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Cross Reference Lid retraction Dazzle Dazzle is a painless intolerance of the eyes to bright light (cf depression great buy generic anafranil 50 mg line. It may be peripheral in origin (retinal disease; opacities within cornea, lens, vitreous); or central (lesions anywhere from optic nerve to occipitotemporal region). Cross Reference Photophobia Decerebrate Rigidity Decerebrate rigidity is a posture observed in comatose patients in which there is extension and pronation of the upper extremities, extension of the legs, and plantar exion of the feet (= extensor posturing), which is taken to be an exaggeration of the normal standing position. Painful stimuli may induce opisthotonos, hyperextension, and hyperpronation of the upper limbs. Decerebrate rigidity occurs in severe metabolic disorders of the upper brainstem (anoxia/ischaemia, trauma, structural lesions, drug intoxication). A similar picture was rst observed by Sherrington (1898) following section of the brainstem of cats at the collicular level, below the red nuclei, such that the vestibular nuclei were intact. The action of the vestibular nuclei, unchecked by higher centres, may be responsible for the profound extensor tone. Decerebrate rigidity indicates a deeper level of coma than decorticate rigidity; the transition from the latter to the former is associated with a worsening of prognosis. The lesion responsible for decorticate rigidity is higher in the neuraxis than that causing decerebrate rigidity, often being diffuse cerebral hemisphere or diencephalic disease, although, despite the name, it may occur with upper brainstem lesions. Cross References Coma; Decerebrate rigidity Deja Entendu A sensation of familiarity akin to deja vu but referring to auditory rather than visual experiences. However, since the term has passed into the vernacular, not every patient complaining of deja vu has a pathological problem. Recurrent hallucinations or vivid dream-like imagery may also enter the differential diagnosis. A phenomenon of slight confusion in which all is not clear although it is familiar has sometimes been labelled presque vu. Epileptic deja vu may last longer and be more frequent and may be associated with other features such as depersonalization and derealization, strong emotion such as fear, epigastric aura, or olfactory hallucinations. Epileptic deja vu is a complex aura of focal onset epilepsy; specically, it is indicative of temporal lobe onset of seizures and is said by some authors to be the only epileptic aura of reliable lateralizing signicance (right). Deja vecu (already lived) has been used to denote a broader experience than deja vu but the clinical implications are similar. Deja vu has also been reported to occur in several psychiatric disorders, such as anxiety, depression, and schizophrenia. Cross References Aura; Hallucination; Jamais vu Delirium Delirium, also sometimes known as acute confusional state, acute organic reaction, acute brain syndrome, or toxic-metabolic encephalopathy, is a neurobehavioural syndrome of which the cardinal feature is a decit of attention, the ability to focus on specic stimuli. Diagnostic criteria also require a concurrent 102 Delirium D alteration in level of awareness, which may range from lethargy to hypervigilance, although delirium is not primarily a disorder of arousal or alertness (cf. Subtypes or variants are described, one characterized by hyperactivity (agitated), the other by withdrawal and apathy (quiet). The course of delirium is usually brief (seldom more than a few days, often only hours). On recovery the patient may have no recollection of events, although islands of recall may be preserved, corresponding with lucid intervals (a useful, if retrospective, diagnostic feature). Delirium is often contrasted with dementia, a chronic brain syndrome, in which attention is relatively preserved, the onset is insidious rather than acute, the course is stable over the day rather than uctuating, and which generally lasts months to years. However, it should be noted that in the elderly delirium is often superimposed on dementia, which is a predisposing factor for the development of delirium, perhaps reecting impaired cerebral reserve. Risk factors for the development of delirium may be categorized as either predisposing or precipitating. It is suggested that optimal nursing of delirious patients should aim at environmental modulation to avoid both understimulation and overstimulation; a side room is probably best (if possible). However, if the patient poses a risk to him/herself, other patients, or staff which cannot be addressed by other means, regular low-dose oral haloperidol may be used, probably in preference to atypical neuroleptics, benzodiazepines (lorazepam), or cholinesterase inhibitors. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Cross References Agraphia; Attention; Coma; Delusion; Dementia; Hallucination; Illusion; Logorrhoea; Obtundation; Stupor; Sundowning Delusion A delusion is a xed false belief, not amenable to reason. Delusions are not only a feature of primary psychiatric disease (psychoses such as schizophrenia; neuroses such as depression), but may also be encountered in neurological disease with secondary psychiatric features (organic psychiatry). Cross References Delirium; Dementia; Hallucination; Illusion; Intermetamorphosis; Misidentication syndromes; Reduplicative paramnesia Dementia Dementia is a syndrome characterized by loss of intellectual (cognitive) functions sufficient to interfere with social and occupational functioning. Cognition encompasses multiple functions including language, memory, perception, praxis, attentional mechanisms, and executive function (planning, reasoning). These elements may be affected selectively or globally: older denitions of dementia requiring global cognitive decline have now been superseded. Amnesia may or may not, depending on the classication system used, be a sine qua non for the diagnosis of dementia. Attentional mechanisms are largely preserved, certainly in comparison with delirium, a condition which precludes meaningful neuropsychological assessment because of profound attentional decits. Multiple neuropsychological tests are available to test different areas of cognition. Although more common in the elderly, dementia can also occur in the presenium and in children who may lose cognitive skills as a result of hereditary metabolic disorders. The heterogeneity of dementia is further exemplied by the fact that it may be acute or insidious in onset, and its course may be progressive, stable, or, in some instances, reversible (dysmentia). A distinction is drawn by some authors between cortical and subcortical dementia: in the former the pathology is predominantly cortical and neuropsychological ndings are characterized by amnesia, agnosia, apraxia, and aphasia. However, not all authors subscribe to this distinction and considerable overlap may be observed clinically. Cognitive decits also occur in affective disorders such as depression, usually as a consequence of impaired attentional mechanisms. This syndrome is often labelled as pseudodementia since it is potentially reversible with treatment of the underlying affective disorder. It may be difficult to differentiate dementia originating from depressive or neurodegenerative disease, since depression may also 105 D Dementia be a feature of the latter. Impaired attentional mechanisms may account for the common complaint of not recalling conversations or instructions immediately after they happen (aprosexia). Behavioural abnormalities are common in dementias due to degenerative brain disease and may require treatment in their own right. Because of the possibility of progression, reversible causes are regularly sought though very rare. Specic treatments for dementia are few: cholinesterase inhibitors have been licensed for the treatment of mild-to-moderate Alzheimers disease and may nd a role in other conditions, such as dementia with Lewy bodies and vascular dementia, for behavioural as well as mnestic features. Depersonalization is a very common symptom in the general population and may contribute to neurological presentations described as dizziness, numbness, and forgetfulness, with the broad differential diagnoses that such symptoms encompass. Such self-induced symptoms may occur in the context of meditation and self-suggestion. Cross References Derealization; Dissociation Derealization Derealization, a form of dissociation, is the experience of feeling that the world around is unreal. Cross References Alien hand, Alien limb; Intermanual conict Diamond on Quadriceps Sign Diamond on quadriceps sign may be seen in patients with dysferlinopathies (limb girdle muscular dystrophy type 2B, Miyoshi myopathy): with the knees slightly bent so that the quadriceps are in moderate action, an asymmetric diamondshaped bulge may be seen, with wasting above and below, indicative of the selectivity of the dystrophic process in these conditions. Cross Reference Calf head sign Diaphoresis Diaphoresis is sweating, either physiological as in sympathetic activation. Diaphoresis may be seen in syncope, delirium tremens, or may be induced by certain drugs.

