Teen Females with PSB

The client is a 15-year-old girl referred by her guidance counselor. “Amber” has been disciplined by her high school for sending naked selfies to her boyfriend, which came to the attention of a teacher as the sexts were liberally shared around the sprawling suburban campus. Her horrified parents initially labeled the behavior a momentary judgment lapse fueled by “bad influences,” until a search of her phone revealed a couple of well-hidden hook-up aps. Her laptop browser history added to their concern.

The parents are college educated professionals, who responded to their daughter’s difficulty by grounding her for two weeks and taking away her phone and tablet indefinitely. They banned her boyfriend from the house and insisted she talk with her female church youth leader. Mom and dad were relieved when they got through the two-week home arrest with Amber “just being angry at first, then sullen and often disrespectful, but it could have been a lot worse.” They added, “We were sure she’d learned her lesson and everything would be fine. We just wanted to put this whole sorry mess behind us.”

teen girl sex addiction, teen girl psb, pornography, SASH, Bethesda WorkshopsAnd it seemingly was, until a few weeks later when they discovered Amber had gotten another phone and was exchanging explicit texts with a guy who claimed to share her interest in soccer and just wanted to get to know her better. The parents asked their pediatrician what they should do, and he said he had no idea other than finding a therapist. The school social worker also was unable to provide an appropriate referral, but she was aware of a local program for adult males who used pornography compulsively, and she gave the parents our number

“Please help us!”

“Please help us!”the mom wailed. “Our beautiful, talented daughter has gone off the deep end. We taught her better than this, but she won’t listen when we tell her how terrible she is. We need to send her to your facility and have you straighten her out. We’re so embarrassed and want this fixed before it further damages our family reputation.”

Yes, indeed. “Straightening out” is exactly what needs to be done with teen females struggling with problematic sexual behavior, right? And labeling an acting teen as “terrible” is sure to motivate her positively. Not.

The reality is that untold numbers of teens, both males and females, are engaged in potentially problematic sexual behavior. According to Statistics Brain (https://www.statisticbrain.com/sexting-statistics/), the numbers are staggering. In an online survey with 1280 respondents ages 13-19:

teen girl psb, teen girl sex addiction, sexting, sex addiction, pornography, SASH

 

 

 

Perhaps it’s reassuring that 71% of teen girls and 67% of teen boys say they’ve sent or posted sexually suggestive content to a boyfriend or girlfriend. Less comforting, 21% of teen girls and 39% of boys say they’ve shared such content with someone they wanted to date or hook up with. Most frightening, 15% of teens in this age group (not broken down by gender) report they’ve sent nude or semi-nude pictures to someone they only met online- in other words, to a stranger.

Our sexually-saturated culture has far outrun most families’ - and counselors’ - ability to protect or even adequately inform and guide their children. The information presented by Dr. Gail Dines and Culture Reframed provides overwhelming evidence that pornography, not parents, are providing sex education for today’s kids. (https://parents.culturereframed.org/).

The culture is swamped with gender and sexual messages, images and values - most of them unrealistic and unhealthy.“Pornland,” as Dr. Dines calls it, increases early sexual awakening before the child is developmentally able to process what’s happening. It further encourages objectification of self and others, often in a violent form.

Recent research shows that early exposure to pornography is more predictive of later problematic sexual behavior than overt sexual abuse. If that finding proves true over time, the impact will only mushroom exponentially. Sadly, the pornified culture is unlikely to reverse itself any time soon, if ever.

teen girl psb, girl sex addiction, sexting, pornography, SASH

Typically, teens won’t recognize their sexual behavior is a problem. They think they’re engaging with their friends and romantic partners like “everyone else.” Unfortunately, they may be right, since sexting and promiscuity are more the norm than the exception, including for teens raised in “good” homes

Teens usually don’t have the maturity to realize the impact of their sexual and relational behavior, which might affect the rest of their lives. Problematic sexual behavior can interfere with education, health, self-esteem, and social and spiritual development. It can also be extremely dangerous when girls (and sometimes guys) put themselves in risky situations.

