Vitamin C supplementation reduces the odds of developing a common cold in Republic of Korea Army recruits: randomised controlled trial.

INTRODUCTION: The Republic of Korea (ROK) military has a high incidence of respiratory diseases at training centres. Vitamin C has been reported to reduce the incidence of colds. For the purpose of preventing soldiers' respiratory diseases, this study aimed to investigate whether vitamin C intake can prevent common colds in the ROK Army soldiers. METHODS: This was a randomised, placebo-controlled, and double-blind trial of soldiers who enlisted in the Korea Army Training Centre for 30 days from 12 February to 13 March 2018. The study participants were divided into groups (vitamin C vs placebo). The military medical records were searched to determine whether the participants had a common cold. Multiple logistic regression analysis was performed to identify the association between vitamin C intake and diagnosis of common colds. In addition, subgroup analysis on the relationship between vitamin C intake and common cold according to smoking status, training camp and physical rank was conducted. RESULTS: A total of 1444 participants were included in our study. Of these participants, 695 received vitamin C (6000 mg/day, vitamin C group), while 749 participants received placebo (0 mg/day, placebo group). The vitamin C group had a 0.80-fold lower risk of getting a common cold than did the placebo group. Subgroup analyses showed that this effect was stronger among subjects in camp A, among never smokers and among those in physical rank 3. CONCLUSION: Vitamin C intake provides evidence to suggest that reducing the common colds in Korean Army soldiers. Our results may serve as a basis for introducing military healthcare policies that can provide vitamin C supplementation for military personnel in basic military training.

Risk Associated With Autologous Fresh Whole Blood Training.

Fresh whole blood (FWB) is increasingly being recognized as the ideal resuscitative fluid for hemorrhagic shock. Because of this, military units are working to establish the capability to give FWB from a walking blood bank donor in environments that are unsupported by conventional blood bank services. Therefore, many military units are performing autologous blood transfusion training. In this training, a volunteer has a unit of blood collected and then transfused back into the same donor. The authors report their experience performing an estimated 3408 autologous transfusions in training and report no instances of hemolytic transfusion reactions or other major complications. With appropriate control measures in place, autologous FWB training is low-risk training.

Readiness Of Medical Providers In The Military Health System: Overview Of Operational And Policy Considerations.

US military forces have diverse missions, including combat, response to natural disasters, humanitarian assistance, training, and diplomacy. The military's medical forces, composed of clinical providers from the Army, Navy, and Air Force, support these operations-often on a moment's notice. The Military Health System (MHS) must ensure that medical providers are always trained and equipped to deliver care when deployed on missions in often austere environments. As part of its approach to this challenge, the MHS has initiated a data-driven effort to determine required clinical competencies by identifying and measuring the knowledge, skills, and abilities required for care in these environments. These efforts are being implemented while the MHS is undergoing significant organizational change. In this article we describe past and current efforts to maintain a "ready medical force" as well as current challenges and opportunities related to maintaining the readiness of medical providers while the MHS intends to evolve into an integrated health system.

Optimizing Warfighter Lethality Through Human Performance Education.

Humans are the heart of our warfighting efforts and, as such, human performance must be optimized and sustained to maintain effective and successful SOF Operators over the long haul. How do we do this? Based on the July 2018 signing of a Joint Requirements Oversight Council Memo (JROC) making Total Force Fitness (TFF) a required framework for taking care of our military Servicemembers, we propose three solutions for further optimizing the performance of SOF. The proposed solutions are human performance optimization (HPO)/TFF capability-based blueprinting (CBB), HPO integrator profession (HPO-I), and HPO-centric education and training across the total force. These solutions would potentiate the Preservation of the Force and Family (POTFF) concept by improving the targeting of resources and support of Operator and unit operational readiness. These solutions, the knowledge, skills, abilities, and experiences in HPO from a holistic perspective and the opportunity to obtain college credits through the Uniformed Services University of the Health Sciences (USU) College of Allied Health Sciences (CAHS) are described here.

Effectiveness of Acceptance and Commitment Therapy in Increasing Resilience and Reducing Attrition of Injured US Navy Recruits.

