Proposed changes to the GIC classification

The above mentioned dilemma—regarding how best to provide a classification that ensures access to care while at the same time providing recognition rather than pathologization or stigmatization—provided the background to the current proposal of the WHO’s Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH). Several recommendations relevant to the GIC diagnosis were made by this group (for proposed GIC criteria see [12]):

1. The diagnosis would no longer be included in the mental health chapter, but be part of an independent chapter on sexual health.
2. The ICD diagnostic term to be used would be changed from Gender Identity Disorder of Childhood into Gender Incongruence of Childhood.
3. Stricter criteria for the new diagnosis of GIC would be used in order to reduce the risk of false positives.
4. Distress due to gender incongruence would not form part of the diagnostic criteria.

The working group noted:

“…there are individuals who today present for gender reassignment who may be neither distressed nor impaired. This may be particularly true for young adolescents who are aware of the possibility of gender transition, live in an accepting environment, and who can have access to puberty suppressing treatments until they are able to take such a decision.” [2]

The WHO published a beta draft of the proposed ICD-11 in order to receive input on the proposed structure and diagnostic criteria (see [12]). As indicated above, Gender Incongruence of Adolescence and Adulthood and Gender Incongruence of Childhood are placed in the proposed new chapter entitled ‘Conditions related to sexual health’, which is a deviation from the preferences for placement of the WGSDSH, whose first preference was for placement in a separate chapter focused on gender incongruence only [2]. Their second preference was for the gender incongruence diagnoses to be placed in a new chapter focusing on sexual and gender health [2]. In the current ICD beta version, the focus on gender is lost and reads: Conditions related to Sexual Health, see [12]. The suggested changes concerning placement and characteristics of the childhood diagnosis were made by the WGSDSH based on the assumption that the diagnosis would remain part of the ICD-11.

Field testing

The WHO has subjected the WGSDSH’s initial recommendations to field testing in a variety of relevant health care settings in different WHO regions. In all previous revisions, Gender Incongruence has never been subject to formal field-testing. The WHO has decided that the new revision should improve clinical utility. WHO views clinical utility as a global public health issue [13]. Indeed, clinicians consider an important purpose of a diagnostic system to be a facilitator of communication among clinicians and to inform treatment and management. Rather than a strict criteria-based approach, clinicians prefer a simple and descriptive system that can be used by specialists as well as general healthcare providers, in high- as well as middle- and low-income countries [14].

The WHO is already performing field studies in several low- and middle-income countries regarding these issues. However, field studies are also necessary in countries with well-developed healthcare systems, since some of the controversial issues can only be tested in clinical settings where a sufficient number of patients are assessed. This is particularly the case for children and adolescents with gender incongruence, as there are few clinical centres in the world that are accessible to those children. These are the reasons why the Netherlands and the United Kingdom (UK) have been selected to undertake these field studies.

The Dutch and UK healthcare systems

Healthcare systems differ across the world, and also between the Netherlands and the United Kingdom. As the way healthcare is organized might influence ideas about diagnostic classification, a short overview of the Dutch and UK systems and the organization of transgender healthcare is provided. It is mandatory for people who legally live or work in the Netherlands to have basic healthcare insurance and several insurance providers exist (some for-profit, others non-profit) that allow consumers choice during annual open enrolment periods. These companies are obliged to accept every person for the basic package and are not allowed to select only people with low health risks (e.g., the young, not having a chronic illness). Discrimination based on health risks and conditions is therefore not allowed [15]. Consumers may, however, choose to buy supplemental insurance covering care that is not included in the mandatory basic insurance. For this supplementary health insurance, insurers are not required to accept all applicants [16].

Applicants for transgender related healthcare within this system are referred through a general practitioner and healthcare reimbursement is based on their diagnosis or that of another appropriate professional. Regarding specialist care in the Netherlands, multidisciplinary transgender related healthcare can be obtained at three centres: Leiden University Medical Centre (children and adolescents), University Medical Centre Groningen (adults), and the Center of Expertise on Gender Dysphoria (CEGD) of the VU University Medical Centre in Amsterdam (children, adolescents, and adults). A number of other hospitals do not have multidisciplinary teams, but do provide transgender related surgery after referral. Aside from this, some transgender people go abroad to obtain surgical interventions, though this is not always reimbursed by healthcare insurers.

