Issues Regarding Sexuality and Nursing

Afza.Malik GDA

 Geriatric Nursing and Sexual Issues 

Issues Regarding Sexuality and Nursing

Whats is sexuality and sexual health age related sexual issues their assessment and nursing care.Patient view to ward sexuality.

Whats is Sexuality

    Sexuality is an innate quality present in all human beings and is extremely important to an individual's self-identity and general well-being (Wallace, 2008), Sexuality is defined as “a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction (World Health Organization (WHO), 2010).” 

Sexual Health

    Sexual health as a manifestation of sexuality is “a state of physical, emotional, mental and social well-being related to sexuality (WHO, 2010),” Sexual health contributes to the satisfaction of physical needs; however, it is often not as apparent that sexual contact fulfills many social, emotional, and psychological components of life as well. 

    This is evidenced by the fact that human touch and a healthy sex life may evoke feelings of joy, romance, affection, passion, and intimacy, whereas despondency and depression often result from an inability to express one's sexuality (Kamel & Hajjar, 2003). When this occurs, sexual dysfunction, defined as impairment in normal sexual functioning, may result (American Psychiatric Association (APA), 2000).

    It is frequently assumed that sexual desires and the frequency of sexual encounters begin to diminish later in life. Furthermore, the notion of older adults engaging in sexual activities has become taboo in today's youth-loving society (Kamel & Hajjar, 2003). 

    Despite this stereotype, sexual identity and the need for intimacy do not disappear with increasing age, and older adults do not morph into celibate, asexual beings. In a study of 3,005 US older adults, current sexual activity was reported in 73% of adults aged 57-64 years, 53% of adults aged 65-74 years, and 26% of adults aged 75-84 years (Lindau et al. , 2007).

Sexual Problem and Age

    Despite the persistence of sexual patterns throughout the lifespan, there is limited research and information to assist nurses to assess and intervene to promote sexual health among older adults. Lack of research literature and insufficient clinical resources are a product of the lack of societal recognition of sexuality as a continuing human need and a factor that perpetuates lack of sexual assessment and intervention among the older population. 

    In addition to the lack of literature, there are several factors that further impact the sexual health of older adults. These factors include the presence of normal and pathological aging changes, environmental barriers to sexual health, and special problems of the older adult that interfere with sexual fulfillment, such as cognitive impairment.

Views Toward Sexuality and Aging

    Nurses' hesitancy to discuss sexuality with older adults has a significant impact on the sexual health of this population. Gott, Hinchliff, and Galena (2004) reported that general practitioners do not discuss sexual health frequently in providing primary care to older adults. Their study of 55 older men and women resulted in the finding that a major factor affecting sexual discussion between patients and their physicians included the hesitancy of discussing sexuality with a health care provider who was not the patient's age or sex.

    In this qualitative study, clients stated that sexuality discussions would be more comfortable and forthcoming with health care providers who matched their sex and age. Furthermore, attitudes toward sexuality later in life, making jokes about sexuality. Shame or embarrassment and fear, perception of sexual problems as not serious, and lack of knowledge regarding available interventions were also seen as barriers to sexual discussion between older clients and health care providers (Gott et al., 2004).

    General discomfort with discussing sexuality among nurses and lack of experience in assessment and management of sexual dysfunction among older adults often prevents nurses from addressing the sexual needs of this population. Furthermore, the sexuality of older adults is generally excluded from sparse gerontological curricula. 

    Without education and experience in managing sensitive issues around sexuality, health professionals are often not comfortable discussing sexual issues with older adults. Health care providers may lessen discomfort with addressing sexual issues by increasing their knowledge on the subject and routinely introducing this dimension of health into routine assessment and management protocols.

    Nurses' understanding of sexuality should be broadened beyond that of a relationship between just men and women. Many clients within various health care systems are gay or lesbian, bisexual, and transgender (GLBT) adults, and these alternative sexual preferences require respect and consideration. In a focus group study, older gay and lesbians reported extensive discrimination in accessing health care services by excluding them from program planning (Brotman, Ryan, & Cormier, 2003). 

    Discrimination among GLBT older adults is especially seen in the development of residential services to meet the needs of older adults. In a larger study of 400,000 GLBT adults, discrimination was seen among administrators, care providers, and other residents of the retirement care community (Johnson, Jackson, Arnette, & Koffman, 2005). Normal and Pathological Aging Changes .

