The Focused Sex History

19 May

The Focused Sex History

A focused sex history is the clinician’s most important tool in evaluating SD, as it is most consistent with the “review of systems” common to all aspects of medi- cine. This limited history gives clinicians critical information in ,5 min. Both sex therapists and physicians juxtapose detailed questions about the patient’s current and past sexual history unveiling an understanding of the causes of dysfunction  and  noncompliance.  A  good,  focused  sex  history  assesses  all current sexual behavior and capacity. The interview is rich in detail, providing a virtual “video image,” clarifying many aspects of the individual’s behavior, feelings, and cognitions regarding their sexuality. A flood of useful material emerged when actively and directly evoked. A focused sex history critically assists in understanding and identifying the “immediate cause”—the actual beha- vior and/or cognition causing or contributing to the sexual disorder. Armed with this information, a diagnosis could be made and a treatment plan formulated. These  sexual  details  provide  important  diagnostic  leads.  Significantly,  the sexual information evoked in history taking will help anticipate noncompliance with medical and surgical interventions. Kaplan’s “Cornell Model” heuristically used immediate, intermediate, and remote causal layering to help determine timing and depth level of intervention (7). Modifying immediate psychological factors results in less medication being needed for men and women, regardless of their specific SD. Sex therapist’s interventions are exercises and interpret- ations. In general, physicians will intervene with pharmacotherapy and brief “sex counseling,” which address “immediate causes” (insufficient stimulation) directly,  intermediate  issues (e.g., partner) indirectly,  and rarely  focuses on deeper (e.g., sex abuse) issues. Nonpsychiatric physicians typically  manage current  obstacles  to  success,  which  are  both  organic  and  psychosocial  in nature. In fact, when deeper psychosocial issues are the primary obstacles, it is usually time for referral (4).

Many clinicians learned about the statistically significant increase in the incidence of depression in individuals with SD. Treatment of SD may improve mild-reactive depression, whereas depressive symptoms might alter response to therapy of SD (44). A clinician’s history taking must parse out this “chicken or egg problem”: Is SD causing depression, or is depression and its treatment (e.g., SSRIs) causing the SD? Here, the value of direct questioning about sex becomes clear in particular. If clinicians did not ask, the patients may not tell. When asked direct questions, SSRI patients reported an increase, from 14% to 58%, in the incidence of SD vs. spontaneous report (45). True incidence was probably underestimated as PDR data was based on patient spontaneous report (46). To manage adverse effects of medication, physicians must adjust dose or, combine  with  other  drugs,  to  ameliorate  the  problem.  For  instance,  many might reduce the SSRI and supplement with bupropion or try sildenafil as a pos- sible adjunct (43,47). Although “alternative medicine” (herbs, etc.) or other treat- ment approaches might be effective, sex therapy enhances all of these strategies. In particular, teaching immersion in the sexual experience through fantasy is helpful  to  eroticize  both  the  experience  and  the  partner.  However, fantasy could be about anything erotic; masturbatory fantasies are usually quite effective. Fantasy of an earlier time with the current partner may be especially helpful for those who feel guilty about fantasizing in their own partner’s presence. Referral to a sex therapist can help when extensive and specific discussions of masturba- tion are useful to develop, recalibrate and/or restore the sexual response (20).

The focused sex history allows the clinician to initiate therapy with the least invasive method available; literally an “oral therapy.” For this author, one question helps pin down many of the immediate and remote causes: “tell me about your last  sexual experience?” Common immediate  causes of  SD  are quickly evoked by the patient’s response. The most important cause of SD is lack of adequate friction and/or erotic fantasy, in other words, insufficient stimu- lation. Sex is fantasy and friction, mediated by frequency (20). To function sexu- ally, people need sexy thoughts, not only adequate friction. Although fatigue may be the most common cause of SD in our culture, negative thinking/anti-fantasy, whether a reflection of performance anxiety or partner anger, is also a significant contributor. Of course, the clinician initiating the discussion of sex with the patient, in a mutually comfortable manner, transcends the importance of which question is asked. The clinician follows-up, with focused, open-ended questions to obtain a mental “video picture.” Inquiries are made about desire, fantasy, fre- quency of sex, and effects of drugs and alcohol. Did arousal vary during manual, oral, and coital stimulation? What is the masturbation style, technique, and frequency?

