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In se Lack of muscle strength in the masseter muscle erectile dysfunction young male causes kamagra polo 100mg online, especially fol vere cases erectile dysfunction hypertension buy generic kamagra polo online, it can result in a triple longitudinal furrowing of lowing a sustained chewing effort thyroid erectile dysfunction treatment generic kamagra polo 100mg amex, may cause the mouth to facts on erectile dysfunction discount kamagra polo 100mg with amex the to erectile dysfunction after radiation treatment prostate cancer buy kamagra polo overnight delivery ngue (Gallagher, 1981). Tongue atrophy with associated hang open, unless the mandible is held shut by hand (Mason, fasciculation has been reported in an elderly man (Burch, 1964; Spicer, 1965). A case of initial presentation to the emergency depart to have significantly lower values for maximal bite force and ment with a swollen to ngue resulting in subjective airway dis maximal electromyography activity of the jaw-closing and tress in a 56-year-old patient, despite a 5-month his to ry of re jaw-opening muscles than control subjects (Weijen, 1998). The myasthenic facies is character Dental Care Issues 152 Eating can be further inhibited by dysphagia, when the to ngue (Weijen, 1998). A significant correla than in healthy controls when the to ngue was pushed in both tion was found suggesting that those with lower maximal upward and sideward directions against a lever to ngue force tend to swallow more slowly (Weijen, 1998). Affected individuals may have continu munoglobulin and mechanical ventila to ry support for crisis in ous breathiness with progression and an increase in severity five patients. Impaired phonation and articula fied for these 16 patients, including one case each of extrac tion, combined with involvement of the muscles of facial ex tions under intravenous anesthesia or general anesthesia in pression, make verbal and nonverbal communication difficult the operating room. In a review of studies evaluating a particular patients were associated with neuromuscular sequelae. Appointments are best scheduled approximately one to rate of neuromuscular sequelae (0/10; 0. If an exacerbation is precipitated, the patient tremity weakness, necessitating treatment with intravenous should be evaluated for severity of neuromuscular involve edrophonium or plasma exchange. One treatment visit in a pa ment by the patient’s neurologist and given an intravenous in tient with moderate generalized weakness (Class 4) resulted jection of a rapid onset cholinesterase inhibi to r. Removal by suction It is important to realize that oral infections and the psycho ing of secretions and debris from the oral and hypopharyngeal logical stress of anticipating or undergoing dental treatment regions is important to prevent aspiration and mechanical may lead to onset of a myasthenic crisis. Manual retraction of the weakened ing appointments will minimize fatigue and take advantage of to ngue may prevent obstruction of the airway. Use of a vasoconstric to r, such as 1:100,000 epinephrine Gentamicin* Metronidazole* in combination with lidocaine is beneficial in maximizing anes Penicillin & Neomycin* Polymyxin Tetracycline* derivatives thesia efficacy at the oral site, while minimizing to tal anes B* Bacitracin* Vancomycin* thetic dose. Intravenous sedation techniques and nar cotic analgesics should be used with caution to avoid respira to ry depression (Howard, 1981). The patho genesis of drug-induced gingival overgrowth is uncertain (Sey mour, 1996). The gingival response, which may begin as early as the first month of drug use, seems to be dependent upon the presence of dental plaque or other local irritants causing gingival inflammation, individual genetic susceptibility in fi broblasts and pharmacological variables including the dose of cyclosporine used (Butler, 1987; Seymour, 1996). Several medications with common use in dental practice are contrain nique, close observation following surgical treatment and con dicated in the patient on cyclosporine. Drugs that exhibit sideration for antibiotic coverage with amoxicillin or penicillin nephro to xic synergy with cyclosporine include: gentamicin, are warranted. Additionally, steroid-dependent patients may vancomycin, ke to conazole and the nonsteroidal anti have adrenal suppression and may benefit from consideration inflamma to ry drugs. Drugs that increase cyclosporine levels, of prophylactic glucocorticoid supplementation prior to com possibly resulting in to xicity, include: erythromycin, ke to cona plicated or stressful dental procedures, such as multiple extrac zole, fluconazole and itraconazole. Adrenal crisis is a rare event in dentistry, especially for the ability to manage complete dentures may be compro patients with secondary adrenal insufficiency and most rou mised by the inability of the flaccid muscles to assist in retain tine dental procedures can be performed without glucocorti ing the mandibular denture and to maintain a peripheral seal coid supplementation (Miller, 2001). Efficient high speed evacuation, applica of difficulty in closing the mouth, to ngue fatigue, a tight upper tion of a rubber dam for res to rative procedures and constant lip, dry mouth, impaired phonation, dysphagia and mastica saliva ejec to r use may diminish the risk of aspiration of excess to ry problems (Bot to mley, 1977). Oral hygiene efforts may myasthenic crises and may be needed for the phobic or anx be compromised by muscle weakness in the extremities and a ious patient. Electric to othbrushes or man ing relationship with the patient should be established (Ya ual brushes with modified handles may decrease the muscle rom, 2005). Nitrous oxide/ oxygen sedation may provide anxi effort required to accomplish effective oral hygiene. Use of a ety management and reduce the stress associated with dental mouth prop during operative dental procedures may ease mas treatment. When intravenous sedation is required, it should tica to ry muscle strain and fatigue. His to pathology of different types of atrophy of the Standard general anesthetic technique usually requires the human to ngue. Management of patients with curonium and succinylcholine, to facilitate control of the air myasthenia gravis who require maxillary dentures. J Prosthet way and allow procedures to be performed on a motionless pa Dent, 1977;38:609-614. Age Ageing, cal ventilation is accomplished with the use of specialized 2006;35:87-88. Drug-induced gingival depth of sedation and rapid emergence when extubation is ap hyperplasia: pheny to in, cyclosporin and nifedipine. A prospective assessment of the characteristics of ease, bulbar symp to ms, or poor pulmonary function (Kern dysphagia in myasthenia gravis. Preoperative preparation of the patient with gravis associated with reduced mastica to ry function. The clinical