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How to minimize cross-border clinical trial mishaps? Conflicts of interest abound. Isn't an international forum the obvious answer? No, for the simple reason that international guidelines have existed for more than 50 years yet they haven't prevented clinical trial mishaps.In 1963 the World Medical Association (WMA) created and endorsed the Declaration of Helsinki (DoH). Purpose of the DoH is to guide the proper ethical conduct of human clinical trials, and to prevent clinical trial mishaps.Has the DoH prevented clinical trial mishaps? Obviously not if one goes by the high profile Phase 4* HPV (Human Papilloma Virus) Vaccine trial in India, a multinational endeavor stopped in 2010 by the Government of India, leading to an Indian Parliamentary inquiry as well as an ongoing PIL (Public Interest Litigation) at the Indian Supreme Court. Let's examine these issues in sequence and see where that leads us.First, let's examine the DoH, the WMA's explicitly drafted recommendations for the proper conduct of human clinical trials.Next, let's examine examine the history of informed consent, particularly how it came into existence. This history teaches us that informed consent can either promote or prevent clinical trial mishaps. Promote mishaps when trial administrators and funders pay lip service to it (tokenism) and aren't held accountable. Prevent them when used sincerely to promote and preserve patient autonomy.Since existing structures appear inadequate to the task, is there another way to prevent or minimize clinical trial mishaps? Yes, public pressure for stricter implementation of existing country-specific laws. Where existing country-specific laws prove inadequate, the citizenry need to push their government to enact clearer and more comprehensive laws. Two compelling reasons for this. For one, citizens of one country are unlikely to be as motivated in seeing justice done for clinical trial mishaps that happen in another country. For another, isn't it morale-boosting and integral to a citizen's identity to hold their government accountable rather than have some foreign entity step in and do so on their behalf? In fact, isn't the alternative shameful? Here, the history of the use of informed consent is a poignant guide, teaching us that the central problem is not absence of adequate laws but rather lack of accountability in the existing system.* A Phase 4 trial is a post-approval surveillance trial where effects are monitored on thousands of people to uncover unforeseen side-effects.The Declaration of Helsinki (DoH)The DoH was the WMA's declaration of ethical principles for medical research involving human subjects.From 1963 till 2013 it has undergone 7 revisions.The history of the DoH is pockmarked with controversy.For example, the 5th revision in 2000 was approved without consensus from national medical associations in the aftermath of the controversial sub-Saharan nevirapine studies on vertical HIV transmission. These studies revealed a blatant double standard in human clinical trial practice. A 1994 US study (1) showed that Zidovudine (AZT) given intravenously prenatally, during delivery and postpartum reduced perinatal (vertical) HIV transmission by ~2/3rds. It then became the standard of care in developed countries. However, when it came time to test whether the 2nd generation drug nevirapine could also minimize or prevent vertical transmission in the high-risk but much poorer sub-Saharan populations, the 1st world trial sponsors chose to give a single nevirapine dose to pregnant women during labor and once to their infants within 72 hours of birth (2). This when it was already known 'at the time that single-dose nevirapine would not be as effective as more comprehensive and much more expensive treatment regimens that also targeted transmission during pregnancy (3). Rationale of the trial sponsors? The needed infrastructure, comprehensive perinatal care and drug cost couldn't be adequately provisioned at the trial site. In other words, in a tussle between money and ethics, money won.The 7th revision of the DoH, adopted in October 2013 at the 64th WMA General Assembly in Fortaleza, Brazil, also has its share of controversy. In particular, it says 'placebos, no intervention or any intervention less effective than the best proven one may be used only when the patients who receive them will not be subject to additional risks of serious or irreversible harm as a result of not receiving the best proven intervention' (4). In response, the Latin American and Caribbean Medical Confederations refused to approve this wording of placebo use stating, 'the poor and vulnerable populations, discriminated by their lack of resources, cannot be subjected to biomedical research that have levels of safety less than those applied to more developed societies' (5, 6).Another ambiguity of the 7th DoH revision is 'risk of serious or irreversible harm'. Which is it, not treating a simple skin cut or not treating an HIV positive pregnant woman? After all, don't we live with a vast, unbridgeable chasm in health care access between the haves and have-nots so much so that even a simple skin cut could be construed as 'risk of serious or irreversible harm' in the 1st world even as an HIV positive pregnant woman is left untreated in the 3rd world?What is informed consent and why is it essential in human clinical trials?Informed consent stems from the need for patient autonomy.In a clinical trial, patient autonomy is the basic human right of a trial participant to not be subjected to medical research abuse.The egregious Nazi regime medical experiments on concentration camp inmates drove the need to prevent future outright medical research abuse so in 1947 the Nuremberg Code (Nuremberg Code) was created, i.e. research ethics guidelines for human experimentation.Article 1 of the Nuremberg Code explicitly identifies the need for consent, 'The duty and responsibility for ascertaining the quality of the consent rests upon each individual who initiates, directs or engages in the experiment. It is a personal duty and responsibility which may not be delegated to another with impunity' (See page 182 of 7).Did the 1947 Nuremberg Code prevent ongoing and future medical abuse?Obviously not since the Tuskegee syphilis experiment ran uninterrupted in the USA from 1932 until 1972. In this study, African-Americans diagnosed with syphilis were left untreated because the physicians wanted to follow the natural disease progression. This is a painfully compelling example that an international code alone is insufficient in and of itself in preventing future or ongoing outright medical practice abuse, let alone clinical trial mishap.Something more than an international agreement is needed to prevent medical research abuse of human trial participants. History teaches that this something more is lawsuits. In particular, today's informed consent is the legacy of two key US medical malpractice lawsuits.How did informed consent come into existence in human clinical trials? The two landmark US lawsuits that helped create it.The 1st lawsuitThe judge in the first case, Salgo v. Leland Stanford, Jr. University Board of Trustees (1957), coined the phrase 'informed consent' in his jury instruction.The plaintiff Mr. Salgo's now defunct treatment entailed 'puncturing the aorta through the back in order to inject a radio-opaque dye, and was left with permanent paralysis of the legs. According to the direction given to the jury: “The physician has . . . discretion [to withhold alarming information from the patient] consistent, of course, with the full disclosure of facts necessary to an informed consent” ([1957] 317 P.2d 170 (Cal. Ct. App.) at 181)' (8).'discretion to withhold alarming information' and 'full disclosure of facts necessary to an informed consent' are obviously contradictory in nature. Regardless, this was the first instance requiring that disclosure to patients needed to conform to 'professional practice standard', i.e. what is expected from a reasonable health-care practitioner (8).The 2nd lawsuitIn the second US case, Canterbury v. Spence ([1972] 464 F.2d 772 (D.C. Cir.), the patient fell out of his hospital bed after undergoing a spinal procedure and suffered major paralysis.Since the patient had not been warned about 'the possibility of this rare outcome', the 'professional practice standard' was deemed inadequate by failing to respect the patient's self-determination.Instead it gave way to the patient-centered 'reasonable person standard', i.e. what a reasonable patient considers necessary and sufficient to know rather than what health-care practitioners consider necessary to disclose (9).According to the philosopher Peter Singer and his colleague Helga Kuhse, 'this single move served to overcome three main weaknesses of the professional practice standard: first, that agreed professional standards of disclosure were typically set too low to satisfy patient demand for information; second, that there were no agreed standards for new procedures; and, third, that patients were put at a significant disadvantage in having to rely upon expert witnesses (usually other health-care practitioners) in disputes about standards of care' (8).With a 'reasonable person standard', health-care providers have to disclose to patients or clinical trial participants the four elements necessary for informed patient consent: the nature (therapeutic/not), risks, alternatives and benefits of the procedure and/or treatment. When the patients or clinical trial participants are below the age of consent, the disclosure is given to and consent sought from the parents or legal caregivers.A recent human clinical trial mishap: Phase 4 HPV (Human Papilloma Virus) Vaccine study in IndiaTo generate data to support inclusion of HPV vaccine in India's UIP (Universal Immunization Programme).Actual vaccinations started in 2009 in the Indian states of Andhra Pradesh and Gujarat.Girls aged 10 to 14 years of age, i.e. dependents so consent presumably sought and obtained from parents/caregivers.Two-component trial: Phase 4* HPV vaccine clinical trial and observational research on vaccine delivery.Designed and executed by PATH (Program for Appropriate Technology in Health), a US-based NGO, in collaboration with the ICMR (Indian Council of Medical Research) and the State Governments of Andhra Pradesh and Gujarat.The vaccines: Merck's Gardasil and GlaxoSmithKilne's Cervarix.Funded by the Bill and Melinda Gates Foundation.Trial suspended by the Government of India in April 2010.After the reported post-vaccination deaths of 7 girls in the two