Developmental endocrine influences on gender identity: implications for management of disorders of sex development

When a baby is born, the first medical pronouncement is usually, "It's a boy," or "It's a girl." In most cases, this pronouncement is based simply upon the appearance of the child's external genitalia. Due to variations in the process of sexual differentiation, sometimes the gender that should be assigned is not apparent from inspection of the external genitalia, either because they are "ambiguous" or because their appearance is not congruent with the internal anatomy. Decisions must be made not only about the most appropriate gender to assign the infant but also about the medical and rearing practices that will facilitate optimal psychological development and quality of life for the affected individual. This article will review the approach to managing gender disorders that has evolved since the 1950s. Three issues are identified as central to current shifts that are occurring in the management of these disorders: (a) increased understanding of the biological substrates of gender identity; (b) questions regarding the indications for irreversible cosmetic genital surgeries as a means of reinforcing gender assignments in infancy, and (c) ethical issues pertaining to informed consent and who is entitled to give it, particularly with regard to surgical gender reassignments in infancy. In keeping with the neuropsychiatry theme of this issue, the focus of this article is on prenatal sexual differentiation of the brain as it pertains to the question of psychosexual neutrality at birth.

Psychological long-term outcome in intersex conditions

For decades, sex assignment in children with intersex conditions has depended more on surgical possibilities than on other criteria, since it was assumed that children are psychosexually neutral at birth. Adults with intersex conditions and professionals in the field have increasingly criticized this policy after the publication of studies suggesting that prenatal brain exposure to sex hormones determines gender development. Although prenatal brain exposure to androgens plays some part in the development of gender role behaviour, the current evidence is not in line with the idea of determination of gender identity through prenatal sex steroid exposure. Recent reviews on gender dysphoria and gender change in patients with intersex conditions show that initial gender assignment still seems to be the best predictor of adult gender identity.

Revealing the diagnosis of androgen insensitivity syndrome in adulthood

It is always going to be difficult for a woman to find out that she is genetically male. What are the ethical issues generated by being confronted by outdated practice on disclosure?

Gender dysphoria and gender change in androgen insensitivity or micropenis

This review article answers three questions relevant to the medical management and care of individuals born with complete androgen insensitivity syndrome (CAIS), partial androgen insensitivity syndrome (PAIS), or a micropenis: (1) Do any of these individuals reassign themselves from their initial gender assignment? (2) Do more reassign than the ones who do not? (3) Is there evidence of gender dysphoria in those who do not self-initiate reassignment? Reviewed were all articles on CAIS, PAIS, and micropenis cited in K. J. Zucker (1999) plus articles published through 2004. There were no documented cases of gender change in individuals with CAIS (N= 156 females) or micropenis (N= 89: 79 males, 10 females). Nine (9.1%) out of 99 individuals with PAIS changed gender. Thus, self-initiated gender reassignment was rare. Gender dysphoria also appears to be a rare occurrence. The best predictor of adult gender identity in CAIS, PAIS, and micropenis is initial gender assignment.

Clinical, hormonal, behavioral, and genetic characteristics of androgen insensitivity syndrome in a Brazilian cohort: five novel mutations in the androgen receptor gene

Androgen insensitivity syndrome (AIS) is caused by mutations in the androgen receptor gene and is associated with a variety of phenotypes in 46,XY individuals, ranging from phenotypic women [complete form (CAIS)] to men with minor degrees of undervirilization or infertility [partial form (PAIS)]. We studied 32 subjects with male pseudohermaphroditism from 20 families (9 CAIS, 11 PAIS) with the following criteria for AIS: 46,XY karyotype, normal male basal and human chorionic gonadotropin-stimulated levels of serum testosterone and steroid precursors, gynecomastia at puberty, and, in prepubertal patients, a family history suggestive of X-linked inheritance. The entire coding region of the androgen receptor gene was analyzed, and mutations were found in all families with CAIS and in eight of 11 families with PAIS. Fifteen different mutations were identified, including five (S119X, T602P, L768V, I898F, and P904V) that have not been described previously. Detailed clinical and hormonal features were compared with genotype in 25 subjects with AIS and confirmed by mutational analysis. LH hormone levels and the LH x testosterone product were high in all postpubertal subjects with AIS. All subjects with PAIS maintained at postpubertal age the gender identity and social sex that was assigned to them in infancy, in contrast to other forms of pseudohermaphroditism.

