Breastfeeding . Why Human milk is irreplaceable?

World Breastfeeding Week  1–7 August 2011

      World Breastfeeding Week is celebrated every year from 1 to 7 August in more than 120 countries to encourage breastfeeding and improve the health of babies around the world. It commemorates the Innocenti Declaration made by WHO and UNICEF policy-makers in August 1990 to protect, promote and support breastfeeding.

      Breastfeeding is the best way to provide newborns with the nutrients they need. WHO recommends exclusive breastfeeding until a baby is six months old, and continued breastfeeding with the addition of nutritious complementary foods for up to two years or beyond.

Introduction to Breastfeeding

          Breast milk is thought to be the best form of nutrition for neonates and infants. The properties of human milk facilitate the transition of life from in utero to ex utero. This dynamic fluid provides a diverse array of bioactive substances to the developing infant during critical periods of brain, immune, and gut development. The clinician must be familiar with how the mammary gland produces human milk and how its properties nourish and protect the breastfeeding infant.

             Clinicians play a crucial role in a mother's decision to breastfeed and can facilitate her success in lactation. Although a mother may not be aware of the evidence indicating that breast milk contributes to her baby's short-term and long-term well-being, she has developed certain attitudes and cultural beliefs about breastfeeding. The issue of bonding between mother and newborn may be a strong factor; however, stronger cultural or societal barriers may result in the decision to formula feed. Such issues must be understood for successful counseling. The mother makes her decision regarding breastfeeding prior to delivery in more than 90% of cases; therefore, her choice of infant nutrition should be discussed starting in the second trimester and continue as part of an ongoing dialogue during each obstetric visit.

          Breastfeeding or bottle feeding your newborn baby is a personal decision. If you choose to breastfeed, it will be helpful if you are in a supportive environment and have resources to assist you with questions you may have or problems that may develop. 

• Consider attending a series of La Leche League meetings or reading La Leche League's book on breastfeeding (The Womanly Art of Breastfeeding) before the birth of your baby.
  
  
• Ask other breastfeeding mothers for advice.
  
  
• A supportive network including other like-minded mothers helps with the commitments of this style of feeding.
  
  
• If you are undecided at birth time, consider a one-month trial. It is easy to go from breastfeeding to bottle-feeding.
  
  
• The first month of breastfeeding is the most difficult, so if you get through that period, the rest will be easier.

Campaign Video : "Breastfeeding: First food for champions!"  

Comparison with Formula-Feeding

• The ideal food for human infants is human milk. Human milk contains all the right ingredients—protein, carbohydrates, fats, vitamins, minerals, and water—in just the right balance. No formula can make that claim. Infant formula manufacturers attempt to artificially duplicate human milk. Formula feeding is a practice that is relatively recent—about 60 years—compared to the beginning of humankind (not to mention all other mammals) relying on breast milk.
  
  
• Formula does not contain the disease-fighting factors or the digestive enzymes that breast milk has. The nutrients in formula are more difficult for a baby to digest and absorb than the nutrients in human milk, requiring the baby to handle excess waste. Some formulas may have a less than optimal composition by containing too much salt and/or not enough cholesterol, fats, lactose, zinc, and iron, among other nutrients.

• Some infants fed a cow's milk-based formula may develop allergies to the proteins in the cow's milk. Infants who are allergic to cow's milk often are also allergic to "hypoallergenic" (non-allergy-causing) soy formulas.
  
  
• During the early months, a formula-fed baby may develop signs of allergy to or intolerance of a particular formula. These signs may include the following:
  
  
  • Bouts of crying after feeding
    
    
  • Vomiting after most feedings
    
    
  • Persistent diarrhea or constipation
    
    
  • Colic with a distended tense painful abdomen after feeding
    
    
  • Generally irritable behavior
    
    
  • A red, rough sandpaper-like rash especially around the face or anus or in both places
    
    
  • Frequent colds and ear infections
    
    
  • Red itchy rash especially in the folds of the elbow and knee joints
    
    
• These signs, or the baby's preference, may lead you through a series of different formulas, often each more expensive than the last.
  
  
• Formula-fed infants may be exposed to a variety of environmental substances used during the preparation of the formula or carried as a minor contaminate from which breastfed infants are protected. 