states, the Indian Parliament's Standing Committee on Health investigated this study, and released its report in August, 2013 (10).Salient problems identified by the Committee (page 11 of the Committee report, see reference 10):'6.14 The Inquiry Committee, while going through the above report, noticed the following irregularities and discrepancies in the study:The warden/teachers/headmasters were not given written permission by the parents/guardians to sign on behalf of their girls.On many forms witness had not signed and of the forms which are signed, it is not clear whether they are signed by full time government employees, as per rules.Neither the photograph nor the photo ID card of parents/guardians/wardens is pasted in consent form.On many forms investigator has not signed.On some forms signature of parents/guardians is not matching with their names.The date of vaccination is much earlier than the date of signature of parents/guardian in the consent forms. Apparently they were obtained post-facto.In some forms, the name is of the father but signature is of probably mother (lady’s name).'Salient conclusions of the report (pages 14-15 of the Committee report, see reference 10):'(i) Irregularities in obtaining consent forms and actual implementation of the consent process;(ii) Lack of monitoring and preparedness to deal with serious adverse events;(iii) Inclusion of vulnerable and tribal population groups;(iv) Blurring of distinction between Universal Immunization Programme and PATH study;(v) Absence of insurance coverage for the study participants; and(vi) Inclusion of the statement in the consent form that “you will not be charged for your daughter to receive the vaccine” that could be construed as covert inducement.'News reports (11, 12, 13, 14, 15, 16, 17, 18) and sponsor comments (19, 20) about this trial.So whether or not the girls' deaths were attributable to the HPV vaccine, the resulting investigation revealed a thoroughly messed up informed consent process and seriously inadequate process for reporting adverse events. But wait a minute? Isn't all this thoroughly covered by the overarching DoH? Let's examine the relevant DoH provisions to make sure.In any case, so far the government actions have resulted in predictable shake-ups, committees, new procedures, even though existing procedures appear to be adequate on paper.What about accountability? Who is responsible? When human clinical trials are outsourced and off-shored, who bears responsibility for adverse events, especially for seemingly unanticipated adverse events, as happened in this Phase 4 Indian HPV vaccine trial? Let's examine a relevant landmark and precedent-setting judgment (18).In 2012, a judge in Argentina upheld fines against GlaxoSmithKline, the sponsor of an Argentinian clinical trial testing the safety of the vaccine Synflorix against pneumococcal disease in children.Issues of informed consent?In some instances, consent was given by parents who were minors themselves.Grandparents who were not authorized to give consent for their grandchildren.A child vaccinated even after mother explicitly refused her consent.Signatures on consent forms not matching those of the individuals giving consent.GlaxoSmithKline appealed the fine using the defense that alleged errors and poor documentation in the informed consent process were a mere formality that didn't pose actual risks to trial participants.The judge rejected this defense and upheld the fine, against both the investigators and the sponsor.His rationale? Even minor deficiencies in trial procedure could later become relevant since adverse health effects might appear only in the future.This precedent-setting judgment bestows supervisory duty on the trial sponsor regarding informed consent. It also paves the way for hope. For example, the Indian Supreme Court is well-known to be highly responsive to PILs, using them as tools to demand improvements in state laws and regulations (Public interest litigation in India). Currently, it's considering one such PIL with respect to the Phase 4 HPV trial (18). In India, PILs arise when the State is perceived to have violated constitutional and/or statutory provisions, and they have served as indispensable bulwark protecting essential rights of Indian citizens.Further, since this case involved US and UK trial sponsors and manufacturing companies, this PIL includes an amicus brief (21) submitted by the European Center for Constitutional and Human Rights 'outlining the legal framework on clinical trials in the respective home countries' (18), in order to cover obvious gaps in judicial precedents.Finally, and more importantly, in our globalized age of cross-border, outsourced and off-shored clinical trials, an obvious and perhaps steep learning curve lies ahead for all entities involved in them, namely, government regulatory bodies, sponsors, investigators and other health-care staff. Especially these latter need to be rigorously trained in the ethical and legal aspects of human clinical trials. It then becomes a natural and necessary mandate for each and every national medical association and department of health to help ensure that such training becomes part and parcel of each country's health care practice (22), i.e. that it no longer remains the select purview of developed countries' health care infrastructure. Now, wouldn't that be leveling of a playing field that actually matters, one of autonomous life and death?BibliographyConnor, Edward M., et al. "Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment." New England Journal of Medicine 331.18 (1994): 1173-1180.Marseille, Elliot, et al. "Cost effectiveness of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa." The Lancet 354.9181 (1999): 803-809.Millum, Joseph, David Wendler, and Ezekiel J. Emanuel. "The 50th anniversary of the Declaration of Helsinki: progress but many remaining challenges." Jama 310.20 (2013): 2143-2144 Page on nih.govWorld Medical Association (WMA). Declaration of Helsinki. Amended by the 64th WMA General Assembly, Fortaleza, Brazil, October 2013. WMA Archives, Ferney-Voltaire, France. WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human SubjectsConfederacion Medica Latinoamericana y el Caribe (CONFEMEL). Declaracion de Pachuca Sobre la Revision de Helsinki. 22 and 23 November 2013. (Accessed May 5, 2014. Page on confemel.comHellmann, Fernando, et al. "50th Anniversary of the Declaration of Helsinki: The Double Standard Was Introduced." Archives of medical research 45.7 (2014): 600-601.http://www.loc.gov/rr/frd/Military_Law/pdf/NT_war-criminals_Vol-II.pdfA Companion to Bioethics, Second Edition. Helga Kuhse, Peter Singer, editors. A Companion to Bioethics; A Companion to Bioethics, Second EditionFaden, Ruth R., Tom L. Beauchamp, and Nancy M. King. "A history and theory of informed consent." (1986).Page on 100.47.5Mudur, Ganapati. "Human papillomavirus vaccine project stirs controversy in India." BMJ 340 (2010).Mudur, Ganapati. "Row erupts over study of HPV vaccine in 23 000 girls in India." BMJ 345 (2012).Sharma, Dinesh C. "Rights violation found in HPV vaccine studies in India." The Lancet Oncology 14.11 (2013): e443. Page on thelancet.comSuba, Eric J., and Stephen S. Raab. "Cervical cancer mortality in India." The Lancet 383.9931 (2014): 1804. Page on thelancet.comCalls in India for legal action against US charityClinical trials in India: ethical concernsIndia Outlines Plans for Upgrading Clinical Trial ProceduresTerwindt, Carolijn. "Health Rights Litigation Pushes for Accountability in Clinical Trials in India." Health and human rights 16 (2014): 2. Health Rights Litigation Pushes for Accountability in Clinical Trials in IndiaLaMontagne, D. Scott, and Jacqueline D. Sherris. "Addressing questions about the HPV vaccine project in India." The Lancet Oncology 14.12 (2013): e492. Page on thelancet.comStatement from PATH: cervical cancer demonstration project in IndiaAmicus curiae brief concerning non-state actor responsibility in clinical trials, November 22, 2013, submitted to the Supreme Court of India by the European Center for Constitutional and Human Rights and the Essex Business and Human Rights Project in Writ Petition (Civil) No. 558 of 2012, on file with ECCHR.Poongothai, Subramani, et al. "Why are clinical trials necessary in India?." Perspectives in clinical research 5.2 (2014): 55. Why are clinical trials necessary in India?Thanks for the A2A, Kritika Gupta.

Hysteria and the Strange History of VibratorsFrom the Vault of the Museum of Sex: Macaura’s PulsoconWarning adult content19th-century American author and humorist Mark Twain once observed, on the difference between history and fiction, that: “it’s no wonder that truth is stranger than fiction. Fiction has to make sense”.[1][1][1][1] Twain was correct: many truths about history are so strange that they are believable when fictionalised only if the author/creator can point to an historical precedent.Until the 20th century, American and European men, including physicians, subscribed to the belief that women did not experience sexual desire or pleasure.[2][2][2][2] Women were simply warm receptacles for male lust, and that intercourse culminating in male ejaculation fulfilled women's erotic needs. Women were socialized to believe that they possessed no sex drive,[3][3][3][3] and that duty required them to put up with sex in order to keep their husbands happy and have children.During the 19th century, doctors were obsessed with trying to cure the female illness of hysteria, – a now-defunct medical term that covered everything from headaches to nervous breakdowns.[4][4][4][4] As the story goes, physicians figured only an orgasm could relieve women of this ailment.[5][5][5][5] Due to high demand and because doing that manually took ages, the vibrator was invented, a steampunk cure all that could cure women in minutes, not an hour.Mention vibrators, and most people immediately think of women’s sexual pleasure. And no wonder: an estimated one-third of adult American women now own at least one.[6][6][6][6] Clitoral stimulation with vibrators produces orgasms reliably even in women who have difficulty experiencing them in other ways. And women who use vibrators consistently report sexual enhancement in both solo and partner sex.The Invention of the VibratorBut the theory of medicinal vibrators didn't become prevalent until the '90s -- the 1990s not 1890s. That's when historian and scientist Rachel Maines released her book. The Technology of Orgasm, which became the basis of a myth linking the evolution of the vibrator to curing hysteria.