Better together: Addressing maternal and child health outcomes through community health worker continuing education curricula

Background. The incidence of birth defects is a significant public health issue in the United States, adversely affecting the quality of life for parents as well as children born with these defects. Minority populations face a greater burden of birth defects and associated health problems. Prenatal practices can have a large impact on infant health outcomes. Several behaviors during pregnancy, including the intake of folic acid, can greatly influence the likelihood of a child being born with a birth defect. Community Health Workers have been shown to be effective agents at improving prenatal practices, especially when they facilitate support groups that feature pregnant women. ^ Methods. A continuing education curriculum has been created for Community Health Workers that provides content in the area of Maternal and Child Health. Content was selected after conducting a review of relevant literature and theory. Materials for conducting a training for Community Health Workers have been created in addition to materials that were designed for the population with whom the CHWs work. ^ Results. A description of each "key point" of the curriculum and a justification how it relates to the literature of the prevention of birth defects is given here. Additionally, the process of creating the curriculum using the platform delineated in the methods is described. ^ Discussion. Insights for future curriculum development are discussed along with next steps in the process of certifying the curriculum at the state level. A framework for future evaluation of the curriculum is given.^

Health outcomes, quality improvement and cost-effectiveness of the Community Diabetes Education (CoDE) program: Results of a randomized controlled trial

The objectives of this dissertation were to evaluate health outcomes, quality improvement measures, and the long-term cost-effectiveness and impact on diabetes-related microvascular and macrovascular complications of a community health worker-led culturally tailored diabetes education and management intervention provided to uninsured Mexican Americans in an urban faith-based clinic. A prospective, randomized controlled repeated measures design was employed to compare the intervention effects between: (1) an intervention group (n=90) that participated in the Community Diabetes Education (CoDE) program along with usual medical care; and (2) a wait-listed comparison group (n=90) that received only usual medical care. Changes in hemoglobin A1c (HbA1c) and secondary outcomes (lipid status, blood pressure and body mass index) were assessed using linear mixed-models and an intention-to-treat approach. The CoDE group experienced greater reduction in HbA1c (-1.6%, p<.001) than the control group (-.9%, p<.001) over the 12 month study period. After adjusting for group-by-time interaction, antidiabetic medication use at baseline, changes made to the antidiabetic regime over the study period, duration of diabetes and baseline HbA1c, a statistically significant intervention effect on HbA1c (-.7%, p=.02) was observed for CoDE participants. Process and outcome quality measures were evaluated using multiple mixed-effects logistic regression models. Assessment of quality indicators revealed that the CoDE intervention group was significantly more likely to have received a dilated retinal examination than the control group, and 53% achieved a HbA1c below 7% compared with 38% of control group subjects. Long-term cost-effectiveness and impact on diabetes-related health outcomes were estimated through simulation modeling using the rigorously validated Archimedes Model. Over a 20 year time horizon, CoDE participants were forecasted to have less proliferative diabetic retinopathy, fewer foot ulcers, and reduced numbers of foot amputations than control group subjects who received usual medical care. An incremental cost-effectiveness ratio of $355 per quality-adjusted life-year gained was estimated for CoDE intervention participants over the same time period. The results from the three areas of program evaluation: impact on short-term health outcomes, quantification of improvement in quality of diabetes care, and projection of long-term cost-effectiveness and impact on diabetes-related health outcomes provide evidence that a community health worker can be a valuable resource to reduce diabetes disparities for uninsured Mexican Americans. This evidence supports formal integration of community health workers as members of the diabetes care team.^

Improving disclosure of medical errors: Including patients and family members in the disclosure process

