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R. Jobe Fix, MD

• Professor
• Department of Surgery, Division of Plastic Surgery
• University of Alabama at Birmingham School of Medicine
• Active Staff
• Surgical Service: Plastic Surgery
• University Hospital
• Birmingham, Alabama

Nearly half (49%) of all participants lived in a house or apartment they rented or shared depression checklist 20 mg geodon with visa, and almost a third (32%) lived in a house anxiety 6 year old discount geodon online amex, condominium or coop that they owned or coowned anxiety 9 dpo buy geodon with a mastercard. Another 8% lived rentfree in a house or apartment depression quick fix 40mg geodon sale, and 3% lived in assisted depression symptoms acronym order geodon 40 mg without prescription, temporary or transitional housing great depression test answers order geodon without prescription. The most common living arrangements among participants were living alone (29%), with a significant other (19%), with their spouse (15%), with gay lesbian or bisexual roommates (11%), with straight roommates (10%), or with immediate birth families (9%). Transgenderspecific Demographics Table 2 shows transgenderspecific demographic characteristics. Transgender (42%) was the most commonly reported gender identity among all participants. Intersex conditions include chromosomal anomalies, mixed sex characteristics, and sometimes ambiguous genitalia, and the participants reported a much higher rate of intersex conditions than found in a nontransgender population. A transgender person who has gender transitioned is living fulltime in a gender opposite to physical sex assigned at birth. However, most transgender people who gain access to hormonal therapy and cosmetic surgeries eventually pass well enough in their chosen genders to conceal their transgender status. Fortyfive percent of all participants had transitioned at the time of the survey, at an overall median age of 26 years. Almost another third (32%) were planning to transition, with 40% planning to do so in a year or less, and 37% within two to three years. However, these data should be interpreted carefully, since identity 15 driven risk behavioral assumptions commonly associated with nontransgender people may not apply here. Moreover, gender transition is also a time of questioning and experimenting with their sexualities for many transgender persons, and shifts in sexual orientation are not uncommon. Participants with insurance included those who had private insurance, either through their employers (54%), through their parents or families (16%), or that they paid for directly (10%), and those with 16 Medicare (12%) or Medicaid (6%). Six percent of respondents had been denied enrollment in a health insurance plan because of their transgender status. Sixtytwo percent of participants had a doctor they saw regularly for health care, and 38% did not. Just over a half (51%) of those who were out felt their regular doctors were either knowledgeable or very knowledgeable about transgender health care issues. The most common reasons these participants reported for their discomfort were fear of an insensitive reaction (64%), fear of being denied treatment (49%), fear of ridicule (43%), and fear of a hostile reaction (42%). Access to Transgenderrelated Health Care (including Mental Health) Most participants became aware at an early age that their gender identities (their internal sense of their own gender) did not match their bodies or physical appearances. The most common reasons given for why changing their body was important were: wanting to be comfortable in their own body (88%), selfesteem (64%), safety (46%), and secure employment (34%). The top three sources of information were the internet (69%), transgender support groups (50%), and word of mouth (47%). Table 4 shows participant levels of access to transgenderspecific services, as well as their average ratings of the service quality and the sensitivity of service providers. Counseling or psychotherapy demonstrated the highest levels of access by participants (72%), followed by transgender hormonal therapy (48%). Overall, the lowest average ratings for quality of service were gynecological care (3. Among transgenderrelated services explicitly wanted by participants in the past year, transgender hormonal therapy (33%) was the most difficult to obtain, followed by transgenderrelated surgery (27%), counseling or psychotherapy (26%), transgenderrelated electrolysis (23%), transgender sensitive gynecological care (21%), and transgenderrelated speech therapy (19%). Across all transgenderrelated services sought by participants, the most common barriers were inability to pay for the services, their health insurance plans not covering them, and not knowing if the service was available in their area. The most common barriers were not knowing if it was available in their area (29%), inability to pay (21%), provider insensitivity or hostility to transgender people (10%), and health insurance plans not covering it (10%). Twentynine percent had no blood tests done to monitor the effects of the hormones they took. Among the hormonenaive participants and those who were hormoneexperienced but not currently taking hormones, 52% were planning to take hormones in the future and 25% were unsure. Employment and Housing Discrimination Table 5 shows employment and housing discrimination data. Nearly twothirds (65%) of the participants were employed by people other than themselves, and of those, 42% reported their employers were aware of their transgender status, with another 12% not knowing or unsure. Twenty percent of the participants felt they had been denied a job for which they applied due to their transgender status or gender expression. Five participants reported being homeless at the time of the survey, with the lack of affordable housing cited as the principal reason. Among all participants, 17% had been evicted in their lifetimes, with inability to pay the rent (54%) and their transgender status or gender expression (29%) the most common reasons for the evictions. Of those who experienced forced sex, 20% reported one incident, 26% reported two incidents, 19% reported three to five incidents; another 19% reported six to 19 incidents, and 16% reported 20 or more incidents. The most common perpetrators were an acquaintance (48%), a complete stranger (26%), father or stepfather (16%), a former spouse or partner (14%), current spouse or partner, and brother or sister (both 12%). Overall, 83% of the participants who experienced forced sex did not report any incidents to the police. Of those who experienced physical assaults, 18% reported one incident, 23% reported two incidents, 30% reported three to five incidents, 17% reported six to 19 incidents, and 12% reported 20 or more. The most common perpetrators were a complete stranger (47%), an acquaintance (27%), another person not categorized (27%), father or stepfather (16%), mother or stepmother (9%), current spouse/partner, brother/sister, or a former spouse or partner (all 8%). Overall, 70% of the respondents who were attacked did not report any assault to the police. Suicidal Ideation and Attempts Participants were asked to assess the level of support they experienced from their immediate social environments. The highest levels of support came from their transgender friends, transgender support groups, and nontransgender friends. The lowest levels of support came