[7][7][7][7] Despite the book’s resounding popularity and acclaim – including the 1999 Herbert Feis Award from the American Historical Association[8][8][8][8] –the theory is not rooted in either historical or medical evidence, according to recent paper published in the Journal of Positive Sexuality.[9][9][9][9] The study is the latest piece of research by historians seeking to undermine the claims of The Technology of Orgasm – and its holds on both the history of sexuality and the popular imagination.Maines argues that Victorian physicians routinely treated female hysteria patients by stimulating them to orgasm using electromechanical vibrators. The vibrator was, according to Maines, a labor-saving technology that replaced the well-established medical practice of clitoral massage for hysteria. She states that physicians did not perceive either the vibrator or manual massage as sexual, because neither method involved vaginal penetration.[10][10][10][10]The book has two main arguments: firstly, that 'massage to orgasm' was a staple of medical practice among Western physicians for thousands of years; and secondly, that vibrators increased the number of patients that Victorian doctors could treat for hysteria.[11][11][11][11] This argument has been repeated in dozens of scholarly works and cited with approval in many more. A few scholars have challenged various parts of the book. Yet, until the last few years, none have contested her central argument, at least not in peer-reviewed literature. Her argument even spread to popular culture, appearing in a Broadway play[12][12][12][12] , a feature-length film, several documentaries (Passion and Power 2007)[13][13][13][13] and many mainstream books and articles. This once controversial idea has now become an accepted fact.English women suffering from hysteria, 1876-1880. D.M. Bourneville and P. Régnard (File:Hysteria.jpg - Wikimedia Commons)However, Maines' key sources were two turn-of-the-century physicians who never claimed they used Victorian vibrators to orgasm hysteria out of women. They only promoted the devices as glorified back massagers to fix small problems and promote general wellness.[14][14][14][14] Mechanical devices known as ‘vibrators’, and advertised as back or neck massagers were being used by women in intimate ways as early as the 1900s and 1910s.[15][15][15][15] But there’s no evidence that that was the case prior to 1900, when vibrators were being marketed to physicians, not directly to consumers.Physicians of the era did describe conducting pelvic and gynecological massages, but these didn’t involve the clitoris or lead to orgasm. One Victorian physician quoted advocates for vibrator use on "the intestines, kidneys, lungs, and skin",[16][16][16][16] another for gout and hearing loss.[17][17][17][17] There is no mention of its use on genitals. There are some French sources suggesting the odd doctor in 19th-century France may have tried manual clitoral massage, but it was never a widely accepted treatment.[18][18][18][18]The term ‘pelvic massage’ usually meant uterine massage, a treatment frequently used for conditions such as dysmenorrhea or uterine prolapse.[19][19][19][19] Dysmenorrhea is the medical term for extreme menstrual cramps,[20][20][20][20] and uterine prolapse is when the uterus slips from its normal position and into the vagina.[21][21][21][21]Pelvic massage was pioneered by physicians and the Swedish obstetrician and gynaecologist, Thure Brandt (1819-1895), who began treating women in 1861.[22][22][22][22] The ‘Brandt method’ of pelvic massage and ‘manipulating the womb’ proved very popular and was widely reported at the time. The New York Medical Journal (1876) was one of many journals that described the technique in some detail. “Brandt claims that his method of treatment is useful in prolapses and protrusion of the uterus; prolapse of the vagina; hypertrophy and induration of the uterus; ulcerations; abnormal haemorrhage, depending on relaxation of the uterus; tendency to miscarriage; slight hypertrophy of the ovaries.”[23][23][23][23]Much of the massage is carried out externally, and involves the physician pushing down on the patient’s pelvic area, ‘combined with vibratory shaking’, as well as stretching out her arms, spine and legs – again, with ‘vibratory shaking’.[24][24][24][24]Confused? Doctors eventually realized the machines were useless as a medical tool and stopped recommending them.[25][25][25][25] Overnight, medical vibrators lost their legitimacy, forcing women to hide them in their nightstands tainting the surest cure for their hysteria, nervousness and anxiety and troublesome behavior.She looks placid and relaxed, but odds are good that a doctor would have diagnosed her with hysteria.She looks placid and relaxed, but odds are good that a doctor would have diagnosed her with hysteria. (10 Bizarre Treatments Doctors Used to Think Were Legit)For millenia, philosophers and historians knew for certain that women didn't have orgasms. Hysteria was the first mental disorder attributed to women (and only women)[26][26][26][26] ,a catch-all for symptoms including, but by no means limited to: nervousness, hallucinations, emotional outbursts and various urges of the sexual variety, including excessive vaginal lubrication.[27][27][27][27] Women relied upon their physician to perform a special type of pelvic physical therapy to achieve something called "hysterical paroxysm”- essentially an orgasm.[28][28][28][28]For over 4000 years, this “disease” was considered from two perspectives: scientific and demonological. It was cured with herbs, sex or sexual abstinence, or punished and purified with fire for its association with sorcery[29][29][29][29] and finally, clinically studied as a disease and treated with innovative therapies.A womb of one’s own… Part one. - Menstrual MattersPelvic massages have been around since the dawn of humanity. According to a comprehensive history of female hysteria, compiled by researchers from the University of Cagliari in Italy[30][30][30][30] , Egyptian texts, dating as far back as 1900 BC argued that hysterical disorders were caused by women's wombs moving throughout their bodies, putting pressure on other organs and causing serious illness, and even death.[31][31][31][31] The ancient Greeks believed in hysteria as well. In the 5th century BC, Hippocrates first coined the term "hysteria" -- from "hysterika," or uterus -- and also attributed its cause to abnormal movements of the womb in a woman's body.[32][32][32][32] According to Hippocrates and his associates, a woman's body is physiologically cold, and in order to warm up, it needs, well, sex.[33][33][33][33] Thus, the term "hysteria" was often used to diagnose women with inactive or incomplete sex lives.In Roman times, physicians largely followed the Hippocratic tradition, without questioning the validity of the ‘wandering womb’ theory. Aretaeus of Cappadocia, a contemporary of Galen, included in his medical treatises a section describing the wandering womb.[34][34][34][34]In women, in the hollow of the body below the ribcage, lies the womb. It is very much like an independent animal within the body for it moves around of its own accord and is quite erratic. Furthermore, it likes fragrant smells and moves toward them, but it dislikes foul odors and moves away from them… When it suddenly moves upward [i.e., toward a fragrant smell] and remains there for a long time and presses on the intestines, the woman chokes, in the manner of an epileptic, but without any spasms. For the liver, the diaphragm, lungs and heart are suddenly confined in a narrow space. And therefore the woman seems unable to speak or to breathe. In addition, the carotid arteries, acting in sympathy with the heart, compress, and therefore heaviness of the head, loss of sense perception, and deep sleep occur… Disorders caused by the uterus are remedied by foul smells, and also by pleasant fragrances applied to the vagina…[35][35][35][35]However, not everyone accepted the wandering womb prognosis. Soranus of Ephesus (98-138 A.D.), and Galen of Pergamon (130-210 A.D.) both insisted that the uterus was fixed in place, as Galen made clear, “We must consider as totally preposterous the opinion of those who… make the womb into an animal”.[36][36][36][36] Sadly, this more advanced understanding of the physiology of the womb, was then largely ignored for centuries.Pelvic massages remained the most effective means of treating a "wandering womb", a practice that persisted in Western medical practice until the 1920s.[37][37][37][37]The 'Veedee' massager is said to have been used by doctors to cure Victorian women of hysteria. But this has been disputed as myth (The 'sex toys' dating back 28,000 years)Documented complaints of female hysteria date back to the 13th century. Doctors of that era understood that women had libidos and advised them to relieve their sexual frustration with dildos.[38][38][38][38] In the 16th century, physicians told married hysterics to encourage their husbands’ lust. One influential physician named Thomas Sydenham, who lived from the mid- to late-1600s, thought that hysterical ladies were everywhere.[39][39][39][39] Apparently, Sydenham once declared that female hysteria, which he attributed to “irregular motions of the animal spirits,” was the second most common malady of the time—behind another nebulous term, "fevers".[40][40][40][40]In 1653, the physician Alemarianus Petrus Forestus published a medical compendium titled Observationem et Curationem Medicinalium ac Chirurgicarum Opera Omnia,in which Forestus devotes a full chapter to the diseases of women.[41][41][41][41] Specifically, he noted that with regard to treatment of hysteria, many male doctors "sought every opportunity to substitute other devices for their fingers, such as the attentions of a husband, the hands of a midwife, or the business end of some tireless and impersonal mechanism."[42][42][42][42]The compendium directed:“This kind of stimulation with the finger is recommended by Galen and Avicenna, among others, most especially for widows, those who live chaste lives, and female religious … it is less often recommended for very young women, public women, or married women, for whom it is a better remedy to engage in intercourse with their spouses.”[43][43][43][43]For hysteria unrelieved by husbandly lust, and for widows, single and unhappily married women, doctors advised horseback riding, which, for some, provided enough clitoral stimulation to trigger orgasm.[44][44][44][44] But riding provided many women little relief, and by the 17th century, dildos were less of an option, because the arbiters of decency had succeeded in demonizing masturbation as “self-abuse.”