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Do you express affection with your partner in non- d) Pain Measurement In Vestibulodynia sexual ways? For the purpose of diagnosis and treatment outcome erectile dysfunction herbal treatment options purchase viagra capsules in india, What consequences does the pain have on your it is advisable to erectile dysfunction drugs sales buy viagra capsules line measure the pain in the genital sexual functioning and intimate relationships? Some clinicians also ask that the patient rates the pain intensity of the pressure on numerical rating What diagnostic tests have been done? If the cotton-swab test reveals a pattern of sensitivity in which the pain What diagnoses have you received? Which treatments should be randomized as it has been demonstrated helped erectile dysfunction interesting facts discount 100mg viagra capsules with amex, and which ones did not? As such erectile dysfunction drugs at walgreens generic viagra capsules 100mg with mastercard, the cotton-swab test is prone to measurement error when used for experimental purposes or to measure treatment outcome. Therefore, a new b) Adequate Spreading mechanical device, the vulvalgesiometer (see Figure 25. This enables her to observe the 304], and has demonstrated that, in women with consequences of pelvic loor muscle activity. The vulva is carefully inspected, including the skin of the outer part of the vulva, labia minora, labia majora, the crease between the labia, the clitoral hood and clitoris, the posterior fourchette, vestibule, hymen, and hymenal edge. For women with introital dyspareunia, sites of allodynia are investigated using a cotton-swab (q-tip), applying light pressure along the outer edge of the hymen where it meets the inner edge of the internal surfaces of the labia minora. In cases where vaginal discharge is noted, relatively pain-free samples for vaginal pH and microscopy using a cotton-swab are possible to obtain. Additional testing is indicated by clinical indings; however, routine bacterial vaginal cultures are generally not useful. Although speciic studies are currently lacking, the vulvalgesiometer can be Measures of psychological function may also aid used as a diagnostic tool capable of differentiating in treatment planning. Additionally, the Personality pain (mild, moderate, severe) experienced by these Assessment Inventory [358] yields a global proile of women. The vulvalgesiometer has been used psychological function, and it has been validated with to measure changes in vestibular pressure-pain chronic pain populations. The administration of any sensitivity as a result of treatment [114, 312, 316, 346]. The following Involuntary contraction on the gynecology table does algorithm with three distinctive characteristics meets not infer that this response is also necessarily present these requirements. Conversely, some women can undergo a a) General Recommendations (Grade C) gynecological examination without any problem, but have vaginismic reactions in other circumstances, A multidimensional and multidisciplinary aptt depending on what they ind threatening. Instead of proach with speciic attention to 6 areas: the mutt asking a patient to relax, offering her information and cous membrane, the pelvic loor, the experience of tools is usually more successful to decrease anxiety pain, sexual & relationship function, psychosocial and hypertension of the pelvic loor muscles [341]. Simply focusing on one symptom or facet of the Physician assessment of pelvic loor muscle tone experience may lead to improvement in that single is imprecise but still of some value (Grade C) [349]. The woman is asked to bear Individualized treatmentAfter careful listening to her down while the physician (slowly) moves the inger story and after she has been well informed about the inside, keeping it dorsally curved to feel the pelvic condition,itsnaturalcourse,andpossibletreatmentop-- loor muscle without touching painful areas at the tions and management tips, a treatment plan is made. At the end of the examination, the Patienttfocused approach: it is up to the woman inger is slowly withdrawn as the patient bears down. With respect to b) A Counseling Model antidepressant medications, low doses are indicated This approach implies that the health care provider for neuropathic pain reduction whereas higher doses has to be familiar with the counseling model. He or are recommended for improvement in depressive she is an advisor and counselor but it is the patient symptoms. Treatments medications, regardless of dosage, have a dual for sexual pain disorders are time-consuming, and effect in that both pain and depressive symptoms they require great patience and empathy, sensitivity can be targeted simultaneously. Further research to non-verbal signals and insight in to relational is needed to assess this issue. The treatment provider should be able cited above were controlled (level 3) and, apart to identify any ambivalent feelings on the part of the from their methodological limitations, the results are patient regarding coitus, sexuality, her partner, her disappointing. Despite this issue, many clinicians continue to include in their biopsychosexual therapeutic approaches, 2. They include chronic pain medications along encouraged to establish eficacy of these commonly with sexual and psychological counseling. In addition, the patient examined the effectiveness of Fluconazol [378] one is encouraged to drink suficient luids to produce investigated the usefulness of Cromolyn 4% [379], approximately 1500 ml of non-concentrated urine and one assessed the effectiveness of botulinum daily. Hydration with sitz baths may help reduce toxin injections [380]; however, neither Fluconazol inlammation and symptoms. These results are contrary to the pattern guilty about their restricted sexual activities, which of indings in smaller uncontrolled studies examining may lead to frustration in their partners. Education treatment outcomes following the administration of about the effects of sexual pain on the sexual these injections [381, 382]. Deeper vaginal shortening, loss of achieves beneicial effects on different pause, hypothalamic dyspareunia when vagi-- rugae, narrowing, or