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Christopher Whaley PhD

• Assistant Adjunct Professor

https://publichealth.berkeley.edu/people/christopher-whaley/

Group Therapy: Social Skills Training Given the prominence of social decits in many people with schizophrenia nti virus 3 mg ivermectin free shipping, clinicians often try to improve a patients social skills antibiotic vitamin c buy discount ivermectin 3 mg on-line. Social skills training usually occurs in a group setting infection specialist 3 mg ivermectin overnight delivery, and its goals include learning to read other peoples behaviors latest antibiotics for acne discount 3 mg ivermectin fast delivery, learning what behaviors are expected in particular situations treatment for uti gram negative bacilli purchase ivermectin without prescription, and responding to others in a more adaptive way virus mutation rate discount 3mg ivermectin otc. Social skills training teaches these skills by breaking down complex social behaviors into their components: maintaining eye contact when speaking to others, taking turns speaking, learning to adjust how loudly or softly to speak in different situations, and learning how to behave when meeting someone new. The leader and members of a group take turns role playing these different elements of social interaction. In contrast to techniques that focus specically on behaviors, cognitive techniques focus on group members irrational beliefs about themselves, their knowledge of social conventions, the beliefs that underlie their interactions with other people, and their ideas about what others may think; such beliefs often prevent people with schizophrenia from attempting to interact with others. These social skills may be applied to interactions with mental health professionals, such as discussing with a psychiatrist the side effects a medication is causing. Each element of the training is repeated several times, to help overcome patients neurocognitive problems when learning new material. Research has shown that although social skills training does improve social skills and daily functioning that depends on social skills, it is less effective in preventing relapse or directly increasing employment (Bustillo et al. Apparently such training is not sufficient to remove enough stress or reduce other contributing factors that may trigger a relapse. Inpatient Treatment Short-term or long-term hospitalization is sometimes necessary for people with schizophrenia. A short-term hospital stay may be required when someone is having an acute schizophrenic episode (is actively psychotic, extremely disorganized, or otherwise unable to care for himself or herself) or is suicidal or violent. Inpatient treatment includes various therapy groups, such as a group to discuss medication side effects. Once the symptoms are reduced to the point where appropriate self-care is possible and the risk of harm is minimized, the patient will probably be discharged. Long-term hospitalization may occur only when other treatments have not signicantly reduced symptoms and the patient needs full-time intensive care. Legal measures have made it difficult to hospitalize people against their will (Torrey, 2001). Although these tougher standards protect people from being hospitalized simply because they do not conform to common social conventions (see Chapter 1), they also mean that people who have a disorder that by its very nature limits their ability to comprehend that they have an illness may not receive appropriate help until their symptoms have become so severe that normal functioning is impossible. Early intervention for ill adults who do not want help but do not realize that they are ill is legally almost impossible today. Minimizing Hospitalizations: Community-Based Interventions In Chapter 1 we noted that asylums and other forms of 24-hour care, treatment, and containment for those with severe mental illness have met with mixed success over the past several hundred years. Traditionally, people with chronic schizophrenia were likely to end up in such institutions. However, beginning in the 1960s with the widespread use of antipsychotic medications and building into the 1970s, the U. Not everyone thinks that deinstitutionalization was a good idea, at least not in the way it has been implemented. The main problem is that the patients were sent out into communities without adequate social, medical, or nancial support. The good news is that some communities have adequately funded programs to help people with chronic schizophrenia and other chronic and debilitating psychological disorders live outside of institutions. Community care (also known as assertive community treatment) programs allow mental health staff to visit patients in their homes at any time of the day or night (Mueser et al. Patients who receive such community care report greater satisfaction with their care; however, such treatment may not necessarily lead to better outcomes (Killaspy et al. Residential Settings Deinstitutionalization was mandated without Some people with schizophrenia may be well enough not to need hospitalization adequate funding for communities to take care of people with schizophrenia and other serious but are still sufficiently impaired that they cannot live independently or with family mental illnesses. At poverty and homelessness among those with one extreme is highly supervised housing, in which a small number of people live such disorders. They also have household chores and attend house meetings to work out the normal annoyances of group living. Those able to handle somewhat more responsibility may live in an apartment building lled with people of similar abilities, with a staff member available to supervise any difficulties that arise. In independent living, in contrast, a staff member provides periodic home visits to patients living on their own. Vocational Rehabilitation A variety of programs assist people with schizophrenia to acquire job skills; such programs are specically aimed at helping patients who are relatively high-functioning but have residual symptoms that interfere with functioning at, or near, a normal level. Those who are more impaired may participate in sheltered employment, working in settings that are specically designed for people with emotional or intellectual problems who cannot hold a regular job. Individuals in such programs may work in a hospital coffee shop or create craft items that are sold in shops. Those who are less impaired may be part of supported employment programs, which place individuals in regular work settings and provide an on-site job coach to help them adjust to the demands of the job itself and the social interactions involved in having a job (Bustillo et al. Examples of supported employment jobs might include work in a warehouse packaging items for shipment, or restocking items in an office or a store (Project search, 2006). What predicts how well a patient with schizophrenia can live and work in the world Researchers have found that an individuals ability to live and perhaps work outside of a hospital is associated with a specic cognitive function: his or her ability to use working memory (Dickinson & Coursey, 2002). Iris was less able to live independently and lived in the hospital, in supervised residential settings, or at home with Mrs. Genain died in 1983, Myra moved Programs that allow mental health care providers to visit patients in their homes at into her mothers house with her older son. Like Iris, Hester spent many years in the any time of the day or night; also