[45][45][45][45]French pelvic douche device, circa 1860 (File:Pelvicdouche.jpg - Wikimedia Commons)According to Maines' investigations, at various points, high-pressure showers or hoses were also used to treat hysteria[46][46][46][46] (as were clitoridectomies)[47][47][47][47] . One French physician, writing in the mid 1800s, explained that at first this sort of high-powered douching was unpleasant, but then, "the reaction of the organism to the cold, which causes the skin to flush, and the reestablishment of equilibrium all create for many persons so agreeable a sensation that it is necessary to take precautions."[48][48][48][48] Women weren't supposed to indulge in this hydro-therapy for more than four to five minutes or longer.At the end of the 19th century it was estimated that 75 percent of American women suffered from hysteria.[49][49][49][49] With so many possible symptoms, hysteria was always a natural diagnosis when the ailment could not be identified. For instance, before the introduction of the electroencephalography (EEG) test, epilepsy was frequently confused with hysteria.[50][50][50][50] While there is some circumstantial evidence that genital massage was practiced before the 20th century, they could find no proof at all that this was ever a "staple of medical practice".[51][51][51][51]During this period of experimentation for a cure for hysteria, doctors or midwives applied vegetable oil to women’s genitals and then massaged them with one or two fingers inside and the heel of the hand pressing against the clitoris.[52][52][52][52] With this type of massage, women had orgasms and experienced sudden, dramatic relief from hysteria. But doctors didn’t call women’s climaxes orgasms. They called them “paroxysms” because everyone knew that women were incapable of sexual feelings, so they could not possibly experience orgasm.[53][53][53][53]According to research conducted over the past two decades, the treatment was so popular, in fact, that physicians sought a faster, more efficient way to perform the treatment than with their own hands. Unfortunately for doctors, hysteria treatment had a downside — achy, cramped fingers and hands from all that massage. In medical journals of the early 1800s, doctors lamented that treating hysterics taxed their physical endurance.[54][54][54][54] Chronic hand fatigue meant that some doctors had trouble maintaining the treatment long enough to produce the desired (and lucrative) result. A disturbing insight, vibrators succeeded not because they advanced female pleasure, but because they saved labor for male physicians.Science Museum Group CollectionNecessity being the mother of invention, physicians began experimenting with mechanical substitutes for their hands. They tried a number of massage contraptions, among them water-driven gadgets (the forerunners of today's shower massage devices), and pumping, steam-driven dildos.[55][55][55][55] But the machines were cumbersome, messy, often unreliable, and sometimes dangerous.The first electric vibrator was manufactured in the late 1800s, decreasing treatment times from as much as an hour to as little as 10 minutes[56][56][56][56] Joseph Mortimer-Granville’s invention in 1883 was a late achievement in a life devoted to treating mental disorders and devising methods of memory improvement.[57][57][57][57] The vibrator was intended to be used on the male nerve centres, principality those of the spine.[58][58][58][58] Mortimer-Granville was horrified by the mere thought of using vibrators on women (although he failed to say why).[59][59][59][59]But many of his colleagues on both sides of the Atlantic ignored his maledictions on vibrating female patients. One of these colleagues was Alfred Dale Covey, whose book Profitable Office Specialities,[60][60][60][60] which included “vibrotherapy,”[61][61][61][61] went into multiple editions in the early 20th century. It didn’t take long for Mortimer-Granville’s sober-and-serious medical instrument to discover the market for pleasure. The American inventor of a steam-powered, coal-fired vibrator called The Manipulator, George Taylor, wrote in 1869 that physicians had to be careful to limit the “treatment” of women’s pelvic disorders, as the patients would be inclined to demand too much of a good thing.[62][62][62][62]When Doctors Used to Finger Their Patients: Female HysteriaOne of the most enduring misconceptions about the Victorian era is that individuals were often characterized as universally prudish, sexually dysfunctional and repressed. Victorian sexual mores have a bad reputation. So bad, in fact, that some historians have claimed women were brought to a “hysterical paroxysm” (supposedly an orgasm that nobody wanted to admit to), by their doctors through “pelvic massage” (masturbation). To aid them, a vibrating device was invented because there were just so many women who needed this form of treatment that the poor doctors’ hands were getting tired, and they had to use a machine.Machines with hand-held attachments that vibrated were part of the elaborate system of cures for hysteria, neurasthenia, and more common ailments like back pain or asthma. Doctors thought that applying vibration or massage to affected parts of the body (such as the head, neck or back) might help restore electrical imbalances causing the health problems. Doucheing and other forms of water treatments were extremely popular at spas both in Europe and America. Surely some women figured out how to use these devices for masturbatory purposes.The Chattanooga…stood nearly 2m tall and required a couple of men to operate it. Being steam-powered, the engine of the machine was located in a small room and two men shoveled coal into the furnace and monitored the steam temperature, pressure, and thrust required to drive the Chattanooga. The engine room was separated from the doctor’s room by a wall which had a hole in it. A mechanical arm extended from the engine through the wall and into the consulting room where the doctor controlled it and used the vibrating arm to administer the appropriate genital massage to the grateful patient.[63][63][63][63](Chattanooga Choo-Choo: A Brief History of the Vibrator)But just because something is aimed at your genitals doesn’t mean that it is enjoyable, and no one understood this better than the Victorians. Treatments for male sexual neurasthenia and impotence included devices were supposed to enclose the penis and transmit regular shocks[64][64][64][64] In one treatment for both men and women, one electrode was inserted in the rectum and a second one in the urethra if you were a woman, or placed between the penis and the scrotum if you were a man.The Sanax device 1913. In a series of photographs, a serious-faced woman in a ruffled white dress holds this vibrator to her forehead, her jaw, her throat and her chest (The vibrator: from medical tool to revolutionary sex toy).So did Dr Granville invent an electronic device for massage? Yes. Was it anything to do with the female orgasm? No. He actually invented it to help stimulate male pain relief, just as massage is used today. Victorian doctors knew exactly what the female orgasm was; in fact, it’s one of the reasons they thought masturbation was a bad idea. A few theorised that it might be beneficial to a woman for her period pain, but the majority of doctors saw the art of self-pleasure as highly dangerous to your health.[65][65][65][65] This attitude was not because they were on some sort of anti-pleasure, or anti-sex crusade, but because orgasms were actually important to the Victorians.Marriage guides discussing the sex act often claimed that a woman in a sexually satisfying relationship was more likely to become pregnant, as the wife’s orgasm was just as necessary to conception as her husband’s.[66][66][66][66] A book called The Art to Begetting Handsome Children, published in 1860, contains a detailed passage on foreplay, and shows us that, for the Victorians, sex, pleasure and love were concepts that were universally tied together.[67][67][67][67] In A Guide To Marriage, published in 1865 by the aptly named Albert Sidebottom, the advice to young couples exploring their relationship for the first time is that “All love between the sexes is based upon sexual passion”.[68][68][68][68] This is something I’ve come across time and again in researching Victorian attitudes to sex: sexual pleasure, and especially female sexual pleasure, really mattered.Cora Pearl.(The humble English girl who became Cora Pearl, one of the most scandalous courtesans of the Second Empire in 19th century Paris)Unfortunately, scholars and historians seem to be incapable of seeing women in the Victorian period as anything other than sexually passive, a gender so disconnected from their bodies that they had to be stimulated by the inventions of men. This just isn’t true. From the erotic life of courtesan Cora Pearl, to the romantic female relationships of Mary Benson, wife of the Archbishop of Canterbury, Victorian female sexuality was just as expressive and expansive as it is today.[69][69][69][69]Sexual fulfilment isn’t always about getting pregnant, and Victorian women seem to have had a healthy interest in protecting their bodies, while still being able to enjoy a sexual relationship. In 1877, Annie Besant, a one-time vicar’s wife, helped to publish Fruits of Philosophy, a guide that set out every possible contraceptive method available to its Victorian reader.[70][70][70][70] From vaginal douches to early forms of spermicide and even condoms, the information in the pamphlet became so popular that its British circulation reached over 125,000 in the first few months alone.c. 1891 Demonstration using the vibrator (A man invented vibrators because doctors were tired of giving orgasms)Between having their organs crushed by their undergarments (corsets), being poisoned by their underwear (Arsenic),[71][71][71][71] and spontaneously combusting once again thanks to their underwear (crinolines), the life of a Victorian woman was, to say the least, “Not Fun”.[72][72][72][72] And nothing sums up their struggles quite like the infamous illness of "hysteria" – a diagnosis foisted upon women for any number of reasons, for which the only known treatment was hours of industrious masturbation at the hands of a physician. Seen by male doctors as non-sexual because it didn't involve penetration (modern men, of course, would never believe this)[73][73][73][73] these "pelvic massages" eventually proved so tiring that the medical community invented the mechanical vibrator. And the rest, as they say, is history- history that has erroneously become accepted as fact in the last 20 years, despite an obvious lack of evidence and source material for the preceeding 150 years.So can we please stop saying Victorian women were having unknown orgasms stimulated by their doctors? The vibrators from the Victorian period are the least orgasmic devices you have ever seen, because they had nothing to do with sex.