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Title: A%20Dream%20too%20Far


1
A Dream too Far
  • Transgendered Individuals and the Medical
    Community
  • A Presentation to the OHSU
  • Physicians Assistant Program
  • July 27, 2005

2
Metamorphosis
  • The past is but the beginning of a beginning and
    all that is and has been is but the twilight
    of the dawn

  • H. G Wells

3
Sara Becker, MD
  • Sara Kristine Becker is a board certified Family
    Physician who has practiced Family Medicine and
    Obstetrics in Portland, Oregon for 24 years.
    She obtained a Bachelors of Science in Computer
    Science at Michigan State University where she
    taught for two years. She graduated from the
    University of Michigan Medical School with her MD
    Degree in 1977. Her residency in Family Medicine
    was completed in 1980. She started her
    practice in Milwaukie, Oregon in 1980. She is a
    Diplomat of the American Board of Family Practice
    and an Associate Clinical Professor of Family
    Practice at Oregon Health Sciences University in
    Portland, Oregon. She is a licensed
    multiengine instrument rated commercial pilot
    and an Aviation Medical Examiner for the Federal
    Aviation Administration. Her hobbies are flying,
    computers, piano, guitar, growing orchids,
    walking, and teaching.
  • Her professional interests are general Family
    Medicine, Aviation Medicine, and hormone
    replacement therapy. She is a member of the Harry
    S. Benjamin International Gender Dysphoria
    Association, the Oregon Academy of Family
    Medicine, the Oregon Medical Association, the
    American Academy of Family Physicians, and the
    Civil Aviation Medical Association. She is on the
    Active Staff of Providence Milwaukie Hospital  an
    the Courtesy Staff of Portland Adventist Medical
    Center.

4
To Change Ones Gender
  • Oddity, perversion or fact of nature
  • Frequency
  • Why is it important for health professionals to
    understand gender change or transsexualism in
    Human Beings

5
Jurassic Park
6
Jurassic Park
7
Finding Nemo
8
The Genetics of Sex
  • Note the boy slapping the girl

9
Sex and Gender
  • The genetics of sex
  • The biochemical expression of sex
  • The variability of nature
  • The difference between sex and gender

10
The Variability of Nature
  • Many different types of expression of sex.
  • Over 17 known intersexed conditions in Humans.
  • Some are genetic others biochemical
  • Understanding this variation may form the basis
    for transsexualism.

11
The Genetics of Gender
  • The Y Chromosome is the key

12
The Genetic Expression of Sex
  • The biological pattern in humans is female
  • The Y chromosome triggers the release of
    chemicals which inhibit the formation of female
    structures and instead produces male structures
    1/3 size of X
  • Arose after split between chimps and humans
  • 60 genes produce the male testis and exist in
    multiple copies of the gene. The SRY and ZFY
    direct chain of masculinization.
  • Y chromosome only one that self corrects

13
The Genetic Expression of Sex
  • Prior to six weeks the rudimentary reproductive
    systems in human fetuses appear identical.
  • At 6-7 weeks the gonads differentiate into
    testicles that produce testosterone in XY
    individuals
  • Absence of testosterone causes the Mullerian
    ducts to develop into female genitalia

14
The Genetic Expression of Sex
  • Between six and twelve weeks of pregnancy in an
    XY fetus, testosterone and its derivative
    dyhydrotestosterone promotes masculinization of
    the genitals and produce a penis and testicles
  • Absence of the above produces the clitoris and
    labia,

15
The Biochemical Expression of Sex
16
The Genetic Expression of Sex
  • Between 0.1 and 2.0 of individuals develop
    atypical sexual differentiation.
  • Some are intersexed. Others are developmental
    anomalies
  • There are genetic variations such as XXX, XXY,
    XYY, XO as well

17
The Biochemical Expression of Sex
  • Effects on the Hypothalamus (behavior)
  • Hoch 8 genes
  • Estrogen plays no role in fetal development.
    Females develop because of an absence of
    testosterone not the presence of estrogen

18
The Biochemical Expression of Sex
  • The genes on the chromosomes produce enzymes that
    moderate masculinization.
  • Deficiencies of certain enzymes such as 5
    a-reductase deficiency and 17b hydroxysteroid
    dehydrogenase deficiency produce female like
    genitalia in XY (male) infants because there is a
    lack of dihydrotestosterone required for external
    male genitalia

19
The Biochemical Expression of Sex
  • At puberty, these genetic males but in
    appearance females often masculinize.
  • In one study of 18 individuals with this defect
    raised as girls, 17 rejected the female role and
    adopted a male gender. This is a contradiction
    of rearing producing gender behavior

20
The Biochemical Expression of Sex
  • Guevodoces
  • Penis at 12

21
The Biochemical Expression of Sex
  • Congenital adrenal hyperplasia makes genetic
    females appear as males. This is often
  • associated with increased male behavior.

