Table of ContentsView AllTable of ContentsSymptomsCausesDiagnosisTreatmentCoping

Table of ContentsView All

View All

Table of Contents

Symptoms

Causes

Diagnosis

Treatment

Coping

Retrograde ejaculation is whensemenmoves into thebladderinstead of being pushed out of thepenisduring anorgasm. Although retrograde ejaculation does not affect your ability to reach sexual climax, you may produce little or no semen when youejaculate(“cum”).

Retrograde ejaculation, also known as a dry orgasm, is not harmful but can causemale infertility. There are several causes, including bladder or prostate surgery, nerve damage, and certain medications. Retrograde doesn’t necessarily need treatment unless it affects your ability to conceive.

This article explains the symptoms and causes of retrograde ejaculation and describes what is involved in the diagnosis and treatment of this uncommon urological condition.

AmnajKhetsamtip / Getty Images

Person consults with healthcare provider at desk with clipboard and pen

Symptoms of Retrograde Ejaculation

Retrograde ejaculation can happen acutely after a recent procedure or new medication. It can then becomechronic(ongoing). When the person masturbates, very little (if any) semen is produced.

Three common symptoms characterize retrograde ejaculation, which are:

Retrograde ejaculation doesn’t cause pain or discomfort and is considered harmless outside of fertility issues. Furthermore, studies have shown that the volume of semen produced during orgasm has no impact on how intensely a person experiences sexual pleasure.

Even so, retrograde ejaculation can be a source of anxiety for people trying to conceive.

Causes of Painful Ejaculation

It is only later during urination that the semen will be expelled from the body in urine.

There are several causes for retrograde ejaculation, some of which are more easily treated than others.

How Common Is Retrograde Ejaculation?The actual prevalence of retrograde ejaculation is unknown as it is often left unreported. With that said, around 4% of males with infertility are found to have retrograde ejaculation.

How Common Is Retrograde Ejaculation?

The actual prevalence of retrograde ejaculation is unknown as it is often left unreported. With that said, around 4% of males with infertility are found to have retrograde ejaculation.

Dysautonomia

Ejaculation is the result of a complex series ofautonomic(involuntary) functions that are coordinated so that semen is forcefully propelled from the body at the time of orgasm.

Dysautonomiadescribes the breakdown of autonomic functions, including those involved with blood pressure, digestion, body temperature, and sexual function. When the male reproductive system is affected, a person may experience any number of ejaculatory problems, including retrograde ejaculation,premature ejaculation,delayed ejaculation, oranorgasmia(the inability to orgasm).

With retrograde ejaculation specifically, dysautonomia impairs the contraction of the bladder neck muscles.

Dysautonomia can occur on its own in the absence of other diseases, referred to asprimary dysautonomia. The underlying cause may be genetic (something inherited from your parents) or idiopathic (meaning of unknown origin).

Dysautomia can also occur as a result of another disease, referred to assecondary dysautonomia. This typically involves diseases that damage autonomic nerves.

Diabetes and Retrograde EjaculationDiabetesis one of the most common forms of secondary dysautonomia in people with retrograde ejaculation. When blood sugar is left uncontrolled, diabetes can cause progressivenerve damagethat undermines the function of the bladder neck.Some studies suggest that 1 in 3 maleswith diabetes age 35 to 55 have ejaculatory problems as a result.

Diabetes and Retrograde Ejaculation

Diabetesis one of the most common forms of secondary dysautonomia in people with retrograde ejaculation. When blood sugar is left uncontrolled, diabetes can cause progressivenerve damagethat undermines the function of the bladder neck.Some studies suggest that 1 in 3 maleswith diabetes age 35 to 55 have ejaculatory problems as a result.

Diabetesis one of the most common forms of secondary dysautonomia in people with retrograde ejaculation. When blood sugar is left uncontrolled, diabetes can cause progressivenerve damagethat undermines the function of the bladder neck.

Some studies suggest that 1 in 3 maleswith diabetes age 35 to 55 have ejaculatory problems as a result.

Other forms of secondary dysautonomia linked to retrograde ejaculation includemultiple sclerosis (MS)and Parkinson’s disease.