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Some are classified according to the duration of the psychosis and some according to the cause depression symptoms handout order genuine anafranil line. No single symptom is definitive for diagnosis; rather the diagnosis encompasses a pattern of signs and 17 symptoms. These symptoms may result in lack of attention to personal hygiene and the need for help with everyday tasks. Symptoms may include fear of abandonment, unstable relationships, self-image, and identity, self-damaging 19 impulsivity, suicidal behavior and severe dissociation. Symptoms may include failure to abide by lawful behavior without 21 remorse, impulsivity, deceitfulness, and aggressiveness. Mental Health Procedures (2014) Chapter 9 Evaluation, Diagnosis and Medication 377 Section 9. If a patient continues to be unable or unwilling to give consent, the hospital should pursue either guardianship or clinical review panel. The patient has the right to appeal the decision of the clinical review panel within 48 hours of receipt of the panels decision. If the decision is appealed, medications may not be given unless authorized by the Administrative Law Judge. Since the medication may be administered pending the decision by the court, the appeal is expedited. May not involuntarily medicate a patient who is either voluntarily admitted or committed for evaluation. The Court held that the government may involuntarily medicate the defendant for the purpose of rendering him/her competent to stand trial if: 1. Involuntary medication is necessary to further the governments interest; and 4. Some of the medications have non-psychiatric uses (for example, Tegretol is also used to control seizures). However, if a person is prescribed one of these medications, it is a good indication that the individual has been diagnosed as having a mental illness. It reduced psychotic symptoms, but had many undesirable side effects, such as tremors and tardive dyskenesia. While there are fewer side effects with the newer medications, there are some that could be experienced, including weight gain, drowsiness, and reduced sexual function. Typical Anti-psychotics Atypical Anti-psychotics Haldol (haloperidol) Abilify (aripiprazole) Loxitane (loxapine) Clozaril (clozapine) Moban (molindone) Geodon (ziprasidone) Mellaril (thioridazine) Risperdal (risperidone) Prolixin (fluphenazine) Seroquel (quetiapine) Stelazine (trifluoperazine) Zyprexa (olanzapine) Thorazine (chlorpromazine) Mood Stabilizers Mood stabilizers used in the treatment of bipolar disorder or personality disorder, with the exception of lithium, are either anticonvulsant medication or atypical anti-psychotic medication. Depakene (valproic acid) Depakote (Divalproex sodium) Eskalith (lithium carbonate) Gabitril (tiagabine) Lamictal (lamotrigene) Lithobid (lithium) Neurontin (gabapentin) Tegretol (carbamazine) 23 the sources for the information contained in this section on Psychotropic Medication are: National Institute of Mental Health. Judges guide to mental health jargon: A quick reference for justice system practitioners. Mental Health Procedures (2014) Chapter 9 Evaluation, Diagnosis and Medication 382 Medications to treat side effects Cogentin (benztropine) Artane (trihexyphenidyl) Benadryl (diphenhydramine) Antidepressants Antidepressant medications are designed to balance some of the neurotransmitters in the brain. In addition, there are anti-anxiety medications, benzodiazepines that work more quickly than the antidepressants. However, benzodiazepines can be habit forming and can be sold on the street, so the potential for abuse may be an issue. An example is Depade or ReVia (naltrexone), which is used to treat both alcohol and opiate abuse. Aversion Therapy Aversion therapy medications produce acute withdrawal symptoms if the abused drug is consumed. An example of this type of medication is Antabuse, which causes nausea in a person who has consumed alcohol. Mental Health Procedures (2014) Chapter 9 Evaluation, Diagnosis and Medication 384 this page intentionally left blank for two-sided printing purposes. Mental Health Procedures (2014) Chapter 10 Housing and Employment 389 Introduction In Maryland, as well as nationwide, the lack of accessible affordable housing has been identified as a primary barrier to diversion of mentally ill justice involved individuals and to re-entry of this population from jails, prisons, and hospitals. In the absence of quality, affordable housing, many people with mental illness live on the streets, in homeless shelters, or in substandard housing. The relationship between homelessness and arrest is well documented, as is the over representation of the mentally ill in the criminal 12 justice system. A basic understanding of State and Federal housing assistance programs and the types of housing needed by and available to the mentally ill offender is necessary in order to develop and implement viable and sustainable continuing care plans. A range of promptly available housing opportunities is critical not only to timely discharge from hospitals, but also to maintaining stability and enhanced quality of life in the community. The public mental health system must take an active role in expanding the range of sustainable housing models for consumers, and the judiciary and the criminal justice partners should support and encourage efforts made to address the longstanding housing needs of the justice involved population. Many jurisdictions in Maryland apply stricter policies than required by federal law. Prevalence of Serious Mental Illness Among Jail Inmates, Psychiatric Services, Jun 2009; 60:761-765. Report of the Re-Entry Policy Council: Charting the Safe and Successful Return of Prisoners to the Community. Private landlords have greater flexibility than state or federally subsidized programs in the selection of tenants, but they are subject to Fair Housing Laws, which prohibit discrimination on the basis of: sex; race; age; disability; color, creed or national origin; religion or familiar status. However, as a practical matter in the private rental market, 3 income based barriers are the primary reason for exclusion. The two federal tenant based rental assistance programs are the Certificate Program and the Housing Voucher Program. The primary difference between the two programs is that there is no cap on rent level in the Voucher Program. If the tenant is willing to pay more than the allocated rental subsidy, they may do so. In most rental certificate programs, a family pays either 30% of its monthly adjusted gross income, 10% of its monthly gross income, or the welfare assistance designated for housing toward rent, whichever is greater. However, this does not affect the amount of rent a landlord may charge or the family may pay. A family or individual is free to choose any housing that meets the requirements of the program where the owner agrees to rent under the program. The goal of the program is to enable these households to move from homelessness or temporary emergency housing into more permanent housing and to return to self-sufficiency. The first significant federal legislation aimed at addressing homelessness was the McKinney Homeless Assistance Act of 1987. Building specific housing: this program involves units located in identified buildings that are owned by private landlords, nonprofit organizations, or public entities, and often involves purchasing and developing the building or partnering with a private housing developer. The public mental health commission selects a building or development and helps the consumer rent there. The building specific model can be either mixed population or single purpose housing. Tenants represent several groups in mixed population housing, including people with mental illness, the elderly, low income and moderateincome individuals and families. In single purpose housing, people with mental illness occupy all units, and the building is not integrated. Emergency Housing: Emergency housing is short-term housing, either in emergency shelters or motel rooms, that is made available in response to a crisis. A Housing Toolkit: Information to help the public mental health community meet the housing needs of people with mental illness. To qualify, the person can have no other residence; and must lack the resources or support networks. Housing Choice vouchers (Section 8): Assistance to individuals that can be used for rental payments and security deposits (tenant based vouchers), or direct subsidies to landlords (project-based vouchers). These vouchers can only be used for very lowincome residents (individuals earning less than 50 percent of the areas median income level), who lease housing units in the private market or in subsidized housing projects. Tenant payments are usually limited to not less than 30 percent of the tenants income. Housing First: A program that features quick access to permanent housing for people who are homeless. Support services are available following the placement in order to provide housing stability and meet individual needs.

