.The second phase involved a comprehensive search of grey literature using the Google Advanced function to customize the search and allow for a refined and targeted search strategy . CustomiThe third phase was the creation of a stakeholder group (n = 26) that were recruited through a LinkedIn post, or contacted directly through LinkedIn, who could contribute knowledge of any additional instruments or suggest further resources that could be reviewed to identify any potentially relevant instruments. A targeted website review was also conducted on 27 different websites, including the Centre for Disease Control (CDC), World Health Organization (WHO), International Labor Organization (ILO), and Institution of Occupational Safety and Health (IOSH). The main psychological assessment publishing houses’ catalogues  were also reviewed for any relevant materials. These websites were chosen after consultation with the stakeholder group.The scientific articles included for screening were managed using the systematic review system, Covidence (v2601). All other entries, including the grey literature, Google Scholar articles, websites, stakeholder advice, and relevant references were collated via separate purpose-built Excel spreadsheets. The articles and resources included for title and abstract screening were double screened by a second reviewer, A.M., with any conflicts reconciled through discussion or joint consultation with a third reviewer, J.R.A data charting form was developed for recording the data used to answer our research question, according to our specific definitions . This foThe decision was made to review whether an instrument, examined at the scale level, could be used to assess one or all of the domains of an integrated approach to workplace mental health, as defined in our eligibility criteria see . InterprThe three phases of our search strategy identified 388 resources that were eligible for title and abstract screening, with 73 resources identified for full text review . A totalA summary of the number of instruments that were mapped to one or more domains of an integrated approach and their suitability to one or more of the KTA activities are captured in Alignment with integrated approach domains: determining whether an instrument can assess ‘prevent harm’, ‘promote the positive’, ‘respond to problems’ or all three domains: The FlourishDX and Guarding Minds at Work resources were the only instruments located that were relevant to all three domains of an integrated approach to workplace mental health [l health ,26. A tol health ,30,31,32l health ,34. No il health ,67,89, jl health ,61, and l health ,73. Workl health , social l health , and bell health . In contl health  and retul health .KTA activities: determining whether an instrument may be suitable to assist organizations to ‘identify gaps and opportunities’, ‘identify priorities and design new/enhanced interventions’, ‘monitor, review and improve’ or for multiple purposes: A total of 4% of instruments (n = 4) were found that may assist organizations in completing all three of the KTA activities. The instruments that may assist with all three KTA activities were FlourishDX, Guarding Minds at Work, the Workplace Psychological Safety Index, and the WorkPlace Wellbeing Insights Survey [s Survey ,32,103. Accessibility of information about the instruments themselves: resources/information on the development of an instrument: A total of 77% (n = 84) of instruments had resources or information on how the instrument was developed. The majority (n = 76) of the resources on development, located through scientific databases, grey literature, and stakeholder consultation, were research articles. The remaining (n = 8) resources located were government and industry reports. A total of 23% (n = 25) of instruments had no resources or information on how the instrument was developed. A total of 81% (n = 59) of instruments relevant to the ‘prevent harm’ domain had resources or information on how the instrument was developed. A total of 92% (n = 13) of ‘promote the positive’ instruments, and 42% (n = 3) of ‘respond to problems’ instruments had resources or information on how the instrument was developed. A total of 95% (n = 60) of instruments sourced through scientific databases and references had information about the development of the instrument. A total of 54% of the instruments located through grey literature had resources or information on the development of an instrument, however, most of these instruments were located through a researcher-developed fact sheet [ct sheet . A totalThis paper identified 109 workplace mental health instruments that are available to assist organizations interested in implementing an integrated approach to workplace mental health using the KTA framework. A total of 10 instruments were located that were relevant to multiple domains of an integrated approach. Most of the instruments located may be suitable for the ‘monitor, review and improve’ activity specific to the ‘prevent harm’ domain. Instruments relevant to the ‘promote the positive’ domain were largely absent and those found were primarily designed for the ‘monitor, review and improve’ activity and aimed at individual-level well-being factors. Workplace mental health instruments relevant to the ‘respond to problems’ domain were the least common in this review with most of those located suitable for ‘identifying gaps and opportunities’ and/or ‘identifying priorities and designing new/enhanced interventions’. Most instruments located in this review had resources and information on their development.The only instruments relevant to all three domains of an integrated approach were FlourishDX and Guarding Minds at Work ,26. FlouIn most industrialized democracies, there is a legal and ethical mandate to provide work that is safe from psychological and physical harm . To do tTo complement psychosocial hazard reduction strategies, under an integrated approach, organizations should focus on strength-based approaches to maximize positive mental health among workers ,7. InstrWorkplace mental health instruments for assessing the ‘respond to problems’ domain were the least common in this review. Nine of the thirteen instruments relevant to the ‘respond to problems’ domain may be suitable for the ‘identify gaps and opportunities’ and/or ‘identify priorities and design new/enhanced interventions’ activities. The nine instruments located in this review may assist an organization seeking to audit their current services, practices, and programs. Most of these instruments focused on auditing the presence of mental health literacy training, mental health leadership and access and awareness of mental health services ,129,130.When determining which instruments to use to implement an integrated approach to workplace mental health, organizations should ensure that those that they select have information regarding the instrument’s development. In Australia, People at Work is one example of a free psychosocial risk assessment, that has information on how the instrument was developed due to the collaboration between researchers, practitioners, and decision-makers . SimilarDue to the purpose of this scoping review, it was necessary to focus on the core components of each domain of an integrated approach to avoid overcomplicating our coding strategy. It is recommended that organizations that are interested in implementing an integrated approach still seek guidance from experts. Some guidance materials, in the form of journal articles, fact sheets, books, and commercial publishing houses have been created to help organizations and researchers locate instruments, however, a free and centralized platform for housing these instruments would be an efficient way of assisting organizations to locate suitable instruments for their organizational context.This scoping review only included instruments produced in the English language, with eight non-English  instruments excluded. Due to this language restriction the identified instruments were predominately developed in the U.S.A., Australia, Canada, and Europe. Further research into instruments published in other languages, and those developed in other countries, is needed to broaden the scope of understanding of how other instruments can be utilized to assist organizations wishing to implement an integrated approach to workplace mental health. We encourage practitioners to consider instruments catalogued in our review as they progress towards implementing an integrated approach to workplace mental health. We also recommend that researchers continue to work on the creation and development of new instruments that can assist organizations with these efforts, particularly in the domains of ‘promote the positive’ and ‘respond to problems’, and all domains collectively.This paper located 109 instruments that organizations can use when implementing an integrated approach to workplace mental health. There were some instruments located that may be relevant to multiple domains of an integrated approach. Most of the instruments located, though, were relevant to the ‘prevent harm’ domain, primarily suitable for the ‘monitor, review and improve’ KTA activity. Some instruments were relevant to the ‘promote the positive’ domain, with most suitable for the ‘monitor, review and improve’ KTA activity, that look at individual, rather than job or workplace, factors. Limited instruments relevant to the ‘respond to problems’ domain were located, with most being suitable for the ‘identify gaps and opportunities’ and/or ‘identify priorities and design new/enhanced interventions’ KTA activities. Most instruments had development information and resources. There is an opportunity for the expansion of instruments available that more fully reflect the variety of workplace supports and strategies in relation to the ‘promote the positive’ and ‘respond to problems’ domains and an integrated approach in its entirety.


