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Coleman-Chair-BP-7.jpgMedical advances, improved access to care, prevention initiatives, and our nation's aspiration of an AIDS-free generation are all good signs, but as a culture we will need to shift our perspective to stop the spread of HIV.

 
Over the last 30 years, where have we failed? We know that HIV is still mostly spread by sexual behavior. Yet, the disease is rather easily preventable through the use of condoms. Condoms are reasonably inexpensive, potentially readily available, easy to use, and highly effective in preventing HIV and other sexually transmitted infections (and unintended pregnancy). What a bargain! So, why are they not used more?


Behavioral HIV prevention strategies and interventions have tried to get people to reduce risky sexual behavior and promote condom use. While reasonably effective, there needs to be continuous implementation of these interventions, and they are costly. Investment in prevention strategies has always been difficult.


New strategies are overdue. In the United States, we continue to experience 50,000 new infections a year, with young people aged 13-29 accounting for 39% of all new HIV infections.* And, there are serious health disparities.  People of color, youth, and sexual minorities are much more likely to become infected than other groups. While 60% of new infections around the world are found in gay and bisexual men, only 2% of the global prevention budget is directed at this group. Also, transgender individuals are an overlooked population at major risk for HIV, due in large part to continued stigma and discrimination. This disparity in funding efforts represents the institutionalized stigmatization, heterosexism, and homophobia that exist in our cultures as well as in our public health systems. If we do not attend to this population as well as other marginalized populations such as sex workers and drug users, we will fail in our efforts to stop the spread of infections.


A fundamental problem remains. We remain a sexually dysfunctional culture. We live in a culture that is still uncomfortable talking about sex and sexuality in a mature and honest fashion. We continue to debate and hold back on providing comprehensive sexuality education. It is very clear that what distinguishes the United States from other developed countries in sexual health indicators is the existence of (or lack thereof) early and sustained comprehensive sexuality education. When kids are educated early they grow up to be more comfortable with talking about sexuality, more likely to be sexually responsible, and have lower rates of sexually transmitted infections and unintended pregnancies. They contribute to a cultural climate that is sexually healthy. That climate then insists on comprehensive sexuality education and thereby creates a cycle of healthiness. In the United States, we are still caught up in a negative and unhealthy vicious cycle. The goal of the Joycelyn Elders Chair in Sexual Health Education is to reverse this negative cycle.


As the current Chair in Sexual Health, I continue to push a sexual health agenda in HIV prevention. I believe in the need for a broad sexual health approach to stem the tide of the HIV epidemic. I envision an approach that goes beyond venereology and on an individual level

• emphasizes a positive and respectful approach to sexuality and sexual expression throughout the lifespan;

• acknowledges sexuality as a basic and fundamental aspect of our humanness and that the pursuit of sexual pleasure is natural and desirable;

• combats sexual coercion, shame, discrimination, and violence;

• promotes positive sexual identity and esteem;

• encourages honest communication and trust between partners;

• supports the possibility of having pleasurable, fulfilling, and satisfying sexual experiences;

• insists that individuals take responsibility of the consequences of their sexual choices and their impact on others; and

• optimizes reproductive capacity and choice

 

At the community level, it is achieved through

• access to developmentally appropriate, comprehensive, and scientifically accurate sexuality education;

• clinical and preventative sexual health services; and

• respect for individual differences and diversity and a lack of societal prejudice, stigma, and discrimination.

As the Chair in Sexual Health, I will continue to work with our faculty at the Program in Human Sexuality and with partners around the world to promote a sexually healthier culture - not only to address the sexual problems in the world -- but to advance the opportunity for everyone to lead sexually healthier lives which are pleasurable and satisfying.

Eli Coleman, PhD
Professor and Director
Chair in Sexual Health

 

New HIV Infections in the United States by Centers for Disease Control and Prevention

Letter from the Chair in Sexual Health

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Coleman-Chair-BP-7.jpgFirst of all, I have to say that I am grieving the loss of one our pioneering faculty members - Mary Briggs who you will read about in this newsletter. She was an amazing woman and I was fortunate enough to receive some training from here when I was an intern at PHS some 36 years ago!

I am writing this from Mexico where I have started a 6-month sabbatical. The purpose of this sabbatical is to study gender variance which is widespread throughout the world but cultures place different values upon gender identities and cross-gender behavior. In most parts of the world, gender variant identifies and behavioral expressions of those identities are highly stigmatized - although the struggle for acceptance is growing around the world. However, there are cultures where variations in gender identities are much more tolerated, embedded into the normative and historical societal structure of gender, and sometimes a revered phenomenon.

I have started my work here in Mexico in a small indigenous community in Juchitan, Oaxaca. Fifteen years ago, I began my work on this subject, and I have been back to Juchitan many times. From here I will be going to French Polynesia, Thailand, and Burma. These societies (or parts thereof) have a unique and less stigmatized view of gender variance and cross-gender behavior. I will also be visiting Micronesia (Marshall Islands) and Melanesia (Fiji) which have interesting phenomenon but not as positive a situation - but are useful as contrast. I have been studying these societies for many years in my spare time, and I am back to revisit and finalize my observations and conclusions. I am accompanied by Mariette Pathy Allen who will be accenting the data with a photographic study.

I am just concluding my field research with the muxes of Juchitan. Juchitan is a small indigenous community (Zapotec) in the state of Oaxaca, Mexico. I have been able to observe the changes and evolution of the culture and the individual lives of many of the muxes. In Juchitan, muxes are a broad spectrum of gender non-conforming males - which would span our western constructs of gay, cross-dresser, transgender, and transsexual. The vast majority of them have sex with other men - and they are mostly distinctively sexually attracted to 'straight men' or 'bisexual men' known as mayates. Some muxes are heterosexually married and have children - their status as muxe is well recognized by the wife and society. A muxe is identified as such from an early age - and because of the relatively small community is known by everyone as muxe. Most parents in Juchitan would simply understand this as a fate of nature as the Zapotec people are fairly agnostic.

