Cover Page


Title Page

To my mother, Janet, who taught me never to be constrained by expected age or gender roles, that love and respect were the most important relationship parameters, and that life was mine to craft and live to the full


To Amma and Dad, for having the courage to let me be me



Catherine Butler

Dr Catherine Butler is currently working in her most challenging role, learning to be a mother, while working part time as a Senior Lecturer in Family Therapy at UWE. Prior to this, she was the Consultant Clinical Psychologist for Infection and Immunology at Barts & The London Hospital Trust. She has worked in HIV and Sexual Health since qualifying and was the research officer on the BPS HIV and Sexual Health Faculty committee. Dr Butler also previously worked as a Clinical Tutor on the Doctorate in Clinical Psychology at the University of East London, as well as in the private and voluntary sector, including as a Couple/Family Therapist at PACE and as a therapist, trainer and Clinical Associate with Pink Therapy. She was previously on the BPS Lesbian and Gay Psychology Section committee and won their Postgraduate Research Prize. She is a member of the Working Party responsible for writing the BPS guidelines on Working Therapeutically with Sexual and Gender Minority Clients. Her previous publications and academic interests include co-editing the book Sex, Sexuality and Therapeutic Practice, editing special editions of The Psychologist, Lesbian and Gay Psychology Review, Clinical Psychology Forum and numerous book chapters and articles on the topics of minority sexualities, sexual assault, HIV, working with interpreters, and personal/professional integration. She won the London Independent Film Festival ‘Best LGBT Film’ (2009) for co-producing Homoworld, based on her 2004 publication.

Roshan das Nair

Dr Roshan das Nair works as a Consultant Clinical Psychologist in HIV & Sexual Health with the Department of Clinical Psychology and Neuropsychology at the Nottingham University Hospitals NHS Trust, and is a Research Tutor on the Trent Doctorate in Clinical Psychology programme at the University of Nottingham. He has previously worked in the areas of sex, sexuality, and HIV/AIDS in Zambia and India. Roshan is a board member of the Nottingham Sexual Health Providers’ forum. He was the Editor-in-chief of the Psychology of Sexualities Review of the British Psychological Society's (BPS) Psychology of Sexualities Section (2007–10). He is also their representative on The International Network on Lesbian, Gay, and Bisexual Concerns and Transgender Issues in Psychology. He has been a member of the Working Party responsible for writing the BPS guidelines on Working Therapeutically with Sexual and Gender Minority Clients. His academic interests include HIV and sexual health in marginalised populations, the interface between ethnicity and sexuality, disability and sexuality, critical theory and cultural studies, and neuropsychological issues related to HIV infection.

Sonja Ellis

Dr Sonja J. Ellis is a Principal Lecturer in Psychology at Sheffield Hallam University where she teaches and researches primarily in the field of gender and sexuality. She has published widely on a range of issues relating to the experiences of lesbians and gay men including homophobia at university, lesbian and gay human rights, and LGB community. Together with Victoria Clarke, Elizabeth Peel, and Damien Riggs she is author of the leading textbook LGBTQ Psychologies: Themes and Perspectives.

Sarah Fairbank

Dr Sarah Fairbank is the Clinical Psychologist for the Community Assessment and Treatment Service in Nottingham city, working with people who experience mental health difficulties. She is also a visiting therapist for the Centre for Trauma, Resilience and Growth in Nottingham. She has over ten years experience of working in a variety of mental health settings including adult mental health, learning disabilities, forensic, child and older adults services. She divides her time between clinical, research and teaching commitments on both nursing and clinical psychology programmes. She is the founder and chair of the Sexuality, Relationships and Intimacy Forum for Adult mental health, Nottingham and was the lead trainer for Nottingham on the Department of Health Sexual Abuse training course in 2008. Her main research interests are sexuality and mental health, service user involvement and the link between trauma and psychosis.

Stuart Gibson

Dr Stuart Gibson is a Chartered Clinical Psychologist who works at a multi-disciplinary mental health service for people living with HIV in south London. For more than 12 years he has practiced clinical psychology, lectured, trained, and conducted research on the psychological aspects of living with HIV in the United Kingdom, Canada and the United States. Stuart also has many years of experience in sexual diversity awareness training in psychology and psychiatry. He is the current Chair of the British Psychological Society's Faculty for HIV & Sexual Health.