During humanitarian crises, such as a pandemic, healthcare systems worldwide face unknown challenges. This study aimed to explore and describe the effect of the SARS-CoV-2 pandemic on the needs of non-infected patients and family caregivers in specialist palliative care, using qualitative, semi-structured interviews. Data were analyzed using inductive content analysis, following the framework approach. Thirty-one interviews were conducted with patients/family caregivers (15/16) in palliative care units/specialist palliative home care (21/10) from June 2020 to January 2021. Well-known needs of patients and family caregivers at the end of life remained during the pandemic. Pandemic- dependent themes were (1) implications of the risk of contagion, (2) impact of the restriction of social interactions, (3) effects on the delivery of healthcare, and (4) changes in the relative’s role as family caregiver. Restriction on visits limited family caregivers’ ability to be present in palliative care units. In specialist palliative home care, family caregivers were concerned about the balance between preserving social contacts at the end of life and preventing infection. Specialist palliative care during a pandemic needs to meet both the well-known needs at the end of life and additional needs in the pandemic context. In particular, attention should be given to the needs and burden of family caregivers, which became more multifaceted with regards to the pandemic. In early 2020, SARS-CoV-2, a viral disease first described in 2019, became epidemic in China and spread across borders, being classified as a pandemic by the WHO in March 2020 ,4 - centWhen considering what preoccupies patients at the end of life and what their needs are, the fundamental complexity of this situation becomes apparent. Physical symptom control represents only the first obvious aspect that may be affected by the SARS-CoV-2 pandemic. The structures, processes, and workforce capacities of palliative care are strained. Although specialist palliative care services responded rapidly to the SARS-CoV-2 pandemic , staff sCompared to pre-pandemic times, general practitioners indicated a decline in quality of end of life care in almost 40% of their patients . HoweverBeyond its effects on patients, the SARS-CoV-2 pandemic had a profound impact on family caregivers of severely ill and dying patients. Informal social, emotional, and practical support for family caregivers has been constrained by social distancing policies, restricted travel, quarantine, and self-isolation. The reluctance of family caregivers to ask for help might even have increased, given the fears of having people coming to their home who could spread the virus . ConsequWe aimed to explore and describe how the experience of patients and their families not infected with SARS-CoV-2 receiving specialist palliative care has been affected by the exceptional pandemic situation.We conducted a qualitative study interviewing patients without infection and receiving specialist palliative care in hospital wards and at home, as well as their family caregivers, in Hamburg and Munich, representing the North and the South of Germany.This qualitative study was part of a national mixed-methods project, aiming at developing a National Strategy for Palliative Care of Severely Ill and Dying People and their Relatives in Pandemics  in Germany . This reWe followed a purposive sampling strategy, including adult patients and family caregivers in specialist palliative care in a palliative care unit or at home. The sampling framework see  allowed Persons not fluent in German and those considered to be too burdened, as judged by their clinical team, were excluded. Participants were recruited in two German university hospitals. Eligible participants were approached by the clinical teams. Those interested in participation were contacted by the researchers and interviewed in person or via telephone, based on interviewee preference or contact regulations. All participants provided written informed consent.The interview guide included open-ended questions related to the participants’ perceptions of their needs and experiences of care during the pandemic .The interview guide  was deveWe applied content analysis supported by the “framework approach” ,26 to anThe study was approved by the Research Ethics Committee at the Ludwig-Maximilians-University Munich (Ref: 20-403) and by the Research Ethics Committee of the Medical Council of Hamburg (Ref: 2021-746582-BO-bet), Germany. This study was registered on the German Clinical Trials Register (DRKS00023839).We conducted 31 interviews with 15 patients and 16 family caregivers between June 2020 and January 2021. Five people declined interviews due to psychological burden (three patients) or without giving a reason . The characteristics of the 31 participants are presented in Interview duration ranged between 9 and 75 min  for patients and between 10 and 87 min  for family caregivers. No interview was stopped on demand of the participant. Twenty-four interviews were conducted face-to-face and seven by telephone.Strikingly, patients often denied being affected by the virus when asked directly, but implicitly expressed great concern in the course of the interview.“Corona has no meaning for me. What is important for me now is simply that, yes, at some point I will close my eyes forever because of this disease [COPD]. And that there… there is nothing stopping me.” (4th minute of the interview) “(…) But right at the beginning [emergency room] it was cruel that my wife, for example, was bringing a bag with stuff, she stood in front of the door and was not allowed in. That is inhumane (…)” (16th minute of the interview) Furthermore, many patients and family caregivers voiced concerns about the global and personal impact of the pandemic and, eventually, its meaning for humanity.“So what I notice is that through COVID (…) there is a latent fear of health hazards [present] that I never had explicitly like this.”“Why is this spreading all over the world? From north to south, from east to west. It makes you think, right. (…) Well, now it’s here and we have to live with it.”These insights relate to human experiences during a global crisis, narrated by people who—beyond their “being a severely ill and dying patient” or “being a family caregiver”—are human beings faced with unprecedented challenges.We identified two types of needs, those independent of the pandemic and those associated with the pandemic. Although the interview focused on the palliative care experience in the pandemic, patients and family caregivers addressed needs that are paramount in the palliative care situation and independent from external conditions. Being at the end of life was an exceptional experience, shaped by well-known dimensions, which we called pandemic-independent needs. Themes and subthemes are listed in While basic palliative care needs did not cease to exist, patients and family caregivers named new needs associated with the pandemic . Themes Patients and family caregivers described a variety of ways in which possible SARS-CoV-2 infection affected them. Most patients reported not to care about being infected by SARS-CoV-2, some felt ambiguous. However, some patients perceived the virus as a second enemy and protested against the disproportionate danger of becoming a victim of the pandemic whilst fighting cancer.“Personally, I’m not so much afraid of COVID-19 right now… the present story may also weigh a little more, because it is more tangible, while COVID is still not really that tangible. I mean, it is THERE, but I simply don’t happen to have it. I do have lung cancer though.”“And I’m always afraid for my [NAME SON], when he goes shopping or something, that he won’t come home healthy and so on. What do I DO then? These are fears, you know?”In contrast, many family caregivers worried about themselves, visitors, or healthcare professionals being a risk for the vulnerable patients.