Integrating Transwomen and Female Athletes with Differences of Sex Development (DSD) into Elite Competition: The FIMS 2021 Consensus Statement

Blair R Hamilton^{1

2}, Giscard Lima^{3

4}, James Barrett², Leighton Seal², Alexander Kolliari-Turner¹, Guan Wang⁵, Antonia Karanikolou¹, Xavier Bigard^{6

7

8}, Herbert Löllgen⁷, Petra Zupet⁷, Anca Ionescu⁷, Andre Debruyne^{7

8}, Nigel Jones^{9

10}, Karin Vonbank¹¹, Federica Fagnani⁴, Chiara Fossati^{4

12}, Maurizio Casasco^{7

8

13}, Demitri Constantinou^{8

14}, Bernd Wolfarth^{8

15}, David Niederseer¹⁶, Andrew Bosch¹⁷, Borja Muniz-Pardos¹⁸, José Antonio Casajus¹⁸, Christian Schneider^{8

19}, Sigmund Loland²⁰, Michele Verroken^{21

22}, Pedro Manonelles Marqueta^{8

23}, Francisco Arroyo^{8

24}, André Pedrinelli^{8

25}, Konstantinos Natsis^{7

8

26

27}, Evert Verhagen²⁸, William O Roberts^{8

29}, José Kawazoe Lazzoli^{8

30}, Rogerio Friedman³¹, Ali Erdogan^{8

32}, Ana V Cintron^{8

33}, Shu-Hang Patrick Yung^{8

34}, Dina C Janse van Rensburg³⁵, Dimakatso A Ramagole³⁵, Sandra Rozenstoka^{7

8

36}, Felix Drummond^{7

8

37}, Theodora Papadopoulou^{7

8

38}, Paulette Y O Kumi³⁹, Richard Twycross-Lewis⁴⁰, Joanna Harper⁴¹, Vasileios Skiadas⁴², Jonathan Shurlock⁴³, Kumpei Tanisawa⁴⁴, Jane Seto^{45

46}, Kathryn North^{45

46}, Siddhartha S Angadi⁴⁷, Maria Jose Martinez-Patiño⁴⁸, Mats Borjesson^{8

49

50}, Luigi Di Luigi^{8

51}, Michiko Dohi^{8

52}, Jeroen Swart^{8

53}, James Lee John Bilzon^{8

54}, Victoriya Badtieva^{8

55

56}, Irina Zelenkova¹⁸, Juergen M Steinacker^{7

8

57}, Norbert Bachl^{7

8

58

59}, Fabio Pigozzi^{4

7

8

12}, Michael Geistlinger^{8

60}, Dimitrios G Goulis⁶¹, Fergus Guppy^{1

62}, Nick Webborn⁶³, Bulent O Yildiz⁶⁴, Mike Miller⁶⁵, Patrick Singleton⁶⁵, Yannis P Pitsiladis^{66

