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PENIS SIZE AND THE SMALL PENIS SYNDROME

WYLIE and EARDLEY

Penis size and the 'small penis syndrome'

Kevan R. Wylie* and Ian Eardley†
Porterbrook Clinic, Sheffield Care Trust, Sheffield, *Urology, Royal Hallemshire Hospital, Sheffield, and
†Urology, St James's Hospital, Leeds, UK
Accepted for publication December 15, 2006

The male is often troubled by concerns that his excessive, might present as the 'small penis treatment options in detail with the man, is
penis is not large enough to satisfy his partner syndrome', an obsessive rumination with essential to allow the matter to be
or himself. He is ashamed to have others compulsive checking rituals, body dysmorphic consolidated satisfactorily within the male
view his penis, especially in the flaccid state. disorder, or as part of a psychosis. However, it ego.
Such concerns might be unfounded in reality is often a worry that can be described as
and might be a presentation of social anxiety or within the normal experience of many men. KEYWORDS
some other clinical problem, such as erectile Various potential causal factors are
dysfunction. Concern over the size of the penis, considered. A thorough assessment, penis size, anxiety, micropenis, small penis,
when such concern becomes normalizing the worry and then exploring the body dysmorphophobia, erectile dysfunction

INTRODUCTION the size of their penis is an important issue. concern It might be an obsessive rumination,
It is perhaps more surprising that when men are part of a body dysmorphic disorder (BDD), or
The penis, particularly in its erect state, is a concerned about their penile size, this as part of a psychosis (see below). The degree
symbol of masculinity. In many cultures it has concern relates not only to the erect but also to of emotional distress and behaviour
come to symbolize attributes such as the flaccid penis. These concerns, when impairment is often much greater than the size
'largeness, strength, endurance, ability, severe, can lead a man to go to extreme and nature of the defect felt within
courage, intelligence, knowledge, dominance lengths to try to change the size of his penis. the self. Often the specific matter of penile size
over men, possession of women; a symbol of This review deals with issues surrounding the is not an overtly acknowledged issue, and is
loving and being loved'. A review [1] is aetiology, psychology and management of often situational or context-driven [7]. As such,
recommended which describes Indian Sadhus these men, who might be considered to have the clinician might need to consider this matter
using weights, Dayak men in Borneo piercing the 'small penis syndrome' (SPS). Classically, as part of the overall assessment of different
the glans and then inserting items in the the SPS is found in men with a normal-sized presenting problems within urology and
resulting holes to stimulate the partner, and the penis but who are anxious about the size of the psychiatry.
Topinama of Brazil, who encourage penis, in contrast to men who have a truly small
poisonous snakes to bite their penis to make it penis (micropenis). Dysmorphophobia has been described for
enlarge (for 6 months!). Some of these more than a century; it is a psychiatric
concepts date back over many thousands of It is perhaps relevant that while men with a condition, also termed BDD, and is observed
years, and there is evidence that prehistoric larger penis, in length and circumference, as a fixation on an imaginary flaw in the
cave dwellers attributed the symbolic values of have a better body image, genital image and physical appearance. In cases in which a
strength and power to penile size, as well as have a feeling of greater sexual competence minor defect truly exists, the individual with BDD
those of virility and fertility, a process also [4], women do not necessarily believe that a has an inordinate degree of anguish.
recommended in the Kama Sutra [ 2]. Given the larger penis is 'better' . For instance, it was People with BDD frequently develop major
historical context it is perhaps no surprise that shown that 90% of women prefer a wide depressive episodes and are at risk of suicide.
even today many men place great importance penis to a long one [5,6]. The issue of They might also show violent behavior
on the size of their penis. Hegemonic attractiveness to women is complex, but most towards their treatment providers that can
masculinity is defined by attributes such as data suggest that penile size is much lower cause concern to clinical caregivers. In many
physical strength, heterosexuality with down the list of priorities for women than such cases, individuals with BDD have drastic social
authority over women and other men, issues as a man's personality and external and occupational dysfunctions that might
showing no emotions (such as remorse grooming. progress to the point of social isolation. There is
and uncertainty, which might suggest embarrassment and fear of being
vulnerability), economic independence, and an DEFINITIONS scrutinized or mocked, which often causes
ability to demonstrate sexual 'conquest'. While these individuals to avoid social situations
most men do not embody all of these qualities, The SPS is defined as an anxiety about the and intimate relationships. As victims of poor
society supports hegemonic masculinity genitals being observed, directly or indirectly self-image, these individuals typically do not
within most of its institutions [3]. (when clothed) because of concern that the show sufficient social skills and are frequently
flaccid penis length and/or girth is less than the single or divorced. People with BDD can
Given this historical and cultural background, it normal for an adult male, despite evidence from firmly believe that a marked change in their
is perhaps unsurprising that for many men a clinical examination to counter this perceived body defect is a prerequisite to their