Benefits of Breastfeeding

• With rare exceptions, breast milk is the preferred feeding for infants and confers unique benefits.
  
  Breastfed babies (for at least 6 months) may be at reduced risk for many acute and chronic diseases, including gastrointestinal tract infection (like diarrhea), lower respiratory tract infections (like a cold), urinary tract infections, otitis media (ear infections), and allergic reactions (like atopic dermatitis and asthma).
  The effect of breastfeeding in protecting against infection is well established. Infants who were fully breastfed for 6 months or more seem to have higher mental development when compared with infants who were never breastfed. Some studies show that the effects of breastfeeding may carry over and also protect young children and adolescents from becoming overweight.
  
  
• Milk has biologic specificity—meaning that every species of animal who breastfeeds their babies makes a milk that is unique for the young of that species.
  
  
• The amounts of nutrients change to match your baby's rapidly changing needs.
  
  
• The fat content increases during a feeding so that the baby gets the right amount of fat. Human milk contains the right kinds of fats along with an enzyme (lipase) that helps digest the fat.
  
  
• Cholesterol is high in human milk, lower in cow's milk, and very low in formulas. Cholesterol promotes brain growth and provides basic components of hormones, vitamin D, and intestinal bile.
  
  
• Milk (cow's, formula, and human) contains two main proteins: whey and casein. Whey is easier for humans to digest and is found in higher concentrations in human milk.
  
  
• Around 6 months of age, the baby's intestines mature and become less open to proteins that may harm the body as allergenic proteins (allergens). Giving only human milk until the intestines mature is the best way to keep potentially allergy-causing proteins out of baby's blood.
  
  
• Human milk includes helpful proteins not naturally found in milk made by cows or companies.
  
  
• Human milk is fresh and contains more lactose (sugar) than cow's milk. Formulas add sucrose or glucose (other types of sugars).
  
  
• Vitamins and minerals have a higher bioavailability in human milk. In other words, the body uses most of what is in the milk. There is very little waste.
  
  
• The germs in the baby's environment, to which the mother has been exposed, cause the mother to produce antibodies to that germ, which are passed on to the breastfeeding infant.
  
  
• Breastfeeding relaxes mother and baby.
  
  
• Women who breastfeed have a lower incidence of breast cancer.
  
  
• Breastfed babies tend to be healthier.
  
  
• Breastfeeding is less expensive.

Prepare for Breastfeeding

• There is really no physical preparation that is necessary for breastfeeding. Education about the benefits and practice of breastfeeding is the best preparation. Contrary to some popular beliefs, it is not necessary to "toughen up" or prepare the nipples in advance for breastfeeding. Some techniques of stimulating the nipples may actually be harmful.
  
  
• Sometimes women prepare for breastfeeding by exposing the nipples to air for a certain amount of time each day; while this has not been shown to be medically useful, it is likely not harmful either.
  
  
• Take a breastfeeding class. Your hospital may offer breastfeeding classes as part of the childbirth class. These classes can put you in touch with a lactation specialist who may later be your personal breastfeeding consultant.
  
  
• Join your local La Leche League or other breastfeeding support group. Call (800) LA LECHE to find your local leader.
  
  
• Talk with supportive friends who encourage your feeding choices.
  
  
• Learn proper positioning and latch-on techniques.

First Feedings

• Within a few minutes after birth, most babies can be introduced to breastfeeding. Relax. Most babies take a few licks, sucks, and pause. Sucking in frequent bursts and pauses is the usual pattern for the first few hours and sometimes even the first few days. The first milk the mother produces, colostrum, is the best food.
  
  
• Breastfeeding also helps the uterus contract, which helps stop uterine bleeding.
  
  
• Try to room-in with your baby. When you see your baby begin to open its eyes, look around, and put his or her fist into his or her mouth, then it is time to offer your breast.
  
  
  • Try to make the nurses understand that you wish to breastfeed and that your baby should not be given sugar water or formula without you and your health care provider being aware and consenting.
    
    
  • You may need to have the nurses actually put a sign on your baby's bed restricting bottle-feeding.
  
  
• Try latching the baby on at the first signs of hunger. Do not wait until the baby cries, or you will teach the baby to cry to get your attention. The baby will get upset more quickly the longer you take to respond.