While it is not something that is necessarily desired and many fathers have negative reactions to their son's cross-gender behavior, most muxes become recognized as an asset to the family. Muxes take on a social role of caretakers of the parents and family members (they do this from a very young age). They are traditionally bound to live with the family and living in long-term relationship with another person is not really acceptable (except it seems for the ones who marry a woman and raise their own family). There have been some recent stories of two muxes living together - which is a very new and rare phenomenon.

The muxes are a very interesting phenomenon - and one which you cannot find even in other parts of the state of Oaxaca - never mind Mexico. They have long held a unique status within society, recognized and respected because of their role within the family, and they often inherit family fortune. I would say that they gain acceptance through hard work and good deeds - but at least that option is afforded them. As such, many hold positions of respect and power. The muxes organized themselves as a "gay rights organization in the 1970s - becoming Mexico's earliest gay rights organization. They now wield considerable political power.

It is hard to generalize about muxes - as this is a phenomenon quite complex and dynamically changing. There has been a blending of modern constructs of "gay" and "trans." They defy fitting into either construct and may best be understood in the western constructs of "queer."

The situation in Juchitan is extremely unique and exists as a stark contrast to other indigenous communities or other rural areas in Mexico. Muxes defy simple definition as it is a unique gender role within society which is expressed in a variety of ways - which are, to varying degrees, accepted. Many hold on to the traditional cultural belief that there is a place for sexual and gender diversity in a community.

It is an illustration of a community where sexual and gender diversity can coexist and that diversity can be celebrated. It is not paradise as our binary way of thinking of gender and sexual orientation continues to cause pressure to conform or create prejudice for those that don't fit the binary. And the struggle to maintain the traditions and create even more acceptance continues. But, it is an interesting challenge to other societies to think about how everyone can contribute to society capitalizing on their uniqueness and differentness. And, all can be enriched by those who do not conform to gender expectations. I do believe that celebration of sexual and gender diversity is essential to everyone's sexual health.

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Letter from the Chair in Sexual Health

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Coleman-Chair-BP-7.jpgIt is an end of an era. Virginia E. Johnson, pioneering sex researcher and sex therapist, died on July 24, 2013, in St. Louis, MO. At age 88, she was one of the last great pioneers in the field of sexology and sex therapy.

Johnson worked with William Masters, MD, for more than three decades. They were researchers, teachers, and clinicians, and they were not afraid to be in the public eye to inform the public on sexual health matters. Their collaboration revolutionized our field through studying the human sexual response and pioneering sex therapy approaches. They helped to establish modern sex therapy and trained a generation of therapists throughout the country and around the world. The impact of their pioneering work is felt today as some of the basic understandings of human sexuality and treatment of sexual problems are rooted in their work. Masters and Johnson became household names, bringing public awareness to the importance of sexual pleasure and functioning in intimate relationships. Their research findings debunked a number of myths and led to an increased understanding of how to give and receive sexual pleasure based upon sound scientific understanding.

VC410JohnsonVE01-BP.jpgMasters and Johnson along with Alfred Kinsey, Helen Singer Kaplan, Harold Lief, John Money, and other pioneers made major contributions to our understanding of human sexuality and helped to legitimize the field of sexology and sexual therapy. With their deaths and now with hers, it seems like an end of an era.

The work of Masters and Johnson helped to influence the development of the Program in Human Sexuality (PHS). Masters was on the original national advisory committee when PHS was founded. More than any investigator before them, Masters and Johnson studied human sexual behavior in the laboratory and collected direct physiological and observational data. This forged the way to studying sexuality objectively and scientifically using direct physiological measurement.

In the 1970s, PHS conducted similar ground breaking research under the guidance of Joseph Bohlen, MD, PhD, Margaret Olwen Sanderson, MD, and James Held, BChE (see list below). These researchers refined the findings of Masters and Johnson and develop new approaches for sexual arousal measurement. They also documented women's multiple orgasm pattern. This led to other psychophysiological research which continues. Today scientists are able to record and observe sexual arousal and response not only in the genitals but also in the brain.

Currently at PHS Michael Miner, PhD, is investigating the phenomenon of compulsive sexual behavior through measurement of sexual arousal following negative mood induction to understand the basic mechanisms that are at play.

While the work of Masters and Johnson has continued to influence the field, unfortunately the Masters and Johnson Institute (1964 - 1994) that they built died with them. That is true for many of the pioneers in our field.

At PHS we are trying to ensure that our legacy is preserved and that the work will carry on for generations to come. While we carry on a tradition of harmonizing research, teaching, clinical practice, and advocating for a sexually healthier society, we are working diligently to preserve our institution through development. Through our fundraising effort and the establishment of endowed chairs, research funds, and fellowships, we not only enhance our work, but ensure its future. While we honor Johnson and the other pioneers in our field, we must not be complacent or take for granted the institutions we create. It takes great effort and determination to establish these institutions, and an even greater resolve to ensure their life beyond our work. So as we honor an end to an era, we must recognize our accomplishments, and prepare for the future.

Bohlen, J. G., Held, J. P., & Sanderson, M. O. (1980). The male orgasm: Pelvic contractions measured by anal probe. Archives of Sexual Behavior, 9(6), 503-521. doi: 10.1007/BF01542155

Bohlen, J. G., Held, J. P., & Sanderson, M. O. (1983). Update on sexual physiology research. Marriage & Family Review, 6(3-4), 21-33. doi: 10.1300/J002v06n03_03

Bohlen, J. G., Held, J. P., & Sanderson, M. O., & Ahlgren, A. (1982). The female orgasm: Pelvic contractions. Archives of Sexual Behavior, 11(5), 367-386. doi: 10.1007/BF01541570

Bohlen, J. G., Held, J. P., Sanderson, M. O., & Boyer, C. M. (1982). Development of a woman's multiple orgasm pattern: A research case report. Journal of Sex Research, 18(2), 130-145. doi: 10.1080/00224498209551144

Bohlen, J.G., Held, J.P., Sanderson, M., & Patterson, R.P. (1984). Heart rate, rate-pressure product, and oxygen uptake during four sexual activities. Archives of Internal Medicine, 144(9), 1745-1748. doi: 10.1001/archinte.1984.00350210057007

Photo of Virginia Johnson courtesy of Bekcer Medical Library, Washington University School of Medicine

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Coleman-Chair-BP-7.jpgAs I have said before, we are facing a crisis in declining curriculum on sexuality education in medical schools across the United States and Canada. There is a very clear need to better prepare medical students to be able to attend to the myriad of sexual health problems that their patients face. We have a public health imperative to address these problems.