features of these neuro to xins are quite varied as many have associated to xic Pharmacist ity of other parts of the central, peripheral or au to nomic nervous systems. Unlike the neuromuscular transmission in susceptible indi blood-brain barrier that protects the brain and viduals. Many occur as natural vis Foundation of America and recent reviews of substances of plants or animals, other result the to pic (Howard, 2007). Therefore this section from the actions of widely prescribed pharmaceu will focus on those pharmaceutical agents that tical compounds, and still others are environ are most commonly implicated in the acute wors mental hazards. Treatment like effects or potentiation of depolarizing or non-depolarizing includes discontinuation of the offending drug and when nec neuromuscular blocking agents; or, in varying degrees, both. An While it is most desirable to avoid drugs that may adversely up- to -date list of these potential drug-disorder interactions is affect neuromuscular transmission, in certain instances they maintained on the web site of the Myasthenia Gravis Founda must be used for the management of other illness. Unfortunately, much of the literature is anec situations a thorough knowledge of the deleterious side effects dotal and there are only a few comprehensive in vitro studies can minimize their potential danger. If at all possible it is wise of drug effects on neuromuscular transmission in animal or to use the drug within a class of drugs that has been shown to human nerve-muscle preparations. Unfortu fects of these medications must be taken in to consideration nately, studies, which allow such comparisons, are quite few. Lincomycin and clindamycin can cause neuromuscular blocking which is not readily reversible with 11. Polymyxin B, colistimethate, and colistin are also re the aminoglycoside antibiotics may produce neuromuscular ported to produce neuromuscular weakness particularly in pa weakness irrespective of their route of administration (Pit tients with renal disease or when used in combination with tinger C, 1972). These drugs have pre and post-synaptic ac other antibiotics or neuromuscular blocking agents (Pittinger tions; many have elements of both. Clinically, gentamicin, kanamycin, neomycin, to bramycin, and strep to mycin have 11. Myasthenic patients given the macrolides, erythro reactions in patients with neuromuscular disorders. Different fi cillins, sulfonamides, tetracyclines, and fluroquinolones may blockers have reproducibly different pre and postsynaptic ef cause transient worsening of myasthenic weakness, potentiate fects on neuromuscular transmission. Of the group, propra the weakness of neuromuscular blocking agents, or have theo Guidelines for the Pharmacist 164 nolol is most effective in blocking neuromuscular transmis sion and atenolol the least. The effects of calcium channel blockers on skeletal muscle are not unders to od, and studies have provided conflicting infor mation. The rapid onset of neuro muscular block and the rapid resolution of symp to ms follow ing discontinuation of the drug suggest the drug has a direct to xic effect on synaptic transmission, rather than the induc tion of an au to immune response against the neuromuscular junction. Myas weakness a myasthenic patient, although this cannot be sub thenic crisis may even develop with inter feron alpha therapy stantiated with objective reports. It is likely that this erro In each instance, the pharmacist must have a thorough knowl neous statement was due to the unrecognized steroid-induced edge of the patient’s problem list and freely utilize pharmacol exacerbation of muscle weakness that may occur with steroid ogical databases to minimize either a significant drug interac initiation. Dialog with the Cyclosporine, an immune modulating drug that selectively in treating physician will be most helpful. Some of the effects are to increase the level of the active metabolite and with others to reduce it. An increase in se in rheuma to id arthritis, with and without penicillamine treat rum concentration can also be seen with foodstuffs. Drug-induced neuromuscular blockade and my non-steroidal anti-inflamma to ry agents. Interaction of neuromuscular magnesium, iodinated contrast dyes and of course, the neuro blocking agents with calcium channel blockers. Anesthesiol muscular blocking agents used by anesthesiology during sur ogy, 1982;57:A268-A268. The neuromuscular blocking effects of therapeutic concentrations of various antibiotics on Guidelines for the Pharmacist 167 normal rat skeletal muscle: a quantitative comparison. American thenic crisis after alpha-interferon therapy for chronic hepati Journal of Ophthalmology, 1984;98:244-245. Myasthenia gravis after syndrome induced by expression of interferon in the neuro interferon alpha treatment. Adverse drug effects on neuromuscular transmis Penicillamine-associated myasthenia gravis, antiacetylcholine sion. The neuromuscular effects ergic antagonists on neuromuscular transmission in rat skele of quinidine. Guidelines for the Pharmacist 168 Perez A, Perella M, Pas to r E, Cano M, Escudero J. Fluoroquinolone antibiotics block neuromuscular gravis induced by alpha-interferon therapy. Quinidine exacerbating myasthenia gravis: a case report and intracellular recordings. Patients taking cholinesterase inhibi to rs are excluded from this category because their use suggests the presence of weakness. Label “A” and “B” and note which is placebo and active drugLabel “A” and “B” and note which is placebo and active drugLabel “A” and “B” and note which is placebo and active drugLabel “A” and “B” and note which is placebo and active drug o If weakness occurs, discontinue the test as it is positive with cholinergic excess. Appendices 177 • Record your results as shown below: • the timing of the test (drug peak or trough) depends upon the information you are trying to obtain. Clinical interpretation of this must be based upon the muscle groups you are most interested in; at all times, bulbar and respira to ry groups have priority. Up to date information regarding the potential for drug-induced exacerbation of myasthenic patients may be 4. The decision to use a potentially dangerous drug must be made on the Demerol, morphine) basis of the clinical decision, urgency of need and lack of alternative 8. Assess and document respira to ry status, rate, rhythm and breath sounds at time of admission, then every 4 1. Determine at time of admission when cholinesterase inhibi to r medications were last taken. Place cholinesterase inhibi to r drug schedule at head of bed with dose and time to be administered 6. Self-care deficit related Within 24 hours of to europhysiologic admission, demonstrate 2. Assess muscle strength q8h according to myasthenia function energy conservation record. Provide alternative nurse call system for increased weakness Appendices 182 Appendix 3.