  Conclusion :
 
          Human milk, in addition to its numerous nutrients that make it an ideal food source for the growing term infant, is a bioactive fluid that evolves from colostrum to mature milk as the infant matures. This bioactive fluid contains numerous factors and live cells that, in concert, promote the growth and well-being of the breastfeeding infant. Oliver Wendell Holmes said it best when he stated, "A pair of substantial mammary glands has the advantage over the two hemispheres of the most learned professor's brain, in the art of compounding a nutritious fluid for infants." With the ever-expanding knowledge resulting from current research, commercial formula clearly cannot replicate all of the valuable properties that are inherent in human milk.

Source:
world_breastfeeding_week
breastfeeding/article
http://emedicine.medscape.com/article/1835675-overview       
 http://www.cdph.ca.gov/HealthInfo/healthyliving/childfamily/Pages/CommonQuestions.aspx
http://www.cdph.ca.gov/HealthInfo/healthyliving/childfamily/Page  /EducationalMaterialsforBreastfeedingFamilies.aspx
http://www.webmd.com/parenting/baby/baby-food-nutrition-9/default.htm
http://www.happybabyfood.com/health-nutrition/47/210-happybaby-nutrition-guide
 Age by age guide to feeding your baby  http://www.babycenter.com/0_age-by-age-guide-to-feeding-your-baby_1400680.bc

In China 1.3 million websites have been shut in 2010

Chinese web users are frequently blocked from accessing sites such as Youtube...

More than one million websites closed down in China last year, a state-run think tank has said. The Chinese Academy of Social Sciences said there were were 41% fewer websites at the end of 2010 than a year earlier.
Chinese officials have tightened regulations on the internet in recent years, and they launched a crackdown on pornography websites in 2009.
The academy's researcher said there was no link, insisting China had a "high level of freedom of online speech".
Liu Ruisheng said that despite the declining number of sites, the number of web pages had risen to 60 billion during 2010 - a 79% increase on the previous year.
"This means our content is getting stronger, while our supervision is getting more strict and more regulated," he said.
Civil rights campaigners have long railed against China's web censors, who impose controls known as the Great Firewall of China.
A number of websites are routinely blocked, such as the BBC's Chinese language service, and social media sites like Facebook, Youtube and Twitter.

What Color Eyes Would Your Children Have?

           What Color Eyes Would Your Children Have? is an interactive eye color calculator which allows visitors to explore and learn about genetic inheritance. Using this online exhibit visitors can see the probabilities of their children's eye color or that of their parent's children. In addition, adjustments for populations that have predominantly brown or green eyes can be made.
          Working closely with The Tech Museum of Innovation, Ideum designed and developed this interactive application as part of the Understanding Genetics online exhibition. The program was developed using Macromedia Flash.

What's Your Learning Style?

    Learning styles refer to the ways you prefer to approach new information. Each of us learns and processes information in our own special ways, though we share some learning patterns, preferences, and approaches. Knowing your own style also can help you to realize that other people may approach the same situation in a different way from your own.

Take a few minutes to complete the following questionnaire to assess your preferred learning style. Begin by reading the words in the left-hand column. Of the three responses to the right, circle the one that best characterizes you, answering as honestly as possible with the description that applies to you right now. Count the number of circled items and write your total at the bottom of each column. The questions you prefer will offer insight into how you learn.