ure-- aspects of sexual functioning without or pituitary disease, nal atrophy advanced. F Give dopaminergic drugs such as bromcriptine, cabergoline, or both to reduce prolactin; with surgery or radiation as appropriate. Irrespective of the Ovarian tumour; organic or functional nature of the pain, a his-- Abdominal wall pain. I Lower Urinary Introital and deep Perineal and vulvar Voiding dysfunction, recurrent bacterial Tract Symptoms dyspareunia or vulvar inlammation. In case of prolapse, surgical treatment can be curative but can also have undesired effects on sexual functioning. Introital and deep dys-- Thinning and fragility of Preventive measures such as transposition pareunia. Chronic vulvovaginal Introital dyspareunia Erythema, swelling of vul-- oral agents recommended for recurrent candidiasis associ-- and with penile vaginal va, and thick white or pale symptomatic candidiasis. Vulvar burning and pain that causes sexual Generalized Introital dyspareunia and psychological distress accompanied by vulvodynia. Clarify the legal and ethical responsibility of the physician, who must decline any request to re-inibulate after childbirth. Estrogen and progestogen use in postmenopausal women: July 2008 position statement of The North American Menopause Society. Vaginal atrophy in the postmenopausal woman: the importance of sexual activity and hormones. The prevalence of sexual dysfunction and associated risk factors in women with chronic pelvic pain: a cross-sectional study. Arch Gynecol Obstet 2006;274(5):297-302 [365] H Latthe P, Mignini L, Gray R, Hills R, Khan K. The impact of lower urinary tract synptoms and urinary incontinence on female sexual dysfunction using a validated instrument. A randomized, open, parallel group study of preventive effect of an estradiol-releasing ring (Estring) on recurrent urinary tract infections in postmenopausal women. The consequences of female curcumcision for health and sexuality: An update on the evidence. Cult Health Sex 2005;7:443-61 [372] P Catania L, Abdulcadir o, Puppo V, Baldaro Verde J, Abdulcadir J. Therefore, normalizing, reframing terms of clinical presentation and may respond to and encouraging non-penetrative sexual activity is some similar treatment options (e. It is recommended that the for vaginismus typically tend to target the muscle couple focus on positive, pleasurable and relaxing spasm over and above the symptom of (feared) sexual activities. Despite claims that treatment outcome for blockade and vestibulectomy are useful interventions vaginismus is generally excellent, many treatment (level 2b-4b) [247, 248, 314, 396, 397]. A Cochrane treatment gains of vestibulectomy are maintained review concluded that there is very limited evidence long term [314, 398-402]. This similarity of treatment for the effectiveness of treatments for vaginismus effect may indicate a non-speciic treatment effect in from controlled trials [227]. Characteristics of vaginismus before the surgery on herself, in the presence of a female therapist. Lifelong introital dyspareunia Results indicated that 90% of women were able to c. Largeamountofsurfaceareainvolvedwithallodynia experience intercourse after two exposure sessions, and results were maintained at 1-year follow-up [228]. Caution should be taken when dealing with women with vaginismus about their fear of penetration. The coexistence of depression and anxiety women with lifelong vaginismus, some patients and h.
If a sponsor cannot determine at the point of sale whether an enrollee is currently taking a drug (e. Part D sponsors may conduct consultations with physicians regarding treatment options and outcomes in all cases. For guidance on submitting formularies for employer group waiver plans, see chapter 12, section 20. When developing their formulary tier structure, sponsors should utilize standard industry practices. Tier 1 should be considered the lowest cost-sharing tier available to beneficiaries. Any subsequent tiers within the formulary structure will be higher cost-sharing tiers in ascending order, except that plans may assign a low cost share to Tier 5 or 6 when assigned as a Select Care tier. For example, drugs in Tier 3 will have a higher cost-share for beneficiaries than drugs in Tier 2. Best practices in existing formularies and preferred drug lists generally place drugs in a less preferable position only when drugs that are therapeutically similar (i. This list of conditions does not represent an exhaustive list, but merely serves as another check in the review process. The drugs identified will be expanded to the class level and used in the formulary review process. Examples of this may include a lack of appropriate drug classes to treat certain diseases, a lack of sufficient drugs in a therapeutic class, inappropriate tier placement that would discriminate against a group of beneficiaries, or missing drugs that could discourage certain types of beneficiaries from enrolling in the plan. If any of the outliers appear to create problems of access, sponsors will have the opportunity to present reasonable clinical justifications. However, prescription drug therapies are constantly evolving, and new drug availability, medical knowledge, and opportunities for improving safety and quality in prescription drug use at a low cost will inevitably occur over the course of the year. As recognized in the statute and regulations, these new developments may require formulary changes during the year in order to provide high-quality, low-cost prescription drug coverage. Sponsors should consult the Prescription Drug Benefit Manual, Chapter 2 (Medicare Marketing Guidelines), Section 60. Part D sponsors should make such formulary changes only if enrollees currently taking the affected drug are exempt from the formulary change for the remainder of the contract year. These additional types of change requests include, but are not limited to: • Changing preferred or non-preferred formulary drugs, adding utilization management, or increasing cost sharing on preferred drugs (unrelated to the reasons stated above); • Removing dosage forms; or • Exchanging therapeutic alternatives (either by formulary addition/removal or tier exchanges). Medicare beneficiaries select Part D