The United Kingdom is made up of four countries (England, Scotland, Wales, and Northern Ireland) each of which has a separate National Health Service (NHS) and all of whom use the ICD-10 [1]. The NHS is funded through central taxation and provides a comprehensive range of health services, the vast majority of which are free at the point of access for people legally resident in the United Kingdom. It is not an insurance-based system and although ICD diagnoses are collected, the funding is not dependent upon them. Therefore diagnoses which are part of Z-codes are normally funded. Services for adult people (>17 yrs) with gender dysphoria who live in England and Wales are funded by NHS England and are provided via seven NHS Gender Identity Clinic services, all of which are based in England. There is also one Gender Identity Clinic service in Glasgow, Scotland, and one in Belfast, Northern Ireland. The clinical services were originally developed according to the interests of individual clinicians, rather than on a national, strategic level, hence the lack of these services in some parts of country such as the North-West. As in the Netherlands, applicants of transgender related healthcare are referred through a general practitioner, although clinicians in secondary care services can also refer. Currently, there is only one NHS service for children and adolescents with gender dysphoria in the United Kingdom which is based in London, with two satellite clinics in Exeter and Leeds, England.

Aim of the study

This field study aimed to: 1) collect the views of transgender individuals and professionals regarding the retention of the diagnosis; 2) see if the proposed GIC criteria were acceptable to transgender individuals and health care providers 3) compare results between two countries with two different healthcare systems to see if these differences influence opinions regarding the GIC diagnosis; and 4) determine whether healthcare providers from high-income countries feel that the proposed criteria are clinically useful and easy to use.

Methods

Materials

The research team from the Center of Expertise on Gender Dysphoria of the VU University Medical Center Amsterdam, developed a questionnaire with the input of experts and stakeholders [17]. This questionnaire covered questions regarding both the Gender Incongruence of Childhood classification (GIC) and the Gender Incongruence of Adolescence and Adulthood (GIAA). The results of the survey questions regarding the GIAA diagnosis are reported elsewhere, see [17]. The final survey consisted of two parts (see S1 Text for the complete survey). The first part focused on the view of the service users and clinicians with regard to the various changes proposed in the ICD-11 (as compared to the ICD-10). A special effort was made to explain concepts that some participants may have been unfamiliar with through the use of pop-up information windows accessible via a mouse click on blue-colored, bold and underlined words. For example, explanations were provided on the concept of a Z-code (this concerns “factors that affect health and also influence contacts with the healthcare system” but does not concern diseases or disorders). The second part of the survey was available for healthcare providers only (including transgender participants who were healthcare providers) and aimed to examine the clinical utility and the clinical implications of the proposed GIC diagnosis. The ICD-11 GIC criteria used were the final draft criteria of the WGSDSH (see S2 Text).

The Dutch survey went live on June 2^nd 2014 and was open for 10.5 months. For the UK study, the Dutch version of the questionnaire was translated into English by a Dutch translation company and then further amendments to the language were made to ensure appropriateness and ease of use by lay people. The questionnaire was then sent to the lead clinicians at all Gender Identity Clinic services in the United Kingdom, as well as the main providers of gender-related surgery. A meeting took place where stakeholders could comment on the questionnaire and no major amendments were suggested, but the length of the questionnaire was questioned by various stakeholders. However, changes to this could not be made for reasons of consistency with the original Dutch version. During the same period, representatives from the major trans stakeholder groups in the United Kingdom were invited to meet and discuss the questionnaire in detail. The overarching remit given to this group was to remain as closely as possible to the original Dutch version of the questionnaire. Amendments were made to some of the language used, the order of questions, response options, and a small number of new questions was added. The final version was then translated back into Dutch by another Dutch translation company and shared with the team in the Netherlands. The online questionnaire went live in the UK on October 1^st 2014 and was open for 7.5 months (see also [17]).

The survey began with a series of demographic questions that asked about age, geographical location, gender identity (identification and description), birth assigned gender, education, employment status, and respondent category (i.e., trans, relative, healthcare provider). It then went on to ask about general opinions towards diagnosis and whether the respondent was receiving or had received treatment (if applicable). All questions were fixed-choice options, with spaces provided to answer “other” and add more information if required. The answer options going through the survey were a mixture of one-option responses or multi-option responses, depending upon the question. Options were provided to cover all eventualities, including neutral/no opinion; always with the addition of “other, please specify” or “please explain your answer” to allow for additional comments. For example, questions that asked for level of agreement would give seven main options: “Strongly agree, Agree, Agree a little, Neutral; Neither agree nor disagree, Disagree a little, Disagree, and Strongly disagree”, plus “please explain your answer”. Questions that asked about opinions (e.g., “Do you think….”) would give four main options: “Yes, No, No opinion, Don’t know” plus “please explain your answer” (see also [17]).