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With tracheotomy or endotracheal intubation and ventilatory assistance anxiety 24 hours discount anafranil 75 mg, fatalities are less than 5 percent today, although initial unrecognized cases may have a higher mortality. Preventing nosocomial infections is a primary concern, along with hydration, nasogastric suctioning for ileus, bowel and bladder care, and preventing decubitus ulcers and deep venous thromboses. Intensive and prolonged nursing care may be required for recovery, which may take up to 3 months for initial signs of improvement, and up to a year for complete resolution of symptoms. Antitoxin: Early administration of botulinum antitoxin is critical, as the antitoxin can only neutralize the circulating toxin in patients with symptoms that continue to progress. When symptom progression ceases, no circulating toxin remains, and the antitoxin has no effect. Antitoxin may be particularly effective in foodborne cases, where presumably toxin continues to be absorbed through the gut wall. Animal experiments show that after aerosol exposure, botulinum antitoxin is very effective if given before the onset of clinical signs. If the antitoxin is delayed until after the onset of symptoms, it does not protect against respiratory failure. This product has all the disadvantages of a horse serum product, including the risks of anaphylaxis and serum sickness. Two "despeciated" equine heptavalent antitoxin preparations against all seven serotypes have been prepared by cleaving the Fc fragments from horse IgG molecules, leaving F(ab)2 fragments. However, 4% of horse antigens remain, so there is still a risk of hypersensitivity reactions. Administration of the antitoxin may first require skin testing with escalating dose challenges to assess the degree of an individuals sensitivity to horse serum before full dose administration of the vaccine. The injection site is monitored and the patient is observed allergic reaction for 20 minutes. The skin test is positive if any of these allergic reactions occur: hyperemic areola at the site of the injection > 0. If no allergic symptoms are observed, the antitoxin is administered as a single dose intravenously in a normal saline solution, 10 ml over 20 minutes. Medical personnel administering the antitoxin should be prepared to treat anaphylaxis with epinephrine, intubation equipment, and intravenous access. This product has been administered to several thousand volunteers and occupationally at-risk workers, and historically induced serum antitoxin levels that correspond to protective levels in experimental animals. The currently recommended primary series of 0, 2, and 12 weeks, followed by a 1 year booster induces protective antibody levels in > 90 percent of vaccinees after 1 year. Adequate antibody levels are transiently induced after three injections, but decline before the 1-year booster. In the future, changes may be made to the protocol, to add a dose at 6 months and to add annual booster doses. Laboratory workers should be aware that the vaccine cannot be used as the sole protection against a possible laboratory exposure to A-E serotypes. Contraindications to the vaccine include sensitivities to alum, formaldehyde, and thimerosal, or hypersensitivity to a previous dose. Reactogenicity is mild, with 2 to 4 percent of vaccinees in a passive surveillance system reporting erythema, edema, or induration at the local site of injection which peaks at 24 to 48 hours. The frequency of such local reactions increases with subsequent inoculations; after the second and third doses, 7 to 10 percent will have local reactions, with higher incidence (up to 20 percent or so) after boosters. Severe local reactions are rare, consisting of more extensive edema or induration. Systemic reactions are reported in up to 3 percent, consisting of fever, malaise, headache, and myalgia. More recent data based on active surveillance revealed 23 percent reported local reactions and 7. There is no indication at present for using botulinum antitoxin as a prophylactic modality except under extremely specialized circumstances. Posteposure prophylaxis, using the heptavalent antitoxin, has been demonstrated effective in animal studies; however, human data are not available, so it is not recommended for this indication. The antitoxin should be considered for this purpose only in extraordinary circumstances. Airway necrosis and pulmonary capillary leak resulting in pulmonary edema may occur within 18-24 hours, followed by severe respiratory distress and death from hypoxemia in 3672 hours. Diagnosis: Acute lung injury in large numbers of geographically clustered patients suggests exposure to aerosolized ricin. The rapid time course to severe symptoms and death would be unusual for infectious agents. Nonspecific laboratory and radiographic findings include leukocytosis and bilateral interstitial infiltrates. Treatment: Management is supportive and should include treatment for pulmonary edema. Gastric lavage and cathartics are indicated for ingestion, but charcoal is of little value for large molecules such as ricin. Prophylaxis: There is currently no vaccine or prophylactic antitoxin available for human use, although vaccination appears promising in animal models. Ricin is non-volatile, and secondary aerosols are not expected to be a danger to healthcare providers. Castor beans are ubiquitous worldwide, and the toxin is fairly easy to extract; therefore, ricin is widely available. When inhaled as a small particle aerosol, this toxin may produce pathologic changes within 8 hours and severe respiratory symptoms followed by acute hypoxic respiratory failure in 36-72 hours. When ingested, ricin causes severe gastrointestinal symptoms followed by vascular collapse and death. This toxin may also cause disseminated intravascular coagulation, microcirculatory failure, and multiple organ failure if given intravenously in laboratory animals. Worldwide, one million tons of castor beans are processed annually in the production of castor oil; the waste mash from this process is 3-5 percent ricin by weight. The toxin is also quite stable and extremely toxic by several routes of exposure, including the respiratory route. Ricin was apparently used in the assassination of Bulgarian exile Georgi Markov in London in 1978. Markov was attacked with a specially engineered weapon disguised as an umbrella, which implanted a ricin-containing pellet into his body. This technique was used in at least six other assassination attempts in the late 1970s and early 1980s. In 1994 and 1995, four men from a tax-protest group known as the Minnesota Patriots Council, were convicted of possessing ricin and conspiring to use it (by mixing it with the solvent dimethylsulfoxide) to murder law enforcement officials. In 1995, a Kansas City oncologist, Deborah Green, attempted to murder her husband by contaminating his food with ricin. In 1997, a Wisconsin resident, Thomas Leahy, was arrested and charged with possession with intent to use ricin as a weapon. In October 2003, ricin powder was discovered in a South Carolina postal facility and in February 2004 in the mail room of a United States senator. There were no injuries and these events remain under investigation as of July 2004. Ricin has a high terrorist potential due to its ready availability, relative ease of extraction, and notoriety in the press. The toxins are made up of two polypeptide chains, an A chain and a B chain, which are joined by a disulfide bond. Large quantities of ricin can be produced relatively easily and inexpensively by low-level technology. Ricin can be prepared in liquid or crystalline form, or it can be lyophilized to make a dry powder. It can be disseminated as an aerosol, injected into a target, or used to contaminate food or water. Ricin is stable under ambient conditions, but is O O detoxified by heat (80 C for 10 minutes or 50 C for about an hour at pH 7. An enemy would need to produce it in large quantities to cover a significant area on the battlefield, limiting its large-scale use. In rodents, the histopathology of aerosol exposure is characterized by necrosis of upper and lower respiratory epithelium, causing tracheitis, bronchitis, bronchiolitis, and interstitial pneumonia with perivascular and alveolar edema.