 

Attachment theory illuminates the importance of healthy bonding between parents and children, yet more and more, today’s teens seem adrift in a technology wasteland. Many parents are similarly engulfed in their devices or work, or are themselves struggling sexually or relationally. Most parents label the acting out teen as the problem, and they miss the attachment wounds that may be driving his or her search for connection, however exploitive or fleeting. As Amber’s mom expressed it, parents want the teen “fixed,” and they may be unwilling to be involved in that solution beyond carting the teen in for therapy.

The field of treating problematic sexual behavior has evolved positively to include effective models for helping partners as well as addicts. Resources for teens, though, are woefully lacking. As far as I’m aware, only two in-patient treatment programs that accept adolescent males are equipped with clinicians who have specific certification or training for treating problematic sexual behavior. None of the programs I’ve found for adolescent girls have a specialized PSB program with therapists who are specifically trained in the field. A few outpatient support or therapy groups exist for teen males with PSB, but a group for teen females is rare. The need is huge for clinically informed, excellent resources, especially ones based on attachment theory and a family systems perspective.

Real change for a hurting teen happens within a systems framework, which means the whole family engages in the healing process. Parents need and deserve personal help to address their own emotional struggles and learn how to help their teen through altering their parental attitudes and behaviors. It’s vital that the whole family be involved in a coordinated process of understanding, growth, and change. The therapeutic environment should be non-judgmental, non-adversarial, and engaging for all involved.

Today, adolescents are probably the largest under-served population of those struggling with problematic sexual behavior. If you’re like me, the prospect of treating a teen is a bit terrifying. Yet we need more specialists in this area who can offer prevention and intervention, so that teens are spared some of the pain experienced by addicts and partners in adulthood.

 

sex addiction, SASH, pornography, Marnie Feree
Marnie Ferree, therapist, speaker, author

by Marnie C. Ferree, M.A., LMFT, CSAT

Marnie C. Ferree, M.A., is a licensed marriage and family therapist in Nashville, Tennessee, where she directs Bethesda Workshops, which provides Christian-based treatment for sexual addiction in an intensive setting. The workshop she established for female sex addicts in 1997 was the first of its kind in the country. Her book, No Stones: Women Redeemed from Sexual Addiction, is one of the earliest books to address sexual addiction in women. She is also the volume editor and a contributing writer for Making Advances – A Comprehensive Guide to Treating Female Sex and Love Addicts.

Bethesda Workshops has launched a new Healing for Teens & Their Parents Workshop, which offers gender-specific clinical intensive workshops (four-days) for adolescent females and males. The first workshop, June 13-16, 2018 is for teen females. Later dates, August 8-11 and September 26-29, will provide services for teen males. Parents accompany their teen and are required to attend the workshop. Visit http://www.bethesdaworkshops.org/workshops/healing-for-teen-females-and-parents/for complete information or call Bethesda Workshops at 615-467-5610.


Blog Disclaimer

The Society for the Advancement of Sexual Health (SASH) sponsors this blog for the purpose of furthering dialog in the field of problematic sexual behaviors and their treatment. Blog authors are encouraged to share their thoughts and share their knowledge. However, SASH does not necessarily endorse the content or conclusions of bloggers.

Information in blogs may not always be complete, up-to-date, accurate, relevant, or applicable to all situations. Legislation, case law, standards, regulations, descriptions of products and services, and other information are often complex and can change rapidly. Always double-check and confirm that any information you find on the internet is accurate, current, and complete in regard to your specific situation, question, concern, or interests.

This website and its agents make no promises, guarantees, representations, or warranties, expressed or implied, and assume no duty or liability with regard to the information contained herein or associated in any way therewith. No legal or other professional services are being rendered and nothing is intended to provide such services or advice of any kind. The inclusion of external hyperlinks does not constitute endorsement, recommendation, or approval of those sites or their contents. This website bears no responsibility for the accuracy, legality or content of the external sites or for that of subsequent links. Those who visit or use this website, links or any other information assume all risks associated therewith.

Todays’ Pornography,  #Metoo, and   Some Very  Disturbing Patterns of Porn Fueled “Bad Dates”

When I think about pornography  and its impact on society these days,  I am stunned by how things have changed over the last 25 years.   As a sex therapist certified in the very early 1990’s   I was trained in the late 1980’s,  and back then, all of us viewed pornography  as something that could be helpful to couples. Watching it could be fun. It would spice things up. I and other AASECT members never thought of pornography as ” Sexual Education.”  But neither did we think of it as imparting despicably  horrible messages to young men who might happen to look at it.   I do now.