Idiosyncratic masturbation is a frequent hidden cause of ED, as well as RE (41a,41b). The clinician becomes implicitly aware of the patient’s sexual script and expectations, leading to more precise and improved recommen- dations and management of patient expectations (20). For instance, a clinician would improve outcome by briefly clarifying whether a patient was better-off practicing with masturbation, or reintroducing sex with a partner? A recently divorced man, who was using condoms for the first time in years, was probably better-off  masturbating  with  a  condom rather  than  attempting  sex  with  his partner, the first time he tried a new sex pharmaceutical.

Patient  Preference, Sexual Scripts, and Pharmaceutical Choice

Patients suffering from SD, first express preference when they choose to seek help from a MHP vs. a nonpsychiatric physician. Most MHPs (having ruled out organic etiology) will initially proceed with sex therapy in cases where psy- chogenic etiology is paramount. For many of these patients, sex therapy will be effective in and of itself. For others, the MHP will facilitate incorporating sexual pharmaceuticals into the treatment process, to help “bypass” or overcome PSOs. The use of sexual pharmaceuticals for these patients may be a temporary rec- ommendation, until a more pro-sexual equilibrium is established for the patient and partner. Reciprocally, pharmacotherapy may be either continuously or inter- mittently integrated with other attitudinal and behavioral changes necessary for a successful sexual and emotional experience. This will vary based on patient and partner pathologies interacting with the progressive organicity, often secondary to  aging.  Understanding  relapse  prevention  requires  consideration  of  these issues  and  factors  (16,20,48).  How  these  issues  are  currently  managed  by MHPs is illuminated within this chapter’s Case Studies.

Owing to multiple factors including the organization of health care deliv- ery, attitudinal beliefs, and pharmaceutical advertising; the majority of patients suffering from ED (when they do seek treatment) are likely to consult their PCP or a nonpsychiatric physician specialist (21). Although a few select phys- icians (primarily multiskilled psychiatrists) will provide sexual counseling as an exclusive modality when appropriate, most nonpsychiatric physicians will initiate treatment with a PDE-5 regardless of etiology. All three PDE-5s are used  worldwide  and  are  now  FDA  approved  in  the  USA.  All  have  good success rates! Simple cases do respond well to oral agents, with proper advice on pill use, expectation management, and a cooperative sex partner. However, physicians should offer  patients  choices, especially  those  who  are  pharma- ceutically na¨ıve. Providing an unbiased, fair-balanced description of treatment options, including pharmaceutical benefits on the basis of the pharmacokinetics, efficacy studies, and the physician’s own patients’ experience will result in the  patient  attributing greater importance  to  the  physician’s opinion. Incor- porating  patient  preference  provides  important  guidance  and  will  enhance healer/patient relations, minimize PSOs, and improve compliance. Preliminary comparator data, abstracted from the 2003 European Society of Sexual Medicine, suggested, patient preferences reflected, key marketing messages of the respect- ive pharmaceutical companies (49). Prescribing physicians might take advantage of that hypothesis to increase efficacy. If safety and long-term side effects are the primary concern, sildenafil has the oldest/longest database (12). If, pressed by questions regarding hardness of erection; in vitro selectivity may or may not translate to clinical reality, yet some patients believe vardenafil provides the best quality erection with the least side-effect (13). What is the physician’s experience with their own patients?

By taking a sex history and evaluating the premorbid sexual script (what used to work sexually), a skillful clinician may make an educated guess, as to which pharmaceutical to first prescribe. This transcends, “try it, you’ll like it.” Knowledge of pharmacokinetics (onset, duration of action, etc.) and sexual script analysis helps optimize treatment, by improving probability of initially selecting the right prescription. Many physicians initiated treatment with sildena- fil and will continue to do so. However, psychosocial factors and previous sexual scripts, may suggest a different drug on the basis of pharmacokinetic profile. Partner issues help determine correct pharmaceutical selection on the basis of analysis of the couple’s premorbid sexual script and relationship dynamics. Understanding the  couples “sexual  script” can  help  the  physician fine tune pharmaceutical selection, leading to better orgasm and sexual satisfaction, not merely improved erection (50). Sexual script in this situation refers to style and  process  of  the  couple’s  premorbid  sex  life  (51).  For  those  fortunate enough  to  have  had  a  good  premorbid  sex-life,  dosing  instructions should focus on returning to previously successful sexual scripts—as if medication was not a necessary part of the process. This maximizes patient likelihood of getting adequate stimulation in a manner likely to be comfortable and conducive to partner sensitivities. Awareness of within individual differences improves the quality of recommendations made for that person or couple’s sexual recovery. Differences between individuals in sexual style (sex script analysis) can deter- mine  which  medication  might  be  used  by  a  couple  effectively,  with  less change  required  in  their  “normal”  sexual  interactions.  For  instance,  some couples mutually presume that the man is “in charge” and should initiate and seduce like he used to. As he is planning the sexual encounter, sildenafil or vardenafil might be good choices. However, tadalafil may be preferable, if a more spontaneous response to an externally evoked situation is desired.