67

68

69

70}

Affiliations

¹ Centre for Stress and Age-Related Disease, University of Brighton, Brighton, UK.
² The Gender Identity Clinic Tavistock and Portman NHS Foundation Trust, London, UK.
³ Centre for Exercise Sciences and Sports Medicine, FIMS Collaborating Centre of Sports Medicine, Rome, Italy.
⁴ Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy.
⁵ Sport and Exercise Science and Sports Medicine Research and Enterprise Group, University of Brighton, Brighton, UK.
⁶ Union Cycliste Internationale (UCI), Aigle, Switzerland.
⁷ European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland.
⁸ International Federation of Sports Medicine (FIMS), Lausanne, Switzerland.
⁹ British Association Sport and Exercise Medicine, Doncaster, UK.
¹⁰ British Cycling and University of Liverpool, Liverpool, UK.
¹¹ Department of Pneumology, Pulmonary Function Laboratory, Medicine Clinic (KIMII), University of Vienna, Vienna, Austria.
¹² Villa Stuart Sport Clinic, FIFA Medical Center of Excellence, Rome, Italy.
¹³ Italian Federation of Sports Medicine (FMSI), Rome, Italy.
¹⁴ Centre for Exercise Science and Sports Medicine, University of the Witwatersrand, Johannesburg, South Africa.
¹⁵ Department of Sports Medicine, Humboldt University and Charité University School of Medicine, Berlin, Germany.
¹⁶ Department of Cardiology, University Hospital Zurich, University Heart Centre, University of Zurich, Zurich, Switzerland.
¹⁷ Division of Exercise Science and Sports Medicine, University of Cape Town, Cape Town, South Africa.
¹⁸ GENUD Research Group, FIMS Collaborating Center of Sports Medicine, Department of Physiatry and Nursing, University of Zaragoza, Zaragoza, Spain.
¹⁹ Orthopaedic Center Theresie, Munich, Germany.
²⁰ Department of Sport and Social Sciences, Norwegian School of Sport Sciences, Oslo, Norway.
²¹ Centre of Research and Innovation for Sport, Technology and Law (CRISTAL), De Montfort University, Leicester, UK.
²² Sporting Integrity Ltd, Stoke Mandeville, UK.
²³ Department of Sports Medicine, San Antonio Catholic University of Murcia, Murcia, Spain.
²⁴ FIMS Collaborating Center of Sports Medicine, Guadalajara, Mexico.
²⁵ Department of Orthopaedics, University of São Paulo Medical School, São Paulo, Brazil.
²⁶ Interbalkan Medical Center, FIMS Collaborating Center of Sports Medicine, Thessaloniki, Greece.
²⁷ Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
²⁸ Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands.
²⁹ Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, USA.
³⁰ Biomedical Institute, Fluminense Federal University Medical School, Niterói, Brazil.
³¹ Universidade Federal do Rio Grande do Sul, Endocrine Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil.
³² Gloria Sports Arena, FIMS Collaborating Centre of Sports Medicine, Antalya, Turkey.
³³ Puerto Rico Sports Medicine Federation, San Juan, Puerto Rico.
³⁴ Asian Federation of Sports Medicine (AFSM), Hong Kong Center of Sports Medicine and Sports Science, Hong Kong, China.
³⁵ Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
³⁶ FIMS Collaboration Centre of Sports Medicine, Sports laboratory, Riga, Latvia.
³⁷ FIMS Collaboration Centre of Sports Medicine, Instituto de Medicina do Esporte, Porto Alegre, Brazil.
³⁸ Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK.
³⁹ Centre for Sports and Exercise Medicine, Queen Mary University of London, London, UK.
⁴⁰ School of Engineering and Materials Science, Queen Mary University of London, London, UK.
⁴¹ School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.
⁴² University Hospital Southampton, Southampton, UK.
⁴³ Brighton and Sussex University Hospitals, Brighton, UK.
⁴⁴ Faculty of Sport Sciences, Waseda University, Tokorozawa, Japan.
⁴⁵ Murdoch Children's Research Institute, Melbourne, VIC, Australia.
⁴⁶ Department of Paediatrics, University of Melbourne, The Royal Children's Hospital, Melbourne, VIC, Australia.
⁴⁷ Department of Kinesiology, School of Education and Human Development, University of Virginia, Charlottesville, VA, USA.
⁴⁸ Faculty of Educational Sciences and Sports, University of Vigo, Galicia, Spain.
⁴⁹ Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Center for Health and Performance, Goteborg University, Göteborg, Sweden.
⁵⁰ Sahlgrenska University Hospital/Ostra, Region of Western Sweden, Göteborg, Sweden.
⁵¹ Unit of Endocrinology, Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy.
⁵² Sport Medical Center, Japan Institute of Sports Sciences, Tokyo, Japan.
⁵³ UCT Research Unit for Exercise Science and Sports Medicine, Cape Town, South Africa.
⁵⁴ Department for Health, University of Bath, Bath, UK.
⁵⁵ I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia, Moscow, Russian Federation.
⁵⁶ Moscow Research and Practical Center for Medical Rehabilitation, Restorative and Sports Medicine, Moscow Healthcare Department, Moscow, Russian Federation.
⁵⁷ Division of Sports and Rehabilitation Medicine, Ulm University Hospital, Ulm, Germany.
⁵⁸ Institute of Sports Science, University of Vienna, Vienna, Austria.
⁵⁹ Austrian Institute of Sports Medicine, Vienna, Austria.
⁶⁰ Unit of International Law, Department of Constitutional, International and European Law, University of Salzburg, Salzburg, Salzburg, Austria.
⁶¹ Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
⁶² School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK.
⁶³ School of Sport and Service Management, University of Brighton, Eastbourne, UK.
⁶⁴ Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, 06100, Ankara, Turkey.
⁶⁵ World Olympian Association, Lausanne, Switzerland.
⁶⁶ Centre for Exercise Sciences and Sports Medicine, FIMS Collaborating Centre of Sports Medicine, Rome, Italy. Y.Pitsiladis@brighton.ac.uk.
⁶⁷ Centre for Stress and Age-Related Disease, University of Brighton, Brighton, UK. Y.Pitsiladis@brighton.ac.uk.
⁶⁸ Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy. Y.Pitsiladis@brighton.ac.uk.
⁶⁹ European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland. Y.Pitsiladis@brighton.ac.uk.
⁷⁰ International Federation of Sports Medicine (FIMS), Lausanne, Switzerland. Y.Pitsiladis@brighton.ac.uk.

