Jenny said that she would love to be married and have children but felt that no one would want to take on the responsibility of caring for her and that she was not strong enough to have a child buy 10 mg slimex with amex weight loss 60617. It has stopped me from making plans and getting on with my life buy slimex 10 mg overnight delivery weight loss hacks, like going to university or doing things which might be boring for a few years but lead on to something better’ purchase slimex no prescription weight loss pills. Asked what he might want to change about himself, again like some of the others Rob replied, ‘I’m happy with my character, I’m very happy with what’s happening in my life at the moment’, and he was more keen to talk about how to change society. For example, one man with Down’s syndrome described being pushed and shoved in the street by his neighbours, and another was fed up with being Prenatal counselling and images of disability 205 treated by new work colleagues as if he were stupid, though he added, ‘They learn in the end, and then they realize that are the ones who look silly’. Their conditions did not appear to dominate their lives in most cases, and much time was spent talking about the many things they had in common with their ‘ordinary’ peers: work or unemployment, income, housing, relationships, leisure activities and ambitions. The other more disabled people with spina biWda included a young single mother who was also a college student, and Richard and Vivian who both used wheelchairs. He enjoyed going to city clubs with friends, and could haul himself in his chair up and down stairs, so he used underground trains despite oYcials trying to stop him. He said that when he joined mainstream secondary school, the wheelchair users were all taught mobility and coping with stairs and pave- ment kerbs, which helped him to become very Wt. You do feel low and in pain and angry with people and it is important to have friends and to go out for a drink’, and she talked enthusiastically about her many interests. Vivian was planning to have a baby and she talked of her mixed feelings about taking folic acid to reduce the risk of the baby having spina biWda, yet ‘being proud that I have spina biWda’ because it had given her such experience, knowledge and opportunities she would not otherwise have had. They also tended to say that they would respect any decision made by prospective parents after being properly informed, whether to continue or end a pregnancy aVected by their condition, though they hoped the pregnancy would continue and some had mixed feelings. For example, two men with Down’s syn- drome, who had been talking intently about their acting, suddenly looked very sad when asked about screening, and said they did not want to talk about it, as if the subject was too painful. However, the interviewees had far more similarities than diVerences, including the ways they reXected on their lives, and their belief that they suVered from the general stigma of disability more than from their actual condition. This raises questions about why the prenatal literature, policy makers and counsellors make so little mention of the potential range of each condi- tion from mild to severe, of the increasingly eVective treatments which Jenny mentioned, and of the possibility that some therapeutic abortions may prevent potentially rewarding lives. A further complication for prenatal predictions is the mismatch, shown particularly by the people with spina biWda, between the degree of severity of physical disability and the way people value and enjoy their lives. Prenatal counselling and images of disability 207 The implications of the interviews for prenatal counselling and maternal–fetal relations The overall impression given by the interviewees was of very interesting, thoughtful and pleasant people. Most of them appeared to value and enjoy their lives, sometimes despite pain and serious illness, as much as any average group of 40 young adults might say they do. One man with sickle cell anaemia was in such pain that his interview took place over three separate visits, but this was because he was so keen to take part. Their friends appeared to value them, and so did their families, with one exception as might be expected in any group of 40 adults (her mother had died and her father had remarried). Most interviewees had far more in common with their ‘ordinary’ peers than diVerences, and none showed any clear reason why their life would have been better prevented. Even allowing for the artiWcial nature of the research interview, and the way our methods partly shape the evidence, as is inevitable in every type of research, the interviewees provide compelling evidence for questioning the assumptions on which prenatal policies