from their family by marriage; their church, temple or mosque; and their birth family. Onethird of those attempting suicide had made one attempt; another 30% had made two attempts; 16% made 3 attempts; 14% made 4 to 9 attempts; and 8% made 10 or more attempts. However, only four of the problem drinkers felt their current drinking was a problem for them, with three not seeking treatment at the time and one on a waiting list. Ninetyone percent felt their current smoking was a problem for them, but 70% of those were not seeking treatment at the time. Of those for whom smoking was a problem, 16% were successful in finding a cessation program, 5% could not find a program in their area, and another 5% were afraid to join a program due to their fears of their transgender status being revealed. Eleven percent had other reasons that kept them from joining a smoking cessation program. Table 6 shows lifetime drug use by participants, with drugs rank ordered by most common use. Participants reported much lower levels of current drug use than lifetime use, with marijuana (18%), downers (5%), painkillers (5%), poppers (3%), and powder cocaine (3%) the most popular. Of those 11, eight were not looking for a treatment program, two were afraid to join because their transgender status would be revealed, and one was successful in finding treatment. Participants were asked if they strongly agreed (1), agreed (2), neither agreed nor disagreed (3), disagreed (4), or strongly disagreed (5). The responses to both these questions suggest that gender identity validation through sex with a nontransgender opposite gender partner may be a contributing factor in sexual risktaking. The most common reason given for abstinence by just over half (52%) of these participants was not finding a partner with whom they wanted to have sex. Those who received a service were asked to rate its quality and the sensitivity of their provider to them as a transgender person on a five point scale from 1 (extremely poor) to 5 (excellent). However, among the four services, these printed materials were rated the lowest for quality and provider sensitivity to the participants as transgender persons. The most common reasons for not being able to access these services were not knowing if they were available in their area and the lack of transgender staff or outreach workers. The most common reasons for not getting tested were always having safer sex (38%) and another reason not classified (28%). Of all participants who were tested, 16% had received tattoos or piercings since their last test. The most commonly reported probable means of becoming infected was unprotected sex with a non transgender man (86%). Four each needed hospitalization, case management, counseling, legal services, and support groups. After northern, eastern reported the highest percentage of strictly unemployed participants (10%). The eastern region had the highest percentage of participants with a regular doctor (72%) and the lowest reported percentage of participants reporting discrimination by a health care provider (14%). However, only 16% of eastern participants reported accessing gynecological care, compared to a high of 35% in the central region. Eastern had the most participants who had not sought any transgenderrelated treatment, the lowest percentage of participants who had gender transitioned (30%), and the lowest percentage of access to transgender hormonal therapy (37%) among all regions. Eastern also had the highest percentage of hormoneexperienced participants who received street hormones (73%), and over half had injected their hormones or received an injection from someone other than a medical provider. Eastern also had the highest level of injection silicone use (19%) among its participants. Although participants in the eastern region were the least likely to report suicidal ideation (53%), those who did were the most likely to have made suicide attempts (51%). Eastern had the highest regional current use percentage for any drug reported by participants (marijuana, 27%). Among the regions, eastern had the highest percentage of participants who had sex in the past six months (84%). Western had the lowest percentage of participants with health insurance (67%) among all regions and with regular doctors (58%). The western region had the highest percentage of participants reporting forced sex (32%) and physical attacks (45%) and the lowest median number of contacts with other transgender people (3) among all regions, suggesting more isolation and less support. This region had the highest percentage of 32 participants reporting suicidal ideation (77%), the highest percentage of those reporting an alcohol problem in their lifetimes (31%), and a history of tobacco use (71%). Western participants rated all four prevention and education services notably lower for quality and sensitivity than participants in the other regions. There may be an association with these data and the presence of a local program in hormonal therapy in Richmond. Among all regions, northern had the highest percentage of Latino/a participants (20%) and regular Spanish speakers (8%). Northern had the highest percentages of collegeeducated participants (60%) and those with health insurance (81%). It also had the highest individual median incomes (in the $50, 000$69, 999 range) but also the highest percentage of strictly unemployed participants (12%). The northern region also had the highest levels of any form of transgenderrelated surgery among all regions. The northern region reported the highest number of participants who had injected drugs (6. The least utilized services were substance abuse treatment, transportation services, and home health care. The sample was composed of 39% of persons with individual incomes and 26% with household incomes below the poverty line ($17, 000) compared with 9. According to the Kaiser Family Foundation, 14% of Virginians lacked health insurance in 2004 2005, compared with 27% in this sample. Fiftyfour percent of those with health insurance in the sample had obtained it through their private employers, compared with 60% of other Virginians. Limitations No true population data are available on transgender persons, due to the lack of standard definitions of transgender status and the understandable refusal of transgender individuals to identify as such on governmentsponsored surveys. Given opportunities to selfidentify in community surveys, many transgender persons may consider this an unsafe step to take. At this stage in transgender health research, the best studies are those that build on what others have found through the most rigorous sampling methods available and in which members of the target population have been fully involved. We first reviewed all surveys and needs assessments about transgender health that we could find. We next conducted statewide focus groups with diverse segments of the target population to develop the best ideas and methods for a statewide survey. This survey would be the hallmark of the threeyear effort undertaken by a broad group of individuals and organizations committed to ensuring access to quality health care for transgender residents of Virginia. This report presents results from the statewide survey of selfidentified transgender Virginians, who completed an extensive questionnaire that they received in a variety of ways, according to how they learned about the study and how they chose to participate.

