Another interesting finding is that the activity of one form of the enzyme monoamine oxidase (MAO), the function of which is to destroy amines such as serotonin in platelets, is lower during an attack of migraine than at other times. It might be thought that this lowering of MAO activity would lay the body open to amines which would then exert their noxious influence, but this is not so. However, we do not know precisely when this lowering occurs; whether it is a primary change or secondary to the headache; nor do we know what the other MAOs are doing.This yo-yo behaviour of the platelet MAO in migraine seems to be at odds with findings that people with a consistently low level of platelet MAO are at greater risk of mental illness; a measurement that is constant, highly reproducible, and probably a genetic trait.In our own studies, we found three individuals who not only had a low level of MAO during a migraine attack but also between attacks. There were no obvious psychiatric problems in any of them but, interestingly, they showed a response to tyramine similar to that found in depression. Although infusions of adrenalin and noradrenalin, as well as hard exercise, seem to increase the activity of MAO, no clear overall picture has emerged as yet.The responses to all these tests in migraine patients differ from the normal but this does not mean that migraine sufferers are inherently different from other people. It is more likely that there is a gradation from normals to headache sufferers to migraine sufferers. It is because of this lack of sharp distinction that research on migraine is so difficult.There are certain more clear-cut differences between the migraine sufferer and others. First, migraine can be inherited; second, there is an increased incidence of epilepsy in migraine sufferers, and, third, the EEG may be more often abnormal. The last two differences could be explained by repeated migraine attacks or by drugs used in treatment, and a good deal of research has been done to clarify this particular problem.
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In 1953 the world was startled to learn about Christine Jorgensen, an American ex-Marine who underwent surgery in Denmark to convert his anatomical appearance from male to female. Since then transsexualism has achieve J considerable notoriety. Jan Morris’s autobiography, Conundrum, provides some fascinating details into her own transsexual odyssey. Renee Richards, an accomplished eye doctor and tennis player as a male, provoked quite a stir when she insisted on joining the women’s pro tennis circuit as a converted female. Transsexual individuals persistently feel an incongruity between their anatomical sex and gender identity. They frequently describe their dilemma as “being trapped in the wrong body.” Their psychological sense of existence as male or female (their gender identity) does not match the appearance of their genitals and secondary sex characteristics. Looking and being biologically male, the male transsexual wishes to change to female anatomy and live as a woman. Conversely, looking and being biologically female, the female transsexual wishes to change to male anatomy and live as a man.Precise statistics on the prevalence of this gender identity variation are not available, but one estimate suggests the figure asone in 100,000 for male transsexuals and one in 130,000 forfemale transsexuals. Among persons who contact gender identity clinics and request change-of-sex surgery, there are manymore men than women. Although there has been considerable speculation about the possible cause(s) of transsexualism, there is little agreement on this matter among researchers in the field.Both biological and psychological factors have been suggested as causes.In the best defined cases of transsexualism, the person has a lifelong sense of being psychologically at odds with his or her sexual anatomy. Typically, this psychological discomfort is partially (but only temporarily) relieved by pretending to be a member of the opposite, desired sex. Many transsexuals describe having had great interest in cross-dressing (i.e., wearing clothes of the “other” sex) during childhood or adolescence. Transsexuals, however, should not be confused with transvestites, who cross-dress to become sexually aroused but usually do not want a permanent change of anatomy or appearance. In at least some cases, discovery of transsexual impulses does not occur until adulthood.Psychotherapy has been generally unsuccessful in resolving the transsexual’s basic distress of feeling trapped in the wrong body. As a result, those judged to be authentic transsexuals have been treated in programs designed to lead to change-of-sex surgery — in effect, redoing the body to match the mind. Since such surgery is irreversible, responsible practitioners take a cautious approach and require a one- to two-year trial period beyond the initial evaluation during which the transsexual patient lives in a cross-gender role. During this time, the transsexual begins living openly as a person of the opposite sex, adopting hairstyles, clothing, and mannerisms of that sex, and also assuming a name that “matches” the new gender.The transsexual male is given estrogens on a daily basis to produce a certain degree of anatomic feminization: breast growth occurs, skin texture becomes softer, and muscularity decreases, for example. However, treatment with estrogens does not remove facial or body hair (electrolysis is required) or raise voice pitch (some male-to-female transsexuals take voice lessons to learn to speak in a more feminine fashion). Estrogen therapy also reduces the frequency of erections and causes the prostate gland and seminal vesicles to shrink.Transsexual women are treated with testosterone to suppress menstruation, increase facial and body hair growth, and deepen the voice. Surgery is required to reduce breast size. For both male and female transsexuals, hormone treatments are given throughout the trial period of cross-dressing and adjusting to a new set of gender roles. At the same time, the patient’s progress is periodically evaluated by a psychiatrist or psychologist. Attention is also directed to achieving legal recognition of the sex change and to personal matters, such as family or religious counseling.If all goes fairly smoothly in the trial period and the transsexual is judged to be psychologically stable and able to adjust socially to the conversion, the final stage of treatment is surgery to change the sexual anatomy. At present, it is much simpler to perform male-to-female conversion surgery than the reverse. The male-to-female operation requires removing the penis and testes and creating an artificial vagina and female-appearing external genitals. The more difficult female-to-male procedure involves creating a “penis” from a tube made from abdominal skin or from tissue from the vaginal lips and perineum. While the artificial vagina created in the male-to-female transsexual often looks authentic and may allow a fairly full range of sexual response (e.g., vaginal lubrication and orgasm have both been claimed but not scientifically verified), female-to-male transsexual surgery creates an artificial penis that cannot become erect or feel tactile sensation.In female-to-male transsexual surgery, it is sometimes possible to attain a degree of sexual function by implanting a mechanical inflatable device inside the penis to produce an artificial erection. Experience with this method is limited at the present time, and in any event, ejaculation is not possible. Many female-to-male transsexuals choose to have hormone therapy and surgical removal of their breasts and uterus but do not opt for an artificial penis.Transsexual surgery is not a cure for this disorder but is only a procedure that may foster a sense of emotional well-being. Recently, the wisdom of surgery for transsexuals has been questioned by researchers from Johns Hopkins University who claimed to find no significant psychological benefits in patients who had undergone such operations compared to those who did not. The matter is unresolved at present, although several prominent medical centers stopped doing transsexual surgery in 1980 because of the lack of solid evidence that the surgery is beneficial.*106\342\2*

Universal precautions are a set of rules to protect health care workers from certain infectious diseases. Included among those diseases are HIV infection, hepatitis, and any other infectious disease transmitted through body fluids (blood, saliva, urine). All hospitals in the United States are required to practice universal precautions.     Though the rules of universal precaution apply to all body fluids, the major concern is for blood and bloody fluids. The rules require a barrier between the health care worker and the fluid. The barrier rule means that gloves are to be worn when obtaining blood samples or dressing wounds and the like. Goggles, face shields, or similar devices may be used during procedures (like childbirth) that may result in splattering of blood. Hospital gowns must be worn when clothes might be soiled. For such day-today care as taking temperatures and blood pressure, no gloves or other barriers need be used.     It should be emphasized that universal precautions are universal. They apply to all people participating in the care of any patient in the hospital. There are no precautions that are special to people with HIV infection. Exceptions are the opportunistic infections—like salmonella, tuberculosis, and shingles—that pose a threat to health care workers. But these infections require the same precautions regardless of HIV status.*168\191\2*