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Barut A, Mohamud SA. The psychosexual and psychosocial impacts of polygamous marriages: a cross-sectional study among Somali women. BMC Womens Health 2023; 23:669. [PMID: 38093249 PMCID: PMC10720057 DOI: 10.1186/s12905-023-02830-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Polygamous marriages are common in many Africa countries. This study aimed to document psychosexual and psychosocial problems of Somali women engaged in monogamous or polygamous marriages. METHODS This cross-sectional study included 607 consecutive women who had presented between June 7 and October 1, 2022, to the Department of Gynaecology of Mogadishu Somali Turkey Training and Research Hospital in Mogadishu, the capital city of Somalia. Data included maternal age, type of marriage (polygamy, monogamy, and arranged marriage), wives' education, husbands' education, husband income, residence area (rural or urban), number of marriages, living in houses (same or different), number of co-wives, and age of marriage. The participants were asked to complete three questionnaires: The Female Sexual Function Index (FSFI), the Rosenberg Self-Esteem Scale (RSE), and the Brief Symptom Inventory-18 (BSI-18). RESULTS Of 607 women, 435 (71.7%) had monogamous marriages and 172 (28.3%) had polygamous marriages. The mean age was 29.0 ± 7.2 years (range 16-46). In polygamous marriages, the mean number of wives a husband had was 2.4 ± 0.7 women (range 2- 4). The overall incidences of sexual dysfunction, low self-esteem and arranged marriage were 59.8%, 79.4% and 64.4%, respectively. Wives in polygamous marriages differed from those in monogamous marriages with significantly higher rate of illiterateness (41.9% vs. 27.4%, p = 0.004). Increases in husband income corresponded to higher rates of polygamous marriage. Women in polygamous marriages had significantly lower scores in the desire, arousal, orgasm, and satisfaction sub-domains. Sexual dysfunction, with a significantly increased rate among women in polygamous marriages. Polygamous marriages were associated with significantly higher levels of anxiety, and depression, and a significantly higher total BSI score (p = 0.010, p = 0.004, and p = 0.020, respectively). Women in both groups had similar levels of low self-esteem (p > 0.05). In univariate analysis, polygamous marriage was in significant inverse associations with the total FSFI score and subdomain scores of desire, arousal, orgasm, satisfaction, and sexual dysfunction and in significant associations with the BSI total score and subdomain scores of anxiety and depression (p < 0.05). CONCLUSION Our findings suggest that women in polygamous marriages experience considerably higher psychosexual and psychosocial adverse effects as compared with their monogamous counterparts.
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Affiliation(s)
- Adil Barut
- Obstetrics and Gynaecology Department, Somali-Mogadishu Recep Tayyip Erdoğan Research and Training Hospital, Mogadishu, Somalia.
| | - Samira Ahmed Mohamud
- Obstetrics and Gynaecology Department, Somali-Mogadishu Recep Tayyip Erdoğan Research and Training Hospital, Mogadishu, Somalia
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2
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Nielsen S, Dobrescu SR, Dinkler L, Gillberg C, Gillberg C, Råstam M, Wentz E. Effects of autism on 30-year outcome of anorexia nervosa. J Eat Disord 2022; 10:4. [PMID: 35000620 PMCID: PMC8744255 DOI: 10.1186/s40337-021-00518-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 11/30/2021] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Long-term consequences of comorbid autism spectrum disorder (ASD) in individuals with anorexia nervosa (AN) are inadequately investigated. METHODS In the 1980s, 51 adolescent-onset AN cases (AN group) and 51 matched controls (COMP group) were recruited from the community. They have been examined on five occasions. The four last assessments included the Morgan-Russell Outcome Assessment Schedule (MROAS) to assess eating disorder outcomes (weight, dieting, menstruation), and related problems including psychiatric, psychosexual and socioeconomic state. In the present study, at age 44, when 30 years had elapsed, MROAS data were compared with previous results. At age 16, 21, 24 and 32 years, all individuals had been assessed regarding ASD. At the 30-year follow-up, the impact of the ASD on the MROAS data was analysed. RESULTS In the AN group, all core anorectic symptoms (weight, dieting, menstruation) were on a par with the COMP group at the 30-year follow-up, but the positive outcomes were limited to those who had never had an ASD diagnosis. Psychiatric state was significantly worse in the AN group, particularly in the subgroup who had an ASD