Susan Hansen

Dr Susan Hansen is a Senior Lecturer in Psychology at Middlesex University. She has research interests in the application of conversation analysis to sexuality and gender, and to various social problems. She has particular research interests in the negotiation of sexual consent and refusal and in the discrimination and threat to safety gender queer folk may experience in gendered public spaces.

Stephen Higgins

Stephen Higgins is a final year Clinical Psychology trainee at the University of Easy London. His thesis examines the resettlement experiences of Iranian and Iraqi men who have claimed asylum in the UK because of persecution of their sexual identity. Steve has 25 years working in the NHS within mental health and learning disability services.

Adam Jowett

Dr Adam Jowett is a research fellow at the Academic Unit for Elderly Care and Rehabilitation, Bradford Royal Infirmary. His research interests cohere around health, sexuality and social support. His current research uses qualitative methods to investigate longer-term social adaptation after stroke. His PhD thesis examined chronic illness in non-heterosexual contexts and he has also conducted research on Civil Partnership.

Elizabeth Peel

Dr Elizabeth Peel is a Senior Lecturer in Psychology at the School of Life & Health Sciences, Aston University, Birmingham, UK. Her research is located in critical health psychology (particularly chronic illness), sexualities and gender. She is the author, with Victoria Clarke, Sonja Ellis and Damien Riggs, of Lesbian, Gay, Bisexual, Trans & Queer Psychology: An introduction (Cambridge University Press, 2010). Her current research centres on dementia care.

Damien W. Riggs

Dr Damien W. Riggs is a lecturer in social work at Flinders University, Australia. His research areas encompass critical race and whiteness studies, gender and sexuality studies, and parenting and family studies. He is the author of Becoming a Parent: Lesbians, gay men and family (Post Pressed, 2007), What About the Children! Masculinities, sexualities and hegemony (Cambridge Scholars Press, 2010), and (with Victoria Clarke, Sonja Ellis and Elizabeth Peel) Lesbian, Gay, Bisexual, Trans, and Queer Psychology: An introduction (Cambridge University Press, 2010). He is also the founding editor of the Australian Psychological Society journal Gay and Lesbian Issues and Psychology Review.

Esther D. Rothblum

Prof. Esther Rothblum is Professor of Psychology at San Diego State University. She also serves as Editor of the Journal of Lesbian Studies. Her research and writing have focussed on lesbian mental health, and she is former chair of the Committee on Lesbian and Gay Concerns of the American Psychological Association. She received the 1991 Distinguished Scientific Contribution Award from the Society for the Psychological Study of Lesbian and Gay Issues, and also served as President of the division. Prof. Rothblum has edited over 20 books, including Lesbian Friendships (New York University Press, 1996), Preventing Heterosexism and Homophobia (Sage Publications, 1996), Lesbians in Academia (Routledge, 1997), Boston Marriages: Romantic But Asexual Relationships Among Contemporary Lesbians (University of Massachusetts Press, 1993) and Loving Boldly: Issues Facing Lesbians (Haworth Press, 1989).

Sonya Thomas

Sonya Thomas is a London based freelance writer and equality consultant with over 20 years’ experience of equalities work, both in the public and voluntary sectors. She has provided political advice on equalities to local government elected members and political leads and has authored a number of speeches on various aspects of equalities and diversity for Commissioners within the Equality and Human Rights Commission and senior civil servants in the Department of Health. She has an MA in Human Resource Management and post-graduate diplomas in Industrial Relations and Journalism.


I feel honoured to be invited by Catherine and Roshan to write the Foreword for this book. Catherine and I have been co-training therapists together for around five years and in recent times have added information on our training programmes on working with clients who have intersecting identities and the impact of various oppressive forces on the individual. We felt it was an absolutely vital component of any training and I feel somewhat ashamed of my lack of knowledge not to have included it in earlier training programmes I have convened. This clearly demonstrates the adage: ‘We teach what we know’ and as much explains why counselling and therapy programmes in Britain are generally still ridiculously uninformed about the differences experienced by gender and sexual minorities. This is lamentable for two reasons: first, the research which shows poorer mental health in these populations and how Lesbian, Gay, Bisexual and Transgender (LGBT) people are more likely to present for psychological support than heterosexual people, and second, that one in six British therapists have willingly entered into therapy contracts to reduce same-sex attractions, despite there being no evidence based research to show this is possible.

