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Kung KTF, Louie K, Spencer D, Hines M. Prenatal androgen exposure and sex-typical play behaviour: A meta-analysis of classic congenital adrenal hyperplasia studies. Neurosci Biobehav Rev 2024; 159:105616. [PMID: 38447820 DOI: 10.1016/j.neubiorev.2024.105616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 03/08/2024]
Abstract
Thousands of non-human mammal experiments have demonstrated that early androgen exposure exerts long-lasting effects on neurobehavioural sexual differentiation. In humans, females with classic congenital adrenal hyperplasia (CAH) are exposed to unusually high concentrations of androgens prenatally, whereas prenatal concentrations of androgens in males with CAH are largely normal. The current meta-analysis included 20 independent samples and employed multi-level meta-analytic models. Consistently across all 7 male-typical and female-typical play outcomes, in the expected directions, the present study found significant and large average differences between control males and control females (gs = 0.83-2.78) as well as between females with CAH and control females (gs = 0.95-1.08), but differences between males with CAH and control males were mostly negligible and were non-significant for 6 of the 7 outcomes (gs = 0.04-0.27). These meta-analytic findings suggest that prenatal androgen exposure masculinises and defeminises play behaviour in humans. Broader implications in relation to sex chromosomes, brain development, oestrogens, socio-cognitive influences, other aspects of sex-related behavioural development, and gender nonconformity are discussed.
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Affiliation(s)
- Karson T F Kung
- Department of Psychology, Jockey Club Tower, Centennial Campus, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region.
| | - Krisya Louie
- Department of Psychology, Jockey Club Tower, Centennial Campus, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region
| | - Debra Spencer
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, United Kingdom
| | - Melissa Hines
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, United Kingdom
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Aziz NA, Mohd Ali MH, Ramli R. Hysterectomy in a phenotypic male with congenital adrenal hyperplasia (CAH). BMJ Case Rep 2022; 15:e246603. [PMID: 35135794 PMCID: PMC8830105 DOI: 10.1136/bcr-2021-246603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/04/2022] Open
Abstract
A young adult patient with 46XX congenital adrenal hyperplasia (CAH) presented with recurrent painful haematuria. CAH was diagnosed at birth following ambiguous genitalia. Hormonal treatment was started, female gender was assigned and feminising genitoplasty was planned, however the patient was lost to follow-up. Gender dysphoria started to occur during childhood which prompted the family to raise the patient as a boy. He eventually identified himself as a male. Examination revealed a male phenotype with severely virilised genitalia. Imaging studies confirmed the presence of uterus with low confluent urogenital sinus. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed, and the troublesome symptoms were cured.
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Affiliation(s)
- Nor Azimah Aziz
- Department of Obstetrics & Gynaecology, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia
| | - Masliza Hanuni Mohd Ali
- Department of Internal Medicine (Endocrinology Unit), Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia
| | - Roziana Ramli
- Department of Obstetrics & Gynaecology, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia
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Risso R, Einaudi S, Crespi C, Caldarera A, Verna F, Merlini E, Lala R. Sex attribution, gender identity and quality of life in disorders of sex development due to 45,X/46,XY mosaicism: methods for clinical and psychosocial assessment. AIMS GENETICS 2021. [DOI: 10.3934/genet.2015.2.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AbstractThe choice of sex in newborns with genital ambiguity is challenging. Information concerning the satisfaction of subjects with disorders of sex development from childhood to adulthood is required in order to address sex attribution policies. This study focuses on the methods that enable clinicians to investigate the alignment of phenotypes with gender identity and quality of life in people with disorders of this kind. These methods are presented as tools for studying a cohort of ten subjects with 45,X/46,XY mosaicism examined between 1985 and 2014 in the Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Turin: five children and five young adults, four reared as females and six as males. Clinical outcome was assessed by means of a clinical scoring system considering height, genital appearance, gonads and pubertal development. The Gender Identity Questionnaire for Children and the World Health Organization Quality of Life assessment were adopted. The four male children strongly identified with their assigned sex: male attribution was satisfactory until pubertal age. In young adults the clinical scores ranged between 55–65% for both genders. In the young male, the reduced sexual activity and the poor body image perception strongly affected his quality of life. The clinical scores of the two young female adults (60% for both) were not balanced with their quality of life scores (87.5% and 68.75% respectively): individual traits and social-familial context should be investigated in order to explain these differences. Clinical and psychosocial assessment in people with disorders of sex development is mandatory in order to plan care procedures; a detailed analysis requires adequate tools. Clinical scoring system, Gender Identity Questionnaire for Children and World Health Organization Quality of Life assessment can be used to investigate the alignment of physical phenotype with gender identity and quality of life.