INTRODUCTION: US Navy recruits who have injuries preventing them from participating in intense physical conditioning are pulled out of boot camp training and receive treatment that includes daily physical therapy, pain medications, and psychoeducational groups. Graduation from boot camp for these recruits requires not only recovering from their injuries but also passing a required Physical Fitness Assessment consisting of a timed 1.5-mile run, curl-ups, and push-ups. About 50-60% of these recruits will eventually be separated out and sent home. The purpose of this study is to examine the effectiveness of an Acceptance and Commitment Therapy (ACT)-based program called Mindfulness for Pain and Performance Enhancement (MPPE). This treatment program was designed to help recruits effectively handle pain and assist them in improving their physical performance in the service of recovery, boot camp completion, and entrance into the Navy. MATERIALS AND METHODS: This study was approved by the Edward Hines VA Hospital/Captain James A. Lovell Federal Health Care Center Institutional Review Board and the Naval Services Training Command. Treatment was voluntary and a total of 373 recruits enrolled in one of the 32 cycles of MPPE administered. Attrition was 35.1% (131 recruits). The control group comprised 310 recruits who did not enroll in MPPE. Recruits continued to receive standard treatment services (e.g., physical therapy, medical interventions, and psychoeducational groups) while participating in MPPE. Chi-square tests and one-way analysis of variance were used to analyze comparisons among treatment, control, and attrition groups on demographic, clinical, and boot camp training variables. Paired sample t-tests and Cohen's d effect sizes were computed to assess change on treatment outcome measures. Logistic regression was performed to identify demographic, clinical, and boot camp training variables predictive of graduation. RESULTS: All of the pre- to post-treatment outcome measures were significant and Cohen's d effect sizes ranged from 0.41 to 0.84. Effect size changes were small for anxiety and experiential avoidance; moderate for pain acceptance, mindfulness, cognitive inflexibility, and depression; and large for pain reduction. Treatment completers graduated at a higher rate (58.3%) than attrites (34.4%) or controls (45.5%). Based on a logistic regression model, variables predictive of graduation included MPPE completion, age, and reported pain rating. CONCLUSION: MPPE is a six-session, 2-wk-long Acceptance and Commitment Therapy-based approach to pain and physical performance that was added to existing treatment services. Results supported the use of this program for helping recruits recover from injuries and successfully pass physical training requirements for graduation. Recruits were not randomly assigned to treatment, thus limiting the interpretation of outcomes. Incorporating this treatment earlier in boot camp training and making it available to more recruits (i.e., not only injured recruits) may further reduce attrition and contribute to greater resiliency of sailors within the US Navy fleet.

Building Capacity for Complementary and Integrative Medicine Through a Large, Cross-Agency, Acupuncture Training Program: Lessons Learned from a Military Health System and Veterans Health Administration Joint Initiative Project.

Introduction: Complementary and integrative medicine (CIM) use in the USA continues to expand, including within the Military Health System (MHS) and Veterans Health Administration (VHA). To mitigate the opioid crisis and provide additional non-pharmacological pain management options, a large cross-agency collaborative project sought to develop and implement a systems-wide curriculum, entitled Acupuncture Training Across Clinical Settings (ATACS). Materials and Methods: ATACS curriculum content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts and provider feedback. Course content was developed to be applicable to the MHS and VHA environments and training was open to many types of providers. Training included a 4-hr didactic and "hands on" clinical training program focused on a single auricular acupuncture protocol, Battlefield Acupuncture. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Immediately following training, providers completed an evaluation survey on their ATACS experience. One month later, they were asked to complete another survey regarding their auricular acupuncture use and barriers to use. The present evaluation describes the ATACS curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. Results: Over the course of a 19-mo period, 2,712 providers completed the in-person, 4-hr didactic and hands-on clinical training session. Due to the increasing requests for training, additional ATACS faculty were trained. Overall, 113 providers were approved to be training faculty. Responses from the trainee surveys indicated high satisfaction with the ATACS training program and illuminated several challenges to using auricular acupuncture with patients. The most common reported barrier to using auricular acupuncture was the lack of obtaining privileges to administer auricular acupuncture within clinical practice. Conclusion: The ATACS program provided a foundational template to increase CIM across the MHS and VHA. The lessons learned in the program's implementation will aid future CIM training programs and improve program evaluations. Future work is needed to determine the most efficient means of improving CIM credentialing and privileging procedures, standardizing and adopting uniform CIM EHR codes and documentation, and examining the effectiveness of CIM techniques in real-world settings.

