Howard J. Nathan, MD, FRCPC

• Professor and Vice Chairman (Research)
• Department of Anesthesiology
• University of Ottawa
• Ottawa, Ontario, Canada

Victims of Trafficking and Violence Protection Act of 2000: Trafficking in Persons Report arteria carotis interna cheap zestoretic 17.5mg amex. Senate Foreign Relations Committee arteria vertebralis order zestoretic 17.5 mg without a prescription, Near Eastern and South Asian Affairs Subcommittee: Hearings on International Trafficking of Women and Children blood pressure normal unit purchase 17.5 mg zestoretic free shipping. Analysis of Herpes simplex virus 1 and 2 infection in women with high risk sexual behaviour in Mexico blood pressure chart during the day order zestoretic 17.5 mg overnight delivery. Sexually transmitted infections blood pressure medication and fatigue purchase 17.5 mg zestoretic amex, drug use blood pressure up zestoretic 17.5mg discount, and risky sex among female sex workers in Guyana. Integration of the Human Rights of Women and the Gender Perspective: Violence Against Women. No woman or child would want to be a sex slave and endure the evil that I have gone through. This paper is an introduction to trafficking in the Americas4, offering a brief discussion of relevant issues. However, this paper focuses on the trafficking of women and children for sexual exploitation, referring to the practice simply as trafficking or sex trafficking. Around the world most trafficked people are women and children of low socio-economic status, and the primary trafficking the demand aspect of sex trafficking remains the least visible. The insatiable demand for women and children in massage parlors, strip shows, escort services, brothels, pornography and street prostitution is what makes the trafficking trade so lucrative. While for some men involvement in prostitution may be motivated by sexual desire, for others it is an expression of misogyny and/or racism. Brazilian women, for example, are marketed as dark-skinned, easy and available, reinforcing racist and colonial stereotypes13. In this way poverty and gender inequality create a large pool of potential and seemingly willing recruits. The psychological impact and social stigma of victimization can increase womens vulnerability to manipulation and exploitation by traffickers. Though relatively little is known about traffickers routes, networks, and associations with organized crime in the Americas, one can easily understand the factors Figure 1: the Trafficking Triangle that allow them to practice Impunity their trade with impunity. The success of traffickers business relies on their ability to keep activities hidden from law enforcement agencies. Most information on crime rings is uncovered only when a participant is caught and agrees to inform15. In the absence of hard statistical data, which is difficult to obtain for illegal activities in general, an analysis must rely on estimates and indicators associated with trafficking. An estimated 50,000 women from the Dominican Republic16 and 75,000 women from Brazil17 work abroad in the sex industry, mainly in Europe, though it is not clear what proportion of this number refers to trafficking victims. Casa Alianza reports that adolescents from Colombia, the Dominican Republic and the Philippines have been trafficked to Costa Rica for prostitution in areas known as sex tour destinations23. Organized crime groups from various regions of the world are involved in trafficking women and children to North America25. This practice leaves the women in a vulnerable position, especially if they did not enter the country legally. The confinement may be enforced through barred windows, locked doors, posted guards and similar means. Various survivors have described how they could only go outside if a guard or boss was with them, and some reported that guards would monitor their phone calls home35. Traffickers also exert control by creating situations of dependence and debt bondage. Traffickers usually charge a transportation fee, informing the victims upon arrival that they must pay the fee through prostitution of some kind. Debt bondage occurs when the traffickers do not allow the women to leave prostitution until the debt is paid; in many cases the original transportation fee is augmented by charges for room and board, or punishment fines. The situation leads to dependence on traffickers for money, food, clothes and other necessities. Physical assault and rape are used to initiate women into the sex industry, to force compliance. Other health risks in transit include exposure to violence and communicable diseases. Little scientific investigation of the health of trafficking victims has been conducted, perhaps because the population is difficult to access. To supplement this knowledge, the general health risks of prostitution can be used as an approximation of those faced by women and children trafficked into the sex industry. However, knowledge of these risks comes from samples drawn from prostitutes working on the street or visiting health clinics. Since trafficking victims are often not free to leave the brothel or visit health clinics, the conclusions of these studies may not fully represent the experiences of trafficking victims. They are beaten, sometimes with weapons, and severely enough to require emergency room visits42. This risk can be mediated or worsened by client volume and patterns of condom use. Anecdotes of trafficking experiences and studies of women in the sex industry suggest that trafficking victims experience many threats to their sexual and reproductive health. The risk of unwanted pregnancy depends on access to contraceptives and control over their use. Victims have reported forced pregnancies and forced abortions at the insistence of traffickers48. Some trafficking survivors report being drugged by brothel owners, to keep them more compliant. In addition to the risk of chemical addiction, substance abuse also has implications for sexual health, as it is associated with increased risk-taking49. The long-term effect of trafficking on survivors human development and emotional health needs further exploration. Where services are available, trafficking victims face almost limitless barriers to accessing them. Trafficking victims may not be able to afford services, and they are unlikely to have access to health insurance. Even with good information, children may lack the skills, power and ability to negotiate condom use, increasing their risk of infection. Girls are especially vulnerable to sexually transmitted infections due to their immature reproductive tracts, and they are more likely to suffer long term damage from them. Children are likely to experience the health and developmental effects of sexual exploitation well into adulthood. The convention also fails to address forms of exploitation that were not widespread in 1949, including mail-order bride industries, sex tourism and trafficking of organs51. Laws of