“The thing with COVID is, of course, that if I got infected, I would miss out here as well. Meaning that he would need (…) a professional nurse, who cares for him. Even worse, well yes, if he catches the virus, what happens then? Then he might die of the virus because I was contagious?”However, no patient reported worrying about being contagious themselves, and actually being a risk for their family caregivers while spending quality time. The patients found their own illness and fate more relevant than the pandemic.Patients focused on the challenge they saw in their changed role in their own and others’ life, enhanced through social distancing. The simple reality that the risk of contagion is associated with social interaction shaped the patients’ experience. Experiencing sudden contact restrictions and no-visitor-policies made them feel lonely:“Suddenly I was so lonely, all the time. EVERYONE had withdrawn. (…) There was no phone call anymore. As if, everything was INFECTED somehow. (…) I can’t even express what it felt like. The loneliness and being alone, and that no one is there anymore.”Many patients were concerned with being able to see their loved ones safely and stated they had not met many of their family or friends since the onset of the pandemic. This was especially true for hospitalized patients, who described severe isolation because of quarantine policies and strict visitor-restrictions.Family caregivers linked social isolation to observed declines in patients’ mental and physical health. Sadness and depressive symptoms were the most mentioned problems:“….and that [visitor restrictions] was of course very, very hard for her. This made her mentally exhausted. She constantly said how much she suffered from it. I totally understood. Stunningly, her condition really did get worse from the time the pandemic broke out.”Patients and family caregivers reported heavily burdening and traumatizing situations due to tight regulations for visitors, leading to acute mutual worries about the other’s wellbeing, loss of sense of control, anger, and fear, resulting in increased and lasting emotional stress.“At the very beginning [in the emergency department], it was cruel that, for example, my wife brought me a bag with some things, she stood in front of the door and was not allowed in. That’s inhuman. So, whoever decided that has no brain, he has never thought about what that means for families.”.In this context, family caregivers reported the negative impact on their confidence in the patient’s best care:“…if the person (…) had said ‘you know what don’t you worry, I won’t leave your husband alone before I know that the next one will take care of him’ or whatever. Instead, I felt, I let him go, the door [of the emergency room] opens, the door closes and he is gone (…) I’ve become a little less trusting. It’s more difficult for me to say, everything will be fine, and they will take care and they will do what they can.”However, one family caregiver also indicated a positive aspect of the stay-home-order, allowing her to spend more time with her loved one than usual:“Without COVID-19 I am not sure whether I would have had time to accompany my mother in her last phase to the extent that I am currently able to do.”Patients and family caregivers claimed limitations of telecommunications when compared to in-person contact.“I do have a social sphere and a family too, and they also call every day and ask how things are going. (…) Those are the contacts outside. That helps me to bear it all. (…) I mean, today you can also look at each other via WhatsApp and so on, but it’s just different if you can only see each other or touch each other.”Patients and family caregivers described a variety of ways in which the pandemic situation disrupted access to healthcare services, particularly in non-specialist palliative care. Mobile patients receiving palliative and supportive care in outpatient clinics reported worries or actually disrupted care, which worried them in terms of their prognosis and reliable care.“For example, I wanted to see my doctor. And called him, that’s a pulmonologist. And they said the practice would be closed for 14 days due to Corona, bang, out. Who will take you? Where else can you go? Which doctor is willing to listen to you or take you in? THAT worried me a bit.”However, one family caregiver perceived that integration of specialist palliative home care was delayed.“I think we already asked once in March, my husband, about this palliative home care situation. And we were told ’Yes, it’s really bad at the moment, unfortunately we can’t do it. Because of Corona.’ (…) He was still undergoing radiation therapy, of course. That was a bit of a step backwards, because we were hanging in the air a bit, because he was already in pain. So if Corona hadn’t been there, maybe they could have supported us earlier?”Patients chose to avoid care in hospital settings because they feared that visitor restrictions would prevent them from seeing their family caregiver. Some voiced that they decided to postpone or cancel treatments, to avoid a setting in which family caregivers would not be able to accompany them:“That is why I’m so happy that I ended up here on the palliative care unit and not on an oncology ward. Because there was also the question of whether I would have chemotherapy, the last cycle, and I thought, no (…). I’m staying here and then I won’t have it done, that’s just the way it is.”However, many patients voiced positive experiences regarding the quality of specialist palliative care, both inpatient and at home. When inpatient care became necessary, the palliative care units represented a refuge. Despite the restrictions, no one felt abandoned, and the feeling of being well looked after remained.“And as I said, I have ALWAYS had wonderful care. I didn’t suffer more under it than I did before in my illness. I say, it was a surreal dream. But now, I never had the feeling that I was or had been DESERTED.”“But this one-to-one care was still quite normal for her. (…) There were always regular calls from Mrs. (NAME) or the doctor (NAME), whether everything was still working. And if something happened, someone still came to the place and looked after her straight away, (…) So everything was still as usual, the care was simply well-regulated to one hundred percent.”Most patients accepted protective equipment like clinical masks and other hygienic procedures and perceived them as inevitable, even in intimate care situations and when faced with sensitive information.“…with all the COVID-19 swab testing (…) we have to go through that, I am not afraid at all. I’ve already been tested like 8, 9, 10 times and I do hope it stays like this…that I continue to be negative [for SARS-CoV-2].”Family caregivers also acknowledged the precautionary measures to avoid spreading the virus, but they demanded more and precise information about protective equipment, specific regulations, and procedures.“It would be easier if they were clearer. (…) Although it might be a little uncomfortable at first, (…) when someone says ‘Please understand that due to the pandemic, the rules are so and so for safety reasons (…)’ Friendly, factual, short and precise.”Additionally, family caregivers experienced an imbalance of power between themselves and those who decide over hygienic procedures, regarding both healthcare professionals and security staff. Family caregivers who are in a vulnerable situation felt exposed to non-supportive others, who were controlling them:“However, it happened to me that one of the nurses shot up to me and said in a rough attitude ‘Who are you and what are you doing here?’ I had already registered myself at the reception and looked like a fool, feeling like a school kid in a test. I experienced that moment as very unpleasant. And also, as very lecturing.”Physical social distancing also had a psychological dimension, interfering with traditional attachments and the supportive network of family and friends, as well as professional services. When able to spend time with their loved ones, family caregivers were grateful for the opportunity to stay connected with the patient, but also reported burdening and upsetting aspects.“Well, it’s always like this, after all only I can come and that only here. Just me. And that is sometimes very stressful (…) But of course I would be so relieved, if someone just once said ‘And today you only have to do two hours, because the other three hours I’m going this time.’ And that it could have been shared a bit, that maybe a second person had access. That’s so—so, not just one person per day but sometimes maybe two, then you of course have to decide again who the second person is.”Being the person on whom the patient’s care crucially depended also increased the pressure of responsibility regarding the risk of infection. In addition to the risk that family caregivers could infect the patient, there was also the risk that family caregivers could become infected with SARS-CoV-2, which would result in failure to provide care. Holding the balance of contacts between distancing and accompanying became one of the biggest challenges for family caregivers. In palliative home care, family caregivers felt responsible for the best care of the terminally ill family member. However, the focus and definition of best care differed considerably between families. Some complied with the recommendations regarding hygienic measures and social distancing, while others voluntarily disregarded these, because they attached greater importance to loving contact with the patient than to the risk of lethal SARS-CoV-2 disease in the face of the life-limiting underlying disease.“My decision was really to weigh it up and say, okay, if my mom WOULD get infected and WOULD get pneumonia and die from it, then I MUST, can and want to take responsibility for it. Because otherwise she might not for weeks, maybe months see the persons who are extremely important to her and who contribute to life sustainment at a different level and who are, yes, essential for her quality of life. Finally, I very clearly accepted the risk of shortening life.”Family caregivers whose loved ones became patients in palliative care units or other inpatient facilities felt confronted themselves with visitor restrictions. Family caregivers reported this as a distressing period, since they could not fulfil their tasks as family caregivers, such as practical caregiving, monitoring the patient’s condition, supporting the patient’s social connectedness, or simply holding the patient’s hand. Most importantly, the perception of restrictions as resulting in being stopped from accompanying the terminally ill family member corresponded well with the patients feeling of being lonely.“With regard to COVID-19, I have to say that it really was difficult for me because I was unable to maintain any contact with her [the mother] at all. In the meantime, (…) her dementia progressed, thus she was in the protected department [of a nursing home], and so I could not reach her by phone. I haven’t been able to visit her since she was moved there.”We explored the experience of non-infected patients and family caregivers facing a palliative care situation during the SARS-CoV-2 pandemic in palliative care units and specialist palliative home care in two German cities. The results of this study informed healthcare professionals, providers, and policy via the National Strategy for Palliative Care of Severely Ill and Dying People and their Relatives in Pandemics  in Germany ,27,28.Palliative patients and family caregivers reported unmet needs regarding coping with the risk of contagion, social interaction being affected by social distancing, effects of the pandemic on healthcare delivery, and the challenged role of family caregivers increasing the burden of responsibilities. Nevertheless, the well-known needs of patients and their family caregivers at the end of life remained.The qualitative approach allowed for an in-depth exploration of patients’ reactions, which extended beyond their explanations and captured what they were less aware or even unconscious of. From this, we found that, in daily clinical practice, a discussion process is important to capture the concerns and burdens of patients receiving palliative care during the pandemic.A systematic review synthesizing all patient-valued dimensions of palliative care found eight aspects relevant from the patients’ perspective: physical, personal autonomy, emotional, social, spiritual, cognitive, healthcare, and preparatory . AlthougWhile patient worries in pandemic and non-pandemic times were largely comparable, family caregivers differed in some aspects from patients regarding their worries during the pandemic. Worries and fears are repercussions of the end of life situations experienced by any family caregiver, but these are exacerbated by the risk of contagion with SARS-CoV-2 and the potential consequences for all affected. First quantitative studies with family caregivers reported the majority feared that the cancer patient may contract SARS-CoV-2 , or thatPatients and family caregivers reported isolation, feelings of loneliness, and traumatic situations, due to social distancing and visitor restrictions. Considering the significance of connectedness at the end of life , and theRegarding the delivery of healthcare, family caregivers reported their need for clear and detailed information about infection prevention, rules, and procedures when a patient is cared for in an inpatient setting. Others found caregivers’ informational needs regarding hospital regulations and procedures to be very important, both in light of visitor restrictions due to the pandemic , as wellOur study showed that family caregivers continued to deliver complex care, but had to cope with unlimited responsibility, additional duties, and novel challenges in the support of the severely ill or dying patients. Family caregivers have an essential role in enabling the connectedness of patients. Family caregivers for other severely ill patients reported similar experiences, for example end-stage renal disease , AlzheimThe results clearly emphasize the need of personal contact between patient and family. Both, patients and family caregivers referred to the burden of isolation. Facets of these burdens included feelings of loneliness, mutual uncertainty, and worries about the loved one’s wellbeing. Furthermore, being the only visitor for a severely ill and dying patient can be a burdening experience. Accordingly, to support a feeling of certainty in an uncertain situation, a visiting concept for family caregivers of severely ill and dying people should be developed, granting regular visits by non-infected family caregivers jointly or alternatingly. Furthermore, regulations on how infected family caregivers can be enabled to visit are required. Of paramount importance is communication of regulations to patients and family caregivers. When personal visits by the family are not possible or are only possible to a limited extent, means of communication should be provided for establishing communication and closeness, e.g., video calls. The use of these means should be offered proactively and at a low threshold, including having team members ready and trained to support patients and family caregivers less familiar in using electronic communication devices ,28. KuntOur data indicate that family caregivers are worried about not being able to fulfil their duties. Family caregivers have a crucial role in caring for severely ill and dying people , and manThe importance of supporting family caregivers becomes even more pressing when looking ahead to future societal challenges. The workforce of specialist palliative inpatient and outpatient teams was challenged in the pandemic, in addition to the demographic gap identified so far ,49,50. HTo date, the pandemic has seen a series of SARS-CoV-2 waves and interviews were conducted during the first wave; both during the most severe lockdown and the greatest restrictions, and at several stages of lifting the restrictions, as well as during the second wave, when restrictions were gradually reintroduced in Germany. The experience of patients and family caregivers may have been impacted by these dynamics. However, this study may best reflect the direct impact of the pandemic on patients and their family caregivers receiving specialist palliative care. Both sites are metropolitan, and the results may not fit for patients and family caregivers in non-metropolitan areas; however, the purposeful sampling according to the sample framework ensured high socio-demographic variation. Access to the study may have been limited, because there were no options for self-recruitment, partially due to pandemic restrictions. Patients and family caregivers in specialist palliative home care are particularly hard to reach. We were able to overcome these obstacles by approaching patients and family caregivers in the care of the services associated with the researchers’ institutions, who are experienced in patient assessment and accept research. The latter would also be a safeguard against the risk of gate keeping associated with the exclusion criterion of patients or family caregivers judged too burdened for interview participation. However, we did not systematically record all patients admitted to the services for exclusion criteria, because the purposive sampling focused on socio-demographic variation, rather than a high number to reach interview content saturation.The exploration of the impact of the pandemic on the patient’s and family caregiver’s experience of specialist palliative care at home and in hospital resulted in two main outcomes. First, basic palliative care needs do not change during a pandemic. Second, patients and family caregivers in specialist palliative care have additional needs and burdens, depending on pandemic challenges. Thus, maintaining healthcare services, including specialist palliative care, during the pandemic needs not only to focus on the contagious and infected patients, but also on those who are already under care in existential situations. Some interventions may be postponed, some patients can wait, but at the end of life, impeccable care for patients and support for family caregivers cannot wait, because there is only one chance.


This article is a historical review of the medical and psychiatric diagnoses associated with transgender people across epochs. Ancient Greek and Roman writings already mention gender change. Before a diagnosis even existed, historical documents described the lives of numerous people whom we would consider transgender today. The development of medical classifications took off in the nineteenth century, driven by the blooming of natural sciences. In the nineteenth century, most authors conflated questions of sexual orientation and gender. For example, the psychiatrist Krafft-Ebing reported cases of transgender people but understood them as paranoia, or as the extreme degree of severity in a dimension of sexual inversion. In the early 1900s, doctors such as Magnus Hirschfeld first distinguished homosexual and transgender behaviour. The usual term for transgender people was transvestite, before Harry Benjamin generalised the term transsexual in the mid-20th century. The term transgender became common in the 1970s. This article details the evolution of diagnoses for transgender people from DSM-III and ICD-10 to DSM-5 and ICD-11. Gender Dysphoria (GD) became a psychiatric diagnosis in the fifth edition of DSM (2013), and Gender Incongruence (GI) appeared in ICD-11, the WHO classification that was approved in 2019 and should be effective in 2022. GI was not included in the section on mental health but instead in a section on sexual health. The introduction of GD and GI in today’s medical nomenclatures was hailed as progress because it intended to facilitate the provision of hormonal therapy and surgical reassignment in the context of sexual transition. However, some critics argue that gender identity is a free choice that medical authorities should not sanction. In addition, a diagnostic category is a simplistic way of describing all the nuances of gender fluidity that have asserted themselves in recent decades.This historical review shows that the usages and connotations of terms associated with sex and gender have evolved across places and historical periods. Therefore, we should be wary of making anachronisms by understanding historical terms with our current references.The medical classifications that appeared in the Age of Enlightenment regarded themselves as heirs to the Greco-Roman models of antiquity. Non-binary gender and gender transformations were common themes in Greco-Roman mythology. In the Metamorphoses (the Greek μεταμορφώσεις means ‘Transformations’), the Roman poet Ovid (ca. 8 A.D.) relates how Tiresias was transformed into a woman, punished for disturbing two giant snakes mating. He lived as a woman for seven years before being turned into a man again. Once Jupiter, ‘expansive with wine and exchanging pleasantries with Juno,’ told her that women derive more sexual pleasure [voluptas] than men . Juno denied it, and they agreed to ask Tiresias for his opinion since he had known sex from both perspectives. As the arbiter of the dispute, Tiresias. did confirm Jupiter’s words. Ovid further narrates  how Caenis (Καινις), a renowned beauty, was raped by Poseidon, the god of the sea. In response to Poseidon’s offer to realise a wish, she asked to be transformed into a man to prevent the repetition of such an assault. Thus, Caenis became as a man, Caeneus (Καινεύς), a famous warrior who received the additional faculty of having a skin that any weapon could not wound.Transgender themes are not limited to mythology but are also associated with Roman emperors. According to Varner , Roman iThe Roman emperor Elagabalus (ca. 204–11 March 222), also called Heliogabalus, might be the first historical record of a famous person asking to be addressed femininely and requesting surgical sexual reassignment. According to Cassius Dio (c. 155–c. 235 AD)  ran away from her convent in Spain in the early seventeenth century as a young woman. She adopted a male identity and embarked to America, where she was active in business or the military in almost all the provinces of the Spanish Empire. She is said to have posed as a castrato – a legitimate social status at the time – to pursue love relationships with feminine partners. She achieved such fame that she gained audiences with the king of Spain, Philip IV, and the Pope, Urbano VIII, who granted her permission to wear male clothes. She died in Mexico under the name Antonio de Erauso. Another exceptional biography is the Chevalier d’Éon, who served the French King Louis XV as an envoy and spy in Russia and as an officer on the Seven Years’ War battlefields. He spent the last part of his life in England as The current psychiatric classifications were initially developed by German-speaking authors in the nineteenth century. At that time, homosexuality, transvestism, or transgender behaviours were conceptualised as various degrees of a single dimension of ‘gender/sexual inversion.’ This conflation of homosexuality and gender contrasts with modern notions that homosexuality is independent of gender identity and related exclusively to sexual object choice.anima muliebris in corpore virili inclusa’). Ulrichs believed that both possibilities of sexual development remained possible in the embryo’s early stages when the sexual organs were not yet differentiated. He saw confirmation of this idea in the existence of hermaphrodites. He postulated that there must be a ‘germ’ [‘Keim’] that determined whether the sexual organs would develop male or female. To explain the discrepancy between the sexual organs and the sexual orientation, he postulated the existence of another ‘germ’ that determined the direction of the sex drive. We will see that this model prefigures modern biological conceptions. The term homosexuality was coined in 1869 by the Austro-Hungarian writer Karl Maria Kertbeny.The essential point in Karl Heinrich Ulrichs’ theory of homosexuality (1864) was the conviction that the male homosexual possesses a female soul enclosed in a male body , a physician born as a male in Hungary in 1844, writes autobiographically:Krafft-Ebing (1840–1902), influenced by the theory of degeneracy, postulated a gradient of severity from effeminacy and homosexuality to complete hoc modo sensi, me libentius sub puella concubuisse et penem meum cum cunno mutatum maluisse  … But, even on my marriage-night, I felt that I was only a woman in man’s form.at the age of twelve or thirteen, I had a definite feeling of preferring to be a young lady. A young lady’s form was more pleasing to me; her quiet manner, her deportment, but particularly her attire, attracted me. But I was careful not to allow this to be noticed. I am sure that I should not have shrunk from the castration-knife, could I have thus attained my desire. If asked why I preferred female attire, I could have said nothing more than that it attracted me powerfully… I remember, when fifteen, to have first expressed to a friend the wish to be a girl. In answer to his question, I could not give the reason why … when in high school I finally had once coitus; Metamorphosis sexualis paranoiaca’ indicating that he understood it as delusional.Krafft-Ebing diagnosed this case as ‘Before World War I in Berlin, Magnus Hirschfeld first distinguished between the questions of sexual orientation and those of gender identity, putting an end to the confusion between the fields of homosexuality and gender identity. However, Hirschfeld still used the word transvestite to refer to what we call transgender today. After the World Wars in the United States, Harry Benjamin clearly defined the difference between transvestite and transsexual. After the 1970s, the term transsexual gave way to transgender (Yarbrough Wissenschaft-humanitäres Komitee (WhK) in 1897, and then the Institut für Sexualwissenschaft (1919) whose staff included transgender people , which aimed to spread scientific research to carry out advocacy on behalf of sexual minorities  was a physician who practiced in the Charlottenburg district of Berlin. He founded two organisations committed to the support of homosexuals and sexual minorities, first the  Dobler, . One of  Dobler, , Hirschf Dobler, . One of Jahrbuch , a British physician, also studied transgender phenomena as a question distinct from homosexuality. He disagreed with Hirschfeld’s term ‘transvestitism’ and proposed in 1913 the term Harry Benjamin visited the United States in 1913. As fate would have it, the First World War broke out shortly after that, and the Royal Navy blockade cut him off from the way back to Germany. He lived in the United States till the age of 101-½ Green . Guided Benjamin’s most famous patient, George Jorgensen, went to Denmark as a natal man and returned to the US in 1952 as trans woman Christine Jorgensen. When she died at 62 in 1989, a New York Times obituary retraced her biography. Growing up, she was frustrated by feelings that she was a woman trapped in a man’s body. She served as a clerk in the army and was honourably discharged. Her sexual conversion began with hormone injections in 1950 when she was 24 years old and was completed in 1952 with surgery in Copenhagen under the care of Christian Hamburger, a Danish specialist whose first name she adopted to form her own. Hamburger and his colleagues published a report in the Journal of the American Medical Association  and secondary (penis and others), are disgusting deformities to be changed by the surgeon's scalpel. It is only because of the recent and great advances in endocrinology and surgical techniques that the picture has changed. Benjamin Out of the Ordinary, was published posthumously in 2017. He has been called the first female to male ‘transsexual,’ although that term would become common only after his lifetime.Another historical pioneer is Michael Dillon (1915–1962). Born as a girl in London, he started self-administering testosterone tablets in 1939. He underwent his first operation for phalloplasty in 1945. He graduated from medical school at Trinity College in Dublin in 1951. He finished his life in India as a Buddhist monk under the name Lobzang Jivaka. His autobiography, Today, expressions of gender variance or gender nonconformity are frequently subsumed by the popular term transgender, although this term does not appear in the DSM or ICD. ‘Transgender’ is a relatively recent word. According to the Oxford English Dictionary, ‘transgender’ was first used in the early 1970s to designate a person whose sense of personal identity and gender does not correspond to that person’s sex at birth or does not otherwise conform to conventional notions of sex and gender. It is also an umbrella term which includes any or all non-conventional gender identities.A diagnostic category needs an aetiological hypothesis to enhance its validity. Authors have been searching in three main fields for influences that might make a person transgender: psychology, sociology, and biology. A proponent of the role of sociology and education was John Money, a New Zealand psychologist. He published theories in the 1950s that one’s sense of being male or female was acquired and determined by external, environmental factors. Based on cases of gender assignment in intersex children born with ambiguous genitalia, Money believed parental attitudes had a substantial effect on whether a child accepted the gender category that had been surgically and medically assigned.in utero. This belief seemed to be confirmed by a milestone paper published in Nature in 1995 . In ICD-10, Transsexualism designated a desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one’s anatomic sex and a wish to have hormonal and surgical treatment to make one’s body as congruent as possible with the preferred sex. To qualify for this diagnosis, the transsexual identity had to persist for at least two years. Dual-role transvestism designated the wearing of clothes of the opposite sex for part of the individual’s existence to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment. No sexual excitement accompanied the cross-dressing, which distinguished the disorder from fetishistic transvestism.The ICD-10, endorsed by the Forty-third World Health Assembly in 1990, followed the DSM-III’s lead and included the diagnoses of transsexualism and gender identity disorder of childhood. ICD-10 also created the diagnosis of dual-role transvestism  was included in the ICD-11 to preserve access to health services, but it was moved from the ICD-11 chapter on Mental and Behavioural Disorders to the chapter on Sexual Health. Following DSM-5, The ICD-11 abandoned ICD-10 terms such as ‘opposite sex’ and ‘anatomic sex,’ using more contemporary and less binary terms such as ‘experienced gender’ and ‘assigned sex.’ Unlike ICD-10, but like DSM-5, the proposed ICD-11 diagnostic guidelines do not implicitly presume that all individuals seek or desire complete transition to the ‘opposite’ gender. In ICD-11 (Reed et al. The ICD-10 categories fetishistic transvestism and dual-role transvestism disappeared in ICD-11. These conditions involve consensual or solitary sexual activity, cause no inherent harm to self or others, and are not necessarily distressing to the individual or associated with functional impairment. Therefore, these arousal patterns were not considered per se as mental disorders but more accurately as variants in sexual arousal (Krueger et al. DSM-5 emphasises distress and dysfunction related to gender identity through the category’s name and criteria. Distress and dysfunction are also the central rationales for classifying gender dysphoria as a mental disorder. In CIM-11, the diagnostic guidelines indicate that GI may be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, particularly in disapproving social environments and where protective laws and policies are absent, but that neither distress nor functional impairment is a diagnostic requirement.The theme of gender change is frequent in ancient Greco-Roman sources. The reliable historical documents available in the premodern era produced numerous and continuous testimonies of people who led lives that would seem transgender today. The interest in medical diagnosis started in the mid-nineteenth century, thanks to expanding natural sciences. In the twentieth-century culture, giving a medical diagnosis is double-edged, allocating both help and pathological labelling to the person. The concern for depathologization guides the most recent classifications. The aetiology of transgender behaviours is unknown, but research suggests that they have a biological basis in the brain. If this is the case, transgender expression is not a matter of choice influenced by social fads. Nor is it a matter that must be subject to religious or political rules.


Fake news and disinformation (FNaD) are increasingly being circulated through various online and social networking platforms, causing widespread disruptions and influencing decision-making perceptions. Despite the growing importance of detecting fake news in politics, relatively limited research efforts have been made to develop artificial intelligence (AI) and machine learning (ML) oriented FNaD detection models suited to minimize supply chain disruptions (SCDs). Using a combination of AI and ML, and case studies based on data collected from Indonesia, Malaysia, and Pakistan, we developed a FNaD detection model aimed at preventing SCDs. This model based on multiple data sources has shown evidence of its effectiveness in managerial decision-making. Our study further contributes to the supply chain and AI-ML literature, provides practical insights, and points to future research directions. According to Wardle  to counteract the spread of false information is vital in acting against disruptive effects . Although emerging technologies such as AI may sometimes have negative effects, they can be utilized to combat disinformation. As scholarship is showing increasing interest in how AI can improve operationally and supply chain efficiencies   proposes a systematic comprehension of processing and exchanging of information to increase capacities. OIPT reasons that firms need a stabilizing mechanism by possessing resources and capacities in operations to cope with uncertainties and manage unforeseen events that disturb normal business and supply chain operations . Since 1955, AI has evoked the idea of relevant human intuition and artificial machines that could stimulate the human brain and come up with environmental abstractions to work on difficult problems. During the following decade, in 1966, Joseph Weizenbaum created the famous ELIZA computer program, a ‘natural language processing (NLP) tool that was capable of holding a conversation with a human being and maintaining the illusion of comprehension. This was labelled heuristic programming and AI . In supply chain management and the manufacturing industry, there has been an upsurge in AI  is construed as: “false information that is given deliberately”. The impact of FNaD is substantial, disrupting economic operations and societal activities. FNaD also threaten brand names and potentially affect the consumption of products and services, ultimately impacting supply chain operations and demand  is defined as: “The persuasive power of fake news could continuously damage global supply chains, such as meat, vegetables, fresh food, and fruits in different parts of the world  The Dataset Enrichment was based on two techniques—i.e., Porter stemmer (PS) and Term Frequency-Inverse Document Frequency (TFIDF). 2) Query Expansion was utilized for natural language processing (NLP) to precisely predict the accuracy of fake news. (3) The Support Vector Machine (SVM) classifier was utilized to train the model and then finally evaluate fake and real news outcomes for effective decision-making SCDs. Table  Query ExSecondly, the involved cases for interviews were from Indonesia, Malaysia, and Pakistan. These countries share similarities. Furthermore, these are emerging countries with common economic and political ties as well as government-to-government contacts. Similarly, these nations are making strides toward digitization and AI. Numerous previous studies  was used to index each news page/article to filter out any stop, repeated, and common words to avoid noise in the dataset. The algorithm was used, over several rounds, to remove any non-relevant words from the datasets/textual scripts before considering all criteria or defined rules  was utilized for the classical ML models. TDIF is a text classification technique utilized for organizing textual documents from raw datasets into predefined categories to obtain useful information. This is done by representing textual documents into feature vectors consisting of weights that indicate the contribution of each term in text classification  and information retrieval such as metrics of text semantic similarity are the most used techniques  to precisely compute the relevancy of keywords related to FNaD by calculating the semantic distance between keywords related to SCDs, queries, and news articles. This phase explains the keywords used in SCDs to train a classifier to predict the appropriateness of SCDs in the news. We analyze the significance of each SCD keyword to a news category. We have news articles in the category “Business” and we wish to evaluate whether it is appropriate for a SCD example such keywords in the category; “natural disasters”, “man-made disasters”, “marine incidents”, and “mass trauma incidents”. We consider the degree of appropriateness of the news category with each of the SCD keywords based on the feature’s relevancy score. In this scenario, -1 represents that a news item with the category “sports” is utterly inappropriate to be examined with supply chain disruption keywords “offshore oil rig mishaps,“ but a + 1 score suggests that it is perfectly appropriate. Table The WordNet ontology  produced the best results, therefore, we only provide the findings of the SVM classifier in this study.Support Vector Machine: We develop a model for each news item by training a binary classifier using two possible outcomes positive  and negative  news with the appropriateness of SCDs. We chose a binary classification because it is assumed that a responsible user will want to verify the news before spreading it. In order to determine whether the news is real or fake, the user would most likely check online sources (databases/publishers), and in the process, the user may be able to verify or refute the information depending on the source. Subsequently, if the model is trained using a supervised learning technique with only two possible outcomes, the model is forced to make a binary decision, this increases the model’s accuracy significantly. Therefore, the Support Vector Machine (SVM)  . “if FNaD is included in routine or prolonged decision