Sexual function in women with complete androgen insensitivity syndrome

OBJECTIVE

To investigate sexual function in women with complete androgen insensitivity syndrome (CAIS) and to investigate the prevalence of factors that might contribute to sexual difficulties.

DESIGN

Cross sectional survey and clinical examination.

SETTING

Tertiary hospital multidisciplinary intersex clinic and an international peer support group for CAIS.

PATIENT(S)

Sixty-six adult women with CAIS.

INTERVENTION(S)

Self-completed survey of sexual function, genital normality perceptions, and compliance and satisfaction with vaginal hypoplasia treatments. Hospital case notes review, and genital examination for prevalence of vaginal and clitoral hypoplasia.

MAIN OUTCOME MEASURE(S)

Golombok-Rust Inventory of Sexual Satisfaction (GRISS) scores of study participants were compared against the scores of the test validation population (as control). In physical examination participants, anatomical dimensions were assessed against published normal values for clitoral and vaginal sizes.

RESULT(S)

We found that 90% of women with CAIS in this study had sexual difficulties when compared with the general female population, most commonly sexual infrequency and vaginal penetration difficulty; 77% perceived their vagina as small, but on genital examination only 35% had vaginal hypoplasia.

CONCLUSION(S)

Androgen deficiency leads to sexual problems. Vaginal hypoplasia and negative psychological adaptation to living with an intersex condition are likely to have contributed to the high rates of sexual problems found in this study. Treatments for vaginal hypoplasia need to be evaluated with outcome studies of long-term sexual function, quality of life, and satisfaction. Clinical services for the management of intersex conditions need to be multidisciplinary and aim to optimize the patient's physical and psychological health.

Psychological outcomes and gender-related development in complete androgen insensitivity syndrome

We evaluated psychological outcomes and gender development in 22 women with complete androgen insensitivity syndrome (CAIS). Participants were recruited through a medical database (n = 10) or through a patient support group (n = 12). Controls included 14 males and 33 females, of whom 22 were matched to women with CAIS for age, race, and sex-of-rearing. Outcome measures included quality of life (self-esteem and psychological general well-being), gender-related psychological characteristics (gender identity, sexual orientation, and gender role behavior in childhood and adulthood), marital status, personality traits that show sex differences, and hand preferences. Women recruited through the database versus the support group did not differ systematically, and there were no statistically significant differences between the 22 women with CAIS and the matched controls for any psychological outcome. These findings argue against the need for two X chromosomes or ovaries to determine feminine-typical psychological development in humans and reinforce the important role of the androgen receptor in influencing masculine-typical psychological development. They also suggest that psychological outcomes in women with CAIS are similar to those in other women. However, additional attention to more detailed aspects of psychological well-being in CAIS is needed.

Long-term perspectives for 46,XY patients affected by complete androgen insensitivity syndrome or congenital micropenis

Controversy concerning optimal treatment for individuals affected by syndromes of abnormal sex differentiation can best be resolved with knowledge about long-term medical, surgical, and psychosexual outcomes of patients. Follow-up information has recently been gathered on older cohorts of the following patient groups: (1) those affected by complete androgen insensitivity syndrome (CAIS) raised female and (2) those affected by congenital micropenis raised male or female. As a group, women with CAIS were satisfied with their female gender and sexual function. However, a need for better patient education was identified for this specific population. Most patients with congenital micropenis, whether raised male or female, were satisfied with their gender. Regardless of sex of rearing, dissatisfaction with the appearance and function of the genitalia as judged by both physicians and subjects was evident. For patients with congenital micropenis, male sex of rearing was concluded to be optimal because genital reconstructive surgery is not required with this choice.

Amative orientation: the hormonal hypothesis examined

The hypothesis that human male and female amative orientation, arousal and courtship are sex-hormone dependent had as its precursor John Hunter's recorded but unpublished 18th century experiments of cross-sexed gonadal transplants in chicks. The hypothesis gained momentum in the 20th century after the discovery and eventual marketing of the sex hormones, and after the experimental demonstration by William C. Young that, in guinea-pigs, cross-sexed hormone administered prenatally influenced their subsequent male/female courtship and mating behavior. Comparatively and in review, human clinical syndromes of hypermasculinization and hypomasculinization do not disconfirm the hormonal hypothesis, but they do not adequately confirm it, either. They are compatible with the idea of a cofactor that governs whether amative orientation in practice, ideation and imagery is homosexual, heterosexual or bisexual.