22
The Biochemical Expression of Sex
  • A Sex Difference in the Human Brain and its
    relationship to Transsexuality 1998, Nature
    37868-70 Zhou J, et al.
  • Male-to-Female Transsexuals Have Female Neuron
    Numbers in a Limbic Nucleus, 2000, J Clinical
    Endocrine Metab 85(5)2034-41
  • John and Joan
  • Finger length

23
The Biochemical Expression of Sex
  • This suggests that gender identity may evolve
    independent of genitals
  • Transmen (F2M) and Transwomen (M2F)tend to be
    left handed more than their age and gender
    matched normal controls. (Green and Young,
    2000) (Zucker 2001)

24
The Variability of Nature
  • In sum, gender identity is, whether consistant
    or inconsistant with other characteristics may be
    understood to be much less a matter of choice
    and much more a matter of biology (Coolidge
    2000) The scientific evidence supports the
    paradigm that transsexualism is strongly
    associated with the neurodevelopment of the brain
    (Zhou 1995)

25
The Biochemical Expression of Sex
  • For more info consult
  • http//www.gires.org.uk

26
The Difference Between Sex and Gender
  • Sex is the physical expression of genes.
  • Gender is the concept of how one relates to
    another in society (masculine vs feminine) and
    self perception.
  • The organic basis of gender identity may be a
    reflection of hormonal effects in utero

27
Gender Identity Dysphoria
  • Considered to be a birth defect
  • Born with the body of one sex and the brain of
    another
  • The disparity between body and mind produces
    depression which often becomes overwhelming
  • Most likely related to intrauterine hormone
    exposure but true causes are unknown
  • Considered throughout the civilized world as a
    medical condition not a psychiatric one
  • The German Prisoner

28
Gender Identity Dysphoria
  • Transsexualism (Christine Jorgenson)
  • History
  • Incidence .2 to 1.0 (true incidence is unknown)
  • Males to Females (M2F) or MTF
  • Females to Males (F2M) or FTM

29
Gender Identity Dysphoria
  • Who you are
  • Who you love

30
The Farthest Journey
  • A Journey too Far
  • A Trip from one existence to another
  • How long does it really take?

31
Feelings and Memories
  • Of Mind and Thought
  • The Deep Feelings
  • The Bedtime Prayer
  • Living The Lie
  • The False Construct
  • Puberty the Treason of the Body
  • The Wakening Dream

32
The Shell Cracks
  • The pain of not being--?relation to testosterone
  • The emergence of Gender Identity Dysphoria
  • The Ultimate Dilemma
  • Addressing the mirror
  • The spiral downward
  • Facing the end of being or a new being in the end

33
The Shell Cracks
  • Gender Identity Disphoria is a situational
    depression.
  • It cannot be cured with drugs, therapy, or prayer
  • Dysphoria means difficult to bear in Greek
  • Some patients become acutely suicidal when the
    feelings cannot be contained and they face a loss
    of all they hold dear knowing the stigma of
    changing gender

34
From True Selves by Mildred Brown
35
Gender Identity Dysphoria
  • Since the mind cannot be changed, the body must
    be changed
  • In modern therapy, no attempt is made to cure the
    transsexual. Rather, options are explored
  • Some exist living part-time in the gender of
    their mind. Most seek to transition
  • Our society is not geared for us to live In
    Between

36
Symptoms of GID
  • A situational depression
  • Drugs and Alcohol abuse
  • Devotion to profession, military commitment
  • To transition or not-endless rumination
  • The price of truth
  • Mildred Brown

37
The Harry S. Benjamin International Gender
Dysphoria Association

38
The Harry S. Benjamin International Gender
Dysphoria Association
  • The Harry Benjamin International Gender Dysphoria
    Association, Inc. (HBIGDA) is a professional
    organization devoted to the understanding and
    treatment of gender identity disorders. There are
    approximately 350 members from around the world,
    in the fields such as psychiatry, endocrinology,
    surgery, psychology, sexology, counseling,
    sociology, and law.
  • HBIGDA provides opportunities for scientific
    interchange among professionals through its
    biennial conferences and publications. It
    develops and publishes Standards of Care for the
    treatment of gender identity disorders. These
    internationally accepted guidelines are designed
    to promote the health and welfare of persons with
    gender identity disorders.