known as hospital, then with Mrs. She lived with Nora in a supervised apartment until assertive community treatment. When successful, medication (treatment targeting neurological factors) can reduce the positive and negative symptoms, and even help improve cognitive functioning. These changes in neurological and psychological factors, in turn, make it possible for social treatments, such as social skills training and vocational rehabilitation, to be more effective. If patients are not psychotic and have improved cognitive abilities, they can better learn social and vocational skills that allow them to function more effectively and independently. As family and social interactions become less stressful, cortisol levels should decrease. Dependsuch treatment because of side effects or because the medicaing on the severity of an episode of schizophrenia, a patient tion did not help them enough. People who stop taking medicamay be treated in an inpatient facility or as an outpatient in the tion are much more likely to relapse. Summary of What Are schizophrenia: paranoid, disorganized, catatonic, Symptoms of the disorder typically evolve in Schizophrenia and Other undifferentiated, and residual schizophrenia. Many researchers argue that a more to have a comorbid disorder that is associated marked by two or more symptoms, at least useful way to distinguish subtypes of schizowith violent behavior, such as a substanceone of which must be a positive sympphrenia would be based on whether the individrelated disorder. Research ndings overlap with those of other disorders, notably suggest that the disorganized symptoms mood disorders and substance-related disorThinking like a clinician form their own distinct cluster and should ders. The category of psychotic disorders speSuppose you are a mental health clinician workbe grouped separately from delusions and cifically requires symptoms of hallucinations ing in a hospital emergency room in the sumhallucinations. What information omitting important cognitive and social de personality disorder, are part of a spectrum of would you need in order to make that diagnocits that lead to positive and negative sympschizophrenia-related disorders. What other psychological disorders could, toms and that are closely associated with Most people with schizophrenia have at with only brief observation, appear similar to prognosis. Although antipsychotic medications in the frontal and temporal lobes, the thalacan decrease positive and, in some cases, Executive functions (p. Moreover, certain negative symptoms, many patients disconbrain areas do not appear to interact with each Paranoid schizophrenia (p. People with schizophrenia are or because the medication did not help them Disorganized schizophrenia (p. Depending on the severity of an though, cannot explain why a given individual episode of schizophrenia, a patient may be Biological marker (p. Community-based with schizophrenia and shape the symptoms interventions include residential care and Theory of mind (p. In Treating Personality Disorders: Rthe opening of the book, Reiland remembers Cindy, the General Issues golden-haired grade-school classmate who was their teachOdd/Eccentric Personality Disorders ers favorite. At the end of a painting class, Cindys painting Paranoid Personality Disorder was beautiful, with distinctive trees. Unfortunately, Rachels Schizoid Personality Disorder painting looked like a putrid blob. I seized a cup of brown Personality Disorders paint and dumped half of it over my picture. Glaring at Cindy, I leaned Treating Odd/Eccentric across the table and dumped the other half over her drawing. Schwarzheuser frantically wiped up paint to keep it Narcissistic Personality Disorder from dripping onto the oor. It was the same way I felt when Daddy pulled off his belt Dependent Personality Disorder and snapped it. Obsessive-Compulsive Personality Disorder In all my years, Ive never seen a child like you. Such episodes dont necessarily indicate that a child, or the adult he or she grows up to be, has a disorder. These problems have existed for so long that they seem to be a part of who the person is, Personality disorders a part of his or her personality. Such persistent problems indicate A category of psychological disorders personality disorders, a category of psychological disorders characcharacterized by a pattern of inexible and terized by a pattern of inexible and maladaptive thoughts, feelings, maladaptive thoughts, feelings, and behaviors and behaviors that arise across a range of situations and lead to disthat arise across a range of situations and lead tress or dysfunction. Her teachers were frustrated with her, and angry at her; for instance, she vividly remembers when she was 12 years old, in her Catholic school, and sent, yet again, to the principals office for breaking the rules: Miss Marsten [Reilands maiden name], Sister Luisa said disapprovingly. In Reilands case, she went on to do well academically in high school and college, but in the nonacademic areas of her life things didnt go as well. In high school and college, she frequently got drunk and was sexually promiscuous. She hadnt yet grown out of the maladaptive childhood patterns of behavior that got her into so much trouble with Sister Luisa. In her mid-20s, Reiland unintentionally became pregnant when dating a man named Tim. They decided to marry and did so, even though she had a miscarriage before the wedding. It seemed that Reiland had straightened out her life and that her childhood problems were behind her. One day during this period of her life, her husband called to say hed be late at work and wouldnt be home until 6 or 7 p. Look, sweetheart, Ive got to do this presentation this afternoon because its too late to cancel. I dont do a thing around this house, and here I am, wanting you to help me clean. Youre gonna wake up the kids; the neighbors are gonna wonder what in the hell is going on. Personality Disorders 569 Reilands behavior seems extreme, but is it so extreme that it indicates a personality disorder, or is it just an emotional outburst from a mother of young children who is feeling overwhelmed In order to understand the nature of Reilands problems and see how a clinician determines whether an individuals problems merit a diagnosis of personality disorder, we must focus on personality, and contrast norPersonality disorders are characterized by a mal versus abnormal variations of personality. Similarly, angry with little provocation and had difficulty when you imagine how family members will react to bad news youre going to controlling her anger in a variety of settings. Some people consistently and persistently exhibit extreme versions of personality traits, for example, being overly conscientious and rule-bound or, like Reiland, being overly emotional and quick to anger. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individuals culture. The enduring pattern is inexible and pervasive across a broad range of personal and of events, other people, and oneself. The enduring pattern leads to clinically signicant distress or impairment in social, chological functioning are relatively inexible and occupational, or other important areas of functioning. The pattern is stable and of long duration and its onset can be traced back at least to Table 13. The enduring pattern is not better accounted for as a manifestation or consequence in a wide variety of situations and the individual of another mental disorder. The enduring pattern is not due to the direct physiological effects of a substance ing any differently.