Surgery

Different surgeries can cause damage to nerves that regulate the bladder neck contractions or alter the anatomy of the urethra making a person more prone to retrograde ejaculation.

As many as 75% of people who undergo TURP experience a degree of retrograde ejaculation.A TURP can be done with a bipolar generator or laser, both of which can increase risks of retrograde ejaculation.

Procedures forprostate cancerwhich include removal of the entire prostate (prostatectomy) can also lead to a dry orgasm.In this case, the dry ejaculate is not because of issues of the bladder neck but more because the organs that produce the ejaculate volume are removed during the procedure.

Retrograde ejaculation can also occur afterretroperitoneal lymph node dissection. This is a procedure commonly used in people withtesticular cancerin which lymph nodes are removed from the lower abdomen to diagnose or treat the disease.

Spinal Cord Injury

In the same way that secondary dysautonomia can damage nerves that regulate ejaculation, a spinal cord injury can damage thespinal nerve rootsthat service the genital and urinary tract.

Some studies suggest that retrograde ejaculation affects 17% to 29% of males with spinal cord injuries. What differentiates these injuries from conditions like MS and diabetes is that the symptoms can either be chronic or intermittent depending on the location and extent of the injury.

Medications

These include:

If you experience problems with ejaculation, be sure to advise a healthcare provider of any medications you take, whether prescription, over the counter (nonprescription), herbal, or recreational.

What to Know About Semen Retention

Retrograde ejaculation is usually diagnosed with a urine specimen collected after ejaculation. For this test, your healthcare provider will ask you to empty your bladder and then masturbate to climax. You will then provide a fresh urine sample for the lab to check. If there is a high volume of semen in the sample, you have retrograde ejaculation.

To help narrow the possible causes, the healthcare provider will review your medical history and physically examine your penis, testicles, and rectum. This can ensure there are no anatomical causes of your symptoms. Based on the findings, other tests may be ordered.

Retrograde ejaculation usually doesn’t require treatment unless it causes infertility. In such cases, the treatment can vary based on the underlying cause. Some “fixes” may be easier than others.

Other treatments may require a fertility specialist or aurologistwho specializes in diseases of the urinary tract and male reproductive system.

Medications can help tighten the bladder neck and increase the output of semen during ejaculation. This, in turn, can help improve the odds of pregnancy.

Tofranil (imipramine), a tricyclic antidepressant used to treat depression as well asenuresis(bed-wetting), is sometimes used as a first-line treatment.

Other drugs commonly used to treat other medical conditions but have proven effective in retrograde ejaculation include:

These drugs are typically taken one to two hours before sex. While potentially useful, they can cause side effects like drowsiness, dizziness, and blurred vision.

Deflux InjectionsAlthough highly experimental, there is evidence that Deflux, an injectable gel used to treatvesicoureteral reflux(the backflow of urine into the bladder), may help reverse retrograde ejaculation in some people.

Deflux Injections

Although highly experimental, there is evidence that Deflux, an injectable gel used to treatvesicoureteral reflux(the backflow of urine into the bladder), may help reverse retrograde ejaculation in some people.

Can Frequent Ejaculation Prevent Cancer?

Infertility Treatment

If medications are unable to produce enough semen for fertilization,intrauterine insemination (IUI)may be recommended. This would involve collecting enough sperm to facilitate pregnancy, after which the sample is delivered to the partner’suterus.

While retrograde ejaculation does not make getting pregnant impossible, the chances are reduced. With assisted fertility procedures like intrauterine insemination (IUI), the pregnancy rate per cycle can increase to as high as 24%, which is approaching the rate seen in couples without infertility.

If IUI doesn’t accomplish pregnancy,in-vitro fertilization (IVF)and other procedures may be explored.

IUI vs. IVF: Which Is Best?

Coping With Retrograde Ejaculation

Although retrograde ejaculation is not harmful and doesn’t affect sexual pleasure, it can still cause awkwardness or embarrassment when “nothing comes out” during sex. This is a bigger issue than some people recognize.

While the vast majority of female partners do not feel this way, a dry orgasm might suggest to some that their partner was “less excited” or experienced less sexual pleasure.

The simple solution, of course, is to talk. Rather than leaving things unspoken, let your partner know more about your condition and what you feel and experience during sexual climax.