Last fall we brought together 55 experts for a summit on medical school education in sexual health. The purpose of the summit was to examine the situation, discuss the challenges and opportunities, share lessons learned, and make recommendations for ensuring that physicians are properly trained to address the sexual health needs of their patients as they go into practice. In April the meeting report was published in the Journal of Sexual Medicine.

The expert consensus recommended:

•  Sexual health education should be integrated longitudinally throughout four years of medical school.

•  Sexual health education should be "introduced early and often."

•  Working together should be the norm and not the exception. There are other disciplines and experts who have an interest and a need in sexual health education.

•  Developing evaluation mechanisms incorporating multiple methods of measurement to help medical schools understand how to best teach sexual health.

•  Much like students, faculty members need content and curricula to build their skills and comfort in sexual health.

•  Create a cross-organizational effort using multiple partnerships to advance the cause.

•  Participants strongly endorsed an initiative to commission an Institute of Medicine (IOM) report, which would also describe the need to address sexual health education for health care providers. This IOM report would be a collaborative project.

One approach to building a healthier society is to better train physicians. The training of medical students is an essential step to advance sexual health. It is time to ensure that in our society new doctors as well as practicing health professionals are prepared to address the sexual health needs of their patients from adolescence through seniority.

As Joycelyn Elders, MD, said in the closing of the summit, "A society grows great when old men and old women plant trees under whose shade they will never sit. At least we're planting trees." The passion displayed by the summit participants needs to continue. The group is committed to carrying out the recommendations.

The Program in Human Sexuality has been on the forefront of sexual health education for medical students since it began in 1970. We have been able to preserve one of the country's premier courses and curriculum. With the support of the Joycelyn Elders Chair in Sexual Health Education, we are committed to taking a leadership role in ensuring that not only our curriculum remains the best, but that we foster the highest quality sexual health education for other medical students in the United States and around the world.

Coleman, E., Elders, J., Satcher, D., Shindel, A., Parish, S., Kenagy, G., Bayer, C. R., Knudson, G., Kingsberg, S., Clayton, A., Lunn, M. R., Goldsmith, E., Tsai, P., & Light, A. (2013). Summit on Medical School Education in Sexual Health: Report of an Expert Consultation. Journal of Sexual Medicine, 10(4), 924-938. doi:10.1111/jsm.12142

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Letter from the Chair in Sexual Health

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Coleman-Chair-BP-7.jpgSo what does the New Year hold for the future of sexual health? Can we be optimistic? I think so. There are four broad reasons to feel optimistic.

1.  As governments struggle with the complexities of the sexual problems and declining resources to commit to alleviate the myriad of problems, they will have no choice but to create broad strategies to promote sexual health. We have a public health imperative. We have an opportunity to use an evidence-based approach to public policy. Public health policies recognize that there is no choice but to address the barriers and opportunities for all citizens to enjoy the right to sexual health. They also recognize more and more that sexual health is a function of the recognition of basic human rights for all citizens.

2.  Sexual Health has taken root in public health policy and sexual science will be needed to guide it. Now is the time of a unique opportunity in history of which we must take advantage.

3.  The field of sexology has clearly established itself as a key player in the effort to promote a healthier society in the new millennium. The HIV pandemic alone continues to drive home the need to understand human sexuality in its full complexity--from the interdisciplinary perspective of sexology. Now sexologists are being asked to come to the table and help direct public policy by sharing our knowledge, research, and expertise.

4.  Public health officials recognize more than any other time that comprehensive sexuality education is essential. They need to support sexuality research and we see a flourishing of funding that is rooted in sound theory and scientific methodology. We see an increase in research publications which add to our knowledge and legitimacy of our scientific field.

In the United States, we have seen major developments that are guiding lights for the future of sexual health. There have been 5 major developments which will have a major impact in the coming year.

1.  In 2010, the Centers for Disease Control and Prevention (CDC) held a sexual health consultation to develop a broad consensus of how we could develop a strong, comprehensive, broad and integrated approach to sexual health. The meeting report was published in 2011. After another year of further consultation, the CDC is about to publish a white paper outlining the basic and fundamental strategies for the coming decades. The CDC adopted its own sexual health definition that could guide its work in this area.

2.  In 2010, the office of the President of the United States published a National HIV Strategy - the first comprehensive national strategy since the beginning of the epidemic! In this strategy, there was a strong statement that we must move away from thinking that one approach to HIV prevention will work, whether it is condoms, pills, information or prevention programs. Instead, we need to develop, evaluate, and implement effective comprehensive prevention strategies and combination therapies. While obvious, it was stated clearly that all Americans should have access to a shared base of factual information about HIV - a revival of the basic premise that US Surgeon General Koop stood upon in disseminating frank and scientifically accurate information to all households in the mid-1980s. Finally, this new strategy outlined a public health approach to sexual health that includes HIV prevention as one component. This was the first time the term sexual health was used in public policy in the United States. The President and Secretary of State Hillary Clinton have called for a concerted approach to creating an AIDS-free generation.

3.  In 2011, the office of the US Surgeon General released a report that was developed by the National Prevention Council. This report was the first national strategy on prevention that called for us to work together to improve health and quality of life by moving from a focus on sickness and disease to one based on prevention and wellness. Reproductive and sexual health is one of the seven targeted priorities. Many of these recommendations have been incorporated and will be funded by the Affordable Care Act.

4.  In 2011, a report commissioned by the Secretary of Health and Human Services and conducted by the Institute of Medicine, was released on the health of gay, lesbian, and transgendered individuals. This report called upon more understanding and research on these marginalized populations and outlined a broad strategy to promote the health and wellbeing of these American citizens. This report has already had profound positive impact on public policies and public attitudes.

5.  In 2011, the Department of Health and Human Services set broad health goals for the coming decade entitled --Healthy People 2020. In this broad health strategy "Reproductive and Sexual Health" was clearly identified as a leading health indicator. The outcomes of the recent national elections have ensured that these broad strategies to promote sexual health will go forward with commitment, leadership, and essential funding.