The humane endpoint is the point at which pain or distress in an experimental animal is prevented virus que esta en santo domingo discount 3 mg ivermectin with mastercard, terminated antibiotics cause fever discount 3 mg ivermectin otc, or relieved antibiotic resistance process discount 3mg ivermectin mastercard. The use of humane endpoints contributes to refnement by providing an alternative to experimental endpoints that result in unrelieved or severe animal pain and distress infection game order ivermectin 3mg on line, including death antibiotic 1p 272 order ivermectin 3mg. The humane endpoint should be relevant and reliable (Hendriksen and Steen 2000; Olfert and Godson 2000; Sass 2000; Stokes 2002) bacteria webquest order ivermectin master card. While all studies should employ endpoints that are humane, studies that commonly require special consideration include those that involve tumor models, infectious diseases, vaccine challenge, pain modeling, trauma, production of monoclonal antibodies, assessment of toxicologic effects, organ or system failure, and models of cardiovascular shock. The identifcation of humane endpoints is often challenging, however, because multiple factors must be weighed, including the model, species (and sometimes strain or stock), animal health status, study objectives, institutional policy, regulatory requirements, and occasionally conficting scientifc literature. An understanding of preemptive euthanasia (Toth 2000), behavioral or physiologic defnitions of the moribund state (ibid. Numerous publications address specifc proposals for the application and use of humane endpoints. Unexpected Outcomes Fundamental to scientifc inquiry is the investigation of novel experimental variables. Because of the potential for unexpected outcomes that may affect animal well-being when highly novel variables are introduced, more frequent monitoring of animals may be required. Regardless of whether genetic manipulation is targeted or random, the phenotype that initially results is often unpredictable and may lead to expected or unexpected outcomes that affect the animals well-being or survival at any stage of life. These examples illustrate the diversity of unanticipated outcomes and emphasize the need for diligent monitoring and professional judgment to ensure the animals well-being (Dennis 2000). Investigators may fnd that the phenotype precludes breeding of particular genotypes or that unexpected infertility occurs, situations that could lead to increases in the numbers of animals used and revision of the animal use protocol. Physical Restraint Physical restraint is the use of manual or mechanical means to limit some or all of an animals normal movement for the purpose of examination, collection of samples, drug administration, therapy, or experimental manipulation. Animals are restrained for brief periods, usually minutes, in many research applications. Restraint devices should be suitable in size, design, and operation to minimize discomfort, pain, distress, and the potential for injury to the animal and the research staff. Dogs, nonhuman primates, and many other animals can be trained, through use of positive reinforcement techniques, to cooperate with research procedures or remain immobile for brief periods (Boissy et al. Systems that do not limit an animals ability to make normal postural adjustments. Animals that do not adapt to necessary restraint systems should be removed from the study. When restraint devices are used, they should be specifcally designed to accomplish research goals that are impossible or impractical to accomplish by other means or to prevent injury to animals or personnel. The presence of lesions, illness, or severe behavioral change often necessitates the temporary or permanent removal of the animal from restraint. Regardless of classifcation, multiple surgical procedures on a single animal should be evaluated to determine their impact on the animals wellbeing. Multiple major surgical procedures on a single animal are acceptable only if they are (1) included in and essential components of a single research project or protocol, (2) scientifcally justifed by the investigator, or (3) necessary for clinical reasons. Cost savings alone is not an adequate reason for performing multiple major survival surgical procedures. Some procedures characterized as minor may induce substantial postprocedural pain or impairment and should similarly be scientifcally justifed if performed more than once in a single animal. Food and Fluid Regulation Regulation of food or fuid intake may be required for the conduct of some physiological, neuroscience, and behavioral research protocols. In addition, the following factors infuence the amount of food or fuid restriction that can be safely used in a specifc protocol: the species, strain, or stock, gender, and age of the animals; thermoregulatory demand; type of housing; time of feeding, nutritive value, and fber content of the diet (Heiderstadt et al. The degree of food or fuid restriction necessary for consistent behavioral performance is infuenced by the diffculty of the task, the individual animal, the motivation required of the animal, and the effectiveness of animal training for a specifc protocol-related task. The animals should be closely monitored to ensure that food and fuid intake meets their nutritional needs (Toth and Gardiner 2000). In the case of conditioned-response research protocols, use of a highly preferred food or fuid as positive reinforcement, instead of restriction, is recommended. Caloric restriction, as a husbandry technique and means of weight control, is discussed in Chapter 3. Use of Non-Pharmaceutical-Grade Chemicals and Other Substances the use of pharmaceutical-grade chemicals and other substances ensures that toxic or unwanted side effects are not introduced into studies conducted with experimental animals. Many feld investigations require international, federal, state, and/or local permits, which may call for an evaluation of the scientifc merit of the proposed study and a determination of the potential impact on the population or species to be studied. Principal investigators conducting feld research should be knowledgeable about relevant zoonotic diseases, associated safety issues, and any laws or regulations that apply. In preparing the design of a feld study, investigators are encouraged to consult with relevant professional societies and available guidelines (see Appendix A). Veterinary input may be needed for projects involving capture, individual identifcation, sedation, anesthesia, surgery, recovery, holding, transportation, release, or euthanasia. Issues associated with these activities are similar if not identical to those for species maintained and used in the laboratory. When species are removed from the wild, the protocol should include plans for either a return to their habitat or their fnal disposition, as appropriate. The Guide does not purport to be a compendium of all information regarding feld biology and methods used in wildlife investigations, but the basic principles of humane care and use apply to animals living under natural conditions. Agricultural Animals the use of agricultural animals in research is subject to the same ethical considerations as for other animals in research, although it is often categorized as either biomedical or agricultural because of government regulations and policies, institutional policies, administrative structure, funding sources, and/or user goals (Stricklin et al. This categorization has led to a dual system with different criteria for evaluating protocols and standards of housing and care for animals of the same species on the basis of stated biomedical or agricultural research objectives (Stricklin and Mench 1994). With some studies, differences in research goals may lead to a clear distinction between biomedical and agricultural research. For example, animal models of human diseases, organ transplantation, and major surgery are considered biomedical uses; and studies on food and fber production, such as feeding trials, are usually considered agricultural uses. Regardless of the category of research, institutions are expected to provide oversight of all research animals and ensure that pain and distress are minimized. The protocol, rather than the category of research, should determine the setting (farm or laboratory). Housing systems for agricultural animals used in biomedical research may or may not differ from those used in agricultural research; animals used in either type of research can be housed in cages, stalls, paddocks, or pastures (Tillman 1994). Some agricultural studies need uniform conditions to minimize environmental variability, and some biomedical studies are conducted in farm settings. Agricultural research often necessitates that animals be managed according to contemporary farm production practices (Stricklin and Mench 1994), and natural environmental conditions might be desirable for agricultural research, whereas control of environmental conditions to minimize variation might be desirable in biomedical research (Tillman 1994). The Guide applies to agricultural animals used in biomedical research, including those maintained in typical farm settings. Information about environmental enrichment, transport, and handling may be helpful