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Challenges and treatment of a transsexual in Jamaica/Desafios que Afrontan y tratamiento que reciben los transexuales en Jamaica/Difficultes et traitement du transsexuel en Jamaique.

ABSTRACT

It is no secret that the Jamaican society is described as 'homophobic' and for a male-to-female who dresses and behaves female there could be serious repercussions. This case study attempts to make meaning of the lived experiences of a transsexual in the Jamaican context as well as her perceptions of the therapeutic intervention received. She makes every effort to ensure that the proposed sex reassignment surgery will take place. She sees this as vital to her survival in the larger society. This study provides an initial look at the challenges faced by transsexuals in the Jamaican context.

No es un secreto que la sociedad jamaicana es considerada 'homofobica'; lo que pudiera tener serias repercusiones para un hombre tornado en mujer que se viste y se comporta como una mujer. El presente estudio de caso trata encontrar sentido a las experiencias vividas por un transexual en el contexto jamaicano, asi como su percepcion de la intervencion terapeutica recibida. Ella esta haciendo todo lo posible para que se realice la propuesta cirugia de cambio de sexo, la que considera vital para su supervivencia en la sociedad en general. Este estudio presenta un analisis preliminar de los desafios afrontados por los transexuales en el contexto jamaicano.

Que la Jamaique soit presentee comme une societe homophobe n'est un secret pour personne, et pour un MTF (homme-vers-femme) qui s'habille et se comporte en femme, les repercussions pourraient etre graves. Cette etude de cas tente de decoder les experiences vecues par un transsexuel dans le contexte jamaicain ainsi que sa perception de l'intervention therapeutique qui lui est prodiguee. Elle fait tout pour que l'operation de changement de sexe proposee ait bien lieu. Elle la considere d'une importance vitale pour sa survie dans la societe dans son ensemble. Cette etude constitue un premier regard sur les defis auxquels sont confrontes les transsexuels dans le contexte jamaicain.

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Janet is the pseudonym we will use for the 31-year old black, Jamaican, male-to-female transsexual in this study. Janet is a biological male who wants to transition to female and is referred to as "she" throughout this article. She was referred for psychological and psychiatric evaluation, with the aim of helping her cope with her gender identity and body dysmorphoria issues as well as to assess if she would be a suitable candidate for sex reassignment surgery. Body dysmorphia occurs when an individual has a distorted view of his or her body.

Janet was introduced to the Caribbean Sexuality Research Group (CSRG) by the Jamaica Forum for Lesbians, Allsexuals and Gays (J-FLAG) who had offered her protection from the brutal attacks she was undergoing while living on the streets. The CSRG is a non-profit working group located at the University of the West Indies, Mona Campus, Jamaica consisting of healthcare professionals who are primarily engaged in research on the sexual knowledge, attitudes, practices and behaviours (KAPB) of Caribbean nationals. Janet's treatment team consisted of a psychiatrist, sexologist, clinical psychologist and associate clinical psychologist. With written consent, treatment began in February 2008. All sessions were tape recorded. The team members met periodically to discuss the way forward.

Description of Janet

Physically, Janet is about 5 feet 7 inches in height and weighs approximately 150 lbs and has what appears to be small breasts. For a woman within this culture she would be seen as average weight and height but for a man she would be seen as below average. Her body is hard and angular and somewhat androgynous. Her jaw line is clearly defined and masculine and there is evidence of her having removed the facial hair. In our first consultation with her she is casually-dressed in female attire: a tight fitting pink top, corduroy cream pants, her hair pulled tightly into a pony tail. Initially appearing uncomfortable in the interview, she sits stiffly upright in the chair, her tone is sharp, her answers abrupt and defensive, her gestures exaggerated and theatrical. She expresses herself clearly and coherently but appears generally disgruntled. Janet admits to entertaining suicidal thoughts from time to time, however, unlike most patients who do commit suicide, she has not yet formulated a plan.