and counselling are based – that it is reasonable to prevent such lives. The interviewees challenge the view that it is kinder to terminate any aVected pregnancy, however mildly the fetus might be aVected, because life is so awful for the severest cases. Repeatedly, interviewees spoke of the crucial importance to them of being involved in mainstream society – schools and colleges, homes and jobs, clubs and pubs and friendships. They tended to stress their need to see beyond their condition as a personal predicament, and to press for greater inclusion by challenging negative attitudes in society, and by showing how they could be involved. They were grateful to parents who encouraged them to be strong and who, as one woman with Down’s syndrome said of her mother, were ready to ‘Wght for my rights [even through] the High Court, the High Court of Justice! Some of them helped to train medical students, and they criticized inaccurate medical images of disability, such as the sickly child advertisements that raise funds for medical research. Richard was referring to a theme that ran through the interviews – of adaptation, ingenuity and a resilience that grows through accepting and surmounting diYculties. This is in contrast to prenatal screening policies which propose eVorts to prevent and avoid diYculties, as if human beings cannot or should not have to experience them, and as if disability is not inevitable for most human beings, at least at the beginning and end of life. The interviewees quoted earlier suggest that this approach is unrealistic, because ordinary people’s lives so often involve problems – such as with relationships, loss, frustrating limitations or poverty. Fearful avoidance of disability, rather than promoting ways to support disabled people’s lives, is liable to diminish people rather than freeing them into new achievement and conWdence. The diYculty in these criteria is the current limitations in predicting how severe an impairment might be or might become, how much it may be ameliorated by social or medical support, and how the aVected person and family may experience similar diYculties either as hardship and suVering or as part of a worthwhile rewarding life. Some parents value their Prenatal counselling and images of disability 209 child’s very short life far more than no life at all (Delight and Goodall, 1990). Unawareness may include unawareness of suVering, which would obviate the criterion of suVering, and uncertainty again prevails over the diagnosis and prognosis of unawareness. Children who have been dismissed as ‘vegetables’ are perceived by others to experience profound feelings, such as by the researcher who commented, ‘Cabbages do not cry’ (Oswin, 1971). The argument that prenatal selection is diVerent from ending such lives after birth, and aVects attitudes towards impaired fetuses only, is unconvincing. The interviewees show that some disabled people feel threatened and disad- vantaged by the prejudices which are, perhaps inadvertently, promoted through prenatal screening. The emphasis on particular impairments when selecting an embryo or fetus as worth preserving suggests that any policy diVerence between preserving an embryo or a person with, say, thalassaemia is not one of principle but of practicality. Social exclusion, school exclusion and family exclusion (in numbers of teenagers living on the streets) are increasing rapidly, as are expectations that children should conform to ever more speciWc milestones, school tests and behaviour standards with an unjust ‘zero-tolerance’ which does not allow for contingencies and disadvantages. Prenatal programmes are not responsible for these changes, but they are part of them, and are powerful medical and oYcial indirect endorsements of them. Another theme of injustice is when public rejection, expressed through national prenatal programmes, is made to appear to be a matter of private grief and responsibility, as when each individual woman faces the ‘choice’ of termination of pregnancy, a choice constrained by social and economic circumstances. Tests which screen ‘negatively’ for one or a few speciWc impairments are soon likely to become multi-package tests to screen simultaneously for numerous impair- ments, and then tests to select ‘positively’ for growing numbers of preferred features such as intelligence or height. When the embryo and fetus, and implicitly the baby and child, are presented to women by health professionals as a means of fulWlling adults’ dreams of perfection, rather than as ordinarily imperfect mortals to love as ends in themselves, then maternal– child as well as maternal–fetal relationships are likely to become ever more tentative and conditional. I am grateful to everyone who took part in the research,and to my