Trans kids 2: The intersex brain

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The very large differences between one trans person’s needs and another, which were made clear via the resource guide  Families in TRANSition, at the end of the first part of this blog on transgender youth – and were later commented upon knowledgeably by Peace in the course of some excellent exchanges between readers – draw further attention to the question of what being transgender really means.

For this, that we have to ponder what constitutes gender itself. As Robin Marantz Henig wrote for the National Geographic’s special issue, gender is an amalgamation of several elements, including our biological sex: chromosomes (those X’s and Y’s), anatomy (internal sex organs and external genitals), hormones (relative levels of testosterone and oestrogen), psychology (self-defined gender identity), and culture (socially defined gender behaviours).

What gender includes can be very confusing, though, because it depends on the context. Sexologist John Money introduced the terminological distinction between biological sex and gender as a role in 1955 (long before his now discredited recommendation of surgical sex-reassignment on David Reimer in his infancy). However, Money’s meaning of the word did not become widespread until the 1970s, when feminist theory embraced the concept of a distinction between biological sex and the social construct of gender. For the purpose of today’s discussion, we definitely need to engage with the biological side.

Intersex model Hanne Gaby Odiele is genetically male but was born with ambiguous external genitalia. At age 10 she had undescended internal testes removed and transitioned to live as a female. But she now feels this surgery was unnecessary. She says, “I am proud to be intersex, but very angry that these surgeries are still happening… It’s not that big of a deal being intersex … it became a trauma because of what they did.” According to the UN, up to 1.7% of the world’s population is born with intersex traits, about the same as the number of people with red hair.

Intersex model Hanne Gaby Odiele is genetically male but was born with ambiguous external genitalia. At age 10 she had undescended internal testes removed and transitioned to live as a female. But she now feels this surgery was unnecessary. She says, “I am proud to be intersex, but very angry that these surgeries are still happening… It’s not that big of a deal being intersex … it became a trauma because of what they did.” According to the UN, up to 1.7% of the world’s population is born with intersex traits, about the same as the number of people with red hair.

The necessity of bringing in biology becomes clear once we begin to drill down into the detail of where gender dysphoric feelings are coming from. Research into foetal growth has implicated pre-natal brain development in the womb. People who want to change their assigned gender usually have completely normal genitalia at birth in accordance with their assigned sex. In these cases there is no reason to suspect a genetic abnormality or any other unusual physical condition.

Intersex, as usually understood, is different.  An intersex person has any of several variations in sex characteristics including chromosomes, gonads, sex hormones, or genitals. Such variations may involve genital ambiguity at birth. These intersex people are the ones who used to be called hermaphrodites, a term that was dropped as it was thought stigmatising. A second type of individual has typical-looking genitals but with internal intersexed features that are not apparent. These are known medically as “occult” intersex conditions. The point is that intersexed persons have, in the same body, both male and female biological characteristics that are typically found only separately in each sex. Well-known conditions of this kind include Turner syndrome and Klinefelter syndrome. Congenital adrenal hyperplasia (CAH) is associated with a specific defective gene. There are even mosaic situations in which the same individual possesses both XX (female) and XY (male) cell types. Bizarrely, as reproduction expert Milton Diamond puts it “a person might have an arm considered male because its cells are all XY while the same person’s leg might be considered female because its cells are all XX”. Bet you didn’t know that!

It is hardly surprising that people with these clearly fundamental intersex conditions may be unhappy with their assigned sex and seek sex reassignment surgery, SRS, later on.

However, Diamond has also made the striking claim that there are significant natural in-born sex differences found between the brains of trans people and others that are sufficient “to conclude that persons with a transsexual condition are intersexed. Simultaneously it is recognized that many intersexed persons will switch from their assigned gender, yet many will not. Transsexual people are persons now also commonly referred to as… transgender persons.” Here is his explanation:

It is known that the genitals and brain develop at different times. The genitals develop early prenatally during the first 6 – 12th week and they may develop in masculine or feminine form. If the genitals develop under the influence of the androgen testosterone they are masculinized. If they are not, female genitals develop. In comparison, the brain, it is believed, develops during the latter period of pregnancy and also is subject to the influence of androgen. If there is significant androgen present at that time there will be brain masculinization, if not, there will be brain feminization. It thus is clear that the brain and genitals can develop independently and under different forces.