in both agricultural and biomedical research settings. Additional information about facilities and management of farm animals in an agricultural setting is available from the Midwest Plan Service (1987) and from agricultural engineers or animal science experts. A variety of mechanisms can be used to facilitate ongoing protocol assessment and regulatory compliance. The depth of such reviews varies from a cursory update to a full committee review of the entire protocol. Some institutions use the annual review as an opportunity for the investigator to submit proposed amendments for future procedures, to provide a description of any adverse or unanticipated events, and to provide updates on work progress. For the triennial review, many institutions require a complete new protocol submission and may request a progress report on the use of animals during the previous 3 years. Based on risks to animals and their handlers, other study areas may require more or less frequent inspections. Institutions may also consider the use of veterinary staff and/or animal health technicians to observe increased risk procedures for adverse events. The plan should defne the actions necessary to prevent animal pain, distress, and deaths due to loss of systems such as those that control ventilation, cooling, heating, or provision of potable water. If possible the plan should describe how the facility will preserve animals that are necessary for critical research activities or are irreplaceable. Knowledge of the geographic locale may provide guidance as to the probability of a particular type of disaster. Disaster plans should be established in conjunction with the responsible investigator(s), taking into consideration both the priorities for triaging animal populations and the institutional needs and resources. Animals that cannot be relocated or protected from the consequences of the disaster must be humanely euthanized. The disaster plan should identify essential personnel who should be trained in advance in its implementation. Efforts should be taken to ensure personnel safety and provide access to essential personnel during or immediately after a disaster. Law enforcement and emergency personnel should be provided with a copy of the plan for comment and integration into broader, areawide planning (Vogelweid 1998). Guidelines on Choosing an Appropriate Endpoint in Experiments Using Animals for Research, Teaching and Testing. Primary Containment for Biohazards: Selection, Installation and Use of Biological Safety Cabinets, 2nd ed. Title 29, Part 1910, Occupational Safety and Health Standards, Subpart G, Occupational Health and Environmental Control, and Subpart Z, Toxic and Hazardous Substances. Occupational Safety and Health Standards; Subpart I, Personal Protective Equipment. Inspection Procedures for the Hazardous Waste Operations and Emergency Response Standard. Agricultural Bioterrorism Protection Act of 2002: Possession, Use and Transfer of Select Agents and Toxins. Recommendations for prevention of and therapy for exposure to B virus (Cercopithecine herpes irus 1). Training strategies for laboratory animal veterinarians: Challenges and opportunities. Guide for the Care and Use of Agricultural Animals in Research and Teaching, 3rd ed. Evaluating the effectiveness of training strategies: Performance goals and testing. The effect of chronic food and water restriction on open-feld behaviour and serum corticosterone levels in rats. ErgonomicErgonomic considerations and allergenconsiderations and allergen management. Establishing a culture of care, conscience, and responsibility: Addressing the improvement of scientifc discovery and animal welfare through sciencebased performance standards. The use of positive reinforcement training techniques to enhance the care, management, and welfare of primates in the laboratory. Selection, acclimation, training and preparation of dogs for the research setting. Guidelines for the Use of Non-Pharmaceutical-Grade Chemicals/Compounds in Laboratory Animals. Musculoskeletal Disorders and Workplace Factors: A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. Education and Training in the Care and Use of Laboratory Animals: A Guide for Developing Institutional Programs. Guidelines for the Care and Use of Mammals in Neuroscience and Behavioral Research. Guidance Document on Humane Endpoints for Experimental Animals Used in Safety Evaluation Studies. Department of Health and Human Services, National Institutes of Health, Offce of Laboratory Animal Welfare. Training adult male rhesus monkeys to actively cooperate during inhomecage venipuncture. Food or fuid restriction in common laboratory animals: Balancing welfare considerations with scientifc inquiry. Reducing unrelieved pain and distress in laboratory animals using humane endpoints. Oversight of the use of agricultural animals in university teaching and research. Integrating agricultural and biomedical research policies: Conficts and opportunities. Food and water restriction protocols: Physiological and behavioral considerations. A guide to risk assessment in animal care and use programs: the metaphor of the 3-legged stool. Developing emergency management plans for university laboratory animal programs and facilities. Frequently asked questions about the Public Health Service Policy on Humane Care and Use of Laboratory Animals. Guide for the Care and Use of Laboratory Animals: Eighth Edition 3 Environment, Housing, and Management his chapter provides guidelines for the environment, housing, and management of laboratory animals used or produced for research, Ttesting, and teaching. These guidelines are applicable across species and are relatively general; additional information should be sought about how to apply them to meet the specifc needs of any species, strain, or use (see Appendix A for references). The chapter is divided into recommendations for terrestrial (page 42) and aquatic animals (page 77), as there are fundamental differences in their environmental requirements as well as animal husbandry, housing, and care needs.

People who listened to the songs played backward and had schemata of this music as dangerous or evil perceived the threatening messages due to top-down processing infection 4 months after surgery buy 3mg ivermectin free shipping. Instead of using our experience to perceive an object antibiotics zone of inhibition cheap 3 mg ivermectin otc, we use only the features of the object itself to build a complete perception bacteria on scalp buy ivermectin toronto. We start our perception at the bottom with the individual characteristics of the image and put all those characteristics together into our final perception antibiotic jeopardy cheap ivermectin generic. Bottom-up processing can be hard to imagine because it is such an automatic process virus buster buy cheap ivermectin on line. The feature detectors in the visual cortex allow us to perceive basic features of objects virus protection software order genuine ivermectin, such as horizontal and vertical lines, curves, motion, and so on. We are constantly using both bottom-up and top-down processing as we perceive the world. Top-down processing is faster but more prone to error, while bottom-up processing takes longer but is more accurate. Principles of Visual Perception the rules we use for visual perception are too numerous to cover completely in this book. One of the first perceptual decisions our mind must make is the figure-ground relationship. What part of a visual image is the figure and what part is the ground or background One example is the famous picture of the vase that if looked at one way is a vase but by switching the figure and the ground can be perceived as two faces (see. Gestalt Rules At the beginning of the twentieth century, a group of researchers called the Gestalt psychologists described the principles that govern how we perceive groups of objects. The Gestalt psychologists pointed out that we normally perceive images as groups, not as isolated elements. Proximity Objects that are close together are more likely to be perceived as belonging in the same group. Similarity Objects that are similar in appearance are more likely to be perceived as belonging in the same group. Continuity Objects that form a continuous form (such as a trail or a geometric figure) are more likely to be perceived as belonging in the same group. Objects that make up a recognizable image are more likely to be perceived as belonging in the same group even if the image contains gaps that the mind needs to fill in. Constancy Every object we see changes minutely from moment to moment due to our changing angle of vision, variations in light, and so on. Our ability to maintain a constant perception of an object despite these changes is called constancy. Size Objects closer to our eyes will produce bigger images on our retinas, but we take distance constancy into account in our estimations of size. We keep a constant size in mind for an object (if we are familiar with the typical size of the object) and know that it does not grow or shrink in size as it moves closer or farther away. Shape Objects viewed from different angles will produce different shapes on our retinas, but we constancy know the shape of an object remains constant. For example, the top of a coffee mug viewed from a