Back then, as  part of the AASECT annual conferences, we used to screen erotica/ pornography as part of our education.  Some of it was Candida Royalle’s femme-friendly erotica/pornography, although  some of it was more male-centric.  There were directors like Cecil Howard  who created porn where there were actual plots, and  stories were creative, fun, and humorous. In Howard’s  movies, production values were high,  there was no violence towards women,  and women were normal looking, with different sized breasts (many small and perky) and glorious pubic hair. Men generously gave women  oral sex .   Watching much of this porn was arousing. I have  to confess that back then, I and other AASECT members shamefully  seemed  ignorant of the exploitative and abusive  way that the actresses were treated by  the producers, and to my recollection, we never talked about the kind of porn that actually is human trafficking.

That was porn then.  Internet porn now has  permeated thoughout society,  and it has poisoned young people’s visions of what sex is.  Pornography is having an  increasing negative  effect on what is seen as normal in sexual relationships,  and it frightens me that young women are either buying into this dark vision of sexuality (as some part of their version of feminism and the fight against slut shaming)  or they don’t have the assertiveness skills to stop men in their tracks when dating feels more like an assault.

Here is a piece I wrote (Mindful Dating)  for Boston public radio after the Aziz Ansari date tell all and it's still relevant today.

 

SASH, sex addiction, sexual health, Aline Zolbrod

 

 

Aline Zoldbrod Ph.D. is a licensed psychologist, seasoned sex therapist, teacher and trainer in sexuality, and author of multiple books on sexuality.

 

 


Blog Disclaimer

The Society for the Advancement of Sexual Health (SASH) sponsors this blog for the purpose of furthering dialog in the field of problematic sexual behaviors and their treatment. Blog authors are encouraged to share their thoughts and share their knowledge. However, SASH does not necessarily endorse the content or conclusions of bloggers.

Information in blogs may not always be complete, up-to-date, accurate, relevant, or applicable to all situations. Legislation, case law, standards, regulations, descriptions of products and services, and other information are often complex and can change rapidly. Always double-check and confirm that any information you find on the internet is accurate, current, and complete in regard to your specific situation, question, concern, or interests.

This website and its agents make no promises, guarantees, representations, or warranties, expressed or implied, and assume no duty or liability with regard to the information contained herein or associated in any way therewith. No legal or other professional services are being rendered and nothing is intended to provide such services or advice of any kind. The inclusion of external hyperlinks does not constitute endorsement, recommendation, or approval of those sites or their contents. This website bears no responsibility for the accuracy, legality or content of the external sites or for that of subsequent links. Those who visit or use this website, links or any other information assume all risks associated therewith.

‘Compulsive Sexual Behavior Disorder’ Will Soon Be Diagnosable Using the ICD 

SASH, sex addiction, Marnia Robinson
Marnia Robinson, sexual health advocate.

In 2013 the editors of the Diagnostic and Statistical Manual (DSM-5), manual of mental health diagnoses, declined to add a disorder called “Hypersexual Disorder.” This has caused major problems, according to experts:

This exclusion has hindered prevention, research, and treatment efforts, and left clinicians without a formal diagnosis for compulsive sexual behaviour disorder.

The World Health Organization (WHO) publishes its own diagnostic manual, known as the International Classification of Diseases (ICD), which includes diagnostic codes for all known diseases, including mental health disorders. It is used worldwide, and it is published under an open copyright.

The APA promotes the use of the DSM instead of the ICD. Elsewhere in the world, however, most practitioners rely on the free ICD. The code numbers in both manuals conform to the ICD.

The next edition of the ICD, the ICD-11, is due out sometime in 2018. Unlike the DSM-5 editors, the editors of the ICD-11 propose to include a new diagnosis that would encompass those with disorders relating to sexual behavior addictions. Here’s the current proposed language:

ICD, SASH, sex addiction

6C92 Compulsive sexual behaviour disorder is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.