Over the last decade, adverse events and medical errors have become a main focus of interest for the standards of quality and safety in the U.S. healthcare system (Weinstein & Henderson, 2009). Particularly when a medical error occurs, the disclosure of medical errors and its practices have become a focal point of the healthcare process. Patients and family members who have experienced a medical error might be able to provide knowledge and insight on how to improve the disclose process. However, patient and family member are not typically involved in the disclosure process, thus their experiences go unnoticed. ^ The purpose of this research was to explore how best to include patients and family members in the disclosure process regarding a medical error. The research consisted of 28 qualitative interviews from three stakeholder groups: Hospital Administrators, Clinical Service Providers, and Patients and Family Members. They were asked for their ideas and suggestions on how best to include patients and family members in the disclosure process. Framework Analysis was used to analyze this data and find prevalent themes based on the primary research question. A secondary aim was to index categories created based on the interviews that were collected. Data was used from the Texas Disclosure and Compensation Study with Dr. Eric Thomas as the Principal Investigator. Full acknowledgement of access to this data is given to Dr. Thomas. ^ The themes from the research revealed that each stakeholder group was interested and open to including patients and family members in the disclosure process and that the disclosure process should not be a "one-way" avenue. The themes gave many suggestions regarding how to best include patients and family members in the disclosure process of a medical error. Secondary aims revealed several ways to assess the ideas and suggestion given by the stakeholders. Overall, acceptability of getting the perspective of patients and family members was the most common theme. Comparison of each stakeholder group revealed that including patients and family members would be beneficial to improving hospital disclosure practices. ^ Conclusions included a list of recommendations and measureable appropriate strategies that could provide hospital with key stakeholders insights on how to improve their disclosure process. Sharing patients and family members experience with healthcare providers can encourage a shift in culture where patients are valued and active in participating in hospital practices. To my knowledge, this research is the very first of its kind and moves the disclosure process conversation forward in a patient-family member inclusion direction that will assist in improving disclosure practices. Future research should implement and evaluate the success of the various inclusion strategies.^

An analysis of the revenue policy -making process of the Texas Legislature

The purpose of this dissertation was to develop a conceptual framework which can be used to account for policy decisions made by the House Ways and Means Committee (HW&MC) of the Texas House of Representatives. This analysis will examine the actions of the committee over a ten-year period with the goal of explaining and predicting the success of failure of certain efforts to raise revenue.^ The basis framework for modelling the revenue decision-making process includes three major components--the decision alternatives, the external factors and two competing contingency theories. The decision alternatives encompass the particular options available to increase tax revenue. The options were classified as non-innovative or innovative. The non-innovative options included the sales, franchise, property and severance taxes. The innovative options were principally the personal and corporate income taxes.^ The external factors included political and economic constraints that affected the actions of the HW&MC. Several key political constraints on committee decision-making were addressed--including public attitudes, interest groups, political party strength and tradition and precedents. The economic constraints that affected revenue decisions included court mandates, federal mandates and the fiscal condition of the nation and the state.^ The third component of the revenue decision-making framework included two alternative contingency theories. The first alternative theory postulated that the committee structure, including the individual member roles and the overall committee style, resulted in distinctive revenue decisions. This theory will be favored if evidence points to the committee acting autonomously with less concern for the policies of the Speaker of the House. The Speaker assignment theory, postulated that the assignment of committee members shaped or changed the course of committee decision-making. This theory will be favored if there was evidence that the committee was strictly a vehicle for the Speaker to institute his preferred tax policies.^ The ultimate goal of this analysis is to develop an explanation for legislative decision-making about tax policy. This explanation will be based on the linkages across various tax options, political and economic constraints, member roles and committee style and the patterns of committee assignment. ^

Health and safety in the construction : subject pending to be included in the curriculum of architecture in Spain

The art of construction is a risky activity that directly affects the life and physical integrity of persons. Since the approval of Law 31/1995, of November 8, Prevention of Occupational Risks was the first legislation that established the current basis in all sectors and then transposed into Spanish law Directive 92/57/CEE called Royal Decree 1627/1997 of October 24, on minimum safety and health dispositions in construction works, measures have been proposed to develop a mixed body of scientific literature composed of researchers and professionals in the field of occupational safety and health, but even today there is still no clear and firm proposal, showing a lack of awareness in the occupational risk prevention and, therefore, a consolidation of the culture of prevention in society. Therefore, the technicians, who make up the building process, can incur in very high responsibilities, such as: Author of the project, Coordinator of Safety and Health during the preparation of the project and during the execution of works, Site Management: Site Manager. This involves the immediate creation of a general training in prevention for all architects starting when still studying, as well as specific training, appropriate and complementary to all the architects that will be devoted to the specialty of occupational safety and health in construction works. That is, first, we must make the responsible bodies aware of the urgent need to integrate risk prevention in the curricula of architecture and later in the continuing education of the profession. It is necessary that our teaching must conform to the laws on safety and health, due to the fact that the law recognizes our academic degrees and professional qualifications to perform functions in that area

