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AEI currently utilizes a RIEGL VZ400 Terrestrial Laser Scanner on various job sites.  This proecss utilizes a high accuracy 3D terrestrial LiDAR unit.  The data collected will be brought into a feature extraction software, TopoDOT.  TopoDOT utilizes a variety of tools to identify adn quickly extrapolate features within pointcloud data.  All features can then be imported into an AutoCAD drawing file.  AEI can provide an accurate 3D pointcloud of terrain plus any existing building or structures.  The pointcloud can also be converted for Building Information Models.

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Allen Engineering is involved with the civil design and surveying for the new park in Palm Bay, Flordia.  This Regional Park will feature 150 full service campsite hookups and is scheduled to break ground in 2018.  We are extremely proud to be involved in this project.

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Allen Engineering is beginning its 21st year associated with the Space Coast Post of the Society of American Military Engineers (SAME).  During our 21 years, we have helped raise over $350,000 in scholarships and endowments.  We are extremely proud to be associated with SAME and its continued commitment to offer opportunities for students pursuing careers in the engineering field.


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By: Stephen R. Thompson, MD, MEd, FRCSC

  • Cooperating Associate Professor of Sports Medicine, University of Maine
  • Medical Director, EMMC Sports Health
  • Deputy Editor, The Journal of Bone and Joint Surgery
  • Eastern Maine Medical Center Bangor, Maine
  • Cofounder and Codirector, Miller Review Course Part II, Denver , Colorado

Vitamin deficiency like gastritis all fruit diet order esomeprazole 40 mg mastercard, Cynocobalamin (B12) gastritis diet buy 40 mg esomeprazole visa, Folic acid gastritis diet 974 purchase 40 mg esomeprazole fast delivery, Pyridoxine (B6) gastritis lipase effective 40mg esomeprazole, Thiamine (B1) and Vitamin-D have all been associated with inflammation. I would recommend Cod Liver Oil 1000mg supplements for children and adults during winters to prevent all autoimmune diseases specially multiple sclerosis. If too much cod liver oil is consumed it will cause skin spots on the face that is time to reduce the dose. Those people who are deficient in vitamins can take supplements but the best way to replace vitamin D-3 is through bright sunlight exposure. Homocysteine is an intermediate compound formed during metabolism of methionine (an amino acid). Elevated serum homocysteine levels are a known risk factor for heart disease, stroke and autoimmune disorders. The plasma levels of homocysteine are dependent on the intake of folic acid, vitamin B6 (pyridoxine), and vitamin B12 (cobalamine). Even if a lab tests shows a normal rage of B12 and normal serum folate levels, the body may actually be deficient in B-12. If homocysteine levels are high, which means higher inflammation, then sub-lingual supplements of vitamin B12, B-6 and folic acid help reduce serums homocysteine levels, this vitamin replacement will also reducing the risk of myocardial infarction and stroke. Instead of testing homocysteine levels in every patient I recommend a diet rich in the vegetables and fruits. In those patients who are clinically anemic, I recommend supplements of these vitamins to be given by sublingual route. The sublingual combination of - 17 - folic acid, pyridoxine and Cynocobalamin is available in health food stores. In all Asian and Mid east countries a injection called Neurobione is sold, I would recommend that any one with symptoms of weakness use neurobione intranmuscular alternate day for a total of seven injections. Do not give this injection directly i/v unless it is mixed in at least 50 cc dextrose. Neurobione can be injected in the abdomen or the upper outer side of the buttocks. Sunshine & Environment: Many of the autoimmune disorders are triggered by excessive cold, protective clothing is required in cold weather. When the skin turns red, on exposure to the sun, this redness is a sign of inflammation, which should be avoided by using proper clothes. Extremes of temperatures will produce stress proteins which causes inflammation in the body. The human body, requires a prolonged exposure to the sun to produce vitamin-D and keep our mood happy with the tryptamines. Avoid routine use of sunglasses, especially on cloudy days, allowing the sunshine to light up the Pineal gland for increased production of tryptamines. There are two types of sunlight, infrared in the early morning and evening and ultraviolet in the afternoon. Infrared warms the skin and helps reduce pain and reduces lipids in the blood vessels by dilating them. If 40% of the body is exposed to full ultraviolet light in the afternoon you will get a 4000 unit Vitamin-D dose in 10 minutes. Black skin is adapted to sunlight and will need twice the exposure as compared