    The “sexual response cycle,” or the organized pattern of physical response to sexual stimulation, changes with age in both women and men. After menopause, a loss of estrogen in women results in significant sexual changes. This deficiency frequently results in the thinning of the vaginal walls and decreased or delayed vaginal lubrication, which may lead to pain during intercourse (Lobo, 2007). 

    Additionally, the labia atrophy, the vagina shortens, and the cervix may descend downward into the vagina and cause further pain and discomfort. Furthermore, vaginal contractions are fewer and weaker during orgasm, and after sexual intercourse is completed, women return to the prearoused stage faster than they would at an earlier age. 

    The result of these physiological age-related changes in women is the potential for significant alterations in sexual health that have traditionally received little attention from research or individual health care providers. The pain resulting from anatomical changes and vaginal dryness may result in the avoidance of sexual relationships in order to prevent painful intercourse.

    Men also experience decreased hormone levels, mainly testosterone, yet this seems to have a limited impact on sexual functioning because only a minimal amount of testosterone is needed for the purposes of sex. This reduction in testosterone that has been controversially labeled vireo pause or andropause and male menopause generally begins between the ages of 46 and 52 years and is characterized by a gradual decrease in the amount of testosterone (Kessenich & Cichon, 2001). 

    The loss of testosterone is not pathological and does not result in sexual dysfunction. However, men may experience fatigue, loss of muscle mass, depression, and a decline in libido. As a result of normal aging changes, older men require more direct stimulation of the penis to experience erection, which is somewhat weaker as compared to that experienced in earlier ages. 

    As with postmenopausal women, orgasms are fewer and weaker in older men, the force and amount of ejaculation is reduced, and the refractory period after ejaculation is significantly increased (Araujo, Mohr, & McKinlay, 2004).

    Bodily changes such as wrinkles and sagging skin may cause both older women and men to feel insecure about initiating a sexual encounter and maintaining emotionally secure relationships. In addition, lack of knowledge and understanding among older adults about sexuality is common because sexual education is rarely provided in formal educational systems as the older adults developed and was rarely discussed informally. 

    Strict beliefs and values are likely to impact sexual action, freedom, and desires and may result in sexual frustration and conflict. Physical changes in the sexual response. cycle that occurs with increasing age do not completely explain the extensive changes in sexuality that occurs among older adults. 

    Many individual psychosocial and cultural factors play a role in how older adults perceive themselves as sexual beings. Although sexual disorders have not been well-addressed among the older population, they have been defined and fall into four categories: hypoactive sexual desire disorder, sexual arousal disorder, orgasmic disorder, and sexual pain disorders (Walsh & Berman, 2004).

    In addition to normal aging changes and pathological sexual disorders, there are a number of medical conditions that have been associated with poor sexual health and functioning in the older population (Morle & Tariq, 2003), Rosen et al. (2009) reported that the main predictors of sexual dysfunction are age, cardiovascular diseases, and diabetes. 

    One of the most frequently occurring medical conditions among older adults includes cardiovascular disease. In a study of 2,763 postmenopausal women, the presence of coronary heart disease was associated with lack of interest, inability to relax. arousal and orgasmic disorders, and general discomfort with sex (Addis et al., 2005). Diabetes is a large problem among older adults, affecting approximately 14.7 million individuals in the United States each year. 

    Approximately, 40% of those with diabetes are aged 65 years or older (Centers for Disease Control and Prevention (CDC), nd). In a study of eight women aged 24-83 years, older women with diabetes reported lower sexual function, desire, and enjoyment than their younger counterparts (Rockliffe-Fidler & Kiemle, 2003). 

    Furthermore, in a study of 373 men aged 45-75 years with Type II diabetes, 49.8% of men reported mild or moderate degrees of erectile dysfunction (ED). and 24.8% had complete ED (Rosen et al., 2009).The presence of depression among older adults impacts sexual health, in that depression often causes a decline in desire and ability to perform with this disease and treatment. 

    Korfage et al. (2009) reported in a study of 3,810 men aged 57-78 years that men with ED reported significantly lower mental health than men without ED. The presence of loss and depression should be assessed among older adults and considered for the impact of these emotional and psychological factors on sexual health. (see Chapter 9, Depression in Older Adults).