Thus we have a clear biological explanation for trans children’s insistence that they are a girl trapped in a boy’s body, or the other way around. They may well truly have a girl’s brain – and mind – trapped in a boy’s body or vice versa.

But this is not to say that biology is destiny. As we have just heard Diamond say: “many intersexed persons will switch from their assigned gender, yet many will not.”

This takes us straight from a biologically fundamental point to an equally profound socially grounded one. Whether anyone wants to make the switch will be hugely influenced by what is socially acceptable in any specific culture. Half a century ago in many developed countries including the UK and US, gay sex was a criminal activity and just being gay was heavily stigmatised. In that atmosphere it made sense for many gender non-conforming children to grow up thinking they might be better off if they could change sex. In those days, though, this was a choice open only to a rare few: usually wealthy, independent-minded people who could find a surgeon, perhaps in another country, willing to risk their own reputation by undertaking what was then pioneering and highly controversial surgery.

Nowadays, however, in countries where homosexuality is still stigmatised, sex changes have become an accepted way of avoiding open homosexuality. The homophobic regime in Iran, for instance, is a big fan of transsexuality. It’s a thought that should give us pause. Do we really think we should be in a rush to emulate such a country?

Why should we be leaping to accept the fashionable view that changing sex is such a great idea, bearing in mind that it requires risky measures such as hormone replacement therapy (HRT), which has potentially dangerous long-term side-effects, and extensive, difficult surgery, when for many gender dysphoric people there is an increasingly viable alternative that does not mean rejecting your body? What I mean is that people, especially the millennial generation, are coming to accept the idea that there is a “gender spectrum”. We do not need to make the binary choice of being either male or female. While it is undeniable that only a tiny proportion of the population is transgender (0.3% of adults in the US, according to one scholarly estimate, with a further 3.5% who identify as lesbian, gay, or bisexual), what matters is that there is  growing public acceptance of gender variance.

Geneticist and paediatrician Eric Vilain –  another sexnetter, by the way, like Bailey, Blanchard, Diamond, Green and Zucker – has a vision for liberating gender expression without going to all the trouble and risk of changing sex. He sees us moving towards a society that thinks beyond gender stereotypes. “I am trying to advocate for a wide variety of gender expressions,” he told National Geographic writer Henig, “which can go from boys or men having long hair, loving dance and opera, wearing dresses if they want to, loving men, none of which is ‘making them girls’—or from girls shaving their heads, being pierced, wearing pants, loving physics, loving women, none of which is ‘making them boys.’ ”

Other cultures have shown that we humans are perfectly capable of such gender flexibility.  One solution adopted by many non-western cultures is, as Henig wrote,  “where a formal role exists that is neither man nor woman but another gender: South Asia (where a third gender is called hijra), Nigeria (yandaudu), Mexico (muxe), Samoa (fa‘afafine), Thailand (kathoey), Tonga (fakaleiti), and even the U.S., where third genders are found in Hawaii (mahu) and in some Native American peoples (two-spirit).”

That said, the right course for some young people will be the fullest possible social and bodily transition. There probably should be an element of pushback from parents and the medical profession in order to test the reality and intensity of their feelings. But not too much. How much is too much? This is a question that would tax the wisdom of Solomon. But if kids pass the “insistent, consistent, persistent” test, it should be good enough, provided that the decisions in question are in accordance with the child’s maturity and ability to make informed decisions.

As I said at the outset, it is not like sexual expression, where simple willingness may be enough. A young child should have free gender expression (without having to face harsh pushback), but it would be mad to let them choose SRS at this stage. Ironically, though, as Richard Green noted in his recent London talk, referred to last time, just a few decades ago there was nothing controversial about sexual reassignment surgery for intersex children from birth onwards – as long as doctors and parents were the ones doing the choosing, which they did with sometimes disastrous results, as in the notorious case of David Reimer, who was called Bruce at birth, surgically changed (with loss of penis and testicles) after a botched circumcision to become Brenda, but reverted to living as a male called David in adulthood before eventually killing himself. This was widely blamed on his traumatic unwanted sex change; but,  as Green has pointed out, Bruce’s twin brother Brian also committed suicide, without having suffered any such trauma.