The Relationship Between Soldier Performance on the Two-Mile Run and the 20-m Shuttle Run Test.

Background: The 20-m shuttle run test (MSRT) is a common field test used to measure aerobic fitness in controlled environments. The U.S. Army currently assesses aerobic fitness with the two-mile run (TMR), but external factors may impact test performance. The aim of this study is to examine the relationship between the Army Physical Fitness Test TMR performance and the MSRT in military personnel. Methods: A group of 531 (403 males and 128 females) active duty soldiers (age: 24.0 ± 4.1 years) performed the MSRT in an indoor facility. Heart rate was monitored for the duration of the test. Post-heart rate and age-predicted maximal heart rate were utilized to determine near-maximal performance on the MSRT. The soldiers provided their most recent Army Physical Fitness Test TMR time (min). A Pearson correlation and multiple linear regression analyses were performed to examine the relationship between TMR time (min) and MSRT score (total number of shuttles completed). The study was approved by the Human Use Review Committee at the U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts. Findings: A significant, negative correlation exists between TMR time and MSRT score (r = -0.75, p < 0.001). Sex and MSRT score significantly predicted TMR time (adjusted R2 = 0.65, standard error of estimate = 0.97, p < 0.001) with a 95% ratio limits of agreement of ±12.6%. The resulting equation is: TMR = 17.736-2.464 × (sex) - 0.050 × (MSRT) - 0.026 × (MSRT × sex) for predicted TMR time. Males equal zero, females equal one, and MSRT score is the total number of shuttles completed. Discussion: The MSRT is a strong predictor of the TMR and should be considered as a diagnostic tool when assessing aerobic fitness in active duty soldiers.

A Shift From Resilience to Human Performance Optimization in Special Operations Training: Advancements in Theory and Practice.

Within the Department of Defense over the past decade, a focus on enhancing Warfighter resilience and readiness has increased. For Special Operation Forces (SOF), who bear unique burdens for training and deployment, programs like the Preservation of the Force and Family have been created to help support SOF and their family members in sustaining capabilities and enhancing resilience in the face of prolonged warfare. In this review, we describe the shift in focus from resilience to human performance optimization (HPO) and the benefits of human performance initiatives that include holistic fitness. We then describe strategies for advancing the application of HPO for future initiatives through tailoring and cultural adaptation, as well as advancing methods for measurement. By striving toward specificity and precision performance, SOF human performance programs can impact individual and team capabilities to a greater extent than in the past, as well as maintaining the well-being of SOF and their families across their careers and beyond.

Effects of proanthocyanidin on oxidative stress biomarkers and adipokines in army cadets: a placebo-controlled, double-blind study.

PURPOSE: The relatively recent advent of polyphenol supplement for exercise studies has been tested in a variety of forms and doses. However, the dose-response on adipokines and oxidative stress biomarker effect remains unknown. The aim of the present study was to assess the effect of intense, long-duration (48-h) exercise, and a single dose of proanthocyanidin, on plasma leptin, adiponectin, and electronegative low-density lipoprotein (LDL(-)) concentrations. METHODS: Fifty-four healthy male army cadets (22 ± 2 years) participated in a double-blind, randomized, placebo-controlled study and were distributed between control (CG; n = 27) and supplemented groups (SG; n = 27). Immediately before the start of the exercise, both CG and SG groups received a capsule containing starch (200 mg) or proanthocyanidin (dry Vitis vinifera extract, 200 mg), respectively. Following a 12-h fasting period, the plasma adiponectin, leptin, and LDL(-) concentrations were measured prior to the start of the exercise after 24 and 48 h of military training, and after 24 h of rest. The effects of the proanthocyanidin (supplement), exercise (time), and their interaction were investigated using factorial two-way ANOVA. RESULTS: Plasma leptin concentration was only influenced by exercise (p = 0.001). Plasma adiponectin concentration was influenced by exercise (p = 0.037), and by the exercise x supplement interaction (p = 0.033). LDL(-) was influenced by the supplement (p = 0.001), exercise (p = 0.001), and their interaction (p = 0.001). CONCLUSIONS: A single dose of proanthocyanidin (200 mg) was able to reduce LDL(-) concentration and increase plasma adiponectin concentration after 24 h of rest in SG group, indicating its potential protective action.