PMID: 33761127
PMCID: PMC7988249
DOI: 10.1007/s40279-021-01451-8

Review

Integrating Transwomen and Female Athletes with Differences of Sex Development (DSD) into Elite Competition: The FIMS 2021 Consensus Statement

Blair R Hamilton et al. Sports Med. 2021 Jul.

. 2021 Jul;51(7):1401-1415.

doi: 10.1007/s40279-021-01451-8. Epub 2021 Mar 24.

Authors

Affiliations

¹ Centre for Stress and Age-Related Disease, University of Brighton, Brighton, UK.
² The Gender Identity Clinic Tavistock and Portman NHS Foundation Trust, London, UK.
³ Centre for Exercise Sciences and Sports Medicine, FIMS Collaborating Centre of Sports Medicine, Rome, Italy.
⁴ Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy.
⁵ Sport and Exercise Science and Sports Medicine Research and Enterprise Group, University of Brighton, Brighton, UK.
⁶ Union Cycliste Internationale (UCI), Aigle, Switzerland.
⁷ European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland.
⁸ International Federation of Sports Medicine (FIMS), Lausanne, Switzerland.
⁹ British Association Sport and Exercise Medicine, Doncaster, UK.
¹⁰ British Cycling and University of Liverpool, Liverpool, UK.
¹¹ Department of Pneumology, Pulmonary Function Laboratory, Medicine Clinic (KIMII), University of Vienna, Vienna, Austria.
¹² Villa Stuart Sport Clinic, FIFA Medical Center of Excellence, Rome, Italy.
¹³ Italian Federation of Sports Medicine (FMSI), Rome, Italy.
¹⁴ Centre for Exercise Science and Sports Medicine, University of the Witwatersrand, Johannesburg, South Africa.
¹⁵ Department of Sports Medicine, Humboldt University and Charité University School of Medicine, Berlin, Germany.
¹⁶ Department of Cardiology, University Hospital Zurich, University Heart Centre, University of Zurich, Zurich, Switzerland.
¹⁷ Division of Exercise Science and Sports Medicine, University of Cape Town, Cape Town, South Africa.
¹⁸ GENUD Research Group, FIMS Collaborating Center of Sports Medicine, Department of Physiatry and Nursing, University of Zaragoza, Zaragoza, Spain.
¹⁹ Orthopaedic Center Theresie, Munich, Germany.
²⁰ Department of Sport and Social Sciences, Norwegian School of Sport Sciences, Oslo, Norway.
²¹ Centre of Research and Innovation for Sport, Technology and Law (CRISTAL), De Montfort University, Leicester, UK.
²² Sporting Integrity Ltd, Stoke Mandeville, UK.
²³ Department of Sports Medicine, San Antonio Catholic University of Murcia, Murcia, Spain.
²⁴ FIMS Collaborating Center of Sports Medicine, Guadalajara, Mexico.
²⁵ Department of Orthopaedics, University of São Paulo Medical School, São Paulo, Brazil.
²⁶ Interbalkan Medical Center, FIMS Collaborating Center of Sports Medicine, Thessaloniki, Greece.
²⁷ Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
²⁸ Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands.
²⁹ Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, USA.
³⁰ Biomedical Institute, Fluminense Federal University Medical School, Niterói, Brazil.
³¹ Universidade Federal do Rio Grande do Sul, Endocrine Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil.
³² Gloria Sports Arena, FIMS Collaborating Centre of Sports Medicine, Antalya, Turkey.
³³ Puerto Rico Sports Medicine Federation, San Juan, Puerto Rico.
³⁴ Asian Federation of Sports Medicine (AFSM), Hong Kong Center of Sports Medicine and Sports Science, Hong Kong, China.
³⁵ Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
³⁶ FIMS Collaboration Centre of Sports Medicine, Sports laboratory, Riga, Latvia.
³⁷ FIMS Collaboration Centre of Sports Medicine, Instituto de Medicina do Esporte, Porto Alegre, Brazil.
³⁸ Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK.
³⁹ Centre for Sports and Exercise Medicine, Queen Mary University of London, London, UK.
⁴⁰ School of Engineering and Materials Science, Queen Mary University of London, London, UK.
⁴¹ School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.
⁴² University Hospital Southampton, Southampton, UK.
⁴³ Brighton and Sussex University Hospitals, Brighton, UK.
⁴⁴ Faculty of Sport Sciences, Waseda University, Tokorozawa, Japan.
⁴⁵ Murdoch Children's Research Institute, Melbourne, VIC, Australia.
⁴⁶ Department of Paediatrics, University of Melbourne, The Royal Children's Hospital, Melbourne, VIC, Australia.
⁴⁷ Department of Kinesiology, School of Education and Human Development, University of Virginia, Charlottesville, VA, USA.
⁴⁸ Faculty of Educational Sciences and Sports, University of Vigo, Galicia, Spain.
⁴⁹ Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Center for Health and Performance, Goteborg University, Göteborg, Sweden.
⁵⁰ Sahlgrenska University Hospital/Ostra, Region of Western Sweden, Göteborg, Sweden.
⁵¹ Unit of Endocrinology, Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy.
⁵² Sport Medical Center, Japan Institute of Sports Sciences, Tokyo, Japan.
⁵³ UCT Research Unit for Exercise Science and Sports Medicine, Cape Town, South Africa.
⁵⁴ Department for Health, University of Bath, Bath, UK.
⁵⁵ I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia, Moscow, Russian Federation.
⁵⁶ Moscow Research and Practical Center for Medical Rehabilitation, Restorative and Sports Medicine, Moscow Healthcare Department, Moscow, Russian Federation.
⁵⁷ Division of Sports and Rehabilitation Medicine, Ulm University Hospital, Ulm, Germany.
⁵⁸ Institute of Sports Science, University of Vienna, Vienna, Austria.
⁵⁹ Austrian Institute of Sports Medicine, Vienna, Austria.
⁶⁰ Unit of International Law, Department of Constitutional, International and European Law, University of Salzburg, Salzburg, Salzburg, Austria.
⁶¹ Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
⁶² School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK.
⁶³ School of Sport and Service Management, University of Brighton, Eastbourne, UK.
⁶⁴ Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, 06100, Ankara, Turkey.
⁶⁵ World Olympian Association, Lausanne, Switzerland.
⁶⁶ Centre for Exercise Sciences and Sports Medicine, FIMS Collaborating Centre of Sports Medicine, Rome, Italy. Y.Pitsiladis@brighton.ac.uk.
⁶⁷ Centre for Stress and Age-Related Disease, University of Brighton, Brighton, UK. Y.Pitsiladis@brighton.ac.uk.
⁶⁸ Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy. Y.Pitsiladis@brighton.ac.uk.
⁶⁹ European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland. Y.Pitsiladis@brighton.ac.uk.
⁷⁰ International Federation of Sports Medicine (FIMS), Lausanne, Switzerland. Y.Pitsiladis@brighton.ac.uk.