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Affiliation(s)
- Roberta Risso
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Città della Salute e della Scienza, 10126, Turin, Italy
| | - Silvia Einaudi
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Città della Salute e della Scienza, 10126, Turin, Italy
| | - Chiara Crespi
- Department of Endocrinology of San Giovanni Battista Hospital, Città della Salute e della Scienza, 10126, Turin, Italy
| | - Angela Caldarera
- Department of Psychology, University of Turin, 10126, Turin, Italy
| | - Francesca Verna
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Città della Salute e della Scienza, 10126, Turin, Italy
| | - Emilio Merlini
- Department of Pediatric Urology, Regina Margherita Children's Hospital, Città della Salute e della Scienza, 10126, Turin, Italy
| | - Roberto Lala
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Città della Salute e della Scienza, 10126, Turin, Italy
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Hamed SA, Attiah FA, Abd Elaal RF, Fawzy M. Behavioral assessment of females with congenital adrenal hyperplasia. Hormones (Athens) 2021; 20:131-141. [PMID: 32740726 DOI: 10.1007/s42000-020-00232-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/22/2020] [Indexed: 11/08/2022]
Abstract
PURPOSE Patients with congenital adrenal hyperplasia (CAH) have an increased risk of psychological/psychiatric symptoms and disorders. This study aimed to assess the behavior of girls with CAH and its independent risk variables. METHODS This cross-sectional study included 55 girls with CAH due to 21-hydroxylase deficiency (mean age 12.64 ± 1.52 years; salt-wasting (SW) form = 20, simple virilizing (SV) form = 35). Psychiatric interviewing and the Strength and Difficulties Questionnaire (SDQ) (parent-reporting questionnaires) were used to assess behavior. RESULTS Compared to controls (n = 60), patients had a high total SDQ score (P = 0.001) and emotional, conduct, and hyperactivity-inattention symptoms, peer relationship problems (P = 0.001 for all), and prosocial behavior (p = 0.01) subscale scores, indicating externalizing and internalizing behavioral problems. Severe emotional symptoms and poor disease control were found with SW compared to the SV form. Multiple linear regression showed that bone age (BA) (β = 0.331, t = 3.608; P = 0.001) and 17-OHP (β = 0.408, t = 4.220; P = 0.001), testosterone (β = 0.348, t = 3.220; P = 0.001), and androstenedione (β = 0.238, t = 2.487; P = 0.015) levels were independently associated with behavioral problems. CONCLUSION Females with CAH had frequent and severe behavioral symptoms. Excess androgenization, which was in part due to suboptimal steroid therapy, was the cause of the behavioral problems. Therefore, early optimization of CAH management should be stressed to prevent psychological consequences.
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Affiliation(s)
- Sherifa Ahmed Hamed
- Department of Neurology and Psychiatry, Assiut University Hospital, P. O. Box 71516, Assiut, Egypt.
| | - Fadia Ahmed Attiah
- Department of Neurology and Psychiatry, Assiut University Hospital, P. O. Box 71516, Assiut, Egypt
| | | | - Mohamed Fawzy
- Department of Neurology and Psychiatry, Assiut University Hospital, P. O. Box 71516, Assiut, Egypt
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5
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Swaab DF, Wolff SEC, Bao AM. Sexual differentiation of the human hypothalamus: Relationship to gender identity and sexual orientation. HANDBOOK OF CLINICAL NEUROLOGY 2021; 181:427-443. [PMID: 34238476 DOI: 10.1016/b978-0-12-820683-6.00031-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Gender identity (an individual's perception of being male or female) and sexual orientation (heterosexuality, homosexuality, or bisexuality) are programmed into our brain during early development. During the intrauterine period in the second half of pregnancy, a testosterone surge masculinizes the fetal male brain. If such a testosterone surge does not occur, this will result in a feminine brain. As sexual differentiation of the brain takes place at a much later stage in development than sexual differentiation of the genitals, these two processes can be influenced independently of each other and can result in gender dysphoria. Nature produces a great variability for all aspects of sexual differentiation of the brain. Mechanisms involved in sexual differentiation of the brain include hormones, genetics, epigenetics, endocrine disruptors, immune response, and self-organization. Furthermore, structural and functional differences in the hypothalamus relating to gender dysphoria and sexual orientation are described in this review. All the genetic, postmortem, and in vivo scanning observations support the neurobiological theory about the origin of gender dysphoria, i.e., it is the sizes of brain structures, the neuron numbers, the molecular composition, functions, and connectivity of brain structures that determine our gender identity or sexual orientation. There is no evidence that one's postnatal social environment plays a crucial role in the development of gender identity or sexual orientation.
