"To control my body" is an absurd political spin on "because they expect me to regret it". Can she imagine that a doctor might actually think "I don't want to perform an irreversible, life-alterring operation on someone who has a good chance of regretting it"?
Deciding one wants kids later in life after thinking they would not is fairly common. Sterilizing young people means a great number of expected people who will be unable to conceive despite wanting to later on. The statistical expected utility of doing the operation may well be negative. Especially if abortion care is readily available (the fact that it is not is a key point here).
People getting sterilized because they’re afraid of lack of birth control rights and abortions is tragic.
People make choices and then change their priorities or at least their minds about a great many things especially as they get older. Many of these choices have higher regret rates than sterilization. Yet, it seems that sterilization has a special status that gives license for people to make decisions about others. Why is this? As a bodily autonomy absolutist it's hard to understand a willingness to accept someone else's authority over my body.
And why should one operationalization of utility be chosen out of the multitudes of conceivable[1] operationalizations?
The first one that popped up is breast reconstruction after mastectomy, 47% of the sample at at least some regret[1]. Tubal ligation regret maxes at 20.3%[2]. While tubal ligation regret deminishes as age at the time of the procedure increases, my point is that it is still well below that of breast reconstruction. People seem to have no worries about reconstruction regret and large worries over people's sterilization regret. The paradox is hypocritical. There must be another factor at play.
Prostate surgery has comparable regret rates(1 in 5)[3] to sterilization. Again, society seems to be perfectly ok with letting folks make decisions about prostate surgeries. Female sterilization in particular seems to be a lightning rod for public discourse.
I don’t know much about prostate surgery. I presume it’s largely for people who have cancer. All I really know is that prostate cancer is very common among older men and is typically non lethal and probably should be done less? They should probably communicate the effects of prostate removal more than they do. Unnecessary surgeries done on underinformed patients is a different but serious problem.
The reversal rates are irrelevant. The fact is that it can be reversed whereas sterilization cannot, and frankly has much larger consequences than some body image issues. We don’t have a lot of studies on regret rates for young childless women because few young childless women get sterilized.
This poses a catch-22: young women are denied the care they request because there is not enough data on the care they request. Surely, the nature of the circular logic must confound you as well. Functionally it's the same as simply denying care.
Is it your understanding that tubal ligation cannot, under any circumstance, be reversed? If not so, then reversal rates are in fact important to this discussion.
> This poses a catch-22: young women are denied the care they request because there is not enough data on the care they request. Surely, the nature of the circular logic must confound you as well. Functionally it's the same as simply denying care.
Lack of evidence of no harm is a hard sell against priors that assume harm.
It feels too close to being asked to prove a negative. Why not simply have an uninformative prior rather than a strong harm prior? Based on the discussion we've hard so far, it sounds like your prior is conditioned in some way, and to find the means by which it is is precisely why I'm digging[1].
Since your premise is impossible (the doctor does not know this for a fact and cannot), the question isn't relevant. In any case, adoption is an option.
If we're going to allow magic in this scenario, I suggest that the woman magically give herself a tubal ligation and skip the patronizing medical professionals altogether.
Or if we're going to skip things, let's start with hypotheticals that will never happen.
Because the doctor is performing the operation, and people are always responsible for their own actions. "They told me they wouldn't ever regret it and I foolishly believed them" isn't an excuse for avoiding responsibility.
That's the inversion of your prescription, not what anyone else is proposing. Nobody is telling anyone they will not regret an elective medical procedure. That's something you need to figure out. Stop being disingenuous.
The common wisdom is that they're afraid of being sued. For example, imagine someone with Bipolar disorder in the midst of a manic episode scheduling and performing a tubal ligation. Then later on, they accuse the doctor of malpractice for not identifying them as being in a state of compromised decision making capacity and denying their request.
It's really simple to say, that the patient asked for it and that the doctor acted as expected, but it doesn't prevent the lawsuit from being filed. If it's especially egregious, it might be dismissed with prejudice, but there's always a chance that it goes further than that.
I think you're right. Though a solution to this problem seems simple. Just like we ought to have timeouts from the moment you want to buy a firearm to the moment you can have it in your possession, we could have a procedure "fill out this form and sign in, have a consultation with your doctor, and if you come back 3 months later with the same request, after you sign one more form, you can have the procedure".