The Dutch study was granted full ethical approval (inclusion of Belgian participants and the consent method for participants under the age of 18 was covered) by the Commissie Wetenschappelijk Onderzoek [Committee of Scientific Research] of the EMGO Institute for Health and Care Research (EMGO⁺) with project ID WC2014-09. The UK study was granted full ethics approval (the consent method for participants under the age of 18 was covered) by the UK National Research Ethics Service Committee East Midlands—Nottingham 1 with IRAS project ID 152591.

Data analysis

Participants who were both healthcare providers and transgender were included in both the Transgender group (TG) and the Healthcare providers (HCP) group. Differences between participants from the United Kingdom (UK) and participants from the Netherlands/Flanders (NL) were explored with a t-test for continuous data (age), Chi-square tests or Fisher’s Exact test (for the HCP only questions where the sample was smaller and Chi-square assumptions were violated) for categorical data and Mann-Whitney U tests for ordinal data or when t-test assumptions were violated. As participants who were both HCP and TG persons were included in both groups, the TG and HCP group were not independent. Therefore, no statistical differences between these groups were explored. The results of the HCP group are described after the TG group and finally, the findings from the specific questions for healthcare providers are described.

Sample characteristics

Based on the participant type categories selected (see S3 Text for the additional information on respondent categories), participants were divided into three categories: healthcare providers (HCP); service users (transgender persons and their partners and/or relatives; TG); and participants who are both healthcare providers and (partners/relatives of) transgender persons. The TG group consists mainly of transgender persons (see Table A in S3 Text), but also partners, relatives, and parents of children/adolescents with gender incongruent feelings were included, as they have first-hand experience with the healthcare provided for their family member. Most participants were in the TG group (n = 522), 89 participants were HCP, and 17 participants were both HCP and TG (see Table 1). These three categories were used to analyse the responses regarding the survey questions. Note that when we refer to the participants from the Netherlands and Flanders, the abbreviation NL is used.

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Table 1. Frequency Table of Gender Assigned at Birth, Gender Identity, and Level of Education (and Percentages for each Column).

Table copied from [17].

https://doi.org/10.1371/journal.pone.0168522.t001

The age of the participants ranged between 16 years and 78 years with a mean of 38.72 years (SD = 14.59). There was no statistical difference between the mean age in the Netherlands (M = 38.47, SD = 13.64, n = 290) and the UK (M = 38.94, SD = 15.38, n = 336), t (624) = -.40, p = .69). The level of education did not differ between the Netherlands and the UK (U = 48589.5, p = .81). For sociodemographic characteristics on assigned gender, gender identity, and level of education see Table 1 below.

General features of the diagnosis

Positioning of the Diagnosis.

Of all response options available, when asked where should the diagnosis go if removed from the mental health chapter, the most frequently selected option by transgender participants was that it should also be removed from the ICD-11 completely (42.9%; n = 222). Thirty-three point six percent (n = 174) of TG participants thought the children’s diagnosis should remain in the ICD-11. Nearly a quarter of the participants had no opinion (20.1%; n = 104) or said it did not matter to them (3.5%; n = 18). There were statistically significant differences between the countries, (χ2(3) = 9.51, p = .02, Cramer’s V = .14) (see Table 2). Among healthcare providers, there was mainly support for the retention of the GIC diagnosis (55.4%; n = 56), while 27.7% (n = 28) of the HCPs wanted to remove GIC from the ICD-11, 12.9% (n = 13) had no opinion and 4.0% (n = 4) said it did not matter to them.

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Table 2. Frequency Table (and Percentage of Column) of Responses of Transgender Participants to the Question: How would you respond if the children’s diagnosis for gender incongruence were to be taken out of the chapter on “Psychiatric disorders”?