    Other medical conditions occurring among older adults also have the potential to impact sexual health. Older adults who have experienced strokes and subsequent aphasias reported alterations in sexual health because of communication difficulties (Lemieux, Cohen-Schneider, & Holzapfel, 2001). Additionally, Parkinson's disease (PD) that is predominantly found in an older adult has the potential to negatively impact sexual health. 

    In a study of 444 older adults with PD, sexual limitations were reported in 73.5% of the sample as a product of difficulty in movement (Mott, Kenrick, Dixon, & Bird, 2005). Benign prostatic hypertrophy (BPH) in older men may result in altered circulation to the penis effecting erectile function and sexual arousal. 

    Derogates and Burnett (2008) stated that sexual dysfunction is prevalent worldwide, and its occurrence and the frequency of symptoms that impact sexual health increase directly with age for both men and women. Pathological changes of aging such as the conditions discussed are major risk factors for sexual disorders.

    Medications used to treat commonly occurring medical illnesses among older adults also impact sexual function. Two of the major groups of medications include antidepressants and antihypertensives. Causative antidepressants include the commonly used selective serotonin reuptake inhibitors (SSRIs). In a study of 610 women and 412 men. 59.1% of the individuals taking SSRI antidepressant medications reported sexual dysfunction (Montejo, Llorca. 

    Izquierdo, & Rico-Villademoros, 2001). Although the use of monoamine oxidase (MAO) inhibitors and tricyclic antidepressants has decreased in favor of the SSRIs with lower side-effect profiles, these medications also impact sexual function by reducing sexual drive and causing impotence and erectile and orgasmic disorders. 

    Antihypertensives, angiotensin-converting enzyme (ACE) inhibitors, and alpha and beta cell blockers also result in impotence and ejaculatory disturbances among older adults (Alagiakrishnan et al., 2005). Antipsychotics, commonly used statin medications, and H2 blockers also impact the sexual health of older adults.

Special Issues Related to Older Adults and Sexuality

    Cognitively impaired older adults continue to have sexual needs and desires that present a challenge to nurses. These continuing sexual needs often manifest in inappropriate sexual behavior. Sexual behaviors common to the cognitively impaired older adults may include cuddling, touching of the genitals, sexual remarks, propositioning, grabbing and groping, use of obscene language, masturbating without shame, aggression, and irritability. 

    In a study of 41 cognitively impaired older adults, 1.8% had sexually inappropriate behavior manifesting in verbal and physical problems (Alagiakrishnan et al., 2005). In a study that used computed tomography (CT) of the head to scan 10 patients with these problematic sexual behaviors, cerebral infarction was seen in six of them, and severe disease in two others, supporting the organic basis for these symptoms (Nagaratnam & Gayagay , 2002)..

    Masturbation is a method in which cognitively impaired men and women may become sexually fulfilled. Nurses in long-term care facilities may assist older adults to improve sexual health by providing an environment in which the older adult may masturbate in private. Alkhalil, Tanvir. Alkhalil, and Lowenthal (2004) reported that the use of gabapentin to decrease sexual behavior problems (such as inappropriate sexual overtures and public masturbation) has demonstrated effectiveness anecdotally. 

    Accurate assessment and documentation of the ability of cognitively impaired older adults to make competent decisions regarding sexual relationships with others while in long-term care is essential. If the resident has been determined to be incapable of decision making, then the health care staff must prevent the cognitively impaired resident from unsolicited sexual advances by a spouse, partner, or other residents.

    Environmental settings may also influence sexuality among older adults. Normally, engaging in sexual intercourse occurs within the privacy of one's bedroom; however, for some older adults, extended care facilities are the substitute for what one called home. Residents of extended care facilities state that many of the obstacles they face regarding their sexuality include lack of opportunity, lack of available partner, poor health, feeling sexually undesirable, and guilt for having these sexual feelings. 

    Furthermore, negative staff attitudes and beliefs regarding residents' sexual activity bar the expression of sexuality in long-term care settings (Hajjar & Kamel, 2004).Twenty-five percent of all HIV cases are developed in adults older than the age of 50 years, underscoring the significant risk of HIV transmission in the older age group. 