This new “Compulsive sexual behaviour disorder” (CSBD) diagnosis is critically important. In addition to offering caregivers a suitable diagnosis for those who require treatment, the existence of a formal diagnosis in the world’s premier medical manual will facilitate future research. Without a formal diagnosis, some sexology journals and professional magazines have not published related research and commentary. This has hindered mainstream recognition of the risks of this disorder.

So, has the ICD-11 “rejected” sexual behavior addictions? Not for now. In fact, experts who serve on the ICD-11 (including Geoffrey Reed who is in charge of all of the mental disorder diagnoses for the ICD-11) clarified the ICD-11 position in a new piece in World Psychiatry (the world’s top-ranked psychiatry journal).

The authors make it clear that the ICD-11 has not ruled out that compulsive sexual behaviors may indeed be addictions (by whatever name). Instead, the ICD-11 has adopted a conservative, wait-and-see approach while further research is published.

...Currently, there is an active scientific discussion about whether compulsive sexual behaviour disorder can constitute the manifestation of a behavioural addiction. For ICD-11, a relatively conservative position has been recommended, recognizing that we do not yet have definitive information on whether the processes involved in the development and maintenance of the disorder are equivalent to those observed in substance use disorders, gambling and gaming. For this reason, compulsive sexual behaviour disorder is not included in the ICD-11 grouping of disorders due to substance use and addictive behaviours, but rather in that of impulse control disorders. The understanding of compulsive sexual behaviour disorder will evolve as research elucidates the phenomenology and neurobiological underpinnings of the condition.

This is the same strategy once used with respect to “gambling disorder.” When gambling was first given a medical diagnosis it too was characterized as an “impulse control disorder” while it was further investigated. Many hundreds of studies later, gambling disorder has now been characterized in the ICD-11 as a ‘disorder due to addictive behavior’.

Who knows what will become of CSBD in the future? The important point is that when the new ICD-11 is published those with problematic sexual behavior (by whatever name) will be diagnosable using the new CSBD. How insurance companies will respond is another matter, of course.

Marnia Robinson is a former corporate attorney who writes about the effects of evolutionary biology on intimate relationships and blogs on Huffington Post.


Blog Disclaimer

The Society for the Advancement of Sexual Health (SASH) sponsors this blog for the purpose of furthering dialog in the field of problematic sexual behaviors and their treatment. Blog authors are encouraged to share their thoughts and share their knowledge. However, SASH does not necessarily endorse the content or conclusions of bloggers.

Information in blogs may not always be complete, up-to-date, accurate, relevant, or applicable to all situations. Legislation, case law, standards, regulations, descriptions of products and services, and other information are often complex and can change rapidly. Always double-check and confirm that any information you find on the internet is accurate, current, and complete in regard to your specific situation, question, concern, or interests.

This website and its agents make no promises, guarantees, representations, or warranties, expressed or implied, and assume no duty or liability with regard to the information contained herein or associated in any way therewith. No legal or other professional services are being rendered and nothing is intended to provide such services or advice of any kind. The inclusion of external hyperlinks does not constitute endorsement, recommendation, or approval of those sites or their contents. This website bears no responsibility for the accuracy, legality or content of the external sites or for that of subsequent links. Those who visit or use this website, links or any other information assume all risks associated therewith.

Dr Donald Hilton
Dr. Don Hilton Neurosurgeon, author and presenter.

Neuroscience and PSBs

In recent years, neuroscience discoveries about the reward system and human sexuality have shed new light on both problematic and healthy sexual behavior. As can be expected with any new paradigm, however, some doubtful neuroscience claims have also appeared in the media. As a neurosurgeon and the author of several papers on problematic sexual behavior and the appetite/reward mechanisms of the brain, I sometimes help to correct these misunderstandings. Here are a few examples that might be of interest to our readers.

ERROR #1 - “Dopamine does not underlie addiction”

Some peculiar claims about dopamine have appeared in recent months, such as “If you want to make an argument that porn is addictive, you can, but if you're relying on dopamine to do it. lol, you're wrong” and “Please stop calling dopamine an addictive rewarding neurochemical.”

Dopamine plays many benign roles in our physiology, such as facilitating movement and choices. However, all experts in the fields of addiction or neuroscience acknowledge the central role of dopamine in addiction.