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WYLIE and EARDLEY

TABLE 1 A summary of reports of measurements of penile size

Mean or range flaccid* Erect*

ages, stretched suprapubic

Studies N years Population length length circumference fat depth length circumference

54 20–25 Caucasian – 13.02 8.55 – – –

[13]
2770 20–59 – 9.7 – – – 15.5 –
[54]
156 – – – – – 16
[19] Mostly Caucasian 13.5 (bass)

[14] 80 54 White 67.5%, Black 8.85 12.5 9.7 (mid shaft) 2.85 12.89 12.3 (mid shaft)

20%, Asian 12.5%

184 – Straight 60% – – – – 15.71
[20] 13.2 (bass)
813 30.8 All gay 10.4 – – 16.4
[16] 9.8 (max) 12.6 (max)
3417 30.5 All heterosexual 9.8 – – 15.6
9.4 (max) 12.2 (max)
111 18–19 Powerful German man 8.6 – – – 14.48 –
[15]
32 40–68 German men with ED 9.22 – – – 14.18 –

3300 17–19 Italian man 9 12.5 – – –

[18] 10 (mid shaft)
20–22 Turkish men 6.8 8.98 – – 12.7 –
[21] two hundred

104 54 British men – – – – –

[22] 13 (median)
124 59 Before RP 9 13 2.5 – –
[17] 9.5 (mid shaft) 10
63 59 After RP 8 12.5 2 – –
(mid shaft) 8.5
123 21.7 Korean man 6.9 9.6 1.1 – –
[11] (mid shaft)

*mean values, in cm, unless stated otherwise. RP, radical prostatectomy.

happiness and well-being. As such, it can be a reported by Lee [10] and Son et al. [11], recorded inevitably reflects the different
manifestation of abnormal body image. although both studies had more men populations studied and differing techniques of
reporting small rather than large penises. measurement. Stretched penile length in these
This contrasts with most men, who are likely to Finally, the effect of the media might studies was typically 12–13 cm, with an erect
be satisfied with their erect (8%) and overall influence men, who give greater emphasis to length of 14–16 cm. For girth, there was again
penile size (71%) than with their flaccid size this trait, that women might want something remarkable consistency of results, with a mean
(51%). Further overall satisfaction with the different from reality, and that women might have girth of 9–10 cm for the flaccid penis and 12–13
genitals was linked to increased body satisfaction a different marketing target to that of men [12]. cm for the erect penis.
[8].
For penile length some general observations
are possible. First, the values for penile length
PREVALENCE NORMAL PENILE SIZE show some consistency, with the marked
exception of the Korean study [11]. Second,
Most men rated their penis as average (66%) Flaccid penile length is just under 4 cm at with a value of 9–10 cm, the flaccid length is
and only 22% as large and 12% as small, in birth and changes very little until puberty, usually 3–4 cm shorter than the stretched
a large Internet-based survey of 52,031 when there is marked growth. Schonfeld and penile length and 5–6 cm shorter than the
heterosexual men and women [9]. Self- Beebe [13] noted that the length of the erect length. Third, as suggested by the work of
reported penile size was positively correlated stretched penis approximated the length of Schonfeld and Beebe [13], there is a good
with height and negatively with body fat level. the erect penis, while the flaccid correlation between stretched penile length and
About 85% of women were satisfied with circumference was a poor indicator of erect erect length [14]. It is generally accepted that a
their partners' penis size, although only 55% of circumference. There is marked variation true micropenis is >2.5 SDs below the mean
men were satisfied, with 45% wanting to be within individuals, with heat and exercise, as length, and given the values shown in Table 1,
larger (and 0.2% to be smaller). Most well as anxiety, all contributing to the it was suggested that any penis with a stretched
women who reported their partners' penis as variation. length of <7 cm is a true micropenis [14].
small were not satisfied. Men reporting a
larger than average penis also rated their There have been several reports of
appearance most favorably. The authors measurements of penile size, which are There are several areas where further work is
noted that it might be the reverse; the men's summarized in Table 1 [11,13–22]. These needed. For instance, except for the Korean
more general body image influenced their studies measured various aspects of penile study, there is little evidence of racial
estimates of penis size [8]. Furthermore, self size, including flaccid length, stretched differences. This runs counter to many widely
esteem might influence their estimate of length, erect length, flaccid girth and erect held suppositions and needs further
penile size. These findings are similar to those girth. The variability of some of the values investigation. For the issue of age (in adults