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The lower extremities erectile dysfunction yoga exercises purchase kamagra polo online now, piri sacrum (medial trigger point) with rectal/vaginal moni formis impotence 60784 order 100 mg kamagra polo amex, and other short lateral rota to erectile dysfunction viagra does not work purchase genuine kamagra polo line rs erectile dysfunction 21 purchase kamagra polo now. If previous measures fail erectile dysfunction treatment needles generic 100mg kamagra polo fast delivery, surgical transection of & Wilkins, Baltimore, 1992, pp. Social and Physical Disabilities Difficulty sitting for prolonged periods and difficulty with physical activities such as prolonged walking, standing, bending, lifting, or twisting compromise both sedentary and physically demanding occupations. Main Features Metastases to the hip joint region produce continuous System aching or throbbing pain in the groin with radiation Nervous system. In some cases peripheral causes have through to the but to ck and down the medial thigh to the been described; the spinal cord is probably also in knee. A me tastatic deposit to the femoral shaft produces local pain, Main Features which is also aggravated by weight-bearing. Sometimes re Pain at rest due to tumor infiltration of bone usually re lieved by activity, though it may be worse following sponds reasonably well to nonsteroidal anti exercise. Pain due to ments may be florid or almost imperceptible, and in the hip movement or weight-bearing responds poorly to latter case, the patient may never have noticed them. They consist of irregular, involuntary, and sometimes writhing movement of the to es, and they cannot be imi Signs and Labora to ry Findings tated voluntarily. They can be suppressed for a minute or There may be tenderness in the groin and in the region two by voluntary effort and then return when the patient of the greater trochanter. There is not usually a relation between the formity unless a pathological fracture has occurred. Complications the major complication is a pathological fracture of the Relief femoral neck or the femoral shaft. Pathology Precise pathology unknown, but nerve root lesions have Summary of Essential Features and Diagnostic been described, and spinal cord damage. There is usually tenderness in the groin and increased pain on internal and external rota References tion. Differential Diagnosis the differential diagnosis includes upper lumbar plexo Nathan, P. Psychiatry, 41 (1978) pathy, avascular necrosis of the femoral head, and septic 934-939. Definition Usual Course Pain in the limbs, usually constant and aching in the feet, Unremitting. Pathology Site Degenerative changes appear in the dorsal root ganglion the distal portion of the limbs, more often in the feet cells or mo to r neurons of the spinal cord with resulting than in the hands, and across the joint spaces. Cold, damp, and changes in the weather appear to cause an increase in the symp to m. Rest, simple analgesics the pain arises in association with peroneal muscular such as paracetamol (acetaminophen) and nonsteroidal atrophy. Age anti-inflamma to ry drugs, and transcutaneous electrical of Onset: the illness normally appears in childhood and stimulation help to ease the pain. Relief is also associ adolescence, with a reported age range for prevalence ated with warmth, massage, lying down, sleep, and dis from 10-84 years. The sex linked form is less common than the other Conduction velocities in mo to r nerves may be de types. Pain Quality: pain is relatively rare in the disease, creased, or denervation may be evident. It may be continuous or intermittent but is aggra Essential Features vated by activity, stress, cold, and damp. This aching Pain in the relevant distribution in patients affected by pain appears most often as a complication of surgical the typical muscle disorder. Anxiety and Pain affecting joints only fatigue appear in association with the pain. There is Pain affecting the belly of the muscle distal muscle wasting with the “classical” inverted 205. Definition System Severe, sharp, or aching pain syndrome arising from Musculoskeletal system. The patient characteris tically finds it impossible to sleep on the affected side. Cases are often secondary to systemic Aggravated by climbing stairs, extension of the back inflamma to ry disease, such as ankylosing spondylitis, from flexion with knees straight. Relief Usual Course Injection in to the ischial bursa with local anesthetic and Usually of sudden onset. The pain tends to be severe and steroid; “doughnut” cushion as used for treatment of persistent. Local infiltration of local anesthetic and steroid in to the area of the greatest tenderness produces excellent pain Pathology relief. Essential Features Recurring pain in ischial region aggravated by sitting or Pathology lying, relieved by injection. Inflamma to ry process of bursa caused by repeated trauma or generalized inflammation such as rheuma to id Differential Diagnosis arthritis. X3 Local pain aggravated by climbing stairs, extension of the back from flexion with knees straight. Aching or burning pain in the high lateral part of the thigh and in the but to ck caused by inflammation of the Code 634. Definition Pain due to primary or secondary degenerative process involving the hip joint. Treatment with qui Pain due to a degenerative process of one or more of the nine, calcium supplements, diphenhydramine, diphenyl three compartments of the knee joint. X8 ology, aggravating and relieving features, signs, usual course, physical disability, pathology, and differential diagnosis as for osteoarthritis (I-11). Main Features Pain with insidious onset in the plantar region of the System foot, especially worse when initiating walking. Main Features Signs Severe aching cramps in the calves of the legs, often Tenderness along the plantar fascia when ankle is dorsi preventing the patient from sleep or waking him or her flexed. Page 206 Radiographic Findings Pathology Often associated with calcaneal spur when chronic. Fifteen percent have some form of systemic rheumatic disease, usually a seronegative form of spondylarthritis. Relief Arch supports, local injection of corticosteroid, oral non Differential Diagnosis steroidal anti-inflamma to ry agents. Many of the terms were already es process by which the terms were first delivered and the tablished in the literature. The “The usage of individual terms in medicine often terms have been translated in to Portuguese (Rev. Dehen, vided that each author makes clear precisely how he Lexique de la douleur, La Presse Medicale 12, 23, employs a word. Nevertheless, it is convenient and help [1983] 1459-1460), and in to Turkish (as Agri Terimleri, ful to others if words can be used which have agreed translated by T. A supplementary note was added to these meetings during the period 1976-1978, the present pain terms in Pain (14 [1982] 205-206). The definitions are in additions were prepared by a subgroup of the Commit tended to be specific and explana to ry and to serve as an tee, particularly Drs. Devor, the other tions was provided by the reports of a workshop on Oro colleagues just mentioned, and Dr. We hope that they will the versions now presented are based upon some prove acceptable to all those in the health professions subsequent discussions by correspondence. Not only are they a limited selection the definitions and notes at this point has been the re from available terms, but it is emphasized that except for sponsibility of the edi to r (H. It would be difficult pain itself, they are defined primarily in relation to the now to single out individual contributions, but the edi to r skin and the special senses are excluded. They may be remains heavily indebted to those five members of the used when appropriate for responses to somatic stimula original Subcommittee on Taxonomy who sustained this tion elsewhere or to the viscera. Except for Pain, the work in the form of an Ad Hoc group and whose names arrangement is in alphabetical order. Their knowl It is important to emphasize something that was im edge and patience was repeatedly provided freely and plicit in the previous definitions but was not specifically with good will. The original com clinical practice rather than for experimental work, ments provided as an introduction to the terms are given physiology, or ana to mical purposes. These were for except for very slight alterations in the wording of the merly labeled Reflex Sympathetic Dystrophy and definitions of Central Pain and Hyperpathia. Two new Causalgia, and the discussion of Sympathetically Main terms have been introduced here: Neuropathic Pain and tained Pain and Sympathetically Independent Pain is Peripheral Neuropathic Pain. The terms Sympathetically Maintained Pain and Changes have been made in the notes on Allodynia Sympathetically Independent Pain have also been em to clarify the fact that it may refer to a light stimulus on Page 210 damaged skin, as well as on normal skin. A sentence tabulation of the implications of some of the definitions, has been added to the note on Hyperalgesia to refer to cur the words lowered threshold have been removed from rent views on its physiology, although as with other defini the features of Allodynia because it does not occur regu tions, that for Hyperalgesia remains tied to clinical criteria. Small changes have been made to better Last, the note on neuropathy has been expanded. Note: the inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accord ingly, pain is that experience we associate with actual or potential tissue damage. It is unques tionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain. Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experi ence from that due to tissue damage if we take the subjective report. If they regard their experience as pain and if they report it in the same ways as pain caused by tissue damage, it should be ac cepted as pain. Activity induced in the nocicep to r and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause. Note: the term allodynia was originally introduced to separate from hyperalgesia and hyperesthe sia, the conditions seen in patients with lesions of the nervous system where to uch, light pressure, or moderate cold or warmth evoke pain when applied to apparently normal skin. Allo means “other” in Greek and is a common prefix for medical conditions that diverge from the expected. Odynia is derived from the Greek word “odune” or “odyne,” which is used in “pleurodynia” and “coccydynia” and is similar in meaning to the root from which we derive words with -algia or algesia in them.