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Affiliation(s)
- Dick F Swaab
- Department Neuropsychiatric Disorders, Netherlands Institute for Neuroscience, An Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
| | - Samantha E C Wolff
- Department Neuropsychiatric Disorders, Netherlands Institute for Neuroscience, An Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
| | - Ai-Min Bao
- Department of Neurobiology and Department of Neurology of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; NHC and CAMS Key Laboratory of Medical Neurobiology, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, China.
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Abstract
Human gender-related behavior/psychology is shaped by a developmental system that involves numerous influences interacting over time. Understanding of the full range of elements in the system and how they interact is currently incomplete. The available evidence suggests, however, that early exposure to testosterone, postnatal socialization, e.g., by parents and peers, and self-socialization related to cognitive understanding of gender are important elements. This article focuses on prenatal and early neonatal influences of testosterone on gender-related psychological/behavioral outcomes, and contextualizes these hormonal influences within an understanding of socialization influences. There is consistent evidence that early testosterone exposure influences childhood gender role behavior, including sex-typical toy play, as well as gender identity and sexual orientation. Evidence for similar hormonal influences on spatial ability and on traits related to autism, or autistic spectrum disorder, is inconsistent. Evidence from girls exposed to elevated testosterone prenatally suggests that they experience alterations in processes of external socialization, as well as self-socialization, and that these, along with early testosterone exposure, shape gender-related outcomes.
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Affiliation(s)
- Melissa Hines
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge, CB2 3RQ, UK.
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Flint C, Förster K, Koser SA, Konrad C, Zwitserlood P, Berger K, Hermesdorf M, Kircher T, Nenadic I, Krug A, Baune BT, Dohm K, Redlich R, Opel N, Arolt V, Hahn T, Jiang X, Dannlowski U, Grotegerd D. Biological sex classification with structural MRI data shows increased misclassification in transgender women. Neuropsychopharmacology 2020; 45:1758-1765. [PMID: 32272482 PMCID: PMC7419542 DOI: 10.1038/s41386-020-0666-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/28/2020] [Accepted: 03/23/2020] [Indexed: 12/14/2022]
Abstract
Transgender individuals (TIs) show brain-structural alterations that differ from their biological sex as well as their perceived gender. To substantiate evidence that the brain structure of TIs differs from male and female, we use a combined multivariate and univariate approach. Gray matter segments resulting from voxel-based morphometry preprocessing of N = 1753 cisgender (CG) healthy participants were used to train (N = 1402) and validate (20% holdout N = 351) a support-vector machine classifying the biological sex. As a second validation, we classified N = 1104 patients with depression. A third validation was performed using the matched CG sample of the transgender women (TW) application sample. Subsequently, the classifier was applied to N = 26 TW. Finally, we compared brain volumes of CG-men, women, and TW-pre/post treatment cross-sex hormone treatment (CHT) in a univariate analysis controlling for sexual orientation, age, and total brain volume. The application of our biological sex classifier to the transgender sample resulted in a significantly lower true positive rate (TPR-male = 56.0%). The TPR did not differ between CG-individuals with (TPR-male = 86.9%) and without depression (TPR-male = 88.5%). The univariate analysis of the transgender application-sample revealed that TW-pre/post treatment show brain-structural differences from CG-women and CG-men in the putamen and insula, as well as the whole-brain analysis. Our results support the hypothesis that brain structure in TW differs from brain structure of their biological sex (male) as well as their perceived gender (female). This finding substantiates evidence that TIs show specific brain-structural alterations leading to a different pattern of brain structure than CG-individuals.