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A Little Gender Handbook for Emergencies supply depression anxiety test buy geodon with mastercard, sanitation and hygiene promotion depression urban dictionary cheap 20mg geodon overnight delivery. They are context and timespecifc and change over time anxiety jittery feeling cheap geodon 40 mg on line, within and across cultures mood disorder education day geodon 40mg discount. Gender depression symptoms of schizophrenia discount geodon 20 mg overnight delivery, together with age group depression inventory purchase geodon with paypal, sexual orientation and gender identity, determines roles, responsibilities, power and access to resources. This is also afected by other diversity factors such as disability, social class, race, caste, ethnic or religious background, economic wealth, marital status, migrant status, displacement situation and urban/rural setting. It examines their roles, their access to and control of resources and the constraints they face relative to each other. A gender analysis should be integrated into the humanitarian needs assessment and in all sector assessments or situational analyses. Gender (and age) marker A gender and age marker helps determine if an activity or programme is designed well enough to ensure that women, girls, men and boys will beneft equally from it or that it will advance gender equally in another way. Equality does not mean that women, men, girls and boys are the same; but that their enjoyment of rights, opportunities and life chances are not governed or limited by whether they were born female or male. It is considered part of the process of achieving gender equality in terms of rights, benefts, obligations and opportunities. They are committed to contributing and ensuring the implementation of a genderresponsive humanitarian response. Gender focal points are meant to promote gender equality and mainstream gender to help build the capacities of actors to coordinate efective programming. Gender mainstreaming is the process of assessing the implications for women and men of any planned action, including legislation, policies or programmes, in all areas and at all levels. They are prepared by Humanitarian Country Teams based on a Humanitarian Needs Overview. They are the primary management tools for strategizing and planning responses to set specifc objectives that are governed by needs, priorities and are resultsbased. It involves awareness raising, building selfconfdence, expansion of choices, increased access to and control over resources and actions to transform the structures and institutions that reinforce and perpetuate gender discrimination and inequality. These include the right to receive the highest attainable standard of health in relation to sexuality, including access to sexual and reproductive healthcare services. It includes acts that infict physical, sexual or mental harm or sufering, threats of such acts, coercion and other deprivations of liberty. Sex the physical and biological characteristics that distinguish males and females. It refers to attractions towards individuals of a diferent sex/gender or of the same sex/gender. There are three predominant sexual orientations: same sex/gender (homosexuality), towards the opposite sex/gender (heterosexuality) or towards both sexes/genders (bisexuality). Minors are considered unable to evaluate and understand the consequences of their choices and give informed consent, especially for sexual acts. However, in many developed countries, the age of 65 is used as a reference point for older persons as this is often the age at which persons become eligible for oldage social security benefts. See source for more detailed discussions on defnitions that go beyond a chronological age. Whilst age and gender dimensions are present in everyone, other characteristics vary from person to person. These diferences must be recognized, understood and valuedin each specifc context and operation in order to ensure protection for all people. In a human rights context, lesbian, gay, bisexual and transgender people face both common and distinct challenges. These three areas of law humanitarian norms, standards and principles comprise the main norms, principles and legal frameworks from underlying all humanitarian work, including which we derive our humanitarian response. Efective humanitarian action needs to ensure protection on the dignity of every human being. Always of all people afected by preventing, stopping and remedying keep these principles in mind when designing violations of international law. Learn Treaties are a signifcant component of these areas of about the international, regional, and national international law. By ratifying a treaty, signatory States consent laws and policies that apply to the State(s) in to be legally bound by it. States are in some circumstances, which you are working, and understand what however, permitted to make reservations to certain provisions of the State is both required and not required to a treaty through excluding or modifying the legal efect of those do, and where the State may be failing to live provisions in their application to that State. For more information on core human rights States may also be party to regional treaties (this is especially treaties see: tinyurl. Communities may have their own standards rights instruments applicable to particular groups and practices (sometimes known as customary law); in any case, see: tinyurl. International Establishes the rights Human rights Preexisting human Universal Declaration of Human Rights human inherent in all human law applies rights issues are often (1948), tinyurl. International human on Civil and Political Rights (1966), respect, to protect and rights law provides tinyurl. This There is a large body of All Forms of Discrimination against ensures the respect human rights treaties Women and the Optional Protocol, and protection of the and legal precedents tinyurl. International Various groups Achieving Both the Convention Convention on the Elimination of law regarding needing special gender equality and the Committee All Forms of Discrimination against special protection have their is the explicit on the Elimination of Women and its Optional protocol own body of human purpose of Discrimination against (1979) tinyurl. Members States and regional organizations may create Many humanitarian and peacekeeping agencies national action plans which detail how they will implement a and organizations have detailed action plans specifc resolution. Look into the regional to address the disproportionate and unique impact of armed or national action plan for the country in which confict on women. Protection these resolutions Protection against Similar to the resolutions 1265 (1999), of civilians aim to ensure that all genderbased violence on women, peace and tinyurl. Children these resolutions Protection of children In addition to the uses 1612 (2005), and armed provide concrete needs a separate mentioned for other tinyurl. They are used to communicate the scope of the response to an emergency to donors and the public, and thus serve a secondary purpose for resource mobilization. All atrisk groups should also have a say in the planning and implementation of projects that impact them directly. Department of Justice and prepared the following final report: Document Title: Practical Implications of Current Intimate Partner Violence Research for Victim Advocates and Service Providers Author(s): Barbara J. Practical Implications of Current Intimate Partner Violence Research for Victim Advocates and Service Providers Barbara J. January 9, 2013 Findings and conclusions of the research reported here are those of the authors and do not necessarily reflect the official position of policies of the U. Practical Implications of Current Intimate Partner Violence Research for Victim Advocates and Service Providers Table of Contents Introduction: How to Use this Guide. What Do Victim Advocates and Service Providers Need to Know About the Civil Legal System, Specifically Civil Orders of Protectionfi. What Do Victim Advocates and Service Providers Need to Know About the Criminal Legal Systemfi What Performance Measures Should Advocates Require of Law Enforcement in Terms of Arresting Suspect Abusersfi. The purpose of that work was to describe to these criminal justice practitioners what the research tells us about domestic violence, including its perpetrators and victims, the impact of current criminal justice and court responses to it, and more particularly, the implications of that research for the day to day, real world responses to domestic violence by law enforcement officers, prosecutors and judges. Practitioners found that guide helpful, and it was suggested that it be expanded and enhanced to address the practical implications of current domestic violence research for victim advocates and service providers. Reflecting the new focus of this work, in addition to the National Institute of Justice, the guide is also sponsored by the Office of Victims of Crime, the Office on Violence Against Women and the Family Violence Prevention and Services Program. There are some substantial differences between the earlier work and this guide, although there is also much overlap. When we do so, it is because we are citing a study that includes data on intimate partner violence. As a result, some of the implications we draw are based on more limited research, making our analysis more tentative than it would otherwise be and conditional on additional research confirming findings relied upon in this current work. Further, it is critical to recognize that victim needs for services and advocacy differ among victims and over time. Some victims, for example, may decide to remain with their abusers while others may seek to leave them. Many victims who have survived abuse are looking for healing from the adverse impact of past abuse, while victims still in abusive relationships may, necessarily, be concerned primarily with the immediate safety needs of themselves and their children. To assist advocates in this role, we have reviewed the research to indicate performance standards for various criminal justice and court agencies. While we do not address what standards agencies should obtain, we summarize what agencies have obtained so that advocates can compare the performance of local or state agencies with what other jurisdictions have proven possible. Omission of these does not imply they are less worthy or effective than programs that have been studied. The implications drawn from the research are offered as guidance, not rules of practice. While we tried to be inclusive, examining all research that had implications for victim advocates and service providers, obviously we missed some, probably quite a lot. However, the inclusion or exclusion of any specific study cannot be assumed to reflect a judgment on its quality or methodology.