Specific lab-moni to erectile dysfunction at age 31 order kamagra polo 100 mg without a prescription ring pro to male erectile dysfunction statistics order kamagra polo on line amex cols have been published (Feldman & Safer erectile dysfunction pump cost purchase kamagra polo cheap online, "##%; Hembree et al erectile dysfunction vacuum pumps pros cons order kamagra polo 100 mg overnight delivery. Eficacy and Risk Moni to erectile dysfunction doctors huntsville al buy kamagra polo 100 mg with mastercard ring During Masculinizing Hormone Therapy (FtM) the best assessment of hormone efficacy is clinical response: Is a patient developing a masculinized body while minimizing feminine characteristics, consistent with that patient’s gender goalsfi Moni to ring for adverse events should include both clinical and labora to ry evaluation. Labora to ry moni to ring should be based on the risks of hormone therapy described above, a patient’s individual comorbidities and risk fac to rs, and the specific hormone regimen itself. Specific lab moni to ring pro to cols have been published (Feldman & Safer, "##%; Hembree et al. Hormone Regimens To date, no controlled clinical trials of any feminizing/masculinizing hormone regimen have been conducted to evaluate safety or efficacy in producing physical transition. As a result, wide variation in doses and types of hormones have been published in the medical literature (Moore et al. As outlined above, there are demonstrated safety differences in individual elements of various regimens. Because of this safety concern, ethinyl estradiol is not recommended for feminizing hormone therapy. This possibility needs to be discussed with patients well in advance of starting hormone therapy. Androgen-reducing medications, from a variety of classes of drugs, have the effect of reducing either endogenous tes to sterone levels or tes to sterone activity, and thus diminishing masculine characteristics such as body hair. They minimize the dosage of estrogen needed to suppress tes to sterone, thereby reducing the risks associated with high-dose exogenous estrogen (Prior, Vigna, Watson, Diewold, & Robinow, $%&); Prior, Vigna, & Watson, $%&%). This medication is not approved in the United States because of concerns over potential hepa to to xicity, but it is widely used elsewhere (De Cuypere et al. These medications have beneficial effects on scalp hair loss, body hair growth, sebaceous glands, and skin consistency. However, a clinical comparison of feminization regimens with and without progestins found that the addition of progestins neither enhanced breast growth nor lowered serum levels of free tes to sterone (Meyer et al. There are concerns regarding potential adverse effects of progestins, including depression, weight gain, and lipid changes (Meyer et al. Oral tes to sterone undecanoate, available outside the United States, results in lower serum tes to sterone levels than nonoral preparations and has limited efficacy in suppressing menses (Feldman, "##*, April; Moore et al. Because intramuscular tes to sterone cypionate or enanthate are often administered every "–(weeks, some patients may notice cyclic variation in effects. There is evidence that transdermal and intramuscular tes to sterone achieve similar masculinizing results, although the timeframe may be somewhat slower with transdermal preparations (Feldman, "##*, April). Bioidentical and Compounded Hormones As discussion surrounding the use of bioidentical hormones in postmenopausal hormone replacement has heightened, interest has also increased in the use of similar compounds in feminizing/masculinizing hormone therapy. There is no evidence that cus to m compounded bioidentical hormones are safer or more effective than government agency-approved bioidentical hormones (Sood, Shuster, Smith, Vincent, & Ja to i, "#$$). Therefore, it has been advised by the North American Menopause Society ("#$#) and others to assume that, whether the hormone is from a compounding pharmacy or not, if the active ingredients are similar, it should have a similar side-effect profile. Cases are known of people who received hormone therapy and genital surgery and later regretted their inability to parent genetically related children (De Sutter, Kira, Verschoor, & Hotimsky, "##"). Lessons learned from that group can be applied to people treated for gender dysphoria. MtF patients, especially those who have not already reproduced, should be informed about sperm preservation options and encouraged to consider banking their sperm prior to hormone therapy. In adults with azoospermia, a testicular biopsy with subsequent cryopreservation of biopsied material for sperm is possible, but may not be successful. The frozen gametes and embryo could later be used with a surrogate woman to carry to pregnancy. Studies of women with polycystic ovarian disease suggest that the ovary can recover in part from the effects of high tes to sterone levels (Hunter & Sterrett, "###). Transsexual, transgender, and gender-nonconforming people should not be refused reproductive options for any reason. Competency of Voice and Communication Specialists Working with Transsexual, Transgender, and Gender-Nonconforming Clients Specialists may include speech-language pathologists, speech therapists, and speech-voice clinicians. In most countries the professional association for speech-language pathologists requires specific qualifications and credentials for membership. In some countries the government regulates practice through licensing, certification, or registration processes (American Speech Language-Hearing Association, "#$$; Canadian Association of Speech-Language Pathologists and Audiologists; Royal College of Speech Therapists, United Kingdom; Speech Pathology Australia). Other professionals such as vocal coaches, theatre professionals, singing teachers, and movement experts may play a valuable adjunct role. Such professionals will ideally have experience working with, or be actively collaborating with, speech-language pathologists. Assessment and Treatment Considerations the overall purpose of voice and communication therapy is to help clients adapt their voice and communication in a way that is both safe and authentic, resulting in communication patterns that clients feel are congruent with their gender identity and that refiect their sense of self (Adler, Hirsch, & Mordaunt, "##)). Specialists can best serve their clients by taking the time to understand a person’s gender concerns and goals for gender-role expression (American Speech Language-Hearing Association, "#$$; Canadian Association of Speech-Language Pathologists and Audiologists; Royal College of Speech Therapists, United Kingdom; Speech Pathology Australia). All voice and communication therapy services should therefore include a vocal health component (Adler et al. It is recommended that individuals undergoing voice feminization surgery also consult a voice and communication specialist to maximize the surgical outcome, help protect vocal health, and learn nonpitch related aspects of communication. Voice surgery procedures should include follow-up sessions with a voice and communication specialist who is licensed and/or credentialed by the board responsible for speech therapists/speech-language pathologists in that country (Kanagalingam et al. While many transsexual, transgender, and gender-nonconforming individuals find comfort with their gender identity, role, and expression without surgery, for many others surgery is essential and medically necessary to alleviate their gender dysphoria (Hage & Karim, "###). Moreover, surgery can help patients feel more at ease in the presence of sex partners or in venues such as physicians’ offices, swimming pools, or health clubs. Genital and breast/chest surgical treatments for gender dysphoria are not merely another set of elective procedures. By following this procedure, mental health professionals, surgeons, and patients share responsibility for the decision to make irreversible changes to the body. Rather, conscientious surgeons will have insight in to each patient’s his to ry and the rationale that led to the referral for surgery. In the absence of this, a surgeon must be confident that the referring mental health professional(s), and if applicable the physician who prescribes hormones, is/are competent in the assessment and treatment of gender dysphoria, because the surgeon is relying heavily on his/her/their expertise. Once a surgeon is satisfied that the criteria for specific surgeries have been met (as outlined below), surgical treatment should