diagnosis assigned. The AN group-again particularly those with ASD-had a more negative attitude to sexual matters than the COMP group. The AN group had worse outcomes than the COMP group for 'personal contacts', 'social contacts,' and 'employment record' at the 30-year follow-up and the outcomes were worse the more often an ASD diagnosis had been assigned. LIMITATIONS Rare data collection points throughout 30 years (only 5 assessments). ASD was assessed in the first four studies but was not assessed again at the 30-year follow-up. CONCLUSIONS Mental health, psychosexual, and socioeconomic status were compromised up to 30 years after AN onset. Coexisting ASD contributed to the poor outcome. Core anorectic symptoms had "normalised" three decades after AN onset. Some individuals with anorexia nervosa (AN) also suffer from autism. In this study we have investigated outcome of AN 30 years after the onset of AN and whether the presence of autism affects the outcome. Since the 1980s we have followed 51 individuals with teenage-onset AN and 51 healthy controls. They have been examined on five occasions, and an instrument that measures symptoms of AN (weight, dieting, body image), psychiatric symptoms, ability to work, and relationships with partner, family, and friends has been used to assess outcome. Autism was assessed in the first four studies. Symptoms of AN had normalised at 30-year follow-up, but only among those without autism. Psychiatric symptoms, ability to work, and relationships were issues that persisted after 30 years in the AN group, and those who had both autism and a history of AN had even more pronounced problems in these areas. The AN group had a more negative attitude to sexual matters than the control group, the outcome was worse the more often an autism diagnosis had been assigned. CONCLUSIONS Mental health, psychosexual, and socioeconomic status are affected up to 30 years after AN onset, particularly among those with autism.
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Affiliation(s)
- Søren Nielsen
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark
| | - Sandra Rydberg Dobrescu
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Lisa Dinkler
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Carina Gillberg
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Christopher Gillberg
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Child and Adolescent Psychiatry, University of Glasgow, Glasgow, UK
| | - Maria Råstam
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Sciences Lund, Child and Adolescent Psychiatry, Lund University, Lund, Sweden
| | - Elisabet Wentz
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden. .,Högsbo Hospital, Lilla Kapplandsgatan 26, 42137, Västra Frölunda, Sweden.
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3
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Wibowo E, Wong STS, Wassersug RJ, Johnson TW. Sexual Function After Voluntary Castration. Arch Sex Behav 2021; 50:3889-3899. [PMID: 34704159 DOI: 10.1007/s10508-021-02094-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 05/28/2023]
Abstract
Some genetic males undergo voluntary castration, with and without hormonal supplementation. Here, we investigate the sexual function of 163 such individuals (average age = 52 ± 16-years-old). Specifically, we explored how hormonal, social, and psychological factors play a role in their sexual function. In this study, 47% identified their gender as "eunuch", and 36% identified their gender as "man." Furthermore, 64% were in a relationship (80% with a woman), and 28% had a strong attraction for both sexes (Kinsey 2-4). We found that castrated individuals with androgen supplementation have higher sexual function than those without any hormone supplementation. Individuals with anxiety symptoms reported better sexual parameters (better orgasm satisfaction, easier to achieve an erection and an orgasm) than those without anxiety symptoms. Among those low in anxiety, individuals without hormone supplementation had a weaker sex drive and more difficulty in getting sexually aroused than those on supplemental estrogen or androgen. Hierarchical multiple regressions indicated that control variables (i.e., age, depressive symptoms, time since castration, type of hormone supplementation) accounted for 13-30% of the variances in sexual parameters. Including sexual guilt in the models predicted 4-8% additional variances in all sexual parameters except for ease in getting and maintaining an erection. Adding in participants' sexual trauma scores accounted for an additional 3.7% in the strength of their reported sex drive. In conclusion, various factors-hormone therapy, anxiety, sexual guilt, and childhood trauma-may influence the sexual outcomes for castrated individuals.