Fitting the right medication on the basis of pharmacokinetics to the individ- ual/couple will increase efficacy, satisfaction, compliance, and improve continu- ation rates. Rather than changing the couples’ sexual style to fit the treatment, try to fit the right medication to the couple (50). A sensitive clinician may be tempted to  facilitate  a  relationship of  greater  egalitarian  and  psychological balance. However, a symbiotic relationship with decades of history must be respected. For  the  most  part,  clients  are  seeking  restoration of  sexual  function  not  a “make over,” defined and reflecting a “politically correct” professional bias. Success requires consumer sensitivity. For instance a “rejection sensitive” woman may function as the couple’s sexual “gatekeeper,” yet may never initiate sex. She may  require  him  to  respond to  explicit  initiations or  her implicit initiations through signs of sexual receptivity (leg touching in bed, a subtle caress). The  astute  clinician  might  ask “Couldn’t these  merely be  signs of partner affection and not subtle sexual initiation?” Yes. However, for such a women, his willingness and ability to be sexual, is experienced positively even if she declines sex. She needs to feel both affirmed and in control. They agree that  she  is  the  gatekeeper  and  she  may  encourage  sexuality,  or  limit  the process to affection. Yet, his initiation is an important aspect of their sexual script and relationship equilibrium. By serving as a source of affirmation for her, it reduces the noxious (toxic) manifestations of her insecurity and rejection sensitivity. They both expect that she will decline some initiations. Yet, if he is only willing and able to initiate once dosed, then sildenafil or vardenafil is a poorer choice. For their relationship, multiple initiations are required, and pre- dosing with longer acting tadalafil may be a better choice. Harmony will be restored and satisfaction will increase. Two to three doses of tadalafil weekly, for a month, might be useful for such men who are essentially “on-call” in order to initially facilitate their capacity. As confidence and capacity improves and predictability increases, dosing could be titrated down or the pharmaceutical even weaned away. If the previous sex script was weekend sex, then a Friday night dose may be sufficient. If he has become resistant to her “controlling dom- ination,” then a referral for couples counseling would be appropriate. Although the suggestion of referral may be enough to compel him to try the drug, given the reaction many men have to MHPs. The physician simply makes an educated guess  regarding  pharmaceutical  selection.  Follow-up  may  indicate  greater PSO complexity. Then, the case would be better managed utilizing a multi- disciplinary integrated approach, with a sex therapist working collaboratively with  the  prescribing physician.  Later  in  this  chapter,  this  multidisciplinary method is illustrated with the case of Jon and Linda.

Follow-up and Therapeutic Probe

Discussions of follow-up most vividly illustrate the importance of integrating sex therapy and pharmacotherapy. Urologists, Barada and Hatzichristou improved sildenafil nonresponders by emphasizing patient education (e.g., food/alcohol effect), repeat dosing, partner involvement, and follow-up (52,53). Patient edu- cation about the proper use of sildenafil was crucial to treatment effectiveness. Physicians can increase their success by scheduling follow-up, the first day they prescribe. As with any therapy, follow-up is essential to ensure an optimal treatment outcome. Initial failures examined at follow-up reveal critical infor- mation.  The  pharmaceutical  acts  as  a  therapeutic  probe,  illuminating  the causes of failure or nonresponse (2,15,20). Retaking a quick current sexual history provides a convenient model for managing follow-up. Other components of the follow-up visit include monitoring side effects, assessing success, and con- sidering whether an alteration in dose or treatment is needed. Future comparator trials will help determine which drug works best, for which person(s), under which context. Until then, physicians will likely trust their own judgment and experience. However, physicians must provide ongoing education to patients and their partners, as well as involving them in treatment decisions whenever possible. A continuing dialogue with patients is critical to facilitate success and prevent relapse. The numerous psychosocial issues previously discussed may evoke noncompliance. These are important issues in differentiating treat- ment nonresponders from “biochemical failures,” in order to enhance success rates. Early failures can be reframed into learning experiences and eventual success.

