Susan Ivey MD, MHSA
- Adjunct Professor, UCB/UCSF Joint Medical Program
https://publichealth.berkeley.edu/people/susan-ivey/
Codeine causes as much nausea symptoms liver cancer buy discount cabgolin, vomiting symptoms 0.5 mg cabgolin with amex, constipation and ileus as a dose of morphine of similar analgesic potency symptoms during pregnancy purchase cabgolin 0.5 mg with mastercard. It also causes as much respiratory depression and hypotension (due to histamine release) symptoms and diagnosis discount cabgolin 0.5mg amex. Much is finally excreted after conjugation with glucuronic acid in the urine, making repeated, or high-dose, administration hazardous where there is renal or liver failure. Little has been published relating to the use of codeine in babies less than 3 months old. Tolerance develops with repeated use, and withdrawal symptoms have been documented, even in infancy. While the highest blood level usually achieved is less than a third of the lowest therapeutic blood level, a minority of babies inherit a gene that results in their metabolising very much more of the codeine into morphine, and there is one recent report where this may have caused death from opiate toxicity. In the United Kingdom and Europe, codeine is now contraindicated during breastfeeding. Antidote Overdose causes drowsiness, pinpoint pupils and hypotension and can cause dangerous respiratory depression. Treatment Because it is contraindicated in children less than 12 years, no dosing is given here. Supply Staff caring for mothers should be aware that some tablets of co-codamol, still widely used as an analgesic after childbirth, contain as much as 30mg of codeine as well as 500mg of paracetamol. Pharmacogenetics of morphine poisoning in a breast fed neonate of a codeine-prescribed mother. A comparison of rectal and intramuscular codeine phosphate in children following neurosurgery. Prediction of codeine toxicity in infants and their mothers using a novel combination of maternal genetic markers. Pharmacogenetics of codeine metabolism in an urban population of children and its implications for analgesic reliability. It is an effective treatment for two important protozoan intestinal infections (isosporiasis and cyclosporiasis). Pharmacology Co-trimoxazole is a 5:1 mixture of two different antibiotics that inhibit folic acid synthesis in protozoa and bacteria (and, to a lesser degree, in man). The bacte riostatic effect of the long-acting sulphonamide (sulfamethoxazole) is augmented by the syner gistic effect of trimethoprim (q. The two drugs in combination are active against most common pathogens except Pseudomonas and Mycobacterium tuberculosis. Both drugs are well absorbed by mouth and actively excreted by the kidney with half-lives of about 12 hours. Use during lactation only exposes the baby to about 3% of the weight-adjusted maternal dose. Because both drugs are folate antagonists, the manufacturers still caution against their use during pregnancy, but teratogenicity has only been encountered in folate-deficient animals, and the drug has now been in widespread clinical use for more than 30 years. Caution is understandable however given the unnecessary deaths caused by the prophylactic use of sulphonamide drugs in the early 1950s (as outlined in the monograph on sulfadiazine). Nevertheless, since the problems (including rashes, erythema multiforme and marrow depression) are almost certainly due to the sulphonamide component, trimethoprim is now increasingly prescribed on its own. Drug interactions Treatment with co-trimoxazole increases the plasma half-life of phenytoin. Thus, 20mg/kg of sulfamethoxazole and 4 mg/kg of trimethoprim are prescribed as 24 mg/kg of active drug. Measles: Complications in a resource-poor country can be reduced by giving co-trimoxazole for 7 days. Avoid in babies with limited renal function, unless the plasma sulfa methoxazole trough level is kept below 120mg/l (1mg/l=3. Timing: Give once a day in the first week of life and once every 12 hours after that. Treat Pneumocystis once every 6 hours in babies over 4 weeks old, even if the blood level exceeds 120 mg/l. Supply and administration A sugar-free paediatric oral suspension containing 48mg of active drug per ml (240mg/5ml) costs 1. Cotrimoxazole in the treatment of acute uncomplicated falciparum