Perceived Stigma and Post Traumatic Stress Disorder in Women Victims of Sex Trafficking: Mediating Role of Coping
10 Mar, 2020
19 May, 2022
30 Sep, 2023
The present research examined the relationship between stigma, coping, and post-traumatic stress while looking for the mediating role of coping. Correlation strategy with purposive and snowball sampling was used in the present study to recruit the sample (N = 217), with the age range of 18-40 years (M = 25.11, SD = 6.37) of women victims of trafficking. These participants were approached by visiting the Dar-ul-Aman of 8 districts of the Punjab including the cities of Lahore, Layyah, Muzaffargarh, Multan, Gujranwala, Kasur, Patoki, Bhakkar, Okara and Jehlum as well as from Non-Government Organizations of Lahore City. Socio-demographic sheet, Measure of Stigma, Responses to Stress Questionnaire, Post-traumatic Diagnostic Scale for the DSM-5 and Big five Inventory-K were used to study variables. The results depict those victims who perceive high stigma make less use of primary control strategies of coping such as problem solving, emotional regulation, and emotional expression. Moreover, when they perceive high stigma they are more likely to use involuntary disengagement strategies such as emotional numbing, cognitive interference, inaction and escape to while being facing the stress of sex trafficking. Primary and secondary control strategies have significant negative relationship with symptoms of post-traumatic stress disorder. Mediation analysis revealed that disengagement coping strategy partially mediated the relationship between stigma and post-traumatic stress. The results were discussed in the light of previous literature and cultural context.
Human trafficking has taken many forms in the history however, at present it has been termed as modern-day slavery. People migrate to other cities and countries to find better job, house and an overall better living. Many of them get successful while others get trapped by traffickers (United Nations-Secretary-Council, 2016). Trafficking has been defined in a variety of ways in the past and was being confused with smuggling (Mixed Migration Centre, 2018). However the most comprehensive definition is provided by the trafficking in persons protocol (United Nations Human Rights Office of High Commission 2014):
“Trafficking in persons” shall mean the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs (Article 3, a).
All three elements of the trafficking must be established when it’s related to adult cases of the victims however, illegal means are not relevant in case of child trafficking. Exploitative practices that can be used in the process of trafficking ranging from forced labor to sexual exploitation for prostitution or other forms of sexual exploitation (International Organization for Migration, 2018; Touzenis, 2010; United Nations Office on Drugs & Crime, 2018).
The present study focuses specifically on women victims of sex trafficking. Sexual exploitation is the most unacceptable morally as more social stigma is attached to this activity as compared to other forms of exploitation. Due to the stigma associated with sexual exploitation being an illegal activity in many countries for example China, Croatia, Egypt, Iran, Iraq, South Korea and South Africa it is very difficult to gain their cooperation and reintegrate them in the society (Eleni, 2011; Surtees, 2017; U.S. Department of States, 2018). Impact of stigma is also highly debated in victims of human trafficking (Gallagher & Skrivankova, 2015). International Organization for Migration (2018) in its report presents victims of trafficking face high level of stigma not only because of seeking help but also due to the fear of being caught as illegal migrants so they generally conceal their identity as irregular migrants and remain hidden population. Even when these victims or migrants return to their home countries they are often being stigmatized or discriminated by their families, relatives, acquaintances and service providers. After disclosing their experience of sexual violence rape victims face negative responses from the society that are again contributions of cultural attitudes.
These negative responses may include feelings of disbelief, blaming to the victim, stigmatization, distraction responses, egocentric reactions and controlling responses (World Health Organization, 2007). The survivors may be blamed for their incident of victimization. If some of them enter into prostitution they are blamed as if they have chosen for this situation (Murray & Crowe, 2014). It is often assumed that stigmatized individuals suffer through long term physiological (Clark et al., 1999) and psychological consequences such as ego defenses, low self-esteem, external locus of control and depression (Crocker & Major, 1989; Pasmatzi, et al., 2016). Sexual and physical trauma is linked with the psychological consequences of sex trafficking in women. The trafficking experience is unique mental health outcome (Cary et al., 2016).
