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By: C. Kor-Shach, M.S., Ph.D.
Associate Professor, Michigan State University College of Osteopathic Medicine
One advantage of vaginal closure is to allow positioning of the testicles to a more masculine scrotal shape womens health nyc cheap 1mg anastrozole fast delivery. Scrotoplasty is the construction of a testicle implant laden scrotal sac women's health ketone diet anastrozole 1mg with visa, also known as testicle implants. Certain medical concerns may delay surgery, such as serious cardiac issues, significant obesity, or a smoking habit. The risk of surgical complications for smokers is much higher, and tissue healing following surgery is much slower. The age of the patient by itself is not a determining factor, although the patient must be the legal age of majority in the jurisdiction. Other requirements include that the patient demonstrate an understanding of the surgery, its potential complications and post-surgical complications and the required length of stay in the hospital. The vast majority of studies have shown that sex reassignment surgery is clinically effective. It is exceedingly rare for a patient to express regret following the treatment, and when they do it generally relates to issues of societal discrimination and relationship difficulties. Indeed, in my professional experience, patients who have had sex reassignment surgery have less regret than any other surgery of which I am aware. Sex reassignment surgery has a very low rate of complications, and the complications that may result from sex reassignment surgery are mainly minor in nature. My clinic contacts patients one year after their surgery to determine the impact on their life, and an overwhelming majority of patients report less self-loathing and significantly more confidence and well-being. Many patients report a dramatic improvement in mental health following surgery, and patients have been able to become productive members of society, no longer disabled with severe depression and gender dysphoria. Many thousands of gender corrective surgeries have been performed worldwide for decades, and the treatment is in no way "experimental. It is vital that patients with severe gender dysphoria have access to sexreassignment surgery in a timely manner. Gender dysphoria, if left untreated, can result in clinically significant psychological distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death. We have performed operations on approximately two dozen MediCal contracted patients to date, all with relatively positive outcomes. I base this conclusion on: (i) scientific research on gender dysphoria and its impact on the health and well-being of individuals with that diagnosis; and (ii) information regarding best practices and the generally accepted standards of care for individuals with gender dysphoria, including the efficacy of sex reassignment surgery as a treatment for gender dysphoria. I have actual knowledge of the matters stated herein, except where otherwise stated, and could and would so testify if called as a witness. I have been the chief psychologist at the Chicago Gender Center since 2005, which specializes in the treatment of individuals with gender dysphoria. During the course of my career, I have evaluated and/or treated between 2,500 and 3,000 individuals with gender dysphoria and mental health issues related to gender variance. I have published four books related to the treatment of individuals with gender dysphoria, including the medical text entitled Principles of Transgender Medicine and Surgery. In addition, I have authored numerous articles in peer-reviewed journals regarding the provision of health care to this population. I have served as a member of the University of Chicago Gender Board, and am a member of the editorial boards for the International Journal of Transgenderism and Transgender Health. I have lectured throughout North America, Europe and Asia on topics related to gender dysphoria. On numerous occasions, I have given grand rounds presentations on gender dysphoria at medical hospitals. I have been retained as an expert regarding gender dysphoria and the treatment of gender dysphoria in multiple court cases and administrative proceedings. My compensation does not depend on the outcome of this litigation, the opinions I express, or the testimony I provide. A true and correct copy of my Curriculum Vitae, which provides a complete overview of my education, training, and work experience, and a full list of my publications, is attached hereto as Exhibit A. I have considered information from various sources in forming my opinions expressed herein, in addition to drawing on my extensive experience and review of the literature related to gender dysphoria over the past three decades. A complete bibliography of the materials referenced in this report is attached hereto as Exhibit B. The materials I have relied upon in preparing this declaration are the same types of materials that experts in my field of study regularly rely upon when forming opinions on the subject. Scientific and clinical evidence of gender dysphoria and current medical standards of care for the treatment of gender dysphoria make clear that Section 17.