sponsors, in part, based on the formulary that is marketed during annual open enrollment and, therefore, have a legitimate expectation that they will have continuing access to coverage of the Part D drugs they are using throughout the contract year. This beneficiary expectation will be balanced against the sponsor’s desire to practice good formulary management in order to provide a low-cost, high-quality prescription drug benefit that continues to effectively meet the needs of beneficiaries. Part D sponsors may avoid any appearance of a “bait and switch” concern by exempting enrollees who are currently using the affected drugs from the formulary change for the remainder of the contract year. If a beneficiary is not “affected” by a formulary change (in other words, exempted from a formulary change), notice is not required. As an alternative to providing written notice, Part D sponsors may provide such notice electronically if, and only if, an enrollee affirmatively elects to receive such notice electronically. In instances where there has been an announcement of a market withdrawal, but the withdrawal has not yet taken place, Part D sponsors may opt to either remove the drug immediately with a retrospective notice to “affected enrollees” or provide an advance notice. The sponsor indicates the effective date for this st formulary change will be May 1st. If a beneficiary were to present on April 1 with a new prescription for the brand name drug pending removal, the Part D sponsor would provide written notice of the change and not implement the change until June 1st, in order to provide the full 60 days of advance notice to that beneficiary. A Part D sponsor may elect to provide written notice to all of its enrollees of a pending formulary maintenance change in lieu of notifying only the “affected enrollees. However, Part D sponsors are still required to provide advance written notice of a formulary change and a 60 day-supply of the drug whose formulary status is changing to those beneficiaries who enroll in the plan after the initial advance formulary change notice, as described above. In accordance with our non-maintenance formulary change policy, enrollees currently taking the affected drug must be exempt from the formulary change for the remainder of the contract year. The sponsor indicates the effective date for this formulary change will be May 1st. Because the upcoming year’s formulary is viewed as a new formulary, Part D sponsors are not required to identify specific drug changes impacting enrollees in their explanation of benefits, or provide a 60-day notice of changes for the upcoming year’s formulary. The purpose of providing a transition supply is to promote continuity of care and avoid interruptions in drug therapy while a switch to a therapeutically equivalent drug or the completion of an exception request to maintain coverage of an existing drug based on medical necessity reasons can be effectuated. See Appendix E for a listing of multiple scenarios when beneficiaries may be eligible for a transition fill under this guidance. A Part D sponsor’s transition process must address situations in which an individual first presents at a network pharmacy with a prescription for a drug that is non-formulary, and should be presumed to be unaware of what is covered by the plan or of the sponsor’s exceptions process for providing access to Part D drugs that are not covered. The purpose of the transition policy is to address situations when an enrollee’s ongoing drug therapy (whether the Part D sponsor is able to actually ascertain ongoing therapy or not) could be potentially interrupted by a drug being non-formulary. However, just because a member’s drug therapy could potentially be interrupted does not mean that the member will necessarily receive a transition fill. In this example, for instance, the formulary may not have changed (which means there have also been no addition of utilization management edits). Steps that sponsors should consider to ensure a meaningful transition include: • Analyzing claims data to determine which enrollees require information about their transition supply. In other words, for transition purposes, a brand-new prescription for a non- formulary drug will not be treated any differently than an ongoing prescription for a non- formulary drug when a distinction cannot be made at the point of sale. This 90 day timeframe applies to retail, home infusion, long-term care, and mail-order pharmacies. Thus, plans are required to provide a temporary fill anytime during the first 90 days of a beneficiary’s enrollment in a plan. However, since certain enrollees may join a plan at any time during the year, this requirement applies beginning on such an enrollee’s first effective date of coverage instead of to the first 90 days of the plan year. If an enrollee leaves a plan and re-enrolls during the original 90 day transition period, the transition period begins again with the new effective date of enrollment, because it is possible that the enrollee’s drug therapy changed while the enrollee was not with the plan and that therapy could be potentially interrupted. If the smallest available marketed package size exceeds a 30 day supply, the sponsor must still provide a transition supply when required. If the smallest available marketed package sizes do not align with this timeframe, the sponsor must still provide a transition supply when required. Part D sponsors and their processors must determine how to process claims in such cases. Also, sponsors must honor multiple fills of non-formulary Part D drugs as necessary during the entire length of the transition period. Part D sponsors electing this option must update their existing transition policy to specifically address that: 1. This option must be in place prior to the start of the contract year; otherwise, the Part D sponsor must continue to provide notice directly to the beneficiary (or his/her designated representative) via U. It is vital that sponsors give affected enrollees clear guidance regarding how to proceed after a temporary fill is provided, so that an appropriate and meaningful transition can be effectuated by the end of the transition period. Until that transition is actually