A Review of the Medical Consequences of Homophobia with Suggestions for Resolution

  • Katherine A. O'Hanlan
  • Robert Paul Cabaj
  • Benjamin Schatz
  • James Lock
  • Paul Nemrow


Purpose: This review highlights the effects of homophobia, the antipathy or disdain for gay men and lesbians, which is a widespread response to this largely unfamiliar and previously hidden segment of society. Data Sources: Peer-reviewed and non-peer-reviewed journal articles, published and unpublished survey reports, current newspaper coverage of events, U.S. census data, are all integrated to produce an overview of societal, psychosocial, and medical consequences of homophobia. Data Synthesis: The available information has been analyzed from a psychiatric, medical, and sociocultural perspective in order to provide an update on the known science about homosexuality and the medical effects of homophobia. Conclusions: The medical and psychological effects of homophobic prejudice are profound on the developing self-concept of youths as well as adults who recognize a same-sex orientation. Medical practitioners are not immune from societal prejudice and may demonstrate disdain for gay men and lesbians as patients. Patients perceive this disdain, which alienates them from the medical system, reducing utilization of screening modalities, risking higher morbidity and mortality from infections, cancers, and heart disease. Being gay or lesbian is not genetically or biologically hazardous, but risk factors are conferred through homophobia. Therefore, the process of homophobia—the socialization of heterosexuals against homosexuals and concomitant conditioning of gays and lesbians against themselves—poses a legitimate health hazard. Governmental, institutional, educational, and medical resolutions of homophobia are discussed which would improve the quality of medical care provided to gay men and lesbians, and have a favorable impact on the health and quality of life of this population.

Homosexuality lesbianism gays prejudice 


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  1. 1.
    American Medical Association. Policy 160-991. Health care needs of gay men and lesbians in the U.S. AMA Policy Compendium. Chicago, IL: American Medical Association, 1995:148–9.Google Scholar
  2. 2.
    Merriam-Webster Inc. Merriam-Webster's Collegiate Dictionary. Springfield, MA: Merriam-Webster, 1994.Google Scholar
  3. 3.
    Sophie J. Internalized homophobia and lesbian identity. J Homosex 1987;14:53–65.Google Scholar
  4. 4.
    Ferenczi S. Sex in Psychoanalysis. New York: Basic Books, 1950:154–84.Google Scholar
  5. 5.
    Isay R. Being Homosexual: Gay Men and Their Development. New York: Avon Books, 1989.Google Scholar
  6. 6.
    Herek GM. Attitudes toward lesbians and gay men: a factor-analytic study. J. Homosex 1984;10:39–51.Google Scholar
  7. 7.
    Herek GM. Heterosexism and homophobia. In: Cabaj RP, Stein TS, editors. Textbook of Homosexuality and Mental Health. Washington, DC: American Psychiatric Press, 1996:65–82.Google Scholar
  8. 8.
    Bell A, Weinberg M. Homosexualities: A Study of Diversity Among Men and Women. New York: Simon & Schuster, 1978.Google Scholar
  9. 9.
    Kaplan DA, Klaidman D. A battle, not the war. Newsweek 1996;127:24–30.Google Scholar
  10. 10.
    Shidlo A. Assessing heterosexuals' attitudes toward lesbian and gay men. In: Greene B, Herek GM, editors. Psychological Perspectives on Lesbian and Gay Issues, Vol. 1 Lesbian and Gay Psychology: Theory, Research and Clinical Applications. Thousand Oaks, CA: Sage Press, 1994:176–205.Google Scholar
  11. 11.
    Hart M, Roback H, Tittler B, Wietz L, Walston G, McKee E. Psychological adjustment of non-patient homosexuals: critical review of the research literature. J Clin Psychiatry 1978;39:604–8.Google Scholar
  12. 12.
    Suppe F. Classifying sexual disorders: the Diagnostic and Statistical Manual of the American Psychiatric Association. J Homosex 1984;9:9–28.Google Scholar
  13. 13.
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd edition. Washington, DC: American Psychiatric Association, 1994:538.Google Scholar
  14. 14.
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd edition revised. Washington, DC: American Psychiatric Association, 1987.Google Scholar
  15. 15.