A proposal for improving safety in construction projects by strengthening coordinators’ competencies in health and safety issues

The figure of the coordinator in health and safety issues in the construction sector first appeared in our legislation through the incorporation of the European Directives (in our case Royal Decree 1627/97 on the minimum health and safety regulations in construction works), and is viewed differently in different countries of the European Union regarding the way they are hired and their role in the construction industry. Coordinating health and safety issues is also a management process that requires certain competencies that are not only based on technical or professional training, but which, taking account of the work environment, require the use of strategies and tools that are related to experience and personal skills. Through a piece of research that took account of expert opinions in the matter, we have found which competencies need to be possessed by the health and safety coordinator in order to improve the safety in the works they are coordinating. The conclusions of the analyses performed using the appropriate statistical methods (comparing means and multivariate analysis techniques), will enable training programmes to be designed and ensure that the health and safety coordinators selected have the competencies required to carry out their duties.

A proposal for improving safety in construction projects by strengthening coordinators’ competencies in health and safety issues

The figure of the coordinator in health and safety issues in the construction sector first appeared in our legislation through the incorporation of the European Directives (in our case Royal Decree 1627/97 on the minimum health and safety regulations in construction works), and is viewed differently in different countries of the European Union regarding the way they are hired and their role in the construction industry. Coordinating health and safety issues is also a management process that requires certain competencies that are not only based on technical or professional training, but which, taking account of the work environment, require the use of strategies and tools that are related to experience and personal skills. Through a piece of research that took account of expert opinions in the matter, we have found which competencies need to be possessed by the health and safety coordinator in order to improve the safety in the works they are coordinating. The conclusions of the analyses performed using the appropriate statistical methods (comparing means and multivariate analysis techniques), will enable training programmes to be designed and ensure that the health and safety coordinators selected have the competencies required to carry out their duties.

AFRICA BUILD Portal: developing a social network of African health researchers and educators

One of the main outputs of the project is a collaborative platform which integrates a myriad of research and learning resources. This article presents the first prototype of this platform: the AFRICA BUILD Portal (ABP 1.0). The ABP is a Web 2.0 platform which facilitates the access, in a collaborative manner, to these resources. Through a usable web interface, the ABP has been designed to avoid, as much as possible, the connectivity problems of African institutions. In this paper, we suggest that the access to complex systems does not imply slow response rates, and that their development model guides the project to a natural technological transfer, adaptation and user acceptance. Finally, this platform aims to motivate research attitudes during the learning process and stimulate user?s collaborations.

Health monitoring of web plastifying dampers subjected to cyclic loading through vibration tests

This article investigates experimentally the application of health monitoring techniques to assess the damage on a particular kind of hysteretic (metallic) damper called web plastifying dampers, which are subjected to cyclic loading. In general terms, hysteretic dampers are increasingly used as passive control systems in advanced earthquake-resistant structures. Nonparametric statistical processing of the signals obtained from simple vibration tests of the web plastifying damper is used here to propose an area index damage. This area index damage is compared with an alternative energy-based index of damage proposed in past research that is based on the decomposition of the load?displacement curve experienced by the damper. Index of damage has been proven to accurately predict the level of damage and the proximity to failure of web plastifying damper, but obtaining the load?displacement curve for its direct calculation requires the use of costly instrumentation. For this reason, the aim of this study is to estimate index of damage indirectly from simple vibration tests, calling for much simpler and cheaper instrumentation, through an auxiliary index called area index damage. Web plastifying damper is a particular type of hysteretic damper that uses the out-of-plane plastic deformation of the web of I-section steel segments as a source of energy dissipation. Four I-section steel segments with similar geometry were subjected to the same pattern of cyclic loading, and the damage was evaluated with the index of damage and area index damage indexes at several stages of the loading process. A good correlation was found between area index damage and index of damage. Based on this correlation, simple formulae are proposed to estimate index of damage from the area index damage.