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I think about all the barriers she broke mood disorder ppt purchase cheapest anafranil, and all the meanness that she must still contend with. Despite this, she is still out there giving her friends advice and comfort, and trying to find love. Although I had discussed I him several times with his mother, Danny had steadfastly refused to meet me. I believe that he associated me with concern about his femininity, and he didnt like to be reminded of this. After the ceremony, I passed them in a long hallway, and Leslie and I simultaneously noticed each other. As Leslie Ryan introduced me to her family, I could not help focusing my attention on Danny. A slender boy with medium-length (for a boy) light blonde hair, blue eyes, and fine features, he was impeccably dressed in a navy suit, red tie, and black shoes. When the family friends daughter showed up, she told him how handsome he looked, and he beamed. He cocked his head back dramatically, threw his forearm across his eyes and said, I thought it was entirely too long. The Belgian film Ma Vie en Rose (My Life in Pink, Alain Berliner, Sony Pictures Classics, 1997) is a startlingly effective portrayal of a very feminine boy. For a more exhaustive (and academic) treatment, see Gender Identity Disorder and Psychosexual Problems in Children and Adolescents (New York: Guilford Press, 1995) by Kenneth J. For the conservative, anti-gay approach to atypical gender identity, see George Rekers writings on the National Association for Research and Therapy of Homosexuality website ( For the far-left approach, which criticizes even moderates like Zucker, read Gender Shock (NewYork: Anchor, 1997) by Phyllis Burke. Man andWoman, Boy and Girl (Baltimore: Johns Hopkins University Press, 1973) is the classic book by John William Money and Anke A. Ehrhardt that summarizes the research from the 1950s and 1960s that was used to justify the decision to reassign Reimer as a girl. Tearoom Trade (NewYork: Aldine de Gruyter, 1975), by Laud Humphreys, is a study of men who engage in homosexual acts with strangers in public restrooms. Larry Kramers controversial book, Faggots (New York: Grove Press, 2000), gives a harsh portrait of sexual excess among gay men during the 1970s. For genetics, Dean Hamer and Peter Copelands the Science of Desire (New York: Touchstone Books, 1996) is a fine introduction. Whether or not Hamers Xq28 finding turns out to be correct, his general knowledge about sexual orientation is excellent, and he is witty and refreshingly outspoken. The most influential books have included One Hundred Years of Homosexuality by David M. Halperin (New York: Routledge, 1989) and Michel Foucaults opus the History of Sexuality (New York: Vintage, 1990). The historian Rictor Norton has written the most thorough critique of social constructionist accounts of homosexuality: the Myth of the Modern Homosexual (London: Cassell Academic, 1998). McCloskey (Crossing: A Memoir, Chicago: University of Chicago Press, 1999), focus on the standard transsexual story (I always felt like a female), even though I would guess that both Jorgenson and McCloskey were autogynephilic. This is also true of books about transsexualism and sex reassignment, such as True Selves (Mildred L. Some exceptions include Richard Ekins Male Femaling (NewYork: Routledge, 1997), which provides an excellent sociological overview. Look at case #12, especially, to see that Hirschfeld understands something about autogynephilia, long before Blanchard nailed the concept down. His most accessible treatment of autogynephilia might be Clinical Observations and Systematic Studies of Autogynephilia, published in 1991 in the Journal of Sex and MaritalTherapy (17(4): 235251). Anne Lawrence maintains an awesome website for transsexuals, Transsexual Womens Resources, ( Most of them are thankful that someone is finally talking about the sexual side of transsexualism. Annes essays on autogynephilia have been translated into French, Italian, and Chinese by grateful readers. The film Wigstock (Barry Shils, 1995) focuses more on drag performance than on life between performances, but it, too, is worth watching. The Queen (Frank Simon, 1968) is an earlier documentary of a drag contest that has several very funny moments along with some poignant ones. She also has sections on other relevant issues, such as voice feminization and outcome research. As far as books go, Miss Veras Finishing School for BoysWhoWant to Be Girls (NewYork: Doubleday, 1997), byVeronica Vera, is instructive. Comparison of sexual offenders against children to sexual offenders against adolescents and adults: Data from the New York Sex Offenders Registry. Book review of Personality and culture: Clinical and conceptual interactions by R. Treatment Outcomes and Patient Satisfaction in the Menninger Clinic Adult Services: Results of Patient Self-Assessment from October 1999 to March 2000. American Institute for Advancement of Forensic Studies, Minneapolis, Minnesota Katsavdakis, K. Advanced Assessment of Sexual Offenders: Special Topics Include NonContact and Sexual Sadistic Offenders and Possession of Child Pornography. The Role of Psychiatry & Mental Health Professionals in Threat Assessment and Management. Advanced Assessment of Sexual Offenders: Special Topics Include Non-Contact and Sexual Sadistic Offenders and Possession of Child Pornography. Scientific Sessions, Symposium G: the Assessment Framework: Testing the Limits in Administration and Interpretation. Sex Offender Management and Treatment Act: Joint Training Conference, Saratoga Springs, N. The Association of Student Assistant Professionals of New Jersey, 29th Annual Conference. The Mental Hygiene Legal Service, Second Departments Continuing Legal Education Program. Threat and Risk Assessment and Management: Connecting the Dots, Strategic Interventions for the Prevention of Violence in School Settings. Threat and Risk Assessment and Management of Children and Young Adults: Connecting the Dots for Violence Prevention in School Settings and Communities. Cross-Examination of the Prosecution or Defense Forensic Expert: Collaborative Strategies. Sponsored by the New York State Association of Criminal Defense Lawyers Katsavdakis, K. The Use Benefiting from the Use of Forensic Psychology Experts, Reports and Testimony. How To Provide a Comprehensive Sexual Offender Program in Civil and Forensic Psychiatric Centers. The American Psychological Association Ethics Code, 2001: Relevance to Forensic Psychology. Paternal nurturance as a function of the current relationship between adult-son and father. Forensic Psychology Oral Examination, October 25th 2013, Sponsored by American Board of Professional Psychology, 10 Hours/Credits.