High rates of anxiety, post-traumatic stress disorder (PTSD), depression, suicidal ideation, and suicide attempts are reported in women who are subject to sex trafficking (Zimmerman et al., 2003). The most common psychological problems faced by trafficking victims are depression, anxiety, post-traumatic stress disorder (PTSD), and self-harm and attempted suicide who contacted post-trafficking services (Kiss, et, al., 2015; Ottisova et al., 2016). It is evident that victims experience psychological disorders including trauma related symptoms, PTSD and psychological distress. However, poor mental health may increase the vulnerability to trafficking due to many factors such as ability of decision making and high dependency on others.
An individual’s responses to stress determine his or her overall health. As there is scarcity of research on coping strategies of human trafficking (Okech et al., 2018), literature of rape and sexual assault victims can provide understanding of coping strategies and their psychological effects (i.e. depression, anxiety, and PTSD). Burgess and Holmstrom (1979) examined coping behavior in rape victims first time in the literature. They asserted that women who actively engage in utilizing coping strategies recover quickly from the distress caused by sexual victimization. The present study has incorporated the model of stress coping which includes voluntary and involuntary coping strategies (Compas et al., 2001; Connor-Smith et al., 2000).
Voluntary efforts of coping are discerned in primary and secondary control coping. Primary control includes coping effort that influence objective events or conditions to gain a sense of personal control as well as one’s reactions. Primary control techniques are problem solving and regulation of emotions or even regulating expression of emotions (Miller, & Myers, 1998). Secondary control coping is comprised of adaptation to the situation. It is comprised of distraction, acceptance, positive thinking and cognitive restructuring. It mainly includes changing the feelings about the stressful events (Miller & Kaiser, 2001). Involuntary engagement includes physiological arousal, emotional arousal, rumination, intrusive thoughts and impulsive action; on the other hand, involuntary disengagement includes avoidance that screen out the stigma related stress even at ore-attention level and prevents the undue distress that a stigma related person may face (Mogg et al., 1994). The literature has provided the understanding on the use of maladaptive coping strategies by sexual assault victims’ health (Varni et al., 2012). The studies have also found the mediating role of coping strategies for symptom severity and perception in rape victims characterizing the concealable stigma (Wong, 2012). This literature provides the basis of links between stigma, coping and symptomology of post-traumatic stress. Trafficking has become international issue which is not only a matter of law it impacts at individual level must also be addressed. The understanding of stigma, coping and post-traumatic stress symptomology sets the stage for the present study.
Pakistan has been regarded as source, transit and destination country for the victims of human trafficking. Just like victims in all over the world, victims in Pakistan also suffer from adverse physical and psychological effects on their health. They all face this and have to remain in deplorable conditions due to lack of resources (Khowaja et al., 2012). There has been an increasing rate of women trafficking in Pakistan and according to a recent report there have been 14571 cases of trafficking reported from Pakistan. However, it seemed to be under reporting of the victims and U.S Department claims that only Punjab province provide the consistent reporting of the (U.S. Department of States, 2018). The present study aimed at investigating the relationship between stigma, coping strategies and post-traumatic stress symptomology. Another objective was to find out the mediating role of coping strategies between stigma and post-traumatic stress symptomology in women victims of sex trafficking.
- There is likely to be negative relationship between stigma, primary and secondary control coping and post-traumatic stress symptomology.
- There is likely to be a positive relationship between stigma, disengagement coping, involuntary engagement and involuntary disengagement coping.
- Coping strategies are likely to mediate the relationship between stigma and post-traumatic stress symptomology.
The present study was conducted on women victims (N = 217) of sex trafficking with age range between 18-40 years (M = 25.11 &
SD = 6.367) as most studies show that women and girls are trafficked in this age (Levine, 2017). The sample size was calculated through
G-power. The present study utilizes both purposive and snowball sampling to select the participants as these women belong to hidden population. These participants were approached by visiting the Dar-ul-Aman of eight districts of the Punjab including the cities of Lahore, Layyah, Muzaffargarh, Multan, Gujranwala, Kasur, Patoki, Bhakkar, Okara and Jehlum as well as from Non-Government Organizations of Lahore City. Majority of the participants were Muslims (96%). Among 217 participants, 149 (69%) of participants are reported as sex workers by profession; 44 (21%) of them are not working; others 24 (11%) are maid and work in parlor. Among 217 participants 152 (70%) were trafficked for one time, 47 (22%) trafficked twice and 18 (8%) trafficked thrice. Among total sample 67 (31%) participants were sold/smuggled by family, 59 (27%) were ran away others include debt bondage, sold by relative, for job/work, sold by neighbor and others.