[74][74][74][74] They were used for massage, not masturbation. And the idea that a woman would be brought to orgasm by a device that rotates with a loud grinding buzz, and pummels you with the same finesse as a steam-engine, just doesn’t work. Especially when you compare it with the Victorian sex aides that were created for pleasure. From sex toys to sex chairs, condoms and contraceptives, the Victorians had many of the things sold today.[75][75][75][75] They used rubber, wood, ivory, and leather; some are delicately crafted from silver, others decorated in enamel flowers and hidden inside everyday objects, like a walking cane.[76][76][76][76]A 1910 newspaper advertisement (1910 ad: White Cross Electric Vibrator)In the 1920s, vibrators began to appear in erotic and pornographic films (the first erotic short appeared in 1891), undermining its social camouflage as a medical device. The vibrator’s legitimacy as a medical device declined after the 1920s, when Sigmund Freud correctly identified paroxysm as sexual.[77][77][77][77] They were no longer a doctor's go to therapy for anything and everything related to women's health.[78][78][78][78] However, chiropractors, who concentrated their attentions on the skeletal muscles, not the genitalia continued to use vibrators in their practices.[79][79][79][79]By the beginning of the 20th century, women could choose and buy their own vibrators from publications such as the Sears, Roebuck and Co. catalog, Needlecraft, Women's Home Companion. [80][80][80][80] One 1903 advertisement in the Sears Catalogue touted a popular massager as “a delightful companion . . . all the pleasures of youth . . . will throb within you....”.[81][81][81][81] Vibrator advertisements disappeared from the consumer media, and vibrators were hard to find well into the 1970s.[82][82][82][82] That changed when feminism emerged right around the time that Hitachi introduced its Magic Wand, still the world’s most popular vibrator.[83][83][83][83]Female hysteria remained a popular diagnosis until 1952 when it was removed from the American Psychiatric spectrum of mental disorders after a 2,500-year history as what the 19th century French physician Charles LaSegue called “a wastepaper basket of otherwise unemployed medical symptoms”.[84][84][84][84]Footnotes[1] Stranger Than Fiction[1] Stranger Than Fiction[1] Stranger Than Fiction[1] Stranger Than Fiction[2] The Classification of Hysteria and Related Disorders: Historical and Phenomenological Considerations[2] The Classification of Hysteria and Related Disorders: Historical and Phenomenological Considerations[2] The Classification of Hysteria and Related Disorders: Historical and Phenomenological Considerations[2] The Classification of Hysteria and Related Disorders: Historical and Phenomenological Considerations[3] Sex & Sexuality in the 19th Century[3] Sex & Sexuality in the 19th Century[3] Sex & Sexuality in the 19th Century[3] Sex & Sexuality in the 19th Century[4] The Classification of Hysteria and Related Disorders: Historical and Phenomenological Considerations[4] The Classification of Hysteria and Related Disorders: Historical and Phenomenological Considerations[4] The Classification of Hysteria and Related Disorders: Historical and Phenomenological Considerations[4] The Classification of Hysteria and Related Disorders: Historical and Phenomenological Considerations[5] 7 Crazy Things People Used To Believe About Female Hysteria[5] 7 Crazy Things People Used To Believe About Female Hysteria[5] 7 Crazy Things People Used To Believe About Female Hysteria[5] 7 Crazy Things People Used To Believe About Female Hysteria[6] Use of Vibrators Among American Women[6] Use of Vibrators Among American Women[6] Use of Vibrators Among American Women[6] Use of Vibrators Among American Women[7] Victorian-Era Orgasms and the Crisis of Peer Review[7] Victorian-Era Orgasms and the Crisis of Peer Review[7] Victorian-Era Orgasms and the Crisis of Peer Review[7] Victorian-Era Orgasms and the Crisis of Peer Review[8] Herbert Feis Award Recipients[8] Herbert Feis Award Recipients[8] Herbert Feis Award Recipients[8] Herbert Feis Award Recipients[9] http://he%20theory%20has%20some%20pretty%20unstable%20foundations/[9] http://he%20theory%20has%20some%20pretty%20unstable%20foundations/[9] http://he%20theory%20has%20some%20pretty%20unstable%20foundations/[9] http://he%20theory%20has%20some%20pretty%20unstable%20foundations/[10] Victorian-Era Orgasms and the Crisis of Peer Review[10] Victorian-Era Orgasms and the Crisis of Peer Review[10] Victorian-Era Orgasms and the Crisis of Peer Review[10] Victorian-Era Orgasms and the Crisis of Peer Review[11] (PDF) The Technology of Orgasm: 'Hysteria', the Vibrator, and Women's Sexual Satisfaction[11] (PDF) The Technology of Orgasm: 'Hysteria', the Vibrator, and Women's Sexual Satisfaction[11] (PDF) The Technology of Orgasm: 'Hysteria', the Vibrator, and Women's Sexual Satisfaction[11] (PDF) The Technology of Orgasm: 'Hysteria', the Vibrator, and Women's Sexual Satisfaction[12] 'The Vibrator Play': Why Yes, It Is About Exactly That[12] 'The Vibrator Play': Why Yes, It Is About Exactly That[12] 'The Vibrator Play': Why Yes, It Is About Exactly That[12] 'The Vibrator Play': Why Yes, It Is About Exactly That[13] Passion & Power: The Technology of Orgasm[13] Passion & Power: The Technology of Orgasm[13] Passion & Power: The Technology of Orgasm[13] Passion & Power: The Technology of Orgasm[14] History of Wellness - Global Wellness Institute[14] History of Wellness - Global Wellness Institute[14] History of Wellness - Global Wellness Institute[14] History of Wellness - Global Wellness Institute[15] "Hysteria" and the Strange History of Vibrators[15] "Hysteria" and the Strange History of Vibrators[15] "Hysteria" and the Strange History of Vibrators[15] "Hysteria" and the Strange History of Vibrators[16] The Vibrator's Origin Story Is Fantastically Scandalous, But It's Also Probably Fake[16] The Vibrator's Origin Story Is Fantastically Scandalous, But It's Also Probably Fake[16] The Vibrator's Origin Story Is Fantastically Scandalous, But It's Also Probably Fake[16] The Vibrator's Origin Story Is Fantastically Scandalous, But It's Also Probably Fake[17] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[17] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[17] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[17] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[18] Nineteenth-century Attitudes to Female Sexuality[18] Nineteenth-century Attitudes to Female Sexuality[18] Nineteenth-century Attitudes to Female Sexuality[18] Nineteenth-century Attitudes to Female Sexuality[19] It's a myth that Victorian doctors used vibrators to give their patients orgasms[19] It's a myth that Victorian doctors used vibrators to give their patients orgasms[19] It's a myth that Victorian doctors used vibrators to give their patients orgasms[19] It's a myth that Victorian doctors used vibrators to give their patients orgasms[20] Practice Essentials[20] Practice Essentials[20] Practice Essentials[20] Practice Essentials[21] Prolapsed uterus: Stages, symptoms, and home remedies[21] Prolapsed uterus: Stages, symptoms, and home remedies[21] Prolapsed uterus: Stages, symptoms, and home remedies[21] Prolapsed uterus: Stages, symptoms, and home remedies[22] Full text of "Massage treatment (Thure Brandt) in diseases of women : for practitioners"[22] Full text of "Massage treatment (Thure Brandt) in diseases of women : for practitioners"[22] Full text of "Massage treatment (Thure Brandt) in diseases of women : for practitioners"[22] Full text of "Massage treatment (Thure Brandt) in diseases of women : for practitioners"[23] Full text of "New York medical journal"[23] Full text of "New York medical journal"[23] Full text of "New York medical journal"[23] Full text of "New York medical journal"[24] Victorian doctors were not using vibrators on female patients – it was even stranger than that[24] Victorian doctors were not using vibrators on female patients – it was even stranger than that[24] Victorian doctors were not using vibrators on female patients – it was even stranger than that[24] Victorian doctors were not using vibrators on female patients – it was even stranger than that[25] The vibrator: from medical tool to revolutionary sex toy[25] The vibrator: from medical tool to revolutionary sex toy[25] The vibrator: from medical tool to revolutionary sex toy[25] The vibrator: from medical tool to revolutionary sex toy[26] 7 Crazy Things People Used To Believe About Female Hysteria[26] 7 Crazy Things People Used To Believe About Female Hysteria[26] 7 Crazy Things People Used To Believe About Female Hysteria[26] 7 Crazy Things People Used To Believe About Female Hysteria[27] The History of Hysteria[27] The History of Hysteria[27] The History of Hysteria[27] The History of Hysteria[28] 7 Crazy Things People Used To Believe About Female Hysteria[28] 7 Crazy Things People Used To Believe About Female Hysteria[28] 7 Crazy Things People Used To Believe About Female Hysteria[28] 7 Crazy Things People Used To Believe About Female Hysteria[29] Hysteria, Witches, and The Wandering Uterus: A Brief History[29] Hysteria, Witches, and The Wandering Uterus: A Brief History[29] Hysteria, Witches, and The Wandering Uterus: A Brief History[29] Hysteria, Witches, and The Wandering Uterus: A Brief History[30] Women And Hysteria In The History Of Mental Health[30] Women And Hysteria In The History Of Mental Health[30] Women And Hysteria In The History Of Mental Health[30] Women And Hysteria In The History Of Mental Health[31] THE WANDERING WOMB[31] THE WANDERING WOMB[31] THE WANDERING WOMB[31] THE WANDERING WOMB[32] Ancient Gynecology - Antiqua Medicina: From Homer to Vesalius[32] Ancient Gynecology - Antiqua Medicina: From Homer to Vesalius[32] Ancient Gynecology - Antiqua Medicina: From Homer to Vesalius[32] Ancient Gynecology - Antiqua Medicina: From Homer to Vesalius[33] Male and female bodies according to Ancient Greek physicians[33] Male and female bodies according to Ancient Greek physicians[33] Male and female bodies according to Ancient Greek physicians[33] Male and female bodies according to Ancient Greek physicians[34] Aretaeus of Cappadocia, second only to Hippocrates[34] Aretaeus of Cappadocia, second only to Hippocrates[34] Aretaeus