This organ ism produces a potent neurotoxin that may be toxic to both hu mans and animals women's health center newark beth israel hospital cheapest generic anastrozole uk. When ingested menstruation 6 days after ovulation generic 1mg anastrozole visa, the toxin is absorbed and irreversibly binds to peripheral motor nerves causing paralysis and possible death without antitoxin treatment. Vegetables can carry heat-resistant Type A, B, and F Clostridium botulinum spores that are a major concern in low-acid canned foods. Several out breaks offoodborne illness have been attributed to the viral con tamination of shellfish and of unprocessed fruits. Hepatitis A vi rus and other enteric viruses may be found in shellfish taken from waters polluted by sewage. Fruits grown in fields where hu man waste or sludge is used as fertilizer have the potential for contamination by enteric viruses. Foods most vulnerable to viral contamination would be those not receiving a heat pasteuriza tion step. Thermal, electrothermal and nonthermal food processing the establishment of traditional thermal processes for foods has been based on 2 main factors (Anonymous 1989): 1) knowl edge of the thermal inactivation kinetics of the most heat-resis tant pathogen of concern for each specific food product and 2) determination of the nature of heat transfer properties of the food system, generally defined by a heat transfer rate. These 2 factors are used to calculate the scheduled process, thereby en suring inactivation of pathogen(s) in that product. The validity of the established process is often confirmed using an inoculated test pack study. An inoculated pack study would be tested under actual plant conditions (this includes processing and control equipment, product and packaging) to reproduce the process in every detail. Since it is unwise to introduce viable pathogens into the production area, surrogate organisms are often utilized in the inoculated pack study, and their inactivation is measured to vali date the process. Surrogates play an important role as biological indicators that can mimic the thermal inactivation properties of a pathogen and can help to detect peculiarities or deviations in the processing procedure. One of the challenges in using new processing technologies for food preservation and pathogen inactivation is to determine if traditional methodologies can be used to establish and vali date the new process. For practical purposes, the mechanism of microbial inactivation under electrothermal processes is basical ly the same as under conventional thermal processes: that is, heat inactivation. Thus, the 2 factors described above, which are well established for thermal processes (Anonymous 1996), should be used as a basis for establishing and validating sched uled electrothermal processes. It is also appropriate to use surro gate organisms to assist in determining and validating the pro cess effectiveness. Regarding other preservation processes not based on heat inactivation (that is, high pressure, pulsed electric 3. Cyst-producing Protozoa That Can Remain field, pulsed light), nonpathogenic surrogates still need to be Infectious in Unpasteurized Foods identified and their significance evaluated. The protozoa, Cryptospo more research needs to be done in the area of inactivation kinet ridium parvum and Cyclospora cayetanensis, are not able to ics of pathogens by new technologies as well as in the identifica replicate in foods, but they do produce cysts that can remain tion of nonpathogenic candidates useful as surrogate organisms. Importance of Surrogates can contribute to infection, causing diarrhea in the general Surrogate organisms are invaluable in confirming the efficacy population. Their use, as opposed to using actu since the cysts have a high tolerance for disinfectants, such as al pathogens, derives from the need to prevent the introduction chlorine. Washing food with contaminated water can infect of harmful organisms into the production facility area. Therefore, the use of surrogates by pro (1999), the heat resistance of Cyclospora may be similar to that cessing companies is of great importance to ensure microbiologi of Cryptosporidium (Table 18). The use of non Pathogens of public health significance in foods are vegeta pathogenic spores of the putrefactive anaerobe C. These organisms may survive the process and should be evaluated for their possible value as surrogates. Criteria for Surrogates They include the lactic streptococci (Streptococcus thermophilus), the ideal surrogate would be the pathogen (or target organ the lactobacilli (Lactobacillus delbrueckii spp.
The first response of the hallux is the critical observation menstruation lasting longer than 7 days purchase generic anastrozole canada, which may be facilitated by having ones line of vision directly above the axis of the toe geriatric women's health issues buy anastrozole visa. This normal plantar response is a superficial cutaneous reflex, analogous to abdominal and cremasteric reflexes, whereas the pathological response is often accompanied by activity in other flexor muscles. Assessment of the response may be confounded by withdrawal of the foot in ticklish individuals. Differentiation from the striatal toe seen in parkinsonian syndromes is also important. The plantar response may be elicited in a variety of other ways which are not in routine clinical use. These may be helpful in ticklish patients who object to having their feet stroked. It is often difficult to form a definite judgment on the plantar response and reproducibility is also questionable. There remains a persistent belief, particularly amongst trainees, that an experienced neurologist can make the plantar response go which ever way s/he chooses. Cross Reference Dystonia Plexopathy Lesions confined to the brachial, lumbar, or sacral plexi may produce a constellation of motor and sensory signs (weakness, reflex diminution or loss, sensory loss) which cannot be ascribed to single or multiple roots (radiculopathy) or peripheral nerves (neuropathy). Polyopia may occur as part of the visual aura of migraine and has also been associated with occipital and occipito-parietal lesions, bilateral or confined to the non-dominant hemisphere, and with drug abuse. It has also been described in disease of the retina and optic nerve and occasionally in normal individuals. The pathophysiology is unknown; suggestions include a defect of visual fixation or of visual integration; the latter may reflect pure occipital cortical dysfunction. Cross Reference Winging of the scapula Poriomania A name sometimes given to prolonged wandering as an epileptic automatism, or a fugue state of non-convulsive status epilepticus. Cross References Automatism; Seizures Porropsia Porropsia, or teliopsia, is a form of metamorphopsia characterized by the misperception of objects as farther away from the observer than they really are (cf. Postural and righting reflexes