- Women victims who have been trafficked for internal and international borders.
- Those victims who could understand and speak Urdu, English and Punjabi language.
- Women who have not been integrated in their families after being trafficked.
- Women victims who have been under trafficking condition or in the prison.
- Women who did not identified themselves as victims and did not report psychological distress or symptoms of PTSD.
It was constructed by the researcher and demographic characteristics as well as the questions related to history of trafficking, physical injuries and illnesses due to trafficking were also asked. Reaction of parents, siblings and friends towards trafficking of participants were also inquired.
Measure of Stigma
It was used in the present research to measure stigma (Gibson & Leitenberg, 2001) in the participants. This measure was included as a part of in the measures of stigma, betrayal, and powerlessness developed by the authors. It includes 9 items with a 5 point Likert scale where 1 = not at all, 2 = A little/occasionally, 3 = neutral, 4 = often, and 5 = very much. The recent study showed the internal consistency for self-stigma (α = .83), public stigma (α = .86) showing it to be highly reliable and for a total scale of .93 showing it to be highly reliable.
Responses to Stress Questionnaire (RSQ)
Responses to Stress Questionnaire ([RSQ] Connor-Smith et al., 2000)employed in the present research to identify the responses to cope with the stress of trafficking. It includes two major responses to stress such as voluntary or controlled coping responses and involuntary or automatic reactions. The voluntary responses include engagement and disengagement coping where engagement coping is further divided into primary and secondary control. Two major involuntary coping responses include involuntary engagement and involuntary disengagement. To measure these five factors of responses to stress RSQ includes 57 items compressed into 19 subscales including 3 items in each scale. The internal consistency for the present study was found to be PCEC’s Problem solving (α = .90), Emotional regulation (α = .85), Emotional expression (α = .90), SCEC’s Positive thinking (α = .82), Cognitive Restructuring (α = .65), Acceptance (α = .85), Distraction (α = .79), PCDC’s Avoidant
(α = .53), Denial (α = .66), Wishful thinking (α = .52), IE’s Rumination (α = .57), Intrusive thoughts (α = .61), Physiological arousal (α = .54), Emotional arousal (α = .61), Impulse (α = .59), ID’s Emotional numbing (α = .69), Cognitive interference (α = .52), Inaction (α = .54), and Escape (α = .60).
Post-traumatic Stress Diagnostic Questionnaire
Post-traumatic Stress Diagnostic Questionnaire for DSM-5 (Foa et al., 1995) was used in the present research to identify and ascertain the severity of PTSD symptoms. This measure includes 20 items with a 5 point liker types scale where 0 = not at all, 1 = Once a week or less/a little, 2 = 2 to 3 times a week/somewhat, 3 = 4 to 5 times a week/very much, 4 = six or more times a week/severe. The reliability coefficient for the present study is .92 which shows it to be highly reliable.
Big Five Inventory-K (BFI-K)
BFI-K (Kovaleva et al., 2015) was administered to assess five domains of personality. It consists of 22 items and assesses 5 domains of personality: extraversion (4 items), agreeableness (4 items), conscientiousness (6 items), neuroticism (4 items), and openness to experience (3 items) five-point Likert scale 1 (strongly disagree) to 5 (strongly agree) response categories. The present study showed the internal consistencies for subscales as Extraversion (α = .77), Agreeableness (α = .46), Consciousness (α = .71), Neuroticism
(α = .70), and Openness (α = .68) showing it to be highly reliable. The measures were translated into Urdu language to make it comprehendible for the participants. RSQ was modified and adapted after obtaining permission from the authors of the question to make it relevant to trafficking situation.