    Older adults with HIV are more likely to be diagnosed late in the disease, progress more quickly, and have a shorter survival (Martin, Fain, & Klotz, 2008). The use of antiretroviral medications among older adults may be complicated by multiple chronic comorbidities and treatments (Magalhães, Greenberg, Hansen, & Glick, 2007). 

    Sherr et al. (2009) conducted a study of 778 patients in an HIV clinic. Of the total population, 12% were aged older than 50 years. The findings revealed that older patients reported significantly lower psychological and global burden and were more likely to take antiretrovirals than their younger cohorts. Health care providers are in a unique position to assess and manage HIV among the older population, but greater education regarding the risk for HIV in the older population is needed.

 Assessment of Problem

    A model to guide sexual assessment and intervention is available and has been well used among younger populations since the 1970s. The Permission, Limited Information, Specific Suggestion, Intensive Therapy (PLISSIT) model (Annon, 1976) begins by first seeking permission (P) to discuss sexuality with the older adult. Because many sexual disorders originate in feelings of anxiety or guilt, asking permission may put the client in control of the discussion and facilitate communication between the health care provider and client. 

    This permission may be gained by asking general questions such as “I would like to begin to discuss your sexual health; what concerns would you like to share with me about this area of function?” Questions to guide the sexual assessment of older adults are available on many health care assessment forms. 

    The next step of the model affords an opportunity for the nurse to share limited information (LI) with the older adult. In the case of older adults, this part of the model affords health care providers the opportunity to dispel myths of aging and sexuality and to discuss the impact of normal and pathological aging changes, as well as medications on sexual health. 

    The next part of the model guides the nurse to provide specific suggestions (SS) to improve sexual health. In so doing, nurses may implement several of the interventions recommended for improved sexual health, such as safe sex practices, more effective management of acute and chronic diseases, removal or substitution of causative medications, environmental adaptations, or need for discussions with partners and families. . 

    The final part of the model calls for intensive therapy (IT) when needed for clients whose sexual dysfunction goes beyond the scope of nursing management. In these cases, referral to a sexual therapist is appropriate.

    Sexual assessments will be most effective using open-ended questions such as “Can you tell me how you express your sexuality?” “What concerns you about your sexuality?” “How has your sexuality changed as you have aged?” “What changes have you noticed in your sexuality since you have been diagnosed or treated for disease?” “What thoughts have you had about ways in which you would like to enhance your sexual health?” 

    The loss of relationships with significant, intimate partners is unfortunately common among older adults and often ends communication about the importance of self to the person experiencing the loss. This greatly impacts the older adult's sexual health. Asking the older adult about past and present relationships in his or her life will help to aid this assessment.Barriers to sexual health should be assessed, including normal and pathological changes of aging, medications, and psychological problems, such as depression. 

    More-over, lack of knowledge and understanding about sexuality, loss of partners, and family influence on sexual practice often present substantial barriers to sexual health among older adults. Nurses should assess for the presence of physiological changes through a health history, review of systems, and physical examination for the presence of normal and aging changes that impact sexual health. 

    Older adults may view the normal changes of aging and their subsequent impact on appearance as embarrassing or indicative of illness. This may result in a negative body image and a reluctance to pursue sexual health. It is important for nurses to consider the impact of normal and pathological changes of aging on body image and assess their impact frequently.

    As discussed earlier, there are a number of medical conditions that have been associated with poor sexual health and functioning including depression, cardiac disease, diabetes, stroke, and PD. Effective assessment of these illnesses using open-ended health history questions, review of systems, physical examination, and appropriate lab testing will provide necessary information for appropriate disease management and improved sexual function.

    Assessing the impact of medications among older adults, especially those commonly used to treat medical illnesses such as antidepressants and antihypertensives are essential. Potential medications should be identified by reviewing the client's medication bottles and the client should be questioned about the potential impact of these medications on sexual health. If the medication is found to impact on sexual health, alternative medications should be considered. The older adult should also be questioned regarding the use of alcohol because this substance also has a potential impact on sexual response.

Interventions And Care Strategies

    Following a thorough assessment of normal and pathological aging changes, as well as environmental factors, a number of interventions may be implemented to promote the sexual health of older adults. 