made, however, either through a switch to an appropriate formulary drug, or a decision is made regarding an exception request, continuation of drug coverage is necessary, other than for drugs not covered under Part D. In order to prevent coverage gaps, sponsors choosing this option are expected to provide a transition supply of the requested prescription drug beginning January 1 and provide enrollees with the required transition notice; or • Effectuate a transition for current enrollees prior to the start of the new contract year. In effectuating this transition, sponsors must aggressively work to (1) prospectively transition current enrollees to a therapeutically equivalent formulary alternative; and (2) adjudicate any requests received for exceptions to the new formulary prior to the start of the contract year (consistent with chapter 18, section 30. However, if sponsors have not successfully transitioned affected enrollees to a therapeutically equivalent formulary alternative or adjudicated an exception request prior to January 1, they will be expected to provide a transition supply beginning January 1 and the required transition notice. If a sponsor approves an exception request pursuant to this section, the sponsor must authorize payment prior to January 1 of the new contract year. Current Enrollees - Part D sponsors that can identify objective information demonstrating that a meaningful transition has occurred (such as the adjudication of an exception request and/or evidence of a new prescription claim for a formulary alternative paid by the sponsor prior to the start of the new contract year) do not have to provide a transition supply in the new contract year for that beneficiary as the next fill would either be a covered fill of the medication approved under the exception process or a covered fill of the formulary alternative that the enrollee transitioned to before the start of the new contract year. However, lacking such documentation, the sponsor is expected to provide a transition supply in the new contract year and provide the corresponding transition notice. New Enrollees - Part D sponsors must extend their transition policies across contract years should a beneficiary enroll into a plan with an effective enrollment date of either November 1 or December 1 and need access to a transition supply. During the first 90 days after enrollment, the enrollee will receive a transition supply as described in section 30.
Each Plastibell is supplied in a sterile packet with a ligature – the Plastibell tie. The procedure is easier if, after opening the Plastibell package, the Plastibell tie is placed loosely around the shaft of the penis before the dorsal slit is made (Fig. It is sometimes helpful to hold the foreskin in position by clipping it to the Plastibell handle with an artery forceps (Fig. Infant and paediatric circumcision Chapter 6 - 14 Male circumcision under local anaesthesia Version 3. Cut off the foreskin using scissors, leaving 1– 2 mm of cuff to prevent the ligature from slipping off (Fig 6. Infant and paediatric circumcision Chapter 6 - 15 Male circumcision under local anaesthesia Version 3. If all is well, the child can be sent home and looked after in the normal way, including normal washing and use of nappies. The rim of tissue distal to the ligature will become necrotic and the Plastibell will drop off after 5–8 days. Information for parents the parents of infants and children who have had a Plastibell circumcision should be told that it is not necessary to use a dressing, and the baby can be looked after in the normal way, including normal washing and use of nappies. The parents should be told to come back to the clinic if: • the child appears to be distressed or in pain; • the child has fever; • the child does not wake for feeding as per his usual pattern; • there is any separation of the skin edges; • there is any unusual swelling or bleeding; • the child has any difficulties with urination; • the plastic ring slips onto the shaft of the penis; • the tip of the penis becomes swollen or changes colour • one part of the foreskin remains pink or has not shrivelled after 48 hours; • the plastic ring has not fallen off within 8 days; • the parents have any other worry about healing. Infant and paediatric circumcision Chapter 6 - 16 Male circumcision under local anaesthesia Version 3. There have been several studies comparing it with the Gomco clamp, another widely used device. The Mogen (“shield”) clamp compares favourably, because it is easy to use and has no parts to assemble. The fewest complications with this method have been reported in the context of circumcision of 8-day-old babies. Since the Mogen clamp is reusable, careful precautions have to be taken to ensure the device is properly cleaned and sterilized between procedures. Also there is a risk that the glans can be pulled i into the slit and crushed or partially severed. After cleaning, draping, anaesthesia and marking the line of the circumcision over the corona, retract the foreskin and separate the adhesions to expose the corona, as described above. It is important to separate all adhesions in order to prevent the glans from getting accidentally pulled into the Mogen clamp and injured. Put traction on the foreskin, and introduce it into the slit in the device, with the concavity facing the glans (Fig 6. If there is any doubt, remove the clamp, inspect the glans for any sign of crushing injury and reapply the clamp. Pediatrics 97: 134-136, 1995 Infant and paediatric circumcision Chapter 6 - 17 Male circumcision under local anaesthesia Version 3. If the device is left too long it may be difficult to separate the foreskin to reveal the glans after the device is removed. Manipulate the penis, using gentle pressure from the side, to allow the glans to emerge from under the crushed foreskin (Fig 6. This is an important step to ensure the foreskin heals below the level of the corona. In older infants (>60 days) it may be necessary to place some 5-0 simple sutures to approximate the edges. Infant and paediatric circumcision Chapter 6 - 18 Male circumcision under local anaesthesia Version 3. Information for parents the parents of an infant or child who has had a circumcision using the