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Affiliation(s)
- Erik Wibowo
- Department of Anatomy, University of Otago, 270 Great King St., Dunedin, 9016, New Zealand.
| | - Samantha T S Wong
- Department of Educational and Counselling Psychology, McGill University, Montreal, QC, Canada
| | - Richard J Wassersug
- Department of Cellular & Physiological Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Thomas W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
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Griffin-Mathieu G, Berry M, Shtarkshall RA, Amsel R, Binik YM, Gérard M. Exploring Male Multiple Orgasm in a Large Online Sample: Refining Our Understanding. J Sex Med 2021; 18:1652-1661. [PMID: 37057440 DOI: 10.1016/j.jsxm.2021.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 06/01/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The scientific literature on multiple orgasm in males is small. There is little consensus on a definition, and significant controversy about whether multiple orgasm is a unitary experience. AIMS This study has 2 goals: (i) describing the experience of male multiple orgasm; (ii) investigating whether there are different profiles of multiple orgasm in men. METHODS Data from a culturally diverse online convenience sample of 122 men reporting multiple orgasm were collected. Data reduction analyses were conducted using principal components analysis (PCA) on 13 variables of interest derived from theory and the existing literature. A K-means cluster analysis followed, from which a 4-cluster solution was retained. RESULTS While the range of reported orgasms varied from 2 to 30, the majority (79.5%, N = 97) of participants experienced between 2 and 4 orgasms separated by a specific time interval during which further stimulation was required to achieve another orgasm. Most participants reported maintaining their erections throughout and ejaculating with every orgasm. Age was not a significant correlate of the multiple orgasm experience which occurred more frequently in a dyadic context. Four different profiles of multiorgasmic men were described. STRENGTHS & LIMITATIONS This study constitutes a rare attempt to collect systematic self-report data concerning the experience of multiple orgasm in a relatively large sample. Limitations include the lack of validated measures, memory bias associated with self-reported data and retrospective designs, the lack of a control group and of physiological measurement. CONCLUSION Our study suggests that multiple orgasm in men is not a unitary phenomenon and sets the stage for future self-report and laboratory study. Griffin-Mathieu G, Berry M, Shtarkshall RA, Amsel R, Binik YM, Gérard M. Exploring Male Multiple Orgasm in a Large Online Sample: Refining Our Understanding. J Sex Med 2021;XX:XXX-XXX.
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Affiliation(s)
| | | | - Ronny A Shtarkshall
- Hebrew University of Jerusalem, School of Public Health, Faculty of Medicine, Jerusalem, Israel
| | - Rhonda Amsel
- Université du Québec à Montréal, Department of Psychology, Montreal, Quebec, Canada
| | - Yitzchak M Binik
- Université du Québec à Montréal, Department of Psychology, Montreal, Quebec, Canada
| | - Marina Gérard
- Université du Québec à Montréal, Department of Psychology, Montreal, Quebec, Canada
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Yang L, Comninos AN, Dhillo WS. Intrinsic links among sex, emotion, and reproduction. Cell Mol Life Sci 2018; 75:2197-2210. [PMID: 29619543 PMCID: PMC5948280 DOI: 10.1007/s00018-018-2802-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/27/2018] [Accepted: 03/20/2018] [Indexed: 01/23/2023]
Abstract
Species survival is dependent on successful reproduction. This begins with a desire to mate, followed by selection of a partner, copulation and in monogamous mammals including humans, requires emotions and behaviours necessary to maintain partner bonds for the benefit of rearing young. Hormones are integral to all of these stages and not only mediate physiological and endocrine processes involved in reproduction, but also act as neuromodulators within limbic brain centres to facilitate the expression of innate emotions and behaviours required for reproduction. A significant body of work is unravelling the roles of several key hormones in the modulation of mood states and sexual behaviours; however, a full understanding of the integration of these intrinsic links among sexual and emotional brain circuits still eludes us. This review summarises the evidence to date and postulates future directions to identify potential psycho-neuroendocrine frameworks linking sexual and emotional brain processes with reproduction.
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Affiliation(s)
- Lisa Yang
- Section of Endocrinology and Investigative Medicine, Imperial College London, 6th Floor, Commonwealth Building, Hammersmith Hospital Campus, Du Cane Road, London, W12 ONN, UK
| | - Alexander N Comninos
- Section of Endocrinology and Investigative Medicine, Imperial College London, 6th Floor, Commonwealth Building, Hammersmith Hospital Campus, Du Cane Road, London, W12 ONN, UK.,Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Waljit S Dhillo
- Section of Endocrinology and Investigative Medicine, Imperial College London, 6th Floor, Commonwealth Building, Hammersmith Hospital Campus, Du Cane Road, London, W12 ONN, UK.