Treatment Approaches

Janet's case is the first of its kind within this culture as there are no documented psychological or medical cases of transsexuals who have transitioned successfully. It was therefore important for the assessment team to be thorough and to take a multidisciplinary approach before recommending any medical or surgical procedure. A review of the literature as to which treatment approach(es) is most suitable has indicated controversial debates. On one hand, early researchers such as Benjamin (1966) believed that the best treatment approach was sex reassignment surgery. Others challenged Benjamin's treatment approach as they believed there was no evidence of the efficacy of sex reassignment surgery, specifically when it came to psychosocial improvements. More recent approaches include psychotherapy geared towards helping transsexuals become content with their own identity, which may include dressing and living as their preferred gender. Other approaches may be hormone treatment to alter their physical appearance and for most transsexuals, permanently altering their anatomical gender. (1)

In order to qualify for sex reassignment surgery one of the first steps is to be diagnosed with Gender Identity Disorder GID (Ross 2009). GID is the only disorder that requires that treatment "... confirm, reinforce, and validate the belief that this [GID] is the basis of a mental disorder ..." (Ross 2009, 11:165). Bower (2001) and Dewey (2008) further reiterate this point by highlighting that patients may wish to present symptoms to their treatment team that will confirm a GID diagnosis. Healthcare professionals treating transsexuals have two concerns: 1) the fact that they may be presented with false information and 2) stigmas faced by the transsexuals as well as possible discrimination or poor treatment in the medical arena (Dewey 2008; Blunden and Dale 2009). Taking all these factors into consideration the CSRG felt a team approach was best. Bower (2001) highlights the benefits of the team approach in treating transsexuals as this approach places emphasis on lengthy observations prior to surgery with the decision to operate based on the team's consensus.

Janet's treatment included weekly psychotherapeutic sessions with the clinical psychologists and bi-weekly sessions with the psychiatrist and sexologist. Having confirmed the GID diagnosis with Janet our next priority was to do a psychological profile and treatment plan. Individuals diagnosed with Gender Identity Disorder experience anxiety, they become persistently uncomfortable with the gender they have been socialized into, believing that their physical self is opposite to their psychological self (Blunden and Dale 2009). For example, if they are born biologically male, psychologically they feel female.

It was important that our approach provide quality service directed at understanding and helping Janet come to grips with her situation and make a decision on her way forward so a client-centered approach seemed most feasible. The client-centered approach makes the assumption that, in order for therapy to be successful, the therapist should facilitate an environment where the client experiences unconditional positive regard and sees the therapist as genuine (Rogers 1951 as cited in Kensit 2000). Using the client centered approach meant that Janet was allowed to speak freely and openly in a non-judgmental environment where she worked with her therapists as equals moving towards a common goal. This approach was crucial as Janet was able to express her real self without fear of rejection. Our therapy sessions explored her gender identity, body dysmorphia, trauma, depression, family dynamics and support as well as goals in addressing ways in which she could cope with her Gender Identity Disorder.

The treatment plan included:

* Providing Janet with an atmosphere that was nonjudgmental were both therapists and client worked together as a team.

* Building rapport with the aim of understanding her current situation.

* Obtaining background information which included family, medical and psychological history, employment history and support systems.

* Psychological and psychiatric evaluation:

** Evaluation of mental state of the client.

** Formulating a diagnosis.

** Treatment plan for disorders:

*** Depression: Psychotherapy and medication

*** Post Traumatic Stress Disorder: Psychotherapy

*** Body Dysmorphia

*** Gender Identity Disorder: Psychotherapy

Obtaining the Goals of the Client

Prior to receiving help from CSRG, Janet tried attaining help from general practitioners and a psychiatrist. In contrast to the help she received from a single health professional, this was the first time Janet received help from a multidisciplinary team. The team offered her a link into a hospital community and the possibility of receiving sex reassignment surgery overseas. Janet expressed her most immediate needs were to start hormone treatment and to be considered a candidate for sex reassignment surgery. Ultimately Janet would like to be seen as female, for Janet this meant she could comfortably pursue an intimate relationship with a male. In this relationship Janet sees herself as a housewife carrying out her female responsibilities, while her male partner has the more dominant role of taking care of her financially. Treatment by the team thoroughly examined these goals, the underlying psychological issues and ways of realistically helping Janet to get her needs met.