Doctors seem to have little hesitation regarding other life-altering modifications like sticking silicone balls in your chest, carving your face up because you don't like the outline of your nose, or slicing pieces off your kid's genitals.
I think sterilization is both more life-altering than your examples, and also that doctors, on par, absolutely have some amount of "hesitation" (i.e. making sure they really want it) regarding plastic surgery.
I would argue that anything up to and including assisted suicide performed with informed consent deserves less hesitation than performing arbitrary surgeries on unwilling and unconsenting children. Being willing to do that but not sterilize someone just makes you a hypocrite.
I'm not sure this argument really works, because it's different doctors in both cases. There are lots of doctors who would be unwilling to do what you reference, but they're selected out of that area of practice. The difference here is simply that this selection effect isn't present here because this procedure is a minority of the field
Are you talking about male circumcision? It's hardly a blip on the radar of invasive procedures with no lasting side effects except some minor benefits.
Cutting off an infant's outer ears or doing electrolysis on their armpit hair follicles or burning them with a hot iron also have no long lasting side effects but we don't allow those because of course we don't. Cutting off a male prepuce has just as much effect as cutting off a female prepuce. Can you imagine a doctor agreeing to removing a baby girl's clitoral hood? As someone who did have long-lasting effects from circumcision, I would delight in finding the son of a bitch that did it to me and seeing how he likes having pieces removed. You don't need a spreadsheet to know that causing agony to children is a bad thing.
To elaborate the risk vs benefits[2], circumcision can reduce the risk of UTI in males by 10x. Not 10%, but 10x[1]. It also significantly reduces the risk of STI's particularly HIV. And as you said, there are no lasting negative side-effects (though a very small risk of complications).
Those are good reasons for you to get circumcised. They are not good reasons to do it to someone who cannot consent. You should also consider that statistics regarding complications only count complications that required medical intervention. Nobody goes around asking men "does anything bother you about your penis?" and noting down what annoyances could've been caused by circumcision. There are a lot of men who don't know that not everyone is bothered by loose underwear rubbing on them or that getting your frenulum licked is supposed to feel really nice.
I am sympathetic to the consent argument (I don't know that I would have my boys circumcised). However risk significantly increases with age, so that is something to consider.
This really shouldn't be downvoted. If one is going to pull the "children cannot consent" card, one should be consistent. If it's not actually about consent and actually about something else, let's not pretend it's about consent.
Obviously the implication is that it's "obvious" that the benefits of vaccines outweigh the cons of ignoring consent, but that just prompts the questions: Is this true, and what amount of benefit is necessary to avoid consent in children? Explicit reasoning should laid out.
The vaccine is not taking away part of the pleasures of the child once they become adult, so the choice is between "bad" (vaccine pain) or "more bad" (sick).
The circumcision is between "fine and pleasure with some risks" and "very painful, loss of pleasure in some areas, annoying underwear rubbing, body mutilation, some reduced risks".
Finally, the reason why the vaccine is done without consent is because you can get killed (or kill accidentally due to lack of herd immunity) if you don't do it.
No one is affected by someone going through circumcision or not.
The majority of the world is not circumcised. The majority of the world is not dealing with an STI epidemic; some areas are, and only with some STIs. The US has a very high circumcision rate and a very high STI rate for what the proponents of circumcision would like you to believe. The two are only correlated due to a third variable. Circumcision simply isn't a good replacement in any circumstance for sexual hygiene. Don't mutilate children to control for the root variable.
Males are born with foreskin for a reason. Much like one is not born prozac-deficient, the majority of males are not born with some evolutionary "excess".
If that's the case why not wait until the recipient is an adult and can give consent?
When my son was born (in the US) the woman who did these procedures was very aggressive and persistent about having it done immediately. When I said that he could choose when he was an adult she replied, "But in that case he will say no" which seemed like a very odd position use to try to justify the mutilation.
Because it is way more of a big deal after infancy and especially after puberty. More nerve endings and more connections are made at that point. Not to mention just more skin to be removed.
A blip on the radar? I find completely insane about this response. How could we consider this even somewhat acceptable is insane. Mutilate a baby because "it looks better to me or that's how it looks usually". No, sorry, it completely unreasonable.
Adult deciding for themselves are totally fine.
Children? No, that should be disallowed by law.