1. When I try to concentrate...	I grow distracted by clutter or movement, and I notice things around me other people don’t notice.	I get distracted by sounds, and I attempt to control the amount and type of noise around me.	I become distracted by commotion, and I tend to retreat inside myself.
2. When Ivisualize...	I see vivid, detailed pictures in my thoughts.	I think in voices and sounds.	I see images in my thoughts that involve movement.
3. When I talk with others...	I find it difficult to listen for very long.	I enjoy listening, or I get impatient to talk myself.	I gesture and communicate with my hands.
4. When Icontact people...	I prefer face-to-face meetings.	I prefer speaking by telephone for serious conversations.	I prefer to interact while walking or participating in some activity.
5. When I see an acquaintance...	I forget names but remember faces, and I tend to replay where we met for the first time.	I know people’s names and I can usually quote what we discussed.	I remember what we did together and I may almost “feel” our time together.
6. When I relax...	I watch TV, see a play, visit an exhibit, or go to a movie.	I listen to the radio, play music, read, or talk with a friend.	I play sports, make crafts, or build something with my hands.
7. When I read...	I like descriptive examples and I may pause to imagine the scene.	I enjoy the narrative most and I can almost “hear” the characters talk.	I prefer action-oriented stories, but I do not often read for pleasure.
8. When I spell...	I envision the word in my mind or imagine what the word looks like when written.	I sound out the word, sometimes aloud, and tend to recall rules about letter order.	I get a feel for the word by writing it out or pretending to type it.
9. When I do something new...	I seek out demonstrations, pictures, or diagrams.	I want verbal and written instructions, and to talk it over with someone else.	I jump right in to try it, keep trying, and try different approaches.
10. When Iassemble an object...	I look at the picture first and then, maybe, read the directions.	I read the directions, or I talk aloud as I work.	I usually ignore the directions and figure it out as I go along.
11. When Iinterpret someone's mood...	I examine facial expressions.	I rely on listening to tone of voice.	I focus on body language.
12. When I teach other people...	I show them.	I tell them, write it out, or I ask them a series of questions.	I demonstrate how it is done and then ask them to try.
Total	Visual:	Auditory:	Tactile/Kinesthetic:

The column with the highest total represents your primary processing style. The column with the second-most choices is your secondary style.
Your primary learning style:                                                         
Your secondary learning style:                                                     
Now that you know which learning style you rely on, you can boost your learning potential when working to learn more. For instance, the following suggestions can help you get more from reading a book.
If your primary learning style is visual, draw pictures in the margins, look at the graphics, and read the text that explains the graphics. Envision the topic or play a movie in your thoughts of how you’ll act out the subject matter.
If your primary learning style is auditory, listen to the words you read. Try to develop an internal conversation between you and the text. Don’t be embarrassed to read aloud or talk through the information.
If your primary learning style is tactile/kinesthetic, use a pencil or highlighter pen to mark passages that are meaningful to you. Take notes, transferring the information you learn to the margins of the book, into your journal, or onto a computer. Doodle whatever comes to mind as you read. Hold the book in your hands instead of placing it on a table. Walk around as you read. Feel the words and ideas. Get busy—both mentally and physically.
More information on each style, along with suggestions on how to maximize your learning potential, is available in the book Learn More Now (Hoboken, NJ; John Wiley & Sons, 2004).

  Learn More... 

    Learning techniques   http://research.cs.queensu.ca/~skill/learning.html 
    Learning how to learn http://homepage.ntlworld.com/gkelly68/LearnToLearn/LearningIndex.htm
    Learning toolbox            http://coe.jmu.edu/learningtoolbox/studentstart.htm 
    Multiplication: Learning Times Tables for 8s and 2s http://www.youtube.com/watch?v=SawsAyyrFkQ

Have you Ever Wondered How Alcoholic Drinks Look Like Under The Microscope?

Updated Oct 8th ,2011
    A company called Bevshots has produced a series of shots of booze under the microscope at the Florida State University's chemistry labs.
This is Tequila at 1000x magnification.



The process consist of letting a droplet of liquor dry out completely on a slide in an airtight container, and photographing the result with a 35mm camera. The entire process can take up to three months and as many as 200 attempts to properly capture the drink's constituent parts.
         Cocktails can have fruit and soft drinks in them which contain citric acids and complex sugars which dry out well and look great photographed.  The incredible shapes and colours of the boozy artwork are highlighted by shining natural light on top and through the bottom of the slide. Just like images of snowflakes, each drink is different.
These images are available for sale at Bevshots. Open for business since August 2009, Bevshots estimate that they have sold over 20,000 examples of their alcoholic art works.