Ascertainment of history of breast surgery anxiety xanax or ativan order geodon 20mg with mastercard, trauma depression years after concussion buy cheap geodon 80 mg on-line, or prior lactation failure is important because these situations may present special challenges to successful 288 Guidelines for Perinatal Care breastfeeding anxiety rash cheap geodon generic. The integration of breastfeeding into the total care of the newborn in the first months of life should be discussed symptoms of depression safe 20mg geodon. The mother should be offered the opportunity and be encouraged to breastfeed her newborn as soon as possible after delivery mood disorder code buy cheap geodon on-line. A healthy newborn is capable of latching on to a breast without specific assistance within the first hour after birth depression symptoms wanting to be alone purchase geodon with a visa, and breastfeeding should be initiated within the first hour unless medically contraindicated. Infants should be placed in direct skinto skin contact with their mothers immediately after delivery and should remain there until the first breastfeeding is completed. From the time of delivery to discharge from the hospital, the mother and her healthy infant should be together continuously. The mother should be encouraged to offer the breast whenever the infant shows early signs of hunger, such as increased alert ness, increased physical activity, mouthing, or rooting, and not to wait until the infant cries. In the early weeks after birth, an infant may need to be aroused to feed if 4 hours have elapsed since the last nursing. Usually, it is practical to alternate the breast used to initiate the feeding and to equalize the time spent at each breast over the day. When satisfied, the newborn will fall asleep or unlatch, although some infants may fall asleep before consuming suf ficient nutrition. Supplemental feedings including water, glucose water, formula, and other fluids should not be given to the breastfeeding infant unless ordered by the health care provider after documentation of a medical indication. Supplementation of the breastfed infant is best accomplished with expressed human milk or formula. A formal observation of breastfeeding, including position, latch, and milk transfer should be documented using a standardized evaluation tool. Weight loss beyond 3 days of age, weight loss of more than 7% of birth weight, or failure to regain birth weight by 10 days of age in the term infant requires a careful evaluation of the feeding techniques being used and the adequacy of breastfeeding (Table 81). Infants with impaired tongue mobility resulting in poor latch and maternal nipple pain should be evaluated Table 81. Although most infants with this condition breastfeed successfully, some may benefit from frenotomy. Some mothers may experience a delay in lactogenesis, such as that associated with retained placental fragments. If unrecognized, this failure of lactation may lead to significant dehy dration in the infant, hypernatremia, and hyperbilirubinemia. Firsttime breast feeding mothers are most likely to have difficulty in recognizing failure of lactation and its associated signs and consequences. Exclusive breastfeeding is the ideal nutrition and sufficient to support optimal growth and develop ment for the healthy term infant for approximately 6 months after delivery. In families with a strong history of allergy, breastfeeding is likely to be especially beneficial. Contraindications to Breastfeeding ^440^451 Contraindications to breastfeeding include certain maternal infectious diseases and medications. A mother with active herpes simplex virus infection may breastfeed her infant if she has no vesicular lesions in the breast area, as long as the she observes careful hand hygiene. A mother who has herpes simplex lesions on a breast should not breastfeed her infant on that breast until the lesions are cleared. Endometritis or mastitis that is being treated with antibiotics is not a contraindication to breastfeeding. Despite the demonstrated benefits of breastfeeding, there are some situations in which breastfeeding is not in the best interest of the newborn. Mothers who have received radioactive materials should not breastfeed as long as there is radioactiv ity in the milk, and mothers who are receiving antimetabolites or chemotherapy should not breastfeed until the medication has cleared from the milk. The effects on the newborn of medications taken by a nursing mother have been closely studied. Physicians are encouraged to review available data and recommendations from reputable sources before advising against breastfeeding when mothers are taking medica tions. If the drug presents a risk to the infant, the infant should be carefully monitored to detect any adverse effects, and consideration should be given to measuring blood concentrations. Human Milk Storage There are many situations in which a mother might be separated from her infant, necessitating her to express and store her milk. A mother who is in school or employed outside of the home can maintain exclusive human milk feeding by providing expressed milk to be given in her absence. Therefore, it is important to encourage and support mothers in providing their infants with expressed milk. All mothers who provide milk for their infants should be 292 Guidelines for Perinatal Care instructed in the proper techniques of milk collection to minimize bacterial contamination. Careful hand hygiene is critical before handling the breast, the equipment, or the milk. Previous practices of washing the breast and discard ing the first expressed milk did not result in a decrease in colonization of the milk. Although manual expression, when performed correctly, yields relatively uncontaminated milk, many women prefer to use a breast pump. All parts of the pump that are in contact with the milk should be washed carefully with hot, soapy water, and rinsed and dried thoroughly after each use. However, they should not store milk for their infants while in the nursery because of the risk of infection to other newborns from milk that is potentially contaminated with hepatitis B virus. The Academy of Breastfeeding Medicine recommends that fresh expressed milk be stored in sterile glass, plastic containers, or plastic bags that are free of bisphenol A and made specifically for human milk storage. The very high temperatures that may be reached with these methods can destroy valuable components of the milk and may result in thermal injury to the infant. Previously frozen milk thawed for 24 hours should not be left at room temperatures for more