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd edition. Washington, DC: American Psychiatric Association, 1980:281.Google Scholar
  16. 16.
    Moos RH. Understanding individuals' life contexts: implications for stress reduction and prevention. In: Kessler M, Goldston SE, Joffe J, editors. The Present and Future of Prevention Research. Newbury Park, CA: Sage, 1992:296–313.Google Scholar
  17. 17.
    Moos RH, Billings A. Conceptualization and measuring coping responses and processes. In: Goldberger L, Bresnitz S, editors. Handbook on Stress: Theoretical and Clinical Aspects. New York: The Free Press, 1993:234–57.Google Scholar
  18. 18.
    Saghir MT, Robins E, Walbran B, Gentry KA. Homosexuality: III. Psychiatric disorders and disability in the male homosexual. Am J Psychiatry 1970;127–147.Google Scholar
  19. 19.
    Saghir MT, Robins E, Walbran B, Gentry KA. Homosexuality: IV. Psychiatric disorders and disability in the female homosexual. Am J Psychiatry 1972;120:477.Google Scholar
  20. 20.
    Savin-Williams RC. Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: associations with school problems, running away, substance abuse, prostitution, and suicide. J Consult Clin Psychol 1994;62:261–9.Google Scholar
  21. 21.
    DiPlacido J. Stress, behavioral risk factors, and physical and psychological health outcomes in lesbians. APA Women's Health Conference, 1994.Google Scholar
  22. 22.
    Bradford J, Ryan C, Rothblum ED. National Lesbian Health Care Survey: implications for mental health care. J Consult Clin Psychol 1994;62:228–42.Google Scholar
  23. 23.
    Larson D, Chastain R. Self-concealment: conceptualization, measurement, and health implications. J Soc Clin 1990;9:439–455.Google Scholar
  24. 24.
    Dupras A. Internalized homophobia and psychosexual adjustment among gay men. Psychol Rep 1994;75:23–8.Google Scholar
  25. 25.
    Cochran SD, Mays VM. Depressive distress among homosexually active African American men and women. Am J Psychiatry 1994;151:524–9.Google Scholar
  26. 26.
    Mays VM, Cochran SD. The Black Women's Relationships Project: a national survey of black lesbians. In: Shernoff M, Scott WA, editors. A Sourcebook of Gay/Lesbian Health Care. Washington, DC: National Gay and Lesbian Health Foundation, 1988.Google Scholar
  27. 27.
    Gartrell N. The lesbian as a “single” woman. Am J Psychother 1981;35:502–16.Google Scholar
  28. 28.
    Berger RM. Passing: impact on the quality of same-sex couple relationships. Soc Work 1990;35:328–32.Google Scholar
  29. 29.
    Bybee D. Michigan lesbian survey: a report to the Michigan Organization for Human Rights and the Michigan Department of Public Health. Detroit, MI: Michigan Department of Health and Human Services, 1990.Google Scholar
  30. 30.
    Remafedi G, Resnick M, Blum R, Harris L. Demography of sexual orientation in adolescents. Pediatrics 1992;89:714–21.Google Scholar
  31. 31.
    Uribe V, Harbeck KM. Addressing the needs of lesbian, gay, and bisexual youth: the origins of PROJECT 10 and school-based intervention. J Homosex 1992;22:9–28.Google Scholar
  32. 32.
    American Academy of Pediatrics: Committee on Adolescence. Homosexuality and Adolescence. Pediatrics 1993;92:631–4.Google Scholar
  33. 33.
    U.S. Government Accounting Office. Report to Congress on Homosexuality in the Military. Washington, DC: United States Congress, 1992.Google Scholar
  34. 34.
    Herek GM. Gay people and government security clearances. A social science perspective. Am Psychol 1990;45:1035–42.Google Scholar
  35. 35.
    Jones FD, Koshes RJ. Homosexuality and the military. Am J Psychiatry 1995;152:16–21.Google Scholar
  36. 36.
    Hunter J. Violence against lesbian and gay youth: a report from the Hetrick Martin Institute. New York: The Hetrick Martin Institute, 1989.Google Scholar
  37. 37.
    Remafedi G. Adolescent homosexuality: psychosocial and medical implications. Pediatrics 1987;79:331–7.Google Scholar
  38. 38.