Doctors are not supposed to harm patients even if the patient is above the age of 18. If the patient is likely to regret the operation, doing the operation is causing harm.
On the other hand, she is asking for a form of birth control. Given that abortion is banned in many parts of the US, it's easy to see why she views the denial of birth control as an attempt to control her body.
Sure, some doctors have a preference not to do it, but their stake in the situation is pretty low compared to the patient. Why do we let the doctors preference mean that the procedure becomes unavailable?
Imagine if mail carriers could refuse to deliver to houses with the mailbox up stairs. Yes, its fair that they don't like it but the cost of that is people lose a vital service. In that case the mail carriers have to accept their job might include some elements they don't like.
I have compared with a friend that wanted to get her tubes tied, and the doctor insisted she might change her mind, should wait a few years, and wanted her to speak to her partner about it.
I asked for a vasectomy, and the doctor scheduled it 2 days later. It really is a double standard
And on top of the reversibility, vasectomy is a much simpler out-patient procedure compared to tubal ligation (which means lower risk of complications). There is not a double standard here, just medical reality.
Because the biggest consideration is the reversibility as GP said. If you have Tubal Ligation your odds of getting it successfully reversed is 1%[1]. It is effectively a permanent decision.
My vasectomy doc made it very clear that vasectomies are not always reversible and you should absolutely not count on them being reversible if you anticipate changing your mind.
If only they applied the same logic to males then it would make sense. They don't. Men can get sterilized in the blink of an eye, while women are forced to "have time to think a out it" and such.
I'd love to see some stats on how many doctors turn down men who are looking to get sterilized. I'm assuming men looking to get a vasectomy get much less pushback from doctors.
If men do turn out to get less pushback, I wonder if a contributing reason is that it's less medically risky to reverse a vasectomy than reversing e.g. tubal ligation.
(I don't know that it is less risky and/or more likely to succeed. But the vas deferns is incredibly accessible.)
Aren't vasectomy reversals much more common and successful? If the procedure of "sterilization" is much more irreversible then it would follow that there would be more push back as there is more risk.
Nowhere is this double standard more obvious than in trans healthcare. Everyone has horror stories, but someone else being gatekeepy because of your (supposed) loss of fertility and implied sexual availability as a woman is really common and honestly kind of disgusting.
You can see this with people posting pictures of pre-transition Elliot Page and captions like "remember what they took from us" all the time on social media.
They get much less pushback. It's anecdotal but I know a couple where the wife tried for like 3 years in a row to have a tubal ligation ("tubes tied") and her doctors (I believe she tried multiple) all told her she should wait, had she talked to her husband, what if she changed her mind, and the list goes on. After the 3 or so time her husband went into his doctor and had the vasectomy on the books by the end of the checkup. When I was talking to the wife she made it clear this was not at all unusual according to her friends/acquaintances.
Everyone needs to be their own advocate when it comes to medical care but I've heard multiple horror stories from my female friends that would never have occurred to me ("You're overreacting", "It's not that painful", "Maybe it's just cramps", "Have you tried X?").
They're about 50% likely to be reversible after 5 years. That's not what we generally mean when we say something is "reversible". It's a permanent procedure that can sometimes be reversed.
Is IVF still an option when it cannot be reversed surgically? I realize this is much more expensive; I'm just wondering since I've heard about the reversibility issues and didn't know if that means you're completely SOL.
IIRC mine had a chat with my wife and one of the first things he did was ask me how many kids I had. If he'd gotten answers he didn't like, I assume it would have been a lot harder to convince him to do the procedure.
The doctor chatted with me before my vasectomy, asking how many children I have and their ages. When I said "5, 2, and 0" he made sure that the 0 represented a child who had been born, not a pregnancy. He did not want perform a vasectomy on a man who wanted to have three children but whose 3rd child might miscarry. I explained that I had 3 born children, and he then did the operation.
Right, and when we're talking about these sorts of things, comparisons between rates are what matters. Bringing up the existence of one sort of example or another only muddies the waters.
When the politics of the day, though, are to forcibly modify the rest of your life by using your biology against you, this is clearly about life, liberty and the pursuit of happiness.
Well, when it comes to having kids, it may be full of many surprises but mainly and nearly exclusively, only if they can't have their wishes for sterilization respected. Kids don't tend to just pop out of thin air, but they can happen by accident which is what she's trying to avoid.