So, I think we can look forward to 2013 with a sense of optimism. We cannot be complacent, but we can ride this wave of renewed commitment to the promotion of sexual health for all Americans.

The Program in Human Sexuality will do its part - but it will be made easier by this social and political climate that shares our ideals of creating a sexually healthier climate and overcoming barriers to sexual health.

Thank you all for your support of the Program's activities and we wish you the very best in the coming year!

Eli Coleman, PhD
Director and Professor
Chair in Sexual Health

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Letter from the Chair in Sexual Health

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MSM-global-forum-crop-BP.jpgI am writing this letter from the XIX International AIDS Conference in Washington, D.C. It has been 22 years since the International AIDS conference was held in the United States (mainly due to the unwillingness on the part of the United States to grant visas for HIV-infected individuals- only recently lifted).

Here 25,000 scientists, policy makers, health and education ministry officials, advocates, and activists from around the world are gathered with a renewed determination to stem the tide of this epidemic. Medical advances, improved access to care, prevention initiatives, and our nation's revived determination are all good signs, but as a culture we will need to shift our perspective to stop the spread of HIV.

Recent news of pre-exposure and post-exposure prophylaxis treatment has been encouraging. Last week, the Food and Drug Administration (FDA) approved Truvada (emtricitabine and tenofovir disoproxil fumarate) for Pre-Exposure Prophylaxis (PrEP) to prevent the spread of HIV to high-risk, healthy individuals. Other similar preparations are under investigation and HIV therapeutic drugs are being developed for prophylactic use. These drugs are very costly and require individuals to adhere to rigid compliance in order to be effective.

Also, last week, Health and Human Services (HHS) Secretary Kathleen Sebelius announced nearly $80 million in grants to increase access to HIV/AIDS care across the United States. The funding will ensure that low-income people living with HIV/AIDS continue to have access to life-saving health care and medications. This effort stemmed from President Obama's determination to create an AIDS-free generation.

In addition, there is reduced stigma for HIV infected individuals. The CDC just launched "Let's Stop HIV Together" a new campaign that is part of the 5-year initiative started in 2009 to reduce stigma around HIV and advocate for more access to testing and treatment "Act Against AIDS."

The United States, through its National AIDS Strategy, has outlined a "prevention" strategy through early detection and early treatment, focusing on vulnerable populations.

These new strategies are overdue. In the United States, we continue to experience 50,000 new infections a year. And, there are serious health disparities. People of color, youth, and sexual minorities are much more likely to become infected than other groups.

Over the last 30 years, where have we failed? We know that HIV is still mostly spread by sexual behavior. Yet, the disease is rather easily preventable through the use of condoms. Condoms are reasonably inexpensive, potentially readily available, easy to use, and highly effective in preventing HIV and other sexually transmitted infections (and unintended pregnancy). What a bargain! So, why are they not used more?

Behavioral HIV prevention strategies and interventions have tried to get people to reduce risky sexual behavior and promote condom use. While reasonably effective, there needs to be continuous implementation of these interventions, and they are costly. Investment in prevention strategies has always been difficult. With the recently adopted National Prevention Strategy, National AIDS Strategy, and the Affordable Care Act, there is new hope that these investments will be made.

But a fundamental problem remains. We remain a sexually dysfunctional culture. We live in a culture that is still uncomfortable talking about sex and sexuality in a mature and honest fashion. We continue to debate and hold back on providing comprehensive sexuality education. It is very clear that what distinguishes the United States from other developed countries in sexual health indicators is the existence of (or lack thereof) early and sustained comprehensive sexuality education. When kids are educated early they grow up to be more comfortable with talking about sexuality, more likely to be sexually responsible, and have lower rates of sexually transmitted infections and unintended pregnancies. They contribute to a cultural climate that is sexually healthy. That climate then insists on comprehensive sexuality education and thereby creates a cycle of healthiness. In the United States, we are still caught up in a negative and unhealthy vicious cycle. The goal of the Joycelyn Elders Chair in Sexual Health Education is to reverse this negative cycle.

Both Walter Bockting and I, along with over 600 delegates from around the world attended the "Global Forum on Men who Have Sex with Men (MSM) and HIV" as part of the International AIDS Conference. While 60% of new infections around the world are found in gay and bisexual men, only 2% of the global prevention budget is directed at this group. Also, transgender individuals are an overlooked population at major risk for HIV, due in large part to continued stigma and discrimination. This disparity in funding efforts represents the institutionalized stigmatization, heterosexism, and homophobia that exist in our cultures as well as in our public health systems. If we do not attend to this population as well as other marginalized populations such as sex workers and drug users, we will fail in our efforts to stop the spread of infections.

Walter Bockting and I also attended two important meetings pertaining to transgender health and HIV. The first was called "The Great TRANSformation: Towards a Holistic Approach for Healthier and Happier Trans Communities in Latin America and the Caribbean." Walter Bockting talked about "Avenues for Action for the Provision of Care and the Promotion of Well-Being." This symposium represented some of our ongoing work with the Pan American Health Organization in developing and finalizing a "Blueprint for the Provision of Prevention and Care for Transgender Individuals through Latin American and the Caribbean." We also participated in a second special session on "Addressing Stigma in Transgender & Other HIV-Vulnerable Communities" sponsored by the Human Rights Campaign, the International Association of Physicians in AIDS Care, the International Treatment Preparedness Coalition, and the Pan American Health Organization.
 