39
Treatment of Gender Identity Dysphoria
  • The Harry S Benjamin International Gender
    Identity Dysphoria Association provides
  • Certification and guidelines for counselors who
    treat transsexuals
  • Provide guidelines for cross gender hormone
    therapy
  • Provide guidelines for gender reassignment
    surgery
  • (sex change surgery)

40
The Harry S. Benjamin International Gender
Dysphoria Association
  • Establishing Standards of Care for Gender
    Identity Disorders
  • HBIGDA has established internationally accepted
    Standards of Care (SOC) for the treatment of
    gender identity disorders. These standards are
    updated and revised as new scientific information
    becomes available. The latest revision, SOC
    Version Six, was released February 20, 2001.

41
Transition
  • To change ones body and mind image to the gender
  • Opposite to the cage one is born to.
  • To learn to relate in society as one of the
    opposite
  • Gender.
  • The process of Becoming or Transitioning

42
Transition
  • To actively transition requires skilled
    counseling, emotional support, and intense
    planning.
  • This is an illness that does not favor the
    illiterate, the impoverished, or the ignorant.
  • It does favor the mind that can plan and write.

43
Steps in Transition
  • Counseling
  • Electrolysis or Laser to remove the beard
  • Hormone Therapy to change the body
  • The Real Life Test
  • Surgery
  • Beyond

44
To Find a Chiron
  • The importance of the therapist who is skilled in
    treating transsexualism
  • What am I?
  • How do I adjust to what I am?
  • How do I make myself understood?
  • How do I forgive myself to not being fixable
  • How do I deal with so many others

45
Counseling
  • It is critical to find a therapist that will work
    with to provide the feedback and support to
    succeed.
  • Must be familiar with the Harry S. Benjamin
    International Gender Dysphoria Association
  • Finding the right one

46
Issues of Transition Dealt with in Counseling
  • Timing of transitioning
  • Hormone therapy
  • Informing spouses
  • Informing children
  • Informing friends
  • Informing relatives
  • Job preservation
  • Survival

47
The Role of the Therapist
  • Weighing the options
  • Timing
  • No attempt to cure

48
First Visit
  • Patient fear
  • Shame
  • Guilt
  • Depression
  • LossBe prepared to lose everything and anything
    you keep is a gift
  • The friend
  • The professional

49
The First Believer
  • A close friend one who will be accepting and can
    act as a mirror for the new being
  • Trust
  • Availability
  • Sharing the burden.
  • Jesus started with only 12
  • The Mole

50
Educating Others
  • Being a transsexual means that one wishs to
    change how one relates to others in society as a
    member of the other gender. It does not mean one
    is gay, trying to deceive others or that this is
    a life choice Rather it is the way one has
    always been.
  • Mildred Browns book True Selves

51
Educating
  • Dozens of peopledozens of feelings
  • People basefeelings on their own life
    experiences, moral and religious beliefs
  • Not beneficial to out to large groups
  • The advocate
  • Education of the masses

52
Issues of Transition
  • Electrolysis
  • Hormone therapy
  • Preserving hair Rogaine, Finasteride, Avodart
  • Voice
  • Walking
  • Mannerisms and clothing
  • Physical changes
  • Legal changes
  • Work
  • Surgery

53
Issues of Transition
  • Economics
  • Male to female 20,000-100,000
  • Female to male 10,000 (top) to 100,000
  • Loss of job (70 of professional Ts in San
    Francisco are unemployed)
  • Physicians most likely to be fired
  • Divorce

54
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55
Hormones
  • It is the human sex hormones which shape the clay
    that becomes the being.
  • Human beings are not fixed permanently into one
    gender or another.
  • To a great degree, feminization and
    masculinization can occur in the same body at
    different stages of life.

