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Rarely one comes across women who repeatedly expose their breasts generic 20 mg levitra soft overnight delivery, and very rarely one sees women who do the same with their genitalia cheap levitra soft 20 mg online. Coprophagia - eating of faeces, as the preferred method of achieving sexual arousal; may be part of a masochistic ritual; masochist may have to lick the sadist clean; coprophagia and coprophilia, the storing of 2053 faeces are usually associated with intellectual disability, the degenerative psychoses of childhood, and 2049 The De Gascun ea(2006) Dublin series consisted of 52 cases, 45 male to female, and 7 female to male. In some cases it may be pragmatic to make a fetish more acceptable to a partner, e. Group therapy, the effects of which are modest, aims include accepting responsibility, empathising with the victim, and nourishing true motivation for change/controlling behaviour. Drugs used for excessive (uncontrolled, dangerous) sexual drive: These drugs may be best for paraphilia patients with a high sex drive rather than for antisocial paraphiliacs with a low sex drive. Hormones do not guarantee absence of recidivism and they are not a stand-alone therapy. It is important that patients accept responsibility for their actions and that they become involved in psychotherapy. Anti-androgens like cyproterone and medroxyprogesterone act to 2060 decrease testosterone levels and to block its receptors. It is a competitive inhibitor of testosterone and dihydrotestosterone at androgen receptors. It may cause a reversible atrophy of the 2054 An example would be a Prince Albert ring piercing the penis. Cyproterone reduces sexual interest and activity but does not impair the erectile response to erotic films. Not all patients lose desire for sex or erections despite being on relatively high doses. Cyproterone is considered to be most effective when the paedophile is focused on orgasm and to be less effective when the patient is more focused on forming a relationship with the victim. Cyproterone acetate is found in 2061 low dosage in the contraceptive pills Dianette and Minerva , which has been used in women who suffer from severe acne. Oestrogens can be given as depot injections (oestradiol undeclyenate) or as an oestradiol implant. Oestrogens can cause breast enlargement and nodules, testicular atrophy, osteoporosis and, rarely, breast 2062 tumours. It is used for endometriosis, prostatic cancer, premenopausal breast cancer, and as an adjunct to surgery for uterine fibroids. It can cause hot flushes, loss of libido, headaches, mood changes, and vaginal 2063 dryness. It can cause erectile failure, hot flushes, and reduced bone 2064 density in some men. Physical castration, a thorny ethical issue (Grubin & Beech, 2010), was practised as a voluntary treatment for sexual perversities on rare occasions in some countries, such as in Denmark until 1972. However, it is still carried out in psychiatric hospitals for sexual offending in the Czech Republic. The present author has found records of one intellectually disabled female who received a leucotomy in early twentieth century Ireland for what was deemed to be promiscuous behaviour. People may agree to be castrated in order to gain release from confinement rather than because they truly wish to reduce the risk posed to others. They do not wish to acquire the secondary sexual characteristics of the opposite sex but are uncomfortable with their assigned sex (contrast with transsexualism). Aversion therapy consisted of the pairing of a noxious stimulus (agents such as ammonia, apomorphine, disulfiram, nalorphine, or emetine; electric shocks) with the response/behaviour to be weakened or extinguished (alcohol, morphine, pictures of men and women, etc). Also, patients often became socially isolated and depressed because of the lack of an alternative sexual outlet. Entry of sexual offenders onto a sexual offenders’ register has different implications in different jurisdictions. They may be required to live at a particular address, report at stated frequencies to police, avoid minors or schools, or wear an electronic tag. Problems of sexual desire and interest often carry a poor prognosis, although one should realise that some people who are locked in a relationship in which they have no say develop lack of desire as a form of protest. Osborn ea (1988) reported that one-third of women aged 35-39 had operationally defined sexual dysfunction in a community survey in Oxford, especially impaired sexual interest, vaginal dryness, infrequent orgasm, and dyspareunia. These were significantly associated with increasing age, psychiatric disorder, neuroticism, and marital disharmony. Rust ea (1988) found that marital problems were more closely related to sexual dysfunction in men than in women. Men’s performance oriented approach to sex is inappropriate when applied to sexual intimacy. The person is torn between love and hate for the partner, between a need for closeness and a wish for escape. According to the theory, the person’s mother had maintained her child in an excessively dependent state, causing the child to feel threatened, frustrated and aggressive toward the mother, but at the same time wanting her love and protection.