co-researchers,although I am responsible for any shortcomings and opinions in this chapter. Over time, the initial way a problem is deWned then crystallizes policy debates, producing what can then become a very rigid framework, all but impossible to expand or modify (Rochefort and Cobb, 1994: vii, pp. Constitutionally, in the course of nearly 30 years of Supreme Court reasoning, abortion rights have become rigidly deWned as a problem of decisional autonomy, that is, as a problem of privacy and choice. Politically, during that same time period, the problem of abortion has been deWned by pro-life activists (as we would expect), but also by pro-choice advocates (as we might not expect) on the basis of a very traditional model of motherhood, one invoking cultural and ethical depictions of women as maternal, self-sacriWcing nurturers. The combination of deWning the problem of abortion rights constitu- tionally in terms of the privacy of choice and politically in terms of a traditional view of motherhood has produced a rigid, serious policy conse- quence – namely, failure to obtain access to abortion services for women in the form of public funding of abortions. Correction of this policy conse- quence requires a redeWnition of the problem of abortion rights from both constitutional and political perspectives, which entails, as part of that re- deWnition, a transformation of the traditional model of motherhood to include nontraditional elements. To understand more clearly what is in- volved in this transformative process, let us review the current status of how a traditional model of motherhood underlies the current way the problem of abortion is deWned.
Perhaps a better definition refers to the absence of ‘corresponding external stimulus’ or absence of an ‘external source’ (e discount slimex on line weight loss pills zynadryn. However purchase slimex in india weight loss pills jean coutu, complaints of seeing visions of other people who speak (especially if they converse with the patient) are not likely to reflect hallucinations; rather they are most likely due to lying (malingered or factitious) or a conversion state cheap slimex online master card weight loss pills xenadrine review. Patients often do not seem to care if they cannot explain whence or from whom hallucinations arise. One patient with borderline personality disorder claimed to be able to see ‘little green men’ outside in the garden every time she raised the window blind! Hallucinations would be expected to be present no matter whether the blind was raised or lowered. Likewise, if a patient destroyed his tympanic membranes it should not eliminate auditory hallucinations. Somatic hallucinations are sometimes divided into superficial (haptic: touching, tickling; kinaesthetic: movement, joint position; thermic: hot or cold; hygric: wetness) and deep (visceral changes, sexual stimulation, electricity passing through the body) subtypes. However, they may also be found in schizophrenia, severe affective disorder, following torture (Rasmussen, 1990) and, in 12% of cases in one series, in ‘hysteria’, (Perley & Guze, 1962) which today would be called dissociative disorder. Anticholinergic drugs may be associated with visions of bugs crawling on the skin. Gustatory (taste) hallucinations should not be confused with the various tastes produced by drugs. Pseudohallucinations, an imprecise and controversial term that would be better discarded according to some authors,(Taylor, 1981) involve the reporting of hallucination-like experiences but without an identifiable percept: he may saw he sees things that are not there but is unable to describe an actual specific perception; they are less vivid and realistic than hallucinations, are often located inside the head (internal 104 space), and often coincide with true hallucinations. It should be remembered that visual hallucinations due to disease of the central pathways of the visual apparatus are 105 rare. Hypnagogic (going to sleep ) and hypnopompic hallucinations (on waking) occur when the level of consciousness is between waking and sleep, and they are often normal. Lilliputian or microptic hallucination Bright, funny, everything is much reduced in size Aetiology: Alcohol Anaesthetics Enteric fever Scarlatina Delirium tremens - small, obscene and abusive creatures (Sims, 2003, p. Epstein-Barr virus) and lesions of the non-dominant parietal area A reflex hallucination occurs when one sensory modality is excited and the cause is irritation in another, e. A functional hallucination is provoked by a stimulus and occurs in the same sensory modality as the stimulus; both the stimulus and hallucination are perceived at the same time and are also perceived as being distinct. A classical example would be when a person turns on a tap and only