Permission was sought from Departmental Doctoral Program Committee (DDPC) of Centre for Clinical Psychology and Advanced Studies Review Board (ASRB) of University of the Punjab, Lahore, Pakistan. Then permission was also sought form Home Secretary, Directorate General Social Welfare and Bait-ul-Maal Punjab, Lahore and Federal Investigation Authorities to approach participants of the present study. Although it was very difficult to approach the sample at first place however, when the participant was approached they provided consent to participate. So there was refusal from organizations and brothel houses but the victims approached readily agreed for participation. During data collection one victim was case of acid burn and 2 other victims were case of sexual assault instead of victims of trafficking.
Pearson Product Moment was used to identify the relationship between Stigma (i.e. Self-Stigma and Public Stigma), Coping with Stress and Post Traumatic Stress Disorder. The results are presented in Table 1.
The results revealed that self-stigma, public stigma and stigma as total has negative significant relationship with primary control coping and secondary control coping. It depicts that victims who perceive high stigma make less use of primary control strategies. Likewise they also make less use of secondary control coping strategies to cope with stress such as positive thinking, acceptance, cognitive restructuring and distraction. Next it was found that self-stigma, public stigma and total stigma has significant positive relationship with disengagement coping, involuntary engagement coping and involuntary disengagement coping. It depicts that victims who perceive high stigma make more use of disengagement coping strategies such as denial, avoidance and wishful thinking. These victims are also more likely to use involuntary engagement coping such as rumination, intrusive thoughts, physiological arousal, emotional arousal and involuntary action. Moreover when they perceive high stigma they are more likely to use involuntary disengagement strategies such as emotional numbing, cognitive interference, inaction and escape to while being facing the stress of sex trafficking.
Finally primary control strategies, secondary control strategies have significant negative relationship with symptoms of post-traumatic stress disorder. Disengagement coping, involuntary engagement coping, involuntary disengagement coping, self-stigma, public stigma and total stigma has significant positive relationship with symptoms of post-traumatic stress disorder. It depicts that victims making less use of positive coping strategies and high use of negative coping strategies and perceiving high stigma are related to experience more symptoms of post-traumatic stress disorder such as reliving the trauma, flashbacks and nightmares related to trauma. These victims also perceive high stigma and thus experience more symptoms of post-traumatic stress disorder. Age, sources of trafficking such as trafficked by family, friends, relatives, neighbors; job and debt bondage as well as personality were entered as covariates. It came out that age was positively significantly related to personality traits of extraversion and conscientiousness. Trafficked by family was significantly related with extraversion and conscientiousness.
Correlation Matrix for Covariates and All Study Variables (N=217)
Note. Trf by family= Trafficked by Family; Trfbyfriends= Trafficked by Friends; Trfbydebtbond= Trafficked by debt bondage; Trfbyrelativ= Trafficked by relatives; Trfforjob= Trafficked for job, Trfbyneigh= Trafficked by neighbors , EXT= Extraversion; Agree= Agreeableness; Consc= Conscientiousness; Neuro= Neuroticism; Open= Openness, PCE=Primary Control Engagement; SCE=Secondary Control Engagement; DisEng=Disengagement; InvEng=Involuntary Engagement; InvDis=Involuntary Disengagement; PDS=Post-Traumatic Diagnostic Scale; M= Mean and SD= Standard Deviation.
*p < .05, **p < .01, ***p < .001.
Trafficking by friends was significantly negatively related to conscientiousness and primary control coping. Trafficking source of debt bondage was positively significantly related to primary and secondary control coping and negatively significantly related to involuntary engagement coping, involuntary disengagement coping and post-traumatic stress disorder. Trafficking by relatives was positively significantly related to openness. Personality trait conscientiousness was positively significantly related to primary control strategies and negatively significantly related to involuntary engagement coping. Neuroticism was significantly negatively related to primary control coping, secondary control coping and disengagement coping. Neuroticism is significantly positively related to involuntary engagement coping. These covariates did not predict the post-traumatic stress disorder and coping strategies so these were not dealt in further analysis.
Mediation analysis was conducted to find out the mediating role of coping strategies between stigma and post-traumatic stress disorder. These results are given in Table 2. Mediation analysis was run through PROCESS incorporating Baron and Kenny’s (Hayes, and the results of mediation analysis revealed that stigma negatively predicted primary control engagement coping, secondary control engagement and positively predicted disengagement coping, involuntary engagement coping and involuntary disengagement coping. It is also revealed that disengagement coping strategy positively significantly predicted post-traumatic stress disorder. However, primary control coping, secondary control coping, involuntary engagement coping and involuntary disengagement coping did not predict post-traumatic stress disorder. Indirect effect showed that the values disengagement coping is significantly different from zero with 95% confidence interval lower and upper range of bootstrap (.078 - .327). However, disengagement coping is partially mediating the relationship between stress and PTSD.