malaria in Nigerian children: a controlled clinical trial. Prophylactic antibiotics to prevent pneumonia and other complications after measles: community based randomised double blind placebo controlled trial in Guinea-Bissau. Pharmacology Dalteparin is prepared by nitrous acid degradation of unfractionated heparin from porcine intestinal mucosa. Doses of 7500 units or higher may be given as two smaller doses, but otherwise, once daily dosing is appropriate. Stop 24 hours prior to any planned operative (or epidural) delivery until 4 hours after the procedure is over. Treatment: Give a 100 unit/kg dose of dalteparin by subcutaneous injection once every 12 hours. Start treatment promptly, as soon as a clot or embolus is seriously suspected, after first taking blood for a full thrombophilia screen and confirm that renal and liver function are normal. Routine measurement of peak anti-Xa activity is not usually indicated unless the woman weighs less than 50 kg or more than 90 kg. Neonatal treatment (including infants up to 12 months) Bear in mind that experience is extremely limited. Antidote Protamine sulphate will usually stop overt haemorrhage as summarised in the monograph on heparin. Supply and administration the drug is available in a range of pre-filled syringes (0. Avoid the use of the 4ml multi-dose vial (contains 100,000 units) which contains benzyl alcohol. To make a more dilute 1250 unit/ ml preparation for accurate neonatal use, draw 0. Pharmacological and clinical differences between low-molecular-weight heparins: implications for prescribing practice and therapeutic interchange. The low molecular weight heparin dalteparin for prophylaxis and therapy of thrombosis in childhood: a report on 48 cases. Dalteparin for the prevention of recurrence of placental-mediated complications of pregnancy in women without thrombophilia: a pilot randomized controlled trial. Pharmacology in pregnancy Dexamethasone, a potent glucocorticoid that is well absorbed by mouth, was developed in 1958. It appears as effective as betamethasone in accelerating surfactant production by the preterm fetal lung, reducing the risk of death from respiratory distress. Maternal treatment alters fetal heart rate and its variability and marginally enhances renal maturation. Treatment can control virilisation in fetuses with congenital adrenal hyperplasia, and 4 mg a day may improve the outcome if maternal lupus erythematosus causes fetal heart block (with salbutamol if the heart rate is <55 bpm). Dexamethasone is excreted into breast milk, but it would require prolonged courses of high doses to produce effects in the breastfed infant. Pharmacology in the neonate Dexamethasone can speed extubation in a minority of babies with laryngeal oedema.
W h atis th e role ofgenom icim printing Th e majority ofde novo meth ylation is targeted to transposons and th eir remnants and to repeats such as pericentricsatellite sequences with smaller inm ale germ cells Epigenetic modifications occurring meth ylation th atwillresultin monoallelic expression in th e embryo and during germ cell development are postulated to play roles in gene postnatalindividual treatment skin cancer generic cabgolin 0.5mg on-line. W ithineach regiontherearem ultiplesegm entsseparatedbysepta medications gabapentin generic cabgolin 0.5mg fast delivery, with the num bers of segm ents within each region being variable medications similar to xanax generic 0.5mg cabgolin overnight delivery. Sperm atoz oa leaving the testis are neitherm otile norable to recogniz e orfertiliz e anegg;theym usttraverse a long duct symptoms 0f yeast infectiion in women cheap 0.5mg cabgolin with visa,the epididym is,to acquire these abilities. These post-testicular transform ations of sperm atoz oa are collectively called sperm m aturation. The epididym is is a single highly convoluted duct/tube of approx im ately 1 m eterin length in the m ouse,3 m eters inthe rat,6 m eters inthe hum ananda rem arkable 18 m eters inthe stallion. Hence,itcan take anywhere from 1 to 14 days forsperm atoz oa to traverse the epididym is. It was thought that the m aturation process was inherent to sperm atoz oa andhadlittle to do with the epididym is. Itis now clearthatthe epididym is is verym uch an active participantin the m aturation process,not only providing an