depend not only on the integration of labyrinthine, proprioceptive, exteroceptive, and visual stimuli, mostly in the brainstem but also involve the cerebral cortex. However, abnormalities in these reflexes are of relatively little diagnostic value except in infants. Pushing the patient forward may likewise provoke propulsion or festination, but this manoeuvre is less safe since the examiner will not be placed to catch the patient should they begin to topple over. This myotactic stretch reflex is indicative of a bilateral upper motor neurone lesion, which may be due to cerebrovascular small vessel disease, motor neurone disease or multiple sclerosis. It differs from the snout reflex, which refers to the reflex elicited by constant pressure on the philtrum. Vestibular rehabilitation therapy and avoidance of vestibular suppressant medications may be helpful. Presbycusis Presbycusis is a progressive sensorineural hearing loss, especially for high frequencies, developing with increasing age, which may reduce speech discrimination. It is thought to be due to age-related attrition of hair cells in the organ of Corti and/or spiral ganglion neurones. Cross Reference Age-related signs Presbyopia Presbyopia is progressive far-sightedness which is increasingly common with increasing age, thought to be due to an age-related impairment of accommodation. The eyes can be brought to the other side with the oculocephalic manoeuvre or caloric testing. In contrast, thalamic and basal ganglia haemorrhages produce forced deviation of the eyes to the side contralateral to the lesion (wrong-way eyes). There are also nonneurological causes, such as haematological conditions (sickle cell anaemia, polycythaemia rubra vera) which may cause intrapenile thromboses. Developmental reflexes: the reappearance of foetal and neonatal reflexes in aged patients. Cross References Blinking; Dystonia; Hypomimia; Parkinsonism Pronator Drift Pronator drift is pronation of the forearm observed when the arms are held straightforward, palms up, with the eyes closed. It suggests a contralateral corticospinal tract lesion and may be accompanied by downward drift of the arm and flexion of the fingers and/or elbow. Proprioceptive information is carried within the dorsal columns of the spinal cord (more reliably so than vibration sensation, though not necessarily exclusively). Proptosis may be assessed clinically by standing directly behind the patient and gradually tipping the head back, observing when the globe of the eyeball first comes into view; this is most useful for asymmetric proptosis.
However women's health center vancouver wa buy anastrozole 1 mg otc, in a follow-up study of 70 adolescents who were diagnosed with gender dysphoria and given puberty-suppressing hormones womens health professionals albany ga purchase anastrozole with a mastercard, all continued with actual sex reassignment, beginning with feminizing/masculinizing hormone therapy (de Vries, Steensma, Doreleijers, & CohenKettenis, 2010). In clinically referred, gender dysphoric children under age 12, the male/female ratio ranges from 6:1 to 3:1 (Zucker, 2004). Additional research is needed to refine estimates of its prevalence and persistence in different populations worldwide. Phenomenology in Children Children as young as age two may show features that could indicate gender dysphoria. Page: 242 Filed: 01/03/2018 173 It is relatively common for gender dysphoric children to have coexisting internalizing disorders such as anxiety and depression (CohenKettenis, Owen, Kaijser, Bradley, & Zucker, 2003; Wallien, Swaab, & Cohen-Kettenis, 2007; Zucker, Owen, Bradley, & Ameeriar, 2002). The prevalence of autism spectrum disorders seems to be higher in clinically referred, gender dysphoric children than in the general population (de Vries, Noens, Cohen-Kettenis, van Berckelaer-Onnes, & Doreleijers, 2010). Data from one study suggest that more extreme gender nonconformity in childhood is associated with persistence of gender dysphoria into late adolescence and early adulthood (Wallien & Cohen-Kettenis, 2008). If such treatment is offered, the pubertal stage at which adolescents are allowed to start varies from Tanner stage 2 to stage 4 (Delemarre-van de Waal & Cohen-Kettenis, 2006; Zucker et al. Phenomenologically, there is a qualitative difference between the presentation of gender dysphoria and the presentation of delusions or other psychotic symptoms. The vast majority of children and adolescents with gender dysphoria are not suffering from underlying severe psychiatric illness such as psychotic disorders (Steensma, Biemond, de Boer, & Cohen-Kettenis, published online ahead of print January 7, 2011). Competency of Mental Health Professionals Working with Children or Adolescents with Gender Dysphoria the following are recommended minimum credentials for mental health professionals who assess, refer, and offer therapy to children and adolescents presenting with gender dysphoria: 1. Assess and treat any coexisting mental health concerns of children or adolescents (or refer to another mental health professional for treatment). Provide children, youth, and their families with information and referral for peer support, such as support groups for parents of gender-nonconforming and transgender children (Gold & MacNish, 2011; Pleak, 1999; Rosenberg, 2002). If such a multidisciplinary service is not available, a mental health professional should provide consultation and liaison arrangements with a pediatric endocrinologist for the purpose of assessment, education, and involvement in any decisions about physical interventions. Psychological Assessment of Children and Adolescents When assessing children and adolescents who present with gender dysphoria, mental health professionals should broadly conform to the following guidelines: 1. Assessment should include an evaluation of the strengths and weaknesses of family functioning. Emotional and behavioral problems are relatively Appx240 Case: 17-1460 Document: 126 Coleman et al. Psychological and Social Interventions for Children and Adolescents When supporting and treating children and adolescents with gender dysphoria, health professionals should broadly conform to the following guidelines: 1. Families play an important role in the psychological health and well-being of youth (Brill & Pepper, 2008; Lev, 2004). Formal evaluations of different psychotherapeutic approaches for this situation have not been published, but several counseling methods have been described (Cohen-Kettenis, 2006; de Vries, Cohen-Kettenis, & Delemarre-van 4. They should give ample room for clients to explore different options for gender expression. Hormonal or surgical interventions are appropriate for some adolescents but not for others. Health professionals should support clients and their families as educators and advocates in their interactions with community members and authorities such as teachers, school boards, and courts.