Androgen insensitivity syndrome (AIS): emotional reactions of parents and adult patients to the clinical diagnosis of AIS and its confirmation by androgen receptor gene mutation analysis

The emotional reactions of parents and adult patients on disclosure of the clinical diagnosis of androgen insensitivity syndrome (AIS) and its later confirmation by gene mutation analysis were assessed. A semistructured interview and three questionnaires were used. Parents came from 18 different families with a total of 20 children (15 complete AIS, 5 partial AIS), 19 raised as girls, 1 as a boy. Ten adult women with complete AIS came from six families. The short-term reaction upon the clinical diagnosis was in the majority of both parents and adult patients associated with shock, grief, anger, and shame and in the mothers and adult patients with guilt. Emotional reactions were more long-lasting in mothers and adult patients than in fathers. The confirmation by DNA analysis did not alter the actual feelings of both parents. Adolescents with AIS should be informed completely - but in a step-by-step way - about their condition, since adult patients indicated that they had suffered from being not at all or misinformed about AIS in their adolescence.

Complete androgen insensitivity syndrome: long-term medical, surgical, and psychosexual outcome

Controversy concerning the most appropriate treatment guidelines for intersex children currently exists. This is due to a lack of long-term information regarding medical, surgical, and psychosexual outcome in affected adults. We have assessed by questionnaire and medical examination the physical and psychosexual status of 14 women with documented complete androgen insensitivity syndrome (CAIS). We have also determined participant knowledge of CAIS as well as opinion of medical and surgical treatment. As a whole, secondary sexual development of these women was satisfactory, as judged by both participants and physicians. In general, most women were satisfied with their psychosexual development and sexual function. Factors reported to contribute to dissatisfaction were sexual abuse in one case and marked obesity in another. All of the women who participated were satisfied with having been raised as females, and none desired a gender reassignment. Although not perfect, the medical, surgical, and psychosexual outcomes for women with CAIS were satisfactory; however, specific ways for improving long-term treatment of this population were identified.

Abnormal sexual development and psychosexual issues

Animal models of gonadal hormone influences on the sexual differentiation of brain and behaviour are reviewed and discussed as a basis for predicting hormonal influences on human neurobehavioural development. Behavioural outcomes in clinical intersex cases, including congenital adrenal hyperplasia, androgen insensitivity syndrome, enzymatic deficiencies and situations in which hormones have been prescribed during pregnancy are reviewed. It is concluded that the prenatal or neonatal hormone environment contributes to the development of human behaviours that show sex differences, particularly childhood play behaviour, sexual orientation and core gender identity. There also is some evidence for influences on aggression and cognition. It is also concluded that additional research is needed to determine why some intersex patients assigned and reared as girls are not successful in this identity and role.

Medical ethics and truth telling in the case of androgen insensitivity syndrome

Should a physician always tell the truth to a patient? Is biomedical ethics too "politically correct" in certain situations? The second-place winner in the 1995 Logie Medical Ethics Essay Contest discusses whether telling the truth is the proper course for a physician dealing with certain patients.

Eysenck's personality dimensions and sex steroids in male abstinent alcoholics and nonalcoholics: an exploratory study

This study investigated the relationship between alcoholics' personality characteristics [as indexed by the Eysenck Personality Questionnaire (EPQ)] and sex steroid levels. Three serum samples were drawn over a 90-min period in 58 inpatient male alcoholics (mean 33 days sober) and 33 non-alcoholic controls. The EPQ was administered at approximately the same point in the treatment process. Replicating previous work, we found alcoholics scored significantly higher on the Neuroticism and Psychoticism scales of the EPQ than controls. Alcoholics also had higher levels of estradiol and total testosterone than controls, which may be reflective of a biological rebound or characteristic premorbid levels. A significant positive correlation was found between testosterone and extroversion in controls, but not in alcoholics. Alcoholics showed a positive correlation between estradiol and neuroticism and a negative relationship between estradiol and extroversion. The results suggest that (a) 'normal' hormone-personality relationships are disrupted in male alcoholics, and b) personality and psychological changes consistent with the physical feminization syndrome may occur in male alcoholics.