appropriate lum inal fluid m icroenvironm ent, butalso supplying m anyof them oleculesrequiredbysperm atoz oafortheacquisition of fertility. To the rightare shown cross-sectional environm ent for storage following the m aturation process. F rom a clinicalperspective,anim properfunctioning including:principal,basal,apical,halo,clearandnarrow cells,each of which epididym is results in m ale infertility and therefore, the epididym is is vary in num berand siz e along the epididym alduct. F orex am ple,principal consideredtobeaprim etargetforthedevelopm entof am alecontraceptive. Through ex tensive analyses a m uch clearerpicture is beginning to em erge regarding the functionof each Structureof theepididym is celltype withineach epididym alregion. It of T lym phocytes,m onocytes and cytotox ic T-lym phocytes and m ayhave a is now clear thatbarrier function is a com plex interaction between the role in im m une protection. The function of apicalcells is unclear;however, perm eability properties of the basalateral and apical m em branes. The bestknownof the nullm utations is R os1 (c-R os),an orphan tyrosine kinase receptor. Sperm atoz oa from these nullanim als display flagella angulation when ex posedtotheuterine,hypo-osm otic environm ent,rendering them incapable of reaching the egg forfertiliz ation. Interestingly,the initialsegm entwas foundto be undevelopedinthese anim als,suggesting thatthe veryprox im al region of the epididym is is im portantform ale fertility. In view of there being a blood-testis barrier,itis notsurprising to find a In sum m ary,the epididym is prom otes sperm m aturation,facilitates the sim ilarprotective barrierthroughoutthe epididym is. Soon afterejaculation,the sem en coagulates,form ing a gelatinous clot thatrestricts free m ovem entof sperm atoz oa. To m inutes,the coagulated sem en begins to liquefy as a resultof proteolytic appreciate its function,one m ustunderstand the role of accessory sex digestion by enz ym es produced in the prostate gland. Sem en consists of sperm atoz oa and the fluid bathing them cervix and eventuallyupstream to the ovulated egg. Itisgenerallyacceptedthatsem inalplasm asubstancesarenotessential Prostateglandanatom y forfertiliz ation of the egg by m ature sperm. Zinc and IgA actas bacteriostatic factors while anti-agglutination proteins Although the prostate gland is notlobular,there are distinctive regions or preventsperm cellsfrom clum ping together. The centralz one,lies between the ejaculatory ducts from the the epididym is through thevasdeferens,propelledbyperistaltic contractions bladderbase to the verum ontanum andrepresents ~20% glandularvolum. The last develops in the periurethraland transition z ones surrounding the prox im al and largestfraction of the ejaculate com es from the sem inalvesicles and urethra whereas m ostprostate cancers develop within the peripheralz one. Prostate canceris the m ostcom m on noncutaneous cancerinAm erican m en and the second leading cause of cancer-related deaths in the U nited States. R isk factors include aging,fam ily history and ethnicity with African Am erican m en having a 2:1 incidence ratio com pared to Caucasians and Asian m en having the lowestincidence world-wide. At present,itis notpossible to distinguish between these cancertypes during early stage disease m aking treatm entchoices difficult. Treatm ents focused on new drugs and vaccines are origin from the endoderm al urogenital sinus in contrastto the other currentlyunderdevelopm ent. These are diseases of the aging m ale,m ostoften Suggestedreading appearing afterthe age of 50. Prostatitis,an inflam m atory condition of the prostate N eill,Academ ic Press;1998;360-67. In:Com prehensiveTex tbook sym ptom of this disease is pelvic pain and treatm ents m ay include of GenitourinaryO ncology,Secondedition. E d:N J Vogelz ang, antibiotics,alpha-blockers,anti-inflam m atory drugs,m uscle relax ants,heat P Scardino,W U Shipley,D S Coffey,W illiam s& W ilkins;2000;600-20. H ow does sem en analysis assistin understanding lowerquality than those recovered during sex ualintercourse. In otherspecies such,as cattle, horse, and m any of the z oo anim als, sem en is collected by electro ejaculation. In m onkeys,stim ulation using a penile cuff appears to be m ore efficientthanelectro-ejaculation. Collection