    D'Augelli AR, Hershberger SL. Lesbian, gay, and bisexual youth in community settings: personal challenges and mental health problems. Am J Community Psychol 1993;21:421–48.Google Scholar
  39. 39.
    Schneider SG, Farberow NL, Kruks GN. Suicidal behavior in adolescent and young adult gay men. Suicide Life Threat Behav 1989;19:381–94.Google Scholar
  40. 40.
    Remafedi G, Farrow JA, Deisher RW. Risk factors for attempted suicide in gay and bisexual youth. Pediatrics 1991;87:869–75.Google Scholar
  41. 41.
    Savin-Williams RC. Coming out to parents and self-esteem among gay and lesbian youths. J Homosex 1989;18:1–35.Google Scholar
  42. 42.
    Garland AF, Zigler E. Adolescent suicide prevention. Current research and social policy implications. Am Psychol 1993;48:169–82.Google Scholar
  43. 43.
    Harkavy Friedman JM, Asnis GM, Boeck M, Di Fiore J. Prevalence of specific suicidal behaviors in a high school sample. Am J Psychiatry 1987;144:1203–6.Google Scholar
  44. 44.
    Centers for Disease Control. Attempted suicide among high school students in the United States. MMWR. Morb Mort Wkly Rep 1991;40:1–8.Google Scholar
  45. 45.
    Hartstein NB. Suicide risk in lesbian, gay, and bisexual youth. In: Cabaj RP, Stein TS, editors. Textbook of Homosexuality and Mental Health. Washington, DC: American Psychiatric Press, 1996:819–37.Google Scholar
  46. 46.
    Shaffer D. The epidemiology of teen suicide: examination of risk factors. J Clin Psychiatry 1988;142:1061–4.Google Scholar
  47. 47.
    Patterson CJ. Children of lesbian and gay parents. Child Dev 1992;63:1025–42.Google Scholar
  48. 48.
    Gordon L. What do we say when we hear ‘Faggot’? Rethinking Our Schools 1994; Special ed:82–3.Google Scholar
  49. 49.
    Haldeman DC. The practice and ethics of sexual orientation conversion therapy. J Consult Clin Psychol 1994;62:221–7.Google Scholar
  50. 50.
    Bryant S, Demian. Summary of results, Partners' national survey of lesbian & gay couples. Partners 1990:2–6.Google Scholar
  51. 51.
    Cabaj R. Gay and lesbian couples: Lessons on human intimacy. Psychiatric Ann 1988;18:21–5.Google Scholar
  52. 52.
    Klinger R, Cabaj RP. Characteristics of gay and lesbian relationships, special section: changing perspectives on homosexuality. In: Stein T, editor. Psychiatry, Vol. 12. Washington, DC: American Psychiatric Press, 1993.Google Scholar
  53. 53.
    Cabaj RP. Substance abuse in gay men, lesbians, and bisexuals. In: Cabaj RP, Stein TS, editors. Textbook of Homosexuality and Mental Health. Washington, DC: American Psychiatric Press, 1996:783–99.Google Scholar
  54. 54.
    Cabaj R. Substance abuse in the gay and lesbian community. In: Lowinson J, Ruiz P, Millman R, editors. Substance Abuse: A Comprehensive Textbook. Baltimore, MD: Williams and Wilkins, 1992:852–60.Google Scholar
  55. 55.
    Lesbian & Gay Substance Abuse Planning Group. San Francisco lesbian, gay and bisexual substance abuse needs assessment: executive summary. Sacramento, CA: EMT Associates, 1991.Google Scholar
  56. 56.
    Paul J, Stall R, Bloomfield K. Gay and alcoholic: epidemiologic and clinical issues. Alcohol Health Res 1991;5:151–160.Google Scholar
  57. 57.
    Stall R, Wiley J. A comparison of alcohol and drug use patterns of homosexual and heterosexual men: the San Francisco Men's Health Study. Drug Alcohol Depend 1988;22:63–73.Google Scholar
  58. 58.
    McKirnan D, Peterson P. Alcohol and drug use among homosexual men and women: epidemiology and population characteristics. Addict Behav 1989;14:545–553.Google Scholar
  59. 59.