this type are designed not only to punish the commercial sexual exploitation of children overseas, but also to deter sex tourists who become situational child abusers due to a perception that the sexual exploitation of children is acceptable in some other cultures55. Considering the evidence of growth in trafficking, it appears that existing laws and/or their enforcement are inadequate. Advocates of legal reform have emphasized a three-pronged approach of prevention of trafficking, prosecution of traffickers and protection for victims57. Where prostitution is prohibited, victims can be viewed and treated as criminals, rather than crime victims. Victims of international trafficking frequently are illegal aliens and face the dilemma that if they escape to seek help, they may be arrested and deported. Though in desperate need of medical care, counseling and sometimes drug treatment, victims legal status can prevent them from accessing these services. A priority of the Study of the Trafficking of Women and Children for Sexual Exploitation in the Americas is to standardize criteria, terminology, and definitions. No more than 5,000 victims may be provided visas or nonimmigrant status in any fiscal year. Finally, the law specifies minimum standards for trafficking prevention (mentioned above); countries receiving economic and security assistance must demonstrate compliance with the minimum standards, or sincere and sustained effort at moving towards them, in order to receive further assistance. The law contains provisions for sanctions against nations deemed insufficiently active in trafficking prevention. The State Departments first annual report on trafficking appeared in July 200159. Secretary-General, In Address To Women 2000 Special Session, Says Future Of Planet Depends Upon Women. Investigating International Trafficking in Women and Children for Commercial Sexual Exploitation. Trafico de Mulheres, Criancas e Adolescentes para Fins de Exploracao Sexual no Brasil. Report of the Special Rapporteur on the sale of children, child prostitution and child pornography. Presentation to the Inter American Commission on Human Rights on the Subject of the Commercial Sexual Exploitation of Children in Costa Rica. The term traffickers, as used here, is understood to include the various actors involved in facilitating the prostitution of victims. Violence by clients towards female prostitutes in different work settings: questionnaire survey. Report of the Special Rapporteur on violence against women, its causes and consequences. Soumya Alva for critically reviewing our paper a couple of times and guiding us with their very useful comments. Subjects: the unit of analysis was couples who met the inclusion criteria of being married and having had a child in the three years before the survey. To ensure that the couples were reporting on the same child, we picked couples who gave the same age for their last child. Additionally, most of the efforts to address these determinants, and thus to increase uptake of maternal health services, have mainly addressed women. Studies on male involvement in family planning have shown that men play a key role in family planning decisions, either through their direct participation or by enabling their partners to use contraception (Drennan 1998; Terefe and Larson 1993; Varkey et al. In most families the men are empowered financially and are the main decision-makers in all issues including reproductive health. They may use this opportunity to ensure that their pregnant wives seek maternity services or arrange for skilled care during delivery, if delivery takes place at home. For men to make the right decision for their wives regarding place of delivery and professional attention, they need to understand the importance of maternal health care (Bhalerao et al. There is a general agreement that men who know the danger signs of pregnancy are more likely to act fast to save the lives of their wives (Bhalerao et al. To date, few studies have tried to assess specifically whether male involvement influences men to ensure that their wives get professional attention during 2 pregnancy and delivery. Bringing out such an association clearly would be important for policy and program planning for maternal health care services. One study conducted in this area attributed the high percentage of home deliveries to a combination of economic, geographical, cultural, and psychological reasons (Wabuge 2010). Women are more likely to have skilled birth attendants for the first birth than for later births (Baral et al. Several studies have examined the role of men in influencing uptake of reproductive health services (Bhalerao et al. These studies define male involvement in terms of mens roles as clients of health care services, as partners, or as agents of positive change. In the first stage clusters are stratified by region and urban-rural location and randomly selected in proportion to population size. Men and women were asked separately about maternal care for the most recent birth during this period. To ensure that a husband and wife were reporting on the same birth, we restricted our analysis to couples who reported the same age of the last child. Of 873 couples that reported a birth in the three years before the survey, 737 couples (730 weighted) were thus eligible for our analysis (Appendix 1). Skilled Birth Attendant A skilled birth attendant is an accredited health professional, such as a midwife, doctor, or nurse, who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period and in the identification, management, and referral of complications in women and newborns. In this study we used utilization of a skilled birth attendant during delivery as the main outcome variable. Responses such as doctor and nurse/midwife were classified as skilled, while unskilled included community health worker, traditional birth attendant, family member, friend, or neighbour. Male Involvement Two variables derived from the Mens Questionnaire were used to measure male involvement in maternal health care. The first variable was mens participation in any antenatal care that women received. If the spouse held neither or only one of these two perceptions, the variable was coded as negative. As noted, we sought to examine one main research question: whether, after controlling for other factors, male involvement in maternal health care influences womens utilization of skilled birth attendance. The household wealth index is an indicator of the level of wealth constructed from data on household assets, services, and amenities. In our analysis we considered three categories: rich (which combined the richer and richest quartiles), middle, and poor (which combined the poorer and poorest quartiles). Descriptive statistics are presented mainly as frequency listings and percentages because most of our variables are categorical. Maternal Characteristics Table 1 also shows the results for maternal characteristics.