using a condom during intercourse is not recom m ended because of presence of sperm icidalorinterfering agents in som e condom s and loss of partof the ejaculate during intercourse. The duration of abstinence is noted because shortperiods of abstinence are associated with low sem en volum es and sperm num bers. M ajor elem ents of a hum an sperm atoz oon thatare com m on to allowed to liquefy (by proteases presentin the sem inalfluid) and the m am m alian species. Suppression of the num ber or m otility of usuallyatleasttwo sem ensam ples arerequriedto diagnose thatthe sem en sperm atoz oa in the ejaculate to very low levels is the goal of m ale quality is below the reference range of adultm en. However,inclinicalm edicine sem enanalyses is 4500sam plesfrom m enliving infourcontinentsgivesthereferencerangeof used prim arily for the diagnosis and treatm entof m ale infertility. Thelowerreferencelim its(5 percentile)forsem enparam etersin diagnosis form ale infertility is dependent,in large part,on the analysis of fertileadultm enare: sem ensam ples. M ostm endiagnosedwith have defects insperm atogenesis resulting in low sperm concentration (oligoz oosperm ia),which is generally sem envolum e1. Thus when sem en sperm concentration15m illion/m L analyses showedgrosslylow values m ale factorinfertilityis diagnosed. The sperm progressivem otility32%,totalsperm m otility40% concentration and the quality of sperm param eters guide the clinician to sperm vitality58% alive determ inetheappropriatetreatm entandestim ationof theprognosis. This study showed O ther tests to assess sperm function m ay include the ability of thatincreasing sperm concentrationup to40m illion/m L wereassociatedwith sperm atoz oa to interactand penetrate hum an cervicalm ucus and sperm increasing conception probability. Assessm entof sperm function m ay sperm concentration,totalsperm countand the proportion of sperm with include tests of sperm chrom atin(sperm dam age,Chapter13);the abilityof norm alm orphology are im portantpredictors of m ale fertility up to certain the sperm to swellunderhypo-osm otic conditions (testof sperm m em brane thresholds. Increasing these param eters to beyond these thresholds didnot integrity);the ability of the sperm head to lose the acrosom e cap upon appear to increase the conception probability. Com puter assisted assessm entof sperm m otility characteristics has notproven to be Suggestedreading very usefulfor clinicaldiagnosis butis frequently used in research and epidem iologicalstudies. R odentsem en does notliquefy and Health O rganiz ation reference distribution of hum an sem en cannotbeusedforanalyses. R angeof m ethodsthatassesssperm chrom atinquality There are a num ber of ways of groupings these m any assays. Assaysusedtoevaluategenom ic integrityinclude: International standards to assess sem en param eters have been developed and updated over several decades by the W orld Health Com etAssay. Sm all,brokenpieces of D N A m igrate awayfrom discussedinChapter12,these param eters are usefulinpopulationstudies. The Atthe ex trem es of param eters such as sperm num ber,concentration or percentage of the D N A in the tailof the com etand the taillength are sperm m otility,itis clear thatthere is a strong correlation with fertility m easuredusing specific im ageanalysissoftware. This dam aged and capable of supporting the developm entof norm al,healthy assaycanberunaseitheraslide-basedorflow-cytom etryassay. This assay depends on the principle candelivertheirdam agedchrom atinto the oocyte. An advantage of this Therearem anyaspectsof thecom ponentsof thenucleiof sperm atoz oa assayis thatitrequires verysm all(nanogram)am ounts of D N A,butitis thatcanbeassessed. D N A m ethylation of cytosine residues is one of the based assay wherein the susceptibility of sperm chrom atin to m ajorepigenetic m arks established during sperm atogenesis. M ethods denaturation in acid and detergentis determ ined by using acridine for assessing changes in m ethylation at specific sites are well orange,a dye thatbinds to double-orsingle-stranded D N A,giving a established,butseveralm ethods are underrapid developm entthatwill green or red fluorescence, respectively. Alterations in eitherthe am ountand distribution of histones m easure the am ounts of protam ine present.