    Martin J, Dean L, Carcia M, Hall W. The impact of AIDS on a gay community: changes in sexual behavior, substance abuse and mental health. Am J Community Psychol 1989;17:269–293.Google Scholar
  60. 60.
    Bloomfield K. A comparison of alcohol consumption between lesbians and heterosexual women in an urban population. Drug Alcohol Depend 1993;33:257–69.Google Scholar
  61. 61.
    Schilit R, Lie GY, Montagne M. Substance use as a correlate of violence in intimate lesbian relationships. J Homosex 1990;19:51–65.Google Scholar
  62. 62.
    Hall JM. Alcoholism in lesbians: developmental, symbolic interactionist, and critical perspectives. Health Care Women Int 1990;11:89–107.Google Scholar
  63. 63.
    Morales E, Graves M. Substance abuse: patterns and barriers to treatment for gay men and lesbians in San Francisco. Report to Community Substance Abuse Services. San Francisco: San Francisco Department of Public Health, 1983.Google Scholar
  64. 64.
    Stein TS. A curriculum for learning in psychiatric residencies about homosexuality, gay men and lesbians. Acad Psychiatry 1994;18:59–70.Google Scholar
  65. 65.
    Stevens PE, Hall JM. Abusive health care interaction experienced by lesbians: a case of institutional violence in the treatment of women. Response 1990;13:23.Google Scholar
  66. 66.
    Dardick L, Grady K. Openness between gay persons and health professionals. Ann Int Med 1980;93:115–9.Google Scholar
  67. 67.
    Kass NE, Faden RR, Fox R, Dudley J. Homosexual and bisexual men's perceptions of discrimination in health services. Am J Public Health 1992;82:1277–9.Google Scholar
  68. 68.
    Smith EM, Johnson SR, Guenther SM. Health care attitudes and experiences during gynecologic care among lesbians and bisexuals. Am J Public Health 1985;75:1085–7.Google Scholar
  69. 69.
    Cochran SD, Mays VM. Disclosure of sexual preference to physicians by black lesbian and bisexual women. West J Med 1988;149:616–9.Google Scholar
  70. 70.
    Johnson SR, Guenther SM, Laube DW, Keettel WC. Factors influencing lesbian gynecologic care: a preliminary study. Am J Obstet Gynecol 1981;140:20–8.Google Scholar
  71. 71.
    National Gay and Lesbian Task Force. Anti-gay/lesbian violence, victimization, & defamation in 1993. Washington, DC: National Gay and Lesbian Task Force Policy Institute, 1994.Google Scholar
  72. 72.
    Dunlap D. Survey on slayings of homosexuals finds high violence and low arrest rate. NY Times 1994:A-10.Google Scholar
  73. 73.
    Berrill KT. Anti-gay violence and victimization in the United States: an overview. In: Herek G, Berill KT, editors. Hate Crimes: Confronting Violence and Intergroup Behavior. New-bury Park, CA: Sage, 1992:19–45.Google Scholar
  74. 74.
    Pilkington NW, D'Augelli AR. Victimization of lesbian, gay, and bisexual youth in community settings. J Community Psychol 1995;23:34–56.Google Scholar
  75. 75.
    Due L. Joining the Tribe: growing up Gay in the '90's. New York: Doubleday, 1995.Google Scholar
  76. 76.
    Herek GM. Documenting prejudice against lesbians and gay men on campus: the Yale Sexual Orientation Survey. J Homosex 1993;25:15–30.Google Scholar
  77. 77.
    Usdansky M. Gay couples, by the numbers, data suggest they're fewer than believed, but affluent. USA Today 1993:1a.Google Scholar
  78. 78.
    Phillip M. Gay issues: out of the closet, into the classroom, racism, fear of reprisals forces black gays and lesbians to keep low profile on campus. Black Issues Higher Educ 1993:20–5.Google Scholar
  79. 79.
    Mays VM, Jackson JS, Coleman LS. Perceived discrimination, employment status and job stress in a national sample of black women. J Occup Health Psychol 1995;in press.Google Scholar
  80. 80.
    Schatz B. The AIDS insurance crisis: underwriting or overreaching? Harvard Law Rev 1987;100:1782–1805.Google Scholar
  81. 81.