The same is even more true if you and your partner are trying to get pregnant. By talking to each other and sharing your thoughts with a fertility specialist—including thecostsand the expected outcomes—you can reduce stress and get a better handle on what to expect if retrograde ejaculation is standing in your way of pregnancy.

Summary

Retrograde ejaculation is when semen flows to the bladder rather than being pushed out of the body during orgasm. It is an otherwise harmless condition but one that can lead to infertility.

Causes include prostate or bladder surgery, medication side effects, spinal cord injury, and nerve-related complications of diabetes, multiple sclerosis, or Parkinson’s disease.

Treatment is generally not needed unless retrograde ejaculation causes infertility. In such cases, medications can help tighten bladder muscles and increase semen output. Infertility treatments like intrauterine insemination (IUI) can also improve the odds of conceiving.

19 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Parnham A, Serefoglu EC.Retrograde ejaculation, painful ejaculation and hematospermia.Transl Androl Urol.2016;5(4):592–601. doi:10.21037/tau.2016.06.05Koren G, Koren D.Retrograde ejaculation—a commonly unspoken aspect of prostatectomy for benign prostatic hypertrophy.Am J Mens Health.2020;14(2):1557988320910870. doi:10.1177/1557988320910870Mjeusset R, Malschaerts M, Isus F, Almont T, Daudin M, Hamdi SM.Diagnosis of partial retrograde ejaculation in non-azoospermic infertile men with low semen volume.PLoS One.2017;12(1):e0168742. doi:10.1371/journal.pone.0168742Goldberger JJ, Arora R, Buckley U, Shivkumar K.Autonomic nervous system dysfunction.J Am Coll Cardiol.2019;73(10):1189–1206. doi:10.1016/j.jacc.2018.12.064Alwaal A, Breyer BN, Lue TF.Normal male sexual function: emphasis on orgasm and ejaculation.Fertil Steril.2015;104(5):1051–60. doi:10.1016/j.fertnstert.2015.08.033Cho S.Brief note on signs, symptoms and causes of retrograde ejaculation.Andrology. 2021;10:246.Gaunay G, Nagler HM, Stember DS.Reproductive sequelae of diabetes in male patients.Endocrinol Metab Clin N Am.2013;42(4):899–914. doi:10.1016/j.ecl.2013.07.003Mehta A, Sigman M.Management of the dry ejaculate: a systematic review of aspermia and retrograde ejaculation.Fertility Sterility. 2015;204(5):1074-1082. doi:10.1016/j.fertnstert.2015.09.024National Health Service (UK).Risks transurethral resection of the prostate.Soler JM, Previnaire J, Mieusset R.Evidence of a new pattern of ejaculation in men with spinal cord injury: ejaculation dyssynergia and implications for fertility.Spinal Cord.2016;54:1210-1214. doi:10.1038/sc.2016.78DeLay KJ, Nutt M, McVary KT.Ejaculatory dysfunction in the treatment of lower urinary tract symptoms.Transl Androl Urol.2016;5(4):450–459. doi:10.21037/tau.2016.06.06Otani T.Clinical review of ejaculatory dysfunction.Reprod Med Sci.2019;18(4):331-343. doi:10.1002/rmb2.12289Bulut M, Gozukara K, Kaya MC.Duloxetine-induced retrograde ejaculation: a case report.Bull Clin Psychopharmacol.2015;25(4):429-430. doi:10.5455/bcp.20130925022238Roughley M, Lyall M.Retrograde ejaculation associated with quetiapine and treatment with low-dose imipramine.BMJ Case Rep.2019;12(8):e228539. doi:10.1136/bcr-2018-228539Tai T, Nagao K, Tamura K.AB140: the effectiveness and adverse effects of amoxapine for treatment of retrograde ejaculation.Transl Androl Urol.2015;4(Suppl 1):AB140. doi:10.3978/j.issn.2223-4683.2015.s140Shoshany O, Abhyankar N, Elyaguov J, Niederberger C.Efficacy of treatment with pseudoephedrine in men with retrograde ejaculation.Andrology. 2017;5(4):744-748. doi:10.1111/andr.12361Han H, Liu S, Liang X, et al.Restoration of antegrade ejaculation after transurethral bladder neck injection of Deflux for retrograde ejaculation: a case report of natural conception.Transl Androl Urol. 2020;9(5):2270-2274. doi:10.21037/tau-20-593Gupta S, Sharma R, Agarwal A, et al.A comprehensive guide to sperm recovery in infertile men with retrograde ejaculation.World J Mens Health.2022;40(2):208–216. doi:10.5534/wjmh.210069Burri A, Buchmeier J, Porst H.The importance of male ejaculation for female sexual satisfaction and function.J Sex Med. 2018;15(11):1600-1608. doi:10.1016/j.jsxm.2018.08.014