Prior written consent implies general agreement to the childs inclusion in an immunisation programme blood pressure medication used to treat adhd zestoretic 17.5 mg cheap, but does not address the issue of current fitness and is no substitute for the presence and involvement of a parent when any vaccine is given blood pressure kit walgreens purchase 17.5 mg zestoretic with amex. Documentation Record the batch number and the site of vaccination in the case notes blood pressure what is normal order 17.5mg zestoretic fast delivery, and also record what has been done in the family copy of the childs personal health folder pulse pressure hyperthyroidism order zestoretic with a visa. Always tell the family doctor of every vaccination undertaken in a hospital setting as well cg-6108 arrhythmia ecg event recorder order zestoretic 17.5 mg online, in the United Kingdom heart attack maroon 5 buy zestoretic 17.5 mg on-line, as those who maintain the community child health register. Risk factors for developing apnea after immunisation in the neonatal intensive care unit. Primary immunisation of premature infants with gestational age <35weeks: cardiorespiratory complications and C-reactive protein responses associated with administration of single and multiple separate vaccines simultaneously. Effect of prophylactic paracetamol administration at time of vacci nation on febrile reactions and antibody responses in children: two open-label, randomised controlled trials. Disease-specific Ig are active against only the disease for which use is intended and are used in certain circumstances. Preterm babies have low levels at birth which can decline further, and this may be one reason why they are at risk of nosocomial (hospital-acquired) infection in the first few weeks of life. In contrast, however, another systematic review and one of the largest randomised neonatal trials suggested that when used in the treatment of suspected or proven infection, Ig had no benefit. Pharmacology Human Ig contains IgG prepared from pooled plasma collected during blood donation. The final product contains antibodies against a range of common infectious diseases including measles, mumps, varicella, hepatitis A and other common viruses and can be used to provide immediate but short-lasting passive immunity to a range of viral and bacterial illnesses. The process also removes IgM, the main source of anti-T antibody that some have claimed could be a cause of haemolysis in patients with necrotising enterocolitis and Clostridium difficile infection. Antibody titres can vary widely between preparations from different manufacturers, and formulations are not interchangeable. Any patient requiring long-term treatment should be maintained on the same formulation throughout. Treatment of neonatal haemochromatosis with exchange transfusion and intravenous immunoglobulin. Predicting risk severity and response of fetal neonatal alloimmune thrombocyto penia. Outcome of pregnancies at risk for neonatal hemochromatosis is improved by treatment with high-dose intravenous immunoglobulin. Influenza Epidemics of influenza, or flu, occur every winter, and the most prevalent subtype varies from year to year, making annual immunisation the only way to provide near-certain protection. Currently available vaccines are trivalent, containing two subtypes of influenza A plus one type B virus. Women are at slightly more risk during pregnancy and can occasionally become rapidly unwell. Indications for giving the inactivated vaccine Pregnant women: There is good evidence that vaccination is safe during pregnancy and can also provide the baby with significant short-term protection from infection by viral strains against which the vaccine is active. Children at least 6 months old: these children can be offered the current trivalent inactivated vaccine just before each annual epidemic begins. Contraindications Flu vaccine can be given at the same time as other live or inactivated vaccines, but preferably into a different limb, and certainly at least 2. Anaphylactic reactions are rare, but a mammalian cell-based, and not a hens egg-based, product must be used if there is a history of egg allergy or of an adverse reaction to any earlier vaccine product. Documentation Record the batch number and the site of vaccination in the case notes, and inform the family doctor of any vaccination undertaken in a hospital setting. There is also some limited support for prophylactic use in particularly vulnerable unvaccinated babies who are known to have been exposed to the virus. A trivalent live attenuated vaccine for intra-nasal administration is available in 0. Recommendations for the administration of influenza vaccine in children allergic to egg. Estimating the clinical impact of introducing paediatric influenza vaccination in England and Wales. Neonatal outcomes after antenatal influenza immunization during the 2009 H1N1 influenza pandemic: impact on preterm birth, birth weight, and small for gestational age birth. Influenza vaccine effectiveness among children 6 to 59 months of age during 2 influenza seasons. It can also be used to correct unusually high blood glucose levels (hyperglycaemia) in the neonate and to counteract any dangerous rise in the blood potassium level (hyperkalaemia). Pathophysiology Inadequate insulin production and abnormal resistance to its secretion cause type 1 and type 2 diabetes respectively. All women with diabetes need to optimise glucose homeostasis during conception and pregnancy, aiming for a glycated haemoglobin (HbA1c) level <60mmol/mol to minimise the risk of congenital malformation and miscarriage. Since insulin does not cross the placenta or appear in human milk, it is the treatment of choice for diabetes during pregnancy and lactation. Some women also become less able to stabilise their blood glucose levels during pregnancy (gestational diabetes), and insulin, metformin or a sulphonylurea drug such as glib enclamide will reduce the risk of fetal macrosomia (usually defined as a >4kg baby) if dietary advice alone does not suffice. Giving 10% glucose at a rate appropriate to normal fluid and calorie needs may sometimes exceed the very preterm childs ability to metabolise glucose or turn glucose into glycogen, and a glucose uptake of more than 14mg/kg/minute is not called for in the first week of life. Note that glucose in the urine (glycosuria) will not cause excess water loss until the blood glucose level exceeds 15 mmol/l. A continuous infusion of glucose and insulin can be used to control this and will usually work quicker than a polystyrene sulphonate resin enema (q. Neonatal diabetes: this rare condition, which presents with acidosis, dehydration and hyperglycaemia (usually >20mmol/l), but little ketosis, responds to a very low dose of insulin. Supply and administration 10 ml multi-dose vials of human soluble insulin containing 100 units/ml cost approximately 7 each. Long-acting slow-release products, containing a cloudy zinc suspension, are only suitable for subcutaneous use. It is also more consistent if the set is left standing with fluid in it for an hour before it is flushed through. While this is less essential when treatment is first started because the response will determine the initial infusion rate, failure to prime any replacement set could well destabilise glucose control. Ipratropium blocks muscarinic acetylcholine receptors which results in decreased contractility of bronchial smooth muscle. Pharmacology Ipratropium is a synthetic quaternary ammonium compound that is structurally similar to atropine but with an isopropyl group at the N atom. This latter aspect is important as ~90% of any inhaled dose tends to be swallowed. There are five muscarinic receptor subtypes (designated M1 through M5), all belonging to the family of transmembrane G-protein-coupled receptors. In the human lung, bronchoconstriction is brought about by stimulation of the M3 receptors on smooth muscle. Ipratropium blocks all muscarinic receptor subtypes with equal affinity which is a potential drawback as blocking M2 receptors significantly potentiates vagally induced bronchoconstriction. This had led to the development of selective muscarinic receptor antagonists like tiotropium which dissociates from the M2 receptor more rapidly than the M3 receptor. Ipratropium is sometimes used to treat wheeze in infants with established bronchopulmonary dysplasia where they provide some symptomatic relief. The effects of any bronchodilator in acute viral infections (viral-induced wheeze) are highly variable and do not impact on overall hospitalisation rates or length of