                                                        Scotch

                                                   Dry Martini

 

                                                       Vodka

  
                                                               
                                                                  Vodka Tonic



                                                                       Whiskey

                                               White Russian

                                                      Chablis

                                                Champagne

                                                        Daiquiri 

                                                                    Margarita

                                                 Pina Colada

                                                          Rosé

                                                       Sake

                                                        Japanese Rice Lager

                                                            English Oatmeal Stout

                                                                  Gin Closeup


                                                                    Vodka Tonic




                                                          English Pure Brewed Lager




                                                            Japanese Dry Lager




                                                                            Rum


                                                                     Rum and Cola

                                               American Amber Ale

                                                                          Red Table Wine

                                                                             Mint Julep

Sources:
http://twistedsifter.com/2010/06/alcoholic-art-liquor-under-a-microscope/
http://www.time.com/time/photogallery/0,29307,1999889_2157950,00.html

Killing Us Softly 3 : Advertising's Image of Women

"As timely and important as ever. . .A must for everyone who cares about media literacy and gender equity."-- Susan Douglas | author, Where the Girls Are: Growing Up With the Mass Media

    Jean Kilbourne continues her groundbreaking analysis of advertising's depiction of women in this most recent update of her pioneering Killing Us Softly series. In fascinating detail, Kilbourne decodes an array of print and television advertisements to reveal a pattern of disturbing and destructive gender stereotypes. Her analysis challenges us to consider the relationship between advertising and broader issues of culture, identity, sexism, and gender violence.

Includes a bonus 25-minute interview with Jean Kilbourne.

Sections:
Does the beauty ideal still tyrannize women? |
Does advertising still objectify women's bodies? |
Are the twin themes of liberation and weight control still linked? |
Is sexuality still presented as women's main concern? |
Are young girls still sexualized? |
Are grown women infantilized? |
Are images of male violence against women still used to sell products?

Jean Kilbourne

Jean Kilbourne is internationally recognized for her pioneering work on alcohol and tobacco advertising and the image of women in advertising. Her films, slide lectures and television appearances have been seen by millions of people throughout the world. She was named by The New York Times Magazine as one of the three most popular speakers on college campuses today.

Care of Transsexual Persons [Gender Identity Disorder ]

"A small but significant number of transsexual patients are seen every year in our service and in this journal we reported one such patient. We felt somewhat inadequately informed about the anatomy and postoperative care of our patient. We have thus reviewed the literature which we hope will help others in managing such patients." via  @wiki.ubc.ca

International classification of diseases (ICD) ICD 101 gives five diagnoses of gender identity disorders (GID) .
(1) Transsexualism .
This has three criteria: A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one’s anatomic sex, and a wish to have surgery and hormonal treatment to make one’s body as congruent as possible with one’s preferred sex.The transsexual identity is present persistently for two years.
 The disorder is not a symptom of another mental disorder or a chromosomal abnormality.
(2) Dual role transvestism
(3) GID of childhood
(4) Other GIDs
(5) GID,  unspecified

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV), a person must show strong persistant cross-gender identification (not merely a desire for any perceived cultural advantage of being the other sex) and a persistent discomfort with their sex or a sense of inappropriateness in the gender role of that sex, to be diagnosed with GID. The term transsexualism has been replaced with GID by DSM IV.
PREVALENCE

Studies carried out in Netherlands (data collected from 1975 to 1992) quoted the prevalence of transsexualism as 1:11,900 in men and 1:30,400 in women.A study carried out in Scotland (1998) in primary care units estimated the prevalence of gender dysphoria (a subjective experience of incongruity between genital anatomy and gender identity) among patients aged over 15 years as 8.18 per 100,000, with an approximate sex ratio of 4:1 in favour of men.4 The interdepartmental working group on transsexual people published by the home office reported that 44 maleto- female operations and four female-to-male operations were performed in the National Health Service (NHS) and 104 gender reassignment operations performed in the private sector during 1997/1998. According to hospital episode statistics data 2004–05 (Department of Health, UK),
there were 338 finished hospital episodes of transsexualism (ICD 10 code F64.0) and 114 finished hospital episodes of operation for sexual transformation (OPCS 4 code X15), with 131 days of median waiting period (period of time between date of decision to admit and date of actual admission).6 It should be noted that this data relates to patient care in NHS only.