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However buy 20mg levitra soft fast delivery, we are only now starting to address a problem which can only grow larger in view of the increased ability to store successfully testicular or ovarian tissue for future reproduction generic levitra soft 20 mg fast delivery. In this case the intent, that is the conservation of the reproductive ability of children and adolescents, seems prima facie beneWcent, but that may primar- ily be the parents’ intent, possibly biased by a desire to one day have a grandchild who might remind them of a beloved deceased child. Ovarian biopsy may indeed be a fairly risky procedure in a relatively sick adolescent girl, much more so than sperm donation or testicular biopsy from a boy. Again we face a situation where the intent and the consent of the child or adolescent concerned may not be identical, where one could not be presumed to take place of the other. Could a biopsy be taken, for instance, when the child is unable to consent because he or she is not deemed Gillick competent, or when he or she is so seriously ill that therapeutic privilege is invoked? Cloning and the human embryo Cloning and reproduction, especially cloning the human embryo, made the headlines after the report at one of the American Fertility Society meetings, in 1994, of an experiment describing embryo-splitting. The principle of the creation of identical human beings is thus not a new subject, but the method described by Wilmut and colleagues certainly is (Wilmut et al. Jonas has also stated that the two most awesome kinds of responsibility we may ever face are those of politicians towards society and of parents to their children. This arguably may be extended to future or planned children, the matter Ethical issues in embryo interventions and cloning 155 which concerns us in assisted reproduction. It is indeed because we are responsible, or moral subjects, that we wish to analyse rationally the argu- ments for and against cloning for reproductive purposes. Interestingly, the introduction of the report by the group of advisers to the European Union (European Commission, 1997) states, ‘As there is no dis- crimination against twins per se, it follows that there is no per se objection to genetically identical human beings’. This makes it clear that one must Wnd other arguments than the noumenon (‘thing in itself’) of cloning (its ‘real existence’) in order to counter arguments in favour of human reproductive cloning. The argument of dignity is underlined, using the Kantian categorical precept – ‘to treat each and everyone as an end to themselves and not merely as a means to an end’. Of course we know that a clone obtained by somatic cell nuclear transfer would not be totally identical to the adult donor of the nucleus, because of the recipient cytoplasm bearing the maternal mitochondria; but more im- portantly, the same argument can be used against reproductive cloning by embryo-splitting and transfer to diVerent surrogate mothers at diVerent times. To quote the report: It would be absurd to consider that an adult and his clonal duplicate who must necessarily be born much later, and is bound to have a diVerent life history, could be to any degree presented as two copies of a single and identical person. To believe such a thing would be to fall victim to the reductive illusion which is born of the dismal confusion between identity in the physical sense of sameness (idem) and in the moral sense of selfness (ipse). The report continues: [N]evertheless, although to possess the same genome in no way leads two individuals to own the same psyche, reproductive cloning would still inaugurate a fundamental upheaval of the relationship between genetic identity and personal identity in its 156 F. The uniqueness of each human being, which upholds human autonomy and dignity, is immediately expressed by the unique appearance of body and countenance which is the result of the singularity of each genome. The autonomous human being (who may be deWned as one who is ‘submitted to his or her own laws’) may allegedly be threatened in this very quality by facing his or her relatively identical clones. Can we not argue instead that the best way to counteract discrimination is to accept diVerence as a valuable addition to the rich tapestry of life rather than fear its conse- quences? Indeed if dignity has to be deWned in any essential manner, as it must be if enshrined in international declarations, it is the unique quality of all human beings, also recognized in their diVerences, even if there is a degree of sameness, which gives us dignity. This is obviously absurd, and we have therefore to conclude that even if normal sexual reproduction were a necessary condition for human liberty, it is far from being a suYcient one. It seems reasonable to suppose that the constraints im- posed by the father’s sexual identity would somehow aVect the cloned child; would this be a reduction of the child’s liberty? Ethical issues in embryo interventions and cloning 157 Perhaps feminist psychoanalytical arguments can help us understand the problem of identity – for example, the work of Julia Kristeva (1991) and Luce Irigaray (see Whitford, 1991). Kristeva argues that we cannot respect and accept strangers if we have not accepted our own portion of strangeness, in other words, the stranger within ourselves (Kristeva, 1991). The implication for cloning is that the parent(s) seeking reproductive cloning cannot accept that strangeness carried in the matrix of the gestating mother. In the same analytical vein, one could argue that the fantasy of immortality, or the desire for genetic perpetuation at any cost by those who cannot procreate, seems a more narcissistic venture than the often unconscious choice of a reproductive partner. In a similarly psychoanalytical fashion, Irigaray begins from the Lacanian account of the mirror stage in identity development, but adds a feminist twist. For men, ego formation depends on coming to see the world as a mirror, on which the male projects his own ego; women are part of the mirror, so that they never see reXections of themselves (Whitford, 1991: p. The implication for cloning, after the manner of both Kristeva and Irigaray, is that deeper psychoanalytical forces are at work in popular revulsion at the idea. Because the identity of the subject is shaky, and subjectivity itself something to be constructed rather than a given, cloning poses a threat to our personal identity which we Wnd diYcult to tolerate. Another psychoanalytical question concerns the child thus conceived, rather than the parent – how will the child cope with building his or her sexual identity? Therapeutic cloning (or other applications of cloning technology which do not involve the creation of genetically identical individuals) has led to much less dismay. The European Commission Group of Advisors on the Ethical Implications of Biotechnology (1997) report reiterates in its summary that: As far as the human applications are concerned, it distinguishes between reproductive and non-reproductive (research), and also nuclear and replacement and embryo splitting limited to the in vitro phase, i. The European report stresses that therapeutic cloning should aim either to throw light on the causes of human disease or to contribute to the alleviation of suVering.