stay; they may however improve symptoms. Likewise, bronchodilators do not appear to have any major benefits in bronchiolitis. Maternal use, either during pregnancy or lactation, is usually limited to those women with severe asthma, and because of the poor systemic absorption, it is unlikely to result in either the fetus or breastfed infant being exposed to clinically relevant amounts. Treatment Metered-dose inhaler: 20 micrograms three to four times daily via an appropriate spacer. Supply and administration A 200 dose inhaler providing 20 micrograms of ipratropium bromide per inhalation costs 5. A variety of spacers are available, not all of which are compatible with the ipratropium inhaler; one that works is the AeroChamber plus. This is available in infant (orange) and child (yellow) sizes with a mask and costs 7. Ipratropium bromide nebuliser solution (250 micrograms/ml) is available in 1ml unit dose vials costing 22p; the solution can be further diluted with 0. Bronchodilator response to ipratropium bromide in infants with bronchopulmonary dysplasia. Response to bronchodilators in clinically stable 1-year-old patients with bronchopulmonary dysplasia. In the United Kingdom and most developed countries, the main requirement for oral iron supplements during infancy is in prevention of iron deficiency anaemia during growth in breastfed babies who weighed <2. It is also used after birth to correct the iron loss that a few babies suffer as a result of chronic fetal blood loss before birth. Nutritional factors Iron is a major constituent of the haemoglobin molecule, and routine supplementation was traditional in pregnancy, although the scientific basis for this is far from convincing and the practice is now actively discouraged except in developing countries where the nutritional status of many women is poor. Here, the baby clearly benefits if the mother takes a regular daily supplement (60mg of iron and 400 micrograms of folic acid) during pregnancy. Maternal iron deficiency has to be very severe before it causes neonatal anaemia or iron deficiency during infancy. Newborn babies normally have substantial iron stores even when born prematurely (and even in the face of severe maternal iron deficiency). These stores start to become depleted unless dietary intake is adequate by the time the childs blood volume has doubled. While there is relatively little iron in breast milk, it is extremely well absorbed (as long as the baby is not also being offered solid food). Absorption from formula milks is only one-fifth as good, and the use of unmodified cows milk in the first 12 months of life is particularly likely to cause iron deficiency anaemia. It was thought that this might be due to iron loss as a result of occult gastrointestinal bleeding, but recent studies have failed to confirm this. It is possible that the high phosphate content of whole cows milk may interfere with iron absorption. Most iron deficiency in the first year of life is iatrogenic; early cord clamping can potentially deprive the baby of 20% of the elemental iron normally present in the body after an intervention-free delivery. The most common cause of anaemia in the neonatal unit is also iatrogenic, from people taking blood for laboratory analysis. These babies, if they become symptomatic, should be offered a top-up transfusion: they do not respond to supplemental iron. Almost all the commonly used formula milks in current use contain at least as much iron as this, making the widespread practice of further supplementation quite unnecessary. There is no good reason for starting supplemental iron before this because there is some doubt whether the gut absorbs iron in excess of immediate requirement, and there is some reason for believing that the iron-binding protein lactoferrin, present in milk (and particularly in breast milk), only inhibits bacterial growth when not saturated with iron. Some think that early supplementation of breast milk with iron might also unmask latent vitamin E deficiency. Assessment A serum ferritin <20micrograms/l is considered diagnostic of iron deficiency in a 4-month-old infant, especially if the transferrin saturation is <10%. Anaemia in young children is very seldom due to iron deficiency, and most babies who are iron deficient are not anaemic. Prophylaxis and treatment Healthy term babies: Breastfed babies benefit from supplementation if no other source of iron is introduced into the diet by about 6 months. There is no good evidence that formula-fed preterm babies benefit from further supplementa tion after discharge, and excess can have disadvantages. Babies with anaemia at birth (Hb < 120 g/l): Babies who have suffered chronic blood loss from feto-maternal bleeding or twin-to-twin transfusion may benefit once their initial deficit has been corrected by transfusion. Iron supplements are not needed in anaemic babies after acute blood loss at birth or in haemolytic anaemia. Babies on parenteral nutrition: Babies unable to tolerate even partial enteral feeding by 3 months benefit from 100 micrograms/kg of iron a day intravenously (most conveniently given as iron chloride). Toxicity Get the stomach emptied and organise prompt lavage if oral ingestion is suspected.

I will draw upon that rich experience as I develop a theory about toxic masculinity in prison and related obstacles to the provision of mental health treatment arteria lingualis cheap zestoretic 17.5 mg overnight delivery, and I will employ that theoretical understanding in making some general recommendations for therapists in correctional settings fetal arrhythmia 34 weeks generic zestoretic 17.5mg overnight delivery. Of course pulse pressure 39 order zestoretic master card, every generalization has many exceptions arteria pulmonar generic 17.5mg zestoretic amex, and it is not at all the case that all prisoners fit a mold pulse pressure 90 discount zestoretic online, nor that all prisoners fit the picture of toxic masculinity arteria auditiva purchase zestoretic now. Toxic masculinity is not the only obstacle to mental health treatment behind bars, and any approach to the subject that singles out toxic masculinity as the exclusive cause of treatment resistance misses the complexity of prison reality and contextual variables that intensify the toxicity and also make treatment problematic. In fact, sharing his or her awareness of the structural impediments to treatment is often one of the best tools the therapist has for transcending resistance on the part of male prisoners who are all too aware of and resentful of the obstacles. Before delving into the topic of toxic masculinity as it fosters treatment resistance, I will briefly delineate some of the other factors that intensify the toxicity and contribute to treatment resistance in correctional settings. Some Structural Obstacles to Mental Health Treatment in Prison An unfortunate reality of prison life is a severe shortage of mental health services. The Federal Bureau of Prisons estimates that at least 283,000 prisoners have significant emo tional problems and are in need of treatment (Ditton, 1999). Male prisoners tend to under-report their emotional problems and often do not request help until their condition has deteriorated to the point of psychotic decompensation or a suicide crisis (Kupers, 1999, 2001). In addition, the federal governments figure does not include the large number of men who require treat ment for substance abuse, domestic violence, sex offenses, impulse control, and relatively Toxic Masculinity 715 minor (compared with psychosis and major depression) but disabling conditions such as Attention Deficit Disorder or Obsessive Compulsive Disorder. There are simply an extraor dinarily large number of men in jails and prisons who would benefit from mental health treatment, including psychotherapy (Teplin, 1990; Lamb, 1998). Resources dedicated to the provision of mental health services have not expanded to meet the need of a growing prison population (Correctional Association of New York, 2003). Not only has the number of prisoners nationwide quadrupled in the last three decades, but the proportion of prisoners who suffer from serious mental illness has also expanded dramatically (Human Rights Watch, 2003). There are many reasons why a growing propor tion of prisoners suffer from serious mental illness, including deinstitu tionalization that leaves many individuals suffering from serious mental illness on the streets lacking services and subject to arrest, changes in the laws and the criminal courts that make it less likely than in times past that serious mental illness will preclude a