19 Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Parnham A, Serefoglu EC.Retrograde ejaculation, painful ejaculation and hematospermia.Transl Androl Urol.2016;5(4):592–601. doi:10.21037/tau.2016.06.05Koren G, Koren D.Retrograde ejaculation—a commonly unspoken aspect of prostatectomy for benign prostatic hypertrophy.Am J Mens Health.2020;14(2):1557988320910870. doi:10.1177/1557988320910870Mjeusset R, Malschaerts M, Isus F, Almont T, Daudin M, Hamdi SM.Diagnosis of partial retrograde ejaculation in non-azoospermic infertile men with low semen volume.PLoS One.2017;12(1):e0168742. doi:10.1371/journal.pone.0168742Goldberger JJ, Arora R, Buckley U, Shivkumar K.Autonomic nervous system dysfunction.J Am Coll Cardiol.2019;73(10):1189–1206. doi:10.1016/j.jacc.2018.12.064Alwaal A, Breyer BN, Lue TF.Normal male sexual function: emphasis on orgasm and ejaculation.Fertil Steril.2015;104(5):1051–60. doi:10.1016/j.fertnstert.2015.08.033Cho S.Brief note on signs, symptoms and causes of retrograde ejaculation.Andrology. 2021;10:246.Gaunay G, Nagler HM, Stember DS.Reproductive sequelae of diabetes in male patients.Endocrinol Metab Clin N Am.2013;42(4):899–914. doi:10.1016/j.ecl.2013.07.003Mehta A, Sigman M.Management of the dry ejaculate: a systematic review of aspermia and retrograde ejaculation.Fertility Sterility. 2015;204(5):1074-1082. doi:10.1016/j.fertnstert.2015.09.024National Health Service (UK).Risks transurethral resection of the prostate.Soler JM, Previnaire J, Mieusset R.Evidence of a new pattern of ejaculation in men with spinal cord injury: ejaculation dyssynergia and implications for fertility.Spinal Cord.2016;54:1210-1214. doi:10.1038/sc.2016.78DeLay KJ, Nutt M, McVary KT.Ejaculatory dysfunction in the treatment of lower urinary tract symptoms.Transl Androl Urol.2016;5(4):450–459. doi:10.21037/tau.2016.06.06Otani T.Clinical review of ejaculatory dysfunction.Reprod Med Sci.2019;18(4):331-343. doi:10.1002/rmb2.12289Bulut M, Gozukara K, Kaya MC.Duloxetine-induced retrograde ejaculation: a case report.Bull Clin Psychopharmacol.2015;25(4):429-430. doi:10.5455/bcp.20130925022238Roughley M, Lyall M.Retrograde ejaculation associated with quetiapine and treatment with low-dose imipramine.BMJ Case Rep.2019;12(8):e228539. doi:10.1136/bcr-2018-228539Tai T, Nagao K, Tamura K.AB140: the effectiveness and adverse effects of amoxapine for treatment of retrograde ejaculation.Transl Androl Urol.2015;4(Suppl 1):AB140. doi:10.3978/j.issn.2223-4683.2015.s140Shoshany O, Abhyankar N, Elyaguov J, Niederberger C.Efficacy of treatment with pseudoephedrine in men with retrograde ejaculation.Andrology. 2017;5(4):744-748. doi:10.1111/andr.12361Han H, Liu S, Liang X, et al.Restoration of antegrade ejaculation after transurethral bladder neck injection of Deflux for retrograde ejaculation: a case report of natural conception.Transl Androl Urol. 2020;9(5):2270-2274. doi:10.21037/tau-20-593Gupta S, Sharma R, Agarwal A, et al.A comprehensive guide to sperm recovery in infertile men with retrograde ejaculation.World J Mens Health.2022;40(2):208–216. doi:10.5534/wjmh.210069Burri A, Buchmeier J, Porst H.The importance of male ejaculation for female sexual satisfaction and function.J Sex Med. 2018;15(11):1600-1608. doi:10.1016/j.jsxm.2018.08.014