Mediation Analysis Showing Coping as Mediator between Stigma and Post-Traumatic Stress (N=217)
Note. PCE=Primary Control Engagement (Mediator); SCE=Secondary Control Engagement (Mediator); DIS=Disengagement; InvEng=Involuntary Engagement (Mediator); InvDis=Involuntary Disengagement (Mediator) PTS=Post-Traumatic Stress.
Mediation Path Framework of Stigma, Coping, and Post-traumatic Stress
Note. PCE = Primary Control Engagement (Mediator); SCE = Secondary Control Engagement (Mediator); DIS=Disengagement; InvEng = Involuntary Engagement (Mediator); InvDis = Involuntary Disengagement (Mediator); PTS = Post-Traumatic Stress.
The present study incorporated sample of women victims of sex trafficking that is popularly known as hidden population as these victims are not easily accessible due to stigma associated with trafficking. It has also been revealed that stigma (i.e. self, public & overall stigma) has been negatively linked to primary (and secondary control coping strategies. However, stigma was positively linked to disengagement coping, involuntary engagement coping, involuntary disengagement coping and post-traumatic stress disorder. Moreover adaptive coping (primary and secondary control coping) has been linked negatively with post-traumatic stress disorder and maladaptive coping (disengagement coping, involuntary engagement and involuntary disengagement coping) has been found to be linked positively with post-traumatic stress disorder.
The findings of the present research have been consistent with the diverse literature that is available previously. Previous research studies have found that victims at post trafficking stage and during reintegration phase face lots of stigma (Marion, 2012), self-blame, discrimination and coping with this stigma (Mahendra et al., 2001; Murray & Crowe, 2014; Okech et al., 2018). The previous literature of sexual assault also provided support to the present research as the present research mainly focused victims of sex trafficking. Previous literature on sexual assault are consistent with the present research findings which found relationship between self-blame, disengagement coping and symptoms of PTSD (Hamrick & Owens, 2019). Previously a qualitative research has also found that victims of trafficking used dissociation and coping strategy that can be related with the present research where victims used mainly disengagement, involuntary engagement and involuntary disengagement coping. Data from rape victims also suggests that stigma and coping impact health (Wong, 2012). Adaptive coping strategies utilized by rape victims are found to be highly efficacious in recovery (Gibson & Leitenberg, 2001; Santello & Leitenberg, 1993; Ullman, 2000; Valentiner et al., 1996).
The findings of the present research are consistent with the previous research studies which have found that victims facing high level of stigma at post trafficking stage experience high level of psychological disorders mainly depression, anxiety and post-traumatic stress disorder (Hossain et al., 2010). There has been dearth of literature which found that trafficking victims suffer from stigma and psychological disorders such as depression anxiety and PTSD (Abas et al., 2013; Malakouti-Nejad, 2012; Oram et al., 2016; Zimmerman, et al., 2013).
Living in a country like Pakistan women victims of sex trafficking are more likely to face stigma and blame from others on experiencing any sensitive issue. Being a collectivistic culture people share interfering relationship boundaries and its get even more pertinent to get approval from one’s own family as well as from other people in the society. Failure to get these approvals results in perceived stigma and a burden for psychological health. Specifically women are criticized and major responsibility is put on women when they face any adversity such as sexual assault. In extreme face of adversity such as trafficking women are blamed for making decision for themselves such as to find better employment opportunities and getting married on their will as due to these decisions women are allured which leads to the incidents of trafficking in extreme cases. Thus women are blamed for not taking appropriate measures to avoid the incidents of trafficking and it is imposed as it was mainly their fault. The situation is further complicated when these women are rejected by their families and society at large on their return from trafficked situation. They are forced to choose the profession of sex trafficking as they had been trafficked for sexual exploitation and on the other hand they are blamed for choosing this profession. The results of the present study revealed that majority (69%) victims of the present study chose for the profession of sex work as they were left with no choice other than opt for this profession.