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Dekker LP, van der Vegt EJM, van der Ende J, Tick N, Louwerse A, Maras A, Verhulst FC, Greaves-Lord K. Psychosexual Functioning of Cognitively-able Adolescents with Autism Spectrum Disorder Compared to Typically Developing Peers: The Development and Testing of the Teen Transition Inventory- a Self- and Parent Report Questionnaire on Psychosexual Functioning. J Autism Dev Disord 2017; 47:1716-1738. [PMID: 28299510 PMCID: PMC5432605 DOI: 10.1007/s10803-017-3071-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To gain further insight into psychosexual functioning, including behaviors, intrapersonal and interpersonal aspects, in adolescents with Autism Spectrum Disorder (ASD), comprehensive, multi-informant measures are needed. This study describes (1) the development of a new measure of psychosexual functioning in both parent- and self-reports (Teen Transition Inventory; TTI) covering all three domains of psychosexual functioning (i.e. psychosexual socialization, psychosexual selfhood, and sexual/intimate behavior). And (2) the initial testing of this instrument, comparing adolescents with ASD (n = 79 parent-report; n = 58 self-report) to Typically Developing (TD) adolescents (n = 131 parent-report; n = 91 self-report) while taking into account gender as a covariate. Results from both informants indicate more difficulties regarding psychosexual socialization and psychosexual selfhood in the ASD group. With regard to sexual/intimate behavior, only parents reported significantly more problems in adolescents with ASD.
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Affiliation(s)
- Linda P Dekker
- Department of Child and Adolescent Psychiatry/psychology, Erasmus MC-Sophia, Wytemaweg 8, Room KP 2881, 3015 CN, Rotterdam, The Netherlands. .,Yulius Academy & Yulius Autism, Yulius, Mental Health Organisation, Dennenhout 1, 2994 GC, Barendrecht, The Netherlands.
| | - Esther J M van der Vegt
- Department of Child and Adolescent Psychiatry/psychology, Erasmus MC-Sophia, Wytemaweg 8, Room KP 2881, 3015 CN, Rotterdam, The Netherlands.,Yulius Academy & Yulius Autism, Yulius, Mental Health Organisation, Dennenhout 1, 2994 GC, Barendrecht, The Netherlands
| | - Jan van der Ende
- Department of Child and Adolescent Psychiatry/psychology, Erasmus MC-Sophia, Wytemaweg 8, Room KP 2881, 3015 CN, Rotterdam, The Netherlands
| | - Nouchka Tick
- Department of Child and Adolescent Psychiatry/psychology, Erasmus MC-Sophia, Wytemaweg 8, Room KP 2881, 3015 CN, Rotterdam, The Netherlands.,Yulius Academy & Yulius Autism, Yulius, Mental Health Organisation, Dennenhout 1, 2994 GC, Barendrecht, The Netherlands
| | - Anneke Louwerse
- Department of Child and Adolescent Psychiatry/psychology, Erasmus MC-Sophia, Wytemaweg 8, Room KP 2881, 3015 CN, Rotterdam, The Netherlands.,Yulius Academy & Yulius Autism, Yulius, Mental Health Organisation, Dennenhout 1, 2994 GC, Barendrecht, The Netherlands
| | - Athanasios Maras
- Yulius Academy & Yulius Autism, Yulius, Mental Health Organisation, Dennenhout 1, 2994 GC, Barendrecht, The Netherlands
| | - Frank C Verhulst
- Department of Child and Adolescent Psychiatry/psychology, Erasmus MC-Sophia, Wytemaweg 8, Room KP 2881, 3015 CN, Rotterdam, The Netherlands
| | - Kirstin Greaves-Lord
- Department of Child and Adolescent Psychiatry/psychology, Erasmus MC-Sophia, Wytemaweg 8, Room KP 2881, 3015 CN, Rotterdam, The Netherlands.,Yulius Academy & Yulius Autism, Yulius, Mental Health Organisation, Dennenhout 1, 2994 GC, Barendrecht, The Netherlands
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Hughes G. Psychosexual medicine, general practice, you and me. J Fam Plann Reprod Health Care 2017; 43:335-337. [PMID: 28739630 DOI: 10.1136/jfprhc-2017-101789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 06/01/2017] [Accepted: 06/11/2017] [Indexed: 11/03/2022]
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Nielsen S, Anckarsäter H, Gillberg C, Gillberg C, Råstam M, Wentz E. Effects of autism spectrum disorders on outcome in teenage-onset anorexia nervosa evaluated by the Morgan-Russell outcome assessment schedule: a controlled community-based study. Mol Autism 2015; 6:14. [PMID: 25774282 PMCID: PMC4359566 DOI: 10.1186/s13229-015-0013-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/16/2015] [Indexed: 12/02/2022] Open