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PENIS SIZE AND THE SMALL PENIS SYNDROME

men), while there appeared to be a trend This issue of perspective is of course relevant at all PSYCHIATRIC DISORDER
suggesting that men with a greater mean age had ages.
smaller penises than those in studies where the These include obsessive-compulsive disorder, social
mean age was lower, when this question was RELATIONSHIPS WITH OTHERS phobia, anxiety and depression. BDD is marked by
formally assessed there were no differences [15]. excessive preoccupation with an imaginary or minor
One study compared the values for penile length Fears and anxieties about penile size might also defect in a facial feature or localized part of the body.
in homosexual and heterosexual men [16]. That arise after the breakdown of a Borderline and narcissism personality types might
study was based on measurements made by Kinsey relationship, or after derogatory or malicious remarks be over represented. Narcissism is a pattern of
some decades earlier, and showed statistically made by a partner during sexual activities. The thinking and behaving in adolescence and
significant differences, with homosexuals having receptive partner might report that she or he cannot adulthood, which involves infatuation and
the greater length and girth. The authors feel the man 'inside' obsession with one's self to the exclusion of
suggested that this might reflect greater in utero during sexual intercourse. This might lead to poor
exposure to androgens, but again it is an area sexual self-confidence, with a tendency to feel others.
that needs further research. inadequate in vulnerable public situations,
and this in turn might prevent the man from SEXUAL DYSFUNCTION
establishing further (or any) intimate relationships.
Pelvic surgery, in the form of radical Under these circumstances, the anxiety This condition is often raised by patients with other
prostatectomy, has also been shown to result in is primarily related to the erect penis. There is a clinical conditions, such as ED or ejaculatory
penile shortening [17]. The explanation for this might suggestion that for those men who consider that they dysfunction, and less frequently in conditions such
be a direct consequence of the prostatectomy, but have a small penis, there is an insecurity effect [9], as sexual aversion.
an alternative hypothesis is that, with the onset of although the direction of causality remains unclear.
erectile dysfunction (ED) caused by the prostatectomy, General body image and self-esteem might influence OTHER FACTORS
there is a gradual loss of smooth muscle within the this further. The denigrating effects of other men
penis, with associated fibrosis and shrinking. might have a strong effect on further concern [24]. In men who are overweight, there are dual factors
of a perspective issue (the penis cannot be
This further raises the issue of whether men seen with the abdominal overhang) and with the
who have severe ED have smaller penises than age- presence of a significant suprapubic fat pad
matched potent men. Again, there are few data on DEVELOPMENTAL ISSUES causing the penis to be partially buried [18,26].
this issue. Concerns over levels of female sex hormones and
There is some evidence that for those men industry
with poorly developed and small testicles, the problem pollutants in water have been raised by the media.
AETIOLOGY might be accentuated, as there is no upward and
forward lift to the penis, and so the genital bulge is
EARLY OBSERVATIONS minimal. This has a secondary effect of less
evidence of a penis shape in men wearing tight jeans ASSESSMENT
The SPS or 'locker room syndrome' might have its or swimming attire. Genital confidence can be
origin in childhood, when the young boy observes impaired if there are small testicles, with the The clinician must determine whether the
the larger phallus of an elder sibling or a friend, or perception that the penis is small, when indeed it is main concern relates to flaccid or erect
even of his father. In one study, patients visiting an normal in size. Occasionally there might be a length, and whether girth is a significant concern.
andrology clinic complaining of a small history of congenital abnormality (eg hypospadias). The motivation (internal and external) and
penis were asked when they believed the problem Other impairments of neurological expectations of the consultation must be understood.
had started. Of these men, 62.7% said that their development have been proposed to A full medical, psychosexual and
concerns started in childhood, when they compared explain a variation in normal sensation in psychiatric history should be undertaken. Specific
their penis to that of their friends, while 37.3% said the genital area, with subsequent 'misreading' of themes that must be explored are around concerns
that their concerns began during their teenage any sensations perceived. about appearance, and body image (and
years, after seeing erotic images [23]. None of these specifically for BDD). General beliefs, values,
people had a penis of >2.5 SDs less than the mean. These include neurological impairment of tactile assumptions and behaviors around genitals and
stimulation and sensation in the sexuality should be inquired about. How does this
perineal area. An alternative theory suggests that affect the man? What is he unable to do in his
there might be dysfunction in one of the 'association
Often the first penis that a child sees is his father's, areas' within the parietal lobe that accumulates a life that bothers him? Can he use public toilets?
which will inevitably not only be larger, but which sensory store for 'perception'. Associated Does he socialize in the public house, where beer
will also look relatively larger from a child's more psychological contributions from the effect drinking would necessitate many visits to the toilet?
lowly perspective, especially if the father is of cognition and of disgust (possibly via the Actual paruresis (an inability to urinate in the
seen standing naked after a warm bath or during any amygdala) and of the cognition of parts belonging to presence, real or perceived, of others) might occur
state of arousal. When compared to the child's self (prefrontal cortex) are all possible contributory for many men (another presentation of social
penis, this observational perspective is compounded factors [25], as may that arising from anxiety) and might need specific treatment. Can he
by the child looking down at his own penis. envy. go swimming or participate in athletic sports?