Mogen clamp technique should be told that it is not necessary to use a dressing and the child can be looked after in the normal way, including normal washing and the use of nappies. The parents should be told to come back to the clinic if: • the child appears to be distressed or in pain; • the child has fever; • the child does not wake for feeding as per his usual pattern; • there is any separation of the skin edges; • there is any unusual swelling or bleeding; • the child has any difficulties with urination; • the parents have any other worry about healing. Infant and paediatric circumcision Chapter 6 - 19 Male circumcision under local anaesthesia Version 3. In addition, the crushing of the foreskin is circular (unlike with the Mogen clamp, which is linear).. A disadvantage of the Gomco clamp is that, unlike the Mogen clamp, it consists of four parts – base plate, rocker arm or top plate, nut and bell. There is a risk that parts of the clamp may be mislaid or lost during cleaning and sterilization. Before the start of the procedure and before any anaesthetic is given the surgeon must check that likely sizes of Gomco clamps are available. Once the procedure has started and the correct size has been selected the clamp should be assembled to ensure parts are complete and fit correctly. If a small bell is used with a larger base plate the device will not crush the foreskin or protect the glans, possibly resulting in haemorrhage and penile laceration. Component parts from different clamps or manufacturers are not interchangeable and care must be taken to ensure that the clamp is assembled only from its original parts. The Gomco clamp should also be thoroughly checked and not used if it has stripped threads, a warped or bent base plate, a bent arm, twisted forks on the rocker arm, or a scored or nicked bell. Infant and paediatric circumcision Chapter 6 - 20 Male circumcision under local anaesthesia Version 3. After cleaning, draping anaesthesia, and marking the line of the circumcision over the corona, retract the foreskin and separate the adhesions to expose the corona, as described above. It is usually necessary to make a small dorsal slit to allow the clamp to be placed on the glans (Fig 6. Otherwise, it will extend beyond the ring of crushed tissue produced by the Gomco clamp and may produce an untidy result with increased risk of bleeding. The dorsal slit should be long enough to allow all adhesions to be divided and the bell of the Gomco clamp to be placed over the glans. Place the base plate of the Gomco clamp over the bell, keeping the foreskin pulled over the bell (Figs 6. Put the rocker arm of the clamp in position, taking care to place the crossbar at the top of the bell correctly in the yoke. Before tightening the clamp, make sure that the foreskin is symmetrical over the bell. Finally, the crossbar at the top of the bell should sit Infant and paediatric circumcision Chapter 6 - 21 Male circumcision under local anaesthesia Version 3. Once you are sure that the clamp is in the optimal position, tighten the nut until the foreskin is crushed (Fig 6. Using a scalpel, excise the foreskin circumferentially against the bell, distal to the clamp (Fig 6. American Journal of Obstetrics and Gynecology 1935, 30:146-147 Infant and paediatric circumcision Chapter 6 - 22 Male circumcision under local anaesthesia Version 3. To obtain a good result with the Gomco clamp, the surgeon must ensure: (a) the dorsal slit is not made too long, the apex must be above the crushed skin edge. Information for parents the parents of an infant or child who has had a Gomco clamp circumcision should be told that it is not necessary to use a dressing, and the baby can be looked after in the normal way, including normal washing and the use of nappies. Bleeding is rare Infant and paediatric circumcision Chapter 6 - 23 Male circumcision under local anaesthesia Version 3. Parents should be told to bring the child back to the clinic if: • the child appears to be distressed or in pain; • the child has fever; • the child does not wake for feeding as per his usual pattern; • there is any separation of the skin edges; • there is any unusual swelling or bleeding; • the child has any difficulties with urination; • the parents have any other concern about healing. Infant and paediatric circumcision Chapter 6 - 24 Male circumcision under local anaesthesia Version 3. The information should be given verbally in the local language using non-technical terms. In addition, the clinic should have printed information sheets that the parents can take home. Information given needs to be specific to the clinic, and should include the following topics. It does not affect the ability to pass urine normally and does not affect the ability to father children in adult life. It should be explained that complications from male circumcision are extremely rare but can include poor cosmetic outcome, bleeding, infection, or injury to surrounding structures. If the child becomes ill before the planned operation date, the parents should contact the clinic to postpone the procedure until after the child recovers. The instructions will depend on the procedure that has been used (see descriptions of techniques in Chapter 6).
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Over and again men Fortunately the Capo in my working party was obligated slipped and those following behind stumbled on top of to erectile dysfunction jacksonville doctor quality 100 mg viagra capsules me; he had taken a liking to erectile dysfunction topical treatment buy 100mg viagra capsules visa me because I listened to erectile dysfunction vacuum pump price cheap viagra capsules 100 mg fast delivery his them erectile dysfunction in diabetes pdf purchase viagra capsules 100mg overnight delivery. Then the column would stop for a moment, but not love stories and matrimonial troubles, which he poured out for long. One of the guards soon took action and worked during the long marches to our work site. I had made an over the men with the butt of his rifle to make them get up impression on him with my diagnosis of his character and quickly. The more to the front of the column you were, the with my psychotherapeutic advice. After that he was grate