certain angle will produce an elliptical image on our retinas, but we know the top is circular due to shape constancy. Brightness We perceive objects as being a constant color even as the light reflecting off the object constancy changes. For example, we will perceive a brick wall as brick red even as the daylight fades and the actual color reflected from the wall turns gray. Our brains are able to detect how fast images move across our retinas and to take into account our own movement. Interestingly, in a number of situations, our brains perceive objects to be moving when, in fact, they are not. A common example of this is the stroboscopic effect, used in movies or flip books. Images in a series of still pictures presented at a certain speed will appear to be moving. Another example you have probably encountered on movie marquees and with holiday lights, is the phi phenomenon. A series of lightbulbs turned on and off at a particular rate will appear to be one moving light. If a spot of light is projected steadily onto the same place on a wall of an otherwise dark room and people are asked to stare at it, they will report seeing it move. Depth Cues One of the most important and frequently investigated parts of visual perception is depth. Without depth perception, we would perceive the world as a two-dimensional flat surface, unable to differentiate between what is near and what is far. Researcher Eleanor Gibson used the visual cliff experiment to determine when human infants can perceive depth. An infant is placed onto one side of a glass-topped table that creates the impression of a cliff. Actually, the glass extends across the entire table, so the infant cannot possibly fall. Gibson found that an infant old enough to crawl will not crawl across the visual cliff, implying the child has depth perception. Other experiments demonstrate that depth perception develops when we are about three months old. Researchers divide the cues that we use to perceive depth into two categories: monocular cues (depth cues that do not depend on having two eyes) and binocular cues (cues that depend on having two eyes). If you wanted to draw a railroad track that runs away from the viewer off into the distance, most likely you would start by drawing two lines that converge somewhere toward the top of your paper. You would draw the boxcars closer to the viewer as larger than the engine off in the distance. A water tower blocking our view of part of the train would be seen as closer to us due to the interposition cue; objects that block the view to other objects must be closer to us. If the train were running through a desert landscape, you might draw the rocks closest to the viewer in detail, while the landscape off in the distance would not be as detailed. This cue is called texture gradient; we know that we can see details in texture close to us but not far away. By shading part of your picture, you can imply where the light source is and thus imply depth and position of objects. We see the world with two eyes set a certain distance apart, and this feature of our anatomy gives us the ability to perceive depth. It knows that if the object is far away, the images will be similar, but the closer the object is, the more disparity there will be between the images coming from each eye. As an object gets closer to our face, our eyes must move toward each other to keep focused on the object. The brain receives feedback from the muscles controlling eye movement and knows that the more the eyes converge, the closer the object must be. Effects of Culture on Perception One area of psychology cross-cultural researchers are investigating is the effect of culture on perception. Research indicates that some of the perceptual rules psychologists once thought were innate are actually learned. For example, cultures that do not use monocular depth cues (such as linear perspective) in their art do not see depth in pictures using these cues. Also, some optical illusions are not perceived the same way by people from different cultures. People who come from noncarpentered cultures that do not use right angles and corners often in their building and architecture are not usually fooled by the Muller-Lyer illusion. Cross-cultural research demonstrates that some basic perceptual sets are learned from our culture. Our sense of smell may be a powerful trigger for memories because (A) we are conditioned from birth to make strong connections between smells and events. In a perception research lab, you are asked to describe the shape of the top of a box as the box is slowly rotated. The blind spot in our eye results from (A) the lack of receptors at the spot where the optic nerve connects to the retina. Smell and taste are called because (A) energy senses; they send impulses to the brain in the form of electric energy. What is the principal difference between amplitude and frequency in the context of sound waves Gate-control theory refers to (A) which sensory impulses are transmitted first from each sense. Which of the following sentences best describes the relationship between sensation and perception Color blindness and color afterimages are best explained by what theory of color vision You are shown a picture of your grandfathers face, but the eyes and mouth are blocked out. Which of the following sentences best describes the relationship between culture and perception This connection may explain why smell may be a powerful trigger for emotions and memories. This connection has nothing to do with learning, long-term memory, or deep processing. Smells are eventually communicated to the cortex, but that does not explain the special connection to memory. The hammer, anvil, and stirrup transfer vibrations to the cochlea, not the other way around. The semicircular canals send messages to the brain about the orientation of the head and body. This experiment would not be investigating feature detectors, because the equipment required to measure the firing of feature detectors is not described. Placement of rods and cones in the retina would not affect perception of the top of the box. Binocular depth cues are probably not the target of the research because the researchers are not asking questions about depth. However, these do not occur in everyone, and the question implies the blind spot present in everyones eyes. Choice D is incorrect because all nerve impulses are sent by an electrochemical process. Frequency is the measure of how quickly the waves pass a point, causing the pitch of the sound. This theory is specific to the sense of touch, so choices A, C, and D are incorrect. Choice E is incorrect because gate-control theory has to do with the perception of pain, not how we interpret sensations in general. When an object is close to our face and our eyes have to point toward each other slightly, our brain senses this convergence and uses it to help gauge distance. Some researchers think part of perception may happen in the senses themselves, so choice C is incorrect. The rest of the items are incorrect because they describe functions the retina does not perform. The example does not reflect bottom-up processing because information is being filled in, instead of an image being built from the elements present. Signal detection theory has to do with what sensations we pay attention to , not filling in missing elements in a picture. Gestalt theory might relate to this example because you are trying to perceive the picture as a whole, but there is no such term as gestalt replacement theory. However, some perceptual sets are learned and will vary, so choices A and B are incorrect. Sensory apparatuses do not vary among cultures, and perception is not genetically based as implied in choice E. Early psychologists such as William James, author of the first psychology textbook, were very interested in consciousness. However, since no tools existed to examine it scientifically, the study of consciousness faded for a time. Currently, consciousness is becoming a more common research area due to more sophisticated brain imaging tools and an increased emphasis on cognitive psychology. The historical discussion about consciousness centers on the competing philosophical theories of dualism and monism. Dualists believe humans (and the universe in general) consist of two materials: thought and matter. Thought is a nonmaterial aspect that arises from, but is in some way independent of, a brain. Some philosophers maintain that thought is eternal and continues existing after the brain and body die. Monists disagree and believe everything is the same substance, and thought and matter are aspects of the same substance. However, psychologists are trying to examine what we can know about consciousness and to describe some of the processes or elements of consciousness. Psychologists define consciousness as our level of awareness about ourselves and our environment. We are conscious to the degree we are aware of what is going on inside and outside ourselves. While you are reading this text, you might be tapping your pen or moving your leg in time to the music you are listening to . One level of consciousness is controlling your pen or leg, while another level is focused on reading these words. Research demonstrates other more subtle and complex effects of different levels of consciousness.