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Affiliation(s)
- Claas Flint
- grid.5949.10000 0001 2172 9288Department of Psychiatry, University of Münster, Albert Schweitzer-Campus 1, A9, 48149 Münster, Germany ,grid.5949.10000 0001 2172 9288Department of Computer Science, University of Münster, Einsteinstraße 62, 48149 Münster, Germany
| | - Katharina Förster
- grid.5949.10000 0001 2172 9288Department of Psychiatry, University of Münster, Albert Schweitzer-Campus 1, A9, 48149 Münster, Germany
| | - Sophie A. Koser
- grid.5949.10000 0001 2172 9288Department of Psychiatry, University of Münster, Albert Schweitzer-Campus 1, A9, 48149 Münster, Germany
| | - Carsten Konrad
- grid.440210.30000 0004 0560 2107Department of Psychiatry and Psychotherapy, Agaplesion Diakonieklinikum, 27356 Rotenburg, Germany
| | - Pienie Zwitserlood
- grid.5949.10000 0001 2172 9288Department of Psychology, University of Münster, Fliednerstraße 21, 48149 Münster, Germany
| | - Klaus Berger
- grid.5949.10000 0001 2172 9288Department of Epidemiology and Social Medicine, University of Münster, Albert Schweitzer-Campus 1, D3, 48149 Münster, Germany
| | - Marco Hermesdorf
- grid.5949.10000 0001 2172 9288Department of Epidemiology and Social Medicine, University of Münster, Albert Schweitzer-Campus 1, D3, 48149 Münster, Germany
| | - Tilo Kircher
- grid.10253.350000 0004 1936 9756Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany
| | - Igor Nenadic
- grid.10253.350000 0004 1936 9756Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany
| | - Axel Krug
- grid.10253.350000 0004 1936 9756Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany
| | - Bernhard T. Baune
- grid.5949.10000 0001 2172 9288Department of Psychiatry, University of Münster, Albert Schweitzer-Campus 1, A9, 48149 Münster, Germany ,grid.1008.90000 0001 2179 088XDepartment of Psychiatry, Melbourne Medical School, The University of Melbourne, Parkville, VIC Australia ,grid.1008.90000 0001 2179 088XThe Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC Australia
| | - Katharina Dohm
- grid.5949.10000 0001 2172 9288Department of Psychiatry, University of Münster, Albert Schweitzer-Campus 1, A9, 48149 Münster, Germany
| | - Ronny Redlich
- grid.5949.10000 0001 2172 9288Department of Psychiatry, University of Münster, Albert Schweitzer-Campus 1, A9, 48149 Münster, Germany
| | - Nils Opel
- grid.5949.10000 0001 2172 9288Department of Psychiatry, University of Münster, Albert Schweitzer-Campus 1, A9, 48149 Münster, Germany
| | - Volker Arolt
- grid.5949.10000 0001 2172 9288Department of Psychiatry, University of Münster, Albert Schweitzer-Campus 1, A9, 48149 Münster, Germany
| | - Tim Hahn
- grid.5949.10000 0001 2172 9288Department of Psychiatry, University of Münster, Albert Schweitzer-Campus 1, A9, 48149 Münster, Germany
| | - Xiaoyi Jiang
- grid.5949.10000 0001 2172 9288Department of Computer Science, University of Münster, Einsteinstraße 62, 48149 Münster, Germany
| | - Udo Dannlowski
- Department of Psychiatry, University of Münster, Albert Schweitzer-Campus 1, A9, 48149, Münster, Germany.
| | - Dominik Grotegerd
- grid.5949.10000 0001 2172 9288Department of Psychiatry, University of Münster, Albert Schweitzer-Campus 1, A9, 48149 Münster, Germany
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Ristori J, Cocchetti C, Romani A, Mazzoli F, Vignozzi L, Maggi M, Fisher AD. Brain Sex Differences Related to Gender Identity Development: Genes or Hormones? Int J Mol Sci 2020; 21:ijms21062123. [PMID: 32204531 PMCID: PMC7139786 DOI: 10.3390/ijms21062123] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/21/2020] [Accepted: 02/28/2020] [Indexed: 12/19/2022] Open
Abstract
The complex process of sexual differentiation is known to be influenced by biological and environmental determinants. The present review has the aim of summarizing the most relevant studies on the biological basis of sexual development, and in particular, it focuses on the impact of sex hormones and genetic background on the development of sexual differentiation and gender identity. The authors conducted a search of published studies on Medline (from January 1948 to December 2019). The evidence suggests that the sexual dimorphic brain could be the anatomical substrate of psychosexual development, on which gonadal hormones may have a shaping role during prenatal and pubertal periods. Additionally, according to several heritability studies, genetic components may have a role, but a promising candidate gene has not been identified. Even though growing evidence underlines the primary role of biological factors on psychosexual development, further studies are necessary to better explain their complex interactions.