Strategies and Evidence

General Principles of Treatment

       Professional acceptance of transsexualism and its hormonal and surgical treatment has grown. Interventions are indicated only after comprehensive psychological assessment has confirmed not only that the DSM diagnostic criteria have been fulfilled but also that the patient meets the criteria for readiness to make the transition to the other sex (as detailed below).
Persons with gender identity disorder may have unrealistic expectations about what being a member of the opposite sex entails. Hormonal treatment should therefore be preceded and accompanied by an extended period (at least 1 year) during which the patient lives full time as a person of the desired sex. This real-life experience is essential for providing insight into the new sex status, allowing the patient to become accustomed to the social interactions arising from it. Such sex reassignment, by enabling the patient to experience life as a person of the subjectively appropriate sex, reduces gender dysphoria and improves social and sexual functioning.

Hormonal Sex Reassignment

 

The goals of hormonal treatment are to induce the development of the secondary sex characteristics of the new sex and to diminish those of the natal sex.Prior hormonal effects on the skeleton and vocal cords cannot be reversed. No randomized trials have been conducted to determine the optimal formulations and dosages of cross-sex hormones. Treatment strategies resemble those used for hypogonadal patients (see Table 1 in the Supplementary Appendix, available with the full text of this article at NEJM.org).

Male-to-Female Transsexuals

 

Hormonal therapy is prescribed for male-to-female transsexuals to induce breast formation and a more female distribution of fat and to reduce male-pattern hair growth. To achieve these goals, the biologic action of androgens must be almost completely neutralized. Administration of estrogens suppresses gonadotropin output and therefore androgen production, but combining this treatment with a progestational agent, a gonadotropin-releasing-hormone (GnRH) analogue, or other medications that suppress androgen action (e.g., cyproterone acetate, flutamide, nilutamide, or bicalutamide) appears to be more effective.
Many estrogens are available. Ethinyl estradiol, although efficacious, should be avoided. When taken at the dosages required for sex reassignment, this agent has been associated with significantly increased risks of venous thrombosis and death from cardiovascular causes, as compared with 17β-estradiol.
Although progestins suppress androgen production, they have no role in the feminization of the body and may have harmful metabolic effects; consequently, progestins should be discontinued after orchiectomy. In postmenopausal women, progestins combined with estrogens increase the risk of breast cancer. Men undergoing androgen-deprivation treatment for prostate cancer are at increased risk for features of the metabolic syndrome. Studies assessing the metabolic effects of androgen deprivation and estrogen therapy in male-to-female transsexuals have shown that increases in visceral fat are associated with increases in triglyceride levels, insulin resistance, and blood pressure. Available data from one large practice with a median follow-up of 18.5 years have not suggested an increased risk of death from cardiovascular causes with treatment except among current users of ethinyl estradiol. Data from larger and longer-term studies are not .

Female-to-Male Transsexuals

 

Treatment in female-to-male transsexuals is intended to induce virilization. This includes male-pattern hair growth, the development of male physical contours, and the cessation of uterine bleeding. The principal hormonal treatment is a testosterone preparation . Concomitant progestin therapy is nearly always needed when testosterone is administered transdermally, since serum testosterone levels are lower with transdermal administration than with intramuscular administration, lessening suppression of gonadotropins.

Long-Term Treatment

After sex-reassignment surgery, including gonadectomy, hormonal therapy must be continued. Some male-to-female transsexuals continue to have male-pattern hair growth; continued administration of antiandrogens, typically at only about half the preoperative dose, reduces male-pattern hair growth. Continued administration of cross-sex hormones is required to avoid symptoms and signs of hormone deficiency, such as vasomotor symptoms and, in particular, osteoporosis. Observational studies have shown that bone mass is generally maintained with estrogen alone in male-to-female transsexuals and with testosterone alone in female-to-male transsexuals when prescribed at the doses typically used to treat hypogonadism. Sufficient intake of calcium and vitamin D is also recommended. A blood concentration of serum luteinizing hormone in the normal range is a reliable marker of adequate dosing. If sex-reassignment surgery has taken place, the usual prescribed dose of estradiol in male-to-female transsexuals is approximately 50 μg per day and that of testosterone in female to-male transsexuals is typically the same as that used preoperatively: 200 to 250 mg every 2 weeks in parenteral form or 5 to 10 g per day in gel form. lists the potential side effects of sex steroids and recommendations for monitoring.