than a few hours because of its reduced ability to inhibit bacterial growth. Banked Donor Milk Banked human milk may be a suitable alternative for infants whose mothers are unable or unwilling to provide their own milk. Human milk banks in North America follow national guidelines for quality control of screening and testing of donors and pasteurize all milk before distribution. Fresh human milk from unscreened donors is not recommended because of concerns about infectious disease transmission. Women who donate milk for other newborns should be interviewed carefully regarding past and current infectious diseases, use of drugs and medications, and other factors that may impair the quality or safety of the milk that they provide. These tests should be repeated periodically for donors who continue to provide milk or who seek reinstatement as a donor. The potential risks should be explained to mothers whose newborns are to receive donated milk. Use of Formula Milk Preparations If a mother chooses not to breastfeed or is medically unable to breastfeed her infant, the infant may be prescribed a standard infant formula. The health care provider caring for the infant should direct the selection of milk formula. Appropriate hospital committees and the director of the newborn nursery should review the compo nents and reported benefits of marketed formulamilk preparations before their use. For mothers who intend to breastfeed their newborns, direct marketing and distribution of formula packages on discharge should be discouraged. For mothers who intend to feed their newborns with a milk formula, the distribu tion of formula marketing packages on discharge should be consistent with the written discharge orders. These need not be refriger ated and may be stored in a convenient, clean, cool area. If there is a special area where nipples are uncapped and placed on the bottle, it should be kept very clean and should be used only for formula preparation, donor human milk, or expressed milk handling. The formula and nipple unit should be used as soon as possible, certainly within 4 hours after the bottle is uncapped, and then discarded. Particular attention is needed to maintain hygiene and safety, prevent crosscontamination of oral feeding units, and ensure correct identification of the infant. Vitamin and Mineral Supplementation Vitamin D the vitamin D content of human milk is low, and rickets can occur in deeply pigmented breastfed infants or in those with inadequate exposure to sunlight. Adequate exposure to sunlight is difficult to guarantee and supplementation at the recommended dose is safe. To prevent rickets and vitamin D deficiency in healthy infants, a vitamin D intake of at least 400 international units per day has been recommended. Breastfed and partially breastfed infants should be supplemented with 400 international units per day of vitamin D beginning in the first several days after birth. Formula fed infants do not need vitamin D supplementation unless they are consistently ingesting less than 1 liter per day of vitamin D fortified formula. Fluoride supplementation for both breastfed and bottlefed infants can begin at age 6 months. Approximately 50% of the iron in breast milk is absorbed by newborns who are breastfed exclusively. Breastfed and partially breastfed infants who receive human milk as more than half their daily feedings should be given supple mental elemental iron (1 mg/kg/day) starting at 4 months of age. Formulafed newborns should be placed on ironcontaining milk formulas that contain 12 mg of elemental iron per liter. Term newborns consuming commercial milk formulas do not need vitamin and mineral supplementation for the first 6 months of life. Early hepatitis B immunization is recommended for all medically stable infants with birth weights greater than 2 kg, irrespective of maternal hepatitis B status. For infants born to mothers with negative hepatitis B serology, it is preferable that the initial dose is admin istered before discharge from the nursery. Maternal immunity is the only effective strategy for influenza protection in newborns because the vaccine is not approved for use in infants younger than 6 months. Newborn Screening Newborn screening programs are mandated, statebased public health programs that provide newborns in the United States with presymptomatic testing and necessary followup care for a variety of medical conditions. The goal of these essential public health programs is to decrease morbidity and mortality by 296 Guidelines for Perinatal Care screening for disorders for which early intervention will improve neonatal and longterm health outcomes for the individual. Newborn screening programs test infants for various congenital disorders, including metabolic conditions, endocrinopathies, hemoglobinopathies, cystic fibrosis, hearing loss, and, more recently, severe combined immunodeficiency and related Tcell lymphocyte deficiencies, and critical congenital heart disease. Most of the disorders screened through these programs have no clinical findings at birth. Newborn Blood Spot Screening Almost all states have adopted the 2010 Recommended Uniform Screening Panel suggested by the U. Although the new born screening program in most states includes the Recommended Uniform Screening Panel, there is some variability from state to state. The National Newborn Screening and Genetic Resource Center maintains a current list of conditions screened for in each state, available at genesrus. Newborn blood spot screening programs are developed and managed on the state level and operate through collaborations between public health programs, laboratories, hospitals, pediatricians, subspecialists, and specialty diagnostic centers. A comprehensive screening program includes the following components: Education of parents and practitioners about newborn screening and their participation in the activity Reliable acquisition and transportation of adequate specimens Reliable and prompt performance of screening tests Prompt retrieval and followup of individuals with test results that are out of range. Appropriate further testing of individuals with outof range test results to establish accurate diagnoses Appropriate intervention, treatment, and followup of affected individuals Care of the Newborn 297 Education, genetic counseling, and psychosocial support for families with affected newborns Every birthing facility should establish routines to ensure that all newborns are screened in accordance with state law. States test newborns primarily through blood samples collected from heel pricks that are placed on a special filter paper.