of Cappadocia, second only to Hippocrates[34] Aretaeus of Cappadocia, second only to Hippocrates[35] Magical and Medical Approaches to the Wandering Womb in the Ancient Greek World[35] Magical and Medical Approaches to the Wandering Womb in the Ancient Greek World[35] Magical and Medical Approaches to the Wandering Womb in the Ancient Greek World[35] Magical and Medical Approaches to the Wandering Womb in the Ancient Greek World[36] A womb of one’s own… Part one. - Menstrual Matters[36] A womb of one’s own… Part one. - Menstrual Matters[36] A womb of one’s own… Part one. - Menstrual Matters[36] A womb of one’s own… Part one. - Menstrual Matters[37] Hysteria, the Wandering Uterus, and Vaginal Massage[37] Hysteria, the Wandering Uterus, and Vaginal Massage[37] Hysteria, the Wandering Uterus, and Vaginal Massage[37] Hysteria, the Wandering Uterus, and Vaginal Massage[38] A Brief and Twisted History of Dildos and Vibrators[38] A Brief and Twisted History of Dildos and Vibrators[38] A Brief and Twisted History of Dildos and Vibrators[38] A Brief and Twisted History of Dildos and Vibrators[39] The “English Hippocrates” and the disease of kings[39] The “English Hippocrates” and the disease of kings[39] The “English Hippocrates” and the disease of kings[39] The “English Hippocrates” and the disease of kings[40] Sydenham on Hysteria[40] Sydenham on Hysteria[40] Sydenham on Hysteria[40] Sydenham on Hysteria[41] The Technology of Orgasm[41] The Technology of Orgasm[41] The Technology of Orgasm[41] The Technology of Orgasm[42] Observationem et curationem medicinalium ac chirurgicarum, Opera Omnia, ...[42] Observationem et curationem medicinalium ac chirurgicarum, Opera Omnia, ...[42] Observationem et curationem medicinalium ac chirurgicarum, Opera Omnia, ...[42] Observationem et curationem medicinalium ac chirurgicarum, Opera Omnia, ...[43] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[43] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[43] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[43] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[44] The Little Explored Secret of Women's Orgasms While They Exe[44] The Little Explored Secret of Women's Orgasms While They Exe[44] The Little Explored Secret of Women's Orgasms While They Exe[44] The Little Explored Secret of Women's Orgasms While They Exe[45] r/todayilearned - TIL as late as 17th-Century Europe, masturbation was commonly employed by nannies to put their young male charges to sleep.[45] r/todayilearned - TIL as late as 17th-Century Europe, masturbation was commonly employed by nannies to put their young male charges to sleep.[45] r/todayilearned - TIL as late as 17th-Century Europe, masturbation was commonly employed by nannies to put their young male charges to sleep.[45] r/todayilearned - TIL as late as 17th-Century Europe, masturbation was commonly employed by nannies to put their young male charges to sleep.[46] The Technology of Orgasm[46] The Technology of Orgasm[46] The Technology of Orgasm[46] The Technology of Orgasm[47] The rise and fall of FGM in Victorian London[47] The rise and fall of FGM in Victorian London[47] The rise and fall of FGM in Victorian London[47] The rise and fall of FGM in Victorian London[48] 7 Crazy Things People Used To Believe About Female Hysteria[48] 7 Crazy Things People Used To Believe About Female Hysteria[48] 7 Crazy Things People Used To Believe About Female Hysteria[48] 7 Crazy Things People Used To Believe About Female Hysteria[49] The Racialized History of "Hysteria" | JSTOR Daily[49] The Racialized History of "Hysteria" | JSTOR Daily[49] The Racialized History of "Hysteria" | JSTOR Daily[49] The Racialized History of "Hysteria" | JSTOR Daily[50] https://www.ncbi.nlm.nih.gov/m/pubmed/349116/[50] https://www.ncbi.nlm.nih.gov/m/pubmed/349116/[50] https://www.ncbi.nlm.nih.gov/m/pubmed/349116/[50] https://www.ncbi.nlm.nih.gov/m/pubmed/349116/[51] The Vibrator's Origin Story Is Fantastically Scandalous, But It's Also Probably Fake[51] The Vibrator's Origin Story Is Fantastically Scandalous, But It's Also Probably Fake[51] The Vibrator's Origin Story Is Fantastically Scandalous, But It's Also Probably Fake[51] The Vibrator's Origin Story Is Fantastically Scandalous, But It's Also Probably Fake[52] Photo of the Day – Whale Oil Beef Hooked | Whaleoil Media[52] Photo of the Day – Whale Oil Beef Hooked | Whaleoil Media[52] Photo of the Day – Whale Oil Beef Hooked | Whaleoil Media[52] Photo of the Day – Whale Oil Beef Hooked | Whaleoil Media[53] Definition of Paroxysm[53] Definition of Paroxysm[53] Definition of Paroxysm[53] Definition of Paroxysm[54] The History Of “Female Hysteria” And The Sex Toys Used To Treat It[54] The History Of “Female Hysteria” And The Sex Toys Used To Treat It[54] The History Of “Female Hysteria” And The Sex Toys Used To Treat It[54] The History Of “Female Hysteria” And The Sex Toys Used To Treat It[55] The Steam-Powered Vibrator and Other Terrifying Early Sex Machines NSFW[55] The Steam-Powered Vibrator and Other Terrifying Early Sex Machines NSFW[55] The Steam-Powered Vibrator and Other Terrifying Early Sex Machines NSFW[55] The Steam-Powered Vibrator and Other Terrifying Early Sex Machines NSFW[56] A man invented vibrators because doctors were tired of giving orgasms[56] A man invented vibrators because doctors were tired of giving orgasms[56] A man invented vibrators because doctors were tired of giving orgasms[56] A man invented vibrators because doctors were tired of giving orgasms[57] https://www.google.com/url?rct=j&sa=t&source=web&url=https://alcoholanddrugshistorysociety.files.wordpress.com/2016/10/shad-28-2-kneale.pdf&usg=AOvVaw0m2gEcbQih7F0ZtXKhj3U3&ved=2ahUKEwiMpeXW66_iAhUSRqwKHTr8A0MQFjATegQICRAB[57] https://www.google.com/url?rct=j&sa=t&source=web&url=https://alcoholanddrugshistorysociety.files.wordpress.com/2016/10/shad-28-2-kneale.pdf&usg=AOvVaw0m2gEcbQih7F0ZtXKhj3U3&ved=2ahUKEwiMpeXW66_iAhUSRqwKHTr8A0MQFjATegQICRAB[57] https://www.google.com/url?rct=j&sa=t&source=web&url=https://alcoholanddrugshistorysociety.files.wordpress.com/2016/10/shad-28-2-kneale.pdf&usg=AOvVaw0m2gEcbQih7F0ZtXKhj3U3&ved=2ahUKEwiMpeXW66_iAhUSRqwKHTr8A0MQFjATegQICRAB[57] https://www.google.com/url?rct=j&sa=t&source=web&url=https://alcoholanddrugshistorysociety.files.wordpress.com/2016/10/shad-28-2-kneale.pdf&usg=AOvVaw0m2gEcbQih7F0ZtXKhj3U3&ved=2ahUKEwiMpeXW66_iAhUSRqwKHTr8A0MQFjATegQICRAB[58] Selling Sex Toys: Marketing and the Meaning of Vibrators in Early Twentieth-Century America[58] Selling Sex Toys: Marketing and the Meaning of Vibrators in Early Twentieth-Century America[58] Selling Sex Toys: Marketing and the Meaning of Vibrators in Early Twentieth-Century America[58] Selling Sex Toys: Marketing and the Meaning of Vibrators in Early Twentieth-Century America[59] Nerve-vibration and Excitation as Agents in the Treatment of Functional Disorder and Organic Disease[59] Nerve-vibration and Excitation as Agents in the Treatment of Functional Disorder and Organic Disease[59] Nerve-vibration and Excitation as Agents in the Treatment of Functional Disorder and Organic Disease[59] Nerve-vibration and Excitation as Agents in the Treatment of Functional Disorder and Organic Disease[60] The secrets of specialists (1916 edition) | Open Library[60] The secrets of specialists (1916 edition) | Open Library[60] The secrets of specialists (1916 edition) | Open Library[60] The secrets of specialists (1916 edition) | Open Library[61] http://www.ramsni.com/information_links/Vibrotherapy%20Info/Vibrotherapy%20info.html[61] http://www.ramsni.com/information_links/Vibrotherapy%20Info/Vibrotherapy%20info.html[61] http://www.ramsni.com/information_links/Vibrotherapy%20Info/Vibrotherapy%20info.html[61] http://www.ramsni.com/information_links/Vibrotherapy%20Info/Vibrotherapy%20info.html[62] The Steam-Powered Vibrator and Other Terrifying Early Sex Machines NSFW[62] The Steam-Powered Vibrator and Other Terrifying Early Sex Machines NSFW[62] The Steam-Powered Vibrator and Other Terrifying Early Sex Machines NSFW[62] The Steam-Powered Vibrator and Other Terrifying Early Sex Machines NSFW[63] Chattanooga Choo-Choo: A Brief History of the Vibrator[63] Chattanooga Choo-Choo: A Brief History of the Vibrator[63] Chattanooga Choo-Choo: A Brief History of the Vibrator[63] Chattanooga Choo-Choo: A Brief History of the Vibrator[64] Sexual Neurasthenia ( Nervous Exhaustion ), Its Hygiene, Causes, Symptoms and Treatment, with a Chapter on Diet for the Nervous by George M. Beard, A.M., M.D.[64] Sexual Neurasthenia ( Nervous Exhaustion ), Its Hygiene, Causes, Symptoms and Treatment, with a Chapter on Diet for the Nervous by George M. Beard, A.M., M.D.[64] Sexual Neurasthenia ( Nervous Exhaustion ), Its Hygiene, Causes, Symptoms and Treatment, with a Chapter on Diet for the Nervous by George M. Beard, A.M., M.D.[64] Sexual Neurasthenia ( Nervous Exhaustion ), Its Hygiene, Causes, Symptoms and Treatment, with a Chapter on Diet for the Nervous by George M. Beard, A.M., M.D.[65] Let’s Talk about Sex: Victorian Anti-Masturbation Devices[65] Let’s Talk about Sex: Victorian Anti-Masturbation Devices[65] Let’s Talk about Sex: Victorian Anti-Masturbation Devices[65] Let’s Talk about Sex: Victorian Anti-Masturbation Devices[66] Female Sexuality in the Victorian Age[66] Female Sexuality in the Victorian Age[66] Female Sexuality in the Victorian Age[66] Female Sexuality in the Victorian Age[67] The Victorian Citizen’s Advice To Having A Great Sex Life[67] The Victorian Citizen’s Advice To Having A Great Sex Life[67] The Victorian Citizen’s Advice To Having A Great Sex Life[67] The Victorian Citizen’s Advice To Having A Great Sex Life[68] The struggle for married women’s rights, circa 1880s[68] The struggle for married women’s rights, circa 1880s[68] The struggle for married women’s rights, circa 1880s[68] The struggle for married women’s rights, circa 1880s[69] The humble English girl who became Cora Pearl, one of the most scandalous courtesans of the Second Empire in 19th century Paris[69] The humble English girl who became Cora Pearl, one of the most scandalous courtesans of the Second Empire in 19th century Paris[69] The humble English girl who became Cora Pearl, one of the most scandalous courtesans of the Second Empire in 19th century Paris[69] The humble English girl who became Cora Pearl, one of the most scandalous courtesans of the Second Empire in 19th century Paris[70] Birth Control in the Shadow of Empire: The Trials of Annie Besant, 1877-1878[70] Birth Control in the Shadow of Empire: The Trials of Annie Besant, 1877-1878[70] Birth Control in the Shadow of Empire: The Trials of Annie Besant, 1877-1878[70] Birth Control in the Shadow of Empire: The Trials of Annie Besant, 1877-1878[71] 7 Ways Victorian Fashion Could Kill You[71] 7 Ways Victorian Fashion Could Kill You[71] 7 Ways Victorian Fashion Could Kill You[71] 7 Ways Victorian Fashion Could Kill You[72] Crinolinemania: The dangerous Victorian fashion garment that killed around 3,000 women[72] Crinolinemania: The dangerous Victorian fashion garment that killed around 3,000 women[72] Crinolinemania: The dangerous Victorian fashion garment that killed around 3,000 women[72] Crinolinemania: The dangerous Victorian fashion garment that killed around 3,000 women[73] Victorian doctors were not using vibrators on female patients – it was even stranger than that[73] Victorian doctors were not using vibrators on female patients – it was even stranger than that[73] Victorian doctors were not using vibrators on female patients – it was even stranger than that[73] Victorian doctors were not using vibrators on female patients – it was even stranger than that[74] No, no, no! Victorians didn’t invent the vibrator | Fern Riddell[74] No, no, no! Victorians didn’t invent the vibrator | Fern Riddell[74] No, no, no! Victorians didn’t invent the vibrator | Fern Riddell[74] No, no, no! Victorians didn’t invent the vibrator | Fern Riddell[75] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[75] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[75] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[75] The History of Sex Toys Is Decadent, Depraved And Will Blow More Than Just Your Mind...