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Affiliation(s)
- Jiska Ristori
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
| | - Carlotta Cocchetti
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
| | - Alessia Romani
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
| | - Francesca Mazzoli
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
| | - Linda Vignozzi
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
| | - Mario Maggi
- Endocrinology, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy;
| | - Alessandra Daphne Fisher
- Andrology, Women’s Endocrinology and Gender Incongruence, Careggi University Hospital, Viale Pieraccini 6, 50139 Florence, Italy; (J.R.); (C.C.); (A.R.); (F.M.); (L.V.)
- Correspondence:
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de Jesus LE, Costa EC, Dekermacher S. Gender dysphoria and XX congenital adrenal hyperplasia: how frequent is it? Is male-sex rearing a good idea? J Pediatr Surg 2019; 54:2421-2427. [PMID: 30905417 DOI: 10.1016/j.jpedsurg.2019.01.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/26/2019] [Accepted: 01/30/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The frequency of gender dysphoria (GD) among 46,XX congenital adrenal hyperplasia (CAH) patients is unknown. These data are needed to put into perspective the debate about the timing of reconstructive surgery and possible male-raising of the most severely virilized children. OBJECTIVE To analyze the frequency of female to male GD between 46,XX individuals raised as females; to identify subgroups with higher chances of showing GD; to describe the results of male-raising among 46,XX CAH patients. MATERIALS AND METHODS Analytic/descriptive literature review (January 1988 to April 2018). RESULTS Female-raised patients frequently report the desire to be male, adopt male-typical behavior and are frequently homosexual/bisexual as adults, but this does not correspond to GD. Declared GD among 46,XX CAH patients attained 9% of the reported cohorts, generally in late adolescence/adulthood. We could not prove a relationship between inadequate treatment, null-genotype, late diagnoses, a higher degree of virilization, type of CAH or higher levels of androgens and female to male GD, but this may be due to statistical limitations. Male gender raised patients (MGR) were 10.1% of CAH cohorts included in this review, mostly from underdeveloped countries, with a high proportion of late diagnoses (76.3%) and familial choices. GD was more common in this group than among female-raised patients. Opting for male gender relates to a short final height, the need for multiple surgeries, surgical castration before puberty and infertility. CONCLUSION Both male to female and female to male GD may present in 46,XX CAH patients in a contemporaneous cohort. The proportion of GD is higher among patients raised as males. DSD patients sexual maladjustments are complex and not comparable to the transgender population. Many 46,XX CAH patients with GD define themselves as gender-fluid and do not seek for legal/formal transition. Male-raising Prader 4/5 46,XX CAH patients imply infertility and multiple surgeries. There is no proof that any subgroup of CAH is more prone to GD, despite null genotypes, salt wasting phenotypes and Prader 4/5 cases being related to male-typical behavior and female homosexuality. TYPE OF STUDY Descriptive/analytic non-systematic REVIEW. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Lisieux Eyer de Jesus
- Pediatric Urology and Surgery Department, Servidores do Estado Federal Hospital, UFF, Rio de Janeiro, Brazil; Pediatric Surgery and Urology Department, Antonio Pedro University Hospital, UFF, Rio de Janeiro, Brazil.
| | - Eduardo Corrêa Costa
- Pediatric Surgery and Urology Department, Porto Alegre Clinics Hospital, UFRS, Porto Alegre, Brazil
| | - Samuel Dekermacher
- Pediatric Urology and Surgery Department, Servidores do Estado Federal Hospital, UFF, Rio de Janeiro, Brazil
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10
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Grassi S, Morelli V, Arosio M, Buoli M. Gender Identity Fluctuation in a Genetic Female with Late-Onset, Non-Classical Congenital Adrenal Hyperplasia. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:1265-1268. [PMID: 30911871 DOI: 10.1007/s10508-019-1440-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 03/18/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Silvia Grassi
- Department of Psychiatry, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via F. Sforza 35, 20122, Milan, Italy
| | - Valentina Morelli
- Endocrinology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maura Arosio
- Endocrinology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Massimiliano Buoli
- Department of Psychiatry, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.