hears a hallucinatory voice whilst the water is running, but he also hears the water running. Auditory hallucinations, like those in other sensory spheres, need not be well formed. Auditory hallucinations are commonest in schizophrenia and in alcoholic hallucinosis. In alcoholic hallucinosis the voices respond poorly to neuroleptics but they clear if the patient remains abstinent. Normal people may hear noises or voices when dropping off to sleep, on waking, when tired, when exposed to extreme sensory or social isolation, or at the height of a bereavement - the voice may simply call the person by name, e. Extracampine hallucinations are visual hallucinations seen outside the field of vision, such as behind oneself, or auditory hallucinations reported to be heard from outside the range of unaided hearing (e. The may occur in normal people as a hypnagogic phenomenon , in schizophrenia, or in organic disorders including epilepsy. Metamorphosia means that objects appear irregular in shape when in fact they are not; retinal scars can cause this or macropsia whereas an oedematous retina can be associated with micropsia. Porropsia means that objects may seem to retreat into the distance (overlap with micropsia). A rare complication is the Doppelganger phenomenon where the person also believes that they have a double. Perhaps because of non-recognition of family, a person may believe that other people live in his/her house: phantom boarder syndrome. Prosopagnosia in its severest form may include failure to recognise ones reflection in the mirror. However, this is most commonly found in dementia with its more global manifestations. Rarely, a patient may look in the mirror and decide that the reflection represents an untrue version of the self (shades of Capgras, although the patient may simply be unsure of the facts). Shakespeare’s Caliban, an outcast in the Tempest, appears to have had this syndrome. The dominant hemisphere then views this activity as alien to the self because of a primary dissociation in the functioning of the two cerebral hemispheres in schizophrenia. Hallucinations may be seen as an expression of brain activity or as products of adaptive behaviour, as when seeking organisation in a chaotic array or motivated by dynamic imperatives. In particular, thought-disordered content could be superimposed on either primary or compensatory brain-based phenomena. During simultaneous occurrence of hallucinations and external stimuli, hallucinations were reported to lower N100 amplitudes and changed topography, suggesting competition between auditory stimuli and hallucinations for physiological resources in the primary auditory cortex; auditory hallucinations may therefore be a consequence of abnormal primary cortex activation. Interestingly, subvocalising during reading decreases reading speed but improves comprehension. Bick and Kinsbourne (1987) found that schizophrenic patients reported that the voices they heard went away when they kept their mouths open, so precluding subvocalisation, but not when they merely clenched their fists. Nevertheless, most patients with schizophrenia can make clear distinctions between auditory verbal hallucinations (‘voices’) 123 and their everyday thoughts. Definitions Lability of affect: variably defined as excessive emotional responsivity or unpredictable changes in affect, such as when the happy person suddenly becomes angry, only to sink into despair a short time later (e. Winston Churchill told his doctor on July 3, 1953 that ‘Since this (stroke) happened I have been very lachrymose. At parts of Phineas Finn I became very tearful, though it is not at all a moving story’. In schizophrenia, the emotional reaction may initially be congruous but then not change with altered circumstances, so-called stiffening of affect. The patient with abulia has no impulse to action, his mind is blank and empty, and volition is absent. However, it has also been described in association with damage to the 123 They do this by examining mainly thought content and sense of control, whereas loudness and clarity are of lesser use. Apathy with blunting or flattening of affect may also occur in schizophrenia; also common in dementia and after stroke. There is said to be sustained emotional indifference or diminution of emotional response, although a flat affect is quite compatible with subjective emotional arousal. Should only be diagnosed when subject has been observed in a variety of circumstances and when not sedated. Flattening of affect can accompany frontal lobe lesions as part of an apathetic-akinetic syndrome. Anxiety is characterised by apprehensiveness and tension, but the stimulus is ill defined and may be totally intrapsychic, e. It has been suggested by many authors that anxiety disorders properly belong with the affective disorders.