The first and most obvious point is that I, personally (FWIW), fully support body autonomy so if people want to get sterilized if they want.
The article points out the issue with regret. I'm not sure how you handle that other than maybe coming up with a more easily reversible procedure?
Either way, if someone may end up regretting a decision is no reason to take that choice away from someone.
But you can't talk about this issue without talking about how the medical profession treats women. Women are often ignored and their pain and concerns are downplayed or outright dismissed, sometimes catastrophically. Some women are sterilized without consent for reasons with little or even no medical basis. If you're not aware, look at the "husband's stitch" for an example of misogynist medical barbarism.
You also can't ignore the politics of this and how the fight against reproductive rights sprang out of "Great Replacement" fears [1]:
> In an 1865 essay issued by order of the AMA, Storer went so far as to say of white women that “upon their loins depends the future destiny of the nation.”
If you think that's ancient history, it isn't [2]. Rep. Mary Miller (R-IL) called the defeat of Roe v. Wade a “victory for white life.” This is the same Miller who said "Hitler Was Right on One Thing" [3].
While it is true that anyone saying at 22 that they know for sure definitely that they will never have children might change their mind, it doesn't matter.
We let people make all sorts of regrettable, life-altering decisions at 22.
At 22, you can be 4 years into your service contract with the armed forces. You could have already died or have been permanently disabled due to these choices.
At 22, you can be a few years into a college education in a major you now know you hate.
At 22, you can be 4 years into a marriage to an abusive partner. Or just an asshole.
These are just a few of the choices you can come to regret later in life. Choices that you cannot change. Choices you will have to live with for the rest of your life. That fundamentally alter all of the choices available to you later in life.
So why should potential regret stay our hand here? Yes, she may regret getting her tubes tied and making conception for her impossible. Oh well. Actions have consequences.
No idea about USA, but in Poland a large number of those refusals is due to catholic bigotry. In Poland this is correlated with many fundamentalists choosing this field due to readily available prey. Should be easy to determine comparing the number of refusals between the fundamentalist states and the rest, I guess.
I sort of get it. Looking back, I had 6 friends who were adamant that they would absolutely 100% never have kids. A decade later 3 are happy parents and a 4th is expecting.
Now from a 22 year old's perspective, this is a terrible argument, and I understand they would be upset.
Doctors make a big deal out of it because of history - forced or unwanted sterilization has been a problem in the past, especially for marginalized people. The difference between men and women's experiences are infuriating and MUST be addressed, but the sentiment is correct.
A successful vasectomy ends in a 50-50 reversal-to-conception ratio, including not just pregnancy via intercourse but by any means necessary (fertility treatments, IVF, etc.). Even this minimally-invasive and "easily-reversible" action is considered permanent. Any permanent sterilization (in CA, not sure about rest of US/world) has a default 30-day waiting period, with the ability to waive down to a minimum 72-hour required delay between consent to permanent sterilization and having the procedure.
Making a permanent decision is not something to be taken lightly, it will be interesting to see what other outcomes of Roe v. Wade change behavior and expectations of large populations.
One of the first, if not the first mantras learned by aspiring doctors (and, most likely, others in the medical profession) is First of all, do no harm. This sounds like a simple and logical rule but implementing it is not as straightforward as it may seem. Does sterilising a man or woman who has a 25% chance of later in life wanting this procedure reversed [1] - which, in contrast to what is commonly thought is not easily reversible if at all - do harm to this person or not? For the ~60% who will not come to regret their decision it clearly does not but those who come to regret their decision will have to come to terms with their self-induced infertility.
Unsurprisingly the younger a woman gets sterilised, the bigger the chance that she will come to regret it later in life [2]: Study results showed that the younger women were at the time of sterilization, the more likely they were to report regretting that decision. Women undergoing sterilization at the age 30 years or younger were about twice as likely as those over 30 to express regret. They were also from 3.5 to 18 times as likely to request information about reversing the procedure and about 8 times as likely to actually undergo reversal or an evaluation for IVF. Results of studies that examined risk by continuous age showed a consistent inverse relationship between women's age at sterilization and their likelihood of regretting having had the procedure.
Given these facts it would be surprising if young people did not face resistance when requesting sterilisation.