prison sentence, an incremental and progressive shrinkage of the public mental health budget in the communities, and finally, stresses in prison that cause or exacerbate human breakdown. The result is that the mental health budget and the mental health services within correctional systems are inadequate relative to the immense need for services. When mental health services are in short supply, they tend to be reserved for the most serious cases, i. In addition, and only as clinicians time permits, group treatments exist for select prisoners, including those with substance abuse problems, sex offenders, and those who need help with anger management. However, where there are limited staff to provide these services, the prisoner may near or reach the end of a sentence without having undergone the mandated group treatment. The inadequacies of mental health resources create a situation where many prisoners view provided services as tokens, as if nobody really cares enough to spend sufficient time talking to a prisoner about his problems, and this perception leads prisoners to feel disrespected and contributes to their resistance. The epitome of this shortfall is the cell front mental health interview in the supermaximum security prison unit, where the pris oner is being punished with 23 hours-a-day cell confinement, where there are not enough security staff to transpor t prisoners to a private and confidential office for mental health interviews, and where the prisoner is forced to talk to the clinician who is standing in front of his cell within earshot of prisoners in neighboring cells and the correction offi cers who pass by as the interview proceeds. Is it any wonder that many prisoners simply refuse to talk to the mental health staff in such a setting This kind of resistance to mental health treatment has little to do with toxic masculinity and is more the direct result of both structural deficiencies in the setting and less than optimal mental health services. Confidentiality is a very big issue in correctional settings, and not only in regard to cell-front interviews in segregation. Most correctional systems have policies that require mental health staff to report to custody staff whenever mental health staffers hear of any illegal action or potential threat to the security and smooth operation of the prison. This requirement goes far beyond the Tarasoff requirements that guide therapists in the com munity when it comes to breaching confidentiality (Tarasoff vs. For example, in many states, if a man is threatened by another prisoner who demands sex, the prisoner who has been threatened may have no opportunity to talk the situation over with a psychotherapist before deciding how to respond. This is because the therapist is required by policy to report the threat immediately, and then the security staff will demand that the prisoner 716 Journal of Clinical Psychology, June 2005 disclose the name of the prisoner who threatened him. In prison, the repercussions of snitching are severe, possibly including death at the hands of another prisoner. Thus this policy-mandated lack of confidentiality serves to prevent prisoners from talking openly in psychotherapy about events that occur on a regular basis behind bars. Further, laws and court precedents are making it ever more the case that anything a prisoner tells his ther apist can be used against him in future prosecutions. The inadequacies of correctional mental health services and problems concerning confidentiality are merely two examples of structural obstacles to effective mental health treatment, and structural obstacles must always be taken into consideration as we move on to examine resistances seemingly related specifically to toxic masculinity. Toxic Masculinity as Treatment Resistance Connell defines hegemonic masculinity as the dominant notion of masculinity in a par ticular historical context (Connell, 1987). In contemporary American and European cul ture, it serves as the standard upon which the real man is defined. According to Connell, contemporary hegemonic masculinity is built on two legs, domination of women and a hierarchy of intermale dominance (Connell, 1987; Jennings & Murphy, 2000). It is also shaped to a significant extent by the stigmatization of homosexuality (Frank, 1987). Hegemonic masculinity is the stereotypic notion of masculinity that shapes the socializa tion and aspirations of young males (Pollack, 1998). Todays hegemonic masculinity in the United States of America and Europe includes a high degree of ruthless competition, an inability to express emotions other than anger, an unwillingness to admit weakness or dependency, devaluation of women and all feminine attributes in men, homophobia, and so forth (Brittan, 1989). Hegemonic masculinity is conceptual and stereotypic in the sense that most men veer far from the hegemonic norm in their actual idiosyncratic ways, but even as they do so, they tend to worry lest others will view them as unmanly for their deviations from the hegemonic ideal of the real man. In reality, there are many different forms of masculinity, even if forms of masculinity that do not match the hegemonic norm are subject to stigmatization and marginalization (Bird, 1996). There are masculinities in the community that present alternatives to the hegemonic ideal; for example, gay and transgender men, intellectuals, geeks, sensitive artists, and so forth. Connell argues that hegemonic masculinity is always constructed in relation to various subordinated masculinities and in relation to women (Connell, 1998). The goal of those who would foster gender equity and an end to domination is to permit the free expression of many masculinities, without risk of stigmatization, so that there will be many constructive and attractive alternatives to the stereotypic real-man image of the reigning hegemonic masculinity (Kimmel, 1987; Brod & Kaufman, 1994). The term toxic masculinity is useful in discussions about gender and forms of mas culinity because it delineates those aspects of hegemonic masculinity that are socially destructive, such as misogyny, homophobia, greed, and violent domination; and those that are culturally accepted and valued (Kupers, 2001). After all, there is nothing espe cially toxic in a mans pride in his ability to win at sports, to maintain solidarity with a friend, to succeed at work, or to provide for his family. These positive pursuits are aspects of hegemonic masculinity, too, but they are hardly toxic. The subordinated masculinities that Connell contrasts with the hegemonic, and the profeminist alternative masculinities celebrated in the profeminist and antihomophobic mens movement, are examples of nontoxic aspects of expressed masculinities (Kupers, 1993). There is the caring man, there is the man who is in touch with his feminine attri butes, and there is a fathers dedication to his children. Toxic masculinity is constructed of those aspects of hegemonic masculin ity that foster domination of others and are, thus, socially destructive. Unfortunate male proclivities associated with toxic masculinity include extreme competition and greed, insensitivity to or lack of consideration of the experiences and feelings of others, a strong need to dominate and control others, an incapacity to nurture, a dread of dependency, a readiness to resor t to violence, and the stigmatization and subjugation of women, gays, and men who exhibit feminine characteristics. What can lead to toxicity is the repeated frustration of a mans need to be respected. Thus, there is the well-known caricature of domestic violence or toxic masculinity in the community, where the man feels chronically disrespected at work and in the community, drinks alco hol to numb the pain, and proceeds to beat or otherwise abuse the woman he is closest to while screaming, All I ask for is to be shown a little respect! The need to feel respected is very much on their minds; they talk about it while try ing to explain why they repeatedly get into trouble with other prisoners or with staff. Although the need among men to be respected is not toxic, desperate attempts to gain respect where none seems forthcoming lead to an intensification of toxic masculinity. In other words, the man who feels he cannot get respect in any other way is the one who feels a strong urge to dominate others. At the risk of overgeneralization, it is fair to say that, on average, men who go to prison tend to hail from low-income communities; many have drug and alcohol problems; they tend to pride themselves on their toughness; they include a certain number of men who have perpe