The U.S. Army Occupational and Environmental Medicine Residency at Aberdeen Proving Ground, Maryland: 1960-1996.

BACKGROUND: Reorganization of the Army and critical assessment of Army Graduate Medical Education programs prompted the Occupational and Environmental Medicine (OEM) Consultant to the Army Surgeon General to initiate a review of current Army OEM residency training. Available information indicated the Army OEM residency at Aberdeen Proving Ground, MD, was the first and longest operating Army OEM residency. Describing this residency was identified as the first step in the review, with the objectives of determining why the residency was started and sustained and its relevance to the needs of the Army. METHODS: Records possibly related to the residency were reviewed, starting with 1954 since certification of physicians as Occupation Medicine specialists began in 1955. Interviews were conducted with selected physicians who had strong affiliations with the Army residency and the practice of Army OEM. FINDINGS: The Army OEM residency began in 1960 and closed in 1996 with the transfer of Army OEM residency training to the Uniformed Services University of the Health Sciences, Bethesda, MD. Over 36 years, 47 uniformed residency graduates were identified; 44 were from the Army. Forty graduated between 1982 and 1996. The OEM residency was part of a dynamic cycle. Uniformed OEM leaders identified the knowledge and skills required of military OEM physicians and where these people should be stationed in the global Army. Rotations at military sites to acquire the needed knowledge and skills were integrated into the residency. Residency graduates were assigned to positions where they were needed. Having uniformed residents and preceptors facilitated the development of trust with military leaders and access to areas where OEM physician skills and knowledge could have a positive impact. Early reports indicated the residency was important in recruiting and retaining OEM physicians, with emphasis placed on supporting the Army industrial base. The late 1970s into the 1990s was a more dynamic period. There was heightened interest in environmental protection and restoration of military installations, and in the threats posed by nuclear, biological and chemical weapons. Additionally, President Reagan initiated a military buildup that brought new health risks to soldiers who would use and maintain modern equipment. Army OEM physicians were required to possess competencies in many areas, to include depots in the Army industrial base, occupational health for the soldier for exposures like carbon monoxide in armored vehicles, military unique exposures like those from chemical threat agents, and environmental medicine to assess health risks on contaminated U.S. military sites and from exposures of deployed forces. These offered interesting OEM training opportunities that challenged residents in the program and helped recruit new residents. DISCUSSION: The strength of the first Army OEM residency was that it was part of a dynamic cycle that consisted of identifying and defining Army OEM needs, training physicians to meet those needs and assigning residency graduates to positions where they would have a positive impact. This paradigm can be used as the basis for contemporary assessments of the Army's need for uniformed OEM physicians and a uniformed OEM residency program.

Consumption of a calcium and vitamin D-fortified food product does not affect iron status during initial military training: a randomised, double-blind, placebo-controlled trial.

Ca/vitamin D supplementation maintains bone health and decreases stress fracture risk during initial military training (IMT); however, there is evidence that Ca may negatively affect the absorption of other critical micronutrients, particularly Fe. The objective of this randomised, double-blind, placebo-controlled trial was to determine whether providing 2000 mg/d Ca and 25 µg/d vitamin D in a fortified food product during 9 weeks of military training affects Fe status in young adults. Male (n 98) and female (n 54) volunteers enrolled in US Army basic combat training (BCT) were randomised to receive a snack bar with Ca/vitamin D (n 75) or placebo (snack bar without Ca/vitamin D; n 77) and were instructed to consume 2 snack bars/d between meals throughout the training course. Circulating ionised Ca was higher (P0·05) in markers of Fe status between placebo and Ca/vitamin D groups. Collectively, these data indicate that Ca/vitamin D supplementation through the use of a fortified food product consumed between meals does not affect Fe status during IMT.