to light skin to make the same amount of vitamin-D. Injury as a cause of disease: Injury has been studied for many years as a cause of autoimmune disease. Railway spine was a term used in early 1900 for chronic pain, seen in people following a railway accident, which was later termed the railway brain as a way for people seeking compensation. However the modern malady of Fibromyalgia, is similar to the railroad spine, and is triggered by an injury and considered a valid entity. For over a century, patients and physicians, have dealt with the phenomena, that trauma may precede the onset of multiple sclerosis, but multiple studies have failed to show such a relationship. The literature does show Pemphigus, Fibromyalgia, eye injury (sympathetic ophthalmia), renal failure (glomerulonephritis) and long term neuropathies are triggerd by trauma. Multiple studies from earthquake injured personnel show long term sensory motor neuropathies caused by trauma. Scientists think swelling in the anterior and posterior compartments in the leg, due to injury causes the neuropathies (nerve injury). These observations are helpful for future prevention of autoimmune disease, by administering a dose of prednisone - 18 - at the time of injury the person can avoid swelling in the tissue and prevent these nerve injuries. Activation of stress proteins at the time of injury can cause inflammation and swelling. You can suppress the stress proteins after an injury by consuming Omega-3 Oil 1000 mg for children and 3000mg for adults. Need to take omega-3 after any surgery, injury or child birth for a month to prevent autoimmune disease. In India and Pakistan turmeric in milk is given to prevent inflammation after an injury, and works wonders. Homepathic remedies like Arinca are used all over the world for suppression of inflammation after injury, it should be in every household and in your car. Injury can triggers an immune reaction, just look at the swollen feet of an injured athlete. No bones are broken, the muscles are intact but the swelling is an immune reaction. In any injury the naturally protected proteins, in the body get exposed to the immune system. After a head injury, inflammation develops, in the brain; this is triggered by, stress proteins.

Biomedical psychologists would see depression as the result of some biological cause gastritis diet purchase esomeprazole 20 mg visa. Psychologists adhering to gastritis or stomach flu buy esomeprazole 20 mg lowest price the sociocultural model would fault aspects of society such as racism or poverty gastritis symptoms treatment mayo clinic order esomeprazole 20 mg line. Excessive use of amphetamines is associated with both high levels of dopamine and schizophrenic-like symptoms gastritis symptoms in spanish 40mg esomeprazole with visa. Hypochondriasis is a different kind of somatoform disorder that involves constant, minor physical complaints and the belief that these minor problems are indicative of a serious, medical problem. Masochism is when one needs to be hurt in order to be sexually aroused, and fetishism is when objects, such as shoes, are sexually arousing. These concerns lead them to engage in the binge-purge cycle that typifies bulimia. As is true of most, if not all, disorders, the cause of bulimia is a matter of some debate. Archaeologists have unearthed human skulls with regularly shaped holes that seem to have been purposefully made. Researchers theorize that the making of the holes, a process called trephining was an early form of treatment that was supposed to let the harmful spirits escape. Leading the call to treat victims of mental illness more humanely at the turn of the nineteenth century were Philippe Pinel in France and Dorothea Dix in the United States. These reformers railed against a system that treated the mentally ill as if they were criminals, even caging and beating them. These two helped bring about the development of separate and kinder institutions for people with severe psychological disorders. Several recent trends in the field of mental health in the United States must also be mentioned. Following the development of drugs in the 1950s that could moderate the effects of severe disorders, many people were released from mental institutions. This phenomenon, called deinstitutionalization, was intended to save money as well as benefit the former inpatients. Unfortunately, deinstitutionalization was far less successful than initially hoped. Their psychological needs were supposed to be met by local clinics on an outpatient basis. Many of the people released, however, were schizophrenics who ended up homeless and delusional, unable to secure the psychological or the financial care they needed. Recently, in the United States, a growing emphasis has been placed on preventative efforts. If psychological problems can be treated proactively, or before they become severe, the suffering of the client as well as the cost of providing care can be reduced. Primary prevention efforts attempt to reduce the incidence of