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Does he avoid meeting a potential partner MIRROR WORK but evidence suggests that there is minimal physical
because he is afraid of the consequences of change. A recent study reported on 37 men with a
emotional intimacy? Most men will have a normal The patient is asked to look at himself stretched penis length of <10 cm who used the
sex drive but might not have a partner. undressed in front of a full-length mirror. By doing device for 20 min, three times a week. The mean
Has he avoided certain occupations? If the man so, he will observe the penis in the way that he penile stretched length increased from 7.6 cm
is in a relationship, try to see the man and partner would see other men. The penis looks longer and to 7.9 cm after 6 months of treatment, although this
together, and get the perspective from the partner. larger than when observed from above, looking change was not statistically significant. Interestingly,
down while standing upright. three men had an increase in their penile length of
This can be done at home when alone, or can be >1 cm, and nine were satisfied with the treatment
Psychological profile scores might be helpful to done with a clinician or therapist, with the patient [29].
assess self-confidence, self-esteem, quality of life, standing behind a curtain partition.
social anxiety and symptom distress, but should be This can be very useful for a man who avoids looking
limited to those clinicians at himself naked or has no access to a full-length Penile extenders have also been used as a
skilled in undertaking and interpreting such mirror at home [27]. means of stretching the penis, and devices are
inventories. available for use throughout the day. There are
PSYCHOLOGICAL THERAPIES several commercial devices available
A physical examination should involve an (including the Jes extender and Andropenis)
assessment of body habitus, detailed genital Psychotherapy is important for many men with although there are few data showing efficacy for any
examination (immediately after genital concerns about having a small penis. of them. A recent study of 31 men, with a mean
exposure, to prevent any changes due to Whether the penis is actually small or just baseline stretched penile length of 12 cm, showed
external temperature) with careful perceived to be small, cognitive behavioral therapy that with daily use of the Phallosan® extender
exclusion of genuine penile anomalies such (CBT) can be useful in building confidence system for ÿ3 h, by 3 months there was a mean
as hypospadias, epispadias and Peyronie's and counteracting negative thoughts. CBT stretched length of 13 cm with a further increase to
disease. The presence of a significant involves exploring the typical thinking patterns 13.8 cm by 6 months (P < 0.001) [30]. Changes
suprapubic fat pad should be noted. Careful experienced by the patient and ascertaining if some were also seen in penile diameter. There was a
measurements of flaccid of these can be ascribed as automatic, protective good correlation between the duration of use of
length, stretched length and flaccid girth are but also unhelpful and self-defeating. Substitution the
essential. If the erect size, particularly of girth, is an of alternative generated thoughts (alone or with the device and increase in length, and 80% of patients
issue then measurements after intracavernosal input of the therapist) and/or changes in ways of were happy with the outcome.
alprostadil are also helpful (or ask the patient for a responding (behaving) to such thoughts can bring
digital image of the erect penis). As endocrine about dramatic changes. An older study reported the use of a
abnormalities can cause true micropenis, a general stretching device (Penistretcher®) in nine men with
assessment of the secondary sexual characteristics Where the penis is on the lower side of normal a baseline stretched length of 12 cm.
is valuable. dimensions, the man can be provided with They reported that after using this device for ÿ6 h
suggestions on how to cope and accept these facts. per day over a 4-month period, the mean increase
CBT is also effective in BDD [28]. in stretched length was 1.8 cm [31].
MANAGEMENT AND TREATMENT OPTIONS Wherever possible, exploratory work with a partner Both these reports included few men and were
should be encouraged. Themes around self- only reported as abstracts. There are currently
NORMALIZE AND PROVIDE EDUCATION confidence, self-esteem, anger, fear of rejection no peer-reviewed publications related to the
and narcissism might emerge. Therapy in a use of these devices in men
It is important to avoid dismissing the facilitated group might help men to challenge each with SPS.
concerns raised by the man; to do so might other and their stated anxieties more effectively
further humiliate him and heighten his anxiety than in individual therapy, although equally Other devices that have been used in this
and concerns. It is helpful to normalize the there might be ongoing competitiveness to have group of patients includes 'Cock rings' and
situation, as it is a common concern among many the 'smallest penis' or greatest social impairment. penoscrotal rings. In one small report, there was a
men, and to give the man some reassurance about suggestion that they might help to augment
the condition penile size and maintain erections in men with
and his symptoms. As misinformation or lack of anxiety [32].
information is often apparent, it is important to PHYSICAL TREATMENTS
educate the patient about the normal variation in MEDICATIONS
penile size and how his penile dimensions relate These include the use of vacuum devices, penile
to the normal range. extenders and traction devices, and These might be indicated for use in men with SPS;
It is also important to educate the patient about penoscrotal and penile rings. Evidence on their the main group of drugs used are the selective
the relative importance placed on the size of the efficacy is very limited and it is important serotonin reuptake inhibitors (SSRIs).
penis by most other men and women, as well that the patient is aware of this. Fluoxetine has been shown to be effective in
as society and the media, and how he might Vacuum devices are ordinarily used as a treating BDDs [28] and is better than placebo in
selectively notice certain aspects of external treatment for ED but can also be used to both delusional and non-delusional
cues around the genitals in general . 'exercise' the penis. This can have both a patients. Buspirone is an anxiolytic that can be
psychological uplifting effect for the patient tried in extreme cases of anxiety. ANTI