Partner  Issues

Regaining potency does not automatically translate into the couple resuming sexual intercourse. Psychological issues may render the best treatments futile. PDE-5  discontinuation  or  failure  rates  of  20 – 40%  are  not  due  to  adverse events. Resistance to lovemaking is often emotional and the most common “mid-level” psychological causes of SD are relationship factors (15,20,23). As discussed previously, partner  dynamics can  help  determine  correct  pharma- ceutical selection on the basis of analysis of the couple’s premorbid sexual script and relationship (50). Yet numerous partner related psychosexual issues may also adversely impact outcome.

Cooperation vs. Attendance

Mild immediate causes of SD are often amenable to brief counseling in the phys- ician’s office. Still the most common mid-level relationship causes may present considerable difficulty for the nonpsychiatric physician treating SD within the context of a typically brief office visit. How might this challenge be met? The complexity of this conundrum can be reduced or resolved. The physician’s chal- lenge is not necessarily requiring an office visit with the partner, as many CME programs have advocated. Instead, the emphasis should be on evaluating the level of partner cooperation and support. Since Masters and Johnson, sex therapists have recognized that SD is a “couples problem,” not just the identified patient’s problem (2). However, almost equally long ago, this author and others noted that the key partner treatment issue was supportive cooperation, independent of actual attendance during the office visit (5,20). Generally speaking, encourage partner attendance with committed couples, allowing assessment and counseling for both. However, the issue is never forced. Treatment format is a psychotherapeutic issue and rapport is never sabotaged. Although conjoint consultation is a good policy, it is not always the right choice! A man or woman in a new dating relationship is probably better-off seeing the physician alone, than stressing a new relationship by insisting on a conjoint visit (20,54).

Partner Consultation?

Although CME courses recommended that patient – partner – physician dialogue was best enhanced through patient – partner education during conjoint visits, there was anecdotal evidence that physicians were not regularly meeting with partners of SD patients. This author undertook a 2002 Internet survey of the Sexual Medicine Society of North America, member’s practice patterns. These urologists are all sub-specialists in sexual medicine in general, and ED in particu- lar. Although methodologically limited, the results were interesting. The data pointed to a striking disparity between urologist attitude and actual practice. An overwhelming 79% of the responding urologists considered partner cooperation with ED treatment “important,” regardless of whether the partner actually attended sessions or not? Yet, only 39% of the responding urologists saw only one partner or less in their last five ED patient’s office visits. Nor was there any contact by phone, e-mail, or other means between doctor and part- ners for 90% of the responding urologists, despite the vast majority of patients were married or coupled. However, there were good reasons for not having a con- joint visit, as long as the importance of partner issues in treatment success was understood. Indeed, many urologists reflected thoughtfully on the burden of the treater to not invade the privacy beyond what was freely accepted by the patient. Urologists noted that the men saw ED as their problem, and were not interested  in  involving  their  partner.  These  urologists  gently  encouraged partner attendance, but appropriately did not require it (20). So why are pharma- ceutical ED treatments so effective? Does this data suggest that partner issues do not impact outcome? No, but it does support the thesis that “partner cooperation” is even more important than “partner attendance.” Why are many physicians suc- cessful even when not seeing partners? Sex pharmaceuticals with sex counseling and education work for many people, if the partner was cooperative in the first place. Fortunately, many partners of both men and women are cooperative, which partially accounts for the high success rates of medical and surgical inter- ventions. Indeed, most of the cooperation goes unexplored. The cooperation is assumed based on post hoc knowledge of success. Importantly, many women were cooperating with their partners, or facilitating sexual activity, independent of their knowledge of the use of a sexual aid or pharmaceutical. In other words, serendipitous matching of  sexual pharmaceutical and previous sexual script equaled success: “we did, what we used to do, and it worked.” (20,54).