In fact, addiction cannot develop without high, but brief, bursts of dopamine in response to an addictive substance or activity. As experts Volkow and Koob explained in a recent paper, these dopamine surges elicit reward signals at a cell receptor level, which then trigger so-called Pavlovian learning. The molecular mechanisms that facilitate this process appear similar for all forms of learning and memory. Repeated experiences of reward (for example, porn viewing) become associated with the stimuli in the user’s environment that precede them.

Interestingly, after repeated exposure to the same reward (in this example, porn), dopamine cells tend to fire more strongly in anticipation of viewing rather than in conjunction with actual viewing – although internet porn’s endless novelty means that using and anticipation are interwoven, in contrast with, say, a cocaine habit. As any addiction develops, cues and triggers, such as hearing a porn star’s name, time alone, or a mental state associated with past use (boredom, rejection, fatigue, etc.) can elicit conditioned, sudden surges of dopamine release. These surges then trigger cravings to use or even binge. Such conditioned responses may become deeply ingrained and can bring on strong cravings even long after someone quits using porn.

Although dopamine is sometimes thought of as a "pleasure molecule," this is technically inaccurate. Dopamine drives seeking and searching for reward – the anticipation, the wanting. In some unfortunate people, this seeking deepens into the disorder known as addiction. The user’s desperate search for satiety (that eventually often proves fleeting or unattainable) progresses to the point of marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.

However, addiction is now being defined not solely by this behavioral definition.  It is also increasingly defined as a form of disordered reward learning.  As Kauer and Malenka said, “addiction represents a pathological but powerful form of learning and memory.” This is why the American Society of Addiction Medicine (ASAM) redefined addiction as including both substances and behaviors. ASAM’s position is a recognition of the brain’s central role in driving what Marc Lewis called a “rut, a line of footprints in the neural flesh, which harden and become indelible.” (Lewis, Memoirs of an Addicted Brain, 2011).

ERROR #2 -  “At a brain level sexual activity is no different from playing with puppies”

While playing with puppies might activate the reward system (unless you are a cat person), such activation doesn’t support the claim that all natural rewards are neurological equivalents. First, sexual arousal and orgasm induce far higher levels of dopamine and endogenous opioids than any other natural reward. Rat studies reveal that the dopamine levels occurring with sexual arousal equal those induced by the administration of morphine or nicotine.

Sexual arousal is also unique because it activates precisely the same reward system nerve cells as do addictive drugs.  In contrast, there's only a small percentage of nerve-cell activation overlap between addictive drugs and natural rewards such as food or water. Not surprisingly, researchers have also established that the natural reward of food does not cause the same persistent change in synaptic plasticity as sexual activity (Chen et al., 2008).

However, this is not to say that gustatory reward cannot become addictive or disruptive to individuals and precipitate public health concerns, or cause brain changes in reward circuits. Any physician knows that obesity is a tremendous health concern consuming billions in medical costs, and dopamine receptor depletion in the brain’s reward center returns to more normal density with weight loss after gastric banding surgery. Also, the DNA transcripts which produce reward system proteins important in the craving states that are evoked with salt depletion/repletion are identical to those produced with drug craving (Leidke et al., 2011, PNAS).  A National Geographic article on this paper said drugs “hijack” these natural reward pathways, and this is true for all addiction, whether to poker, porn, or popcorn.

Addictive drugs not only hijack the precise nerve cells activated during sexual arousal, they co-opt the same learning mechanisms that evolved to make us desire sexual activity. Activation of the same nerve cells that make sexual arousal so compelling helps explain why meth, cocaine, and heroin can be so addictive. Also, both sex and drug use can induce transcription factor DeltaFosB, resulting in neuroplastic alterations that are nearly identical for both sexual conditioning and chronic use of drugs.

 

While far too complex to elucidate in detail, multiple temporary neurological and hormonal changes occur with orgasm that do not occur with any other natural rewards. These include decreased brain androgen receptors, increased estrogen receptors, increased hypothalamic enkephalins, and increased prolactin. For example, ejaculation mimics the effects of chronic heroin administration on reward system nerve cells (the ventral tegmental area, or VTA). Specifically, ejaculation temporarily shrinks the same dopamine producing nerve cells that shrink with chronic heroin use, leading to temporary down-regulation of dopamine in the reward center (nucleus accumbens).