Janet's Story

Janet's last permanent place of residence was in her family home with her father, brother, sister and nephew. She was forced to move out of father's house because members of the community found out about her sexuality, became angry and threatened to harm her. Janet was subsequently removed with the help of the police. With no place to live, Janet resorted to living on the streets. According to her during this period she was often approached by men who at first would ask her about her gender identity and after learning of her situation promised her shelter and the security of a relationship. This resulted in her accompanying these men who would make sexual advances to her and would not keep their promises of providing security and shelter. Her life on the streets continued to be one that was subject to physical and sexual assaults. After living on the street for one year Janet reported that she was raped, sexually assaulted and physically abused, by a group of men with whom she had agreed to stay with for the night. These men assumed she was female and later discovered she was anatomically male and became enraged. Janet's last attack was so severe that ]-FLAG had to intervene and offered her protection which is how Janet came to be referred to us.

Janet is the sixth child of eleven children. She has three sisters and two brothers who are older and three sisters and two brothers who are younger. Janet grew up with both parents (who were at the time married) and siblings. Her father was initially the main breadwinner and worked at a pharmaceutical company. Her mother, after being a housewife during her early years decided to join the workforce and was employed as a house-keeper at one point and census-taker at another point. According to Janet, 'mom' was always the one taking care of the family, and although dad provided for them financially, he was usually absent from home. She describes her father as, 'the typical Jamaican male who would not really communicate with his children.' Her mother was described as having a dominant personality while the father was more passive when her parents separated and mother migrated. This migration resulted in Janet taking over the role of mother, doing house-chores and preparing meals for her father. When Janet began dressing in female clothing and acting out as the "wife" her father became concerned.

Since relocating, Janet has not communicated with members of her family. According to Janet, for the most part she has had a good relationship with her family members except when discussing her sexuality which she refers to as "my issue". When her siblings realized that she enjoyed playing female games they showed disapproval by calling her "Miss Jane". Janet revealed that she was not embarrassed by her siblings' disapproval but was actually pleased.

Janet recounts that life in her community was not initially hostile as members had accepted her sexuality and were accommodating towards her. According to Janet, she noted that this changed when she became financially successful, causing community members to suggest that her financial progress was as a result of her male partners and began accusing her of being "gay". In response to this accusation, Janet was adamant that she is "female"-not gay. She believes that she has always been "feminine" but is simply in the "wrong body". Janet expressed the view that being transsexual has always been difficult for her and that her family members would always identify her as male despite her feminine behaviour. Perhaps Janet's family members as well as community are of the opinion that Janet is displaying what Bornstein (1993) believes to be 'ambiguity of gender' in an attempt to challenge and frustrate social expectations. The refusal to conform, and her rejection of the set gender identity as stipulated by society is recognized by the medical discourse as an outlaw and pathology May (2002). Janet appears to enjoy the attention she shown by members of the society who are confused as to whether or not she is male or female.

According to Janet there is no known family history of mental illness, instead, her general practitioner has diagnosed her as having "high blood pressure, depression, obsessive behaviours and hormone problems" (Consultation with Janet 2009). She reports not sleeping well at night which she attributes to flashbacks from her physical assaults. She reports appetite changes which vary from loss of appetite to over-indulgence in food. She also reports loss of interest in pleasurable activities and feelings of hopelessness. She expresses fear of going on the street for fear of being identified as a male and being abused. Janet states that her hormones vary from feminine to masculine and that when she is in her "feminine state" (that is, feeling feminine) everyone recognizes her as female. However when she is in her "masculine state" (feeling masculine) everyone recognizes her as male and in those instances the environment becomes unsafe. As a way of protecting herself, she is always mindful of her surroundings before letting down her guard and letting her feminine state come to the fore. Her inability to fully express herself as female and for others to continue to see her as female has resulted in feelings of hopelessness "there is no point to going on" (Consultation with Janet 2009). She has also lost all desire to go on and her "spirit is broken". She feels like "a dead piece of log" (Consultation with Janet 2009) Janet admits to suicidal ideation but with no concrete plans to act on these thoughts. Tully, in his 1992 transgender study, noted that learned helplessness was a likely explanation for depression (Midence and Hargreaves 1997). Abraham, Seligman and Teasdale (1978) formulate helplessness as a result of failure on the part of the individual. Tully (1992) sees learned helplessness as "failed masculinity". Janet currently resides in a safe place that provides her with food and shelter but is frustrated because her main focus is on her hormone treatment. She believes that hormone treatment will transform her into having a female physique which will allow her to move towards her goals of being perceived by others as female and finding a male partner.