Genitourinary Emergencies 141 • As the infection progresses cheap slimex 15 mg with visa weight loss pills xantrex, gas extends into the perinephric space and retroperitoneum order slimex in united states online weight loss 1. However buy genuine slimex on-line weight loss urination, gas could be demonstrated only on one-third of plain abdominal radio- graphs in some studies. Perinephric Abscess • Perinephric abscess is a life-threatening but treatable process, consisting of suppurative material occupying the space between the renal capsule and the surrounding fascia. Clinical Features • The symptoms of perinephric abscess, including fever, flank pain, chills, nausea, vom- iting, and dysuria, may develop insidiously, making early recognition difficult. While these extensions are rare, direct exten- sions into the flank or psoas muscles are more common, which may even extend to drain as a flank abscess. Renal Abscesses • Intrarenal abscesses are classified into renal cortical abscess and renal corticomedullary abscess. However, mortality rate for intrarenal abscess has been positively correlated with the timeliness of diagnosis. Renal Cortical Abscess (Renal Carbuncle) vs Renal Corticomedullary Abscess Pathogenesis • Renal carbuncles result from hematogenous spread of bacteria from primary focus of infection elsewhere in the body, usually skin lesions such as cutaneous carbuncles, furuncles, paronychia, cellulitis, osteomyelitis, and endovascular infections. Genitourinary Emergencies 143 • Most carbuncles are unilateral, single lesions occurring in the right kidney. Only 10% of these eventually rupture through the renal capsule to form a perinephric abscess. Clinical Features • Unlike other intrarenal abscesses, renal carbuncles are approximately three times more common in men than in women. Diagnosis • The nonspecific clinical presentation of fever, chills, and back pain may be seen with a variety of renal processes. Furthermore, renal cortical abscesses are difficult to distinguish from renal medullary abscesses. Treatment • Unlike emphysematous pyelonephritis, renal abscesses are managed medically as firstline treatment. Clinical Presentation • The classic presentation of renal colic is a history of abrupt onset of severe, crescendo flank pain that eventually radiates into the lower abdomen and ipsilateral testes or labia as the stone progresses down the ureter. Diagnosis • The most important laboratory test to obtain in this clinical setting is the urinalysis. However, the finding of bacteruria implies urinary tract infection and always requires further investigation, especially if fever and chills are present. Renal artery Also presents with acute flank pain Emergent angiography aneurysm and hematuria indicated Usually small and clinically not significant Dissection or rupture is rare—but will cause shock 3. The finding of fever, pyuria, or bacteruria in a patient with renal colic requires further work-up and admission. Patients with only one kidney become essentially anephric with complete obstruction and may require surgical drainage. Patients whose pain can only be controlled by intravenous anal- gesia require admission. Epidemiology/Pathophysiology • Testicular torsion occurs at a baseline frequency with two additional significant peaks occurring at infancy and puberty. Diagnosis • The initial evaluation of a patient with acute scrotal pain or swelling should focus on ruling out the presence of testicular torsion. Genitourinary Emergencies 149 • The absence of a high-riding testicle or the presence of a cremasteric reflex should not be used as evidence that torsion does not exist. He denies any dysuria or urethral discharge; however he states that he has two such epi- sodes in the past two days. The presence of either of these might suggest an infectious etiology of the patient’s pain. Urologic consultation should be obtained early as surgi- cal exploration is definitive therapy. Overall the specificity is reported to be between 83-100% and the sensi- tivity 89-100% for decreased or absent testicular blood flow when compared to the contralateral testicle. Radionuclide imaging has been reported to have a sensitivity of 87-100% and a specificity of 93-100%. Despite these impressive numbers, radionu- clide imaging is considered an alternative in those cases where doppler is not practical or the results are inconclusive. There- fore, it should be stressed once again that the diagnosis of this disease should not rely on any single test. Treatment • Emergency department therapy for patients with a suspected torsion focuses on anal- gesia and preparation for surgical exploration. Overwhelmingly the follow-up literature was not supportive for such a treatment strategy. In some