less often you were disturbed by having to stop and then to ful, and this had already been of value to me. I previous occasions he had reserved a place for me next to was very happy to be the personally appointed physician to him in one of the first five rows of our detachment, which His Honor the Capo, and to march in the first row at an usually consisted of two hundred and eighty men. We had to line up early in the morn As an additional payment for my services, I could be sure ing while it was still dark. Everybody was afraid of being that as long as soup was being dealt out at lunchtime at our late and of having to stand in the back rows. If men were work site, he would, when my turn came, dip the ladle right required for an unpleasant and disliked job, the senior to the bottom of the vat and fish out a few peas. This Capo, Capo appeared and usually collected the men he needed a former army officer, even had the courage to whisper to from the back rows. These men had to march away to an the foreman, whom I had quarreled with, that he knew me other, especially dreaded kind of work under the command to be an unusually good worker. Occasionally the senior Capo chose men but he nevertheless managed to save my life (one of the from the first five rows, just to catch those who tried to be many times it was to be saved). All protests and entreaties were silenced by a few sode with the foreman he smuggled me in to another work well-aimed kicks, and the chosen victims were chased to party. However, as long as my Capo felt the need of pouring out his heart, this could not happen to me. I had a guaranteed There were foremen who felt sorry for us and who did place of honor next to him. But there was another advan- their best to ease our situation, at least at the building site. Since I had the mental stress we had to submit to, not having news of always been especially sorry for people who suffered from our families, who had either been sent to another camp or fearful dreams or deliria, I wanted to wake the poor man. At that lowed myself to say once to a kindly foreman, "If you could moment I became intensely conscious of the fact that no learn from me how to do a brain operation in as short a dream, no matter how horrible, could be as bad as the time as I am learning this road work from you, I would reality of the camp which surrounded us, and to which I have great respect for you. Apathy, the main symptom of the second phase, was a Because of the high degree of undernourishment which necessary mechanism of self-defense. Let us observe the majority of prisoners when typical to hear the prisoners, while they were being herded they happened to work near each other and were, for once, back to camp from their work sites in the evening, sigh with not closely watched. One fellow would ask another working next to It can be readily understood that such a state of strain, him in the ditch what his favorite dishes were. Several of my colleagues in camp future when they would be liberated and returned home. His wishes and desires the form of a special password or number: "The guard is became obvious in his dreams. Of I always regarded the discussions about food as danger bread, cake, cigarettes, and nice warm baths. Is it not wrong to provoke the organism with such having these simple desires satisfied led him to seek wish- detailed and affective pictures of delicacies when it has fulfillment in dreams. Though it may afford momentary psycho I mentioned above how unavoidable were the thoughts logical relief, it is an illusion which physiologically, surely, about food and favorite dishes which forced themselves in to must not be without danger. Perhaps it can be understood, then, that even tion consisted of very watery soup given out once daily, and the strongest of us was longing for the time when he would the usual small bread ration. In addition to that, there was have fairly good food again, not for the sake of good food the so-called "extra allowance," consisting of three-fourths itself, but for the sake of knowing that the sub-human exis of an ounce of margarine, or of a slice of poor quality sau tence, which had made us unable to think of anything other sage, or of a little piece of cheese, or a bit of synthetic honey, than food, would at last cease. In calories, this Those who have not gone through a similar experience diet was absolutely inadequate, especially taking in to con can hardly conceive of the soul-destroying mental conflict sideration our heavy manual work and our constant ex and clashes of will power which a famished man experi posure to the cold in inadequate clothing. They can hardly grasp what it means to stand dig were "under special care"—that is, those who were allowed ging in a trench, listening only for the siren to announce to lie in the huts instead of leaving the camp for work—- 9:30 or 10:00 A. One after another the members of the little community will power, pocketing it again, having promised oneself that in our hut died. After many observations we knew the symptoms well, of certain methods of dealing with the small bread ration, which made the correctness of our prognoses quite certain. This lice, we saw our own naked bodies in the evening, we had the twofold advantage of satisfying the worst hunger thought alike: This body here, my body, is really a corpse pangs for a very short time at least once a day and of already. I am but a small portion safeguarding against possible theft or loss of the ration. We then began the tussle with our wet shoes, in to There were fifty of us in the prison car, which had two which we could scarcely force our feet, which were sore small, barred peepholes. And there were the usual moans one group to squat on the floor, while the others, who had and groans about petty troubles, such as the snapping of to stand up for hours, crowded round the peepholes. We all felt more dead than alive, since we grounds in his bare feet, as his shoes were too shrunken for thought that our transport was heading for the camp at him to wear. In those ghastly minutes, I found a little bit of Mauthausen and that we had only one or two weeks to live. Undernourishment, besides being the cause of the gen After hours of delay the train