As a therapist who has worked with sexual minorities for 30 years and as the principal author and co-editor of the first British textbook on working with LGB people, it is really gratifying to see the development of a small raft of books in the past year that increasingly reflect the nuances of multiple identities and the complexities of gender and sexual minority identities and their relationships. This book, however, takes things much further in exploring the intersections in various identities (gender, age, race and ethnicity, class, disability, mental and physical health, etc.) and from a largely (though not exclusively) British perspective, which given that many of the issues covered are fairly region-specific, makes the book highly relevant to all therapists working with LGB people here in the UK.

Unlike many books which one can simply dip in and out, this book benefits from reading all the way through since there is much to be learned here; or if I am to own that statement for myself, I personally learned so much. As a white gay man who identifies as disabled and comes from a working class background, living with enduring physical health issues, I have seen my own lived experience recognised and affirmed across many of these pages. I have also learned a lot about the intersecting identities of those clients who have other identities from the research and ideas of the contributors. One example perhaps of an insight for me was thinking that therapists should be transparent about their gender and sexual identity, whereas I now realise this can be both unhelpful (and meaningless) for some therapists coming from Black and Minority Ethnic (BME) communities where they may also face social exclusion from their families and communities if they were to be forced to come out so unselectively.

I think we need to recognise that a one-size-fits-all approach that assumes all LGB people experience the world in the same way is overly simplistic and culturally insensitive. The astute therapist will want to understand the nuances and differences experienced by their clients and how their intersecting identities impact on their sexuality. This book will be a valuable resource into becoming better informed so that the therapist or counsellor is not reliant on having their clients be the sole source of educating them.

Dominic Davies
Director – Pink Therapy
Fellow – British Association of Counselling and Psychotherapy
February 2011


If this book is considered a fabric, then many people contributed many threads that we, as editors, have simply woven together. We would like to begin by thanking our clients and friends who shared their stories with us. We thank all our collaborators for willing to contribute to this anthology. We are indebted to Darren Reed from Wiley who was instrumental in getting the project off the ground. We would also like to thank Karen Shield and Tori Halliday at John Wiley & Sons, Ltd for assistance. Dr Tuppy Owens and eirwen yemn edwards from Outsiders, and Dr Andrew Yip from the University of Nottingham have been extremely generous with their time and advice.

Roshan would like to thank Rein Ove Sikveland, the blue-eyed boy from Undheim, for his kindness, encouragement, unfaltering support, and love.

Catherine would like to thank Hazel, Liz and Zoe for distracting Ella so she could work, Ella for her patience, and especially Ray for all his cooking, washing up, childcare and continuous love and ‘non-heteronormative’ support.


Roshan das Nair & Catherine Butler

Lesbian, gay, and bisexual (LGB) literature in health and social sciences is burgeoning. However, much of the early published material focussed on differences between heterosexual and homosexual people, thereby creating a sense of homogeneity of homosexual (and bisexual) lives and experiences. While much of the later work no longer concerns itself with a heterosexual yardstick, and instead explores issues pertinent to LGB lives such as parenting, relationship styles, and so on, much of this work still does not describe the race, ethnicity, social class, or ability of its participants, largely assuming them to be white, middle class and able-bodied (Butler et al., 2010). This book aims to widen the existing psychological and therapeutic literature on LGB issues within a British context. The book unpicks what it means to be LGB by exploring the social-cultural differences within these labels, identities and practices, and how these differences intersect to make being non-heterosexual a unique experience for each person who uses, or chooses not use, these labels or identities.


Although the concept of intersectionality has been around for many years, and Kimberle Crenshaw is credited with coining the term in 1989, its foray into psychology and therapeutics has been more recent. McCall (2005) hypothesised that this was possibly due to of a lack of guidelines for researchers in psychology to empirically answer complex questions or address multi-faceted issues without fractionating them into their constituent components – holding the complexity is what intersectionality requires. More recently, however, Cole (2009) has provided us with a framework to help apply intersectionality to psychology. She does this by posing three questions that therapists need to ask when examining any group or social category:

i. Who is included within this category?

ii. What role does inequality play?

iii. Where are there similarities? (Cole, 2009, p.170).