making, it definitely agonizes the future result” (Respondent 2), and “If any decision is based on lies, how can someone expect positive consequences?” (Respondent 11). Two respondents shared that the purpose of spreading FNaD is to create a specific mindset and narrative in the economy/market to manipulate it: “Misleading information supposed to build a specific narrative and sentiment in the market, enemies and indirect competitors usually involve in it” (Respondent 1). The respondents indicated that fake news directly affects operations and has an indirect influence on supply chain operations, contributing to SCDs.The impact of fake news on supply chain operations emerged as the first theme from the analysis. When asked about their knowledge and understanding of FNaD, the respondents gave detailed replies. Some argued that it is one of the most harmful aspects of the internet, with the potential to create SCDs. Respondent 4 said that “As a business community, together we should deal with misleading information and news. Otherwise it could become a scar in business performance” (Respondent 16). Respondents 12, 15, and 16 mentioned that FNaD should be dealt with as a pandemic like the COVID-19 one. Some respondents mentioned the names of the entities they considered to be primarily responsible for keeping FNaD under control, with Respondents 8, 2, and 11 pointing at the global internet community, social media sites, and the government. On the other hand, respondents 1, 3, 9, 10, 12, and 13 believed that the responsibility of curbing the effects of FNaD on supply chain performance and decision-making should fall on specific industries and businesses. Respondent 13 further explained that “as a business entity, we need to find a mechanism which guides us that specific news or information is legit or not”, while Respondent 6 opined that “in today’s world, if your business isn’t data-driven, then you are definitely living in the jungle.”Dealing with FNaD emerged as the second theme of the analysis. The respondents provided numerous options in this regard, suggesting that global communities, social media sites, government, technology, and top management can play key roles in countering FNaD. FNaD should be dealt with smoothly and promptly; otherwise, it will negatively affect supply chain performance: “The world won’t care about your self-esteem. The world will expect you to accomplish something before you feel good about yourself”, and further added “As a business caretaker, this is my responsibility is to shelter and protect my company from fake news, so that, at the end of the day, I will have no regrets.” Respondents 3, 5, 7, 10, 14, 15, and 16 suggested that AI will provide solutions suited to control and counter FNaD. Respondent 10 advised that “Data crawler integration with AI could provide a solution to FNaD”. Respondent 11 shared a similar thought “Each government should prepare AI-based processes according to specific society and economy to rectify the impact of fake news, and that process in the form of software should be provided free of cost to businesses”. The participants also highlighted the importance of using multiple sources to determine whether the news is fake or real, as a single source could be biased or politically driven. Based on the procedure applied for AI, the SVM, and the interview-based validation, we proposed the FNaD detection model shown in Fig. FNaD filtering and counter modeling process suggestions and preparations became the third theme of the analysis. This enriched session contributed many insights into and inputs about countermeasures to FNaD in business and supply chain operations. When we asked Respondent 7 about this, he shared the following Bill Gates quote “As depicted in Fig. Our study fills the knowledge gap about SCDs by utilizing AI and ML that assist to act against FNaD affecting supply chain operations. Loureiro et al.,  suggesteAdditionally, the study bridges a gap in the literature by providing a practical solution suited to eliminate FNaD in business scenarios affected by SCDs. The scattered and fragmented extant literature had left many questions about FNaD unanswered (Di Domenico & Visentin, The United Nations  has urgeFNaD can be significant determinants of SCDs, as is highlighted in research (Kovács & Sigala, Our model detects FNaD early before they can affect firms or managerial decision-making. The current pandemic scenario has turned the attention of managers and governments toward FNaD and their impacts on supply chain operations, economy, and society. On the other hand, with AI and ML becoming an integral part of firms and operations, managers should consider their adoption to deal with FNaD, given their potential to detect and filter them out. Our model is executed and managed based on major local databases and news outlets to support supply chain operations. Should managers wish to integrate adding any further international data and news outlets, they could do so based on their requirements. The implementation of our model would depend on a willing and authoritative IT infrastructure, with even small and medium enterprises being able to invest in its application. We proposed a process capable of detecting and filtering out FNaD. This process protects firms from the impacts of FNaD, enabling managers to engage in decision-making based on legitimate and valid news or information.From the perspective of specific industries, newsrooms could utilize the FNaD detection model to confirm a news item from different sources. In other words, the FNaD detection model can help in the timely development of a counter-strategy by detecting any fake news before it spreads and causes SCDs. The phenomenon has recently been seen in the context of the COVID-19 pandemic, with people sharing unverified news items on the virus and the side effects of vaccines over social media, thus causing SCDs in vaccine distribution. Moreover, pre-emptive fake news detection can be equally beneficial in avoiding financial market crashes. For government policymakers, the FNaD detection model can be a comprehensive tool to be used during pandemics or similar situations. Governments have been seen to regularly change their decisions, rules, and regulations. Therefore, at the government level, the FNaD detection model can ensure that accurate and on-time legitimate information is received to deal with any economic, social, and health conditions. Another implication for governments pertains to the provision of this process—for free or at a discount—to all business-related entities, especially micro, small, and medium firms. Such a decision would create trust between the government and those entities.SCDs are problematic for business operations. It is believed that SCDs could cause obstacles due to disinformation. Therefore, we proposed the FNaD model that filters the FNaD by utilizing AI and ML. This model takes help from different sources on internet to verify the received information. It then decides and notifies whether that received news is authentic or not. By using a mixed-method approach, we proposed a way to tackle SCD-creating FNaD using AI- and ML-based techniques. In this regard, future research could, first, focus on more specific FNaD and supply chain operation case studies, such as the detection of FNaD in humanitarian operations using AI and ML approaches. Additionally, they could integrate specific operational performance measures in these approaches, combining them with advanced visual methods. Also, given the fast pace of scientific development, any new and effective algorithm or technique could be used in the proposed model in the future. Furthering, testing the model based on longitudinal studies aimed at exploring and understanding the developments in SCDs linked with FNaD would make it more reliable and refined.