Based on Janet's background information we see where there is clear evidence of Gender Identity Disorder as she meets all the criteria as stipulated by the DSM-IV TR. These include:

a) a strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex)

b) a persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex

c) no concurrence with physical intersex condition

d) clinically significant distress or impairment in social, occupational or important areas of functioning (American Psychiatric Association 2000).

Additionally Janet meets the criteria for the following diagnosis:

1. Body Dysmorphic Disorder

2. Major Depressive Disorder (MDD)

3. Post Traumatic Stress Disorder (PTSD)

4. Histrionic Personality Disorder

Societal Response

Healthcare providers will agree that treating transsexuals can be a challenging task. To begin with, an outward display of uncertainty as to one's gender and the gender one wants to be already has serious maladaptive consequences in making personal and social adjustments (May 2002). Transsexuals therefore rely on healthcare providers to help them reduce the dissonance in their self-concept as well as aid in preparation to live with their gender ambiguity. There are growing numbers of transsexuals in the United States of America (USA) and the United Kingdom (UK) who willingly disclosed their situation which resulted in the provision of more inside information on transsexuals and the implications of living with gender contradiction. Gender contradiction affects one's sense of self. A stable sense of self is generally an important requirement for social interaction as it is often assumed that individuals carry with them 'essential selves'. Therefore if one encounters a male one would expect the male to be dressed in masculine clothing and behave in a masculine manner in keeping with the cultural expectations of their society. If a male provides contrary claims and displays feminine tendencies and perceives himself as female this indicates psychological instability and as well as a lack of authenticity. May questions a male's choice to move from an external perception of male to a frequently ridiculed and "questionable" woman and suggests that this scenario is indicative of an individual who is "strange, deviant and unstable" (2002, 5: 451). In individualistic western societies such as the US and the UK "strange, deviant and unstable" behaviour is more accepted than in collectivist pseudo-western societies such as Jamaica where this behaviour is not openly tolerated.

Homophobia and Exposure to Trauma in Jamaica

Janet ended up accepting help from J-FLAG and subsequently the CSRG because of her desire to act out as a female while biologically and physically male. In the Jamaican context, behaviours classified as homosexual, bisexual, transvestite or transexual are often met with disapproval from patriarchy who responds by "sometimes

threatening, often violent and persistently silencing/confining social policing of sexual relations" (Gutzmore 2004, 6: 119). In fact, the Jamaican law prohibits any male homosexual sexual expression as is stipulated in section 76 of the Offences Against the Person Act. The Act forbids the "abdominable crime of buggery" even if this is amongst consenting adult males. (2) "Sexuality-based oppression in Jamaica is institutionalized throughout the legal system, health and social welfare institutions, popular media and culture, and, through extreme social stigma. Buggery and Gross Indecency laws are implicitly anti-gay and include maximum sentences of ten years imprisonment with hard labour for anal sex" (Williams 2000, 7: 349).

The culture of homophobia is embedded in the Jamaican society to the extent that gays internalize such hate for their own group in order to deflect attention from their own selves. Jamaicans' inability to treat, in a civilized manner, their differences and manage attitudes concerning opposition against homosexual relations is said to be equivalent to a violent society (Williams 2000). We have seen evidence of this in Janet's case of the reprisal she faced by her community by virtue of displaying her gender identity. The intervention of law enforcement officers to safeguard the well-being of Janet is indicative of the intensity of the outrage and disapproval expressed by members of her community. The Jamaican society is not equipped with handling cases such as Janet's as the only solution was to safely remove her from the community. Life on the streets was yet another challenge faced by Janet. Despite showing her feminine tendencies, at no point did Janet made clear to society that she is biologically male who psychologically believes she is female. Further to that, on the streets she had subtly avoided the questions asked by males as to whether or not she is male or female. The ambiguity that Janet presents can only lead to assumptions by those inquiring. Therefore if the assumption by Janet's male pursuers is that she is male then we see evidence of homosexuals within the Jamaican context. This would confirm what William's belief that "it is also a badly kept secret that Jamaica has a perceptibly vibrant gay population" (2000, 7:106). For this reason one may find attitudes amongst Jamaicans vary from "gratuitous violence to virulent contempt to reluctant acknowledgment" (Williams 2000, 7:106). The question is, at what point do Jamaicans become violent or reluctantly acknowledge the sexuality of the male who would believe he is female? According to Janet, the members of her community or the males on the street did not initially react violently towards her, therefore showing that something had changed in her interaction with these individuals that resulted in the violent reactions. Perhaps these individuals were reacting to the ambiguity presented by Janet, her need to be seen as female and their discovery that she is biologically male.