The first question challenges the perceived homogeneity of a given group on the basis of a single characteristic, and forces us to see the diversity within such a group. The second question introduces power into the equation, and forces us to recognise that the spaces that people exist in and interact with(in) are not level playing fields, but are fluid hierarchies which offer differing levels of ‘privilege and power’ to some people sometimes. The final question forces us to look for ‘commonalities across categories commonly viewed as deeply different’ (Cole, 2009, p.171).

Another potential reason for the slow uptake of intersectionality within psychology and therapeutics is perhaps because of the slippery task of attempting to define the concept. As Davis (2008) has suggested, intersectionality has been variously thought of as a theory, a concept or heuristic, or even as a reading strategy. Definitions are also deferred because intersectionality is sometimes simultaneously regarded as ‘crossroads’, ‘axes’, or ‘dynamic processes’ (Davis, 2008). But this lack of a consensus towards a unitary definition of intersectionality does not render it useless to interrogate troublesome questions and social phenomena. In fact, as Davis (2008) paraphrasing Murray Davis asserts, ‘successful theories thrive on ambiguity and incompleteness’ (p.69).

Phoenix's (2006) definition of intersectionality as a ‘catchall phrase that aims to make visible the multiple positioning that constitutes everyday life and the power relations that are central to it’ (p.187) is interesting because it highlights at least three key points: (i) making visible multiple identities, (ii) which are relevant in daily life, and (iii) acknowledging that this does not happen in a power-vacuum. Cole (2009) points out that much of intersectionality scholarship has examined the multiple sites of oppression and disenfranchisement of people whose lives fall along the fault-lines of social categories. However, as a theory, intersectionality can also explore issues that pertain to the privileged identities that ‘some members of disadvantaged groups … (e.g., middle class blacks, white women)’ (Cole, 2009. p.171). Therefore, in recognising both disadvantages and advantages of subjectivities, we challenge these frontiers further by examining the possibility for power and agency that these individuals and groups of people experience because of their intersectional positions. We feel that this is an avenue that has not received sufficient attention in intersectionality literature, and view it as a way to move out from a position of disadvantage to one of opportunity. This, of course, should have a particular appeal for therapy and therapists.

The importance of intersectionality was highlighted by Kathy Davis (2008) in her paper Intersectionality as Buzzword. Although speaking from a Gender Studies perspective, Davis’ assertion is applicable to any scholarly pursuit that attempts to understand individual and social phenomena more holistically. She avers, ‘any scholar who neglects difference runs the risk of having her work viewed as theoretically misguided, politically irrelevant, or simply fantastical’ (p.68). This is a sentiment we share.

The project of intersectionality, however, is one that is forever incomplete, whether in terms of scholarship, activism, and/or service provision. This incompleteness is evident because of the endless possibilities of permutations and combinations of identities and social positions that people inhabit, and because of the amorphous and dynamic nature of these identities and positions. Alice Ludwig (2006) refers to this as the ‘Achilles heel of intersectionality’ (p.247). Given this assertion, it should therefore come as no surprise that this book is also incomplete. Sites of power differentials can reside within a matrix that covers gender, race, ethnicity, sexuality, dis/ability, nationality, citizenship, creed, class, geographical location, age, landedness, employment, health, caste, and so on. While we have tried to cover some ground in terms of how a constellation of these identities/locations affect individual and group experiences, with sexuality as our primary lens, we recognise that this viewpoint is limited. But limited as it is, it still offers perspectives for therapists (and others) about how various strands of our lives intertwine, like a complex, sometimes jagged, sometimes incomplete, often changing weave; which hitherto have been ignored or silenced.

The impossibility of the intersectional project does not mean that we should abandon the concept of intersectionality or do away with categories that are already in existence, because these very categories that have the power to disenfranchise certain people also have the potential to bring people together to mobilise action. The triumph of intersectionality therefore is its potential to resist the complacency of accepting categories as predetermined, static, and objective truths, and its ability to proactively challenge the composition and limits of these categories. This book demonstrates intersectionality in action. From a phenomenological perspective, the voices of the people in this book (authors, clients/patients, therapists, research participants, characters from film, etc.) offer their ‘lived experiences’ of intersectionality.