As the current Chair in Sexual Health, I was happy to participate in this conference and push a sexual health agenda in HIV prevention. I was very pleased that the Program in Human Sexuality was a co-sponsor along with the Pan American Health Organization and the Centers for Disease Control and Prevention of a satellite session on "Addressing Sexual Health and Evidence-based Sexual Health Education: Evolving Opportunities." I spoke on "Towards a Broader Vision of Sexual Health in the New Millennium." I emphasized the need for a broad sexual health approach to stem the tide of the HIV epidemic, which emphasizes a positive and respectful approach to sexuality and sexual expression throughout the lifespan and that acknowledges sexuality as a basic and fundamental aspect of our humanness and that the pursuit of sexual pleasure is natural and desirable. A broad sexual health approach combats sexual coercion, shame, discrimination, and violence. But a sexual health approach must go beyond venereology and, on an individual level, promote positive sexual identity and esteem, honest communication and trust between partners, the possibility of having pleasurable, fulfilling and satisfying sexual experiences, taking responsibility of the consequences of one's sexual choices and their impact on others, and optimizing reproductive capacity and choice. At the community level, it is achieved through access to developmentally appropriate, comprehensive and scientifically accurate sexuality education, clinical and preventative sexual health services, and respect for individual differences and diversity and a lack of societal prejudice, stigma, and discrimination.

The Chair in Sexual Health will continue to work with our faculty at PHS and with partners around the world to promote a sexually healthier culture - not only to address the sexual problems in the world -- but to advance the opportunity for everyone to lead sexually healthier lives which are pleasurable and satisfying.

Eli Coleman, PhD
Professor and Director
Academic Chair in Sexual Health

PHOTO: Omar Banos (Impacto at AIDS Project Los Angeles), Rafael Mazin (Pan American Health Organization), and Eli Coleman

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Letter from the Chair in Sexual Health

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Daniel-Zamudio-BP.jpgA Chilean gay man who was brutally beaten in a park in Santiago earlier this month succumbed to his injuries on March 27, 2012.  Prosecutors claim that 24-year-old Daniel  Zamudio was struck with bottles, rocks and other blunt objects before the attackers cut off part of his ear, carved swastikas into his chest, and burned other parts of his body with cigarettes.

The attack has sparked widespread outrage across Chile and throughout Latin America.
A few days after the attack, President Sebastián Piñera and Interior Minister Rodrigo Hinzpeter met with members of Zamudio's family and Movilh, a GLBT human rights advocacy organization.  Hinzpeter and the United Nations have urged Chilean lawmakers to pass a law that would ban discrimination based on sexual orientation, gender identity and expression.

Daniel Zamudio has become Latin America's Matthew Shepard.

What is tragic is that after 40 years of gay liberation, we still face homophobic attitudes that discriminate, stigmatize, and demoralize people based upon their sexual orientation.  In many countries scientific evidence has led to public policy changes and changes in public opinion, but obviously we have not gone far enough.

Thirty years ago, I wrote my most cited article "Developmental Stages of the Coming Out Process."  I wrote it to describe a new model of affirmation therapy as opposed to the outdated "illness model."  It showed how individuals could escape from shame and self-destruction through a process of affirming one's own sexual identity and developing meaningful relationships and integrating their sexual identity with their overall identity and integrating into society.

It was a helpful model then.  I am often struck by how relevant this article still is today.  Today the struggle for self-acceptance and acceptance by others has been made be easier, but true integration is still an issue.  Individuals, families, and communities continue to struggle around these issues.

Oh for the day that this article is irrelevant and meaningless.

Meanwhile, we need to continue to strive to make the world a more accepting place for diversity of sexual and gender identity.  Everyone's life is enriched by this acceptance.

There is obviously no place for the homophobic attitudes and hatred that apparently led to the death of Daniel Zamudio.  I do hope that like Matthew Shepard's death, that this horrible event will lead to greater public awareness, changes in public policy, and new hate crime laws that will help to foster a climate of tolerance, inclusion, and respect for diversity.

In Minnesota, we are struggling with the question of whether individuals who love someone of the same gender can be entitled to the full rights of citizenry - including the right to marry.  There is no scientific evidence which shows that this will have adverse effects on society; and in fact there is ample evidence that laws that assure rights to citizenry will result in better health for all.

We need to move to a more enlightened society based upon the best available science and the principles of democracy and justice.

Coleman, E. (1981/82). Developmental stages of the coming out process. Journal of Homosexuality, 7(2/3), 31-43. doi: 10.1300/J082v07n02_06

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Letter from the Chair in Sexual Health

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Eli-Coleman-BP.jpgOn World AIDS Day, it is certainly a poignant time to reflect on our progress and to reinvigorate our determination to halt this epidemic.  We have encouraging news.  The rates of HIV have fallen to the lowest levels since the peak of the epidemic, new HIV infections were reduced by 21% since 1997, and deaths from AIDS-related illnesses decreased by 21% since 2005 (UNAIDS, 2011).  

While these are encouraging statistics, there are still parts of the world including our own country in which the epidemic rages on.  The number of new HIV infections continues to rise in Eastern Europe, Central Asia, Oceania, the Middle-East, and North Africa.   Here in the US - we still see rises in certain urban centers (particularly among African Americans and men who have sex with men) and, overall, we see an increase in HIV infections in the South-east (particularly in poorest areas).

Poverty is still a major predictor of risk of HIV infection.  The poor, disenfranchised, stigmatized, and marginalized bear the overall burden of disease and HIV remains a serious threat.  Thus racial and sexual minorities are still very much at risk.  Youth in these groups are particularly vulnerable.   

While we need to address the serious issues of poverty, discrimination, prejudice, and the lack of basic sexual rights, we know that even the disenfranchised can be empowered through comprehensive sexuality education and access to preventative services.  We need to put HIV prevention in the context of a comprehensive sexuality approach.

We can be encouraged by the fact that when youth are educated with comprehensive sexuality education, they are more likely to delay the onset of sexual intercourse and use condoms.  We know that condoms are highly effective in preventing the spread of HIV and other sexually transmitted infections.  While the effects of stigma and discrimination are still a powerful force, comprehensive sexuality education can lead to empowerment.

We need an HIV-prevention approach that is sex-positive recognizing that people have a basic instinct and drive to be sexual and that beyond the reproductive utility of sexual activity, people are motivated to experience pleasure and that sex is a fundamental form of communication and expressing intimacy.  We have spent too much time on de-sexualizing HIV prevention, now it is time to promote what I have termed "sexualized HIV prevention."  Let's bring positive sexuality back into HIV prevention - and let's focus on the marginalized populations and empower them to enjoy a fulfilling and pleasurable sexual life.