Risks and Contraindications

A serious concern regarding long-term administration of cross-sex hormones is the possibility of an increased risk of hormone-dependent cancers. There are rare case reports of prolactinomas, breast cancers, and prostate carcinomas in male-to-female transsexuals and rare reports of ovarian carcinoma, breast cancer, and vaginal cancer (one each of the latter two, to my knowledge) in female-to-male transsexuals. Rare cases of hormone-dependent tumors in organs other than the reproductive organs (e.g., lung, colon, and brain [meningioma]) have also been reported in transsexuals who have undergone estrogen treatment. Evidence is lacking to indicate a significantly increased frequency of cancers in association with cross-sex hormonal treatment, but the available data are from studies that involved relatively short-term exposure. Risks may become more apparent as subjects age and the duration of hormone exposure increases. Because a portion of administered testosterone is aromatized to estradiol, female-to-male transsexuals who have not undergone breast removal and oophorectomy–hysterectomy should be monitored for estrogen-sensitive cancers of the breast, endometrium, and ovaries.Although the addition of a progestin may help to prevent endometrial cancer, studies of postmenopausal hormone use suggest that this therapy may increase the risk of breast cancer.It has also been reported that testosterone may contribute to the development of breast and endometrial cancer; therefore, monitoring of female-to-male transsexuals for such cancers is also prudent. Transsexuals may not always be forthright with physicians about their sex change, and this hesitancy can lead to delays in diagnosing cancers of organs specific to the former sex.

Surgical Sex Reassignment

Male-to-female sex reassignment involves the surgical construction of a neovagina, with the penile skin or colon usually used for vaginal lining and scrotal skin used for the labia. The breasts may be augmented if their development is judged to be insufficient. Masculine facial features and a prominent Adam's apple may also be surgically mitigated.
Female-to-male sex reassignment should ideally include removal of the breasts, uterus, and ovaries because the development of cancer in these organs is not easily detected. In rare instances, the clitoris becomes sufficiently hypertrophied after testosterone exposure to serve as a phallus. Otherwise, the patient can undergo a metoidioplasty (see Figure 2 in the Supplementary Appendix), which involves elongation and reconstruction of the clitoris as a small neopenis with erectile function,sometimes allowing urination in a standing position. Free flaps of tissue removed from the arms or legs can be used to construct a neophallus. Procedures have been developed to provide rigidity for penetration, including insertion of autologous cartilage or bone, rigid implants, or an inflatable prosthesis, but these procedures, and their outcomes, remain cumbersome. A scrotum can be constructed from the labia majora along with implantation of a testicular prosthesis. The aesthetic results of surgery depend largely on surgical skill.
Surgical treatment improves the overall quality of life for most transsexual persons. However, 1 to 2% of those who have undergone surgical sex reassignment regret it, the majority being men with late-onset transsexuality. Determining eligibility for hormonal and surgical treatment is more complex with these patients than it is with those who have early-onset transsexuality. When regrets occur, they may reflect difficulties in making the transition to a different lifestyle because of appearance or limited social skills. These problems appear to be more common in patients with late-onset transsexuality, who have lived in their natal sex for a long time, underscoring the importance of actually living as the other sex before undergoing cross-sex surgery.