On the lower extremities medications you can take when pregnant cabgolin 0.5 mg free shipping, the hips are bilaterally dislocated with knees extended treatment 2 prostate cancer generic 0.5mg cabgolin free shipping, and the feet have equinovarus contractures medications with weight loss side effects best purchase for cabgolin. A contracture of a joint could be in a permanently flexed position or a straightened position with restricted movement of the joint symptoms 12 dpo buy cabgolin 0.5 mg mastercard. The shoulders, elbows, knees, wrists, ankles, fingers, toes, and hips are commonly affected. Arthrogryposis multiplex congenita is a heterogeneous condition that could be secondary to disorders of the central or peripheral nervous system, maternal myasthenia gravis, connective tissue disorders leading to decreased fetal movement, vascular causes, uterine crowding caused by uterine fibroids or other uterine anomalies, environmental factors, maternal infections (cytomegalovirus or toxoplasmosis), or teratogenicity. Approximately 50% of cases have a genetic basis, so a thorough family pedigree should be obtained. Thirty percent to 40% of patients have early feeding problems, often necessitating gastrostomy tube or nasogastric tube feedings. Increased rates of bowel atresia and abdominal wall musculature deficiencies have been noted due to vascular pathology. Patients frequently require extensive physical therapy, casting, and orthopedic procedures. Most have gross and fine motor delays, but have normal intelligence and communication skills. Individuals are quite capable of excelling scholastically, but will require extensive parental support because of their physical limitations. Patients are at risk for scoliosis in childhood and arthritis in affected joints starting in the third decade of life. They also have dental problems, hearing loss, and occasionally cleft lip and palate, along with normal intelligence. Peroxisomal biogenesis disorders in the newborn period present with hypotonia, poor feeding, distinctive facies, seizures, and liver cysts with hepatic dysfunction. Prader-Willi syndrome is characterized by severe hypotonia and feeding difficulties in early infancy, followed by excessive eating and gradual development of morbid obesity. Patients have cognitive impairment, hypogonadism, short stature, and a distinctive behavioral presentation (temper tantrums, stubbornness, and obsessive-compulsive behaviors). Crouzon syndrome, peroxisomal disorders, and Prader-Willi syndrome do not present with congenital contractures. Perinatally lethal osteogenesis imperfecta presents with relative macrocephaly, dysmorphic facies, dark blue sclera, intrauterine growth restriction, extreme bowing and shortening of extremities caused by multiple underlying fractures, hypoplastic thorax, and rib fractures, with early death resulting from pulmonary insufficiency. Patients have symmetric congenital rigid contractures involving internal rotation of the shoulders, fixed extension of the elbows, pronation of the forearm, flexion of the wrist, and significant equinovarus deformity of the foot. He is breastfeeding well, but is not eating as much pureed food as he did before the illness. On physical examination, you find erythematous papules and pustules on the penis, scrotum, and inner thighs (Item Q269). There are bilateral middle ear effusions and a few white plaques on the buccal mucosa. An oral antifungal suspension should be used when oral thrush coexists with perineal candidiasis. The diagnosis is usually based on the characteristic clinical findings: beefy red plaques with satellite papules and pustules typically involving the inguinal creases, lower abdomen, mons, scrotum, and base of penis. Microscopic examination of a potassium hydroxide preparation of a smear from a pustule will demonstrate budding yeast or pseudohyphae, but this need only be performed in the case of recalcitrant diaper dermatitis or a severely ill infant. Topical antifungal treatment for candidiasis localized either to the diaper area or oral mucosa would be appropriate. The presumptive cause of diaper dermatitis should be identified to select the appropriate treatment. Antibiotics should be used to treat bacterial infections; Streptococcus typically causes a perianal erythematous rash, whereas Staphylococcus may cause cellulitis or bullous impetigo on the buttocks. Topical antibiotic cream or ointment may be used for well-localized superficial bacterial skin infections. Oral antibiotics should be prescribed for widespread lesions, cellulitis, systemic symptoms, or if there is a