    Randall CE. Lesbian phobia among BSN educators: a survey. J Nurs Educ 1989;28:302–6.Google Scholar
  82. 82.
    Eliason MJ, Randall CE. Lesbian phobia in nursing students. West J Nurs Res 1991;13:363–74.Google Scholar
  83. 83.
    Matthews W, Booth MW, Turner J. Physicians' attitudes toward homosexuality: survey of a California county medical society. West J Med 1986;144:106.Google Scholar
  84. 84.
    Kelly JA, St LJ, Smith Jr S, Hood HV, Cook DJ. Medical students' attitudes toward AIDS and homosexual patients. J Med Educ 1987;62:549–56.Google Scholar
  85. 85.
    Schatz B, O'Hanlan K. Anti-gay discrimination in medicine: results of a national survey of lesbian, gay and bisexual physicians. San Francisco: Gay and Lesbian Medical Association, 1994.Google Scholar
  86. 86.
    Stevens PE, Hall JM. Stigma, health beliefs and experiences with health care in lesbian women. Image J Nurs Scholarship 1988;20:69–73.Google Scholar
  87. 87.
    Moscicki AB, Palefsky J, Gonzales J, Schoolnik GK. Human papillomavirus infection in sexually active adolescent females: prevalence and risk factors. Pediatr Res 1990;28:507–13.Google Scholar
  88. 88.
    Palefsky J. Human papillomavirus-associated malignancies in HIV-positive men and women. Curr Opin Oncol 1995;7:437–41.Google Scholar
  89. 89.
    Wright T, Richart RM. Role of human papillomavirus in the pathogenesis of genital tract warts and cancer. Gynecol Oncol 1990;37:151–64.Google Scholar
  90. 90.
    Johnson SR, Smith EM, Guenther SM. Comparison of gynecologic health care problems between lesbians and bisexual women. A survey of 2,345 women. J Reprod Med 1987;32:805–11.Google Scholar
  91. 91.
    O'Hanlan KA, Crum CP. Human papillomavirus-associated cervical intraepithelial neoplasia following exclusive lesbian sex. Obstet Gynecol 1996;88:702–3.Google Scholar
  92. 92.
    Robertson P, Schachter J. Failure to identify venereal disease in a lesbian population. Sex Trans Dis 1981;8:75–6.Google Scholar
  93. 93.
    Di Bonito L, Falconieri G, Tomasic G, Colautti I, Bonifacio D, Dudine S. Cervical cytopathology. An evaluation of its accuracy based on cytohistologic comparison. Cancer 1993;72:3002–6.Google Scholar
  94. 94.
    Sherlaw-Johnson C, Gallivan S, Jenkins D, Jones MH. Cytological screening and management of abnormalities in prevention of cervical cancer: an overview with stochastic modelling. J Clin Pathol 1994;47:430–5.Google Scholar
  95. 95.
    Daling JR, Weiss NS, Klopfenstein LL, Cochran LE, Chow WH, Daifuku R. Correlates of homosexual behavior and the incidence of anal cancer. JAMA 1982;247:1988–90.Google Scholar
  96. 96.
    Palefsky J. Human papillomavirus infection among HIV-infected individuals. Implications for development of malignant tumors. Hematol Oncol Clin North Am 1991;5:357–70.Google Scholar
  97. 97.
    Weiss NS, Daling JR, Chow WH. Incidence of cancer of the large bowel in women in relation to reproductive and hormonal factors. J Natl Cancer Inst 1981;67:57–60.Google Scholar
  98. 98.
    Holleb A, Fink D, Murphy G. American Cancer Society Textbook of Clinical Oncology. Atlanta, GA: American Cancer Society, 1991:177, 485, 488.Google Scholar
  99. 99.
    Risch HA, Weiss NS, Lyon JL, Daling JR, Liff JM. Events of reproductive life and the incidence of epithelial ovarian cancer. Am J Epidemiol 1983;117:128–39.Google Scholar
  100. 100.
    US Department of Health and Human Services. Health: United States Prevention Profile for 1991. Washington, DC: Department of Health and Human Services, 1991.Google Scholar
  101. 101.
    Shilts R. And the Band Played on: Politics, People, and the AIDS Epidemic. New York: St. Martin's Press, 1987:126, 290.Google Scholar
  102. 102.