Eli Coleman, PhD
Director and Professor
Chair in Sexual Health

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Letter from the Chair

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Eli-Coleman-BP.jpgWe have reached a moment in history with serious global economic challenges and critical and costly sexual health problems. Around the world governments as well as regional and international health agencies are recognizing the importance of having a unified and broad sexual health approach to reduce the burden of disease related to sexual health problems.

There have been several recent, major developments which will certainly have a positive impact on the promotion of sexual health. First, there has been an effort by the Centers for Disease Control and Prevention to consolidate its initiatives in HIV prevention, STI prevention, reproductive health, school-based sexuality education, and sexual violence prevention under a broader and unified effort to promote sexual health as an overarching strategy to deal with the myriad of sexual health problems we face in this country, A Public Health Approach to Advancing Sexual Health in the United States. Second, in July 2010 the White House released a National HIV/AIDS Strategy that acknowledges the importance of addressing sexual health through prevention activities rather than simply more "testing and pills." Third, in March 2011, the Institute of Medicine released its report on The Health of Lesbian, Gay, Bisexual and Transgender People. Finally, in June 2011 the National Prevention, Health Promotion, and Pubic Health Council in the Office of the Surgeon General released a National Prevention Strategy which includes a major section on promoting sexual and reproductive health.

The synergy of these efforts has put sexual health squarely in the center of public health strategies to improve the overall health and wellbeing of all Americans. While PHS has been promoting sexual health for over 40 years, the concept of sexual health has taken root in public policy in a way that represents a revolutionary paradigm shift. It is an exciting time.

We hope that this will translate into improved funding for a strategic approach to change the sexual health climate of this country - using the powerful resources of our government. We hope that this will increase research grants, educational opportunities, and provisions for sexual health care.

During the past decade, it seemed that the leaders in sexual health were in other parts of the world. Now, the US has joined similar international efforts and may be able to assume a leadership role by advancing sexual health through public policy and public health.

PHS is involved in many of these national, regional, and international efforts. Hopefully, through this work, we will truly realize a sexually healthier climate here and around the world. It is an exciting time - a time to "strike while the iron is hot" to consolidate efforts and move the sexual health agenda forward.

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Med-SAR-2-BP.jpgOn June 2-3, 1970, the first Sexual Attitude Reassessment (SAR) seminar was held at the University of Minnesota, and the Program in Human Sexuality was born.  This June, forty years later, the PHS faculty just completed our course in human sexuality required for all first-year medical students, which included a SAR seminar. One could barely recognize the format from the earlier years. We sit on chairs rather than pillows, and we listen to panels of people describing their sexual lives rather than being bombarded with sexually explicit media. However, the goals of the seminar remain: to explore sexual attitudes and behavior, to become "askable" physicians, to separate one's personal values from professional sexual health care, to help physicians become more comfortable in bringing up the topic, and ultimately to provide compassionate, non-judgmental, science-based sexual health care.

The SAR seminar formed the basis of the sexual health curriculum that developed at the University of Minnesota Medical School and has continued through today. The sexual health course of study at the University was one of the first comprehensive curricula developed in the United States. In the 1970s, many medical students had great difficulty talking to their patients about sexuality - especially when it differed from their own. In the 1980s, there was a conservative swing in sexual politics and the medical school curriculum was sharply being attacked under the accusation of "irrelevancy." By the end of the 1980s, more attacks centered around issues of privacy which made conducting small group processing very difficult. In the 1990s, we saw a new kind of medical student who was more interested in holistic medicine and primary care. That shifted in the latter part of the 1990s and early part of the new millennium as students moved away from primary care due to low reimbursement rates and high student debt.  Now we are seeing student motivation shift again - and we hope that health care reform will bring more emphasis on primary care that is holistic and focused on psychosocial issues as much as on new technologies. At each juncture, it has been a challenge to preserve and evolve the sexual health curriculum. Fighting for this and adapting our curriculum has made us one of the survivors and we have remained as a model program in the world.

We are at a period in time where we are facing a public health imperative to provide integrated health care services that address physical, mental, and sexual health. Yet we are losing ground in terms of comprehensive sexual health curricula in our medical schools. We are an endangered species! The movement towards integrated learning in medical schools makes "stand alone" courses very vulnerable. While integrated learning works for many issues, when integrated, the complexities and nuances of human sexuality tend to be over simplified or eliminated. We have seen a national trend to eliminate human sexuality courses - which were already too few and not very comprehensive. For example, I have been part of the human sexuality curriculum at Mayo Medical School for over 25 years and it has evaporated in the last two years.

While some of the current medical students are well informed by sexual information available through the Internet or a sound sexual health education, many students have had limited sexual health education because of "abstinence-only education" programs. In spite of a deficit in basic knowledge, we are seeing students who are eager to provide patient-centered, science-based care.

Due to all these factors, we are in desperate need of a revitalization of sexual health curricula across the country and around the world. New approaches need to be developed that fit within the new paradigms of medical school education. However, there is no forum or vehicle for strategizing how we might do this. I am eager to organize a summit of medical school educators, but I have yet to find a sponsor. With universities facing enormous financial crises and travel budgets slashed, it is difficult to find the resources to make this vision a reality. We are at a critical juncture, and I feel we are losing ground day by day. This is one of the many reasons that establishing the Joycelyn Elders Chair in Sexual Health Education is so very important. We need to find a champion for this cause.

I can only assure you that this issue is at the top of my agenda and I am trying to figure out a way to address this. If you have any thoughts or ideas on this I would love to hear from you phs@umn.edu

PHOTO: Keith and Virginia Laken, authors of Making Love Again: Hope for Couples Facing Loss of Sexual Intimacy, help to instruct the 2010 U of M Medical School SAR. Keith Laken is an active memeber of the PHS Leadership Council. 

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Letter from the Chair in Sexual Health

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Coleman-Chr-BP.jpgThe American Psychiatric Association (APA) has concluded a first step in revising the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association by releasing proposed new classifications and criteria for the next revision of the DSM due to be released in 2013. At the same time, the World Health Organization (WHO) is undergoing its own process of revising its International Classifications of Diseases (ICD). The sexual and gender diagnoses are sure to spark intense debate. Sexual and gender disorders can be barriers to sexual health. Access to care for these disorders can lead to improvements in sexual health. At the same time, pathologizing normative sexual behavior and gender expressions can lead to stigma, discrimination, and poor sexual and other health outcomes. What is considered a disorder by these organizations has an enormous impact on all of us.