be considered and a preoperative surgical consultation should take place. Ensuring that patients have a realistic expectation of outcomes is important in achieving a result that will alleviate their gender dysphoria. All of this information should be provided to patients in writing, in a language in which they are fiuent, and in graphic illustrations. The elements of informed consent should always be discussed face- to -face prior to the surgical intervention. Questions can then be answered and written informed consent can be provided by the patient. Nongenital, nonbreast surgical interventions: facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation (implants/lipofilling), hair reconstruction, and various aesthetic procedures. For the Female- to -Male (FtM) Patient, Surgical Procedures May Include the Following: $. Nongenital, nonbreast surgical interventions: voice surgery (rare), liposuction, lipofilling, pec to ral implants, and various aesthetic procedures. Reconstructive Versus Aesthetic Surgery the question of whether sex reassignment surgery should be considered “aesthetic” surgery or “reconstructive” surgery is pertinent not only from a philosophical point of view, but also from a financial point of view. Aesthetic or cosmetic surgery is mostly regarded as not medically necessary and therefore is typically paid for entirely by the patient. Criteria for Genital Surgery (Two Referrals) the criteria for genital surgery are specific to the type of surgery being requested. If significant medical or mental health concerns are present, they must be well controlled. These criteria do not apply to patients who are having these procedures for medical indications other than gender dysphoria. Criteria for me to idioplasty or phalloplasty in FtM patients and for vaginoplasty in MtF patients: $. The duration of $" months allows for a range of different life experiences and events that may occur throughout the year. Surgery for People with Psychotic Conditions and Other Serious Mental Illnesses When patients with gender dysphoria are also diagnosed with severe psychiatric disorders and impaired reality testing. Reevaluation by a mental health professional qualified to assess and manage psychotic conditions should be conducted prior to surgery, describing the patient’s mental status and readiness for surgery. No surgery should be performed while a patient is actively psychotic (De Cuypere & Vercruysse, "##%). Competency of Surgeons Performing Breast/Chest or Genital Surgery Physicianswhoperformsurgicaltreatmentsforgenderdsyphoriashouldbeurologists,gynecologists, plastic surgeons, or general surgeons, and board-certified as such by the relevant national World Professional Association for Transgender Health &! An official audit of surgical outcomes and publication of these results would be greatly reassuring to both referring health professionals and patients. Surgeons should regularly attend professional meetings where new techniques are presented. For the MtF patient, a breast augmentation (sometimes called “chest reconstruction”) is not different from the procedure in a natal female patient. For the FtM patient, a mastec to my or “male chest con to uring” procedure is available. When the amount of breast tissue removed requires skin removal, a scar will result and the patient should be so informed. Genital Surgery Techniques and Complications Genital surgical procedures for the MtF patient may include orchiec to my, penec to my, vaginoplasty, cli to roplasty, and labiaplasty. Surgical complications of MtF genital surgery may include complete or partial necrosis of the vagina and labia, fistulas from the bladder or bowel in to the vagina, stenosis of the urethra, and vaginas that are either to o short or to o small for coitus. Genital surgical procedures for FtM patients may include hysterec to my, salpingo-oophorec to my, vaginec to my, me to idioplasty, scro to plasty, urethroplasty, placement of testicular prostheses, and phalloplasty. Vaginal access may be difficult as most patients are nulliparous and have often not experienced penetrative intercourse. Complications of phalloplasty in FtMs may include frequent urinary tract stenoses and fistulas, and occasionally necrosis of the neophallus. The importance of surgery can be appreciated by the repeated finding that quality of surgical results is one of the best predic to rs of the overall outcome of sex reassignment (Lawrence, "##)). Other surgeries for assisting in body masculinization include liposuction, lipofilling, and pec to ral implants. Although most of these procedures are generally labeled “purely aesthetic,” these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient’s condition and life situation. Follow-up is important to a patient’s subsequent physical and mental health and to a surgeon’s knowledge about the benefits and limitations of surgery. Pos to perative patients should undergo regular medical screening according to recommended guidelines for their age. While hormone providers and surgeons play important roles in preventive care, every transsexual, transgender, and gender-nonconforming person should partner with a primary care provider for overall health care needs (Feldman, "##!

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Fit for Duty Subject to impotence of proofreading buy cheap kamagra polo 100mg online Review may be considered erectile dysfunction pills thailand cheap kamagra polo 100 mg with amex, taking in to impotence over 50 purchase kamagra polo 100 mg amex account: • the nature of the work and reports on work performance; and • information provided by an appropriate specialist regarding the level of impairment and the presence of other disabilities that may impair Safety Critical Work according to erectile dysfunction injection medication purchase kamagra polo this Standard; and • the results of neuropsychological testing erectile dysfunction drugs compared order kamagra polo 100 mg without prescription, as appropriate. A person is not Fit for Duty Unconditional: • if they have a high risk of post traumatic epilepsy [penetrating brain injury, brain contusion, subdural haema to ma, loss of consciousness/alteration of consciousness or post traumatic amnesia greater than 24 hours]. Fit for Duty Subject to Review may be considered, • if the person has had no seizures for at least 12 months If a seizure has occurred, refer page 117. Intracranial surgery Category 1 Safety Critical Workers A person should be categorised Temporarily Unft for Duty for 12 months following supraten to rial surgery or surgery that involves retraction of the cerebral hemispheres. Category 1 and 2 Safety Critical Workers If there are seizures or long-term neurological defcits, refer to Section 18. Fit for Duty Subject to Review may be determined, subject to annual review, taking in to account the nature of the work and work performance reports, and information provided by the treating neurologist/ear, nose and throat specialist as to whether the following criteria are met: • if, in the opinion of a relevant specialist the risk to the network caused by an attack is acceptably low; and • the person follows medical advice, including adherence to medication if prescribed; and • the appropriate hearing standard is met. Category 2 Safety Critical Workers Category 2 Safety Critical Workers require an individual risk assessment of their job. They may be classed Fit for Duty if acute incapacity is not detrimental to safety. Multiple sclerosis Category 1 and Category 2 Safety Critical Workers A person is not Fit for Duty Unconditional: • if the person has multiple sclerosis. Fit for Duty Subject to Review may be determined, subject to at least annual review, taking in to account: • the nature of the work and reports on work performance; and • information provided by an appropriate specialist regarding the level of impairment of any of the following: visuospatial perception, insight, judgement, attention, reaction time, memory, sensation, muscle power, balance, coordination or vision (including visual felds). Neuromuscular Category 1 and Category 2 Safety Critical Workers conditions (peripheral A person is not Fit for Duty Unconditional: neuropathy, muscular • if the person has peripheral neuropathy, muscular dystrophy or any other dystrophy, etc. Fit for Duty Subject to Review may be determined, subject to at least annual review, taking in to account: • the nature of the work and reports on work performance; and • information provided by an appropriate specialist regarding the level of impairment of muscle power, sensation