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https://doi.org/10.1371/journal.pone.0168522.t002

Respondents were asked what they thought of the statement that gender incongruence among children is a psychiatric disorder on a seven point scale (from strongly agree (1) to strongly disagree (7)). In the TG group (n = 518), the mean (dis)agreement was 5.69 (SD = 1.61). There were no differences between the countries (U = 34362, z = 1.70, p = .10, r = .07). The mean score of the UK TG participants (n = 319) was 5.80 (SD = 1.52, mean rank = 267.72) and 5.51 (SD = 1.72, mean rank = 246.33) for the NL TG participants (n = 199). When the possible responses were grouped into three categories (agree to various degrees, neutral, disagree to various degrees), it was found that 76.1% of the TG respondents (n = 394) disagreed (to various degrees) with the statement, 12.4% (n = 64) were neutral, and 11.6% (n = 60) agreed (to various degrees) with the statement. In line with the results of the transgender participants, the majority of the HCPs (64.4%; n = 65) disagreed (to various degrees) with the statement that gender incongruence among children is a psychiatric disorder, while 12.9% (n = 13) was neutral and 22.8% (n = 23) agreed.

When asked in which chapter participants thought a diagnosis of gender incongruence for children should be included, only 7.2% of the transgender participants said that the GIC diagnosis should not be in the ICD at all (see Table 3). Over one-third of transgender participants (37.5%; n = 188) thought the gender incongruence diagnosis for children should be placed in a separate chapter dealing with symptoms/ disorders regarding sexual and gender health, while 26.7% (n = 134) preferred to include gender incongruence of childhood as a Z-code (see Table 3 for all responses). The responses differed statistically between the Netherlands and the UK, (χ2(8) = 38.21, p < .01, Cramer’s V = .28). See Table 3. In the UK, the most frequently selected option of transgender participants was to include a gender incongruence diagnosis as a Z-code (32.6%; n = 104) and secondly to place it in a separate chapter dealing with symptoms and/or disorders regarding sexual and gender health (30.4%; n = 97). Most NL transgender participants preferred gender incongruence to be placed in a separate chapter dealing with symptoms and/or disorders regarding sexual and gender health (50.0%; n = 91) and their next preferred placement was as a Z-code (16.5%; n = 30). In line with the findings for the transgender participants, healthcare providers (40.0%, n = 40) most frequently selected placement in a separate chapter dealing with symptoms and/or disorders regarding sexual and gender health and 24.0% (n = 24) preferred to include GIC as a Z-code, while 6.0% (n = 6) thought it should not be in the ICD at all.

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Table 3. Frequency Table (and Percentage of Column) of Responses of Transgender Participants to the Question: In what chapter of the ICD-11 do you think the diagnosis of gender incongruence for children should be included?

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https://doi.org/10.1371/journal.pone.0168522.t003

Stigmatization due to a diagnosis

Just over a third (36.6%; n = 188) of transgender participants had no opinion regarding the question: ‘Do you think that the proposed diagnosis for children will have a greater stigmatizing effect (i.e. more so than for adults)?’ (see Table 4). Just over a third (34.5%; n = 177) did not think that the proposed diagnosis for children would have a greater stigmatizing effect for children than for adults. There was a statistically significant difference between the two countries, (χ2(3) = 27.91, p < .01, Cramer’s V = .23), see Table 4. Some participants elaborated on this answer. For example, a Dutch parent who thought the diagnosis did not have a greater stigmatizing effect for children than for adults wrote: “When you know something is wrong but cannot figure out what it is, a diagnosis is a liberation. It is a definition for the problems you are experiencing. It can be stigmatizing but that doesn’t mean, the diagnosis is bad in itself”. A parent from the UK wrote: “…because again, society still likes to have a doctor’s opinion on anything. So having a diagnosis will make people take you more seriously. Problem is until you have that diagnosis. Then everyone looks at you like your kid is only having a tantrum over an extra chocolate.” Examples of parents who thought a diagnosis would have a greater stigmatizing effect for children than for adults include: “A diagnosis made (too early) will remain in your medical record for ever. Even if you are no longer experiencing gender incongruence in puberty. It will remain a stigma if we are not careful.” (Dutch parent) or “…attaching a diagnosis of "incongruence" to a child who is completing a normal process of identity development is premature and implies that the process of identity development is following an "incongruent" path which does not match the norm. It is inappropriate to diagnose a condition that will change as the child grows and matures in their sense of self/identity/esteem” (parent from the UK).