Subconscious Information that we are not consciously aware of but we know must exist due to behavior infection 2 cheats cheap 3mg ivermectin mastercard. Unconscious Psychoanalytic psychologists believe some events and feelings are unacceptable to our level conscious mind and are repressed into the unconscious mind antibiotics rash toddler buy ivermectin american express. See the section on psychoanalytic theory in Chapter 10 for more information about the unconscious antibiotics gel for acne buy cheap ivermectin 3mg on line. Many studies show that a large percentage of high school and college students are sleep deprived antibiotics guidelines order discount ivermectin on-line, meaning they do not get as much sleep as their body wants antibiotic associated colitis buy discount ivermectin 3mg online. During a 24-hour day infection of the heart order ivermectin 3 mg online, our metabolic and thought processes follow a certain pattern. Some of us are more active in the morning than others, some of us get hungry or go to the bathroom at certain times of day, and so on. We might experience mild hallucinations (such as falling or rising) before actually falling asleep and entering stage 1. While we are awake and in stages 1 and 2, our brains produce theta waves, which are relatively high-frequency, low-amplitude waves. However, the theta waves get progressively slower and higher in amplitude as we go from wakefulness and through stages 1 and 2. From there, we move into stages 3 and 4, which are sometimes called delta sleep (also called slow-wave sleep) because of the delta waves that exist during these stages. The slower the wave (slow waves are low-frequency waves), the deeper the sleep and less aware we are of our environment. Delta sleep seems to be very important in replenishing the bodys chemical supplies, releasing growth hormones in children, and fortifying our immune system. A person deprived of delta sleep will be more susceptible to illness and will feel physically tired. After a period of time in delta sleep, our brain waves start to speed up and we go back through stages 3 and 2. However, as we reach stage 1, our brain produces a period of intense activity, our eyes dart back and forth, and many of our muscles may twitch repeatedly. This sleep stage is sometimes called paradoxical sleep since our brain waves appear as active and intense as they do when we are awake. Although research has not answered all the questions about sleep, details about our sleep cycle provide clues as to why we spend so much of our life in this altered state of consciousness. Sleep Disorders Many of us will experience a night, or perhaps a series of nights, of sleeplessness. These isolated periods of disruption in our sleep pattern give us an idea of the inconvenience and discomfort true sleep disorders can cause in peoples lives. Insomnia is far and away the most common sleep disorder, affecting up to 10 percent of the population. Most people will experience occasional bouts of insomnia, but diagnosed insomniacs have problems getting to sleep more often than not. Insomnia is usually treated with suggestions for changes in behavior: reduction of caffeine or other stimulants, exercise at appropriate times (not right before bedtime) during the day, and maintaining a consistent sleep pattern. Doctors and researchers encourage insomniacs to use sleeping pills only with caution, as they disturb sleep patterns during the night and can prevent truly restful sleep. Narcoleptics suffer from periods of intense sleepiness and may fall asleep at unpredictable and inappropriate times. One of my students suffered from narcolepsy from the time he was a preadolescent up until his graduation from high school. After he was finally diagnosed, he estimated that before his treatment he was drowsy almost his entire day except for two to three hours in the late afternoon. Narcolepsy can be successfully treated with medication and changing sleep patterns (usually involving naps at certain times of the day). Sleep apnea may occur almost as commonly as insomnia and in some ways might be more serious. Apnea causes a person to stop breathing for short periods of time during the night. The body causes the person to wake up slightly and gasp for air, and then sleep continues. This process robs the person of deep sleep and causes tiredness and possible interference with attention and memory. Since these individuals do not remember waking up during the night, apnea frequently goes undiagnosed. Apnea can be treated with a respiration machine that provides air for the person as he or she sleeps. I would sit up in bed in the middle of the night and scream and move around my room. Night terrors usually affect children, and most do not remember the episode when they wake up. The exact causes are not known, but night terrors are probably related in some way to somnambulism (sleep walking). They occur more commonly in children, and both phenomena occur during the first few hours of the night in stage 4 sleep. Most people stop having night terrors and episodes of somnambulism as they get older. Some people remember dreams frequently, sometimes more than one per night, while others are not aware of whether we dream or not. Some of us even report lucid dreams in which we are aware that we are dreaming and can control the storyline of the dream. Dreams are a difficult research area for psychologists because they rely almost entirely on self-reports. However, validating these theories is difficult with the limited access researchers currently have to dreams. Freudian psychoanalysis emphasizes dream interpretation as a method to uncover the repressed information in the unconscious mind. Freud said that dreams were wish fulfilling, meaning that in our dreams we act out our unconscious desires. If you dream about showing up at school naked, the manifest content is your nudity, the room you see yourself in at school, the people present, and so on. More important to Freud was the latent content, which is the unconscious meaning of the manifest content. Freud thought that even during sleep, our ego protected us from the material in the unconscious mind (thus the term protected sleep) by presenting these repressed desires in the form of symbols. So showing up naked at school would represent a symbol in this type of analysis, perhaps of vulnerability or anxiety. Check any bookstore, and you will find multiple dream interpretation books based on this theory. Consequently, this analysis is mostly used in psychoanalytic therapy and in pop psychology rather than in research. The activation-synthesis theory of dreaming looks at dreams first as biological phenomena. Researchers know that our minds are very good at explaining events, even when the events have a purely physiological cause. Split-brain patients (see Chapter 3) sometimes make up elaborate explanations for behaviors caused by their operation. According to this theory, dreams, while interesting, have no more meaning than any other physiological reflex in our body. The information-processing theory of dreaming falls somewhere in between the Freudian and activation-synthesis theories. This theory points out that stress during the day will increase the number and intensity of dreams during the night. The day after students see the hypnotists show, I can expect dozens of questions about the process of hypnosis and whether it is a valid psychological phenomenon or some sort of trick. One of these is posthypnotic amnesia, when people report forgetting events that occurred while they were hypnotized. The hypnotist may also implant a posthypnotic suggestion, a suggestion that a hypnotized person behave in a certain way after he or she is brought out of hypnosis. Like many other topics regarding consciousness, many questions about hypnosis are not completely answered. Role theory states that hypnosis is not an alternate state of consciousness at all. This theory points out that some people are more easily hypnotized than others, a characteristic called hypnotic suggestibility. People with high hypnotic suggestibility share some other characteristics as well. They tend to have richer fantasy lives, follow directions well, and be able to focus intensely on a single task for a long period of time. Perhaps during hypnosis, people are acting out the role of a hypnotized person and following the suggestions of the hypnotist because