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

Parnham A, Serefoglu EC.Retrograde ejaculation, painful ejaculation and hematospermia.Transl Androl Urol.2016;5(4):592–601. doi:10.21037/tau.2016.06.05Koren G, Koren D.Retrograde ejaculation—a commonly unspoken aspect of prostatectomy for benign prostatic hypertrophy.Am J Mens Health.2020;14(2):1557988320910870. doi:10.1177/1557988320910870Mjeusset R, Malschaerts M, Isus F, Almont T, Daudin M, Hamdi SM.Diagnosis of partial retrograde ejaculation in non-azoospermic infertile men with low semen volume.PLoS One.2017;12(1):e0168742. doi:10.1371/journal.pone.0168742Goldberger JJ, Arora R, Buckley U, Shivkumar K.Autonomic nervous system dysfunction.J Am Coll Cardiol.2019;73(10):1189–1206. doi:10.1016/j.jacc.2018.12.064Alwaal A, Breyer BN, Lue TF.Normal male sexual function: emphasis on orgasm and ejaculation.Fertil Steril.2015;104(5):1051–60. doi:10.1016/j.fertnstert.2015.08.033Cho S.Brief note on signs, symptoms and causes of retrograde ejaculation.Andrology. 2021;10:246.Gaunay G, Nagler HM, Stember DS.Reproductive sequelae of diabetes in male patients.Endocrinol Metab Clin N Am.2013;42(4):899–914. doi:10.1016/j.ecl.2013.07.003Mehta A, Sigman M.Management of the dry ejaculate: a systematic review of aspermia and retrograde ejaculation.Fertility Sterility. 2015;204(5):1074-1082. doi:10.1016/j.fertnstert.2015.09.024National Health Service (UK).Risks transurethral resection of the prostate.Soler JM, Previnaire J, Mieusset R.Evidence of a new pattern of ejaculation in men with spinal cord injury: ejaculation dyssynergia and implications for fertility.Spinal Cord.2016;54:1210-1214. doi:10.1038/sc.2016.78DeLay KJ, Nutt M, McVary KT.Ejaculatory dysfunction in the treatment of lower urinary tract symptoms.Transl Androl Urol.2016;5(4):450–459. doi:10.21037/tau.2016.06.06Otani T.Clinical review of ejaculatory dysfunction.Reprod Med Sci.2019;18(4):331-343. doi:10.1002/rmb2.12289Bulut M, Gozukara K, Kaya MC.Duloxetine-induced retrograde ejaculation: a case report.Bull Clin Psychopharmacol.2015;25(4):429-430. doi:10.5455/bcp.20130925022238Roughley M, Lyall M.Retrograde ejaculation associated with quetiapine and treatment with low-dose imipramine.BMJ Case Rep.2019;12(8):e228539. doi:10.1136/bcr-2018-228539Tai T, Nagao K, Tamura K.AB140: the effectiveness and adverse effects of amoxapine for treatment of retrograde ejaculation.Transl Androl Urol.2015;4(Suppl 1):AB140. doi:10.3978/j.issn.2223-4683.2015.s140Shoshany O, Abhyankar N, Elyaguov J, Niederberger C.Efficacy of treatment with pseudoephedrine in men with retrograde ejaculation.Andrology. 2017;5(4):744-748. doi:10.1111/andr.12361Han H, Liu S, Liang X, et al.Restoration of antegrade ejaculation after transurethral bladder neck injection of Deflux for retrograde ejaculation: a case report of natural conception.Transl Androl Urol. 2020;9(5):2270-2274. doi:10.21037/tau-20-593Gupta S, Sharma R, Agarwal A, et al.A comprehensive guide to sperm recovery in infertile men with retrograde ejaculation.World J Mens Health.2022;40(2):208–216. doi:10.5534/wjmh.210069Burri A, Buchmeier J, Porst H.The importance of male ejaculation for female sexual satisfaction and function.J Sex Med. 2018;15(11):1600-1608. doi:10.1016/j.jsxm.2018.08.014