The existence of large numbers of cooperative, supportive women who themselves have partners with mild to severe ED account for much of the success of many ED patients who see their physicians alone, for evaluation and subsequent pharmacotherapy. Many of these partners were never seen by the treating physician, nor was their attendance necessary for success. This is likely to be true for other male and female dysfunctions as well, depending on the degree of psychosocial barriers to success. Obviously, the most pleasant, supportive, cooperative partners would rarely be discouraged from attending office visits with any patient. Ironically, these same patients would probably have successful outcomes even if their partners never attended an office visit. However, good becomes better by evaluating, understanding, and incorporating key partner issues into the treatment process (54).

The patient – partner – clinician dialogue is best enhanced through patient – partner education. Partner attendance during the office visit would allow for such education. Yet, many clinicians  do not regularly meet  with partners of SD patients. Although working with couples was often recommended: sometimes there was no partner; sometimes the current sexual partner was not the spouse, raising legal, social, and moral sequella. The reality and cost/benefit of partner participation is a legitimate issue for both the couple and the clinician, and not always a manifestation of resistance. Finally, the patient’s desire for his partner’s attendance may be mitigated by a variety of intrapsychic and interpersonal factors, which, at least initially, must be respected and heeded (15,20).

There are other solutions. When evaluation or follow-up reveals significant relationship issues, counseling the individual alone may help, but interacting with the partner will often increase success rates. If the partner refuses to attend, or the patient is unwilling or reluctant to encourage them; seek contact with the partner by telephone. Ask to be called, or for permission to call the partner. Most partners find it difficult to resist speaking “just once,” about “potential goals” or “what’s wrong with their spouse.” The contact provides opportunity for empathy and potential engagement in the treatment process, which may minimize resistance and improve further outcome. This effective approach could be modified depend- ing on the clinician’s interest and time constraints. Clinicians should counsel partners when necessary and possible. They need to be a resource in treating with medication, counseling, and educational materials. Education needs to be a greater part of SD practice, whether provided within a physician’s practice or externally by other competent healthcare professionals. Success rates can be enhanced through patient – partner – clinician education, which will reduce the frequency of noncompliance and partner resistance, and minimize symptomatic relapse.  Organic and  psychological factors  causing SD, and  noncompliance with treatment, are on a multi-layered continuum. Although some partners will require direct professional intervention, many others could benefit from obtaining critical information from the SD patient and/or multiple media formats both private and public (20,54).

Weaning  and Relapse Prevention

In general, the concept of relapse prevention has not been incorporated into sexual medicine. Yet SD is recognized as a progressive disease in terms of under- lying organic pathology, which may play a role in altering threshold for response and potential re-emergence of dysfunction. Both McCarthy and Perelman have recommended that the clinician schedule “booster” or follow-up sessions in order to help the patient stay the course and provide opportunity for additional treat- ment when necessary (20,48). These concepts are derivative of an “addiction” treatment model where intermittent, but continuous care is the treatment of choice. Additionally, utilizing sex therapy concepts in combination with sexual pharmaceuticals offers potential for minimizing dose and temporary or permanent weaning from medication depending on the severity of organic and psychosocial factors. SDs are frequently progressive diseases, but this is especially  true  for  ED.  Over  time  the  progressive  exacerbation  of  either organic factors (endothelial disease, etc.)  or  PSOs may  adversely impact  a previously successful treatment  regimen.  Furthermore, although there  is  no current evidence for tachyphylaxis, neither are there extensive studies beyond 10 years indicating long-term efficacy of PDE-5s. No doubt, escalating dose and providing alternative medications would be most physician’s initial response of choice. However, both these processes may be modulated and mediated by sexual counseling and education. Sex therapy and other cognitive-behavioral techniques and strategies  could be extremely important  in facilitating long- term  medication  maintenance,  and helping to  ensure continuing medication success. As such, clinicians caring for ED patients, are well advised to incorporate these  counseling techniques into  the  treatment  they  provide themselves,  or through referral. Each case requires individual consideration in part determined by patient preference regarding level of outcome success desired. Levine (16) presented an interesting discussion on multiple dimensions of treatment success.

When to Refer?