[76] Historical Sex: The Victorians - disease, pornography and royal sex chairs[76] Historical Sex: The Victorians - disease, pornography and royal sex chairs[76] Historical Sex: The Victorians - disease, pornography and royal sex chairs[76] Historical Sex: The Victorians - disease, pornography and royal sex chairs[77] Good Vibrations: Medical Science Cures Hysteria[77] Good Vibrations: Medical Science Cures Hysteria[77] Good Vibrations: Medical Science Cures Hysteria[77] Good Vibrations: Medical Science Cures Hysteria[78] victorian decline in vibrator use[78] victorian decline in vibrator use[78] victorian decline in vibrator use[78] victorian decline in vibrator use[79] https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.academia.edu/28556168/Balls_Cups_and_Discs_A_history_of_vibrators_and_massage_machines_1900-_1940_Dissertation_2012&ved=2ahUKEwitq5jzh7LiAhULKawKHbhXC5IQFjADegQIARAB&usg=AOvVaw19o11WLSvlnweR5fW9Pg39[79] https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.academia.edu/28556168/Balls_Cups_and_Discs_A_history_of_vibrators_and_massage_machines_1900-_1940_Dissertation_2012&ved=2ahUKEwitq5jzh7LiAhULKawKHbhXC5IQFjADegQIARAB&usg=AOvVaw19o11WLSvlnweR5fW9Pg39[79] https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.academia.edu/28556168/Balls_Cups_and_Discs_A_history_of_vibrators_and_massage_machines_1900-_1940_Dissertation_2012&ved=2ahUKEwitq5jzh7LiAhULKawKHbhXC5IQFjADegQIARAB&usg=AOvVaw19o11WLSvlnweR5fW9Pg39[79] https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.academia.edu/28556168/Balls_Cups_and_Discs_A_history_of_vibrators_and_massage_machines_1900-_1940_Dissertation_2012&ved=2ahUKEwitq5jzh7LiAhULKawKHbhXC5IQFjADegQIARAB&usg=AOvVaw19o11WLSvlnweR5fW9Pg39[80] 11 Vintage Vibrator Ads To Make You Glad You Live In 2015[80] 11 Vintage Vibrator Ads To Make You Glad You Live In 2015[80] 11 Vintage Vibrator Ads To Make You Glad You Live In 2015[80] 11 Vintage Vibrator Ads To Make You Glad You Live In 2015[81] Vibrators were Sold in the Sears & Roebuck Catalogue[81] Vibrators were Sold in the Sears & Roebuck Catalogue[81] Vibrators were Sold in the Sears & Roebuck Catalogue[81] Vibrators were Sold in the Sears & Roebuck Catalogue[82] The buzz: how the vibrator came to be[82] The buzz: how the vibrator came to be[82] The buzz: how the vibrator came to be[82] The buzz: how the vibrator came to be[83] Hitachi Magic Wand - Wikipedia[83] Hitachi Magic Wand - Wikipedia[83] Hitachi Magic Wand - Wikipedia[83] Hitachi Magic Wand - Wikipedia[84] Charles Lasègue (1816-1883): beyond anorexie hystérique[84] Charles Lasègue (1816-1883): beyond anorexie hystérique[84] Charles Lasègue (1816-1883): beyond anorexie hystérique[84] Charles Lasègue (1816-1883): beyond anorexie hystérique

Here is the short answer:If you were designated male at birth, even if you had sex reassignment surgery, you must register with the Selective Service. However, in the event the draft is resumed, you can file a claim for exemption from military service if you receive an order for an examination or induction.And the long answer, because Quorians deserve to learn the answer to questions not asked, and more in-depth thought…The Federal laws governing the Selective Service Registration require any person who is born a male to register…even if they later elect/change gender.State laws have no effect upon this situation, because of course we live in a Federalist system and there is the established Federal supremacy clause.As others noted in this thread, there are significant consequences for failure to register, including commission of a Federal felony crime (with a rather stiff possible prison sentence and massive fine), denial of Federal financial aid, inability to obtain Federal employment, and other consequences. Many States have companion laws that mirror the Federal laws, such that States would also deny employment, financial aid, etc.Here is what the SSS website says about this situation, as of 30 Aug 2016. It might change, so I thought it important to specify the date of the information. The Gentle Reader should not rely upon this Quora answer as legal advice…and seek out a complete and up to date answer directly from the SSS if your situation is actually in question.See: Selective Service Systems > TransgenderSex Gender Change / TransgenderIf designated female at birth –If you were designated female at birth and have had sex reassignment surgery, you do not need to register with the Selective Service. However, if you are applying for federal benefits that require proof of Selective Service registration (including educational loans), you will need to show that you were never required to register with Selective Service.People designated female at birth are never required to register. You can prove this by requesting a status information letter from the Selective Service System. You must explain in detail why you believe you were not required to register for the selective service (you were designated female at birth, were diagnosed with Gender Identity Disorder [OR] an intersexed condition and have now completed sex reassignment). You should also include supporting documentation, such as a letter of affidavit from your treating physician and a copy of your original birth certificate (with female gender marker).The exemption letter you will receive does not specify why you are exempt so it will not force you to out yourself in any other application process. The Selective Service does, however, require a copy of your birth certificate showing your birth-assigned sex. If the sex on your birth certificate has been changed, attach any documentation you have to that affect. Once you receive your Status Information Letter, keep it in your files. For those female-to-male people who transition before their eighteenth birthdays and change their birth certificates, it is also possible to register with the service. However, no one may register after their 26th birthday. Also, please note that although Selective Service materials refer to transgender people as “people who have had a sex change,” their policies apply to those who have transitioned regardless of surgical history.Complete the ‘Request for Status Information Letter’ form and submit it along with all supporting documentation to:Selective Service System, P.O. Box 94638, Palatine, IL 60094-4638If designated male at birth –If you were designated male at birth, even if you had sex reassignment surgery, you must register with the Selective Service. However, in the event the draft is resumed, you can file a claim for exemption from military service if you receive an order for an examination or induction.People who were assigned male at birth are required to register with the Selective Service within 30 days of their 18th birthday. This includes those who may have transitioned before or since then. The Selective Service uses Social Security and other databases to determine who they believe was assigned male at birth. As of now, it is unclear whether transgender people are eligible for military service, but you are required to register nonetheless, and this is necessary to gain access to certain government benefits.Two questions are often asked:Why register at all, if there is no draft currently?Well, of course, it’s the law of the land. And once that’s out of the way as the obvious answer, the detailed follow up: the draft is the vestigial remnant of the 18th century understanding of the “Common Defense” and the right (indeed obligation) of the President to “call forth the militia” to “repel invasions and repress insurrections.” The power of the President to perform these actions form the bedrock duties imposed by the US Constitution upon the President.Over the past 225 or so years, the “tools” provided to the President to actually perform these tasks have changed. So the President no longer has to “call forth the militia” and have a hastily gathered group of farmers and shop-keepers armed with pitchforks, torches, blunderbusses, rusty old single shot muskets, and the occasional sword, spear, and even rifles.Today, the President’s powers permit calling upon the existing, standing Armed Forces (the formation and funding of which most of the Founders bitterly resisted, believing that the Revolution had showed the “power of the people” to answer the call to repel invasions and put down insurrections…and then go home to their families and “real jobs,” putting away their weapons. The Militia consists of the “whole of the People.” — George Mason (and others)).The President may also call upon a certain number of reservists to augment the active forces of the military, either voluntarily or involuntarily, without a significant “mobilization.”If at that point, the President determines that the situation is so dire that it cannot be handled by active armed forces, or a partial mobilization of the reserves, the next layer in the mobilization ladder is to Federalize as many of the National Guard (both Army and Air) organizations as necessary (meaning of course that their State Governors no longer control them or can use them for tasks inside their own States), and begin to call forth progressively more reservists, and military retirees, to active duty. The President would also likely transfer the Coast Guard from the DHS to the Department of the Navy to assume combat roles, and militarize the Public Health Service, NOAA, and the Merchant Marine at this point. Most of the Cadets and Midshipmen in the Service Academies and ROTC units across America would have their education stopped (or accelerated if they were close to finishing), and either be commissioned into the armed forces, or reverted to enlisted status to be sent off to war. This is called “full mobilization.” We have not had this since World War II…And at a certain point, when there aren’t enough active forces, and there are no more reservists, National Guards, or military retirees, etc., to call forth, and it appears that the military situation will not be resolved in the near term with those forces available, the President has two remaining methods to “call forth” further manpower to provide for the “Common Defense” and “repel invasions and insurrections” as required by the US Constitution to save the Republic.One of the remaining methods is: under a “total mobilization” scenario (think World War II, or any of the sci-fi situations requiring literally EVERYONE to fight for their lives…), the President could, with the consent of Congress, activate the draft. This would then then allow several million military age males to be quickly called up for military service, with alacrity, i.e., “inducted.”