Most of the objection to allowing someone to sterilize themself (either from doctors of this thread) is centered around the potential for regret later. But guarding people from regret is nanny-state BS. People regret tattoos, people regret having kids, people regret getting married, people regret quitting jobs and all kinds of irreversible decisions, and unless you're hurting someone else society rightly defaults to letting them decide for themselves.
The only one of your examples that's actually irreversible is having kids. People get tattoos removed, get divorced, and return to former employers all the time.
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[ 4.8 ms ] story [ 187 ms ] threadPeople getting sterilized because they’re afraid of lack of birth control rights and abortions is tragic.
And why should one operationalization of utility be chosen out of the multitudes of conceivable[1] operationalizations?
1. yes, intentional. yw
Prostate surgery has comparable regret rates(1 in 5)[3] to sterilization. Again, society seems to be perfectly ok with letting folks make decisions about prostate surgeries. Female sterilization in particular seems to be a lightning rod for public discourse.
1. https://www.tandfonline.com/doi/abs/10.1080/1476832060112489...
2. https://pubmed.ncbi.nlm.nih.gov/10362150/
3. https://archive.nytimes.com/well.blogs.nytimes.com/2008/08/2...
The reversal rates are irrelevant. The fact is that it can be reversed whereas sterilization cannot, and frankly has much larger consequences than some body image issues. We don’t have a lot of studies on regret rates for young childless women because few young childless women get sterilized.
Is it your understanding that tubal ligation cannot, under any circumstance, be reversed? If not so, then reversal rates are in fact important to this discussion.
> This poses a catch-22: young women are denied the care they request because there is not enough data on the care they request. Surely, the nature of the circular logic must confound you as well. Functionally it's the same as simply denying care.
Lack of evidence of no harm is a hard sell against priors that assume harm.
1. at this point probably pestering
Or if we're going to skip things, let's start with hypotheticals that will never happen.
It's really simple to say, that the patient asked for it and that the doctor acted as expected, but it doesn't prevent the lawsuit from being filed. If it's especially egregious, it might be dismissed with prejudice, but there's always a chance that it goes further than that.
That's understandable, but I'm curious - do you feel the same about your parents, who presumably scheduled the circumcision?
[1]https://health.choc.org/circumcision-and-urinary-tract-infec... [2]https://www.center4research.org/circumcision-health-benefits...
Should we stop giving kids the polio and MMR vaccines until they can consent?
Obviously the implication is that it's "obvious" that the benefits of vaccines outweigh the cons of ignoring consent, but that just prompts the questions: Is this true, and what amount of benefit is necessary to avoid consent in children? Explicit reasoning should laid out.
The circumcision is between "fine and pleasure with some risks" and "very painful, loss of pleasure in some areas, annoying underwear rubbing, body mutilation, some reduced risks".
Finally, the reason why the vaccine is done without consent is because you can get killed (or kill accidentally due to lack of herd immunity) if you don't do it.
No one is affected by someone going through circumcision or not.
Males are born with foreskin for a reason. Much like one is not born prozac-deficient, the majority of males are not born with some evolutionary "excess".
When my son was born (in the US) the woman who did these procedures was very aggressive and persistent about having it done immediately. When I said that he could choose when he was an adult she replied, "But in that case he will say no" which seemed like a very odd position use to try to justify the mutilation.
Adult deciding for themselves are totally fine. Children? No, that should be disallowed by law.
Imagine if mail carriers could refuse to deliver to houses with the mailbox up stairs. Yes, its fair that they don't like it but the cost of that is people lose a vital service. In that case the mail carriers have to accept their job might include some elements they don't like.
I asked for a vasectomy, and the doctor scheduled it 2 days later. It really is a double standard
[1]https://www.fertstert.org/article/S0015-0282(15)00292-7/pdf
vs
You can't have your tubes tied - there might be consequences to your choice so you shouldn't have to deal with those.
What's different here? Oh right, nothing if the goal is forcing birth.
If men do turn out to get less pushback, I wonder if a contributing reason is that it's less medically risky to reverse a vasectomy than reversing e.g. tubal ligation.
(I don't know that it is less risky and/or more likely to succeed. But the vas deferns is incredibly accessible.)
You can see this with people posting pictures of pre-transition Elliot Page and captions like "remember what they took from us" all the time on social media.
Everyone needs to be their own advocate when it comes to medical care but I've heard multiple horror stories from my female friends that would never have occurred to me ("You're overreacting", "It's not that painful", "Maybe it's just cramps", "Have you tried X?").