Green considers that doctors such as John Money, widely vilified for his part in the Reimer case, acted from good intentions because it was considered vital for a child’s welfare that they should appear normal, which meant they had to fit in with the only two choices available, male or female. Also, it was believed in those days that kids would accept the gender they were brought up in. The controversial element at that time was confined to sex change operations on adults: grown-up were not supposed to have such surgery: it was thought freakish and perverted. It was almost as though there was an age of consent for SRS but you were required to be below that age, not above it!

As puberty approaches, a big decision comes into view. To block, or not to block? Puberty blockers can be used in order to slow the growth of sex organs and the production of hormones. Other effects include the suppression of facial hair, deep voices, and Adam’s apples for boys and the halting of breast growth and menstruation in girls. Temporarily halting the advance of puberty in this way is a hugely important option because it gives time for youngsters to mature and think deeply about their future without finding themselves saddled with irreversible bodily developments that would make later SRS less successful. Puberty blockers, like HRT, are a form of hormone treatment, but unlike the former there seems to be little risk attached to their use. In response to a safety scare earlier this month, the US Food and Drug Administration said it was reviewing the situation but was “not aware of any new documented safety concerns with this class of drugs that should change prescribing practices or warrant discontinuation of these medications.”In fact the safety issue seems to be the other way around: not having access to them involves a substantial risk of leading to unnecessary distress that might well result in suicide or a lifetime of regret over lost opportunities.

In Britain, children can be given hormone blockers to stop puberty at the age of nine, male-to-female or female-to-male sex hormones (HRT) at 16, and can undergo a full sex change at 18. I’d say that’s more or less right in appropriate cases.

But a lot of them will not be appropriate. Where kids have been “insistent, consistent, and persistent” since early childhood that they are in a body of the wrong sex, the case for allowing puberty blockers seems overwhelming. Most gender dysphoria (GD) arises much later, though, in adolescence. In these circumstances, in the absence of any evidence of “intersex brain” or another intersex condition, caution is indicated, based on the time-honoured fundamental medical principle “First, do no harm” (Primum non nocere), as reflected in the Hippocratic Oath. It is psychologist Mike Bailey’s view that adolescent-onset gender dysphoria in natal females, especially, “has a strong social/iatrogenic component”.

This last type is being studied by yet another sexnetter, Lisa Littman, of the Icahn School of Medicine at Mount Sinai, New York, who is currently researching “rapid onset gender dysphoria”. As part of her introduction to a survey she conducted, she wrote:

We have heard from many parents describing that their child had a rapid onset of gender dysphoria in the context of increasing social media use and/or being part of a peer group in which one or multiple friends has developed gender dysphoria and come out as transgender during a similar time frame. Several parents have described situations where entire friend groups became gender dysphoric. This type of presentation is atypical and has not been studied to date.  We feel that this phenomenon needs to be described and studied scientifically.

Quite so. The is precisely the sort of social contagion (which can reverse itself as quickly as it starts) that doctors such as Ken Zucker are very wise to investigate with their patients before undertaking pharmaceutical interventions.

Bailey has identified four types of gender dysphoria, only one of them being early onset with “intersex brain” implicated.  These are: child-onset GD associated with marked gender nonconformity (both natal sexes); adolescent-to-adult onset GD associated with autogynephilia (natal males only); late-onset FTM associated with unusual sexual/gender fantasies (natal females who want to have sex with/as gay men…); and adolescent-onset GD in natal females that has a strong social/iatrogenic component.

Autogynephia is a can of worms I’d rather not open today, as it is both highly controversial and mind-bogglingly confusing. Suffice it to say that it takes us into complex interactions between gender identities and sexual orientations. The idea that sexual motivation could be the underlying driving force for wanting to change sex in some cases tends to be hotly denied. It is seen as a slur. However, for those of us who take a positive view of sex, there is no reason why it should be: a sexual motivation can be as legitimate as any other.

Finally, the future for trans youth is not just about what the medical profession recommends or the law allows. It should be about accepting and celebrating gender diversity, so that youngsters are not put under social pressure to conform to outdated gender stereotypes.