societal problems, such as joblessness or homelessness, that can give rise to mental health issues. Secondary prevention involves working with people at-risk for developing specific problems. One example would be counseling people who live in an area that has experienced a trauma such as a natural disaster or terrorist attack. Psychoanalytic, humanistic, behavioral, and cognitive psychologists share a belief in the power of psychotherapy to treat mental disorders. On the other hand, psychologists who subscribe to a biomedical model assert that such problems require somatic treatments such as drugs. Psychotherapies, except for behavioral treatments, largely consist of talking to a psychologist. Behaviorists, as you know, believe that psychological problems result from the contingencies of reinforcement to which a person has been exposed. Both psychologists with a biomedical orientation and psychoanalysts generally refer to the people who come to them for help as patients. Psychoanalytic Therapy Psychoanalysis is a therapeutic technique developed by Sigmund Freud. Psychoanalysts believe that other methods of therapy may succeed in ridding a client of a particular symptom but do not address the true problem. As a result, psychoanalysts assert that patients will suffer from symptom substitution. Symptom substitution is when, after a person is successfully treated for one psychological disorder, that person begins to experience a new psychological problem. To delve into the unconscious minds of his patients, Freud developed a number of techniques including hypnosis, free association, and dream analysis. Hypnosis, as described in the chapter "States of Consciousness," is an altered state of consciousness. When in this state, psychoanalysts believe that people are less likely to repress troubling thoughts. More commonly, psychoanalysts ask patients to free associate-to say whatever comes to mind without thinking. This technique is based on the idea that we all constantly censor what we say, thereby allowing us to hide some of our thoughts from ourselves. When psychoanalysts use dream analysis, discussed further in Chapter 5, they ask their patients to describe their dreams. All three of these techniques rely heavily on the interpretations of the therapists and are criticized for their inherent subjectivity.

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This act was created after Jimmy Ryce gastritis diet eggs generic esomeprazole 40 mg fast delivery, a 9-year-old boy from South Florida gastritis diet esomeprazole 20 mg, was kidnapped at gunpoint diet for gastritis sufferers buy esomeprazole 40 mg cheap, sexually assaulted youtube gastritis diet 40 mg esomeprazole otc, murdered, and dismembered. The act also raised the penalties for violations of certain laws, and required offenders labeled sexual predators to wait a minimum of 30 years before petitioning for the removal of the designation (Jessica Lunsford Act, 2005). However, if the offender was designated a sexual offender and has been released from supervision for 20 years without rearrest, or if the offender was under 18 at the time of arrest and the victim was 12 or older, and the offender has been released from supervision for 10 years without rearrest, the offender can petition for the removal of the designation sexual offender and be removed from the sexual offender/predator database (Florida Department of Law Enforcement, 2006). Sex Offenders in Florida In the state of Florida, there are two designations for offenders of sexual crimes: sex offenders and sexual predators. Sexual offenders, as classified, present a lesser threat of harm to the community than that of sexual predators. To be classified as a sex offender, one only needs 15 to commit a single violation of a sexual law. Some examples of these violations are the commission of (or attempted) solicitation or conspiracy to commit kidnapping, false imprisonment, attempting to lure a child, sexual battery, procuring a minor for prostitution, lewd or lascivious offenses committed against or in the presence of persons under 16, the elderly or disabled, sexual performance by a child, selling or buying of minors for portrayal in a visual depiction engaging is sexually explicit conduct, and various computer crimes including pornography. Sexual offenders can also be classified as sexual predators by the courts (termed "second strike") if they are convicted of any felony violation or attempt of kidnapping, false imprisonment, attempting to lure a child, sexual battery, procuring a minor for prostitution, lewd or lascivious offenses, sexual performance by a child, or selling or buying of minors for portrayal in a visual depiction engaging is sexually explicit conduct and have a previous conviction for any of the offenses listed for classification of a sex offender, or unlawful sexual activity with certain minors. Biological, psychological, and sociological theories have provided many viable reasons as to why individuals commit sexual offenses. This myriad