Parnham A, Serefoglu EC.Retrograde ejaculation, painful ejaculation and hematospermia.Transl Androl Urol.2016;5(4):592–601. doi:10.21037/tau.2016.06.05

Koren G, Koren D.Retrograde ejaculation—a commonly unspoken aspect of prostatectomy for benign prostatic hypertrophy.Am J Mens Health.2020;14(2):1557988320910870. doi:10.1177/1557988320910870

Mjeusset R, Malschaerts M, Isus F, Almont T, Daudin M, Hamdi SM.Diagnosis of partial retrograde ejaculation in non-azoospermic infertile men with low semen volume.PLoS One.2017;12(1):e0168742. doi:10.1371/journal.pone.0168742

Goldberger JJ, Arora R, Buckley U, Shivkumar K.Autonomic nervous system dysfunction.J Am Coll Cardiol.2019;73(10):1189–1206. doi:10.1016/j.jacc.2018.12.064

Alwaal A, Breyer BN, Lue TF.Normal male sexual function: emphasis on orgasm and ejaculation.Fertil Steril.2015;104(5):1051–60. doi:10.1016/j.fertnstert.2015.08.033

Cho S.Brief note on signs, symptoms and causes of retrograde ejaculation.Andrology. 2021;10:246.

Gaunay G, Nagler HM, Stember DS.Reproductive sequelae of diabetes in male patients.Endocrinol Metab Clin N Am.2013;42(4):899–914. doi:10.1016/j.ecl.2013.07.003

Mehta A, Sigman M.Management of the dry ejaculate: a systematic review of aspermia and retrograde ejaculation.Fertility Sterility. 2015;204(5):1074-1082. doi:10.1016/j.fertnstert.2015.09.024

National Health Service (UK).Risks transurethral resection of the prostate.

Soler JM, Previnaire J, Mieusset R.Evidence of a new pattern of ejaculation in men with spinal cord injury: ejaculation dyssynergia and implications for fertility.Spinal Cord.2016;54:1210-1214. doi:10.1038/sc.2016.78

DeLay KJ, Nutt M, McVary KT.Ejaculatory dysfunction in the treatment of lower urinary tract symptoms.Transl Androl Urol.2016;5(4):450–459. doi:10.21037/tau.2016.06.06

Otani T.Clinical review of ejaculatory dysfunction.Reprod Med Sci.2019;18(4):331-343. doi:10.1002/rmb2.12289

Bulut M, Gozukara K, Kaya MC.Duloxetine-induced retrograde ejaculation: a case report.Bull Clin Psychopharmacol.2015;25(4):429-430. doi:10.5455/bcp.20130925022238

Roughley M, Lyall M.Retrograde ejaculation associated with quetiapine and treatment with low-dose imipramine.BMJ Case Rep.2019;12(8):e228539. doi:10.1136/bcr-2018-228539

Tai T, Nagao K, Tamura K.AB140: the effectiveness and adverse effects of amoxapine for treatment of retrograde ejaculation.Transl Androl Urol.2015;4(Suppl 1):AB140. doi:10.3978/j.issn.2223-4683.2015.s140

Shoshany O, Abhyankar N, Elyaguov J, Niederberger C.Efficacy of treatment with pseudoephedrine in men with retrograde ejaculation.Andrology. 2017;5(4):744-748. doi:10.1111/andr.12361

Han H, Liu S, Liang X, et al.Restoration of antegrade ejaculation after transurethral bladder neck injection of Deflux for retrograde ejaculation: a case report of natural conception.Transl Androl Urol. 2020;9(5):2270-2274. doi:10.21037/tau-20-593

Gupta S, Sharma R, Agarwal A, et al.A comprehensive guide to sperm recovery in infertile men with retrograde ejaculation.World J Mens Health.2022;40(2):208–216. doi:10.5534/wjmh.210069

Burri A, Buchmeier J, Porst H.The importance of male ejaculation for female sexual satisfaction and function.J Sex Med. 2018;15(11):1600-1608. doi:10.1016/j.jsxm.2018.08.014

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