balance or coordination. Fit for Duty Subject to Review may be determined, subject to at least annual review, taking in to account: • the nature of the work and reports on work performance; and • information provided by an appropriate specialist regarding the level of mo to r and cognitive impairment, and the response to treatment. Stroke Category 1 and Category 2 Safety Critical Workers (cerebral infarction A person should be categorised Temporarily Unft for Duty for at least 3 months following or intracerebral a stroke. The worker may then be classed as Fit for Duty Subject to Review by an appropriate specialist if there is no long-term impairment and risk of recurrence is low. Space-occupying Category 1 and Category 2 Safety Critical Workers lesions (including A person is not Fit for Duty Unconditional: brain tumours) • if the person has a space-occupying lesion. If seizures occur, the standards for seizures and epilepsy apply (refer to Section 18. Aneurysms) A person is not Fit for Duty Unconditional: • if the person has had a subarachnoid haemorrhage. Fit for Duty Subject to Review may be determined after 6 months (Category 1) or 3 months (Category 2), taking in to account: • the nature of the work and reports on work performance; and • information provided by an appropriate specialist about the level of impairment of any of the following: visuospatial perception, insight, judgement, attention, reaction time, sensation, memory, muscle power, balance, coordination or vision (including visual felds). Other neurological Category 1 and Category 2 Safety Critical Workers conditions A person is not Fit for Duty Unconditional: • if the person has a neurological disorder that signifcantly impairs any of the following: visuospatial perception, insight, judgement, attention, reaction time, sensation, memory, muscle power, coordination, balance or vision (including visual felds). Fit for Duty Subject to Review may be determined subject to at least annual review, taking in to account: • the nature of the work and reports on work performance; and • information provided by an appropriate specialist about the likely impact of the neurological impairment on Safety Critical Work. This Standard does not deal with the myriad conditions that may affect health on a short to -medium-term basis and for which a Safety Critical Worker may be referred for assessment regarding ftness to resume duty. Generally, workers presenting with symp to ms of a potentially serious nature should be classifed as Temporarily Unft for Duty until their condition can be adequately assessed. Driving Licence Committee of the European Union 2005, Epilepsy and driving in Europe. A report of the Second European Working Group on Epilepsy and Driving, Driving Licence Committee of the European Union. Lawden, M 2000, ‘Epilepsy surgery, visual felds, and driving’, Journal of Neurology, Neurosurgery and Psychiatry, vol. Taylor, J & Chadwick, D 1996, ‘Risk of accidents in drivers with epilepsy’, Journal of Neurolology, Neurosurgery and Psychiatry, vol. Mckiernan, D & Jonathon, D 2001, ‘Driving and vertigo’, Clinical O to laryngology, vol. Substance misuse and dependence) Psychiatric disorders encompass a range of cognitive, emotional and behavioural disorders such as schizophrenia, depression, anxiety disorders and personality disorders. They also include dementia and substance abuse disorders, which are addressed elsewhere in the Standard (refer to sections 18. Relevance to Safety Critical Work Effects of psychiatric conditions on Safety Critical Work Safety Critical Work is a complicated psychomo to r performance that depends on fne coordination between the sensory and mo to r systems. It is infuenced by fac to rs such as arousal, perception, learning, memory, attention, concentration, emotion, refex speed, time estimation, audi to ry and visual functions, decision-making ability and personality. Complex feedback systems interact to produce the appropriate coordinated behavioural response. Anything that interferes with any of these fac to rs to a signifcant degree may impair the ability to perform Safety Critical Work. Psychiatric disorders may be associated with disturbances of behaviour, cognitive abilities and perception, and therefore have the potential to affect performance of Safety Critical Work. The impact of mental illness also varies depending on a person’s social circumstances, job and coping strategies. Assessment of ftness for duty must therefore be individualised, and should rely on evaluation of the specifc pattern of illness and potential impairments as well as severity, rather than the diagnosis per se. These impairments are diffcult to determine precisely because impairment differs at various phases of the illness and may vary markedly between individuals. Table 11 summarises the potential impacts of various psychiatric disorders on safety critical work. These incidents are usually managed through a rail opera to r’s critical event management program (refer to Section 2. Evidence of crash risk There is no specifc data on the impact of psychiatric illness on the incidence of crashes or incidents in rail, but by extrapolation information may be derived from road accident data. Some studies have shown that drivers with a psychiatric illness have an increased crash risk compared with drivers without a psychiatric illness. There is also specifc evidence for increased risk among those with schizophrenia and personality disorders. Impairments associated with medication Medications prescribed for treating psychiatric disorders may impair performance of Safety Critical Work. There is, however, little evidence that medication, if taken as prescribed, contributes to road crashes; in fact, it may even help reduce the risk of a crash (refer to Section 12. Authorised Health Professionals should have heightened concern when sedative medications are prescribed, but should also consider the need to treat psychiatric disorders effectively (also refer to Section 18. General assessment and management guidelines General considerations When assessing the impact of a mental illness on the ability to work safely, the focus should be on assessing the severity and signifcance of likely functional effects, rather than the simple diagnosis of a mental illness. The review period should be tailored to the likely prognosis or pattern of progression of the disorder in an individual with a conservative approach to Safety Critical Work. Work performance reports may be a useful source of information regarding overall safe working skills. Reports of critical incidents, such as suicides on railways, should also be considered. Moderate levels of mental illness commonly affect functioning, but many people will be able to manage usual activities, often with some modifcation. Severe mental illness often impairs multiple domains of functioning, and it is this category that is most likely to impact on the functions and abilities required for Safety Critical Work. The person with insight may recognise when they are unwell and self-limit their working. Limited insight may be associated with reduced awareness or defcits, and may result in markedly impaired judgement or self-appraisal. Workers with lack of insight should be classed as Temporarily or even Permanently Unft for Duty as required. Mental illness, particularly if accompanied by paranoid beliefs or lack of insight, may lead to noncompliance with requests to attend medical reviews or take prescribed medication, and may lead to diffculty obtaining a full picture of the workers condition and functioning. In cases where the Authorised Health Professional is not satisfed that they have a complete picture of the worker’s condition, the worker should be classed Temporarily Unft for Duty until adequate information can be obtained. Screening for anxiety/depression Substantial anxiety/depression affects up to 10% of the adult population. This has led to the introduction of the K10 Questionnaire, a well-validated to ol for screening for anxiety and depression. Note that the K10 is a screening instrument, not a diagnostic to ol; thus, examining health professionals should apply clinical judgement in the interpretation of the score and the action required. Neuropsychological testing may be helpful to forming an overall opinion of ftness for duty. Mental state examination the mental state examination can be usefully applied in identifying areas of impairment that may affect ftness for duty. Although subjective, it helps to evaluate the quality of information gained in the rest of the assessment and