Since the training cns depression symptoms discount geodon 80mg without a prescription, she has noticed a dramatic improvement in many aspects of her life depression diet discount geodon, most notably regarding her attitude toward work depression symptoms after miscarriage generic geodon 80 mg with visa. Despite their clear needs anxiety effects purchase geodon visa, most of these women and men workers are currently left out of community level health interventions anxiety 34 weeks pregnant purchase geodon 80 mg without prescription. Like investing in fnancial education depression symptoms nimh purchase geodon with american express, these interventions may use various methods of communication, such as short flms, music, leafets, displays, workshops, and peer education (see Health Education Materials for the Workplace). They involve communicating information to workers, facilitating their access to information and programs, and providing them with support. Business can take several measures to promote health: Invest in workplace health systems, such as capacitybuilding of onsite health staff and upgrades of onsite clinics; Offer capacitybuilding and training programs focused on health, and specifcally reproductive health, to women in their workforce or supply chain. In some more extreme cases, such as repeated and widespread incidents of workers fainting in Cambodia in 2012 and 2013, we see that poor health among female workers has visible and significant impacts in the workplace. Structural changes in employment, in particular those resulting from new technologies, outsourcing, and the extension of production chains, as well as new types of employment relationships, affect the exercise of this principle. It is worth noting that the representatives are often men, and that men dominate leadership positions. Unless she renounced the union, not only would she be fred, but her uncle (with whose family she lived) would also lose his job as a security guard for the contractor that supplied services to the company. Wage levels and freedom of association are critical, but they do not adequately address issues such as infation and impacts on household costs typically managed by women, such as childcare, healthcare, daily meals, and rent. In this sense, it is important to recognize that organized labor itself is often gender biased. Recommended Revisions Include language that stresses the rights of both women and men to freedom of association and collective bargaining, and that prohibits any related genderbased discrimination. Examples of gendersensitive provisions for Freedom of Association and Collective Bargaining: Workers, without distinction whatsoever and irrespective of sex, shall have the right to establish and join organizations of their own choosing, subject only to the rules of the organization concerned, without previous authorization. Crosscutting many of the above principles and related issues, employment relationship provisions are particularly important considering that women in global supply chains often fall in more vulnerable categories such as migrants, homeworkers, or seasonal/casual workers. If employed by a recruitment agency, they may be even more vulnerable to discriminatory practices1 related to , for example, termination in case of pregnancy or refusal to hire due to required reduced working hours related to childcare responsibilities. As mentioned above, women are often homeworkers, with no access to any type of job security, benefts, or health and safety standards, who often bear most of the operating costs themselves, such as electricity and equipment parts and maintenance. By specifcally addressing this type of employment, companies have the opportunity to integrate more women into the economy and work with their suppliers to reduce associated risks. Denied an education and other options, she has done this work since she was a girl. Before, she might earn 100 or even 150 rupees per day but have to wait months to get paid. These include eye clinics to help counteract the strain caused by such constant, close work. This informality, although a large source of paid employment for women, brings several issues, including job insecurity and lack of social protection. Considering women often have the most precarious or vulnerable employment status, include specifc provisions to protect them. Example of gendersensitive provisions for employment relationship: Standard contract language should be used with employment agencies that specifcally imparts power to employers to directly pay wages to migrant/contract/contingent/temporary women and men workers and ensures equality of compensation and workplace standards. This section may already offer guidance on how suppliers can implement the principles and what basic measures can be put in place to operationalize and monitor them (further detail will be offered in the Gender Sensitive Workplace Assessment Guidance). Another important aspect is that enough resources are allocated to help adequately apply the principles. These must be effectively communicated to all women and men workers in all native languages, whether they are directly employed by the organization, contracted through a third party, or working on its premises for a customer, supplier, or subcontractor. It is important that suppliers communicate these principles to their own suppliers because many genderrelated abuses and other nonconformities often happen with subcontracting. There should be quantitative and qualitative indicators and targets, linked to the above gendersensitive recommendations, as well as methods to collect associated statistical data. Data should be collected in a genderdisaggregated way and capture age when possible, which is particularly important for issues related to reproductive health. For example, around the world each year there are 270 million $ occupational accidents, 160 million occupational diseases, and more than 2 million workrelated fatalities. Few countries collect data on occupational injuries and illnesses by sex, so it is impossible to estimate how workrelated health problems are distributed between women and men worldwide. A confdential, unbiased, nonretaliatory grievance procedure should be established allowing women and men workers to make comments, recommendations, reports, or complaints concerning their treatment in the workplace regarding gender equity. There should also be procedures for investigating, following up on and communicating the outcome to all workers of any complaints in respect to genderrelated issues. There is often an informal approach to grievance/complaints procedures and the biggest challenge is building trust among workers, especially women. Formalizing the procedures and having a genderbalanced structure that processes complaints may mitigate this. Proper monitoring will require training of auditors, not only on the gender standards included in the principles and corresponding policies and/or requirements, but also on how to conduct a gendersensitive onsite assessment, which may include for example participatory auditing methodologies such as womenonly focused groups. Offsite audits may also be required as women workers should feel more comfortable and therefore be more open about voicing workplacerelated complaints. Auditors may need to provide additional explanations on the questions or requests, especially if talking directly with workers. They may not be aware themselves of the subtle nature of certain prejudicial genderrelated practices. The personal and sensitive nature of some of the