left the station. And there eral preoccupation with food, probably also explains the was the street—my street! Apart from ber of years of camp life behind them and for whom such a the initial effects of shock, this appears to be the only ex journey was a great event stared attentively through the planation of a phenomenon which a psychologist was peephole. I began to beg them, to entreat them, to let me bound to observe in those all-male camps: that, as opposed stand in front for one moment only. I tried to explain how to all other strictly male establishments—such as army much a look through that window meant to me just then. Even in his My request was refused with rudeness and cynicism: "You dreams the prisoner did not seem to concern himself with lived here all those years? Well, then you have seen quite sex, although his frustrated emotions and his finer, higher enough already! Politics were talked about everywhere in camp, This was brought home to me on my transfer from almost continuously; the discussions were based chiefly on Auschwitz to a camp affiliated with Dachau. A small lost all hope, but it was the incorrigible optimists who were circle had gathered, among them, quite illegally, the war the most irritating companions. The religious interest of the prisoners, as far and as soon One man began to invoke the spirits with a kind of as it developed, was the most sincere imaginable. In my opinion he must have heard them once in ity was great among the weak, who had to keep on with his life, without recollecting them, and they must have been their hard work as long as they possibly could. The quarters available to the "spirit" (the spirit of his subconscious for the sick were most inadequate, there were practically no mind) at that time, a few months before our liberation and medicines or attendants. The worst case of In spite of all the enforced physical and mental primi- delirium was suffered by a friend of mine who thought that tiveness of the life in a concentration camp, it was possible he was dying and wanted to pray. To avoid these attacks of de to a rich intellectual life may have suffered much pain lirium, I tried, as did many of the others, to keep awake for (they were often of a delicate constitution), but the damage most of the night. Eventually I began to reconstruct the manuscript their terrible surroundings to a life of inner riches and which I had lost in the disinfection chamber of Auschwitz, spiritual freedom. Only in this way can one explain the and scribbled the key words in shorthand on tiny scraps of apparent paradox that some prisoners of a less hardy make paper. In order to make myself clear, I am Once I witnessed something I had never seen, even in my forced to fall back on personal experience. Let me tell what normal life, although it lay somewhat near my own happened on those early mornings when we had to march professional interests: a spiritualistic seance. First secret that human poetry and human thought and belief man about, left and left and left and left! I understood how a man who has nothing left in we passed the gate of the camp, and searchlights were trained upon us. In a position of pulled his cap back over his ears before permission was utter desolation, when man cannot express himself in posi given. The accompanying guards kept shouting at us and For the first time in my life I was able to understand the driving us with the butts of their rifles.
Originating in Canada erectile dysfunction pills don't work order viagra capsules canada, in response to erectile dysfunction dsm 5 generic viagra capsules 100 mg amex the massacre of women in Montreal in 1989 best herbal erectile dysfunction pills purchase viagra capsules without prescription, the White Ribbon Campaign achieved very high visibility in that country impotence young males purchase viagra capsules now, with support from political and community leaders and considerable outreach in schools and mass media. While they have not achieved the visibility of the White Ribbon Campaign they have built up a valuable body of knowledge about the successes and difficulties of organizing among men (Kaufman 1999; Lichterman 1989; Pease 1997). Many heterosexual men see no lessons here for themselves – but ho mosexual masculinities and heterosexual masculinities are not so different as stereotypes would suggest. Gay men have pioneered in areas such as community care for the sick, community education for responsible sexual practices, representation in the public sector, and overcoming social exclusion, which are important for all groups of men concerned with gender equality (Altman 1994; Kippax et al. The struggle for gender equality must engage the energy and passion of men, as it already has with women. Men have specific obstacles to overcome, especially the fact that for many, a move towards gender equality is against their short-term interests. These obstacles can be overcome by a passion for equality or a vision of the general benefits to humanity. All social movements experience human wear and tear, sometimes "burnout" among those committed to the work. The same need arises among men (though conventional masculinity encourages men to deny such needs). Many men around the world are engaged in gender reforms, for the reasons discussed in section 4 above. As this diversity becomes better known, men and boys can more easily see a range of possibilities for their own lives, and both men and women are less likely to think of gender inequality as uncha ngeable. It becomes possible to identify specific groups of men who might engage in alliances for change. There is a spectrum of masculinity politics in the contemporary world – some groups and movements supporting gender equality and some opposing it. What is possible is that those forms of masculinity politics which support gender equality might become hegemonic among men. There is already a broad cultural shift in masculinity politics towards a historical consciousness about gender, an awareness that gender customs came in to existence at specific moments in time and can always be transformed by social action. What is needed now is a widespread sense of agency among men, a sense that this transformation is something they