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Loch Batista R, Inácio M, Prado Arnhold IJ, Gomes NL, Diniz Faria JA, Rodrigues de Moraes D, Frade Costa EM, Domenice S, Bilharinho Mendonça B. Psychosexual Aspects, Effects of Prenatal Androgen Exposure, and Gender Change in 46,XY Disorders of Sex Development. J Clin Endocrinol Metab 2019; 104:1160-1170. [PMID: 30388241 DOI: 10.1210/jc.2018-01866] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 10/29/2018] [Indexed: 12/20/2022]
Abstract
CONTEXT In 46,XY disorders of sexual development (DSD) patients, several factors may affect psychosexual development, leading to gender identity discrepancy and gender change later in life. Prenatal sexual steroid exposure and external genital virilization are considered to influence human psychosexual development, but their roles not completely understood yet. DESIGN A total of 144 individuals (18 to 60 years of age) with a clinical/molecular diagnosis of 46,XY DSD from a single tertiary center were enrolled. Psychosexual outcomes (gender role, gender identity, and sexual orientation) were assessed using questionnaires and psychological test. The Sinnecker score was used for genital virilization measurement. Prenatal androgen exposure was estimated according to 46,XY DSD etiology. RESULTS We found a positive association between prenatal androgen exposure and male psychosexual outcomes. Alternatively, prenatal estrogen exposure, age of gonadectomy, and the degree of external genital virilization did not influence any psychosexual outcome. There were 19% (n = 27) with gender change, which was associated with prenatal androgen exposure (P < 0.001) but not with the external genital virilization. The median age of gender change was 15 years, but most of the patients reported the desire for gender change earlier. CONCLUSIONS Prenatal androgen exposure influenced psychosexual development in 46,XY DSD favoring male psychosexuality in all psychosexual outcomes, whereas the degree of external genital virilization did not influence these outcomes. The organizational effect of sexual steroids on psychosexuality at puberty appears to be weak in comparison with the prenatal effects. Prenatal androgen exposure also influenced female-to-male gender change frequency. All 46,XY DSD conditions with prenatal androgen exposure must be followed for gender issues in their management.
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Affiliation(s)
- Rafael Loch Batista
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marlene Inácio
- Psychology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ivo Jorge Prado Arnhold
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nathália Lisboa Gomes
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - José Antônio Diniz Faria
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Daniela Rodrigues de Moraes
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Elaine Maria Frade Costa
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Berenice Bilharinho Mendonça
- Developmental Endocrinology Unit, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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12
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Kim HJ. Response to Apóstolos et al.'s (2018) "Gender Identity and Sexual Function in 46,XX Patients with Congenital Adrenal Hyperplasia Raised as Males". ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:675-677. [PMID: 30659438 DOI: 10.1007/s10508-018-1386-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 12/19/2018] [Indexed: 06/09/2023]
Affiliation(s)
- Hee Jin Kim
- Department of Internal Medicine, Dankook University College of Medicine, 119, Dandae-ro, Dongnam-gu, Cheonan-si, Chungnam, 31116, Republic of Korea.
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13
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Fisher AD, Ristori J, Morelli G, Maggi M. The molecular mechanisms of sexual orientation and gender identity. Mol Cell Endocrinol 2018; 467:3-13. [PMID: 28847741 DOI: 10.1016/j.mce.2017.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/02/2017] [Accepted: 08/15/2017] [Indexed: 12/21/2022]
Abstract
Differences between males and females are widely represented in nature. There are gender differences in phenotypes, personality traits, behaviors and interests, cognitive performance, and proneness to specific diseases. The most marked difference in humans is represented by sexual orientation and core gender identity, the origins of which are still controversial and far from being understood. Debates continue on whether sexual behavior and gender identity are a result of biological (nature) or cultural (nurture) factors, with biology possibly playing a major role. The main goal of this review is to summarize the studies available to date on the biological factors involved in the development of both sexual orientation and gender identity. A systematic search of published evidence was performed using Medline (from January 1948 to June 2017). Review of the relevant literature was based on authors' expertise. Indeed, different studies have documented the possible role and interaction of neuroanatomic, hormonal and genetic factors. The sexual dimorphic brain is considered the anatomical substrate of psychosexual development, on which genes and gonadal hormones may have a shaping effect. In particular, growing evidence shows that prenatal and pubertal sex hormones permanently affect human behavior. In addition, heritability studies have demonstrated a role of genetic components. However, a convincing candidate gene has not been identified. Future studies (e.i. genome wide studies) are needed to better clarify the complex interaction between genes, anatomy and hormonal influences on psychosexual development.
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Affiliation(s)
- Alessandra D Fisher
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Jiska Ristori
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Girolamo Morelli
- Department of Surgical, Medical, Molecular and of the Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Mario Maggi
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, Florence, Italy.