56
Hormone Therapy
  • Estrogen to change the body to a feminine form
    and soften the skin in M2F
  • Antiandrogens to block testosterone so the
    estrogen can work in M2F
  • Testosterone injections to change female forms to
    male

57
Hormones
  • We all go through this process once.
  • It is called puberty.
  • It takes five to seven years the first time.
  • It is not any faster the second time.
  • To transition one must reverse the effects of the
    first puberty as well as let the second occur.
  • Higher hormone doses do not speed the process but
    do increase risks and side effects.

58
The Harry S Benjamin Standards of Care
  • Reasons for hormone therapy. Cross-sex hormonal
    treatments play an important role in the
    anatomical and psychological gender transition
    process for properly selected adults with gender
    identity disorders.
  • Hormones are often medically necessary for
    successful living in the new gender. They improve
    the quality of life and limit psychiatric
    co-morbidity, which often accompanies lack of
    treatment. When physicians administer androgens
    to biologic females and estrogens, progesterone,
    and testosterone-blocking agents to biologic
    males, patients feel and appear more like members
    of their preferred gender.
  • Clinical departures from these guidelines may
    come about because of a persons unique anatomic,
    social, or psychological situation.

59
The Harry S Benjamin Standards of Care
  • The individual must be known to a clinical
    behavioral scientist for at least three months
    and that provider should endorse the patients
    request for hormone therapy with a letter.
  • Clinical departures from these guidelines may
    come about because of a persons unique anatomic,
    social, or psychological situation.

60
Effect of Hormones
  • Physical changes
  • Mental changes
  • Emotional changes

61
Estrogen in M2F
  • Conjugated estrogens (Premarin, Ogen) 0.625 to
    7.5 mg.
  • Ethiny Estradiol (Estinyl) .02 to2.0.
  • Estradiol (Estrace) 0.5 to 6.0mg.
  • Estradiol Transdermal (Fempatch, Alora, Climara,
    Estraderm) .1 to .2.
  • Delestrogen () 40 mg q 2 weeks.

62
Antiandrogensin M2F
  • Block the production and effects of testosterone.
  • Use allows a lower dose of estrogen to produce
    the same feminization but reduce the risks of
    estrogen.
  • Many different kinds but many are expensive.

63
Antiandrogensin M2F
  • Spironolactone (Aldactone) 100-400 mg.
  • Very effective at blocking testosterone, both
    synthesis and at a receptor level.
  • Side effects are- breast swelling, GI upset,
    drowsiness, headache, rash, confusion, fever,
    decreased libido, vomiting, balance problems,
    fever, elevated potassium.
  • Very useful to measure free testosterone levels.

64
Complications MTF
  • Cancers 2
  • Myocardial Infarction 2
  • Osteoporosis 1
  • Total Serious complications 5.4

65
Typical Hormone Levels
  • Estradiol male 0.30-0.90 pg. /Ml. (Total)
  • Free Estradiol (1.66-2.11) .10-.50 pg./Ml
  • Estradiol female 20-450 pg./Ml. (Total)
  • Free Estradiol (1.49-2.85) or .60-4.10 pg./Ml

66
Typical Hormone Levels
  • Testosterone male 260-1000 ng./Ml. (Total)
  • Free testosterone (1.0-2.7) or 50-210 pg./Ml
  • Testosterone female 15-70 ng./Ml. (Total)
  • Free testosterone (0.5-1.8) or 1.0-8.5 pg./Ml

67
Typical Hormone Therapies in F2M
  • Testosterone Cypionate 100 mg IM weekly or 200
    mg. every two weeks
  • In Portland, often bought at Stroheckers
    pharmacy
  • Cannot give testosterone orally because of liver
    toxicity

68
Aspirin
  • Aspirin 81 mg.
  • Reduces risk of thrombosis and coronary events
  • Increases risks of bleeding
  • Increases bleeding during electrolysis

69
Steps Before Initiating Hormone Therapy
  • The DSM IV criteria
  • The Harry S. Benjamin standards
  • Physical exam
  • Laboratory tests
  • Contraindications for therapy