of theories has made difficult to create a consensus for treatment, and has made it seem as though there is no one theory that can 16 completely account for participation in deviant sexual behavior. Until recently, many of the theories used to explain deviant sexual behavior have lacked empirical support, and empirical studies in this area are still in their infancy (Terry, 2006). This is not unexpected, as it is generally accepted that sexual offenders are a difficult population to sample. But, it is clear that the studies to date have not been adequate enough to provide a sound theoretical background to make any assumptions about sexual offenders. Despite this lack of empirical support, there are some common theories used to describe participation in sexual deviant behavior. Psychodynamic theories describe sexual deviance as a problem associated with developmental problems when dealing with the human psyche (id, ego, and superego). It is difficult to test this theory however, as the id is more of an ideal than something that is tangible, or for that matter, testable. Biological theories suggest that there are physiological reasons for the participation in deviant sexual behavior, such as increased hormone levels or chromosomal makeup. While some rapists have shown that they hate or devalue women, these theories do not adequately account for participation in other sexually deviant behavior that does not have a male female dynamic. Attachment theories suggest that sexually deviant behavior due to the loneliness or isolation felt by loss or emotional distress that can occur in infancy, adolescence, or adulthood. According to this theory, individuals with poor self-esteem and low self-confidence are the most likely to participate in sexually deviant behavior. These theories attribute participation in sexually deviant behavior to classical conditioning, arguing that sexually deviant behavior is learning like any other behavior. Psychosocial theories combine psychological factors and sociological factors to explain sexually deviant behavior. Inappropriate socialization is the catalyst for this behavior according to these theories. Finally, integrated theories try to combine aspects of the individual theories mentioned above to fill in the gaps left by the individual theories alone. Integrated theories posit that a variety of preconditions lead to participation in sexually deviant behavior. These theories focus on the process by which one is motivated to offend and overcomes internal and external inhibitions to participate in the behavior (Terry, 2006). Not all of these disorders are illegal, and not all require actual participation in the activity to be diagnosed. Some only require that impairment in social, occupational, or other important areas of functioning occur from the behavior, sexual urges, or 18 fantasies. Another assessment for sexual offenders is typologies developed from studies on the motivations behind sexual offenses. In some ways, these typologies are diagnostic, and are useful for deciding the best course of action with a given offender, but they have limited predictive power for the general public. There are typologies for rapists, such as sexually motivated and non-sexually motivated. Non-sexually motivated offenders can be classified as power/control (offender desires power or dominance), opportunistic (adventure seeker who commits offense during another offense), or mass rape (seen in war situations where the offender has a need for power while using rape as a weapon) (Terry, 2006). Child molesters can be categorized into two groups, situational and preferential, with numerous subgroups. Preferential offenders prefer children as the focus of their sexual activity, whereas situational offenders offend against children because of a lack of other options (Holmes and Holmes, 2002). Within situational offenders, there are regressed offenders (poor coping skills, victims are easily accessible), morally indiscriminate (offenders use children, or anyone available, for their sexual needs), sexually indiscriminate (abuse children out of boredom, sexually experimental), and inadequate (relationships with children are the only sexual outlet available due to social awkwardness caused by low self-esteem and insecurities). Preferential offenders can be categorized into seductive offenders (court children and try to have real relationships with them), fixated offenders (poor psychosexual development leads to a desire for 19 children that is compulsive) and sadistic offenders (aggressive, excited by violence, target strangers and are very dangerous) (Holmes and Holmes, 2002). Other typologies for child molesters separate offenders into fixated and regressed offenders. Fixated offenders are more likely to reoffend, as they have a compulsive attraction to children. These offenders target extrafamilial female or males, with premeditated offenses which emerge in adolescence. Regressed offenders begin offending in adulthood, with offending brought on by stressors.