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Table 4. Frequency Table (and Percentage of Column) of Responses of Transgender Participants to the Question: Do you think that the proposed diagnosis for children will have a greater stigmatising effect (i.e. more so than for adults)?

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https://doi.org/10.1371/journal.pone.0168522.t004

Of the HCPs, just over half (52.5%; n = 53) did not think that the proposed diagnosis for children would have a greater stigmatizing effect for children than for adults, 26.7% (n = 27) thought it would and 14.9% (n = 15) had no opinion.

The UK survey included the following question: ‘Do you think having a psychiatric diagnosis for gender incongruence could have a beneficial effect for children?’. The most commonly selected response, by a narrow margin, (39.2%; n = 125) was that a psychiatric diagnosis for gender incongruence would not have a beneficial effect for children. Yet, 32.9% (n = 105) of participants thought this could have a beneficial effect. The others had no opinion (15.4%; n = 49) or selected the option ‘Other (please specify)…’ (12.5%; n = 40).

The results from HCPs differed from those of the TG participants; most HCPs (45.8%; n = 11) thought that a psychiatric diagnosis for gender incongruence could have a beneficial effect for children and 25.0% (n = 6) thought it could not.

When asked: ‘Do you think that a child with gender-incongruent feelings needs gender identity care?’, 78.0% (n = 386) of TG participants agreed with this statement (see Table 5). The responses differed statistically between the NL and the UK participants, (χ2(2) = 13.99, p < .01, Cramer’s V = .17), see Table 5. In line with the findings for the transgender participants, most healthcare providers (58.9%, n = 53) thought that a child with gender-incongruent feelings needs gender identity care, or were not sure (34.4%, n = 31) while only 6.7% (n = 6) did not think so.

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Table 5. Frequency Table (and Percentage of Column) of Responses of Transgender Participants to the Question: Do you think that a child with gender-incongruent feelings needs gender identity care?

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https://doi.org/10.1371/journal.pone.0168522.t005

Stricter criteria of the GIC diagnosis

Responses were mixed regarding the following question: ‘Do you consider it an improvement that the proposed ICD 11 criteria for the children’s diagnosis will be stricter than in the ICD-10 (children will have to meet all criteria for a period of two years)?’. Slightly more TG participants (38.2%; n = 189) answered “no” compared to “yes” (33.5%; n = 166) (see Table 6 for all responses). There were statistically significant differences between UK and NL participants, (χ2(3) = 105.37, p < .001, Cramer’s V = .46). In the UK, the majority response (35.8%) was that this was an improvement, while in the NL the majority response (49.5%) was that this was not an improvement, see Table 6.

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Table 6. Frequency Table (and Percentage of Column) of Responses of Transgender Participants to the Question: Do you consider it an improvement that the proposed ICD 11 criteria for the children’s diagnosis will be stricter than in the ICD 10 (children will have to meet all criteria for a period of two years)?

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https://doi.org/10.1371/journal.pone.0168522.t006

Of the HCPs, 46.2% (n = 43) thought the stricter criteria for the diagnosis were an improvement; 18.3% (n = 17) thought it was not; 20.4% (n = 19) was unsure; and 15.1% (n = 14) had no opinion.

Removal distress and impairment criterion

Most TG participants (combining response options 3 and 4: 60.2%; n = 298) thought it was desirable if the distress criterion was removed from the children’s diagnosis (see Table 7 for all responses). Most NL (58.5%; n = 103) and most UK participants (50.2%; n = 160) selected the option: “Desirable, because for both age groups psychological distress should not be a criterion for getting a diagnosis.” The response options differed between the countries, so we cannot make any further comparisons. In line with the findings for the transgender participants, most healthcare providers (49.5%, n = 45) thought the removal was desirable.

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Table 7. Frequency Table (and Percentage of Column) of Responses of Transgender Participants to the Question: How do you feel about removing the distress criterion from the children’s diagnosis (when you think about the children’s diagnosis and the diagnosis for adults)?

https://doi.org/10.1371/journal.pone.0168522.t007

Results from the healthcare provider only questions

There were more HCPs who thought they would able to take care of children (reimbursed by health care insurance) if there was no children’s diagnosis (n = 22, 26.8%), (taking the two ‘yes’ categories together) than HCPs who thought they would not be able to take care of children (n = 11, 13.4%) (see Table 8). Leaving out the HCPs to whom the question was not applicable (who did not see children), 51.2% of the participants thought they could provide care for children (the two ‘yes’ categories together) and 25.6% thought they could not. The responses to this question did not differ statistically between the countries (only people to whom the question was applicable were included).