Los caballos y las Órdenes de Caballería: una visión a través de Las Siete Partidas de Alfonso X 'El Sabio', y de otros documentos / The horses and the Orders of Chivalry: a vision through 'The Seven-Part Code' of Alfonso XI 'The Wise' and other documents

El código de honor que regía la vida del caballero medieval fue una conquista relativamente tardía -durante el S. XII, aproximadamente-, lograda principalmente por la Iglesia para controlar los desmanes de los primitivos guerreros. Los cambios sociales y culturales acentuaron la evolución. Para este estudio, se han utilizado documentos del S. XIII donde se observa la importancia de los Caballos Hispanos de la época, especialmente por su uso bélico contra los musulmanes. Además, se ha extraído la información más interesante dentro de Las Siete Partidas de Alfonso X 'El Sabio', donde se muestra la visión que se tenía de los caballeros y sus armas (siendo el caballo el arma ideal) durante la Baja Edad Media. Todos estos documentos son esenciales para comprender este periodo histórico y la evolución posterior, con la unión de las coronas peninsulares y la formación de un ejército único para toda España, con la caballería como eje

The honor code followed by the medieval knight was a relatively late achievement -during the 12th century, approximately-, mainly thanks to the Church in order to control the abuses of primitive warriors. Social and cultural changes increased evolution. For this work, some documents from the 13th century have been used, which show the importance of Hispanic Horses of that time, in special for their military services against muslims. Besides, the most interesting information from The Seven-Part Code of Alfonso X 'The Wise', has been extracted and it shows how the knights and their weapons (the ideal weapon the horse) were considerated during the Middle Ages. All these documents are essential to understanding this historical epoch and the next period, with the union of peninsular crowns and the consolidation of a unique army for Spain, with the cavalry as a central axis

Calcium and vitamin D supplementation maintains parathyroid hormone and improves bone density during initial military training: a randomized, double-blind, placebo controlled trial.

Calcium and vitamin D are essential nutrients for bone health. Periods of activity with repetitive mechanical loading, such as military training, may result in increases in parathyroid hormone (PTH), a key regulator of Ca metabolism, and may be linked to the development of stress fractures. Previous studies indicate that consumption of a Ca and vitamin D supplement may reduce stress fracture risk in female military personnel during initial military training, but circulating markers of Ca and bone metabolism and measures of bone density and strength have not been determined. This randomized, double-blind, placebo-controlled trial sought to determine the effects of providing supplemental Ca and vitamin D (Ca+Vit D, 2000mg and 1000IU/d, respectively), delivered as 2 snack bars per day throughout 9weeks of Army initial military training (or basic combat training, BCT) on PTH, vitamin D status, and measures of bone density and strength in personnel undergoing BCT, as well as independent effects of BCT on bone parameters. A total of 156 men and 87 women enrolled in Army BCT (Fort Sill, OK; 34.7°N latitude) volunteered for this study. Anthropometric, biochemical, and dietary intake data were collected pre- and post-BCT. In addition, peripheral quantitative computed tomography was utilized to assess tibia bone density and strength in a subset of volunteers (n=46). Consumption of supplemental Ca+Vit D increased circulating ionized Ca (group-by-time, P=0.022), maintained PTH (group-by-time, P=0.032), and increased the osteoprotegerin:RANKL ratio (group-by-time, P=0.006). Consistent with the biochemical markers, Ca+Vit D improved vBMD (group-by-time, P=0.024) at the 4% site and cortical BMC (group-by-time, P=0.028) and thickness (group-by-time, P=0.013) at the 14% site compared to placebo. These data demonstrate the benefit of supplemental Ca and vitamin D for maintaining bone health during periods of elevated bone turnover, such as initial military training. This trial was registered with ClincialTrials.gov, NCT01617109.

Auricular acupuncture: a brief introduction for military providers.

Injured veterans returning from Operation Iraqi Freedom and Operation Enduring Freedom often require long-term medical management for a variety of complex physical and mental health conditions. These conditions can be challenging to treat with conventional Western medicine practices alone. Recently, complementary and alternative medicine practices have been used within military settings, and have been well received by veterans. Auricular acupuncture is a practice that has provided veterans with a new approach to manage symptoms associated with a wide range of health conditions. This treatment has become an attractive treatment option because of its low cost, portability, minimal side effect profile, and ease of use in clinical and operational settings. Although formally trained Oriental medicine practitioners have historically performed these treatments, military health care providers are now receiving education and training to administer these treatments. This education and training allows military health care providers to expand their knowledge of acupuncture and provide this treatment to veterans across the continuum of care. The purpose of this article is to provide a fundamental description of auricular acupuncture and increase awareness of this treatment and its relevance to military settings.