 

Trans kids 1: Insistent, consistent, persistent

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This is the first part of a two-parter on transgender youth. Heretic TOC’s tentative conclusions on trans kids’ rights and well-being, including the right to puberty blocking, will be deferred until part two. By all means send comments straight away, but it would not make sense to judge my opinions until you know what they are. As for the conclusions being “tentative”, I think that as an outsider parachuting myself into this difficult issue for the first time, that’s the way they should be. My view is offered with due humility and I welcome reasoned dissent, not least from one or two people here whose knowledge goes far beyond my own.    

 

What is best for transgender youth? Noisy militants demand the “right” of even little children to adopt the gender of their choice, so that every Stephen can become a Stephanie, start wearing dresses, long-hair and makeup, use the girls’ toilets at school and require everyone to call her “she”.

And every tomboy Stephanie, it is asserted, should be free to do the opposite. Thus the path may be cleared, or so it is hoped, for a smooth transition at adolescence and beyond to a more complete reversal, if so desired, of young people’s originally assigned sex, through hormone treatments and surgery.

Heretic TOC has always keenly advocated children’s rights, so cheerleading for the right of youth with gender dysphoria to change their gender may seem an obvious choice. What is definitely a no-brainer is that we should favour policies and practices aimed at securing their dignity and well-being – aims which should include promoting both a happy childhood and long-term flourishing in adult life.

These welfare aims are not necessarily best advanced, however, simply through declaring and implementing a child’s right to transition. This is because, unlike children’s sexual expression and self-determination, gender transition involves setting out on a path that becomes increasingly harder to reverse as time passes; and irreversible changes of a profound nature, especially sex reassignment surgery (SRS), are sometimes profoundly regretted.

ng-trans-cover-pic

On its Facebook page, the American Family Association posted about this magazine cover: “BE WARNED PARENTS AND GRANDPARENTS!!! National Geographic shakes a fist at God and biblical authority on their radical mission to advocate gender confusion…” The nine-year-old trans girl in the picture, Avery Jackson, and her parents, Debi and Tom, have received an outpouring of public support following the appearance of this very high-profile publicity, but also lots of internet trolling.

This is not to say there should be no early start to transition. Some children make their feelings very clear, very early. From as soon as they learn in infancy about the traditional dress codes and gender roles, they will begin telling their parents they have been assigned to the wrong gender. They just know, from as early as age two or three, that they are really a girl not a boy, or vice versa. In the mantra of therapists approved of by the trans community, if these children are “insistent, consistent and persistent” in such beliefs, then it makes sense to start treating them as belonging to their chosen gender, with a first name and clothes, etc., to match, perhaps just at home to begin with and later at school.

There is nothing irreversible about these symbolic changes, and for that reason there can be no strong reason for making a child’s life miserable by sternly ruling them out. But there are hazards, even at this stage. “Being” a girl instead of a boy, or a boy instead of a girl, may be relatively easy if your mum and dad are relaxed about it and they are the only ones to know; and so will changing back again if so desired. At this stage, there is no commitment beyond the level of any other “let’s pretend” game.

It is much more of a commitment to go to school with a new name and gender though. And a vastly bigger commitment if – as is increasingly happening now that transgender is suddenly such a fashionably high-profile phenomenon – your life as a trans child is featured on a TV reality show such as I Am Jazz, or if your photo is featured on the front cover of National Geographic magazine, as happened to nine-year-old Avery Jackson last month. Once things have reached this stage changing course could be as psychologically tough as getting to the altar with the dreadful sinking feeling that your betrothed is not going to be Mr or Mrs Right after all, but you are already caught in a trap.

The psychiatrist Richard Green, a pioneer in the field of transsexuality since the 1960s, expressed a dim view of transgender children being exposed to the full glare of the media when I heard him speak in London last month on the development of transsexual surgery for adults from its beginnings in the 1930s.

“I’m not convinced that going on TV to announce your child is dysphoric is the best way to ensure their development,” he said. “It might even be considered child abuse. Better if it’s under the radar: allow the child to go to a new school. You test the water. Being on the cover of National Geographic is not necessarily in that kid’s best interests.”

I agree. The high-profile route is a sign not of children being legitimately insistent, consistent and persistent, but rather of militant activism by adults who have shown themselves all too willing to use ruthlessly dishonest tactics. Think of the aggressive noisiness we hear all the time from “victims” of “historic child sexual abuse”: the pushiest ones tell the most sensational yarns and grab the most media and political attention. In this post-truth era, few seem to care whether their stories – with lurid “Satanic abuse” and improbable conspiracy theories based on “recovered memories”, or outright lying – have any basis in reality.