Application of PZT and FBG impedance sensors for structural health monitoring of reinforced concrete beams strengthened with FRP composite materials

Esta Tesis tiene como objetivo principal el desarrollo de métodos de identificación del daño que sean robustos y fiables, enfocados a sistemas estructurales experimentales, fundamentalmente a las estructuras de hormigón armado reforzadas externamente con bandas fibras de polímeros reforzados (FRP). El modo de fallo de este tipo de sistema estructural es crítico, pues generalmente es debido a un despegue repentino y frágil de la banda del refuerzo FRP originado en grietas intermedias causadas por la flexión. La detección de este despegue en su fase inicial es fundamental para prevenir fallos futuros, que pueden ser catastróficos. Inicialmente, se lleva a cabo una revisión del método de la Impedancia Electro-Mecánica (EMI), de cara a exponer sus capacidades para la detección de daño. Una vez la tecnología apropiada es seleccionada, lo que incluye un analizador de impedancias así como novedosos sensores PZT para monitorización inteligente, se ha diseñado un procedimiento automático basado en los registros de impedancias de distintas estructuras de laboratorio. Basándonos en el hecho de que las mediciones de impedancias son posibles gracias a una colocación adecuada de una red de sensores PZT, la estimación de la presencia de daño se realiza analizando los resultados de distintos indicadores de daño obtenidos de la literatura. Para que este proceso sea automático y que no sean necesarios conocimientos previos sobre el método EMI para realizar un experimento, se ha diseñado e implementado un Interfaz Gráfico de Usuario, transformando la medición de impedancias en un proceso fácil e intuitivo. Se evalúa entonces el daño a través de los correspondientes índices de daño, intentando estimar no sólo su severidad, sino también su localización aproximada. El desarrollo de estos experimentos en cualquier estructura genera grandes cantidades de datos que han de ser procesados, y algunas veces los índices de daño no son suficientes para una evaluación completa de la integridad de una estructura. En la mayoría de los casos se pueden encontrar patrones de daño en los datos, pero no se tiene información a priori del estado de la estructura. En este punto, se ha hecho una importante investigación en técnicas de reconocimiento de patrones particularmente en aprendizaje no supervisado, encontrando aplicaciones interesantes en el campo de la medicina. De ahí surge una idea creativa e innovadora: detectar y seguir la evolución del daño en distintas estructuras como si se tratase de un cáncer propagándose por el cuerpo humano. En ese sentido, las lecturas de impedancias se emplean como información intrínseca de la salud de la propia estructura, de forma que se pueden aplicar las mismas técnicas que las empleadas en la investigación del cáncer. En este caso, se ha aplicado un algoritmo de clasificación jerárquica dado que ilustra además la clasificación de los datos de forma gráfica, incluyendo información cualitativa y cuantitativa sobre el daño. Se ha investigado la efectividad de este procedimiento a través de tres estructuras de laboratorio, como son una viga de aluminio, una unión atornillada de aluminio y un bloque de hormigón reforzado con FRP. La primera ayuda a mostrar la efectividad del método en sencillos escenarios de daño simple y múltiple, de forma que las conclusiones extraídas se aplican sobre los otros dos, diseñados para simular condiciones de despegue en distintas estructuras. Demostrada la efectividad del método de clasificación jerárquica de lecturas de impedancias, se aplica el procedimiento sobre las estructuras de hormigón armado reforzadas con bandas de FRP objeto de esta tesis, detectando y clasificando cada estado de daño. Finalmente, y como alternativa al anterior procedimiento, se propone un método para la monitorización continua de la interfase FRP-Hormigón, a través de una red de sensores FBG permanentemente instalados en dicha interfase. De esta forma, se obtienen medidas de deformación de la interfase en condiciones de carga continua, para ser implementadas en un modelo de optimización multiobjetivo, cuya solución se haya por medio de una expansión multiobjetivo del método Particle Swarm Optimization (PSO). La fiabilidad de este último método de detección se investiga a través de sendos ejemplos tanto numéricos como experimentales. ABSTRACT This thesis aims to develop robust and reliable damage identification methods focused on experimental structural systems, in particular Reinforced Concrete (RC) structures externally strengthened with Fiber Reinforced Polymers (FRP) strips. The failure mode of this type of structural system is critical, since it is usually due to sudden and brittle debonding of the FRP reinforcement originating from intermediate flexural cracks. Detection of the debonding in its initial stage is essential thus to prevent future failure, which might be catastrophic. Initially, a revision of the Electro-Mechanical Impedance (EMI) method is carried out, in order to expose its capabilities for local damage detection. Once the appropriate technology is selected, which includes impedance analyzer as well as novel PZT sensors for smart monitoring, an automated procedure has been design based on the impedance signatures of several lab-scale structures. On the basis that capturing impedance measurements is possible thanks to an adequately deployed PZT sensor network, the estimation of damage presence is done by analyzing the results of different damage indices obtained from the literature. In order to make this process automatic so that it is not necessary a priori knowledge of the EMI method to carry out an experimental test, a Graphical User Interface has been designed, turning the impedance measurements into an easy and intuitive procedure. Damage is then assessed through the analysis of the corresponding damage indices, trying to estimate not only the damage severity, but also its approximate location. The development of these tests on any kind of structure generates large amounts of data to be processed, and sometimes the information provided by damage indices is not enough to achieve a complete analysis of the structural health condition. In most of the cases, some damage patterns can be found in the data, but none a priori knowledge of the health condition is given for any structure. At this point, an important research on pattern recognition techniques has been carried out, particularly on unsupervised learning techniques, finding interesting applications in the medicine field. From this investigation, a creative and innovative idea arose: to detect and track the evolution of damage in different structures, as if it were a cancer propagating through a human body. In that sense, the impedance signatures are used to give intrinsic information of the health condition of the structure, so that the same clustering algorithms applied in the cancer research can be applied to the problem addressed in this dissertation. Hierarchical clustering is then applied since it also provides a graphical display of the clustered data, including quantitative and qualitative information about damage. The performance of this approach is firstly investigated using three lab-scale structures, such as a simple aluminium beam, a bolt-jointed aluminium beam and an FRP-strengthened concrete specimen. The first one shows the performance of the method on simple single and multiple damage scenarios, so that the first conclusions can be extracted and applied to the other two experimental tests, which are designed to simulate a debonding condition on different structures. Once the performance of the impedance-based hierarchical clustering method is proven to be successful, it is then applied to the structural system studied in this dissertation, the RC structures externally strengthened with FRP strips, where the debonding failure in the interface between the FRP and the concrete is successfully detected and classified, proving thus the feasibility of this method. Finally, as an alternative to the previous approach, a continuous monitoring procedure of the FRP-Concrete interface is proposed, based on an FBGsensors Network permanently deployed within that interface. In this way, strain measurements can be obtained under controlled loading conditions, and then they are used in order to implement a multi-objective model updating method solved by a multi-objective expansion of the Particle Swarm Optimization (PSO) method. The feasibility of this last proposal is investigated and successfully proven on both numerical and experimental RC beams strengthened with FRP.