    These interventions fall into several broad categories including (a) education regarding age-associated change in sexual function, (b) compensation for normal aging changes, (c) effective management of acute and chronic illness affecting sexual function, (d) removal of barriers associated with difficulty in fulfilling sexual needs, and (e) special interventions to promote sexual health in cognitively impaired older adults.

Customer Education

    The most important intervention to improve sexuality among the older population is education. It is important to remember that sexuality was likely not addressed in formal educational systems as the older adults developed and was rarely discussed informally. Older adults may possess dated values that impact sexual action, freedom, and desires and lead to both sexual frustration and conflict. 

    Masters (1986) reported in his seminal work on the sexuality of older adults that older women were raised to believe that when menstruation ceased, they would cease to be feminine. Knowledge is essential to the successful fulfillment of sexuality for all people.The incidence of HIV and AIDS infection is rising among older adults, with 25% of new cases resulting in adults older than the age of 50 years (Martin et al., 2008). 

    This underscores the significant risk of HIV transmission in the older age group and the need for effective teaching regarding safe sex practices. Teaching about the use of condoms to prevent the transmission of sexually transmitted diseases is essential. In response to this rise in HIV cases and the presence of other sexually transmitted diseases, it is essential to provide older adults with safe sex information provided by the CDC.

Compensating for Normal Aging Changes

 Assisting older adults to compensate for normal aging changes related to sexual dysfunction will greatly lessen the impact of these changes on sexual health. Among women. the discussion of anatomical changes in sexual anatomy will help women to anticipate these changes on sexuality. For example, the decreases in the size of the vagina and increased vaginal dryness among women may require the use of artificial water-based lubricants or topical estrogen agents. 

    In a multicenter, double-blind, randomized, placebo-controlled study, 305 women with symptoms of vaginal atrophy were treated with a low-dose synthetic conjugated estrogen-A (SCE-A) cream twice weekly. The results revealed that the cream significantly reduced symptoms of vaginal atrophy and pain during intercourse compared to the placebo (Freedman, Kaunitz, Reape, Haiti, & Shu, 2009). 

    In men, delayed response and the increased length of time needed for erections and ejaculations are among normal changes of aging, of which older adults may not be aware. When older adults understand the impact of normal aging changes. they then understand the need to plan for more time and direct stimulation in order to become aroused.

    One of the most important preventive measures older adults may undertake to reduce the impact of normal aging changes on sexual health is to continue to engage in sexual activity.

     Planning for more time during sexual activities; being sensitive to changes in one another's bodies; the use of aids to increase stimulation and lubrication; The exploration of foreplay, masturbation, sensual touch, and different sexual positions along with education about these common changes associated with sex and aging may help immensely. 

    By doing so, changes in sexual response patterns are less likely to occur. Eating healthy foods, getting adequate amounts of sleep, exercising, stress-management techniques, and not smoking are also very important to sexual health.

Effective Management of Acute and Chronic Illness

    Effective management of both acute and chronic illnesses that impair sexual health is also important. Interventions that improve sexual health are frame worked within the current interventions to treat disease. In other words, effective disease management using primary, secondary, and tertiary interventions will not only effectively treat the disease but also result in improved sexual health. Consequently, better glucose control among diabetics enhances circulation and may increase arousal and sexual response.

     Appropriate treatment of depression with medication and psychotherapy will enhance desire and sexual response. Although treatment of depression may help to improve libido and sexual dysfunctions such as orgasmic disorders, medications to treat depression often impact sexual function by lowering libido and causing organs mic disorders. 

    As a potential alternative to treat libido problems during antidepressant management, Seidman and Roose (2006) conducted a study of 32 depressed patients with a mean age of 52 years. The sample was randomized to receive either Enanthate (testosterone) 200 mg or sesame seed oil (placebo). Although self-reported sexual functioning improved in both groups, no significant differences were found between groups.

    Oral erectile agents such as sildenafil citrate (Viagra), vardenafil HCI (Levitra), and tadalafil (Cialis) play a significant role in the treatment of sexual dysfunction that occurs with aging and are effective and well-tolerated treatments for ED in older men ( Wespes et al., 2007). In men treated for prostate cancer with radical prostatectomy, the use of oral erectile agents to manage ED immediately following surgery is also gaining increased support (Miles et al., 2007). 