It’s the same, unfortunately, with some trans activists. On BBC’s Newsnight last month, for instance, an activist called Shon Faye made swingeing allegations against Dr Ken Zucker, one of the world’s most eminent clinicians in the transgender field. He falsely claimed that Zucker’s peers, in a  review of his clinical practices, found he had a habit of taking unnecessary photos of his young patients “in various states of undress” and he was “asking them very lurid sexual questions”. Zucker’s long-time colleague Ray Blanchard, also on the programme, intervened to say the allegations were untrue. The presenter stopped Faye from going any further, but by then the damage had been done. The allegations appeared to have been an attempt to recycle an earlier one. A former client, now an adult, claimed Zucker asked him to remove his shirt in front of other clinicians present, laughed when he complied, and then referred to him as a “hairy little vermin”. The accusation was subsequently retracted by the accuser. The resurrected form of the accusation on Newsnight was potentially even more damaging; its vagueness hinted at the possibility of a sexual motive on Zucker’s part – and we need no persuading as to how destructive that can be.

What is certainly true, as H-TOC has reported previously, is that there has been a long-term campaign against Zucker, who is seen by some as a monster who practised a brutal form of “conversion therapy” in which he tried to make kids’ gender identity “normal”, otherwise known in the terminology as cisgender. All this agitation led to a highly critical external review last year of Zucker’s work at his clinic, Toronto’s Centre for Addiction and Mental Health (CAMH), as a result of which he was sacked. Investigative journalist Jesse Singal wrote an in-depth series of articles about this, and concluded:

…the truth about Zucker and his clinic is a lot more complicated. Many of the claims activists have made about him are false or seriously overblown, and the “external review” that led to his firing… was absolutely riddled with errors and falsehoods. CAMH itself quickly decided it couldn’t stand by the review it had commissioned; after we reported that the single most damning allegation in the review was completely false, CAMH yanked the document off its website entirely, replacing it with a toned down “summary.” Zucker has since sued CAMH for releasing what he and his lawyer claim was a defamatory report, and that suit is ongoing.

Zucker had a great chance to put the record straight last month in a BBC 2 documentary called Transgender kids: Who knows best?, and to a significant degree he succeeded – despite a vigorous censorship bid in the shape of a the petition aimed at stopping the show going out, and Shon Faye’s libellous trashing of Zucker, broadcast as part of a Newsnight preview of the show. The programme as a whole was generally well-received by mainstream reviewers, who judged it “cautious”, “well worked out”, “even-handed” and “sophisticated”.

Crucially, it considered the controversial and all-important question of what gender dysphoria actually is. There are those, including clinicians and activists, who believe it always reveals a key aspect of an individual’s innermost, stable identity, by showing there is mismatch between their gender identity and their assigned gender, as traditionally determined by their visible genitalia at birth. Thus until they transition they will never feel at ease with who they are. Arguably, they feel a bit like a gay person before liberation or a Kind one now – forced to hide and deny a fundamental aspect of themselves, and hating the idea that the medical profession wants to wish them out of existence through a “cure”.

Zucker does not deny the importance of the fundamental identity question, but as a clinician he is also aware that people are very complicated and that any particular case may actually be driven by other factors. “Taking any behaviour in isolation when thinking about gender dysphoria is not the way that I think about it,” he says. You also need to know about the child’s family and life history. He gave the example of a girl whose mother had been murdered when she was four. The child wanted to be a boy, he said, in the belief that a boy would have been better able to protect her mother and look after himself too.

It sounded very plausible, but I note that Mike Bailey, one of the top research scientists in the field, is sceptical. Addressing him on Sexnet, Bailey said:

Ken, this mantra that there are many ways to gender dysphoria is possibly true, but it is also possibly false. That your clinical team comes up with various formulations about family dynamics that make sense to the team and that the child gets better when problematic dynamics are treated are not very convincing to me as evidence. (I think a plausible alternative is that the passage of time and a shared commitment to helping the child desist are the active ingredients.) Clinical formulations of this general type (family dynamics) have virtually no evidence supporting them.