trated domestic violence; and many of these men were the victims of domestic violence and other traumas much earlier in their lives (Steiner, Garcia & Mathews, 1997). Exam ples of toxic masculine characteristics that are over-represented among prisoners are a tough-guy posture, outbursts of temper, and the tendency to act out troubling impulses rather than to introspect about their meanings and ramifications (Gerzon, 1982). And the need to be respected, in a situation where prisoners are shown very little respect, inten sifies the tough-guy posturing and leads to many violent incidents. There are many exceptions, of course, and many male prisoners are far from being the so-called tough guys. There are some very heinous criminals behind bars, but the majority of prisoners have been convicted of relatively minor crimes, usually drug related, and will be released after several years. But prisoners are forced to dwell in often-brutal correctional facilities where toughness is the key to survival. Even men who were not especially aggressive and misogynistic when they entered prison confide that they believe they must become versed in hypermasculine posturing and violence merely to stay alive and protect their honor. Many readily share their belief that the best way to avoid a fight is to look like he is not particularly averse to violence. Of course, this training in toughness does not help prisoners prepare for postrelease adjustment as car ing, loving men. In that sense, the toxic masculinity that is fostered in prison is spread beyond prison walls. Reports from adult males in prison about the importance of hypermasculinity or toxic masculinity are entirely consistent with what is known about adolescent male development. Messerschmidt (1993) explains how young men use crime as a means of 718 Journal of Clinical Psychology, June 2005 constructing the kind of stereotypic masculinity that helps them traverse their adoles cence and win the acceptance of peers, as well as fathers, coaches, and other hypermas culine role models. Whether by pulling a heist, joyriding in a stolen car, doing a drive-by to prove one is enough of a mans man to be in the gang, bragging to other males about a sexual conquest or a date rape, or participating in a college fraternity gang rape, young males turn to crime and violence to prove their manhood (Sanday, 1990). Middle class young men take part in illegal and unacceptable activities for a short time in their teen years and then, typically, move on to more socially accepted pursuits including graduation from college, beginning a career, and supporting a family, whereas low income youth and youth of color are much more likely to get trapped in a criminal life and spend time behind bars (Miller, 1996). The prison code that reigns in mens prisons is an exaggeration of the unspoken male code on the outside. According to the code, a real man or a stand-up con does not display weakness of any kind, does not display emotions other than anger, does not depend on anyone, is never vulnerable, does not snitch, does not cooperate with the authorities, and suffers pain in silence. But the prison phenomenon that is viewed in terms of toxic masculinity is not due exclusively to any set of male prisoners individual characteristics, no matter how tough some of their posturing or narcissistic their personality. On the contrary, the institutional dynamics play a huge role in inflaming toxic masculinity on everyones part, and staff are every bit as subject to the expression of toxic masculinity as are the prisoners. The Interplay of Institutional Dynamics and Individual Characteristics That Fan Toxic Masculinity Terrible things go on inside mens prisons. For example, the kind of massive crowding that has characterized American prisons in recent decades is known to increase inci dences of violence, psychiatric breakdown, suicide and medical illness (Paulus, McCain & Cox, 1978; Thornberry & Call, 1983). Since the mid-1970s, meaningful rehabilitation has been dismantled to a significant extent because it has been stigmatized as coddling (Martinson, 1974; Hallinan, 2001). The resulting combination of crowding and idleness has been accompanied by a rise in prison violence and psychiatric breakdown. The supermaximum security prison is partly a product of the male toxicity that exploded in violence inside the prisons in the 1980s (U. In that decade, when the rate of violence began to rise in the prisons, the response on the part of the corrections system was to vilify the worst-of-the-worst among prisoners, the ones presumably responsible for much of the violence, and lock them up in nearly total isolation (King, 1999). The supermaximum security prison, where prisoners are almost entirely isolated and idle in their cells just about all of the time, was designed to diminish prison violence. Evidence is beginning to accrue that long-term cell-confinement with almost no social interaction and no meaningful activity has very destructive psycholog ical effects (Grassian & Friedman, 1986; Hodgins & Cote, 1991). Men in long-term segregated prison housing tend to develop psychiatric symptoms, if not full-blown decompensation, and they universally repor t an accumulation of often uncontrollable rage (Cote & Hodgins, 1990). But a much greater percentage of male prisoners spend time in segrega tion during their prison term, and the presence of harsh segregation units within a prison or prison system has a chilling effect on the entire population. Toxic Masculinity 719 Events that occur inside supermaximum security units serve to illustrate, in extreme, ways that the very structure of a punitive prison environment can ignite toxic masculinity (Martin, 2000). For example, there is this fairly frequently occurring scenario: a prisoner has refused an officers order to return his food tray after the meal is over; the prisoner says, Youre going to have to come in here and get it! A nurse examines the shackled prisoner and asks if he was hurt: He responds that they hardly scratched him. Even though only a small percentage of prisoners are subject to this kind of cell extraction, it illustrates the height of toxic masculinity that occurs in prisons around the country. A cell extraction is not the only crystallization of the worst that men do to each other. Officers in facilities of all levels of security tend to yell at prisoners and tend to threaten prisoners with harsh reprisals if they do not obey orders quickly or thoroughly enough. Prisoners in whom anger has mounted because of the extremity of their situation typically respond in an angry tone, perhaps meeting swearing with swearing. An officer becomes even angrier and writes the prisoner a disciplinary ticket, and the confrontation escalates in ways that foster and express toxic masculinity. Gender is not entirely a matter of social structure or personal psychology; it is formed at the interface of the two. The toxic masculinity that bursts out at angry moments in prison cannot be blamed entirely on any particular set of individual characteristics of prisoners, nor is the emergent toxic masculinity formed in a vacuum. Yes, the prisoners are capable of a significant amount of rage, especially when they feel they are being disrespected. No, they are not known for their ability to maintain a calm demeanor when they feel insulted or attacked by people who have total authority and control over them. In other words, in prison, both prisoners and staff are caught up in the acting out of an unfortunate degree of toxic masculinity. One of the big problems is that in prison, where there are many men who know that they must walk away from trouble when they see it brewing, there is simply no place to go. In a bar in a community, a man who knows he has trouble avoiding fights when he feels disrespected has to learn to get up and leave when somebody starts insulting him or threatening him. Either these men never go to bars, or they have practiced keeping quiet or walking away at the first sign of trouble, and they are, thus, able to avoid the kinds of fights that plagued their early adult years. But in prison, there is no place to go when one wants to walk away from a confrontation. Both prisoners and staff are subject to the effects of the prison environment, an environment in which one group (the officers) exercise total control over the lives of another group (the prisoners). Haney and Zimbardo demonstrated that when one group has total control over another, terrible cruelty is likely to be directed by the keepers toward the kept (Haney & Zimbardo, 1977; Zimbardo & Musen, 1992).