    Medications used to treat diseases may result in sexual dysfunction among older adults (see for a list of these medications). There are many medications that may result in decreased sexual drive and impotence as well as orgasmic and ejaculatory disorders. 

    These medications are widely prescribed for many chronic illnesses among older adults, including psychological disorders such as depression, hypertension, elevated cholesterol, sleep disorders, and peptic ulcer diseases.Furthermore, because of the hesitancy among older adults and nurses to discuss sexual problems, the effect of these medications on sexual function is often not discussed in clinical settings. 

    This may result in either prolonged sexual dysfunction among the older adult or a noncompliance with the medication. Recognition of the continuing sexual needs of older adults among nurses is essential to beginning dialogue about sexual problems. Effective assessment will uncover medications affecting older adult's sexual function and lead to the consideration of stopping the medication in favor of alternative disease management strategies or substituting the medication causing the dysfunction with another one with less sexual effects, Removal of Barriers to Sexual Health .

    One of the greatest barriers to sexual health among older adults lies within nurses' persistent beliefs that older adults are not sexual beings. Nurses should be encouraged to open lines of communication in order to effectively assess and manage the sexual health needs of aging individuals with the same consistency as other bodily systems and treat alterations in sexual health with available evidence-based strategies.

    An essential intervention to promoting sexual health in this population is to educate nurses regarding the continuing sexual needs and desires persisting throughout the lifespan. Education regarding older adult sexuality as a continuing human need should be included in multidisciplinary education and staff development programs. 

    Educational sessions may begin by discussing prevalent societal myths around older adult sexuality. Nurses should be encouraged to discuss their own feelings about sexuality and its role in the life of older adults. Furthermore, the development of policies and procedures to manage sexual issues of older adult clients is important throughout environments of care.

    Environmental adaptations to ensure privacy and safety among long-term care and community-dwelling residents are essential. Arrangements for privacy must be made so the dignity of older adults is protected during sexual activity. For example, nurses may assist in finding other activities for the resident's roommate so that privacy may be obtained or in securing a common room that may be used by the older adults for private visits. 

    Call lights or telephones should be kept within reach during sexual activity and adaptive equipment such as positioning devices or trapezes may need to be obtained. Interventions such as providing rooms for privacy and offering consultations for residents regarding evaluation and treatment of their sexual problems are a few of the many ways this may be accomplished (Wallace, 2008). Roach (2004) suggested that nursing home staff and administration work to develop environments that are supportive and respectful of older resident's continuing sexual rights and promote sexual health.Families are an integral part of the interdisciplinary team. 

    However, for older couples, especially those in relationships with new partners, it is often difficult for families to understand that their older relative may have a sexual relationship with anyone other than the person they are accustomed to them being with. A family meeting, with a counselor if needed, is appropriate in order to help the family understand and accept the older adult's decisions about the relationship.

Special Interventions to Promote the Sexual Health of Cognitively Impaired Older Adults

    Cognitively impaired older adults continue to have sexual needs and desires but may lack the capacity to make appropriate decisions regarding sexual relationships. Accurate assessment and documentation of ability to make informed decisions regarding sexual relationships must be conducted by an interdisciplinary team. If the older adult is not capable of making competent decisions, participation in sexual relationships may be considered abusive and must be prevented. 

    On the other end of the spectrum, nurses should not attempt to prevent sexual relationships and may play an important role in promoting sexual health among older adults who are cognitively competent to make decisions regarding sexual relationships. In these cases, nurses should implement all necessary interventions to promote the sexual health of older adult clients.

    Inappropriate sexual behavior such as public masturbation, disrobing, or making sexually explicit remarks to other patients or health care professionals may be a warning sign of unmet sexual needs among older adults. A full sexual assessment should be conducted using clear communication and limit setting in these situations. Following this, a plan should be developed to manage this behavior while providing the utmost respect and preserving the dignity of the client. 

    Providing an environment in which the older adult may pursue their sexuality in private may be a simple solution to a difficult problem. Medication management for hypersexual behavior may be considered. Tricyclic antidepressants and trazodone are two medications with antilibidinal and anti-obsessive effects that may be safely used to treat hypersexual behavior (Wallace & Safer, 2009). Levitsky and Owens (1999) reported that antiandrogens, estrogens, gonadotropin releasing hormone analogues, and serotonergic medications may be successful when other methods are ineffective.

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