can share in, as a practical proposition. This is, indeed, no more than the cultural presupposition of the "joint responsibility" of men invoked by the General Assembly declaration of the year 2000 (Twenty-third special session of the United Nations General Assembly, Political Declaration, paragraph 6). For gender equality politics to become hegemonic among men does not require that other political views should vanish. It does require effective responses to the resistance that comes from men still committed to gender privilege, or from men who accept gender equality in 28 principle but do little about it in practice. Masculinity politics should be thought of as a dialectic, not an expression of fixed identities or positions. There are many forums in which this dialectic can occur, from family homes to mass media, workplaces and voluntary organizations as well as parliaments and international bodies. Some men have already undertaken profound transformations of personal character and relationships in pursuit of a vision of equality. This is a difficult undertaking, sometimes with high human costs, and its outcome is by no means certain. However it is not practical to ask all men to engage in revolutionary personal change. The core of gender reform is setting up processes of change that will transform unequal gender relations. Men can become partners in such processes by taking specific steps in workplaces and families to equalize resources, share power, end violence and harassment, share childcare, etc. Since men are collectively the beneficiaries of most gender inequalities, and are the agents of most gender-based violence, it is not surprising that men are for the most part defined negatively in gender policy discourse (see section 2. It is therefore very important to see gender equality as a positive project for men. It realizes high principles of social justice, it produces better lives for the women that men care about, and it will produce better lives for the majority of men in the long run. It should not be assumed that methods suitable for one context will work in all others. Women involved in gender equality work have come to recognize the importance of cultural difference and diversity (Bulbeck 1998); the same lesson should be applied with men. At the same time, it is one world, and cultures inevitably interact with each other. The creation of world society, and contemporary globalization, are real processes. At the very least, it is important to learn from each other, and to pool ideas and experiences. Gender equality policy implications : The task for gender equality policy is to encourage an active dialectic about change among men, to present gender equality as a positive project for 29 men, and to create means for continuing international exchange of ideas, knowledge, experience and methods in this work. A suggested policy framework This section outlines a framework, at national level, for incorporating men and boys more systematically in to gender equality policies and processes. While specific measures are mentioned, it is assumed that policy details will vary from country to country. The recent discussion of Nordic experience by Holter (2003, chapter 7) is recommended. It is important that there should be some agreement, among the different groups active in gender equality issues, on the principles go verning change in this area. Define the "gender perspective" as centering on gender rela tions rather than on gender groups separately. Recognize the well-being of men and boys as a legitimate goal of gender equality measures. Address the specific needs of men and boys, where they differ from the needs of women and girls. Public policies in a number of areas impinge on men and boys in specific ways and affect their contribution to gender equality. Suggested measures are: • Undertake a review of existing mainstream policies for the ways they define men and boys (often implicitly) and influence their situation. Such measures include career incentives for childcare contribution; disincentives for employers to demand overtime work; a legal structure for permanent part-time work and incentives for men to use it. Some, though not all, goals in this area can be addressed by specific purpose programmes addressed to men and boys. It is important for overall gender equality outcomes that new programmes of this kind should not compete for funding with programmes addressed to women and girls, but should be funded from existing programmes that implicitly address men and boys. A well-pla nned suite of programmes might include: • Fatherhood education programmes, especially addressed to younger men, combining health, child development and relationship issues. The institutions of government are themselves the bearers of gender patterns, and their organizational processes are a strategic part of the move towards a gender-equal society. Policy makers with responsibility for public sector agencies should address at least these issues: • Use re-structuring of public sector agencies as occasions for removing embedded gender hierarchies, re-organizing labour processes where necessary for this purpose, and developing positive alliances between women and men in achieving gender reform. Government initiatives can have broad social effects both by example and by supporting wider processes of change. Positive influence can be exerted by these means: • Create forums for continuing discussion of gender equality and gender relations in society that systematically include men and boys. Men as Managers, Managers as Men: Critical Perspectives on Men, Masculinities and Managements. Strategien gegen Gewalt im Geschlechterverhaltnis: Bestandsanalyse und Perspektiven. The Violences of Men: How Press Talk About and How Agencies Respond to Men’s Violence to Women. Against the Tide: Pro-Feminist Men in the United States, 1776-1990, A Documentary History. Varones, Sexualidad y Reproduccion: Diversas perspectivas t eorico- motodologicas y hallazgos de investigacion. States, Markets, Families: Gender, Liberalism and Social Policy in Australia, Canada, Great Britain and the United States. Individualisierungsprozesse, Geschlechterverhaltnisse und die soziale Konstruktion des Soldaten.