that is what is expected of the role. They point out that hypnosis meets some parts of the definition for an altered state of consciousness. Hypnotists seem to be able to suggest that we become more or less aware of our environments. In addition, some people report dramatic health benefits from hypnosis, such as pain control and reduction in specific physical ailments. Researcher Ernest Hilgard explained hypnosis in a different way in his dissociation theory. One part or level of our consciousness responds to the suggestions of the hypnotist, while another part or level retains awareness of reality. In an experiment investigating hypnotism and pain control, Hilgard asked hypnotized participants to put their arm in an ice water bath. Most of us would feel this intense cold as painful after a few seconds, but the hypnotized participants reported no pain. However, when Hilgard asked them to lift their index finger if any part of them felt the pain, most participants lifted their finger. This experiment demonstrated the presence of a hidden observer, a part or level of our consciousness that monitors what is happening while another level obeys the hypnotists suggestions. Some of the behavioral and cognitive changes caused by these drugs are due to physiological processes, but some are due to expectations about the drug. Research shows that people will often exhibit some of the expected effects of the drug if they think they ingested it, even if they did not (this is similar to the placebo effect). All psychoactive drugs change our consciousness through similar physiological processes in the brain. Normally, the brain is protected from harmful chemicals in the bloodstream by thicker walls surrounding the brains blood vessels. However, the molecules that make up psychoactive drugs are small enough to pass through the blood-brain barrier. These molecules either mimic or block naturally occurring neurotransmitters in the brain. These drugs fit in the receptor sites on a neuron that normally receive the neurotransmitter and function as that neurotransmitter normally would. However, instead of acting like the neurotransmitter, they simply prevent the natural neurotransmitters from using that receptor site. Other drugs prevent natural neurotransmitters from being reabsorbed back into a neuron, creating an abundance of that neurotransmitter in the synapse. No matter what mechanism they use, drugs gradually alter the natural levels of neurotransmitters in the brain. The brain will produce less of a specific neurotransmitter if it is being artificially supplied by a psychoactive drug. This change causes tolerance, a physiological change that produces a need for more of the same drug in order to achieve the same effect. They range from the headache I might get if I do not consume any caffeine during the day to the dehydrating and potentially fatal night sweats (sweating profusely during sleep) a heroin addict experiences during withdrawal. Dependence on psychoactive drugs can be either psychological or physical or can be both. Persons psychologically dependent on a drug feel an intense desire for the drug because they are convinced they need it in order to perform or feel a certain way. Persons physically dependent on a substance have a tolerance for the drug, experience withdrawal symptoms without it, and need the drug to avoid the withdrawal symptoms. Different researchers categorize psychoactive drugs in different ways, but four common categories are stimulants, depressants, hallucinogens, and opiates. Stimulants speed up body processes, including autonomic nervous system functions such as heart and respiration rate. The more-powerful stimulants, such as cocaine, produce an extreme euphoric rush that may make a user feel extremely self-confident and invincible. All stimulants produce tolerance, withdrawal effects, and other side effects (such as disturbed sleep, reduced appetite, increased anxiety, and heart problems) to a greater or lesser degree that corresponds with the power of the drug. This energizing effect is due to expectations about alcohol and because alcohol lowers inhibitions. Similarly, nicotine is a stimulant because it speeds up our nervous system, but some smokers smoke to relax. Alcohol, barbiturates, and anxiolytics (also called tranquilizers or antianxiety drugs) like Valium are common depressants. Obviously, alcohol is by far the most commonly used depressant and psychoactive drug. A euphoria accompanies the depressing effects of depressants, as does tolerance and withdrawal symptoms. In addition, alcohol slows down our reactions and judgment by slowing down brain processes.

About half of the homosexual transsexuals I have met have worked as prostitutes antibiotics zoloft buy cheap ivermectin 3 mg on-line, and the majority of these worked preoperatively as she-males bacteria que se come la piel purchase ivermectin 3mg on line. One study found that among prostitutes solicitations in aToronto alternative newspaper antimicrobial activity cheap 3 mg ivermectin, about one in twenty was placed by a preoperative transsexual prostitute antibiotics you cannot take with methadone purchase generic ivermectin online. Ray Blanchard is the only researcher who has studied men who are sexually attracted to she-males virus 16 ivermectin 3 mg. Blanchard says that the men are not gay but are more like scrambled up heterosexual men antibiotic resistance in zambia cheap 3 mg ivermectin visa. There is a rather uneasy symbiosis between the homosexual shemales, on their way to sex reasssignment, and the men who want them at that stage. Juanita, who has been a successful prostitute before and after sex reassignment surgery, says simply You would have to be crazy to prefer being a she-male prostitute. She thinks the no-shows want something exotic but simply lose their nerve and decide they cant go through with it. Another thing that irritated Juanita about the customers who called on her when she was a she-male was the way they viewed her. The most frequent activity that she granted was oral sex (the men sucked Juanitas penis). Juanita has had her sex reassignment surgery, and now works as a call girl for men who want real women. None of her frequent customers from before was interested in continuing with her, post-surgery. The new men are more intimate, according to Juanita, because they see her as a real person rather than merely a sex toy. Although I have not met one, some she-male prostitutes allegedly delay sex reassignment surgery because they are concerned that their incomes will suffer after they no longer have their penises. She was one of the few homosexual transsexuals I had met who had a conventional job; she was cheerful and not at all ambivalent about the surgery. When I called her back, she asked to meet at a restaurant in Lincoln Park, Chicagos trendy urban neighborhood. Now she was the kind of woman that men gawk at (and later when we left the restaurant, they did). Wherever she went, Maria was constantly feeling that people were whispering about her, identifying her as a transsexual. I was quite certain that people were whispering about her, but equally certain that they were not clocking her (detecting her status as a transsexual). Then she revealed her current personal situation, which helped explain her paranoia. For over a year she had had a steady boyfriend who did not know that she is a transsexual. Her gay brother collaborated with her to convince her boyfriend of the truth of her false past and to hide the true past. She was extremely concerned that her boyfriend would find out, and the constant worry caused tension in their relationship. For example, she was jealous that he would seek a real woman, although in fact he believed he was already with a real woman, and they had been fighting. Maria had met her boyfriend shortly after getting breast implants but before her vaginoplasty. Evidently, many men had made advances at that time, and she chose him because he was good looking and ambitious. She was able to postpone intercourse with him for a few months, meanwhile frantically managing to get her surgery scheduled sooner. She had sex with him sooner than she was supposed to , but had not had any physical problems as a result. She and her boyfriend had talked fairly specifically about a future, including marriage and children. The boyfriend had integrated her into his circle of friends and