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A. Merdarion, M.B.A., M.B.B.S., M.H.S.

Co-Director, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine

His cross-dressing was sporadic, rather than continuous, and it did not appear to reflect early femininity-he did not say he wanted to be a girl or have other feminine interests, for example. The most fascinating development came when Zucker interviewed the father, who admitted that he had crossdressed erotically since adolescence. There was no indication that the boy had ever seen his father do this or had any opportunity to learn the behavior from him. I predict (as does Zucker) that when he grows up, the boy is very likely to have some variety of autogynephilia. Highly relevant to the nature-nurture question is whether autogynephilia has occurred in most cultures and times. There are a few more-or-less definitive accounts, such as the Abbй de Choisy, who lived in France from 1644 until 1724. In fact, he once arranged a marriage ceremony in which he dressed as the bride, and the woman as the groom. He clearly experienced crossdressing, and particularly being admired as a woman, as erotic. He had periods in which he felt guilty about his unusual preoccupation and purged, just as contemporary cross-dressers do. The cross-cultural occurrence of autogynephilia has not been well established (in contrast to homosexual transsexualism, which has been). Blanchard has seen autogynephilic transsexualism in immigrants from Europe and Asia. In order to progress scientifically toward the causes of autogynephilia, it will be useful to keep in mind that autogynephilia seems to be a type of paraphilia. Paraphilias comprise a set of unusual sexual preferences that include autogynephilia, masochism, sadism, exhibitionism. Because some of these preferences (especially pedophilia) are harmful, I hesitated to link them to autogynephilia, which is not harmful. But there are two reasons to think that these sexual preferences have some causes in common. First, all paraphilias occur exclusively Copyright © National Academy of Sciences. If a man has one paraphilia, then his chances of having any other paraphilia seem to be highly elevated. There is a dangerous masochistic practice called "autoerotic asphyxia," in which a man strangles himself, usually by hanging, for sexual reasons. Cross-dressing has also been linked to sexual sadism-although most autogynephiles are not sexual sadists, they are more likely to be sadists compared with men who are not autogynephilic. Paraphilias tend to seem bizarre to typical gay and straight people, whose sexual desires are primarily directed toward conventional sex acts with adults. What kind of experiences would make men risk their lives to become sexually aroused from being strangled while wearing panties? My gut feelings may say as much about my biases as they do about the evidence, which is admittedly scanty. However, no one could honestly and competently say that we are anywhere close to understanding the causes of autogynephilia, or more generally, paraphilias. One common lie among autogynephiles, according to Petersen, is that they are homosexual rather than hetero- Copyright © National Academy of Sciences. The motivation for that lie is probably the fear that a gender clinic will deny them a sex change if they are determined to be heterosexual. And indeed, some psychiatrists have taken the position that nonhomosexual transsexuals are uniquely inappropriate for sex reassignment because they are not "true" transsexuals. Other common lies, according to Petersen and others, include an exaggeration of early femininity. The most common way that autogynephiles mislead others is by denying the erotic component of their gender bending. For example, when Stephanie Braverman lectures to my human sexuality class, she does not even mention her history of masturbating while cross-dressed. When I spoke at a meeting of Chicago cross-dressers, the men became clearly uncomfortable when I brought up the erotic component of their activity, preferring instead to attribute it to their inner femininity. You slip your arms through the straps of your brassiere and reach behind you to fasten it.