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The expiratory component of vesicular sounds probably originates in more proximal gastritis acute diet order esomeprazole 40mg visa, larger airways gastritis symptoms in toddlers generic 20 mg esomeprazole visa. The intensity of the inspiratory component of breath sounds gastritis diet cheap esomeprazole 20 mg visa, corrected for flow rate at the mouth gastritis earth clinic generic 40 mg esomeprazole mastercard, is roughly proportional to regional ventilation. The inspiratory component of vesicular sounds remains the same as the stethoscope is moved progressively from the upper to lower posterior chest, although the expiratory component becomes softer. Vesicular sounds contain low-frequency components lacking in tracheal sounds that cannot be reproduced in experiments interposing inflated lung between the trachea and the stethoscope. They are normally heard over the right upper chest posteriorly but not over the left upper chest, because the trachea is contiguous with the right lung near the first thoracic vertebra but separated from the left lung by most of the mediastinum. AsymmetricalBreathSoundsafterIntubation If the endotracheal tube is placed too low during intubation of a patient, it risks intubating the right mainstem bronchus and leaving the left lung unventilated, a complication that logically would produce asymmetrical breath sounds. Confirmation of appropriate tube placement by means other than physical examination is always indicated. Normally, the voice sounds muffled, weak, and indistinct over most of the inferior and posterior chest, and words are unintelligible. Abnormal vocal resonance is classified as either bronchophony, pectoriloquy, or egophony, all terms originally introduced by Laennec. Bronchophony Bronchophony describes a voice that is much louder than normal, as if the sounds were emitted directly into the stethoscope. Most clinicians test this by having the patient whisper words like "one-two-three"; intelligible whispered speech is called whispered pectoriloquy. In this experiment, a speaker emitting pure musical tones of different frequencies was placed in the mouth of patients with normal lungs (solid line), pneumonia (long dashes), or pleural effusion (short dashes). Normal lung behaves like a low-pass filter, which means it easily transmits low-frequency sounds (100 to 200 Hz) but filters out high-frequency sounds (>300 Hz). Tactile fremitus also diminishes as a healthy person sings an ascending scale because the underlying lung resonates less well with higher pitches. According to Figure 28-2, consolidated lung transmits both high and low frequencies well; this explains why patients with pneumonia may simultaneously exhibit both increased tactile fremitus and abnormal vocal resonance. A moderate or large pleural effusion, in contrast, may decrease transmission of frequencies below 200 to 300 Hz but augment those greater than 400 Hz, compared with normal lung (see. Nonetheless, egophony (abnormal vocal resonance) in patients with pleural effusion is an inconstant finding, and many patients instead demonstrate reduced or absent vocal resonance over the affected side. Laennec himself taught that egophony is not always present in pleural effusion but first appears when effusions are moderate in size, then disappears as effusions continue to grow larger, and finally reappears as effusions began to resolve. This explanation has never been verified, and it remains a mystery why some patients with effusion have prominent egophony over large areas of the posterior chest wall yet others have diminished vocal resonance. The only study of this finding shows that pleural effusions producing abnormal vocal resonance. According to traditional teachings, an obstructed bronchus should diminish vocal resonance. Adventitious sounds have the most ambiguous and confusing nomenclature in all of physical diagnosis, and studies show clinicians use up to 16 different terms in scientific publications to describe similar sounds. Crackles Crackles are discontinuous sounds, resembling the sound produced by rubbing strands of hair together in front of the ear or by pulling apart strips of Velcro. There are coarse crackles, which are loud, low-pitched, and fewer in number per breath, and fine crackles, which are soft, higher-pitched, and greater in number per breath. Crackles that appear early during inspiration and do not continue beyond midinspiration are called early inspiratory crackles; those that continue into the second half of inspiration are called late inspiratory