rare cases there have been reports of torsion after orchipexy, a phenom- enon which appears to be related to the use of absorbable sutures. Prognosis • Overall, testicular torsion carries a relatively poor prognosis with regards to the in- volved side. Within 10 h, >80% of testes are 150 Emergency Medicine lost and by 24 h the number reaches almost 100%. Reasons for delay include hesita- tion in seeking medical advice as well as misdiagnosis. It has been demonstrated that torsion of one testicle leads to decreased blood flow to the contralateral side, with relative hypoxia and apoptosis. The subsequent decrease in germ cells has been implicated in decreased fertility of these patients. Periuethral Abscess Background • Periurethral abscess is a rare but life-threatening infection of the male urethra and periurethral areas. Genitourinary Emergencies 151 • Retrograde urethrography can show the presence of urine extravasation but provides overall much less information and diagnostic data than ultrasonography of anterior urethral strictures. Management • The mainstay of treatment for periurethral abscesses consists of surgical drainage and antibiotics. Fournier’s Gangrene 6 Epidemiology • First described in 1764 by Jean-Alfred Fournier as a gangrene of the penis and scro- tum, necrotizing fasciitis of the perineum, genital or perianal area affects both sexes and is a true emergency. Pathophysiology • Although seen in children and women, Fournier’s gangrene is more common in males (10:1) and was originally described as a severe gangrenous infection of the scrotum. These organisms work synergistically, with the aerobic bacteria keeping the oxy- gen tension low enough to allow anaerobic growth. Hypocalcemia, caused by chelation of calcium by the bacte- rial lipases, has been reported as an important diagnostic clue, and hyponatremia may also be present. Treatment • Treatment of Fournier’s gangrene is aimed at stabilizing the thermodynamics of the patients and beginning antimicrobial infection as rapidly as possible. Penile Emergencies Phimosis • Condition in which the foreskin cannot be retracted behind the glans penis • By 3 yr of age, 90% of foreskins can be retracted • Fewer than 1% of males have phimosis by age 17 • Usually not painful, but may produce urinary obstruction with ballooning of foreskin • May occur as a result of recurrent balanitis • May lead to chronic inflammation and carcinoma • Treatment in boys older than 4 or 5 yr of age and in those who develop balanitis or balanoposthitis is topical corticosteroids (0.
In this first phase purchase 10mg slimex with visa weight loss pills jacksonville fl, the analysis was focused on the collected texts slimex 10 mg line weight loss 77080, and did not cover other aspects order cheap slimex on line weight loss urination, such as layout, images, audiovisual material etc. They focus mainly on the trans- mission of factual information without showing awareness of the dif- ferent cultural and technical background of the potential readers; much less attention is paid to interpersonal interaction. The German and Dutch texts, on the contrary, are more geared towards their potential readers and are probably the result of an intra-linguistic translation and/or adaptation of more complex texts. In the Italian texts, many descriptions show a high density of terms, typical of a communication between experts and not suitable for informing potential patients. The following excerpts, where we have underlined the more technical terms, exemplify this point: (3) Il lembo, di forma rettangolare, viene successivamente tubulizzato per forma- re il neo-fallo e trapiantarlo in regione pubica dove viene inserito sopra un piccolo lembo cutaneo di forma triangolare creato sul pube per allargare la base di impianto. Come il lembo prelevato dall’avambraccio, anche questo viene trasferito con tecnica microchirurgica eseguendo microanastomosi arte- riose, venose e nervose. As discourse specialist Ren- kema puts it, “a text can fail on the comprehensibility dimension when a writer puts too little effort into adjusting to the reader’s knowledge level” (2004: 183). For other concepts as well, the Italian texts use abbreviations, acronyms and English loan words without providing the full forms or an Italian equivalent. In the German and Dutch texts, on the contrary, many instances of de-terminologisation can be found, that is “the process of recon- textualisation and reformulation of specialized terms aiming at making the concepts they designate relevant to and understandable by a lay audience” (Montalt/Shuttleworth 2012: 16). Traditional terminology of Greek and Latin origin is not completely avoided, as it can be even useful for educational purposes, which are an important feature of patient brochures (Montalt-Resurrecció/González Davies 2007: 31), but it is often accompanied by detailed and understandable explana- tions. In the following examples in German, terms of Latin and Greek origin are preceded by paraphrases (5), and the reader is also provided with an explanation of the adjective frei in its technical meaning (6): 176 Mariella Magris / Dolores Ross (5) Dieser Eingriff dauert etwa sieben bis neun Stunden und beinhaltet: • die Entfernung der Brüste (Mastektomie) • die Entfernung der Gebärmutter (Hysterektomie) • die Entfernung der Eierstöcke und Eileiter (Ovarektomie, Adnektomie) • die Entfernung der Scheide (Kolpektomie) (Klinik Sanssouci Potsdam) (6) Operationsschritt zur Penoidkonstruktion: • Aus freiem Unterarmlappen oder • aus freiem Unterschenkellappen mit Anteilen des Wadenbeins zur Versteifung mit eigenem Gewebe (Fibula-Knochen ) Frei bedeutet, dass das Gewebe vom Unterarm oder vom Unterschenkel bei der Operation unter dem Operationsmikroskop an die Blutgefäße in der Leiste angeschlossen werden muss. But the lexis of the Germanic languages has been enriched with extensive loanwords from Latin, with an admixture from Greek, either directly transmitted or through the influence of French and English (Hawkins 1990: 75, Finegan 1990: 81, Kooij 1990: 140), thus creating a fairly remarkable split in the vocabulary of these languages between popular and learned words. Compared to Italian, the two Germanic languages clearly exploit their double-layered terminology: in German, for instance, almost every term of Latin or Greek origin has a synonym of vernacular origin (Puato 2011: 119), which is often built by substituting the erudite roots, prefixes and/or suffixes with their ‘inherited’ counterparts. In communicating with patients, the use of these ‘doublets’ can enhance comprehension and have an educational effect: “Die Arterien (Schlagadern) und Venen (Bluta- dern) […]”, “Faszien (Bindegewebshüllen)”, “Urethra (Harnröhre)” are just a few examples from the analyzed websites. The following sentence, for instance, avoids Urethra altogether and uses only Harnröhre: “Häufig kann das Prob- Gender Dysphoria 177 lem mit einem durch die Harnröhre geführten endoskopischen Eingriff beseitigt werden”. The following excerpt from a patient brochure on laparoscopic surgery contains very short sentences with simple syntax, word repetitions and explanations of terms in plain lan- guage. See for instance the explanation of the term hormones in this excerpt: (8) Behandeling met geslachtshormonen Hormonen zijn stoffen die op een bepaalde plaats in het lichaam worden gemaakt (de hormoonklier), aan het bloed worden afgegeven en elders in het lichaam hun effect uitoefenen. Zij worden zo genoemd, omdat zij in de geslachtsorganen worden gemaakt en verantwoordelijk zijn voor de ontwikkeling van het lichaam in mannelijke of vrouwelijke richting. Through one of these small incisions a laparoscope is introduced into the abdomen: this is a long, thin tube enabling the doctor to look into the abdomen. Hormones are substances produced in a particular place in the body (hormone gland), they are released into the blood and have an effect elsewhere in the 178 Mariella Magris / Dolores Ross There are only one Italian and one German website providing glossaries of key terms. These glossaries, however, do not cover all specialized terms contained in the texts, they force the reader to interrupt the reading process and definitely do not represent a reader- friendly alternative to lexical clarity of texts. We think that greater attention should be paid to terminological issues, as the terminology of this specific domain includes many neologisms and – as already seen – controversial terms. We have the impression that the authors of the site have made special efforts to guarantee proper communication, as this subject touches on quite delicate questions. The Italian texts are quite impersonal: they never directly address potential readers and refer to them in the third person as persona, soggetto and the like. In Germany and the Netherlands, no court judgment is needed: in Germany two psychological assessments are required, while in the Netherlands the decision is taken by the gender team, which includes physicians from different specialities as well as a psychiatrist. The absence of similar passages in the Dutch and German texts, therefore, might be due not only to differences in communicative style, but also (and perhaps more prominently) to the legal context of the surgical intervention. The next Italian example, on the contrary, is not related to any national specificity, as it points to the side effects, stressing that they can be minor, but also very serious and even life-threatening. Of course, it is fundamental to inform the reader about