concurrent bacterial infection, such as otitis media. In contrast to candidiasis, irritant diaper dermatitis typically spares the intertriginous creases and involves the convex surfaces of the buttocks. The primary method of treatment for irritant dermatitis is frequent diaper changes to keep the area clean and dry. A protective barrier cream, such as zinc oxide or petrolatum-based preparations, can aid in healing. When applied at every diaper change such creams are effective in forming a barrier to protect the skin from ongoing contact with stool and urine. Topical corticosteroids should rarely be used, and only to treat severely inflamed irritant diaper dermatitis. Only low-potency nonhalogenated topical corticosteroid creams should be used, sparingly, twice daily for no longer than 3 to 5 days. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. Among the childhood leukemia diagnoses, the vast majority are acute leukemia, either lymphoid or myeloid. The 2 forms of childhood acute leukemia behave and are treated in very different manners, and have vastly different prognoses. Historically, these were differentiated on the basis of light microscopic appearance and histochemical stains. The cells are incubated with antibodies to surface markers that are conjugated to fluorochromes. After incubation, the cells are drawn in a single file through the flow cytometer in which various lasers hit the cells. If the wavelength of light emitted by the laser excites the fluorochrome conjugated to the antibody, a different wavelength of light is emitted by the fluorochrome that can be detected by the flow cytometer. If that second wavelength is detected, then the targeted surface marker is present on the cell. Irrelevant of the diagnosis, the patient will need a central venous catheter to deliver the chemotherapy. Biology, risk stratification, and therapy of pediatric acute leukemias: an update. After discussing the treatment options, the parents have elected to initiate methylphenidate and plan a follow-up appointment with you in 4 weeks. In addition to these risks, more than 10% of children using stimulants will also experience headaches, stomach aches, dry mouth, and nausea. Two percent to 10% of children using stimulants will experience irritability, dysphoria, cognitive dulling, obsessiveness, anxiety, tics, dizziness, or blood pressure and pulse changes. Less than 2% of children using stimulants could have a notable, but rare reaction of hallucinations (usually visual or tactile rather than auditory) or manic symptoms; these are typically risks that appear when using stimulants at high doses. Of the options listed in the vignette, headaches are the most likely to be experienced by this child. Feedbackfromread roanatomywith basic information in neurology,or ers wasextremelypositive and the book wastrans for revision of the basics of neuroanatomyw ill lated intonumerous languages, proving that the benefit even morefromit. That would go beyond the scope roanatomyw ith the subject of neurological syn of the book and also contradict the basic concept dromes, including modern imaging techniques. Firstand foremostwewant to de this regard we thank our neuroradiology col monstratehow,onthe basis of theoretical ana leagues, and especiallyDr. Kueker,for providing us tomical knowledge and agood neurological exami with images of very high quality. The cause of alesion is initially book,whichparticularly meets the needs of medi irrelevant for the primarytopical diagnosis, and cal students. Modern medical curricula requirein elucidation of the etiology takes place in asecond tegrative knowledge,and medical studentsshould stage. Our book contains acursoryoverviewofthe be taught howtoapplytheoretical knowledge in a major neurologicaldisorders, and it is notintended clinical settingand, on the other hand, to recognize to replace the systematic and comprehensive clinical symptoms by delving into their basic coverage offeredbystandardneurological text knowledge of neuroanatomyand neurophysiology. Our book fulfils these requirementsand illustrates We hope that this newDuus, likethe earlier the importance of basic neuroanatomical knowl editions, will merit the appreciation of its edge for subsequent practical work,asitincludes audience, and we look forward to receiving read actual case studies. Alesion of the eyes closedwithout wobbling and perhaps fal anterior spinothalamic tract at a cervical level, ling over. The loss of proprioceptive sense can however, will produce mild hypesthesia of the con be compensated for,toaconsiderable extent, by tralateral lowerlimb.