A 2000 fMRI study compared brain activation using two different natural rewards, one of which was porn. Cocaine addicts and healthy controls viewed films of: 1) explicit sexual content, 2) outdoor nature scenes, and 3) individuals smoking crack cocaine. The results: cocaine addicts had nearly identical brain activation patterns when viewing porn and viewing cues related to their addiction. (Incidentally, both cocaine addicts and healthy controls had the same brain activation patterns for porn.) However, for both the addicts and controls, brain activation patterns when viewing nature scenes were completely different from the patterns when viewing for porn. In short, there are multiple biological reasons we experience an orgasm differently from playing with puppies or viewing sunsets.  Millions of adolescent boys and increasingly girls are not just watching puppies on the Internet, and Mindgeek knows that to make billions in ad revenues you name a site “Pornhub,” not “PuppyHub!”

 

ERROR #3 - “The brain effects of today’s porn are no different than static porn of the past”

This claim implies that all porn is equally harmless. However, as the recent paper Park et al., 2016 points out, research demonstrates that video porn is significantly more sexually arousing than other forms of porn. (I know of no research on VR porn yet.) In addition, the ability to self-select material makes internet porn more arousing than pre-selected collections. Today’s porn user can also maintain or heighten sexual arousal by clicking to a novel scene, new video or fresh genre. Novel sexual visuals trigger greater arousal, faster ejaculation, and more semen and erection activity than familiar material.

Thus today’s digital porn, with its limitless novelty, potent delivery (hi-def video or virtual), and the ease with which the user can escalate to more extreme material, appears to constitute a “supranormal stimulus.” This phrase, coined by Nobel laureate Nikolaas Tinbergen, refers to an exaggerated imitation of a stimulus that a species has evolved to pursue due to its evolutionary salience, but which can evoke more of a neurochemical response (dopamine) than the stimulus it imitates.

Tinbergen originally found that birds, butterflies, and other animals could be duped into preferring artificial substitutes designed specifically to appear more attractive than the animal's normal eggs and mates. Just as Tinbergen's and Magnus's ‘butterfly porn’ successfully competed for male attention at the expense of real females (Magnus, 1958; Tinbergen, 1951), so today’s porn is unique in its power to compete for users’ attention at the expense of real partners.

The three errors discussed above are typical of commentators anxious to ignore the brain’s central role in human volition, behavior, and emotion.  One sexologist wrote, “There is brain science and neuroscience, but none of that applies to sexual science.”  On the contrary, those educated in biology will increasingly understand the brain’s central role in every human activity. After all, both sexologists and neuroscientists alike should understand that the genitals take their marching orders from the brain, the primary sex organ.

Donald L. Hilton Jr, MD, FACS, FAANS is an adjunct associate professor of neurosurgery at the University of Texas Health Science Center at San Antonio, the director of the spine fellowship and the director of neurosurgical training at the Methodist Hospital rotation. He has authored numerous articles and speaks nationally and internationally on the neurobiology of porn use.

 

Blog Disclaimer

The Society for the Advancement of Sexual Health (SASH) sponsors this blog for the purpose of furthering dialog in the field of problematic sexual behaviors and their treatment. Blog authors are encouraged to share their thoughts and share their knowledge. However, SASH does not necessarily endorse the content or conclusions of bloggers.

Information in blogs may not always be complete, up-to-date, accurate, relevant, or applicable to all situations. Legislation, case law, standards, regulations, descriptions of products and services, and other information are often complex and can change rapidly. Always double-check and confirm that any information you find on the internet is accurate, current, and complete in regard to your specific situation, question, concern, or interests.

This website and its agents make no promises, guarantees, representations, or warranties, expressed or implied, and assume no duty or liability with regard to the information contained herein or associated in any way therewith. No legal or other professional services are being rendered and nothing is intended to provide such services or advice of any kind. The inclusion of external hyperlinks does not constitute endorsement, recommendation, or approval of those sites or their contents. This website bears no responsibility for the accuracy, legality or content of the external sites or for that of subsequent links. Those who visit or use this website, links or any other information assume all risks associated therewith.

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