70
Side Effects of Estrogen on Genetic Males
  • Excessive breast tenderness or discharge
  • Pituitary tumors and Hyperprolactinemia
  • Thromboembolic events (particularly first year of
    HRT)
  • High blood pressure
  • Breast cancer
  • Decreased libido, loss of erections, infertility
  • Depression or mood disorder
  • Loss of muscle mass (leg cramps, 30 loss of
    strength)

71
Side Effects of Testosterone on Females (F2M)
  • First changes are deepening of the voice in about
    1-3 months
  • Periods cease within 1-2 months (titration) with
    IM shots Cream takes 6-8 months
  • Facial hair develops in 6-24 months and may take
    five years to maximize. Highly individual
    results
  • Acne develops in 2-4 months
  • Skeletal structure does not change (???)
  • Breast size does not change

72
Side Effects of Testosterone on Females (F2M)
  • Muscle mass increases about 30, reduces fat and
    redistributes fat to male pattern
  • Facial Changes
  • Effects on bone
  • Effects on skin
  • Psychological effectsRoid Rages
  • Neurologic effects--

73
Changes on Testosterone in FTM
  • Cliteromegaly-seems to occur very early
  • Length is 1.5 to 2.5 inches

74
History and Physical Examination
  • Must be done to look for preexisting medical
    conditions which would complicate or preclude
    hormone therapy
  • After hormone therapy is instituted, regular
    visits should be carried out at three to six
    month intervals to look for complications and
    adjust doses
  • Insurances sometimes will cover this as hormone
    replacement therapy

75
Contraindications for Hormone Therapy
  • Strong family history of breast cancer in first
    degree relatives or presence of breast cancer in
    genetic males
  • Uncontrolled high cholesterol in genetic females
  • Strong family history of osteoporosis in genetic
    females
  • Extreme obesity
  • Coexistent mental illness, particularly
    uncontrolled depression

76
Contraindications for Hormone TherapyCaveats for
the Patient
  • Usually with good medical care and treatment of
    underlying illness, hormone therapy can be
    started.
  • Honesty is very important in dealing with the
    physician.
  • The physician is not the enemy.
  • He or she is your best ally to get where you want
    to go to and to arrive safely.
  • Achieving your dream is not satisfying if you are
    dead or stroked out.

77
Long Term Effects of Hormone Therapy
  • Thromboembolism (clotting abnormalities)
  • Arteriosclerosis (heart disease)
  • Osteoporosis (thinning of bones)
  • Cancer
  • Dementia
  • Little actually known

78
Complications MTF
  • 291 Males to Females ages 24 to 79
  • 3 cases mild liver disease
  • 4 cases of detected osteoporosis in MTFPO age
    35-52
  • 1 case of pulmonary embolus antithrombin 3 defect
  • 1 case of death myocardial infarction age 49
    smoker no aspirin
  • 1 case of death, MI, 1 wk after srs, smoker,
    ASA, patch 42
  • 1 case of myocardial infarction age 52 during
    hair transplant nonsmoker, no ASA
  • 1 case during SRS Thailand prev smoker, no ASA
  • 1 case Sudden death age 49 smoker not started HRT

79
Complications MTF
  • 1 case of prolactin secreting tumor
  • 2 cases of carcinoma of the throat
  • 1 case of small cell carcinoma lung
  • 1 case of malignant Melanoma
  • 1 case of invasive prostate cancer 10 years on
    10 mg of Premarin
  • 2 incidence

80
Complications FTM
  • Females to males
  • 2 cases of liver disease alcoholic suspect in one
  • No need to stop hormones
  • Increase in red cell mass in all test from HCT
    of about 38 to 50-52
  • No strokes, heart attacks or breast cancer
  • Frequent vaginitis
  • Acne
  • Three cases of sleep apnea (size 16 neck)

81
Survival
  • Be flexible
  • Support groups
  • Churches
  • Journal
  • Internet

82
Identification
  • The importance of proper identification
  • The role of the therapist
  • Drivers licenses
  • Letter of passage

83
Real Life Test
  • The real life test is the period of time that one
    must work in the gender one is becoming
  • With completion of the real life test, one can
    seek the two letters for Gender Reassigment
    Surgery (Sex Change Surgery)