Other health professionals with appropriate training in behavioral health treatment definition statistics buy cheap cabgolin on line, particularly when functioning as part of a multidisciplinary specialty team providing access to feminizing/masculinizing hormone therapy medicine 5513 best 0.5 mg cabgolin, may also screen for mental health concerns and medications ending in lol purchase cabgolin 0.5 mg on-line, if indicated spa hair treatment generic cabgolin 0.5 mg fast delivery, provide referral for comprehensive assessment and treatment by a quali ed mental health professional. Mental health professionals can help clients who are considering hormone therapy to be both psychologically prepared. Referral for feminizing/masculinizing hormone therapy People may approach a specialized provider in any discipline to pursue feminizing/masculinizing hormone therapy. Hormone therapy can be initiated with a referral from a quali ed mental health professional. Alternatively, a health professional who is appropriately trained in behavioral health and competent in the assessment of gender dysphoria may assess eligibility, prepare, and refer the patient for hormone therapy, particularly in the absence of signi cant coexisting mental health concerns and when working in the context of a multidisciplinary specialty team. The recommended content of the referral letter for feminizing/masculinizing hormone therapy is as follows: $. A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this. However, mental health professionals have a responsibility to encourage, guide, and assist clients with making fully informed decisions and becoming adequately prepared. To best support their clients decisions, mental health professionals need to have functioning working relationships with their clients and sufficient information about them. Referral for surgery Surgical treatments for gender dysphoria can be initiated by a referral (one or two, depending on the type of surgery) from a quali ed mental health professional. A statement about the fact that informed consent has been obtained from the patient;). A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this. Relationship of Mental Health Professionals with Hormone Prescribing Physicians, Surgeons, and Other Health Professionals It is ideal for mental health professionals to perform their work and periodically discuss progress and obtain peer consultation from other professionals (both in mental health care and other health disciplines) who are competent in the assessment and treatment of gender dysphoria. Open and consistent communication may be necessary for consultation, referral, and management of postoperative concerns. Psychotherapy Is Not an Absolute Requirement for Hormone Therapy and Surgery A mental health screening and/or assessment as outlined above is needed for referral to hormonal and surgical treatments for gender dysphoria. Third, clients and their psychotherapists differ in their abilities to attain similar goals in a speci ed time period. Typically, the overarching treatment goal is to help transsexual, transgender, and gender-nonconforming individuals achieve long-term comfort in their gender identity expression, with realistic chances for success in their relationships, education, and work. Psychotherapy for Transsexual, Transgender, and Gender-Nonconforming Clients, Including Counseling and Support for Changes in Gender Role Finding a comfortable gender role is, rst and foremost, a psychosocial process. Mental health professionals can provide support and promote interpersonal skills and resilience in individuals and their families as they navigate a world that often is ill-prepared to accommodate and respect transgender, transsexual, and gender-nonconforming people. Psychotherapy can also aid in alleviating any coexisting mental health concerns. For transsexual, transgender, and gender-nonconforming individuals who plan to change gender roles permanently and make a social gender role transition, mental health professionals can facilitate the development of an individualized plan with speci c goals and timelines. Because changing gender role can have profound personal and social consequences, the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. Many transsexual, transgender, and gender-nonconforming people will present for care without ever having been related to , or accepted in, the gender role that is most congruent with their gender identity. Mental health professionals can help these clients to explore and anticipate the implications of changes in gender role, and to pace the process of implementing these changes. Psychotherapy can provide a space for clients to begin to express themselves in ways that are congruent with their gender identity and, for some clients, overcome fears about changes in gender expression. Calculated risks can be taken outside of therapy to gain experience and build con dence in the new role. Assistance with coming out to family and community (friends, school, workplace) can be provided. Other transsexual, transgender, and gender-nonconforming individuals will present for care already having acquired experience (minimal, moderate, or extensive) living in a gender role that differs from that