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Table 8. Frequency Table (and Percentage of Column) of Responses of Health Care Providers to the Question: If no children’s diagnosis existed, would you still be able to treat (and keep treating) children who have gender incongruence (reimbursed by health care insurance)?

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https://doi.org/10.1371/journal.pone.0168522.t008

Half of the HCPs (50.0%; n = 37) thought the criteria for children were easy to use in their clinic; 5.4% (n = 4) disagreed; and 44.6% (n = 33) had no opinion. There were no statistically significant differences between the countries. Furthermore, regarding the duration criterion of 2 years, 39.2% (n = 29) of the HCPs thought it was not difficult to determine whether this criterion was fulfilled; 27.0% (n = 20) thought it was difficult to determine; another 27.0% (n = 20) had no opinion; and the others (6.8%; n = 5) had another response. There were no statistically significant differences between the countries. The highest percentage of HCPs (28.8%; n = 21) thought they could properly make the distinction between slight gender variance and a situation in which the criteria for the GIC diagnosis have been met; 19.2% (n = 14) thought this would not be easy; 24.7% (n = 18) had no opinion; and 27.4% (n = 20) did not know. No differences were found between the countries. Of the Dutch HCPs, 35.8% (n = 19) thought it would be harder to give a diagnosis if children did not have to express GI feelings than if it were required to express their feelings; 18.9% (n = 10) thought it would be easier; 26.4% (n = 14) said it did not matter; and 18.9% (n = 10) had no opinion (NL only question).

Limitations

Next to the limitations mentioned above regarding the possible influence of the order of response options, wording of the questions and the low response rate. There are some additional points to consider also. First, the majority of the transgender participants were individuals who intended to receive, were receiving, or had received gender identity care (see S3 Text). This group may be less opposed to GI diagnoses in ICD-11 since they receive(d) reimbursed medical treatment made possible (in the NL at least) through a diagnostic code. In other words, people who want to receive, have received, or are receiving medical care are benefitting from the presence of a diagnosis because they are eligible for reimbursed health care. As a result, they might be more positive and less worried about the possible stigmatizing effect of including GI diagnoses in ICD-11 when compared to transgender people who do not use medical interventions or who have used them a long time ago. It is therefore important to realize that this study’s sample is not representative of all transgender people in the Netherlands and the UK (see also [17]).

A second limitation was that the survey was long and involved some complex concepts which may have made it difficult to understand for some participants. Indeed, the sample was biased towards participants with a high level of education. Also, the length of the survey may have discouraged participants from completing it (see also [17]). Ideally, we would have included the opinions of the children themselves, but the issues are too complex and abstract for them to understand, particularly in the context of a long questionnaire. Rather, face-to-face interviews would have been preferable with young people, but the time and costs associated with this were prohibitive.

A third limitation specific to this study regarding the Gender Incongruence of Childhood diagnosis is that we do not know if the adult transgender participants had received a gender incongruence diagnosis in childhood and have had first-hand experiences with the care provided and possible negative (e.g. stigmatization) or positive (e.g., access to care and information) outcomes of receiving a diagnosis. Such experiences would clearly be important in shaping opinions regarding the diagnosis.

Conclusion

In conclusion, this study suggests that although in an ideal world a diagnosis relating to gender incongruence in children is not welcomed, several participants felt the diagnosis should not be removed. This is likely due to concerns about restricting access to reimbursed healthcare. Furthermore, this study found that the majority choice for positioning of a diagnosis of Gender Incongruence within the ICD-11 is as a separate chapter dealing with conditions regarding sexual and gender health. This was the overall first choice for participants in The Netherlands and second choice for those in the UK, behind the use of a Z-code. The difference reflects the fact that in the UK, Z-codes carry no negative implications of non-reimbursement of treatment costs. This clearly demonstrates the added layer of complexity that comes with having to consider financial implications and not just psychological, social, and moral ones. These findings highlight the challenges faced by the WHO in their attempt to integrate research findings from different countries, with different cultures and healthcare systems and to create a manual that is globally applicable and usable.