genderrelated investigations may also add to the challenges, and having more women auditors to speak to women workers may help circumvent trust issues. Employee health, cultural norms, violence or threats of violence, and infrastructure issues can all play a role. For example, do they provide sanitary pads, proper lighting, and breastfeeding roomsfi To support the implementation of the specifc requirements set in a gendersensitive code of conduct, companies may consider asking for or facilitating the formation of Gender Committees at the workplace. The Gender Committee can be an effective management system to uphold gender inclusive policies and practices and handle related grievance procedures. The Committee should include both male and female employees from management and workers, and in no circumstances should it replace trade union representation. Aside from being a forum to address genderrelated issues, investigate cases, and making recommendations on how management may improve policies and practices, the Gender Committee can also play a role in awareness raising by organizing gendersensitive trainings and events, establishing partnerships with external organizations and the community, and distributing educational and supportive materials. Business can take several measures to promote gender equity management structures: Facilitate the formation of Gender Committees at the workplace; Invest in awarenessraising activities on gender equity, such as training and events for management, supervisors, and workers. The team trained management of the farms about concepts of gender, gender mainstreaming, and genderbased violence, and international and regional conventions that Ethiopia signed and ratified to ensure human rights and rights of women in the country. Womenspecific legislation in Ethiopian constitutions, Ethiopian criminal laws, labor laws and codes, and market labels that are relevant to Ethiopian growers, which mainly focus on social standards (worker welfare, woman, and young people), were also included in the training. The team is also supporting farms in establishing their own Gender Committees and has been conducting workshops to inform local stakeholders about health and gender issues of farms and establish a forum. It is hoped that the forum will be a medium for local stakeholders and farms to plan and work together in the future to address health and gender issues of farms. However, as highlighted earlier in Mainstreaming Gender Equality in Supply Chains, additional mechanisms and drivers are essential to ensure effective implementation of the recommendations put forward in this Guidance. Codes of conduct are operationalized through a system of implementation resources, auditing tools, and performance metrics that clarify the intention of the code and delineate the means by which the code should be met. It will also explore other less traditional assessment methodologies to facilitate the adoption of more inclusive and effective monitoring frameworks. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Overview this Coverage Policy addresses diagnostic testing to establish the etiology of infertility and infertility treatments. Coverage Policy Coverage of infertility diagnostic and treatment services varies across plans. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. In addition, coverage for some infertilityrelated services, including certain fertility preservation services may be required by state mandates. Once an individual meets the definition of infertility as outlined in the benefit plan or as listed below, the following services associated with establishing the etiology of infertility are generally covered under the core medical benefits of the plan. Many benefit plans exclude cryopreservation, storage, and thawing of the following, even when benefits are available for infertility treatment. In addition, the inability of a woman to achieve conception after six trials of medically supervised artificial insemination over a oneyear period may necessitate evaluation for infertility. Some underlying factors are reversible through medical intervention; the major underlying causes of infertility include: ovulatory, tubal, cervical, uterine/endometrial, and male partner factors. Diagnostic Testing To Establish the Etiology of Infertility Formal evaluation of infertility is generally initiated in women attempting pregnancy who fail to conceive after one year or more of regular, unprotected intercourse. However, there are an increasing number of women over the age of 35 who are seeking infertility services. Since reproductive potential decreases in the early to midthirties, for this age group formal evaluation typically begins earlier. The preliminary approach to infertility typically begins with the evaluation of ovulatory, tubal, and male factors, and involves physical examination, laboratory studies and diagnostic testing. Other potential contributing causes that may be explored include genetic factors and immunological factors. The female infertility diagnostic workup to determine the underlying etiology includes basic evaluation of ovulatory dysfunction including basal body temperature recordings, laboratory studies and hormone levels, Additional studies are performed when the initial workup fails to provide definitive information. Sonohysterography is an ultrasound procedure performed to visualize the inside of the uterine cavity and involves the installation of fluid into the uterus. If the fallopian tubes are evaluated a fluid containing bubbles of air are instilled through a catheter, bubbles make the fluid easier to see when assessing patency of the tubes. Tubal patency is determined by observing the saline and air contrast flowing into or out of each fallopian tube. Of note, only 6 studies included in the review evaluated saline +air as the contrast media, each study has small sample populations ranging from 31 subjects to 129 subjects. Similarly, endometrial biopsy has been used evaluate secretory development of the endometrium, dating, and to assess the quality of luteal function. Following the physical examination, evaluation of the male begins with the semen analysis, considered the primary screening test for male factor infertility. Semen analysis is generally done through the examination of two specimens at least one month apart, and generally precedes invasive testing of the female partner. The semen analysis provides detailed information on semen volume, sperm concentration, motility, pH, fructose, leukocytes, and morphology. Depending on the clinical situation, repeat semen analyses may be performed every one to three months, up to a total of five. Performing greater than five semen analyses provides little additional diagnostic value. Other laboratory studies include an endocrine evaluation, antisperm antibodies, post ejaculatory urinalysis, urine culture and semen culture. Additional testing includes: transrectal ultrasound in individuals with azoospermia or oligospermia scrotal ultrasound for individuals in whom testicular mass is suspected or for who physical exam is difficult/inconclusive vasography or testicular biopsy in individuals with azoospermia scrotal exploration Genetic testing for cystic fibrosis is performed in males with congenital absence of vas deferens or for males with azoospermia or severe oligospermia. Karyotyping for chromosomal abnormalities and Ychromosome deletion testing may be done in individuals with nonobstructive azoospermia or severe oligospermia.

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