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PENIS SIZE AND THE SMALL PENIS SYNDROME

TABLE 2 The reported results of penile lengthening procedures

follow up, Initial length, cm Length after surgery, cm Mean gain, cm

Studies N, type of patients Technical years (range or SD) (range) (range or SD) Comments
– –
[43] 19, MP + BDD Penile disassembly + 3.3 (mean) 3.6 (F) (2.6–4.7) 6.6 (F) (5.5–8.2)

cartilage insertion 8.3 (E) (6.2–10) 11.4 (E) (9–14)

DSL 1.5–2.5 –
[41] 18, MP + BDD 0.75 (ÿ3) 8.9 (E) 10.5 (E)
DSL – – – 35% satisfied
[42] 42, MP + BDD 1.3 (1.2)
DSL – 27% satisfied
[42] 27, BDD 11.5 (1.7) 1 (1.1)
DSL 2 –
[39] 11, BDD 9.12 (7–11.3) 10.75 (9.2–12.9) 1.65 (1–2.3)
DSL – – –
[44] 31, BDD 8.72 (6.5–10) 2.42 (1.5–4.8)
DSL 2.25 – –
[43] 15, BDD 3.45 (2.1–4.5)

DSL, division of the suspensory ligament; MP, micropenis; (E), erect; (F), flaccid.

psychotic medication can be used to treat However, the results of surgery are poorly Division of the suspensory ligament is the
delusional BDD but there is little evidence documented and significant complications can procedure that has been most commonly
of efficacy beyond the treatment of the ensue. Accordingly, it is recommended that any described for flaccid penile lengthening [39–
psychosis per se. A typical course of surgical procedure should only be used after a 44]; it allows the corpora cavernosa to be partially
treatment might be 8 weeks on an SSRI and/or careful preoperative assessment, which separated from the pubis, thereby increasing the
adjunctive treatments such as buspirone or pimozide should include a thorough psychological apparent flaccid length of the penis. Some form
(a rarely used antipsychotic agent) assessment as outlined above. Furthermore, of adjustment of the suprapubic skin is needed
[33]. Testosterone therapy is only of value in men careful advice on the potential results of surgery (usually a VY advancement flap or a Z-plasty),
with micropenis [34] and is not considered and the potential complications that might ensue and it is sometimes helpful to place a 'spacer'
further here. is essential. Indeed, the 2nd International between the pubis and the corporal bodies to prevent
Consultation on Sexual Dysfunctions concluded re-scarring at the site of the divided suspensory
SELF-HELP SOURCES that 'most men will not wish ligament. At best, the proponents of this
technique suggest a 2-cm increase in flaccid length
Inevitably, many men, rather than seek formal to proceed to surgery when properly (Table 2) [39,41–44]. Potential problems include the
medical help, prefer to use other sources of informed of the likely outcome and risks of inevitability that the erect penis will tend to point
information, but might then seek medical advice. complications' [35]. The ethical issues of offering downwards when the man is upright, rather than
The Internet is a rich resource of such surgery to men with a normal sized penis standing 'erect' and perpendicular to the body.