Systematic Process for Building a Fault Diagnoser Based on Petri Nets Applied to a Helicopter

This work presents a systematic process for building a Fault Diagnoser (FD), based on Petri Nets (PNs) which has been applied to a small helicopter. This novel tool is able to detect both intermittent and permanent faults. The work carried out is discussed from theoretical and practical point of view. The procedure begins with a division of the whole system into subsystems, which are the devices that have to be modeled by using PN, considering both the normal and fault operations. Subsequently, the models are integrated into a global Petri Net diagnoser (PND) that is able to monitor a whole helicopter and show critical variables to the operator in order to determine the UAV health, preventing accidents in this manner. A Data Acquisition System (DAQ) has been designed for collecting data during the flights and feeding PN diagnoser with them. Several real flights (nominal or under failure) have been carried out to perform the diagnoser setup and verify its performance. A summary of the validation results obtained during real flight tests is also included. An extensive use of this tool will improve preventive maintenance protocols for UAVs (especially helicopters) and allow establishing recommendations in regulations

Raising the bar: the importance of hospital library standards in the continuing medical education accreditation process*

The Connecticut State Medical Society (CSMS) reviews and accredits the continuing medical education (CME) programs offered by Connecticut's hospitals. As part of the survey process, the CSMS assesses the quality of the hospitals' libraries. In 1987, the CSMS adopted the Medical Library Association's (MLA's) “Minimum Standards for Health Sciences Libraries in Hospitals.” In 1990, professional librarians were added to the survey team and, later, to the CSMS CME Committee. Librarians participating in this effort are recruited from the membership of the Connecticut Association of Health Sciences Librarians (CAHSL). The positive results of having a qualified librarian on the survey team and the invaluable impact of adherence to the MLA standards are outlined. As a direct result of this process, hospitals throughout the state have added staffing, increased space, and added funding for resources during an era of cutbacks. Some hospital libraries have been able to maintain a healthy status quo, while others have had proposed cuts reconsidered by administrators for fear of losing valuable CME accreditation status. Creating a relationship with an accrediting agency is one method by which hospital librarians elsewhere may strengthen their efforts to ensure adequate library resources in an era of downsizing. In addition, this collaboration has provided a new and important role for librarians to play on an accreditation team.