introduced her to his family, who loved her. In fact, Maria worried that a resentful transsexual might track down her boyfriend and tell him merely to spoil things for her. As we spoke, I sympathized with Maria, but I also pondered her and her boyfriends predicaments. Ray Blanchard once presented the following dilemma to a prominent and open-minded heterosexual male scientist. When I asked Juanita, the sexy transsexual prostitute (now post-op, and not generally open about her past) about the best, and worst, reactions she had had from lovers after she revealed that she used to be a man, she replied I have really never had a good experience. He ran from her apartment and called her later to say that he could not deal with her revelation just now. Juanita knows only one transsexual who has been with a man for more than a year, and that transsexuals boyfriend pimps for her. All the homosexual transsexuals I have talked to say that they wish they could find a man they could tell and who would love them anyway, but they all worry that such a man does not exist. Cher has made it clear to her friends, such as Juanita, that she disapproves of such deception, and that she intends to be honest with her own prospects. Furthermore, I do not believe that Chers attraction to men is as intense or as unambiguous as that of homosexual transsexuals. So the loss of a potential sex partner is less of a loss, overall, to Cher than it is to the homosexual transsexuals, who simply lust after men. On the one hand, any person to whom it mattered would seem to have the right to know. On the other hand, this is a man who by all accounts is in love with Maria, and who derives a great deal of satisfaction from being with her. By the kind of utilitarian analysis I am partial to , let us ask which ending would leave the world a happier place: the boyfriend finds out, or he doesnt find out. Assuming that the couple is destined to break up for other reasons (after all, they are only in their early 20s), then surely it is better for both if he does not find out. If they are compatible enough to make a life together, then it is still not clear that he should know. If having biological children were so important to him, he could end the relationship with only that knowledge. Maria asked me to talk to her and her boyfriend, to do couples counseling, pretending that I have known her only as a woman. This would serve both the goals of helping their relationship and covering her story. If Blanchard and I saw the same 100 transsexuals, I would be surprised if we disagreed on more than 2. But most readers will not have met a single transsexual of either type, and even most clinicians who see gender patients are not used to thinking about them this way. Ask each question, and if the answer is Yes, add the number (+1 or 1) next to the question. Finally, if the person has been on hormones for at least six months, ask yourself this question: If you didnt already know that this person was a transsexual, would you still have suspected that she was not a natural-born woman This interview could be invalid if the transsexual is actually autogynephilic but is either (a) worried that you will think badly of her or deny her a sex change if you know the truth, or (b) obsessed with being a real woman. If not a big business, it is at least a lucrative business for a few surgeons, who devote their entire practices to it. Some of them have their own Internet websites and distribute videos that describe their services and show their results. Cher, who had her genital sex change surgery only eight years ago, notes somewhat enviously that neo-vaginas now look so much more realistic, complete with realisticlooking (and sensitive) clitorises, and labia. Few brain surgery patients study their options more closely than do transsexuals, who trade not only opinions but also stories and pictures, both informally and on websites. The urethral opening here is a little lower and harder to see than in some examples: Dr. Here are the main medical procedures that male-to-female transsexuals undergo, in rough chronological order in which they are typically undertaken, with rough costs. Homosexual transsexuals, because they are younger and possibly have less facial hair to begin with, tend to switch roles first. Weekly time can range between one to more than five hours at $40 to $100 per hour. Completion may require less than 100 to more than 700 hours, with an average between 200 and 300 hours. Recently, some surgeons have recommended getting electrolysis on the scrotum between the legs, as well, because this skin is often used to line the neo-vagina, and should be hair-free. Electrolysis hurts and leaves red blotches on the skin for a while after each session. Also, while the transsexual still has her testes, she usually must take some kind of anti-androgen hormone as well; this can be discontinued after she is castrated (which usually happens during sex reassignment surgery). Early enough for complete prevention is prior to puberty, and this does not happen in this country. This is one reason why homosexual transsexuals tend to be more convincing as women compared with autogynephilic transsexuals, who tend to be older before starting hormones. Hormone therapy causes breast growth that is typically about one or two cup sizes less than sisters and mothers reach. Body hair growth slows, becomes less dense and lighter colored (but not on the head, face, or pubic area). Many transsexuals say that female hormones make them feel better, and less depressed. Some say that it makes them more attracted to men, for example, and Cher believes that female hormones make her hold a cup like a woman rather than like a man. Some of these psychological effects of hormone therapy are probably placebo effects, although it is not unlikely that others are real. The worst potential side effect of hormone therapy is blood clots that can travel to the lungs, where they can be fatal. With electrolysis and hormones, the other thing to get started on early is the voice. It is particularly difficult to pass on the phone, when they cannot convey their otherwise (in many cases) very feminine presentation. The medical solution to the voice problem,voice surgery, involves tightening of the vocal cords so that the pitch of the voice is elevated. The most important and obvious focus is raising the pitch of the voice to be as high as possible. In my experience, the transsexual voice remains the most problematic piece of the feminine puzzle. I have met many transsexuals whose physical appearance does not give them away, but I have met only a few whose voice provides no clue. Get rid of the beard, grow long hair, and put on a dress and even with good breast growth, some transsexuals look like men in dresses. Men, especially older men, have higher hairlines, broader chins,brow bossing (a prominence of the male brow ridge), lower eyebrows, narrower cheeks, and more prominent, angular noses. Facial plastic surgery is expensive, potentially the most expensive thing that a transsexual will buy. Some transsexuals (especially the homosexual type) need relatively little, and others need a lot of work. Although hormones cause some breast growth, many transsexuals elect to get breast implants as well. One surgeon offers a discount if the implants are done at the same time as genital surgery (not recommended by some, because there is then no comfortable part of the body to put weight on). More than one transsexual told me that the aftermath of breast implant surgery was far more painful than that of genital surgery. Womens hips and bottoms are wider than mens, so some transsexuals get silicon injections there. Silicon can enter the bloodstream and travel to the lungs, causing a fatal embolism. Also, because the silicon is loose rather than enclosed in surgical implants, there is concern that the silicon will eventually migrate to other places and look bad. Homosexual transsexuals have more motivation to attract men in the short term and seem less concerned with long-term consequences, so they are more apt to get the silicon injections. Ideally, these should be done in series, waiting for each layer to harden before putting another one on. Currently in Chicago, the person who does this procedure for most transsexuals is, herself, a transsexual who works out of her apartment.

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