Black hypertension the silent killer buy generic zestoretic from india, the only racial groups measured abilities heart attack yahoo answers buy generic zestoretic 17.5 mg online, which is not possible with current statistical software arteria 3d order zestoretic 17.5mg line. Indescribingthetrendsinthetext heart attack romance purchase zestoretic 17.5mg with amex,wewill sometimes employ common labels for the generations such as Procedure theG heart attack zippy discount zestoretic 17.5mg visa. Thesebirth and the composite for sexual attitudes in Table 1 and for the in year cutoffs are arbitrary and are not necessarily justied by em dividualsexualbehavioritemsinTable 2 blood pressure chart for male and female buy discount zestoretic 17.5mg on-line. Datacollectedover pirical evidence, but are useful labels for those born in certain time can be analyzed in many ways, including grouping by eras. We felt that separating the data into 5-year intervals provided thebestcompromisebetweenspecicity andbreadth. Afterlevelingoffinthe1990s,acceptance ofpremarital on the sexual attitudes composite and on two variables capturing sexcontinuedtoriseinthe2000sand2010s. We focused on number of sexual partners as we felt that that premarital sex wasnot wrong at all. Sex 42 % in the 1980s and stayed there through the 1990s, rising to ual partners in the last year captures only a short amount of time, 49 % in the 2000s and to 55 % in the 2010s (59 % of men, 52% and the other variables (extramarital sex, sex with a casual date or of women). In addition, the use of number of compared to 50 % of GenXers in the early 1990s and 62 % of sexual partners connects this research with the literature on Millennials in the 2010s. Thus,ef maining at a low level, acceptance of extramarital sex (sex be fectively, an intercept (mean attitudes toward sexuality) score tween a married person and someone other than his/her spouse) was calculated (using empirical Bayes) for each cohort and declined signicantly from 4 % in 1973 (5. In addition, a xed intercept (grand mean) is women) to 1 % in 2012 (2 % for men. Thismodelhas Acceptanceofsexualactivity among twoadultsofthesame three variance components: One for variability in intercepts sex increased the most, especially after the 1990s. Among18-to29-year-oldsreportingnon-partnersex, aremoreacceptingofsexbetweentwoadultsofthesamesexin 35 %ofGenXersin thelate1980shadsexwithacasualdateor the 2010s, even though they remain less accepting of premarital pickup(44 %ofmen,19 %ofwomen),comparedto45 %of sex, sex among teens, and extramarital sex. Total num Next, we turned to the mixed-effectsanalysestodetermine berofsexualpartnerssinceage18increasedfrom7. The random effects of time period and generation, which statistically control for each other and age, are plotted in. Acceptance of non marital sex declined slightly between the early 1970s and the early 1990s (d=-. Attitudeswerefairlysteadybet ween 1994 and 2004 and then became more accepting between 2004 and 2012 (d =. Thegenerationaltrendwassomewhatcurvilinear,withthe largest difference between those born in the 1900s and Boomers borninthe1940sand1950s(d =. Number of partners then declined slightly between the religious service attendance. However, Millennials error terms of signicance tests of random effects coefficients, reportedconsiderablymoresexualpartnersthanthosebornin we instead report effect sizes, considering any difference in the 1900s, d = 1. The generational shift was larger for Whites fects were curvilinear, with the mean number of partners mov (d =. Among those born in the 1900s, Blacks reported signicantly Overall, the results suggest that rising cultural individual moresexualpartnersthanWhites(d = 1. Among those born in the1900s,those 2014), more Americans believe that sexuality need not be re who attended college reported more partners than those who stricted by social conventions. Byregion,generationalshiftswerelargest these trends may also be due to shifting norms around mar in the Northeast (d=1. Among those born in 21 for women and 23 for men in 1970, and by 2010 was 27 for the 1900s, those living in the Northeast reported the fewest num women and 29 for men. The generational moreopportunitiestoengageinsexwithmorepartnersandless shift was larger among those who did not attend religious ser reasontodisapproveofnon-maritalsex. Among ingly disconnected from parenting: More than 40 % of babies those born in the 1900s, attending religious services had little were born to unmarried mothers in 2012, up from 5 % in 1960 inuence on number of sexual partners (d =. Afterchanginglittleintheirattitudesduringthe1980sand eration,andagedemonstratedthatthechangesinsexualattitudes 1990s, Americans became more acceptingof non-marital sexdur andbehaviorwereprimarilyduetogeneration/cohort. How and age showed that the trends were primarily due to gen ever, Millennials still reported more sexual partners than those eration. Once age and timeperiodeffects were removed, many borninthersthalfofthetwentiethcentury. Thus, contrary to the position that gen anygeneration,thoughtheychosetohavesexwithfewerpartners erational differences are non-existent or small. The reduced number of part 123 Arch Sex Behav ners among Millennials may reect changes in dating and rela Our results were in partial agreement and partial disagree tionship patterns toward sexual relations (not necessarily involv mentwithMonto and Carey (2014),who statedtheyfoundno ingintercourse)betweenfriendswithbenetswhilepostponing evidence of substantial changes in sexual behavior that would thetransitionintomorecommittedromanticrelationships(Bogle, indicateaneworpervasivepatternofnon-relationalsexamong 2007;Wentland&Reissing,2011). However,examiningonlytheselatercohortsmissesthe notalterthemmuchbeyond theirformative developmentalyears standard-deviation shift in number of sexual partners between (Rauer,Pettit, Lansford,Bates,& Dodge,2013). In addition, our analysis gest that parents and their adolescent and emerging adult chil found alarge generationalshiftin attitudestoward non-marital dren may have signicant generation gaps in their views of non sex and a substantial increase (from 28 to 38 %) in those re marital sexuality, potentially leadingtoconict. Thus, we conclude, in should examine the role of the dominant cultural norms and contrast to Monto and Carey (2014), that meaningful gen values and parental inuences exerted at these key stages of erational changes in sexual attitudes and behavior have