The results of mediation analysis revealed that disengagement coping mediated the relationship between stigma and symptoms of post-traumatic stress disorder. Self and public stigma predicted post-traumatic stress disorder and it is also evident that these women make less use of adaptive coping strategies. Previous literature on coping provides support to the model of the present study as coping strategies played role of mediator for symptom severity and perception in rape victims is also examined. Thus, it was found that avoidant coping styles buffered the level of public stigma and symptoms of PTSD (Gibson & Leitenberg, 2001; Wong, 2012).
More specifically impact of stigma is known to affect trafficked women in two ways such as before stigma, gender and poverty are vulnerable factors for trafficking. Secondly, after being trafficking victims do not seek help or support due to stigma associated with the trafficking and related sexual assault (Cody, 2018). Trafficked women also do not acknowledge or display lack of disclosure about their trafficked experience due to coercive nature of captivity during the assault. Force through coercive strategies is the hallmark feature of the trafficking process (Djuranovic & Kuosmanen, 2009; U.S. Department of Health & Human Service, 2009). In the present study this lack of exposure is evident in their lack of using primary and secondary control coping which includes acceptance, emotional expression, emotional regulation and problem solving.
These findings can also be related to the cultural and religious explanation found in Pakistani society. The collectivistic nature of the society provides support and security at one hand however; there is a darker side of this support as well. Trafficked women do not express their emotions and traumatic experiences as they fear receiving rejection from the society. Also the most pertinent element is infringement of the trust as women leave their places trusting people who promise them better living and jobs. However, this so called support system deceive them in form of trafficking at the end as in the present research majority of the victims are trafficked by their family (67%), by relatives (25%) and debt bondage (24%) that is again done by family in most of the cases.
Although the dominant religion in this country is Islam but the Islamic teachings are mostly interpreted in terms of strict sanctions on behavior hence the flexibility and rights of women are largely neglected due to this unilateral interpretation of Islamic teachings. Men are given the dominant role not to exert his powers on women negatively instead in Islam this dominance mean that men is regarded as care taker and also responsible to provide security to women. However as it can be seen in the present study this is not practiced according to teachings of Islam.
Based on findings of the present study it can be concluded that high level of stigma leads to more use of disengagement coping, involuntary engagement and involuntary disengagement coping strategies and lack of adaptive coping strategies such as primary as well secondary control coping strategies. Moreover this perceived stigma is also interpreted in terms of cultural and religious factors as religion is misinterpreted while providing rights and dignified place in the society.
Limitations and Suggestions
- Although the researchers tried at maximum level to involve law enforcement agencies however, this kind of empirical research needs planning on large scale level to make the data collection process more systematic and to gain access to larger network of victims of trafficking.
- The present study was designed specifically for women victims of trafficking however the research can also be planned on men and even child trafficking that is also prevalent.
- The tools used in the present study are self-report measures as with any other research self-report measures the present research also rely on truthfulness of the participants while responding. As this research was a preliminary effort to do research on women victims of trafficking next research can be planned to use some behavioral strategies and to incorporate other multiple sources of data to validate the responses such as observational method.
- The present study included victims of internal trafficking, however future research could include sample of international trafficked victims as it can give valuable information related to routes and mechanisms involve in trafficking.
The present research is first of its kind to find out the mediation role of coping between stigma and PTSD. The findings raise important concerns related to the psychological manifestation as a result of trafficking experience. It also raises the need to take measures at precautionary level by raising awareness about possible threat associated with taking certain decisions in their lives. Due to financial problems women are pursuing jobs in different fields so awareness can also be provided at jobs to choose safe ways for promotions. The present study highlights the importance of collaboration between different stakeholders, policy makers and academicians. Besides this it can be argued that Government cannot be blamed for all the happenings as the change can also be brought about through involvement of the community. If the strategies will not be followed by the citizens in community, then any well-planned strategies can be failed at the level of implementation. This thing requires to give awareness at the community level to make them sensitize about the issue of trafficking and its repercussions that are faced at the Government level as a nation. Lastly but very importantly therapy should be implemented to address the psychological needs of the victims.
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Received 10 March 2020
Revision received 19 May 2022
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