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14
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Razzaghy-Azar M, Karimi S, Shirazi E. Gender Identity in Patients with Congenital Adrenal Hyperplasia. Int J Endocrinol Metab 2017; 15:e12537. [PMID: 29201068 PMCID: PMC5701969 DOI: 10.5812/ijem.12537] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 05/23/2017] [Accepted: 07/02/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Sex assignment in infancy for patients with disorder of sex development (DSD) is a challenging problem. Some of the patients with congenital adrenal hyperplasia (CAH) have DSD that may affect their gender identity. OBJECTIVES The study aimed to assess gender identity in patients with CAH. METHODS In this study, 52 patients with CAH, including 22 prepubertal children and 30 adolescents and adults, were assessed using two separate gender identity questionnaires for children and adults based on the criteria of diagnostic and statistical manual of mental disorders, 5th edition. RESULTS In the children group, compatibility was seen between gender identity and rearing gender. In the adult group, there were three cases of mismatching between gender identity and sex assignment composed of two females with poor control and one male with good control with 21-hydroxylase deficiency (21-OHD). Three girls with 11-hydroxylase deficiency (11-OHD) were reared as boy. Two of them with late diagnosis at 5 and 6 years of age had pseudoprecocious puberty. Parents and children did not accept to change the gender. One of them is 36 years old now, is depressed and unsatisfied with her gender, another girl is still child and has male sexual identity. One girl with 11-OHD and early diagnosis at birth with Prader 5 virilization but with good hormonal control was changed to female gender at 12 years of age when female sexual characteristics appeared; she is 34-years-old now, married, and with two children, and she is satisfied with her gender. CONCLUSIONS In patients with CAH, gender identity disorder is a rare finding. Hormonal control, social, familial, and religious beliefs have impacts on gender identity of these patients.
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Affiliation(s)
- Maryam Razzaghy-Azar
- H. Ali-Asghar Children’s Hospital, Iran University of Medical Sciences, Tehran, Iran
- Metabolic Disorders Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sakineh Karimi
- H. Ali-Asghar Children’s Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Elham Shirazi
- H. Ali-Asghar Children’s Hospital, Iran University of Medical Sciences, Tehran, Iran
- Mental Health Research Center, Tehran Institute of Psychiatry-School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
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15
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Westcott GP, Sadeghi-Nejad A, Munoz-Pena J, Blau A, Goodman M, Siegel RD. Gender Reversal And Bilateral Giant Adrenal Myelolipomas In A 46,XX Patient With 21-Hydroxylase Deficiency: Case Report And Review Of The Literature. AACE Clin Case Rep 2017. [DOI: 10.4158/ep161343.cr] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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16
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Khattab A, Yau M, Qamar A, Gangishetti P, Barhen A, Al-Malki S, Mistry H, Anthony W, Toralles MB, New MI. Long term outcomes in 46, XX adult patients with congenital adrenal hyperplasia reared as males. J Steroid Biochem Mol Biol 2017; 165:12-17. [PMID: 27125449 DOI: 10.1016/j.jsbmb.2016.03.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/12/2016] [Accepted: 03/28/2016] [Indexed: 01/11/2023]
Abstract
Patients with Congenital Adrenal Hyperplasia (CAH) owing to 21-hydroxylase deficiency and whose karyotype is 46, XX are usually assigned to the female gender. Reported herein are the long term outcomes in three patients with CAH whose karyotype is 46, XX and who were reared as males. A retrospective review of three CAH patients with a 46, XX karyotype who were reared as males was conducted. Gender assignment, clinical and biochemical data, pre and post-genitoplasty genital examinations were reviewed. Gender identity was tested by an extensive questionnaire. Gender role, sexual preference, marital status and sexual satisfaction were evaluated by interview. The three patients were genotyped for the CYP21A2 gene confirming the diagnosis of CAH. Owing to genital virilization, cultural preferences for male gender and the lack of newborn screening programs the three patients reported herein were assigned to the male gender at birth before the diagnosis of CAH was established. In adulthood the patients remained significantly virilized. Thorough psychosexual assessments in adulthood revealed well established male gender identities compatible with their male gender assignments at birth. In all three patients, gender role and behavior were consistent with male gender identity including sexual intercourse with female partners. The three patients reported herein revealed that male gender assignment to CAH patients with a 46, XX karyotype may have a successful outcome providing there is strong parental support and expert endocrine care. No standard guidelines have been published for the gender assignment of CAH patients with a 46, XX karyotype and genital ambiguity. More studies concerning gender assignment in CAH patients with a 46, XX karyotype reared as males are needed.
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Affiliation(s)
- A Khattab
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - M Yau
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - A Qamar
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - P Gangishetti
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - A Barhen
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - S Al-Malki
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - H Mistry
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - W Anthony
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - M B Toralles
- Genetica Medica, Universidade Federal da Bahia, Salvador, State of Bahia, Brazil
| | - Maria I New
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA.