The physicians “time crunch” can be managed, when brief counseling of the SD patient is sufficient. If the partner’s support for successful resolution of the SD is not present, then active steps must be taken to evoke it. Sometimes, a conjoint referral for adjunctive treatment to a sex therapist for the partner may also be required (20). Of course, the more problematic the relationship, the more pro- found the marital strife, the less likely that patient – partner sex education will be able to successfully augment treatment in and of itself. Inevitably, a referral to  a  MHP  would  be  required,  albeit  not  necessarily accepted  successfully. Additionally, there are numerous organically determined reasons making referral to a multiplicity of medical specialists (urologists, gynecologists, neurologists, psychopharmacologists, endocrinologists, etc.) necessary and appropriate. However, elaborating all of them is beyond the scope of this chapter.

Integration vs. Collaboration

Does a multidimensional understanding of a SD always require a multidisciplin- ary team approach? Clearly, the answer is no. When there is a question of collab- oration vs. integration  within an  individual  clinician;  how does one decide whether to be a multitalented physician or part of a multidisciplinary team?

There are a variety of sexual medicine thought leaders conversant with both organic and psychosocial predisposing, precipitating, and maintaining factors of SD, including some notable PCPs, psychiatrists, and urologists. Additionally, there is a convergence towards a bio-psychosocial consensus initially reflected by the “Process of Care Guidelines,” and elaborate upon, in the published Proce- edings  of  the  WHO 2nd  International  Consultation on  Erectile  and  Sexual Dysfunction (40,42). These publications are the result of multidisciplinary cooperation, with collaborative knowledge being appreciated, independent of specialty of origin. These consensus reports, speak to the importance of integra- ting medical,  surgical, and psychosocial treatments for SD. Sometimes, the physician’s treatment is only partially successful, and the lack of psychosocial sensitivity causes an exacerbation of the problem. This may be corrected. Reciprocally,  psychotherapists  may  be  fairly  criticized  for  failing  to  refer quickly enough for medical consultation, in order to benefit from incorporating a sexual pharmaceutical to speed-up the recovery process and reduce the time and cost of treatment. Discussed subsequently is Roberto’s ED case, treated by the author and two different urologists; when an expert sexual medicine physi- cian, who had adequate time and motivation, may have managed equally well.

Case Study: Roberto

A 32-year-old Italian man was suffering from primary ED. Roberto had “two hypospadias operations” at ages 3 and 6. He reported “at 8 years old, circumci- sion removed ‘excess skin’.” He remembered friends teasing, about his urinating from the “underside.” He had primary ED and 2 years ago (as a visiting student), he consulted a US urologist who prescribed sildenafil. The urologist reportedly told Roberto that he would never function normally, because of his congenital hypospadius. Roberto left that consultation devastated, fearing he was sexually handicapped  for life. No great  surprise, the sildenafil did not work when he used it with masturbation. He was afraid to date women. The same urologist observed on follow-up that Roberto seemed depressed and was not using the sildenafil, or dating. He referred Roberto to the author. Accurate information incorporated  within a  cognitive-behavioral sex therapy,  improved Roberto’s self-esteem, reduced his fear of rejection, decreased performance anxiety, and encouraged dating. His confidence was increased through his masturbation, aug- mented with sildenafil and fantasy. It worked! He began dating and had erections with foreplay.

Vacationing in Italy, Roberto began a sexual relationship with a woman. He went to an Italian  urologist who complemented his sex therapy progress, and  provided  him with samples  of sildenafil, vardenafil,  and  tadalafil.  All worked wonderfully, but he preferred tadalafil, because of the 36 h duration of action. He reported that his new girlfriend supposedly “had six orgasms in 27 years with all her boyfriends; yet with me, she had five in one day.” He suspected, she knew, he used “sex drugs.” They reportedly had sex twice daily. Back in the USA, he used 1/3, of a 100 mg sildenafil and fantasy about sex in Italy, to mas- turbate successfully. Roberto was gradually weaned from the sildenafil when he masturbated. When his girlfriend visited 6 months later, he initially used low dose sildenafil successfully. Then, she seduced him one night when he had no medi- cation available. She remained with him in the US. Reportedly, they now have twice weekly coitus, fully weaned from medication, for the past 5 months. The author will see him again in 2 months for follow-up to minimize relapse potential. Roberto recognizes, “it is mostly in the brain.” He wisely said, “If we break up or in a period of stress, okay let me take a pill a couple of times. I will use it as a crutch once in a while. When I feel less secure or very stressed.”

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