PMID: 33761127
PMCID: PMC7988249
DOI: 10.1007/s40279-021-01451-8

Erratum in

Correction to: Integrating Transwomen and Female Athletes with Differences of Sex Development (DSD) into Elite Competition: The FIMS 2021 Consensus Statement.
Hamilton BR, Lima G, Barrett J, Seal L, Kolliari-Turner A, Wang G, Karanikolou A, Bigard X, Löllgen H, Zupet P, Ionescu A, Debruyne A, Jones N, Vonbank K, Fagnani F, Fossati C, Casasco M, Constantinou D, Wolfarth B, Niederseer D, Bosch A, Muniz-Pardos B, Casajus JA, Schneider C, Loland S, Verroken M, Marqueta PM, Arroyo F, Pedrinelli A, Natsis K, Verhagen E, Roberts WO, Lazzoli JK, Friedman R, Erdogan A, Cintron AV, Yung SP, Janse van Rensburg DC, Ramagole DA, Rozenstoka S, Drummond F, Papadopoulou T, Kumi PYO, Twycross-Lewis R, Harper J, Skiadas V, Shurlock J, Tanisawa K, Seto J, North K, Angadi SS, Martinez-Patiño MJ, Borjesson M, Di Luigi L, Dohi M, Swart J, Bilzon JLJ, Badtieva V, Zelenkova I, Steinacker JM, Bachl N, Pigozzi F, Geistlinger M, Goulis DG, Guppy F, Webborn N, Yildiz BO, Miller M, Singleton P, Pitsiladis YP. Hamilton BR, et al. Sports Med. 2021 Jul;51(7):1417-1418. doi: 10.1007/s40279-021-01467-0. Sports Med. 2021. PMID: 33835352 Free PMC article. No abstract available.