We know from history that psychiatrists once classified masturbation, oral sex, and homosexuality as perversions. With new knowledge regarding human sexuality, these were removed from the category of "sexual disorders." While the American Psychiatric Association declassified homosexuality in 1973, it was not until 2001 that the Chinese Psychiatric Association did so.

At present, there is quite a bit of concern and disagreement about the existing diagnostic categories and criteria for the sexual and gender diagnoses. Several national health boards have broken from the ICD and have declassified previously classified "disorders." For example, Denmark removed sadomasochism from their classification system in 1995, and as of January 1, 2009, Sweden declassified dual-role transvestism, gender identity disorder of childhood, fetishism, sadomasochism and multiple disorders of sexual preference. They retained transsexualism in order to preserve medical and psychological treatment for this condition (Pink News, 2008).

In February 2010, Norway followed suit and declassified these same "disorders" from their national health board. In February 2010, France became the first country in the world to remove transsexualism from its official list of mental disorders but has retained under a special category the ability for individuals with severe gender dysphoria to received appropriate treatment. The French Health Ministry has already agreed to push other countries in the European Union to drop transsexualism from their lists of mental disorders (Time, 2010). As noted in the article below, Cuba has recommended that transsexualism be removed from the ICD as well.

Last revised in 2000, there seems to be a general feeling that revision of ICD is necessary because of advances in knowledge, a deep concern about balancing the restriction of sexual freedoms and pathologizing normal variations in sexual and gender expressions, and the need to define pathological states for research purposes and access to care (and the right to the best possible care).

There is certainly intense concern regarding ridding the ICD of old and pejorative terms such as impotence, frigidity, premature ejaculation, nymphomania and satyriasis and excessive sexual drive.

A fundamental shift has been suggested in classification of sexual dysfunctions according to the traditional Kaplan/Masters and Johnson model of sexual response. This has mostly been driven by research on female sexual functioning and dysfunction that challenges the old assumption of parallelism of sexual response. Many argue that there is a fundamental difference in sexual response and dysfunctions in men and women are fundamentally different and therefore need different diagnostic criteria. Also, as we further understand the interplay between psychogenic and organic factors, many believe that there is a false dichotomy between organic and psychogenic factors in sexual dysfunction and perhaps in the other sexual and gender disorders. Sexual disorders may involve multiple psychological, interpersonal, and biologic/organic causes, and these influences are not always separate entities. They challenge the prevailing notion that organic sexual problems can be separated from psychogenic problems. There have been suggestions to creating a different category for sexual problems, eliminating the "dependence" of psychiatry and the stigma of a mental illness.

The debate over the paraphilias and whether to retain fetishism, transvestic fetishism, sadism and masochism will be contentious. The proposed new category of hypersexual disorder is clearly an attempt to recognize that some "normal" sexual activity can become excessive, driven, compulsive and in some ways "addictive." The potential misuse (and threat of over pathologization) of this category is enormous and there are also still fundamental questions regarding pathophysiology and nomenclature. And the debate over gender identity disorders will loom even larger. Clinicians, physicians, and researchers have made many important recommendations. The APA has responded to some of these recommendations but the stigmatizing nature of the proposed revisions still remains. Changing gender identity disorder to gender incongruence has not seemed to satisfy anyone on either side of the debate. The APA has responded to some of these recommendations but the stigmatizing nature of the proposed revisions still remains. Changing gender identity disorder to gender incongruence has not seemed to be received well by many on either side of the debate.

I am pleased that the faculty of the Program in Human Sexuality have been involved in this debate and that their research has been used to inform the revision process. Having just reviewed and made recommendations to the WHO regarding proposed revisions to the ICD sexual and gender diagnoses, I am very aware of how difficult this task will be. It will be very challenging for the APA and WHO to find the right balance in the revision of the sexual and gender diagnoses in the DSM-V and ICD-11. Both bodies have opened up the revision process to public discussion and debate (DSM and ICD).

In considering the revisions, sexual health and rights need to be taken into consideration. Based on work from the World Association for Sexual Health (WAS), I offer these guiding principles.

1.    Recognition and treatment of sexual and gender disorders is a basic sexual and human right.

2.    DSM and ICD should take into consideration the sexual rights of individuals as it considers pathologizing sexual behaviors or gender expressions and individuals' right to freedom to express their full sexual potential, as well as to freedom from sexual coercion, exploitation, and abuse. The individual has a right to individual decisions and behaviors as long as they do not intrude on the sexual rights of others.

3.    Sexual and gender diagnoses should not be used in any way to support any forms of discrimination regardless of sex, gender, sexual orientation, age, race, social class, religion, or physical and emotional disability.

4.    Sexual and gender diagnoses should not be used in any way to pathologize the derivement of sexual pleasure, including autoeroticism, as a source of physical, psychological, intellectual and spiritual well being.

5.    Sexual and gender diagnose should not be used in any way to pathologize those who decide to marry or not, to divorce, and/or to establish other types of responsible sexual associations.

6.    Sexual and gender diagnoses should not be used in any way to infringe on the individuals right to make free and responsible reproductive choices. This encompasses the right to decide whether or not to have children, the number and spacing of children, and the right to full access to the means of fertility regulation.

7.    The DSM and ICD sexual and gender diagnoses should support the right to sexual health care. Sexual health care should be available for prevention and treatment of all sexual concerns, problems and disorders.

8.    There has not been enough research into the understanding or treatment of female sexual dysfunctions and that a gender perspective is needed.

9.    A lack of scientifically valid information concerning sexual function within the general population is pervasive and the negative impact of this ignorance is felt around the world.

10.    Given the importance of adequate sexual functioning for general sexual health, overall health and well-being, and the health of interpersonal relationships, the updating of the DSM and ICD is welcomed to recognize the distinctions between normal range of sexual and gender expression, and the concerns, problems, and dysfunction and disorders that require intervention. Appropriate sexual health services must be made available throughout the world.