Juvenile Gender Dysphoria

Over the past two decades, awareness of gender identity disorder in children and adolescents has grown.Although most juveniles with gender identity disorder are otherwise psychologically healthy, certain forms of psychiatric conditions may be present (most commonly anxiety, mood, and disruptive disorders) and can complicate accurate diagnosis and assessment of eligibility for treatment. Gender identity disorder must be distinguished from conditions also associated with feelings of being different (e.g., extreme transvestic fetishism and autism spectrum disorders). As a rule, only extreme cases of gender identity disorder persist into adolescence and beyond. An experience of the first somatic signs of hormonal puberty as alienating is diagnostically significant and a marker that that the gender identity disorder will probably persist.
If diagnostic criteria for gender identity disorder are met in adolescence, development of secondary sex characteristics may be suspended with the use of GnRH analogue treatment alone. This intervention is reversible and allows time for reflection on the desire to undergo sex reassignment while pubertal development is halted.  Although correct diagnosis requires that the first signs of physical puberty be allowed to emerge, GnRH analogue administration should begin before it is too late to reverse the process. This is possible during stage B3 (breast bud extending beyond areola) in girls and during stage G3 (increase in testicular volume of ≥4 ml, with measurable nocturnal testosterone values) in boys. Once daytime testosterone production commences (testicular volume ≥10 ml), virilization becomes irreversible. For the duration of GnRH analogue administration, increases in bone mass cease, but there is typically no loss. The goal of treatment is the same as that for the treatment of precocious puberty — returning hormone levels to prepubertal levels.
GnRH analogues are expensive and progestins offer an alternative treatment that also suppresses gonadotropin secretion. In addition, the use of antiestrogens in girls and antiandrogens in boys delays the progression of puberty, although neither class of agents is as effective as GnRH analogues. 
If the follow-up diagnostic process confirms the diagnosis of gender identity disorder and the well-being of the patient increases with the cessation of pubertal development, cross-sex hormones may be added in a stepwise fashion in accordance with the treatment protocols for hypogonadal children.The addition of cross-sex hormones usually begins at the age of legal medical competence (16 years of age in most Western countries). Parental agreement may be required, but even if it is not, parental support is of paramount importance. Follow-up should include anthropometric measurements, assessment of bone mineral density and metabolic measures (e.g., lipid and glucose levels and bone turnover), psychometric testing, and ongoing counseling.
Limited observational data from juvenile transsexuals have indicated that gender dysphoria is reduced and relationships and academic skills are improvedafter early treatment for sex reassignment. Beginning treatment at the time of puberty appears to be associated with better outcomes (e.g., in psychopathologic scores) than beginning in adulthood, by which time irreversible sex characteristics may pose lifelong barriers to successful sex reassignment.

Areas of Uncertainty

Although several studies have shown amelioration of gender dysphoria and improvements in social and sexual functioning in transsexuals who have undergone sex reassignment, none have conclusively demonstrated that medical interventions resolve gender dysphoria. Comparative studies are lacking to inform decision making regarding regimens and dosing of cross-sex hormones. Recommendations for management are based on expert opinion; studies of the efficacy and safety of hormone preparations are lacking, as are dose–response studies of sex hormone preparations. Large, long-term studies are needed to provide data on the long-term risk of disease, especially for cardiovascular disease and cancer, which are of particular concern in older patients and in those who have had prolonged exposure to sex hormones. Data are also needed on how the administration of GnRH analogues followed by cross-sex hormonal treatment affects pubertal development. Unresolved questions are whether there is an age at which cross-sex hormonal treatment should be discontinued and whether hormone replacement should be avoided in older male-to-female transsexuals.

Guidelines from Professional Societies

Guidelines for the treatment of transsexuals have been formulated by the World Professional Association for Transgender Health and are published in its 2001 report, Standards of Care for Gender Identity Disorders.  These guidelines have been elaborated, with a special focus on cross-sex hormones, in the most recent guidelines from the Endocrine Society The recommendations in this review are consistent with these guidelines.

Conclusions and Recommendations

The person described in the vignette has gender dysphoria that is probably consistent with a diagnosis of gender identity disorder. The diagnosis must be verified by an experienced mental health professional, with attention to eligibility and readiness for sex reassignment. The patient needs to understand that sex reassignment brings relief of gender dysphoria only — other psychological problems may remain. Expectations about physical appearance and life after sex reassignment must also be realistic. Because real-life experience is indispensable, a prerequisite for surgical sex reassignment is at least a year of experience living entirely as a member of the new sex, with complete habituation to the new behaviors and to the responses of others. Patients who follow this procedure rarely have regrets after sex reassignment.
Persons undergoing sex reassignment can be reassured that serious short-term complications of cross-sex hormonal treatment appear to be uncommon. However, longer-term effects on the risks of cardiovascular disease, metabolic disease, and cancer are not well charted.

Dr. Gooren reports receiving consulting fees and compensation for travel from Bayer Schering Pharma. No other potential conflict of interest relevant to this article was reported.



Reference:
Care of Transsexual Persons     http://www.nejm.org/doi/full/10.1056/NEJMcp1008161
Health Insurance Discrimination for Transgender People http://www.hrc.org/issues/9568.htm
Gender identity disorder: treatment and post-transition care in transsexual adults   http://wiki.ubc.ca/images/f/f9/Article_1-Wik