84
Real Life Test
  • Usually one year
  • One has to work as the future gender
  • Time off work for SRS

85
Real Life Test
  • Difficult for individuals because of numerous
    licensing agencies, insurance companies,
    employers, prejudice
  • Real life test is difficult especially for
    professionals
  • Loss of family, friends, home, life

86
Facial Surgery
  • Forehead
  • Nose
  • Upper lip
  • Chinsliding genioplasty
  • Jaw
  • Tracheal Shave
  • Doug Osterhoud, MD
  • Electrolysis

87
Sex Reassignment Surgery
  • Sex Reassignment Surgery is the goal of many but
    not all who are transgendered
  • Can be offered only after the real life test
  • Not an option for physicians with GID
  • There is a harmony in having your body match your
    mind
  • Less fear of being caught in social situations
  • The two lettersMA, PhD., MD
  • Ten surgeons in the world

88
Sex Reassignment Surgery in Females to Males
  • Sex Reassignment Surgery in F2M usually limited
    to Breast reconstruction top surgery
  • Genital surgery limited

89
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93
In The End
  • After all of the above what is left?
  • Time and experience
  • Posttraumatic Stess Disorderregret, loss
  • Memories and reflections
  • Dreams, feelings and thoughts become one
  • To gaze on ones own countenance with peace
  • To savor the milieu, to just live

94
How long Does it Take
  • Range is 2 to 5 years
  • Real answer is at least 5 years
  • Probably a lifetime

95
Importance
  • Why is it important for Health Professionals to
    understand transsexuals?

96
Most Important
  • It is not a choice of life, it is a biological
    imperative. Individuals with this cannot make it
    go away. It is a pain similar to what one feels
    in the death of a child. Often face with loss of
    all they hold dear, transsexuals often consider
    or attempt suicide. The transsexual is often an
    individual of extraordinary courage.
  • It is not an attempt to deceive but to survive.
  • Who you are and who you love are different areas
    of the brain. Over 30 male to female
    transsexuals stay with their mate if they can.

97
Why Is It Important For Professionals to
Understand Transsexuals
  • There are many of us--thousands
  • We hide because of fear and prejudice
  • We are 16 times more likely to be murdered
  • We have the highest unemployment of any minority
    group
  • Not associated with any other mental or medical
    condition

98
Why is it Important For Professionals to
Understand Transsexuals
  • Do we deprive the community of human beings
    because we do not understand?
  • If a human were burned or paralyzed, would they
    be less a human being?
  • Transition does not change the essence of a Human
    being
  • Would any Medical Professional deny a patient the
    only internationally recognized treatment for a
    condition because they do not themselves
    understand it.

99
Why is it Important For Professionals to
Understand Transsexuals
  • The Health Professional may be the first outside
    of the transsexual themselves to know what is
    really happening.
  • How you respond may influence the future of that
    patient.
  • Almost all transsexuals consider suicide when the
    shell breaks. Estimates of 20 active attempt.
  • Suicide without a letter

100
Gender Dysphoria
  • A human being who survives this has a unique
    perspective on both genders that can be helpful
    to others
  • You may be the only professional between a
    successful transiton and suicide

101
Gender Dysphoria
  • The Federal Aviation Administration is charged
    with maintaining the safety of the public in
    Aviation in the United States
  • A Pilot who is diagnosed with Gender Identity
    Disorder is not allowed to fly again until they
    have fully transitioned to their new gender and
    have had surgery. There is no other way back to
    the cockpit.

102
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103
Resources
104
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105
Web Resourcesannelawrence.com
106
Web Resourcessarabecker/t/index.htm
107
Web Resourcessarabecker/t/index.htmsara_at_sarabe
cker.com
108
Questions?
  • He who asks a question is a fool for five minutes
  • He who fails to ask a question is a fool for life
  • Old
    Chinese Proverb

109
Questions
  • A New Years Prayer
  • Dear Lord, please give me
  • A few friends who understand me
  • and yet remain my friends
  • A work to do which has real value,
  • without which the world
  • would feel the poorer
  • A mind unafraid to travel,
  • even though the trail be not blazed
  • An understanding heart
  • A sense of humor.
  • Time for quiet silent meditation.
  • A feeling of the presence of God.
  • And the patience to wait
  • For the coming of these things,
  • with the wisdom to know them
  • when they come
  •  
  • -W. R. Hunt.
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