Research with hypnosis and direct insertion of false information (Loftus & Coan, in press) demonstrates that therapists can take actual events or dreams and suggest that abuse occurred or can generate memories out of whole cloth. For example, children who lived in a neighborhood where a sniper attack occurred on a playground vividly remembered the attack even though they were not present. It seems unlikely that recovery of repressed memories for child sexual abuse occurs with the frequency that is currently being reported. It is difficult to square the rate of abuse repression with the fact that, in a study of children who witnessed the murder of a parent, not a single child repressed the memory. To the contrary, they could not get the images and emotions out of their minds (Malmquist, 1986). Loftus (1993) argues that uncritical acceptance of even the most dubious allegations is a drain on society in interminable therapy, a source of unspeakable anguish for wrongly accused parents, and, perhaps most tragic, the "increased likelihood that society in general will disbelieve the genuine cases of childhood sexual abuse that truly deserve our sustained attention" (p. Nevid, Rathus, and Greene (1994) offer these glimpses into the cultural anthropology of sex. Chapter 10: Sexual and Gender Identity Disorders 159 Some societies believe that men and women eating together is a mild form of sexual behavior. Therefore, in such societies brothers and sisters are forbidden from eating meals together since this behavior approaches incestuous relations. Some women who have charged men with rape have been prosecuted for adultery, but their assailants, claiming that if sex occurred it was consensual, have been acquitted. They suggested that tension caused by fear of failure created a selffulfilling prophesy in the form of erectile disorder and female orgasmic disorder. Helen Singer Kaplan (1979) claimed that all sexual dysfunctions were caused by anxiety. David Barlow and his colleagues (Barlow, Sackheim, & Beck, 1983; Abrahamson, Barlow, Sackheim, Beck, & Athanasiou, 1985; Barlow, 1986) have tested this hypothesis in the laboratory and found it only partially accurate. Fear, it seems, can lead to increased arousal and performance in some men, decreased arousal in others. The initial study sought to simulate in the laboratory the fearfulness some experience in the bedroom. All subjects were sexually functional men, and all were given a harmless but somewhat painful electric shock before being put into one of three conditions. In condition one (control), the subjects were told they were going to watch an erotic movie and they should just enjoy it. In condition two, subjects were told that there was a 60 percent chance of receiving an electric shock while they were watching the erotic movie. Nothing they would do could alter the chances of getting the shock (a noncontingent condition). Condition three was contingent shock: Subjects were told that if they did not achieve an "average" erection, they had a 60 percent chance of receiving a shock. This condition was seen as most closely simulating performance anxiety in the bedroom. Subjects in both shock conditions showed more arousal than those who simply relaxed and the contingent shock group were significantly more aroused than the noncontingent group. Incidentally, research on women (Palace & Garzalka, 1990) produced similar findings. Later, the Barlow team found that although sexually functional men showed increased performance in the shock-demand condition, sexually dysfunctional men showed reduced sexual arousal. Functional men were accurate in estimating their level of arousal, but dysfunctional men underestimated it. Barlow constructed a model that accounts for these puzzling findings and applies to sexual arousal disorders. In essence, functional men have a positive feedback loop that interprets both external and internal sexual stimuli in a way to increase arousal, whereas dysfunctional men have a negative feedback loop that does the opposite. They focus their attention on the erotic stimuli, and when they feel increases in arousal, pay further attention to erotic cues. For dysfunctional men: When there are similar demands for sexual performance, they think of past failures, perceive themselves to have little control, and maintain a negative mood. They focus their attention on the negative consequences of not performing adequately or on other nonerotic stimuli.

Again try this exercise around the house without distractions before trying it with other puppies present. Praise your puppy the moment he sits, take him by the collar, offer the piece of kibble as reward, and then let him resume playing. Also, with repeated trials your puppy sits sooner and sooner and with you farther and farther away. Eventually your dog will sit promptly at a single softly spoken request from a distance. From now on, whenever your dog is off-leash, repeatedly and frequently interrupt his activity with numerous short training interludes. Or walk up to your dog and take him by the collar before telling him to resume playing. Above: Three visiting Rocky Mountain Search and Rescue Shepherds challenge Oso to a home game of cookie-search in the living room. Train your puppy little but often in at least fifty training sessions a day, with only one or two being more than a few seconds long. Each quick sit is immediately reinforced by allowing the dog to resume walking or playing-the very best rewards in domestic dogdom. Integrate short training interludes into every enjoyable doggy activity-riding in the car, watching you fix their dinner, lying on the couch, and playing doggy games. For example, have your dog sit before you throw a tennis ball and before you take it back. For example, ask the pup to lie down and roll over for a tummy rub, or to lie down and stay a while before being invited for a snuggle on the couch. Have her sit before you put her on leash, before you open the door, before you tell her to jump in the car, before you allow her to get out of the car, and before you let her off-leash. With total integration, your puppy will see no difference between playing and training. For example, call your puppy for a bodyposition sequence with variable length stays in each position every time you open the fridge, make a cup of tea, turn a page of the newspaper, or send an e-mail. If you instruct the pup to perform a simple body-position sequence on every such occasion, you will easily be able to train your puppy over fifty times a day without deviating from your normal lifestyle. Remember that you are responsible for a young, impressionable, developing canine brain. During the program it is easy to keep an eye on your puppy as she settles down, and commercial breaks are an ideal time for short training interludes. Alternatively, have your puppy settle down while you watch dog training videos and then periodically let your pup join in as you practice together. Once your dog is well-trained, she may enjoy full run of your house, will be welcome almost anywhere, and may eventually graduate to couch work. Occasionally, I may ask them to do something during breaks, like move over, fetch the paper, change the channel, vacuum the living room, or fix dinner. The same problems can be time-consuming and extremely difficult to resolve in adulthood. Separation anxiety, fearfulness, and aggression toward people must be prevented before your puppy is three months old. Consequently, have family members and friends check that you do your homework each day. Check each box or include a score (number of times, length of time, percentage) where appropriate. Home Alone in the Household During his first week in your home, your puppy must learn housetraining and household manners, and how to amuse himself when left by himself. Success depends on two things: (1) your puppy spending most of his time in the self-teaching environments of short-term and long-term confinement and (2) your puppy receiving all of his food from stuffed chewtoys or being handfed by people vs. Percentage of time your puppy spends in: Short-term confinement S S M T W T F with stuffed chewtoys.