sources offering to help men 'increase their (which is usually the case [36]) are reviewed by Specific complications include re-scarring of the
manhood'. Inevitably, there are no efficacy data Vardi [37], especially as this appears to be increasing infrapubic region, with the consequence that there
relating to most of these treatments (especially in the private sector rather than research or university might be no increase in length and in some
the many pills and lotions available). settings [ 38]. cases there might even be penile shortening. A
Common sense advice can be found by some surgical approach to prevent this complication was
retailers, including 'bulge underpants' and swim reported recently [45].
shorts, body and genital hair trimming or If, after such an approach, the man wishes to
shaving, the use of 'hot towels and wraps' and consider surgery, then several surgical options are
'jelqing'. The last is an ancient Arab technique available. Some surgical approaches will potentially Finally, the advancement skin flaps, when
whereby the hand pulls on the penis causing increase the flaccid length of the penis (eg division healed, might be unsightly and might result in the
stretching (and effectively self-focus work of the suspensory ligament of the penis), while disfiguring advancement of suprapubic hairy skin
encouraging psychological acceptance of the others have been reported to increase both flaccid onto the shaft of the penis [14]. It is relevant that in
penis, which will change in size and shape during and erect length. one series, of men with BDD who had this surgery,
the process) and is recommended on many Similarly, some approaches offer an increase in despite a mean increase in length of 1 cm, only 27%
websites. Some websites advocate that 'small erect girth only, while others offer an increase were satisfied and 54% requested further surgery.
in both erect and flaccid girth.
is beautiful' and that the smaller penis can be
celebrated by both the man and his partner. Either liposuction or suprapubic lipectomy is The so-called 'Perovic procedure' involves penile
potentially valuable in men with a significant disassembly, with dissection of the glans penis
SURGICAL TREATMENT suprapubic fat pad, thereby making a partially off the corpora cavernosa in continuity with the
buried penis appear more prominent. Other than dorsal neurovascular bundle and the urethra
This would appear to be an attractive option for bruising, there are few complications with such [46]. A piece of costal cartilage is then sutured onto
many men with SPS, and indeed, for those who an approach, and the cosmetic results are the distal corpora before the glans is replaced
research the Internet there is no shortage of sites reasonable. However, there are few reported results over the cartilage. This procedure should result in an
encouraging such an approach. for this approach [39].

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