    Public Law. Labor—Health and Human Services Appropriations for Fiscal Year 1988. Federal Register 1988:100–202.Google Scholar
  103. 103.
    AIDS Commercials. Groups pan new AIDS commercials. Faulkner Gray's Med Health 1992;March 30.Google Scholar
  104. 104.
    O'Hanlan KA. Recruitment and retention of lesbians in health research trials. Recruitment and Retention of Women in Clinical Studies 1995. National Institutes of Health, NIH Publication 95-3756:101–4.Google Scholar
  105. 105.
    Michaels S. The prevalence of homosexuality in the United States. In: Cabaj RP, Stein TS, editors. Textbook of Homosexuality and Mental Health. Washington, DC: American Psychiatric Press, 1996:43–63.Google Scholar
  106. 106.
    American Psychiatric Association. Position paper on homosexuality and civil rights. Am J Psychiatry 1974;131:497.Google Scholar
  107. 107.
    American Medical Women's Association. Position paper on lesbian health. J Am Med Womens's Assoc 1993;49:86.Google Scholar
  108. 108.
    Office of Student Affairs. A community of equals: a resource guide for the Temple medical community about gay, lesbian and bisexual people. Philadelphia, PA: Temple University School of Medicine, 1992.Google Scholar
  109. 109.
    Cabaj RP, Stein TS, editors. Textbook of Homosexuality and Mental Health. Washington, DC: American Psychiatric Press, 1996.Google Scholar
  110. 110.
    Cranston K. HIV education for gay, lesbian, and bisexual youth: personal risk, personal power, and the community of conscience. J Homosex 1992;22:247–59.Google Scholar
  111. 111.
    Griffin P. From hiding out to coming out: empowering lesbian and gay educators. J Homosex 1992;22:167–96.Google Scholar
  112. 112.
    McConaghy N, Silove D. Opposite sex behaviors correlate with degree of homosexual feelings in the predominantly heterosexual. Aust N Z J Psychiatry 1991;25:77–83.Google Scholar
  113. 113.
    Ellis AL, Vasseur RB. Prior interpersonal contact with and attitudes towards gays and lesbians in an interviewing context. J Homosex 1993;25:31–45.Google Scholar
  114. 114.
    Remafedi G. The impact of training on school professionals' knowledge, beliefs, and behaviors regarding HIV/AIDS and adolescent homosexuality. J School Health 1993;63:153–7.Google Scholar
  115. 115.
    Governor's Commission on Gay and Lesbian Youth. Report on Gay and Lesbian Youth. Massachusetts State House, Room 111, Boston, MA: State of Massachusetts, 1993.Google Scholar
  116. 116.
    Fried B. Report of the subcommittee on domestic partners' benefits. University Committee for Faculty and Staff Benefits, Standford University, 1992:37–8.Google Scholar
  117. 117.
    Hammelman T. Gay and lesbian youth: contributing factors to serious attempts or considerations of suicide. J Gay Lesbian Psychiat 1993;2:77.Google Scholar
  118. 118.
    Glascock E. Access to the traditional health care system by nontraditional women: perceptions of a cultural interaction. American Public Health Association, Los Angeles, 1981.Google Scholar
  119. 119.
    Bradford J, Ryan C, Rothblum ED. National Lesbian Health Care Survey: implications for mental health care. J Consult Clin Psychol 1994;62:228–42.Google Scholar

Copyright information

© Gay and Lesbian Medical Association 1997

Authors and Affiliations

  • Katherine A. O'Hanlan
    • 1
  • Robert Paul Cabaj
    • 2
  • Benjamin Schatz
    • 3
  • James Lock
    • 4
  • Paul Nemrow
    • 5
    • 6
  1. 1.Division of Gynecologic Oncology, Department of Obstetrics and GynecologyStanford University School of MedicineStanford
  2. 2.Department of PsychiatryUniversity of CaliforniaSan Francisco
  3. 3.Gay and Lesbian Medical AssociationSan Francisco
  4. 4.Division of Child Psychiatry, Department of Psychiatry and Behavioral MedicineStanford University School of MedicineStanford
  5. 5.Physical MedicineSt. Mary's HospitalSan Francisco
  6. 6.Stanford University School of MedicineStanford

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