11. Given the concern about "Americanization of mental illness," as an international classification of diseases (Watters, 2010a, b), ICD will need to pay particular attention to the influence of culture and globalization in arriving at a classification system that will meet the needs of the world.

I welcome your comments and encourage you to express your opinions to the APA before April 10, 2010 and to the WHO.

Pink News. Sweden removes transvestism and other 'sexual behaviours' from list of diseases November 19, 2008 Accessed from the Internet on March 14, 2010, http://www.pinknews.co.uk/news/articles/2005-9616.html/

Time. In France, Transsexuals Celebrate a Small Victory. March 1, 2001. Accessed from the Internet on March 14, 2010 at http://www.time.com/time/world/article/0,8599,1968767,00.html?xid=rss-topstories

Watters, E. (2010a)The Americanization of Mental Illness. New York Times Magazine, January 8, 2010. Accessed from the Internet on March 14, 2010 at http://www.nytimes.com:80/2010/01/10/magazine/10psyche-t.html?scp=1&sq=ethan%20water&st=cse

Watters, E. (2010b). Crazy Like Us: The Globalization of the American Psyche. New York: Free Press.

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Letter from the Chair in Sexual Health

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Coleman-Oaxtepec-BP.jpgI recently attended the National Congress of Sexual Education and Sexology sponsored by the Mexican Federation of Sexual Education and Sexology (FEMESS) in Oaxtepec, Mexico.

I talked about the barriers, necessities, and opportunities that are confronting sexuality education now and in the future.  I called for a strategic plan for the next generation of sexuality education programs. 

Education is the basic tool by which we can confront the sexual health problems we face around the world.  We see the HIV pandemic stabilizing overall but growing rapidly among disadvantages groups.  Sexual violence is still at unacceptable levels.  Gender equity remains ideal rather than a reality.  Individuals and couples are struggling to find sexual satisfaction and pleasure.  We have a syndemic - a constellation of epidemics that feed one another.  We are going to need a systematic approach to promote sexual health to address the syndemic.  This is not just a sexual health problem but a public health problem.  Sexual health is essential to overall health and human development.

There are enormous barriers to overcome.  We need to face some fundamental facts. 

● There is the ubiquitous taboo of talking about sex in our cultures and this is not going to go away. 

● Parents, by the nature of parent-child dynamics, are never going to be the most effective sexuality educators. 

● We can not seem to get over the notion that to talk about sex with children means that they are more likely to engage in sexual activity (and irresponsibly).

● Sexual education is a threat to the social order which preserves patriarchy and heteronormativity.

● Science-based sexual education is a threat to certain religious views and beliefs.

● The belief that the state should not interfere in something so private as one's sexuality

● Sexual education by professionals in structured environments is the only way to deal with these barriers.

Despite the barriers, we have tremendous opportunities to overcome them.  The United Nations has declared 8 human development goals for 2015.  Embedded in these goals are a few of them that specifically address sexual and reproductive health.  However, in all of these 8 goals, promotion of sexual health is obviously a means of addressing them.  (See the World Association for Sexual Health's (WAS) Declaration and Technical Document - Sexual Health for the Millennium).  The fundamental premise of this declaration is that it is essential to promote sexual health to enhance overall human development.  Sexual health is on par with the necessity to promote physical and mental health.  The three are like a three-legged stool and without one - the chair will fall.

The fourth point of the WAS Declaration specifically addresses the importance of providing universal access to comprehensive sexuality education.  To achieve sexual health, all individuals, including youth, must have access to comprehensive sexuality education and sexual health information and services throughout the life cycle.  This has been recognized more and more in health promotion strategies as illustrated by the Inter Ministerial Declaration of Health and Education Ministers of Latin America and the Caribbean and the Maputo Plan of Action that was endorsed by the Ministers of Health from 48 African countries and their governments.  So there is openness and opportunity to build upon when public policy officials are recognizing the importance of sexual health education as a general public health policy.

Sexual health has been legitimized in public health policy and science will be needed to guide it.  It is a unique opportunity in history that we must seize.

In order to overcome these barriers and seize these opportunities, we have the following necessary actions.

● Provide mandatory comprehensive sexuality education - that is rights-based, gender sensitive, and culturally appropriate - as an essential component of school curricula at all levels and provide the necessary resources.

● Work with community organizations to reach young people who are not in school or other high-risk populations with comprehensive sexuality education.

● Issue guidelines to ensure that sexuality education programs and services are grounded in the principle of fully informed, autonomous decision-making.

● Ensure that sexuality education programs are evidence-based and include the characteristics that have been shown to contribute to effectiveness. This should be done in a way that allows for creativity and community specific needs in the development and evaluation of innovative programs.

● Promote further research in human sexuality education designed to promote sexual health and responsible sexual behavior.

We only have a few years to show that comprehensive sexuality education can work before the tides can turn and we return to abstinence-only approaches.

We must create a better climate for discussion of sexuality.

We need to ensure access to information and access about sexuality.

We need a society where every child (no matter what their sexual or gender identity) can get basic sexuality information.

We need to ensure that every health care provider is trained to address sexuality as part of their practices. 

And that is the only way that we will achieve sexual health and foster human development. 

African Union Commission.  (2006). Plan of Action on Sexual and Reproductive Health and Rights (Maputo Plan of Action).  Addis Adaba, Ethiopia:  African Union Commission.

Coleman, E. (2002). 'Promoting sexual health and responsible sexual behavior: An introduction'. Journal of Sex Research, 39(1), 3-6.

Coleman, E. (2010).  From sexology to sexual health.  In P. Aggleton, and R. Parker (Eds.), Routledge International Handbook of Sexuality, Health and Rights:.  London:  Routledge.

Ministers of Health and Education in Latin America and the Caribbean (2008).  Ministerial Declaration: 1st Meeting of Ministers of Health and Education to Stop HIV and STIs in Latin America and the Caribbean to Stop HIV and STIs:  Preventing Through Education.   

World Association for Sexual Health (2008).  Sexual Health for the Millennium Declaration.

PHOTO:  Ligia Peralta, Eli Coleman, Luis Perelman

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