crackles. If sound were conducted down the airways, its characteristics would change with different gas mixtures. To elicit the finding, the clinician listens to the lower chest wall near the posterior axillary line with the patient in three sequential positions: sitting, supine, and supine with legs elevated 30 degrees. If crackles are absent when the patient is upright but appear when the patient either is supine or has the legs elevated, the test is positive. WheezesandRhonchi According to the American Thoracic Society, a wheeze is a high-pitched, continuous musical sound and a rhonchus is a low-pitched one (see Table 28-1). This distinction may be superfluous because both sounds have the same pathophysiologic characteristics, and there is no proven clinical importance to separating them. The term rhonchus is probably best avoided, not only for these reasons but also because many use the term to refer to the coarse discontinuous sounds heard in patients with excess airway secretions. Stridor Stridor is a loud, musical sound of definite and constant pitch (usually about 400 Hz) that indicates upper airway obstruction. Stridor is confined to inspiration, whereas wheezing either is confined entirely to expiration (30% to 60% of patients) or occurs during both expiration and inspiration (40% to 70% of patients)51,52 2. Stridor is always louder over the neck, whereas wheezing is always louder over the chest52 In some patients with upper airway obstruction, stridor does not appear until the patient breathes rapidly through an open mouth. PleuralRubs Pleural rubs are loud grating or rubbing sounds associated with breathing that occur in patients with pleural disease. Sometimes, a pleural rub has a crackling character (pleural crackling rub) and acoustically resembles the crackles heard in patients with parenchymal disease. InspiratorySquawk the squawk is a short, late inspiratory musical sound associated with parenchymal crackles in patients with interstitial lung disease,57 although the sound has also been described in pneumonia. Crackles Crackles39,47,54,60­62 were initially attributed by Laennec and early auscultators to air bubbling through airway secretions. Although some crackles result from secretions, these promptly clear after the patient coughs. All remaining crackling sounds are felt to represent the sounds of distal airways, collapsed from the previous exhalation, as they abruptly open during inspiration. Crackles are predominantly heard during inspiration, whereas air bubbling through secretions would cause both inspiratory and expiratory sounds.

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Androgen reducing medications ("anti-androgens") A combination of estrogen and "anti-androgens" is the most commonly studied regimen for feminization gastritis diet purchase 40 mg esomeprazole overnight delivery. Androgen reducing medications collagenous gastritis definition discount 20 mg esomeprazole visa, from a variety of classes of drugs gastritis diet wikipedia buy generic esomeprazole 20 mg on-line, have the effect of reducing either endogenous testosterone levels or testosterone activity chronic gastritis outcome discount esomeprazole 20 mg with amex, and thus diminishing masculine characteristics such as body hair. They minimize the dosage of estrogen needed to suppress testosterone, thereby reducing the risks associated with high-dose exogenous estrogen (Prior, Vigna, Watson, Diewold, & Robinow, 1986; Prior, Vigna, & Watson, 1989). Common anti-androgens include the following: Spironolactone, an antihypertensive agent, directly inhibits testosterone secretion and androgen binding to the androgen receptor. Blood pressure and electrolytes need to be monitored because of the potential for hyperkalemia. However, these medications are expensive and only available as injectables or implants. These medications have beneficial effects on scalp hair loss, body hair growth, sebaceous glands, and skin consistency. Progestins With the exception of cyproterone, the inclusion of progestins in feminizing hormone therapy is controversial (Oriel, 2000). Because progestins play a role in mammary development on a cellular level, some clinicians believe that these agents are necessary for full breast development (Basson & Prior, 1998; Oriel, 2000). Progestins (especially medroxyprogesterone) are also suspected to increase breast cancer risk and cardiovascular risk in women (Rossouw et al. Micronized progesterone may be better tolerated and have a more favorable impact on the lipid profile than medroxyprogesterone does (de Ligniиres, 