What does have strong evidence going for it, though, is a connection between gender nonconformity and autism spectrum disorder (ASD), which can definitely be a profound mental health issue at the severe end of the spectrum. According to paediatric neuropsychologist John Strang, children and adolescents on the autism spectrum are seven times more likely than other young people to be gender nonconforming. And, conversely, children and adolescents at gender clinics are six to 15 times more likely than other young people to have ASD. Zucker has himself pointed out this connection; pro-trans activists play it down.

James/Jasmine, are you reading this? Our brilliant, geeky, teenage male-to-female transgender contributor here at Heretic TOC a couple of years ago also identified as autistic, but at the mild end of the spectrum, such that she felt it was not a mental health problem but a valid and positive aspect of her identity. If you see this, Jasmine, we’d love to hear your reaction!

Even more convincing evidence on Zucker’s side came in the programme from “Lou”, who was born female and had a double mastectomy as part of transitioning to a man. Now she feels “freakish” and regrets it deeply. She says it is a decision that “haunts” her and she feels her gender dysphoria should have been treated as a mental health issue. The identity that now feels truest to her is as a cisgender lesbian.

And yet when she was a girl entering puberty she was desperate to be a boy. Distressed by her unwanted periods, she attempted suicide. She was told by the trans community she really had no choice: it was transition or die. She did not think he had a mental health problem.

Also on Who Knows Best? was trans therapist Hershel Russell, who is based in Toronto, like Zucker, and was one of the people who helped get him sacked. Russell  tried to talk Lou’s case away as a rare exception. But even one exception is enough to prove that matters are not as simple as the more gung-ho activists would have us believe. They also have a problem with the widely-touted claim (albeit the figures are disputed) that around 80% of children and adolescents diagnosed with gender dysphoria do not in the end go through with transition: they desist, sticking with their sex as assigned at birth.

In the Q&A session following his talk on transsexual surgery, I asked Richard Green about the reasons for this desistance. I was particularly interested to know whether he thought the persistors were mainly people with a potentially diagnosable gender-related biological condition underpinning their gender dysphoria, whereas perhaps the desistors had become transgender for socially-motivated reasons.

He favoured a biological explanation for persistence, especially when it was really insistent and consistent. As for those who desist, he said a lot of them become gay or lesbian. And nobody knows better than Green, who wrote a classic book on the subject, that gender non-conforming boys tend to be homosexual later on. It appears to me that gender dysphoria and sexual orientation probably have a connected common origin. Given the present scientific consensus that sexual orientation has pre-natal biological origins, it also seems a good bet that gender dysphoria is triggered further back in an individual’s development than any social influences.

For yet another Toronto angle on all this I can thank Peace, who has guest-blogged and commented here. Transitioning from female to male, Peace has chosen not to guest-blog about his personal journey, but responded instead to my request for general information, thoughts and resources on the subject. One such resource I found particularly helpful was Families in TRANSition: A Resource Guide for Parents of Trans Youth, published by Central Toronto Youth Services.

What struck me most from this publication was its calmly reasonable tone – a million miles, one might think, from the militant, angry activism that sees Ken Zucker libelled and branded a monster. Bizarrely, however, one of those pleasant, sensible contributors turns out to be none other than Hershel Russell, one of Zucker’s most strident critics. He confesses he worries a bit about parents who seem immediately very accepting of their child’s wish to transition. Zucker himself could have written that!

A point I feel Peace would particularly agree with is this:

Trans people often describe puberty, the point at which their bodies begin to change and visibly betray their inner experience, as traumatizing – “nature’s cruel trick” – and a time of true despair. It is a time when feelings of depression or thoughts of suicide may emerge or worsen.

But the guide makes clear that being transgender is not always about heading towards radical anatomical change:

Some youth are clear that their survival depends on fully transitioning from one gender to another. Other youth find that they only need to change one aspect of their bodies, or need no medical interventions at all but rather wish to express their unique gender identity through clothing and behaviour. Whatever the case, these needs come from inside the child and, for better or worse, are unlikely to be changed by pressure or persuasion.

 

The next part of this two-part blog will go deeper into the question of what being transgender really means. It will introduce the scientific basis for a striking claim: that there is such a thing as an intersex brain. It will also discuss transgender choices in relation to wider cultural issues.  

 

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