associated with their birth-assigned sex. Mental health professionals can help these clients to identify and work through potential challenges and foster optimal adjustment as they continue to express changes in their gender role. Family Therapy or Support for Family Members Decisions about changes in gender role and medical interventions for gender dysphoria have implications for, not only clients, but also their families (Emerson & Rosenfeld, $%%); Fraser, "##%a; Lev, "##. Mental health professionals can assist clients with making thoughtful decisions about communicating with family members and others about their gender identity and treatment decisions. For example, they may want to explore their sexuality and intimacy-related concerns. Follow-Up Care Throughout Life Mental health professionals may work with clients and their families at many stages of their lives. Psychotherapy may be helpful at different times and for various issues throughout the life cycle. E-Therapy, Online Counseling, or Distance Counseling Online or e-therapy has been shown to be particularly useful for people who have difficulty accessing competent in-person psychotherapeutic treatment and who may experience isolation and stigma (Derrig-Palumbo & Zeine, "##*; Fenichel et al. By extrapolation, e-therapy may be a useful modality for psychotherapy with transsexual, transgender, and gender nonconforming people. E-therapy offers opportunities for potentially enhanced, expanded, creative, and tailored delivery of services; however, as a developing modality it may also carry unexpected risk. Telemedicine guidelines are clear in some disciplines in some parts of the United States (Fraser, "##%b; Maheu, Pulier, Wilhelm, McMenamin, & Brown-Connolly, "##*) but not all; the international situation is even less well-de ned (Maheu et al. Until sufficient evidence based data on this use of e-therapy is available, caution in its use is advised. A more thorough description of the potential uses, processes, and ethical concerns related to e-therapy has been published (Fraser, "##%b). Educate and Advocate on Behalf of Clients Within Their Community (Schools, Workplaces, Other Organizations) and Assist Clients with Making Changes in Identity Documents Transsexual, transgender, and gender-nonconforming people may face challenges in their professional, educational, and other types of settings as they actualize their gender identity and expression (Lev, "##(, "##%). Mental health professionals can play an important role by educating people in these settings regarding gender nonconformity and by advocating on behalf of their clients (Currah, Juang, & Minter, "##); Currah & Minter, "###). This role may involve consultation World Professional Association for Transgender Health #! Provide Information and Referral for Peer Support For some transsexual, transgender, and gender-nonconforming people, an experience in peer support groups may be more instructive regarding options for gender expression than anything individual psychotherapy could offer (Rachlin, "##"). Culture and Its Rami cations for Assessment and Psychotherapy Health professionals work in enormously different environments across the world. Cultural settings also largely determine how such conditions are understood by mental health professionals. Cultural differences related to gender identity and expression can affect patients, mental health professionals, and accepted psychotherapy practice. Professionals must adhere to the ethical codes of their professional licensing or certifying organizations in all of their work with transsexual, transgender, and gender-nonconforming clients. If mental health professionals are uncomfortable with, or inexperienced in, working with transsexual, transgender, and gender-nonconforming individuals and their families, they should refer clients to a competent provider or, at minimum, consult with an expert peer. Issues of Access to Care Quali ed mental health professionals are not universally available; thus, access to quality care might be limited. Providing mental health care from a distance through the use of technology may be one way to improve access (Fraser, "##%b). When faced with a client who is unable to access services, referral to available peer support resources (offiine and online) is recommended. Finally, harm-reduction approaches might be indicated to assist clients with making healthy decisions to improve their lives. Some people seek maximum feminization/masculinization, while others experience relief with an androgynous presentation resulting from hormonal minimization of existing secondary sex characteristics (Factor & Rothblum, "##&). A referral is required from the mental health professional who performed the assessment, unless the assessment was done by a hormone provider who is also quali ed in this area. In selected circumstances, it can be acceptable practice to provide hormones to patients who have not ful lled these criteria. Health professionals should assist these patients with accessing nonhormonal interventions for gender dysphoria. A quali ed mental health professional familiar with the patient is an excellent resource in these circumstances.
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