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Distinguishing Child Pornography Offenders Who Have Committed Other Sex Offenses Other researchers have focused on distinguishing child pornography offenders who also have committed other sex offenses from those child pornography offenders who have not done so anxiety urinary problems purchase 25mg anafranil amex. The limited research suggests there may be differences between child pornography offenders who engaged in other sex offenses and those who have solely engaged in child pornography collecting and trading activities. One study of a relatively small number of child pornography offenders compared offenders who had no known history of contact sex offending with offenders who were known to 162 have committed contact sex offenses against children. The study found that there were no statistical differences between the two groups in personal characteristics such as age, race, 163 marital status, educational background, or history of themselves being victims of abuse. There were statistically significant differences in a variety of other characteristics, however. The child pornography offenders who had a known history of contact sex offending were more likely to have a criminal history including a sex offense, have a history of drug abuse, 164 and to be diagnosed as a pedophile. The study found that child pornography offenders who also committed contact child sex offenses were more likely to use child pornography for purposes of masturbation, save child pornography images to multiple devices, maintain larger collections of child pornography on average, and communicate with other child pornography 165 offenders. The study also found that child pornography offenders who also committed contact child sex offenses were more likely to view child modeling sites (which may not constitute child pornography), read sexually explicit stories about children, and engage in grooming 166 behavior with minors (or law enforcement officers posing as minors). Another study examined three categories of offenders: child pornography offenders without a known history of contact child sex offending (child pornography-only offenders), contact child sex offenders who had no known history of child pornography offending (contact sex offenders), and child pornography offenders who were known to have committed contact 167 child sex offenses (child pornography/contact offenders). The demographic characteristics of the categories did not vary by age but varied by racial and ethnic breakdown, with the contact 168 child sex offender group showing more racial and ethnic diversity. The study found that the key factor of the presence of a history of nonsexual antisocial behavior, from childhood into adulthood accounted for much of the likelihood that an offender was either a contact child sex offender or a child pornography/contact offender, as 170 opposed to a child pornography-only offender. Discussion of Causal Relationship Between Child Pornography and Other Sex Offending Most current social science research suggests that viewing child pornography, in the 171 absence of other risk factors, does not cause individuals to commit sex offenses. Nevertheless, research has identified some correlation between viewing child pornography and 172 sex offending, and some child pornography offenders use child pornography images for 173 174 grooming or as a blueprint for contact child sex offending. For some individuals child pornography exposure appears to be a risk factor for other sex offending as the child pornography may strengthen existing tendencies in ways that may create tipping-point effects 169 Id. Antisocial behavior was measured by asking questions related to such matters as an offenders history of committing violent offenses, childhood bullying behavior, and misconduct resulting in expulsion from school. Absent predisposition, exposure to pornography alone is not likely to instigate an offense); McCarthy, supra note 5, at 194 ([P]ossessing child pornography, by itself, is not a causative factor in the perpetration of child sexual abuse and thus other factors need to be considered when evaluating the dangerousness of these offenders. Nevertheless, at least some child pornography offenders report that they are moved to commit contact sexual offenses in order to access new child pornography. One study attempted to evaluate whether there was a causal relationship between viewing deviant pornography, deviant fantasy, and the commission of sex offenses. The study found that sexually deviant fantasies are highly related to actual commission of sexual offenses but 177 indicated that the causal nature of this relationship cannot be determined by our data. Child Pornography as an Alternative to Other Sex Offending Some child pornography offenders report that they used child pornography as an 180 alternative to other sex offending. For the vast majority of offenders, it is unlikely that viewing child pornography has a cathartic effect that would reduce the likelihood of other sex 181 offending. Related research on the impact of legal pornography on young people suggests that continued exposure helps to sustain young peoples adherence to sexist and unhealthy notions 175 Neil M. Malamuth, & Mark Huppin, Drawing the Line on Virtual Child Pornography: Bringing the Law in Line With the Research Evidence, 31 N. Another study indicated that offenders who considered their use of child pornography 183 therapeutic or preventative were more unlikely to accept responsible for their actions. Finally, some research reports that, for offenders who were already assessed as low risk for future sexual 184 offending, frequency of pornography use does not appear to predict criminal recidivism. However, for offenders at high risk for sexual offending, such research indicates that frequency of pornography use and deviant pornographic content (with children and/or violent content) is 185 associated with higher reoffending rates. Offenders collections may contain a variety of images, including legal but sexually suggestive child images as well as sexually explicit images depicting violence, humiliation, bondage, and bestiality. Some child pornography offenders, particularly pedophilic offenders, collect ancillary child-related items. Such collecting activities may be related to sexual deviance and correlated with other sex offending. Absent predisposition, exposure to pornography alone is not likely to instigate an offense). It appears that [m]en who are relatively high in risk for sexual aggression are more likely to be attracted to and aroused by sexually violent media and may be more likely to be influenced by them. Many child pornography offenders expend considerable efforts to organize their collections. It appears that offenders who engage in more extensive trading are more likely to have particularly organized collections. Images of female victims are more commonly circulated than images of male victims. Some exist primarily as a means to find child pornography trading partners, while others are also dedicated to supporting sexual interest in children by buttressing deviant sexual beliefs or encouraging the commission of other sex offending. Child pornography communities make viewing of sexualized images of children acceptable and implicitly or explicitly condone sexual offenses against children. These relationships appear to support development of deviant sexual beliefs concerning children and validate and normalize child sexual exploitation. Evidence suggests that at least some individuals begin producing child pornography in order to gain access to additional child pornography. Research suggests that deviant sexual beliefs and antisociality are the two primary risk factors for other sex offending. In addition, offenders who considered their use of child pornography therapeutic or preventative were less likely to hold themselves responsible for their actions. The number of identified victims represents only a small portion of the victims whose images are in circulation. It is estimated that there are over five million 2 unique child pornography images on the Internet and some offenders possess over one million 3 images of child pornography. This chapter considers the issues and harms surrounding victimization through the production of child pornography and the continued existence and distribution of child pornography. It also addresses the legal issues surrounding victims rights for child pornography victims. Two primary exceptions are victims whose images were taken with hidden cameras or recorded remotely. While victims of sexual exploitation, they may not have been victims of contact sex abuse. There is limited information available about the subset of child sex abuse victims who are 7 also victims of child pornography production offenses. Though children of both genders are sexually abused, females appear more likely to be victims of child pornography production 8 offenses. Children of all ages are victimized by child pornography producers, from as young as 9 infants and toddlers to adolescents; about half of victims are younger than 12 years of age. Child pornography producers may target young victims because they are pre-verbal and unable to report their abuse. Jones, Arrests for Child Pornography Production: Data at Two Time Points From a Natl Sample of U. Mitchell, Trends in Arrests for Child Pornography Production: the Third Natl Juv. Very young children have little or no awareness of the sexual context to what they are being asked to do, and may be subject to sexual victimisation without the same risk of disclosure to adults. Like 12 other contact sex offenders, they often groom their victims prior to engaging in sexual abuse. While underage children are incapable of legal consent, many child pornography producers will 13 manipulate victims to make them agree to participate. Some offenders produce child pornography by convincing or coercing a child to take images of himself or herself. Coercion of 14 a child to take nude images of himself or herself is production of child pornography. Such images should be distinguished from self-produced nude images without an adult producers 15 involvement (sometimes called sexting or youthonly experimental production).