risks and compli- cations, but not necessarily in such a way as to discourage potential patients. While in German Sie cor- responds to the standard form used in web communication, in Dutch u might seem a formal choice, as in most contexts the second person singular pronoun jij/je is used, but it may have been chosen to express respect towards people with this condition. Uw lichame- lijke geslacht kan in een driejarig traject (achttien maanden preoperatief en achttien maanden postoperatief) worden aangepast aan uw genderidentiteit. In the Dutch excerpt in (14), the authors show a deep understanding of the many individual experiences of being transsexual and of the difficulty of coping with it. Enerzijds zien we dat patiënten vaak jarenlang vermijdingsgedrag hebben laten zien en niet in staat zijn om diepgaande contacten te onderhouden met andere mensen. Your biological sex can be adapted to your gender identity in a 3-year process (with an eighteen-month preoperative and an eighteen-month postoperative phase). On the other hand, we see patients who sometimes try so hard to come to terms with their biological sex, that they show features Gender Dysphoria 181 Another common trait of German and Dutch texts is that they appear to be much more reassuring than the Italian ones. In German, em- phasis is often placed on the possibility of achieving good, sometimes even excellent, results, thanks to well-tested surgical techniques: (15) Mann-zu-Frau-Operationen sind inzwischen zu standardisierten Eingriffen herangereift, die bei sorgfältiger Indikationsstellung und guter Vorbereitung in mehr als 80 Prozent der Fälle nach ein oder zwei Operationen zu guten funk- tionellen und kosmetischen Ergebnissen führen. Dies erfordert viel Erfahrung eines auf Transsexualität hoch spezialisierten Ärzteteams, welches in der Klinik Sanssouci Potsdam fester Bestandteil der transsexuellen Chirurgie ist. As already said, the Italian selected websites are run by public centers, and the same goes for the two Dutch clinics, whereas the German corpus includes some private clinics as well. Moreover, in Italy the sex reassignment surgery is covered by the National Health System (provided that there is a court judgment allowing it), whereas in Germany and the Netherlands it is refunded by health insurance companies. In these two countries, therefore, there could be the need to ‘promote’ this kind of surgical intervention and also the clinics performing it, and this could have influenced the wording of the texts. Conclusion These are in short the first findings of our study, which seem to point to some significant differences between the three countries and lan- guages. As far as communication policies are concerned, while the Italian and German clinics seem to prefer more ‘private’ channels, which imply a direct contact by phone or email, the Dutch clinics attach great importance to online information, aware of the fact that web-mediated communication “has qualified as a powerful strategic resource in healthcare settings”, creating a “new type of self-informed patient” (Vicentini 2013: 53, 54). When considering textual strategies, however, the distinction should be drawn rather between Italy, on the one hand, and Germany and the Netherlands, on the other. The Italian Gender Dysphoria 183 texts appear to be heavily doctor-centered and monological, they present many instances of opacity of medical communication and are definitely not in line with the main functions of patient brochures, i. On the contrary, the German and Dutch websites demonstrate to be aware of the fact that patient brochures are typically used to bridge communication gaps (Montalt-Resurrecció/ González Davies 2007: 59). They show multiple efforts to compensate mismatches of knowledge, through simple syntax, the frequent use of explanations and paraphrases, the combination of specialized and popular terms. Their communication style is more comprehensible for potential patients, and thus more efficient – although comprehensibility is not the only yardstick for measuring the effectiveness of a text (Renkema 2004: 180). This seems to be the background against which the German and Dutch texts have been produced, and it is in line with what we already observed in the field of vaccination programs, where the two language communities have been demonstrated to give much more consideration than the Italian health sector to proper communication for the sake of health literacy and social inclusion (Ross/Magris 2012: 147). In the present study we have also observed that the German and Dutch texts show more empathy with potential patients and adopt a more positive attitude when describing the surgical treatment, often emphasizing the competence of the medical staff and the high success rate of surgery.