Character strengths: a study of Argentinean soldiers.

The primary objective of this research was to study the differences in positive traits between military and civilian college students and between cadets in their first and final years at a military academy. Second, the research aimed to study the relations between positive traits and the academic and military performance of cadets in their first and final years, according to the classification of positive traits by Peterson and Seligman (2004). To accomplish these objectives, a sample of university students from a military educational institution and a sample of civilian university students were studied. The instruments used were a 24-item self-report measure of positive traits, a measure of social desirability, and objective scores of academic and military performance. The results generally showed that when age and career stage were held constant, the scores of the military students were higher than the scores of the civilian students across various strengths. Military students reported higher levels of the character strength of spirituality than did civilian students. The relationships between strengths and performance differed for students in their first and final years at the military academy. In particular, cadets with the higher levels of academic or military performance in their last year, i.e., the cadets best adapted to the academy, reported higher levels of the character strength of persistence when compared to low-performing cadets in the same year of study.

Building spiritual fitness in the Army: an innovative approach to a vital aspect of human development.

This article describes the development of the spiritual fitness component of the Army's Comprehensive Soldier Fitness (CSF) program. Spirituality is defined in the human sense as the journey people take to discover and realize their essential selves and higher order aspirations. Several theoretically and empirically based reasons are articulated for why spirituality is a necessary component of the CSF program: Human spirituality is a significant motivating force, spirituality is a vital resource for human development, and spirituality is a source of struggle that can lead to growth or decline. A conceptual model developed by Sweeney, Hannah, and Snider (2007) is used to identify several psychological structures and processes that facilitate the development of the human spirit. From this model, an educational, computer-based program has been developed to promote spiritual resilience. This program consists of three tiers: (a) building awareness of the self and the human spirit, (b) building awareness of resources to cultivate the human spirit, and (c) building awareness of the human spirit of others. Further research will be needed to evaluate the effectiveness of this innovative and potentially important program.

Effect of psychological skills training during military survival school: a randomized, controlled field study.

In this randomized, controlled field study, we examined the effects of a brief psychological skills training (PST) intervention on stress responses during military survival school. A second purpose was to build upon prior research in this unique environment by extending the follow-up window to 3 months. Baseline subjective distress (dissociative) symptoms were measured in 65 male military subjects, who were then randomized either to PST or a control group that received no training beyond the normal survival school curriculum. PST received training in arousal control, mental imagery, goal setting, and positive self-talk in two separate 40-minute sessions before stressful field exercises. Stress symptoms were then assessed during a mock-captivity phase of training, as well as 24 hours, 1 month, and 3 months after completion of training. Repeated-measures analyses of variance with follow-up paired t tests examined differences between groups and across time. Survival training precipitated remarkable increases in subjective distress, but few substantive group differences emerged. This study extends prior work quantifying the human stress response to intense military training.

War's long shadow: masculinity, medicine, and the gendered politics of trauma, 1914-1939.

War is an inherently traumatizing experience, and during the First World War more than 15,000 Canadian soldiers were diagnosed with some form of war-related psychological wounds. Many more went unrecognized. Yet the very act of seeking an escape from the battlefield or applying for a postwar pension for psychological traumas transgressed masculine norms that required men to be aggressive, self-reliant, and un-emotional. Using newly available archival records, contemporary medical periodicals, doctors' notes, and patient interview transcripts, this paper examines two crises that arose from this conflict between idealized masculinity and the emotional reality of war trauma. The first came on the battlefield in 1916 when, in some cases, almost half the soldiers evacuated from the front were said to be suffering from emotional breakdowns. The second came later, during the Great Depression, when a significant number of veterans began to seek compensation for their psychological injuries. In both crises, doctors working in the service of the state constructed trauma as evidence of deviance, in order to parry a larger challenge to masculine ideals. In creating this link between war trauma and deviance, they reinforced a residual conception of welfare that used tests of morals and means to determine who was deserving or undeserving of state assistance. At a time when the Canadian welfare state was being transformed in response to the needs of veterans and their families, doctors' denial that "real men" could legitimately exhibit psychosomatic symptoms in combat meant that thousands of legitimately traumatized veterans were left uncompensated by the state and were constructed as inferior, feminized men.