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Reliable data about the prevalence and incidence of pain anxiety med best order for anafranil, however, are limited, with available studies being based on either regional surveys of a broad spectrum of painful disorders, or specic pain states. The study revealed that persistent pain was associated with depression, which affected the quality of life and reduced the level of daily activity of the sufferers (7). It was concluded that the essential need to work and to earn income might be a reason why many people in developing countries tolerate pain rather than reporting to doctors or hospitals. Therefore, lack of an adequate social and health-care support network, cost implications and job security must inuence the extent to which people living in developing countries and suffer pain fail to seek help. A detailed study of the prevalence, severity, treatment and social impact of chronic pain in 15 European countries was carried out recently (8). Of the respondents, 25% had head or neck pains (migraine headaches, 4%; nerve injury from whiplash injuries, 4%). Although back pain may have a neurological cause, the likelihood was that in the great majority pain was the result of musculoskeletal disorders or back strain. The authors concluded that one in ve Europeans suffer from chronic pain which is of moderate severity in two thirds and severe in the remainder. The study also reveals that, in the opinion of 40% of the respondents, their pain had not been treated satisfactorily and 20% reported that they were depressed. In economic terms, 61% were less able or unable to work outside their homes, 19% had lost their jobs because of pain and another 13% had changed their jobs for the same reason. A large-scale survey in Australia (9) of just over 17 000 adults with pain daily for at least three months (chronic pain) yielded a prevalence rate of 18. Unfortunately, these gures do not give any detail about pain arising from the nervous system, except for the information about head and neck pain in the European survey. Certain neurological disorders causing pain have been examined in terms of the incidence of pain. For example Kurtzke (11) estimated that the annual incidence of herpes zoster infection in the United States was 400 per 100 000 of the population. A study of the incidence of post-herpetic neuralgia in 1982 revealed a gure of 40 per 100 000 (12). Further information from Bowsher (13) indicated that the number of individuals with post-herpetic neuralgia increases with age so that 40% of people over 80 years of age who acquire acute herpes zoster will suffer from chronic postherpetic neuralgia. In populations in which ever greater numbers are living to 80 years and more, there is likely to be a signicant increase in individuals suffering from post-herpetic neuralgia. One third of patients with multiple sclerosis develop neuropathic pain states, of whom trigeminal neuralgia occurs in 5%, and another one third develop other forms of chronic pain (3). There is an increase in the incidence of trigeminal neuralgia in patients with cancer and other diseases that impair the immunological systems. It is signicant that one third of cancer patients have a neuropathic component to their pain as do a similar proportion of patients with prolonged low back pain (14). It should be noted that stump pain arises from a severed nerve in the limb and may be caused by a local neuroma or by tethering of the severed nerve to local tissues. In contrast, phantom limb pain is central neuropathic pain and more difficult to treat. Central stroke pain is dened as neuropathic pain that follows an unequivocal episode of stroke. For most patients the pain develops gradually during the rst month but delays of many months have been recorded. The pain is incapacitating, distressing and often even more so than other symptoms. Headache disorders have also been the subject of intensive epidemiological research (see Chapter 3. Poor relief of acute pain is a recognized risk factor for the development of chronic pain after various forms of surgery, for example herniotomy, mastectomy, thoracotomy, dental surgery and other forms of trauma. The majority of such patients experience persistent pain one year after the causative event, indicating that acute neuropathic pain is a very denite risk factor for chronic pain. Hernia repair is followed by moderate to severe pain in 12% of patients one year postoperatively and is of the somatic or neuropathic type (17). Breast surgery of various types gives rise to the experience of phantom breast and pain with or without a phantom. Information about the incidence and prevalence of pain generally, and neurologically related pain in particular, is almost totally lacking for developing countries, although there is no reason to believe that conditions that give rise to pain such as stroke, multiple sclerosis, various forms of headache and other disorders vary in nature. There may well be differences, however, in the extent to which some disorders are present, for example multiple sclerosis is less common in developing countries, whereas others are not encountered in the Western world, such as certain forms of poisoning by neurotoxins from foods, and leprosy which is a cause of neuropathic pain. The nature of the pain, which is often neuropathic in type, means that the sufferer has a disabling condition that in time may be primarily the result of pain, which is difficult to relieve. As such, it poses a signicant health problem in terms of its personal, social and economic consequences. Pain reects pathophysiological changes in the nervous system and they, together with changes that usually occur in patients emotions and behaviour, have led to the conclusion that, in such cases, chronic pain is a specic health-care problem and a disease in its own right. This diagnostic category is not fully accepted among clinicians because many continue to believe that pain must be a symptom of an ongoing disease or injury. Current research reveals, however, that the pathophysiological changes mentioned persist when signs of the original cause for pain have disappeared. The signs and symptoms of chronic pain, once it has evolved into a disease, are listed in Box 3. The combination of these features of the condition reveal the potential for physical impairment, disability and handicap which collectively form the basis of signicant degrees of burden for both the patient and the family. Therefore many doctors, nurses and others dealing with patients in pain enter their professional careers inadequately equipped to deal with the most common symptom and cause of considerable suffering worldwide. Politicoeconomic barriers the availability of drugs for the treatment of pain is a problem in over 150 countries. Frequently, pain management has a low priority, because the chief focus of attention is infectious diseases and, often, there are exaggerated fears of dependence with very restrictive drug control policies. In addition, in developing countries, the cost of medicines generally and therefore problems in their procurement, manufacture and distribution, add further barriers to their use. A treatment gap In many countries, therefore, there is a treatment gap, meaning that there is a difference between what could be done to relieve pain and what is being done. That gap exists in a number of developed countries, primarily because of poor pain education and the often limited and patchy nature of specialized facilities for pain treatment. Additionally, in developing countries these problems are far greater and the gap is far wider because of the lack of education, access to appropriate drugs for pain relief and facilities for pain management. The treatment gap can be reduced worldwide by improving pain education, increasing facilities for pain treatment and access to pain-relieving drugs. In the case of opioid analgesics, an increase in their availability and the employment of correct protocols is a matter of urgency. Also, no stricter measures should be enacted than those requested by the international drug conventions and international recommendations (20) on the use of opioid medicines. Management of pain of neurological origin the range of treatments available for pain directly caused by diseases of the nervous system includes pharmacological, physical, interventional (nerve blocks, etc. Treatments for pain are used in association with other forms of treatment for the primary condition, unless of course pain is itself the primary disorder. There are many studies of the medical treatment of peripheral neuropathic pain (21). There are far fewer studies published on the treatment of central neuropathic pain, for example post-stroke pain. Opioids have been shown to have some efficacy in neuropathic pain but there are specic contraindications for their use. Topical agents may give local relief with relatively little toxicity; they include lidocaine and, to a lesser extent, capsaicin cream, particularly in the treatment of post-herpetic neuralgia.