development. Generationalshiftsinsexualattitudesweresmaller Thesendingshaveimplicationsforsexualityresearch,policy among somegroups,suchas Blacks, women,and thoseliving decisions and practices, and education and intervention devel intheSouth. Most responses to sweeping cultural changes in sexual and relation notably,generationaldifferenceswerenearlyabsentamongBlack ship attitudes. Among generations born early in the twentieth ferences in the associations between stigma, mental health, and century, Black Americans held more permissive attitudes and sexual risk behavior among gay and bisexual men (Lelutiu reportedmoresexualpartnersthanWhites,butbythe1950sand Weinberger et al. Other research also indicates racial dif indicatesthatconictingmessagesaboutsexualbehaviorfor ferencesintemporalchangesinsexualbehavior. The move towards table or unwanted sexual experiences (Beres, 2010;Muehlen more restrictive attitudes and behavior may reect increased hard & McCoy, 1991). As such, research should work to under awareness of the disproportionate burden of sexually transmit standthecomplexinterplaybetweensexualattitudesandbehavior. Perhaps one of the clearest examples of at as White adolescents declined in religiosity over the generations titudinal changes impacting public policy is the recent federal while Black adolescents did not (Twenge et al. This normsandthenegotiationofmainstreamandsubculturalnorms occurs at the regional level as well: Lax and Phillips (2009) and practices with public health realities. Overall, this is a time of fascinating and age effects highlight the importance of culturally com changes in the sexual landscape of the United States. For example, youth involvement in the development of sexual education pro References gramsislikelycriticaltoaccuratelyrepresentandinformsexual attitudes and behaviors. Census: Marriage rate at 93-year low, even including turalcontextin which sexual values and behaviors developed same-sex couples. Retrieved September 22, is necessary in examining sexual attitudes and behaviors in dif 2014 from washingtonexaminer. Risky business: Is there an association between casual sex and mental Alimitation ofthe current analysis was that the mixed-effects healthamongemergingadults Sexualpartneraccumulationfromadolescencethroughearly or beyond, and those born in the 1950s had not yet reached adulthood:Theroleoffamily,peer,andschoolsocialnorms. Racial and gender the apparent decline in acceptance of non-marital sex with age differences in adolescent sexual attitudes and longitudinal asso ciations with coital debut. If the age trajectory Tuning into psychological change: Linguistic markers of psycho of sexual behavior and attitudes is different for these groups, then logical traits and emotions over time in popular U. Predictors and consequences of yearssince maybe due to its recognitionwithlegal marriage. Gender, belief in the sexual double standard, and sexual talk in heterosexual dating relationships. Changingattitudestowardpremarital behavior became more permissive and less rule-bound. Americans sexual tion and alcohol-related problems among college students: A behaviorshavechangedaswell,withonesexualpartnerthenorm prospective examination of mediating effects. Civil society,economic tion of the associations between attitudes, norms, and sexual risk distress, and social tolerance. Bowling alone:The collapse and revival ofAmerican sitional empathy in American college students over time: A meta community. GayrightsintheStates:Publicopinion national perspective: A multilevel analysis of 60 countries. A general model for the study of developmental and just-world beliefs from 1973 to 2006. Efficacy of behavioral interventions to sexual and reproductive health outcomes for youth. Generations: the history of Americas sexual attitudes, and sexual behavior among college students. Age-period-cohortanalysis:Newmodels, creases in agentic self-evaluations among American college stu methods, and empirical applications. Changes in pronoun use in American books and the rise of individualism, 1960-2008. Being knowledgeable about anatomy and physiology increases our potential for pleasure, physical and psychological health, and life satisfaction. Beyond personal curiosity, thoughtful discussions about anatomy and physiology with sexual partners reduces the potential for miscommunication, unintended pregnancies, sexually transmitted infections, and sexual dysfunctions. Lastly, and most importantly, an appreciation of both the biological and psychological motivating forces behind sexual curiosity, desire, and the capacities of our brains can enhance the health of relationships. However, the accuracy of answers we get from friends, family, and even internet authorities to questions about sex is often unreliable (Fuxman et al. For example, when Buhi and colleagues (2010) examined the content of 177 sexual-health websites, they found that nearly half contained inaccurate information. If you learn this material, then we promise you wont need nearly as many clandestine Google excursions, because this module contains unbiased and scientifically-based answers to many of the questions you likely have about sexual anatomy and physiology. Learning this vocabulary may require extra effort, but if you understand these terms, you will understand sex and yourself better. Masters and Johnson Although people have always had sex, the scientific study of it has remained taboo until relatively recently. In fact, the study of sexual anatomy, physiology, and behavior wasnt formally undertaken until the late 19th century, and only began to be taken seriously as recently as the 1950s. Notably, William Masters (1915-2001) and Virginia Johnson (1925-2013) formed a research team in 1957 that expanded studies of sexuality from merely asking people about their sex lives to measuring peoples anatomy and physiology while they were actually having sex. Masters was a former Navy lieutenant, married father of two, and trained gynecologist with an interest in studying prostitutes. Johnson was a former country music singer, single mother of two, three-time divorcee, and two-time college dropout with an interest in studying sociology. And yes, if it piques your curiosity, Masters and Johnson were lovers (when Masters was still married); they eventually married each other, but later divorced. Despite their colorful private lives they were dedicated researchers with an interest in understanding sex from a scientific perspective.

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