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A comparison should also be made with previous images for any gradual degradation in uniformity purchase levitra soft 20mg overnight delivery. If a flood tank filled with water is used generic 20mg levitra soft with mastercard, protect the collimator and/or detector from possible contamination with a protective cover. Inappropriate adjustments carried out during service may affect the resolution without necessarily being apparent in the uniformity or other checks. An intrinsic resolution test with a four quadrant bar phantom can be carried out as follows: (1) Place a four quadrant bar phantom on the detector. If a computer is connected to the camera, also collect an image on the computer using at least a 256 × 256 matrix. Check for any degradation in resolution between previous images and the current image. Inappro- priate adjustment during servicing can cause excessive multiple window spatial misregistration without being apparent in the uniformity check. The procedure described below should be followed: (1) Place the four quadrant bar phantom on the detector. Both mechanical problems and drift, inappropriate adjustment of image offset, and size can cause a loss of resolution for whole body scans. The procedure described below should be followed: (1) Place the sheet source and the four quadrant bar phantom on the scanning bed such that the resolution phantom is between the sheet source and the collimator. Position the phantom so that the bars are oriented at 45º to the direction of movement, to ensure that all bars measure to some extent in the direction of the motion. There should be no appreciable loss in the resolution of the whole body image compared with the static image. However, on older systems, particularly those connected to a separate computer, pixel size can change after servicing of the gamma camera or adjustment of the computer interface and should be checked regularly if studies which rely on proper calibration of pixel size for accurate results are performed on the system. Pixel size can be calibrated with sources placed at known distances apart or with slit or grid phantoms. Interpretation is, however, subjective, since this method may not detect minor changes in resolution and only gives semi-quantitative results. A profile is generated on the computer across the image of a line source and the full width of the profile at half the maximum level is found, either by fitting a Gaussian function to the curve or by measuring the width directly from the curve using linear interpolation between the curve points. Use of multiple line sources permits estimation of pixel size in the same acquisition. Thus, a large matrix size and/or large zoom are required to achieve the small pixel size. If this pixel size is difficult to achieve, meaningful results can still be obtained by using a pixel size of around 1 mm. To achieve the required uniformity, flood correction is either applied during acquisition or post-acquisition. To allow accurate measurement and correction of non-uniformities, the variation per pixel as a result of counting statistics has to be small. Drifts in differential uniformity of more than 1% should be investigated and usually require new uniformity corrections. Uniformity corrections should not be used as a substitute for proper camera tuning and adjustment. A 57Co sheet source with guaranteed uniformity is thus preferred to a fillable flood tank. The procedure described below should be followed: 7 (1) At least 3 × 10 counts should be acquired using a 64 × 64 matrix or 1. As the camera slowly drifts over time, the correction tables have to be updated in order to apply proper correction factors during collection of the image. The exact frequency of reacquiring the correction tables depends on the stability of the camera. In general, energy and on-line uniformity corrections require more frequent updating than linearity correction tables. Energy and uniformity tables are usually obtained by operators, whereas linearity correction tables are typically found by service engineers. While energy and on-line uniformity corrections can in some instances take care of relatively large non- uniformities, these should normally be corrected by a retuning of the camera since they can affect the linearity, resolution and overall sensitivity of the camera. The procedure described below should be followed: (i) Collect correction tables (e. They contain a uniform section for detecting ring artefacts, cold spheres of varying sizes for assessing contrast, and cold and/or hot rods. Subsequent phantom studies are then performed under the same conditions and compared with the reference study to detect changes in performance. Recommended frequency of quality control tests The recommended frequency of quality control tests depends on the particular equipment available and its stability.

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