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Secondarily infected animals were in individual cages and separated by approximately 3 meters bipolar depression warning signs order anafranil no prescription. Although the possibility of airborne transmission was suggested, the authors were not able to exclude droplet or indirect contact transmission in this incidental observation. Inconsistencies among the various recommendations have raised questions about the appropriate precautions to use in U. Single gloves are adequate for routine patient care; double-gloving is advised during invasive procedures. N95 or higher level respirators may provide added protection for individuals in a room during aerosol-generating procedures (Table 3, Appendix A). When a patient with a syndrome consistent with hemorrhagic fever also has a history of travel to an endemic area, precautions are initiated upon presentation and then modified as more information is obtained (Table 2). Transmission risks associated with specific types of healthcare settings Numerous factors influence differences in transmission risks among the various healthcare settings. These factors, as well as organizational priorities, goals, and resources, influence how different healthcare settings adapt transmission prevention guidelines to meet 315, 316 their specific needs. However, certain hospital settings and patient populations have unique conditions that predispose patients to infection and merit special mention. These are often sentinel sites for the emergence of new transmission risks that may be unique to that setting or present opportunities for transmission to other settings in the hospital. Furthermore, adverse patient outcomes in this setting 332 are more severe and are associated with a higher mortality. Burn Units Burn wounds can provide optimal conditions for colonization, infection, and transmission of pathogens; infection acquired by burn 320, 339, 340 patients is a frequent cause of morbidity and mortality. Shifts over time in the predominance of pathogens causing 343, infections among burn patients often lead to changes in burn care practices 355-358. Hydrotherapy equipment is an important environmental reservoir of gramnegative organisms. Its use for burn care is discouraged based on demonstrated associations between use of contaminated hydrotherapy equipment and infections. Burn wound infections and colonization, as well as bloodstream 361 362 infections, caused by multidrug-resistant P. Advances in burn care, specifically early excision and grafting of the burn wound, use of topical antimicrobial agents, and institution of early enteral feeding, have led to decreased infectious complications. There also is controversy regarding the need for and type of barrier precautions for routine care of burn patients. One retrospective study demonstrated efficacy and cost effectiveness of a simplified barrier isolation protocol for wound colonization, emphasizing handwashing and use of gloves, caps, masks and plastic impermeable aprons (rather than isolation 365 gowns) for direct patient contact. However, there have been no studies that define the most effective combination of infection control precautions for use in burn settings. Additionally, there is a high prevalence of community-acquired infections among hospitalized infants and young children who have not yet become immune either by vaccination or by natural infection. The result is more patients and their sibling visitors with transmissible infections present in pediatric healthcare settings, 36, 40, 41 especially during seasonal epidemics. Close physical contact between healthcare personnel and infants and young children (eg. Practices and behaviors such as congregation of children in play areas where toys and bodily secretions are easily shared and family members rooming-in with pediatric patients can further increase the risk of transmission. Pathogenic bacteria have been recovered from 379 toys used by hospitalized patients; contaminated bath toys were implicated in 80 an outbreak of multidrug-resistant P. In addition, several patient factors increase the likelihood that infection will result from exposure to pathogens in healthcare settings. Children who attend child 383, 384 385 care centers and pediatric rehabilitation units may increase the overall burden of antimicrobial resistance (eg. In addition, healthcare may be provided in nonhealthcare settings such as workplaces with occupational health clinics, adult day care centers, assisted living facilities, homeless shelters, jails and prisons, school clinics and infirmaries. Each of these settings has unique circumstances and population risks to consider when designing and implementing an infection control program. Several of the most common settings and their particular challenges are discussed below. While this Guideline does not address each setting, the principles and strategies provided may be adapted and applied as appropriate. Nursing homes for the elderly predominate numerically and frequently represent longterm care as a group of facilities. An atmosphere of community is fostered and residents share common eating and 403, 404 living areas, and participate in various facility-sponsored activities. Since able residents interact freely with each other, controlling transmission of infection 405 in this setting is challenging. Residents who are colonized or infected with certain microorganisms are, in some cases, restricted to their room. Agerelated declines in immunity may affect responses to immunizations for influenza and other infectious agents, and increase susceptibility to tuberculosis. Immobility, incontinence, dysphagia, underlying chronic diseases, poor functional status, and age-related skin changes increase susceptibility to urinary, respiratory and cutaneous and soft tissue infections, while malnutrition can impair 419-423 wound healing. Ambulatory Care In the past decade, healthcare delivery in the United States has shifted from the acute, inpatient hospital to a variety of ambulatory and community-based settings, including the home. Ambulatory care is provided in hospital-based outpatient clinics, nonhospital-based clinics and physician offices, public health clinics, free-standing dialysis centers, ambulatory surgical centers, urgent care centers, and many others. In 2000, there were 83 million visits to hospital outpatient clinics and more than 823 million visits to physician 442 offices; ambulatory care now accounts for most patient encounters with the 443 health care system. In these settings, adapting transmission prevention guidelines is challenging because patients remain in common areas for prolonged periods waiting to be seen by a healthcare provider or awaiting admission to the hospital, examination or treatment rooms are turned around quickly with limited cleaning, and infectious patients may not be recognized immediately. Furthermore, immunocompromised patients often receive chemotherapy in infusion rooms where they stay for extended periods of time along with other types of patients. Transmission of infections in 446-448 outpatient settings has been reviewed in three publications. Goodman and Solomon summarized 53 clusters of infections associated with the outpatient 446 setting from 1961-1990. Overall, 29 clusters were associated with common source transmission from contaminated solutions or equipment, 14 with personto-person transmission from or involving healthcare personnel and ten associated with airborne or droplet transmission among patients and healthcare workers. These outbreaks often are related to common source exposures, usually a contaminated medical device, multi-dose 82, 449-453 vial, or intravenous solution. In all cases, transmission has been attributed to failure to adhere to fundamental infection control principles, including safe injection practices and aseptic technique. This subject has been reviewed 454 and recommended infection control and safe injection practices summarized. Measles virus was transmitted in physician offices and other outpatient settings during an era when immunization rates were low and measles outbreaks in the 34, 122, 458 community were occurring regularly. Rubella has been transmitted in 33 the outpatient obstetric setting; there are no published reports of varicella transmission in the outpatient setting. In the ophthalmology setting, adenovirus type 8 epidemic keratoconjunctivitis has been transmitted via incompletely disinfected ophthalmology equipment and/or from healthcare workers to patients, 17, 446, 448, 459-462 presumably by contaminated hands. If transmission in outpatient settings is to be prevented, screening for potentially infectious symptomatic and asymptomatic individuals, especially those who may be at risk for transmitting airborne infectious agents. Upon identification of a potentially infectious patient, implementation of prevention measures, including prompt separation of potentially infectious patients and implementation of appropriate control measures. Patient-to-patient transmission of Burkholderia species and Pseudomonas aeruginosa in outpatient clinics for adults and 464, 465 children with cystic fibrosis has been confirmed. Home Care Home care in the United States is delivered by over 20,000 provider agencies that include home health agencies, hospices, durable medical equipment providers, home infusion therapy services, and personal care and 36 support services providers. Home care is provided to patients of all ages with both acute and chronic conditions. The incidence of infection in home care patients, other than those associated 466-471 with infusion therapy is not well studied. However, data collection and calculation of infection rates have been accomplished for central venous catheter-associated bloodstream infections in patients receiving home infusion 470-474 therapy and for the risk of blood contact through percutaneous or mucosal 475 exposures, demonstrating that surveillance can be performed in this setting. The main transmission risks to home care patients are from an infectious healthcare provider or contaminated equipment; providers also can be exposed to an infectious patient during home visits. Since home care involves patient care by a limited number of personnel in settings without multiple patients or shared equipment, the potential reservoir of pathogens is reduced.