Creating local bibliographic databases: new tools for evidence-based health care*

The Internet has created new opportunities for librarians to present literature search results to clinicians. In order to take full advantage of these opportunities, libraries need to create locally maintained bibliographic databases. A simple method of creating a local bibliographic database and publishing it on the Web is described. The method uses off-the-shelf software and requires minimal programming. A hedge search strategy for outcome studies of clinical process interventions is created, and Ovid is used to search MEDLINE. The search results are saved and imported into EndNote libraries. The citations are modified, exported to a Microsoft Access database, and published on the Web. Clinicians can use a Web browser to search the database. The bibliographic database contains 13,803 MEDLINE citations of outcome studies. Most searches take between four and ten seconds and retrieve between ten and 100 citations. The entire cost of the software is under $900. Locally maintained bibliographic databases can be created easily and inexpensively. They significantly extend the evidence-based health care services that libraries can offer to clinicians.

Infrared microspectroscopy of inflammatory process and colon tumors.

According to the last global burden of disease published by the World Health Organization, tumors were the third leading cause of death worldwide in 2004. Among the different types of tumors, colorectal cancer ranks as the fourth most lethal. To date, tumor diagnosis is based mainly on the identification of morphological changes in tissues. Considering that these changes appears after many biochemical reactions, the development of vibrational techniques may contribute to the early detection of tumors, since they are able to detect such reactions. The present study aimed to develop a methodology based on infrared microspectroscopy to characterize colon samples, providing complementary information to the pathologist and facilitating the early diagnosis of tumors. The study groups were composed by human colon samples obtained from paraffin-embedded biopsies. The groups are divided in normal (n=20), inflammation (n=17) and tumor (n=18). Two adjacent slices were acquired from each block. The first one was subjected to chemical dewaxing and H&E staining. The infrared imaging was performed on the second slice, which was not dewaxed or stained. A computational preprocessing methodology was employed to identify the paraffin in the images and to perform spectral baseline correction. Such methodology was adapted to include two types of spectral quality control. Afterwards the preprocessing step, spectra belonging to the same image were analyzed and grouped according to their biochemical similarities. One pathologist associated each obtained group with some histological structure based on the H&E stained slice. Such analysis highlighted the biochemical differences between the three studied groups. Results showed that severe inflammation presents biochemical features similar to the tumors ones, indicating that tumors can develop from inflammatory process. A spectral database was constructed containing the biochemical information identified in the previous step. Spectra obtained from new samples were confronted with the database information, leading to their classification into one of the three groups: normal, inflammation or tumor. Internal and external validation were performed based on the classification sensitivity, specificity and accuracy. Comparison between the classification results and H&E stained sections revealed some discrepancies. Some regions histologically normal were identified as inflammation by the classification algorithm. Similarly, some regions presenting inflammatory lesions in the stained section were classified into the tumor group. Such differences were considered as misclassification, but they may actually evidence that biochemical changes are in course in the analyzed sample. In the latter case, the method developed throughout this thesis would have proved able to identify early stages of inflammatory and tumor lesions. It is necessary to perform additional experiments to elucidate this discrepancy between the classification results and the morphological features. One solution would be the use of immunohistochemistry techniques with specific markers for tumor and inflammation. Another option includes the recovering of the medical records of patients who participated in this study in order to check, in later times to the biopsy collection, whether they actually developed the lesions supposedly detected in this research.

Transgender Group Therapy: Process and Issues with Male to Female Clients

Transgender issues are garnering more attention within the mental health field. With the increased social awareness of transgender issues, the mental health field is recognizing the need for effective psychological services for this population. Transgender individuals face unique challenges related to gender non-conformity, the coming-out and transitioning processes, and in society at large, all of which can lead to a number mental health concerns. Group therapy is a promising treatment modality for transgender individuals. The purpose of this paper is to offer a rationale for the effectiveness of group therapy, and recommendations for best practices utilizing the current literature and my experience with facilitating a Male to Female transgender therapy group.