J-FLAG'S Intervention

After reportedly being sexually assaulted and physically abused by a group of men, the Jamaica Forum for Lesbians, All sexuals and Gays (J-FLAG) intervened. J-FLAG is an organization that originally developed to protect the rights of homosexuals in Jamaica. This organization collects personal testimonies from gay, lesbian, and transgendered Jamaicans in an effort to document the discrimination and violence faced by sexual minorities in Jamaica. J-FLAG's documentations include "verbal abuse by work colleagues, vicious beatings by police, relatives and community-members, some of which have resulted in death and homelessness after being driven from their communities by angry neighbours." (White and Carr 2005, 7: 349). The protection Janet has received from J-FLAG has made it easier for the CSRG team to assist Janet in working through his gender identity issues.

Causes of Gender Identity Disorder (Transsexualism)

Research has not pinpointed the exact cause of transsexualism although some recent findings suggest that there is a biological component. The debate over the causes of trans-sexualism has been ongoing and has made only some progress in the last 20 years. Stoller (1973) seems to corroborate Janet's experiences in his clinical picture of a transsexual where he describes the adult transsexual male as having feminine tendencies as early as childhood, in some cases as early as a year, and all without a phase of masculinity. By ages three or four the transsexual male will verbalize he wants to be a girl and expects he will lose his penis while his body converts entirely to female. He plays only with girls and in these games he takes on female roles, boys are excluded and females accept him as a part of the group. Usually while still an adolescent he has already passed successfully as a woman and was never recognized as a male.

According to Stoller (1973) this occurs because of the relationship the transsexual has with his parents. He believes that transsexual patients develop an excessive identification with their mothers as a result of mothers' inability to allow their sons to separate from their bodies. Although it is typical of many Jamaican families to have a mother who is domineering, it is uncertain as to whether or not Janet's family dynamics contributed in any manner to her Gender Identity Disorder.

Stoller's theoretical explanation for the existence of transsexualism is based mainly on socialization than on biological determination. Ellis (Midence and Hargreaves 1997) was among the early researchers to examine this issue as to whether or not transsexualism is biologically or socially determined. In 1945 he examined literature of 84 people classified as hermaphrodites or pseudo-hermaphrodites. He noted that during infancy, 39 had been assigned to the male sex and 45 to the female sex. The majority who were raised as boys were attracted to females (87%) and 75% of those raised as females were attracted to males. Of the 84, 82 remained in sex roles they had been assigned. Ellis therefore concluded that sex assignment and rearing were likely to be responsible for the erotic orientation in the sample. (Midence and Hargreaves 1997)

Money, Hampson and Hampson in 1957 did a similar review of 105 hermaphrodites and found that only 5 had Gender Identity Disorder or an erotic orientation different from their assigned sex. Their review of the literature led them to suggest that the critical period for the development of gender identity in individuals is before 27 months of age. Additionally they suggested that it is socialization rather than biology that determines one's psycho-sexuality (Midence and Hargreaves 1997). Diamond was the first to publicly challenge Money's claims that gender identity is based on socialization and provided biological evidence to support his arguments (Oberacker 2007).