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I will present other examples of this kind of paraphilic substitution mood disorder facility order anafranil 50mg without a prescription, in which unacceptable paraphilic fantasies are replaced by more acceptable ones, later in this chapter and in Chap. Forced feminization fantasies are a staple of transgender erotica (Beigel & Feldman, 1963), although there is disagreement about how prevalent and popular they truly are (Buhrich & McConaghy, 1976). In earlier chapters, several informants mentioned such fantasies in passing, with little elaboration. Other informants described their forced feminization fantasies in greater detail: My main fantasies revolved around being forced by a woman into becoming one myself. I started buying the little pink trans novels at the bookstores and became obsessed with their visions of my wife burning all my male clothing, injecting me with giant syringes of hormones, and hauling me off to the beauty parlor against my will. I imagine that I am one of the women, stuck in the role; often forced into it by a man. Specically, I experience erotic fantasies of being coerced or duped into being a woman, against my will initially but then gradually being won over until I cant go back. When I was attracted to some girls in school, I would fantasize about being forced to wear their clothes and have hair like theirs. Sometimes I would add to this fantasy being bound and forced to watch them have sex with their boyfriends. I imagine myself forced to become a woman in dress, manner, and physique (through hormones and surgery). I was particularly attracted to transsexuals who were women in every way except one. I dated transsexuals who could pass in public but who had not yet had nal surgery. Although I dated post-operative transsexuals, I was only satised with pre-operative transsexuals. The idea of a man trapped in the body of a 154 9 Other Aspects of Autogynephilic Sexuality transsexual, experiencing the daily humiliation and degradation of being a woman, forced to wear womens clothes and lipstick, is extremely attractive to me. The conventional explanation is that being forced to become feminine absolves us of responsibility and thereby relieves us of guilt. One informant proposed this exact explanation: I believe that the forced feminization scenario is particularly stimulating to a lot of transsexual women because it relieves us of the guilt of wanting to be feminine. Relief from guilt might make fantasies more pleasant, but it would not necessarily make them more exciting; in fact, I suspect the opposite would be true. Some psychoanalytically inclined writers have attempted to explain forced feminization fantasies as reenactments of childhood experiences in which a boys masculinity was devalued by powerful female caregivers. One might ask why forced feminization fantasies should succeed at all as masochistic fantasies for autogynephilic transsexuals. Wouldnt we experience pride and gratitude instead of shame and humiliation if someone turned us into women Surely no one would need to force us to become women, so it makes no sense that we should identify with protagonists who need to be forced. Even though we now genuinely desire to be women, we nd the idea of becoming women profoundly humiliating. That is plausibly why forced feminization fantasies continue to work as masochistic erotic fantasies for many of us, even years or decades after we have completed sex reassignment: We never entirely get over our shame. Interestingly, forced feminization fantasies are also symbolic representations of our actual life experiences. Because we nd the prospect of becoming women so shameful and humiliating, we really do have to be forced into it. We are forced by our unremitting gender dysphoria, by our powerful erotic desires, by our love and admiration for womens bodies and our wishes to turn our bodies into facsimiles of Co-occurring Paraphilias 155 them, and by our need to honor our strongly held cross-gender identities in order to give meaning and vitality to our lives. If we are prudent, we autogynephilic transsexuals undergo sex reassignment only if we feel we have no other viable alternative: We transition because we feel forced to do so. Thus, those of us who study and describe paraphilias are presented with the confusing situation of having two very similar terms with overlapping but not identical applicability. To summarize: Men with a paraphilic interest in transvestites are properly called gynandromorphophiles. Men with a paraphilic interest in postoperative MtF transsexuals are properly called gynemimetophiles (Money, 1986). A narrative by an informant who was sexually attracted to MtF transsexuals was presented previously in connection with the discussion of forced feminization. Several other informants also described their experience of particular sexual attraction to transvestites, she-males, or postoperative MtF transsexuals. In some cases, their gynemimetophilia or gynandromorphophilia dated from a time prior to their identifying as transsexual or beginning the sex reassignment process. I decided to start dating again, and I nd myself dating heterosexual crossdressers. I fell in love and my rst experience with a transsexual was wonderful, although I was unable to orgasm. She was not fond of my cross-dressing and although she fell in love with me, couldnt be physically involved because I was a crossdresser, which was looked down upon in the homosexual drag community. I met a drag queen almost 6 years ago at a gay bar, and within minutes we were heavily petting on a pool table. As our relationship continued, she was the female and I was the male of the relationship, literally. I became increasingly unhappy about my role and inability to be who I wanted to be. I would sit in extreme jealousy when she would get dressed to go out and I began to realize that I wanted to be who she was. She is very attractive and I found 156 9 Other Aspects of Autogynephilic Sexuality myself dreaming constantly of changing my appearance to be feminine. She will not accept my transition in any way and I can not bring myself to leave her. For the longest time, I felt confusion as to whether my sexual orientation would change with time and exposure to hormones. When I read about MtF-to-MtF attraction, I realized that my sexual orientation was and still is towards other transsexual women. There must be hundreds of thousands of transsexuals, and when I see pictures of them, I am aroused as well. I look at photos of lovely young boys transitioning and am jealous of them, or want to be with them, or wish I were one of them. My greatest moments of joy would be spending hours with transsexual prostitutes, watching them dress and prepare and joining them. My favorite photos are of groups of transsexuals together at parties, dancing, taking baths, etc. I can function sexually with women or transsexuals, but I dont feel much thrill with women. Some informants who described sexual involvement with other MtF transsexuals did not explicitly describe any special or specic attraction to the MtF transsexual phenotype: I began picking up and having sex with transsexual prostitutes, rst acting as the man, but as my guard lessened, wanting to simply be around them, observe and learn from them, and also act feminine. She was able to transition early and has always maintained her interest in men, before and after transition. Pedophilia One informant stated that she was aroused by the fantasy of having sex with female children, although she claimed that she had never acted on her fantasies: I have been diagnosed as transsexual by four separate therapists, and I am taking hormones. I have fantasized about sex with a man a time or two, but mainly I have been aroused by the idea of penetration with female children. I dont have these fantasies anymore, as I am chemically castrated and have gotten Co-occurring Paraphilias 157 relief from them by being on hormones. I have never done any of these things I have fantasized about; I would not be free very long if I did. Autonepiophilia (Paraphilic Infantilism or Adult Baby Syndrome) Autonepiophilia is a paraphilic sexual interest involving sexual arousal to the thought or image of being an infant, often an infant wearing diapers specically (Money, 1986). It is sometimes referred to as paraphilic infantilism (Money, 1986) or adult baby syndrome (Kise & Nguyen, 2011).