The Scope of this Book

We focussed on keeping the book relevant for professionals who offer psychological therapies. We recognise that ‘psychological therapies’ is a rather broad term, but this reflects the nondenominational flavour of this book, which we believe will appeal to therapists of various persuasions. Each chapter includes a client's story for illustration and ends with guidelines for good practice. We attempted to have all chapters co-authored by at least one therapist, and where this was not possible, there was input from us, as editors who are also practicing NHS therapists. Furthermore, each chapter has reviewed literature that includes both male and female perspectives, to ensure that different genders/sexualities are well represented and tokenism avoided.

This desire to avoid tokenism was one of our reasons for not including Transgender issues in this book, as we felt it was beyond the scope of this book to discuss these issues in any detail. Furthermore, the contributors to this book are specialised in working with issues of sexual orientation and not gender, but we believe that some of the issues discussed here may resonate with some Trans experiences. We also recognise that some of these issues are of direct relevance to Trans people who also identify as LGB. As one of our anonymous reviewers indicated at the outset of this project, it was better to exclude Trans issues rather than ‘include Trans experiences into the general body assumptively. A matter for a separate commission perhaps?’. Indeed, we believe these issues, including those related to Intersex, Genderqueer, and other genders and sexualities, need to be dealt with in much greater detail than what can be covered here or in any single book. We are thus aware we sacrificed some important areas for breadth in focus on sexual minorities rather than depth, and recognise that each chapter included here could be extended to a book in itself. However, we hope that the chapters capture the reader's curiosity and act as a springboard for further study if desired. We also believe that the chapters herein do provide sufficient overview to enable therapists to work confidently and competently with non-heterosexual clients presenting with intersecting identity markers and issues.

Given that the anticipated audience for the book is therapists, the chapters focus on issues or problems that clients may bring to therapy. It could be argued that such a focus results in a ‘doom and gloom’ perspective on aspects of social difference within LGB lives. The areas of social difference discussed in this book can all be sites of oppression, but we have also suggested ways in which working through these issues of oppression can result in empowerment. Indeed, the vast majority of LGB people are living positive, well-adjusted and happy existences, with no need for therapy to help them work through their daily challenges. Throughout the book, readers are also invited to locate themselves in relation to clients and their issues, and to consider how their own intersectional identities interact with those of their clients in supportive or oppressive ways.

The Structure of the Book

Although we have split the book into chapters for ease of navigation through various topics, the project of intersectionality demands that none of these topics be viewed in isolation. We demonstrate this interconnectedness by cross-referencing topics between chapters. We suggest that readers start from the chapter which is most relevant to their work, or which captures their immediate interest. The highlighted interconnections with other chapters may then lead the reader to further reading, thus expanding their lens and connecting to the complexities that having multiple identities entails.

The book opens with an in-depth exploration of the concept of intersectionality and how it relates to LGB lives; we therefore suggest this might be relevant for all readers. The chapter summarises critiques of essentialist positions on social difference and concepts such as ‘cultural competence’. The chapter demonstrates how intersectionality invites incompleteness and ambiguity, for example, one part of a person's identity may involve privilege (e.g., male) whilst another may invite disenfranchisement (e.g., gay). Taken for granted assumptions are thus troubled in the hope that the reader proceeds with an open and questioning mind.

The fractionating of areas of social difference begins with an examination of gender and the various theories which have taken up this challenge, and applying them to LGB individuals, couples and family structures. The assumed hetero-norms of gender are unpicked and alternatives presented. This chapter has a section on Transgender issues, with a focus on Trans people who identify as LGB.

A vacuum in the literature is then addressed with a chapter on issues pertaining to non-heterosexual black and ethnic minority people, who may have good reason not to identify with the labels LGB. This chapter in particular invites the reader into the complexities of intersectionality and non-categorical thinking, presenting thorny issues such as the costs of being visible or invisible within non-heterosexual communities and beyond, as well as the interplay between race, religion and family loyalties. The chapter ends with an invitation to therapists to become an agent for systemic change, exploring the intersections between therapist/activist identities.

The theme of religion is picked up and explored in depth in the next chapter, which critically presents the minimal writing on religion in the lives of non-heterosexuals. The chapter focuses on Islam, Hinduism and Christianity, but the reader is directed to other texts that cover other faiths. This chapter provides insights and guidance to therapists (addressing ‘non-believer’ therapists in particular) working with clients who are struggling with combining their sexuality and religious beliefs.