More recent studies have shown evidence of biology contributing to transsexualism. An example of this includes studies done by Kruijver, Zhou, Pool, Hofman, Gooren and Swaab (2000). They examined whether there was a neuronal difference in the central part of the bed nucleus of the stria terminalis (BSTc). Biologically, men, regardless of orientation, are expected to have almost twice as many neurons found in the BSTc than women. Kruijker et. al (2000) noted the number of neurons found in the BSTc of male-to-female transsexuals were similar to that of females (P = .83). Additionally they found the neuron number of a female-to-male transsexual was found in the male range. In support of the biological basis for gender identity disorder, other studies support the notion that Gender Identity is a medical condition rather than a mental disorder. This medical condition is believed to take place before birth. Research studies indicate that Gender Identity occurs because small parts of the baby's brain progress along a different pathway from the sex of the rest of its body. This results in the baby being predisposed to a future mismatch between gender identity and sex appearance. (3)

Despite the intensive psychological and biological research, the aetiology of gender identity disorder continues to be one that is puzzling. Bower (2001) concludes that it could be an interaction of the genetic, hormonal and subtle psychodynamic factors waiting to be elucidated. While research tries to figure this out, Bower (2001, 35: 8) encourages professionals working with this population to focus on "consistent, careful and informed classification" in an effort to diagnose and treat transsexuals.

Outcome of Working with Janet

Our sessions with Janet helped us as healthcare providers to gain first hand experience on working with Gender Identity Disorder. A person with Gender Identity Disorder (GID) suffers tremendously with feelings of hopelessness, of "no point to going on" a "broken spirit" and feeling like "a dead piece of log." Janet did not choose this disorder, rather, she had always felt like a female "trapped in a male's body."

Perhaps it was our approach of being accepting and non-judgmental that allowed Janet to confide in us about her lived experience as an individual with Gender Identity Disorder in the Jamaican context. Our interactions with Janet have resulted in the team's consensus of acknowledging that Janet's perception of self is female regardless of the rejections and consequences of displaying such behaviours in the Jamaican context. Her persistence in displaying feminine tendencies with a rejection of her masculine anatomy has resulted in her diagnosis of Gender Identity Disorder. Living with gender ambiguity can be painful for the individual especially when this occurs in the Jamaican society that has minimal tolerance for males who dress and believe that they are female. It is therefore understandable that over the years, the stigmas faced by Janet would have influenced her perception of her world.

Dewey (2008, 18: 1354) noted that transsexuals, having internalized the stigma by society, enter the treatment process with the view that they will obtain lesser treatment. According to Dewey (2008) the transsexual goes into treatment with the view that doctors may stigmatise or treat them unfairly because of the unconventional treatment they seek. Dewey further reiterates that the way in which transsexuals understand societal and medical views about them contributes to how they present to their doctors to ensure receiving appropriate treatment (2008, 18: 1354).

Janet initially worked well with the treatment team but had minimal tolerance for our continued assessment and our exploration of her treatment goals. She was of the opinion that the team would immediately move towards hormone treatment and sex reassignment surgery. Janet's discount of our treatment recommendations informed us on the intensity of her fear of being rejected as female and her desperate need to eradicate the discrimination she experienced. Her goal is that surpassing the treatment plan and accessing hormone treatment and sex reassignment surgery would 'magically' transform her to female and that she would be accepted in the Jamaican context as female. Janet's need for sex reassignment surgery seems to be consistent with Dewey's (2008) explanation of transsexuals approach to treatment; in that patients will consistently try to maximize the likelihood of receiving the treatment they desire.

It is no doubt that our interaction with Janet, has informed practice on treatment of patients in a society that violently reacts to the display of a characteristics contrary to ones biological sex. For the transsexual living with this type of societal rejection we learn they adamantly seek measures that will resolve their gender ambiguity as the only type of survival means but also of importance, to be accepted by society. An important element to consider when treating transsexuals is that they bring with them the discrimination experienced. It is therefore necessary that part of the therapeutic process be geared towards working through the discrimination as this can impede effective treatment. An area worthy of further exploration is clarity on what specifically instigated the violent reactions of persons such as those mentioned by Janet. It raises questions as to whether or not open communication on ones gender identity as well as biological sex will act as a preventative against violent reactions.

REFERENCES

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(1) http://www.nhs.uk/Conditions/Gender-dysphoria/Pages/Introduction.aspx

(2) Ministry of Justice, Jamaica. L.N. 480/1973 "Offences Against the Person Act". http://www.moj.gov.jm/laws/statutes/Offences%20Against%20the%20Person%20 Act.pdf.

(3) UK Department of Health. 2007. "Transgender experiences--information and support for trans people and their families and healthcare staff", http:// www.gires.org.uk/assets/DOH-Assets/pdf/doh-transgender-experiences.pdf.
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Date:Mar 1, 2011
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