→ Notice that the word “inducted” is not the same as “enlisted” or “commissioned,” but it is possible for an “inductee” to either be enlisted or commissioned “for the duration plus 6 months…”The existing “draft” is only the tip of the iceberg: behind the actual registration and maintenance of information on those males until they “age out” of the system at their 26th birthday, there is a very complex organizational system that is presently inactive…but that system is maintained regularly, and could be reactivated quite quickly as ordered. Think of the draft, once it was ignited into action, as a “Sorting Hat” from Harry Potter films: the new draftee arrives at their designated reception center, and the Sorting Hat is put on their head, “Ok, this one is going to be a Marine, this one a pilot, this one is unqualified and should be sent home, this one speaks a highly desirable language and should be utilized accordingly, and this one has a degree in nuclear engineering…perfect for the Navy’s nuclear ships. Etc.”And the second remaining method? Of course, that is the original method provided for in the Constitution: the President (or successor as may likely be the case by then) “calls forth the militia” to repel invasion and repress insurrections for the Common Defense. What is this militia? Of course, it is the “unorganized militia” that is formally defined by 10 USC 311 as all males between 17 and 45, but in reality has its roots in the 18th century common law understanding of the “Militia” as the “Whole of the People.” (Being “unorganized” also means it is not “regulated” as specified in the Second Amendment: where “regulated” means “trained and ready” in 18th Century upper-crust English, and the “unorganized militia” is really neither trained nor prepared to ACT as a militia…Probably 99.9% of Americans today do not know that the “unorganized militia” exists, and who might be in it…even if THEY are in it, by law.)→ Note: this is an important link between the President’s Constitutional duties, i.e., “call forth the militia to repel invasion and repress insurrection,” and the attempt by the Founders through the various Compromises that resulted in the Bill of Rights as the first 10 Amendments (originally 12, but 2 weren't ratified) to the Constitution to provide a “tool” or “mechanism” to allow the President to actually do what the Constitution compels him to do…in the absence of a standing Army (or Navy) at the time of the enactment of the Constitution and the Bill of Rights, the ONLY military forces available to the President to do ANYTHING was the Militia…in its various flavors, scattered among the 13 original States, in an incredible range of willingness, readiness, and training to do anything remotely resembling “repel invasions” and “repress insurrections.” The Second Amendment was an (admittedly imperfectly stated) effort to put some meat on the bones of the President’s Constitutional powers to “call forth the militia” and actually enable a response that would be worth something…a “well-regulated” militia meant trained and equipped, and the rest of the Second Amendment provided for a non-standing, non-Federal (thus, the least offensive type of military power, as opposed to the bullying Redcoats or even the extant Continental French, Austrian, or Prussian Army examples) military “force in being,” similar to the late-19th Century later Naval thinker and writer Captain Alfred Mahan’s “Fleet in Being” which simply by existing would dissuade enemy attacks and actions. The fallacy of the “Fleet in Being” was not completely extinguished until the advent of the nuclear age, where congregation of warships in any large numbers was unacceptably risky…and the fallacy of the “militia in being” was not fully extinguished until the eve of World War I, when the modern “draft” was instituted that would, for the first time ever, send large numbers (millions...) of American soldiers overseas to neither "repel invasion" nor "repress insurrection." There was simply no other way to "get there" from the tiny standing, peace-time Armed Forces available on the eve of WWI. Even counting the newly established Army, Navy, and Marine Corps Reserves, along with the new dual-authority National Guard answering to two masters (the State Governor until Federalized and then the President), there was simply no way the United States could possibly mobilize sufficient numbers of young men to go "Over There"...as volunteers. The first two years of WWI showed the US that "industrial warfare" would require far more soldiers, and they were needed far sooner, than ever envisioned. And the establishment of the Reserves, the Draft, and the new powers to Federalize the National Guard all did their part to obscure the role of the “militia,” as well as the meaning of the Second Amendment to prepare “We the People” to “repel invasion” and “repress insurrection” if “called forth” by the President under his Constitutional powers. Thus, the President could lawfully “call forth” pretty much all able bodied men (at least those who are left alive, and are not already members of the Armed Forces) and employ them in the Common Defense. While there isn’t a method provided for the President to “call forth” women, and men older or younger than the Unorganized Militia, the “reality” of this extremely unlikely situation would be essentially a “hail Mary”-type call over the “Emergency Broadcast System” just before the aliens destroy most of our military, or a nuclear winter has commenced, or some other type of similar Armageddon catastrophe: “Americans, if we as a People will survive, it will be up to you. You know what you have to do to defend hearth, home, and the Republic…”At which point, the draft will be irrelevant…Why register if I’m severely disabled, transgendered, conscientious objector, etc.?Well, of course, again, it’s the law of the land. And once that’s out of the way as the obvious answer, the detailed follow up: as described above, and in other answers on this thread, the act of registration is NOT the same thing as actually serving in the Armed Forces. It is NOT volunteering for anything. It is NOT a statement that you are, or are not, physically, mentally, or morally qualified to serve in the Armed Forces. It is NOT a method of pre-registering or pre-determining your desires as to future service in any branch of the armed forces or any particular job or skill therein.If, in the extremely unlikely event that the draft should ever be “ignited” and put back into action, AND a person is “drafted” officially and ordered to report to their designated reception center, THAT is the time to have the necessary doctor’s notes, medical records, clergy’s recommendations, etc., to provide.Clearly, if the court-designated guardian of a severely disabled and institutionalized young man presents documents demonstrating that he can’t even leave his rooms, or understand the nature of the requirement, or travel to the reception center…well, then their name will be stricken from the list, and the draft will move on to the next one.If a young man arrives at the reception center with their clergyman in tow, and is able to demonstrate the fullness of their religious convictions as a conscientious objector, then he may be sent home, mission completed. Or he may be drafted anyway, with restrictions placed upon his employment: perhaps he will be an unarmed medical person. Or work with military clergy. Or only be assigned to certain jobs or certain locations. Or be assigned to Alternative National Service as provided for in the laws. Etc.Or a young man sends a letter to the draft board stating he can’t be drafted or serve because he broke his leg in Switzerland skiing, and he happens to be in Switzerland at the time recovering in a hospital…well, a broken leg will heal (in most cases), and won’t be likely to prevent military service. But it might get a temporary deferral of the date to report…“Report not later than 6 weeks after your Doctor releases you from an in-patient status. You will be evaluated at that time by a Medical Doctor at the Reception Center for your status.” Etc.A person born male, who registered withe Selective Service, and is called up by a draft, but is transgendered and now is female, would still be required to report. But they would wish to bring their medical files and doctor notes for evaluation. Two year ago, I would have said they would have simply been sent home, named checked off the list.But now (at least as of August 2016), I would say that such an individual would probably be given at least the choice of answering their Nation’s call: do you wish to voluntarily enlist/be commissioned (as the case may be based on their skills, etc.) to serve, or elect Alternative National Service, or be deferred from this call to service? It is also possible, that in such a dire national situation, many of the usual restrictions would simply vanish, and such an individual might still be given some choices…but could still just be flat out drafted into the service. The “Sorting Hat” would then have to figure out what to do with them…“Now, what should be we do about you…?”