Syndromes

• Cancer
• Activated charcoal
• Repeating sounds over and over in order to teach mouth movements
• What kind of shoes do you wear?
• Vomiting or constipation
• Rule out other problems with the legs (such as blood clot)
• Easy bruising, nosebleeds, or blood in the stool
• Pulmonary edema

See publications from this study under the Publications section, numbers 128 and 129. Principal Investigator: "Analysis of State and Federal Prison Directives Related to Transgender Inmate Medical Care and Placement. Principal Investigator: "Qualitative Analysis of Concerns of Transgender Inmates in the United States. Principal Investigator, "Assessing Health Outcomes, Health Care Utilization, and Health Disparities in Transgender Veterans Receiving Care in the Veterans Health Administration. We find that there is no compelling medical rationale for banning transgender military service, and that eliminating the ban would advance a number of military interests, including enabling commanders to better care for their service members. Transgender personnel should be treated in accordance with established medical standards of care, as is done with all other medical conditions. We determined not only that there is no compelling medical reason for the ban, but also that the ban itself is an expensive, damaging and unfair barrier to health care access for the approximately 15,450 transgender personnel who serve currently in the active, Guard and reserve components. Medical standards for enlistment are generally designed to ensure that applicants are free of conditions that would interfere with duty performance, endanger oneself or others, or impose undue burdens for medical care. The regulations, however, bar the enlistment of transgender individuals regardless of ability to perform or degree of medical risk. Unlike other medical disqualifications, which are based on modern medical expertise and military experience, the transgender enlistment bar is based on standards that are decades out of date. Medical standards for retention are generally designed to identify permanent medical conditions that cannot be corrected and are likely to affect, or have already affected, performance of duty. Existing regulations, however, give commanders complete discretion to separate transgender individuals without medical review ("for the convenience of the government"), regardless of ability to perform or degree of medical risk. As with the enlistment regulations, the retention regulations are inconsistent with modern medical understanding. They include transgender conditions on a list of disqualifying, maladaptive traits assumed to be resistant to treatment and inconsistent with either fitness for duty or good order and discipline. By regulation, service members are simultaneously barred from treatment and also presumed to be unfit, despite the lack of medical evidence to support the policy. Research shows that depriving transgender service members of medically necessary health care poses significant obstacles to their well-being. This leads individuals to go without treatment, allowing symptoms to exacerbate, and causing some to treat symptoms with alcohol or drugs, which could lead to substance abuse or dependence. Existing policies and practices are adequate for identifying rare and extreme circumstances that may affect duty performance. According to a 2013 resolution introduced by the United States and passed unanimously by delegates to the Pan American Health Organization, member states agree to "work to promote the delivery of health services to all people. The ban on transgender military service should be eliminated, and the health care needs of transgender personnel should be addressed in the same way that medical needs of non-transgender personnel are managed. Being transgender does not mean that one has already transitioned to a different gender, or that such a transition will occur in the future. It means recognizing that the gender one has always had does not match the physical gender that was assigned at birth. The transgender community includes people who have already transitioned to the other gender, those who have not yet transitioned but who plan to do so, those who identify with the other gender but do not wish to transition, and others. Social scientists estimate that there are 700,000 transgender American adults, representing. Transgender adult citizens are more than twice as likely as non-transgender Americans (2. Almost no scholarly research has been published on transgender military service, and the available body of literature includes just seven peer-reviewed and three non-peer-reviewed studies. In particular, the rules are (1) binding, in that there is no option or procedure for commanders or doctors to waive rules that disqualify transgender individuals for military service, either for accession or retention; (2) decentralized, in that they are articulated in different provisions of various Department of Defense Instructions; (3) unclear, in that regulatory terminology that references transgender identity is inconsistent; and (4) regulatory, not statutory. Because policies that prohibit transgender service are spelled out in Defense Department as well as service-specific regulations, but not in congressional statute, the Commander in Chief could change policy without obtaining congressional approval. That said, provisions of the Uniform Code of Military Justice that are not specific to transgender service members, such as conduct unbecoming, have been used as the basis for discharging these service members. Alexander (1981), a federal district court noted "evidence that transsexuals would require medical maintenance to ensure their correct hormonal balances and continued psychological treatment and that the army would have to acquire the facilities and expertise to treat the endocrinological complications which may stem from the hormone therapy. The army might well conclude that those factors could cause plaintiff to lose excessive duty time and impair her ability to serve in all corners of the globe.