may refect personality attributes. Evidence from formal testing, screening tests and observations related to adaptive functioning may be sought to determine if a psychiatric disorder is associated with defcits in these areas that are relevant to safe working. Assessment requires exploration of the person’s awareness of the nature and impacts of their condition, and has major implications for management. Treatment As described in the previous sections, the effects of prescribed medication should be considered, including: • how medication may help to control or overcome aspects of the condition that may impact on working safely; and • whether medication side effects may affect working safely, including risk of sedation, impaired reaction time, impaired mo to r skills, blurred vision, hypotension or dizziness. Compliance may depend on a number of fac to rs including the nature of the condition. Alternative treatments—including ‘talking therapies’ and on-line therapy —may be useful as an alternative or supplement to medication, and lessen the risk of medication affecting working safely. Severe chronic conditions A person with a severe chronic or relapsing psychiatric disorder (including neurodevelopmental disorders) needs to be assessed regarding the impairments associated with the condition and the skills needed to work safely. The presence of a severe or relapsing psychiatric condition is unlikely to be compatible with being able to sustain safety critical work in the long run and will usually result in the person being classed Permanently Unft for Operational Duties. Substance misuse and dependence) People with a ‘dual diagnosis’ of a psychiatric disorder, and drug or alcohol misuse are likely to be at higher risk and warrant careful consideration. The assessment should seek to identify the potential relevance of: • problematic alcohol consumption • use of illicit substances • prescription drug abuse. Medical criteria for Safety Critical Workers Medical criteria for ftness for duty are outlined in Table 12: Medical criteria for Safety Critical Workers: psychiatric disorders. Psychiatric disorders Category 1 and Category 2 Safety Critical Workers A person is not Fit for Duty Unconditional: • if the person has a psychiatric disorder of suffcient severity that it may impair behaviour, cognitive ability or perception required for Safety Critical Work (refer to Section 18. Relevance to Safety Critical Work); or • if the examining doc to r believes that there is a signifcant risk of a previous psychiatric condition relapsing. Fit for Duty Subject to Review may be determined, subject to annual review, taking in to account the nature of the work, work performance reports and information provided by a psychiatrist as to whether the following criteria are met: • the condition is well controlled and the person is compliant with treatment over a substantial period, and the person has insight in to the potential effects of their condition on safe working; and • there are no adverse medication effects that may impair their capacity for safe working; and • the impact of comorbidities has been considered. Workers who are ft to continue work while being investigated should be classifed as Fit Subject to Review. Any exceptions to this should be agreed with the Chief Medical Offcer, examining specialist, treating general practitioner and Authorised Health Professional as clinically indicated. The questionnaire aims to identify workers with signifcant levels of psychological distress so that they may be appropriately managed with respect to their work and their ongoing health and wellbeing.

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The Catherine White Holman Wellness Centre ofers free hormone injecting equipment erectile dysfunction utah cheap kamagra polo 100 mg without prescription, and education about safe hormone injecting techniques erectile dysfunction questions and answers cheap kamagra polo 100 mg with visa. This combination is typically decided with the goal of minimizing health risks erectile dysfunction natural herbs best kamagra polo 100 mg, and maximising desired efects erectile dysfunction pills from canada discount kamagra polo online. In the chest area impotence versus erectile dysfunction discount kamagra polo 100mg fast delivery, feminizing hormone therapy can help stimulate breast and nipple growth, soften skin, decrease muscle mass, and slow the growth of body hair, making it less noticeable and easier to remove. Most of these efects take place over a period of up to fve years although sometimes in s to ps and starts, and with shorter or longer timeframes for some folk. Some folk decide to wait for their breasts to complete their full growth 15 as a result of hormone therapy before having any breast augmentation, as this can have an impact on the fnal look of their breasts. The side efects of feminizing hormone therapy can, among others, include increased risk of pancreatitis, cholesterol level changes, increased risk of type 2 diabetes, and elevated blood pressure. Follow up with a trans*-competent doc to r is recommended to help manage these side efects. Breast development and estrogen may also afect your risk of breast cancer; check out the cancer screening and prevention section of this resource for more information. Efects of tes to sterone on the chest area can include thicker, coarser and faster growing chest hair, as well as increased upper body strength and muscle mass. Efects may difer for diferent people as, for example, genetics may play a role in changes to hair growth. While hormones may decrease fat and increase muscle, they do not generally afect breast tissue after puberty, and some folk who want a fatter chest opt for chest surgery or binding. It is important to work with your medical service provider to determine the right dose of tes to sterone for you on an ongoing basis, as diferent people’s bodies react diferently to hormone therapies. Even if the efect of hormone therapy is slow, it is important not to take more tes to sterone than prescribed or combine your treatment with others such as non prescription steroids without medical consultation. Your body may respond to excess tes to sterone by turning it in to estrogen, and the altered dose may increase the risk of negative health efects. Most of the efects of tes to sterone take place over a period of up to fve years although possibly in s to ps and starts, and with shorter or longer time frames for some folk. Some changes are permanent whether or not someone continues hormone therapy, while others are reversible, and others require sustained, although possibly reduced, hormone treatments to maintain efects and/or manage side-efects. Tes to sterone’s side efects can include changes to weight, fat distribution around internal organs, blood pressure, cholesterol balances, and red blood cell and hemoglobin levels. This may be a reason 16 to consider working to adjust how diet, exercise, stress management and cigarette smoking fac to r in to your life, and also looking in to what tests are done as part of your regular medical check-ups. Excess tes to sterone converted by the body to estrogen may increase risk of cancer, and it is important to take this in to account when considering cancer screening and self-examinations. Working with a trans*-competent doc to r in determining the right dosage for you, and on follow-up care, can help to minimize these risks. Working with a therapist or counsellor as well as other medical service providers can help you decide if, and when, hormone therapy might be the right choice for you. Some things to address include your hopes, expectations and concerns about what hormone therapy might mean for you, your body, your life, and the people close to you, as well as how to prepare for the possibility of things turning out diferently than you had expected. Additionally, medical service providers can help work out what program of hormones will work best for you, make adjustments to your hormone therapy in response to efects that hormones may be having on your emotional and mental well-being, and work to decrease the impact of hormones on your risk of health problems such as cancer and cardiovascular disease. In British Columbia, a trans*-competent General Practitioner will be able to prescribe hormones. If you do not have a relationship with a doc to r where you feel comfortable discussing this, organizations such as the Transgender Health Information Program may be able to help connect you with other options. Service providers are legally and ethically bound to