1999; Fitzpatrick, Pace, & Wiita, 2000). Oral testosterone undecenoate, available outside the United States, results in lower serum testosterone levels than non-oral preparations and has limited efficacy in suppressing menses (Feldman, 2005, April; Moore et al. Because intramuscular testosterone cypionate or enanthate are often administered every 2-4 weeks, some patients may notice cyclic variation in effects. This may be mitigated by using a lower but more frequent dosage schedule or by using a daily transdermal preparation (Dobs et al. Intramuscular testosterone undecenoate (not currently available in the United States) maintains stable, physiologic testosterone levels over approximately 12 weeks and has been effective in both the setting of hypogonadism and in FtM individuals (Mueller, Kiesewetter, Binder, Beckmann, & Dittrich, 2007; Zitzmann, Saad, & Nieschlag, 2006). There is evidence that transdermal and intramuscular testosterone achieve similar masculinizing results, although the timeframe may be somewhat slower with transdermal preparations (Feldman, 2005, April). Especially as patients age, the goal is to use the lowest dose needed to maintain the desired clinical result, with appropriate precautions being made to maintain bone density. World Professional Association for Transgender Health 49 the Standards of Care 7th Version Other agents Progestins, most commonly medroxyprogesterone, can be used for a short period of time to assist with menstrual cessation early in hormone therapy. 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 custom compounded bioidentical hormones are safer or more effective than government agency-approved bioidentical hormones (Sood, Shuster, Smith, Vincent, & Jatoi, 2011). Therefore, it has been advised by the North American Menopause Society (2010) 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. Because feminizing/masculinizing hormone therapy limits fertility (Darney, 2008; Zhang, Gu, Wang, Cui, & Bremner, 1999), it is desirable for patients to make decisions concerning fertility before starting hormone therapy or undergoing surgery to remove/alter their reproductive organs. 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, 2002). Health care professionals ­ including mental health professionals recommending hormone therapy or surgery, hormone-prescribing physicians, and surgeons ­ should discuss reproductive options with patients prior to initiation of these medical treatments for gender dysphoria. These discussions should occur even if patients are not interested in these issues at the time of treatment, which may be more common for younger patients (De Sutter, 2009). Besides debate and opinion papers, very few research papers have been published on the reproductive health issues of individuals receiving different medical treatments for gender dysphoria. Another group who faces the need to preserve reproductive function in light of loss or damage to their gonads are people with malignances that require removal of reproductive organs or use of damaging radiation or chemotherapy. 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 an article reporting on the opinions of MtF individuals towards sperm freezing (De Sutter et al. Sperm should be collected before hormone therapy or after stopping the therapy until the sperm count rises again. In adults with azoospermia, a testicular biopsy with subsequent cryopreservation of biopsied material for sperm is possible, but may not be successful. Reproductive options for FtM patients might include oocyte (egg) or embryo freezing. 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 testosterone levels (Hunter & Sterrett, 2000). While not systematically studied, some FtM individuals are doing exactly that, and some have been able to become pregnant and deliver children (More, 1998). Patients should be advised that these techniques are not available everywhere and can be very costly. Transsexual, transgender, and gender nonconforming people should not be refused reproductive options for any reason. A special group of individuals are prepubertal or pubertal adolescents who will never develop reproductive function in their natal sex due to blockers or cross gender hormones. At this time there is no technique for preserving function from the gonads of these individuals. World Professional Association for Transgender Health 51 the Standards of Care 7th Version X Voice and Communication therapy Communication, both verbal and nonverbal, is an important aspect of human behavior and gender expression.

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