Abstract

Sport is historically designated by the binary categorization of male and female that conflicts with modern society. Sport's governing bodies should consider reviewing rules determining the eligibility of athletes in the female category as there may be lasting advantages of previously high testosterone concentrations for transwomen athletes and currently high testosterone concentrations in differences in sex development (DSD) athletes. The use of serum testosterone concentrations to regulate the inclusion of such athletes into the elite female category is currently the objective biomarker that is supported by most available scientific literature, but it has limitations due to the lack of sports performance data before, during or after testosterone suppression. Innovative research studies are needed to identify other biomarkers of testosterone sensitivity/responsiveness, including molecular tools to determine the functional status of androgen receptors. The scientific community also needs to conduct longitudinal studies with specific control groups to generate the biological and sports performance data for individual sports to inform the fair inclusion or exclusion of these athletes. Eligibility of each athlete to a sport-specific policy needs to be based on peer-reviewed scientific evidence made available to policymakers from all scientific communities. However, even the most evidence-based regulations are unlikely to eliminate all differences in performance between cisgender women with and without DSD and transwomen athletes. Any remaining advantage held by transwomen or DSD women could be considered as part of the athlete's unique makeup.

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Conflict of interest statement

Blair Hamilton, Gicard Lima, James Barrett, Leighton Seal, Alexander Kolliari-Turner, Guan Wang, Antonia Karanikolou, Xavier Bigard, Herbert Lollgen, Petra Zupet, Anca Ionescu, Andre Debruyne, Nigel Jones, Karin Vonbank, Federica Fagnani, Chiara Fossati, Maurizio Casasco, Demitri Constantinou, Bernd Wolfarth, David Niederseer, Andrew Bosch, Borja Muniz, Jose Casajus, Christian Schneider, Sigmund Loland, Michele Verroken, Pedro Manonelles Marqueta, Francisco Arroyo, André Pedrinelli, Kostas Natsis, Evert Verhagen, William Roberts, José Kawazoe Lazzoli, Rogerio Friedman, Ali Erdoğan, Ana Cintron, Patrick Yung, Christa Janse van Rensburg, Dimakatso Ramagole, Sandra Rozenstoka, Felix Drummond, Theodora Papadopoulou, Paulette Kumi, Richard Twycross-Lewis, Joanna Harper, Vasileios Skiadas, Jonathan Shurlock, Kumpei Tanisawa, Jane Seto, Kathryn North, Siddhartha Angadi, Maria Patino, Mats Borjesson, Luigi Di Luigi, Michiko Dohi, Jeroen Swart, James Bilzon, Victoriya Badtieva, Irina Zelenkova, Juergen Steinacker, Norbert Bachl, Fabio Pigozzi, Michael Geistlinger, Dimitrios Goulis, Fergus Guppy, Nick Webborn, Bulent Yildiz, Mike Miller, Patrick Singleton and Yannis Pitsiladis declare that they have no conflicts of interest relevant to the content of this review.

References

1. Archives TN. Equality Act 2010. http://www.legislation.gov.uk/ukpga/2010/15/section/195. Accessed 4 Mar 2020.
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1. Harper J, Lima G, Kolliari-Turner A, Malinsky FR, Wang G, Martinez-Patino MJ, et al. The fluidity of gender and implications for the biology of inclusion for transgender and intersex athletes. Curr Sports Med Rep. 2018;17(12):467–472. doi: 10.1249/JSR.0000000000000543. - DOI - PubMed
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Integrating Transwomen and Female Athletes with Differences of Sex Development (DSD) into Elite Competition: The FIMS 2021 Consensus Statement

Affiliations

Integrating Transwomen and Female Athletes with Differences of Sex Development (DSD) into Elite Competition: The FIMS 2021 Consensus Statement

Authors

Affiliations

Erratum in

Abstract

Conflict of interest statement

References

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Substances

LinkOut - more resources

Full Text Sources

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