Abstract
Background The purpose of the study was to evaluate time trends and effects of co-existing autism spectrum disorders (ASD) on outcome in an ongoing long-term follow-up study of anorexia nervosa (AN). Methods The Morgan-Russell Outcome Assessment Schedule (MROAS) was used at 6-, 10- and 18-year follow-up of a representative sample of 51 individuals with teenage-onset AN and a matched group of 51 healthy comparison cases. The full multinomial distribution of responses for the full scale and each of the subscales was evaluated using exact nonparametric statistical methods. The impact of diagnostic stability of ASD on outcome in AN was evaluated in a dose–response model. Results There were no deaths in either group. Food intake and menstrual pattern were initially poor in the AN group but normalised over time. MROAS ‘mental state’ was much poorer in the AN group and did not improve over time. The psychosexual MROAS domains ‘attitudes’ and ‘aims’ showed persistent problems in the AN group. In the MROAS socioeconomic domain, the subscales ‘personal contacts’, ‘social activities’ and ‘employment record’ all showed highly significant between-group differences at all three follow-ups. A statistically significant negative dose–response relationship was found between a stable diagnosis of ASD over time and the results on the subscales ‘mental state’, ‘psychosexual state’ and ‘socio-economic state’. Conclusions Outcome of teenage-onset AN is favourable with respect to mortality and persisting eating disorder, but serious problems remain in the domains ‘mental state’, ‘psychosexual function’ and ‘socioeconomic state’. Outcome is considerably worse if ASD is present. Treatment programmes for AN need to be modified so as to accommodate co-existing ASD.
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Affiliation(s)
- Søren Nielsen
- Department of Child and Adolescent Psychiatry, Region Sjælland, Child Psychiatric Clinic, Næstved, Denmark
| | - Henrik Anckarsäter
- Forensic Psychiatry, Institute of Neuroscience and Physiology, University of Gothenburg, Göteborg, Sweden
| | - Carina Gillberg
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Kungsgatan 12, SE- 411 19 Göteborg, Sweden
| | - Christopher Gillberg
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Kungsgatan 12, SE- 411 19 Göteborg, Sweden ; Department of Child and Adolescent Psychiatry, Strathclyde University, Yorkhill Hospital, Glasgow, UK ; Institute of Child Health, University College, London, UK
| | - Maria Råstam
- Department of Clinical Sciences, Child and Adolescent Psychiatry, Lund University, Lund, Sweden
| | - Elisabet Wentz
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Kungsgatan 12, SE- 411 19 Göteborg, Sweden
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Abstract
OBJECTIVE To review the psychosexual effects on men after hypospadias repair. METHODS We reviewed all English-language publications in the MEDLINE database from the US National Library of Medicine with the search terms 'hypospadias adult', 'psychosexual hypospadias', 'psychosocial hypospadias', and 'social hypospadias'. Each term returned 1036, 35, 19 and 68 results, respectively, which were reviewed. RESULTS While improvements in surgical techniques have improved function, the abnormality and repair still causes a disruption in perceived quality of life for many men. After repair, many men suffer from a negative view of their genitals and some degree of sexual inhibition. However, they still maintain a satisfactory sex life. CONCLUSIONS Psychosexual effects of hypospadias repair they endure in adulthood, although affected men maintain satisfaction with their sexual life.
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Affiliation(s)
- Christopher M Deibert
- Columbia University, College of Physicians and Surgeons, 161 Fort Washington Ave, 11th Floor, New York, NY 10032, USA
| | - Terry W Hensle
- Columbia University, College of Physicians and Surgeons, Teaneck, NJ, USA
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