They're about 50% likely to be reversible after 5 years. That's not what we generally mean when we say something is "reversible". It's a permanent procedure that can sometimes be reversed.
Anyone that says they know their plan that early is just hoping their plan works out. Life is chaotic and full of many surprises.
Choosing not to make strong decisions in fear of some possible regret is it’s own decision, and just as subject to its own possible regret.
Likely the forced birthers will make sterilization illegal too, so the race is on.
The first and most obvious point is that I, personally (FWIW), fully support body autonomy so if people want to get sterilized if they want.
The article points out the issue with regret. I'm not sure how you handle that other than maybe coming up with a more easily reversible procedure?
Either way, if someone may end up regretting a decision is no reason to take that choice away from someone.
But you can't talk about this issue without talking about how the medical profession treats women. Women are often ignored and their pain and concerns are downplayed or outright dismissed, sometimes catastrophically. Some women are sterilized without consent for reasons with little or even no medical basis. If you're not aware, look at the "husband's stitch" for an example of misogynist medical barbarism.
You also can't ignore the politics of this and how the fight against reproductive rights sprang out of "Great Replacement" fears [1]:
> In an 1865 essay issued by order of the AMA, Storer went so far as to say of white women that “upon their loins depends the future destiny of the nation.”
If you think that's ancient history, it isn't [2]. Rep. Mary Miller (R-IL) called the defeat of Roe v. Wade a “victory for white life.” This is the same Miller who said "Hitler Was Right on One Thing" [3].
[1]: https://fivethirtyeight.com/features/how-the-fight-to-ban-ab...
[2]: https://www.youtube.com/watch?v=QtdOAdmqqIY
[3]: https://www.nbcchicago.com/news/local/chicago-politics/illin...
We let people make all sorts of regrettable, life-altering decisions at 22.
At 22, you can be 4 years into your service contract with the armed forces. You could have already died or have been permanently disabled due to these choices.
At 22, you can be a few years into a college education in a major you now know you hate.
At 22, you can be 4 years into a marriage to an abusive partner. Or just an asshole.
These are just a few of the choices you can come to regret later in life. Choices that you cannot change. Choices you will have to live with for the rest of your life. That fundamentally alter all of the choices available to you later in life.
So why should potential regret stay our hand here? Yes, she may regret getting her tubes tied and making conception for her impossible. Oh well. Actions have consequences.
Now from a 22 year old's perspective, this is a terrible argument, and I understand they would be upset.
Doctors make a big deal out of it because of history - forced or unwanted sterilization has been a problem in the past, especially for marginalized people. The difference between men and women's experiences are infuriating and MUST be addressed, but the sentiment is correct.
A successful vasectomy ends in a 50-50 reversal-to-conception ratio, including not just pregnancy via intercourse but by any means necessary (fertility treatments, IVF, etc.). Even this minimally-invasive and "easily-reversible" action is considered permanent. Any permanent sterilization (in CA, not sure about rest of US/world) has a default 30-day waiting period, with the ability to waive down to a minimum 72-hour required delay between consent to permanent sterilization and having the procedure.
Making a permanent decision is not something to be taken lightly, it will be interesting to see what other outcomes of Roe v. Wade change behavior and expectations of large populations.
Are you saying it would be better if men received the same kind of pushback?
> Making a permanent decision is not something to be taken lightly
For sure. And yet - people often have children without too much thought and nobody bats an eye.
(To be clear, that's fine as it's their own business - but the same should be true for sterilization.)
Unsurprisingly the younger a woman gets sterilised, the bigger the chance that she will come to regret it later in life [2]: Study results showed that the younger women were at the time of sterilization, the more likely they were to report regretting that decision. Women undergoing sterilization at the age 30 years or younger were about twice as likely as those over 30 to express regret. They were also from 3.5 to 18 times as likely to request information about reversing the procedure and about 8 times as likely to actually undergo reversal or an evaluation for IVF. Results of studies that examined risk by continuous age showed a consistent inverse relationship between women's age at sterilization and their likelihood of regretting having had the procedure.
Given these facts it would be surprising if young people did not face resistance when requesting sterilisation.
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6203343/
[2] https://pubmed.ncbi.nlm.nih.gov/16413851/