Same-sex sexuality (whether linked to an LGB identity or not) is then considered for those seeking asylum, or having obtained refugee status, on the grounds of their sexuality. This chapter describes various contexts that have a fundamental impact on the phases of exile, including the decision to flee and experiences in host countries. These contexts mark the experiences of LGB asylum seekers and refugees as unique compared to those of heterosexuals, and the narrow use of certain diagnostic categories and the application of western models of sexuality are critiqued.

There follows a chapter on social class, a largely neglected topic in LGB and therapy literature, with there being an unspoken assumption of middle-classness. This chapter therefore focuses mainly on the lives of working class non-heterosexuals, pulling together the scant literature and adding insightful and thorough comment. It also troubles the idea of the ‘chav’ identity, especially in connection with gay spaces, and suggests how this is a vilified, fetishised, and excluded group.

Social class has been strongly linked to health inequalities, and the subsequent chapter on physical health extends these inequalities to consider sexuality. This chapter, while mentioning HIV, makes a point of not having this as its focus as it is already widely considered the, and the only, ‘gay health issue’. Instead, the chapter discusses influences on poor health, such as smoking, alcohol use and eating disorders, and how these relate to LGB populations. It presents, and critiques, associated theories, such as that of ‘internalised homophobia (also referred to in other chapters). It also discusses the prevalence and concerns of chronic health problems and why there are unique issues pertaining to this for LGB people. The chapter ends with considerations for healthcare contexts working with LGB people.

In addition to physical health inequalities, LGB people experience more mental health problems than heterosexuals (King et al., 2008); the next chapter explores the possible reasons for this. The assumed ‘healthiness’ and well-adjustment of coming out is thrown into question, and issues relating to LGB youth explored. While this chapter covers some common mental health issues, and reasons behind them (such as internalised homonegativity), the bulk of the chapter focuses on how healthcare services perform and what needs to be done to better serve LGB populations with respect, dignity and understanding. The chapter also includes a section on sexual issues for LGB people with severe and enduring mental health problems: an area often neglected as service-users are considered to be asexual (McCann, 2003).

This asexual stereotype is also frequently applied to disability (Morris, 1991) and the chapter on disability challenges this by exploring the lives of disabled LGB people, including issues pertaining to relationships and sex. Prejudice and discrimination in different contexts is described (i.e. the heterosexual mainstream, LGB spaces, and the disability movement) and issues pertaining to growing up with a disability and a developing sexual minority awareness are explored. The chapter ends with sections that specifically focus on learning disabilities and HIV, both areas of potential controversy as some authors argue that these are often missed out from disability texts and campaigns (e.g., Thompson et al., 2001, and Shakespeare et al., 1996, respectively).

The final chapter on social difference focuses on age across the lifespan. The variety of ways of ‘doing relationships’ is emphasised, with a focus on the importance of friendships and ‘families of choice’. Issues relating to bisexuality are explored in detail in this chapter, as is sexuality in later life: both areas often neglected in LGB literature.

Finally, the concluding chapter echoes the point made in this introduction, that LGB lives are not all ‘doom and gloom’, by celebrating advantages and achievements. This chapter highlights fluidity and complexity, which is the essence of intersectionality, and proposes that acknowledging such fluidity removes the boundaries of self and other. Thus the reader/therapist is once again invited to examine their own position in relation to the issues mentioned in this book.

We recognise that we are limited by our media, in that by writing a book, the captured lived experiences and related reported research become static: frozen in the historic and cultural context in which they are produced. However, this book provides a useful punctuation to pull together existing thinking in this area and introduce therapists to the variety of issues that reflect the heterogeneity of LGB lives. This book perhaps represents a beginning, where several aspects of LGB lives that are brought to therapy are explored through the lens of intersectionality. We therefore invite our readers to join us in expanding the scope of this project by thinking in terms of how sexuality would relate to other issues, such as urban/rural living, non-monogamous relationships, ‘kink’ or sadomasochistic identities, asexuality, gender variance and the effects of the different permutations and combinations that all these different intersecting identities would have on the individual. In the final analysis, as Crenshaw (1991) suggests, it is only by being aware of identity intersections, that we can acknowledge the differences between us and explore ways in which diversity can be expressed to construct bonding. To this extent, this book is an invitation to celebrate difference in diversity.


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