It then continues its growth and rotation as it reenters the abdominal cavity beginning in the 10th week breast cancer 45 year old woman cheap 1 mg anastrozole fast delivery. Primary palate Formed by the medial nasal prominences as part of the intermaxillary segment pregnancy online test order discount anastrozole. Primaxial domain Region of mesoderm around the neural tube that contains only somite-derived (paraxial mesoderm) cells. Primitive node Elevated region around the cranial end of the primitive streak that is known as the "organizer" because it regulates important processes such as laterality and formation of the notochord. Primitive body cavity Created by ventral body wall closure, this space extends from the cervical region to the pelvis. It will be divided by the diaphragm into thoracic and peritoneal cavities and by the pleuropericardial folds into the pleural and pericardial cavities. Primitive streak Groove formed in the epiblast at the caudal end of the bilaminar germ disc stage embryo through which epiblast cells migrate to form endoderm and mesoderm during gastrulation. Processus vaginalis Outpocketing of peritoneum that precedes the testis through the inguinal canal. Once it reaches the scrotum, it pinches off from the abdominal cavity and forms the tunica vaginalis of the testis. If it fails to pinch off, then it can serve as a path for herniation of bowel through the canal into the scrotum, forming an inguinal (indirect) hernia. Proctodeum Ectodermally lined pit that invaginates to form the lower third of the anal canal. Initially, this region is separated from the remainder of the anal canal by the anal membrane (once the posterior portion of the cloacal membrane), which breaks down to permit continuity between the two parts of the canal. Pronephros Primitive kidney that forms a few nonfunctional vestigial tubules in the cervical region. Prosencephalon One of three primary brain vesicles that form the telencephalon and diencephalon. Pseudohermaphrodite Individual in whom the genotypic sex is masked by a phenotype that resembles the opposite sex. This site is the most common place for an ectopic pregnancy within the peritoneal cavity (the most common site of all is in the ampullary region of the uterine tube). Rhombencephalon One of three primary brain vesicles that form the metencephalon and myelencephalon. Rhombomere One of eight segments that form in the rhombencephalon that contributes to development of cranial nerve nuclei and give rise to neural crest cells that migrate to the pharyngeal arches. Round ligament of the liver Formed by the obliterated umbilical vein that runs in the free margin of the falciform ligament. S Scaphocephaly Type of craniosynostosis in which the sagittal suture closes prematurely resulting in a long, narrow head shape. Secondary palate Derived from the maxillary processes of the first arch and includes the soft and hard palates. Septum primum First septum to grow down from the roof of the common atrium and contributes to the interatrial septum. Prior to contact with the atrioventricular endocardial cushions, programmed cell death creates a new opening in this septum to maintain communication between the atrial chambers. Septum secundum Second septum to grow down from the roof of the common atrium toward the atrioventricular endocardial cushions. It never makes contact with the cushions, such that an oblique opening, the foramen ovale, is created between the septum secundum and septum primum that allows shunting of blood from the right atrium to the left during fetal development. At birth, this opening is closed when the septum primum is pressed against the septum secundum and the adult pattern of blood flow is established. Septum transversum Mesoderm tissue originally lying cranial to the heart but repositioned between the heart and connecting stalk by cranial folding of the embryo. It gives rise to the central tendon of the diaphragm, connective tissue for the liver, and ventral mesentery. Situs inversus Complete reversal of left- and rightsidedness of the organs in the thorax and abdomen. Somatic (parietal) mesoderm That layer of lateral plate mesoderm associated with ectoderm. Somatopleure Combination of the parietal (somatic) layer of the lateral plate mesoderm and the adjacent layer of ectoderm. Somites Epithelial balls of cells formed in segmental pairs along the neural tube from paraxial mesoderm.
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