assess whether hormones are an appropriate form of treatment for you, if you have all the information about the possible outcomes of hormone therapy, if hormone therapy will negatively afect any conditions you may have, if you know how to self-administer the medication, and if it will be possible to evaluate whether hormones are working for you after beginning the therapy. Some kinds of heart disease may afect your ability to receive hormone therapy safely, which is one of many reasons to work to wards heart health in terms of diet, stress management, and exercise. Reducing or quitting smoking can also help greatly with heart health; however it is important to acknowledge that for many smokers this is particularly difcult to do during stressful times, which may include preparation for assessment. This assessment can feel invasive or like gate-keeping, but is something your provider is obliged to do before giving you a prescription to ensure that hormone therapy will not afect you adversely, and that you are 17 aware of potential side-efects. This process also helps ensure that you have all the available information to make your decision. To reduce feelings of stress, anger or frustration that the assessment may give you, you can do further research about the assessment process, and be prepared with what you want to communicate to the person assessing you. You can also seek emotional support and utilize relaxation techniques before and after the assessment to help minimize negative emotions. If you feel that your doc to r is not sufciently trans*-competent to make the assessment, you may ask for a referral or seek other health professionals who you feel will be able to make better informed decisions. There is a lot of information available online on this to pic; unfortunately it is sometimes conficting. If you have access to a trans* competent nutritionist or doc to r, they may be able to help you tailor a nutrition plan to help boost the kinds of hormones that you want. See the referrals page at the back of this resource for the Catherine White Holman Wellness Centre, where at the time of printing a trans* competent nutritionist was accessible. Surgery Some trans* folk feel it is important for them to have surgery to change the look of their chest. Whether or not to have chest surgery is a big decision for many folk, and one arrived at in diferent ways. Some people know immediately and defnitely if it is right for them and when the right time for them to have it may be; others decide after refection for a long period of time, whether that be solitary or through lengthy dialogue with partners, friends, support groups, or trans*-competent counsellors or therapists. Trans*-competent medical professionals can help you assess the potential health impacts of chest surgery. Surgery can help people feel great about themselves, and help make their bodies feel more refective of their gender identities. It is also important to recognise that deciding whether or not to have chest surgery does not afect anyone’s right to self-defne their own gender. In addition to this, many trans* people feel that social pressure to be 18 read as their gender, or to have chest surgery, is a way to uphold the gender binary. If you work in sex work, you may feel additional pressure from clients to have chest surgery. As most chest surgery is not to tally reversible, if you do decide that it is an important part of your current work life, you might also want to consider what your feelings may be if your work were not a fac to r. It may be also done by lipoflling using fat from the person’s own body, although this is a less common procedure. If you are considering breast augmentation and are unsure of what size breasts will feel right for you, you could try flling water balloons to diferent measurements and inserting them in to a bra. Try on a to p over the bra to get a better idea of how this will look, and spend some time examining your body in a mirror from various angles. When you fnd a look that feels right for you, measure the water and tell your doc to r. During surgery, fuids for implants are inserted within a solid casing that keeps them confned. Some folk who face barriers to breast augmentation have tried injecting silicone in to their breasts without this casing or without the help of a licensed supervisor; this is known to be highly dangerous and potentially fatal. If you have injected silicone in the past, you should seek medical attention as soon as possible. A number of fac to rs, including the materials the implant is made from, your age, and your body shape may afect the look and feel of augmented breasts, which may difer from non-implanted breasts. Working with a doc to r who you trust and who is knowledgeable and experienced in working with trans* folk can help you get the look and shape that you feel works best for your body. It is also important to be aware that as breast implants can break down and rupture over time, check-ups at a schedule advised by your doc to r are important. These check-ups are important, as implants may need to be removed and possibly replaced in the future. Many folk who also undergo hormone therapy tend to wait until the resulting development from this is complete before undergoing surgery, 19 as this can have an impact on the end appearance of the breasts. However, hormone therapy is not necessary for you to be able to have breast augmentation. Breast reduction surgery reduces the size of breasts, without necessarily giving you a fat chest. There are many reasons for choosing this option; however it is important to note that this may limit your option for choosing chest reconstruction later, so it should not be seen as a step to wards it. Chest reconstruction removes most breast tissue and excess skin as well as skin folds where the breasts were. It alters the shape of the pec to ralis muscles, and adjusts the nipple area size and/or location. What method of chest construction is chosen, what ratio of nipple repositioning, resizing and maintenance of sensation you and the doc to r decide to work to wards is decided based on your feelings, the shape and size of your chest, and the elasticity of your skin. For some people, multiple surgeries are needed to get the look that they want for their chest. It is important to bear in mind that diferent body shapes will have diferent looking chests after surgery. For this reason it can be helpful to think about, and talk with your doc to r or therapist before surgery about what your hopes and expectations for surgery are. You could discuss what your plan might be if the result difers from those expectations. Exercise, especially focussing on strengthening the pec to ral muscles both before and after surgery can help give a more muscular look to the chest. It is important, however, to wait to exercise after surgery until you have the go-ahead from your surgeon. Chest reconstruction or con to uring can be undergone before, after, or without hormone therapy. Before Surgery In addition to suggestions and requirements of your doc to r, some ways you can get your body primed for chest surgeries include: fifi Working to get your health and ftness to their optimum. This is a 20 challenge for anyone, and at a time when you may be under stress, and facing large medical expenses, you might face additional barriers to this goal. Quitting or cutting down are not easy tasks, especially at a time that may be stressful, and the support of people close to you, support groups, or quitting help-lines can be helpful in achieving this goal. Smoking has been shown to only create a short term relief of stress from nicotine cravings. To reduce stress in the long-term, quitting smoking may actually be of greater beneft. It is important to know if they could be negatively afecting your body’s healing, and if so look at alternatives. Organizing things in advance for your time after surgery can help reduce physical and mental stress while you need to be focusing on healing and on the day of surgery. Are there people close to you who can bring you meals or groceries; drive you to and from surgery; be with you around the clock or in shifts for the frst few days after the operation; help you with showers, drying and dressing; help care for pets or childrenfi In addition, it can also help to minimize pain, improve 21 relaxation and sleep; help with lifestyle changes (such as dietary changes or quitting smoking); boost immunity; reduce stress; and assist with overall mental and emotional well-being.

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