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17
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Meyer-Bahlburg HFL, Baratz Dalke K, Berenbaum SA, Cohen-Kettenis PT, Hines M, Schober JM. Gender Assignment, Reassignment and Outcome in Disorders of Sex Development: Update of the 2005 Consensus Conference. Horm Res Paediatr 2016; 85:112-8. [PMID: 26727471 DOI: 10.1159/000442386] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/10/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Societal changes are increasingly moving the conceptualization of gender from a set of binary categories towards a bimodal continuum, which along with the cautious conclusions resulting from the 2005 Consensus Conference influences gender-related clinical work with patients with disorders of sex development. OBJECTIVE This article provides an update of these developments over the past decade along with an overview of pertinent new data. CONCLUSION Considerably more research is needed on larger sample sizes with systematic long-term follow-up to ground the emerging trends in clinical management of the highly diverse disorders of sex development syndromes in a solid empirical basis.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute and Department of Psychiatry, College of Physicians & Surgeons of Columbia University, New York, N.Y., USA
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18
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Gangaher A, Jyotsna VP, Chauhan V, John J, Mehta M. Gender of rearing and psychosocial aspect in 46 XX congenital adrenal hyperplasia. Indian J Endocrinol Metab 2016; 20:870-877. [PMID: 27867895 PMCID: PMC5105576 DOI: 10.4103/2230-8210.192922] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In congenital adrenal hyperplasia (CAH) with ambiguous genitalia, assigning gender of rearing can be complex, especially If genitalia is highly virilized. Apart from karyotype, prenatal androgen exposure, patient's gender orientation, sociocultural, and parental influences play a role. The aim of this study was to assess gender dysphoria and psychosocial issues in patients of CAH raised as males and females. MATERIALS AND METHODS This is a cross-sectional study that includes patients (old and new) with CAH who were treated by us in the last 6 months. A semi-structured interview proforma was used to elicit history and psychosocial background of the patients. The clinical and biochemical details were noted. For psychological analysis, patients were screened for gender dysphoria using Parent Report Gender Identity Questionnaire for children <12 years and Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. RESULTS We analyzed 22 46 XX CAH patients among which, 3 were reared as males and 19 as females. Among the 19 patients reared as females, 17 patients showed no gender dysphoria. Two patients revealed gender dysphoria as indicated by their marginally low scores on the gender dysphoria assessment. However, in view of current literature and the age groups of the patients, behavior of the 6-year-old patient can be best understood as being tomboyish. Gender dysphoria in the 22-year-old can be explained by the dominance of psychosocial factors and not hormones alone. Among the three patients reared as males, two prepubertal were satisfied with their male gender identity. The third patient, aged 32 years, had gender dysphoria when reared as a male that resolved when gender was reassigned as female and feminizing surgery was done. CONCLUSION Gender assignment in 46 XX CAH is guided by factors such as degree of virilization of genitalia, gender orientation, patient involvement, sociocultural, and parental influences.
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Affiliation(s)
- Arushi Gangaher
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Viveka P. Jyotsna
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Vasundhera Chauhan
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Jomimol John
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Manju Mehta
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
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19
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Fisher AD, Ristori J, Fanni E, Castellini G, Forti G, Maggi M. Gender identity, gender assignment and reassignment in individuals with disorders of sex development: a major of dilemma. J Endocrinol Invest 2016; 39:1207-1224. [PMID: 27287420 DOI: 10.1007/s40618-016-0482-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 05/04/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Disorders of Sex Development (DSD) are a wide range of congenital conditions characterized by an incongruence of components involved in sexual differentiation, including gender psychosexual development. The management of such disorders is complex, and one of the most crucial decision is represented by gender assignment. In fact, the primary goal in DSD is to have a gender assignment consistent with the underlying gender identity in order to prevent the distress related to a forthcoming Gender Dysphoria. Historically, gender assignment was based essentially on surgical outcomes, assuming the neutrality of gender identity at birth. This policy has been challenged in the past decade refocusing on the importance of prenatal and postnatal hormonal and genetic influences on psychosexual development. AIMS (1) to update the main psychological and medical issues that surround DSD, in particular regarding gender identity and gender assignment; (2) to report specific clinical recommendations according to the different diagnosis. METHODS A systematic search of published evidence was performed using Medline (from 1972 to March 2016). Review of the relevant literature and recommendations was based on authors' expertise. RESULTS A review of gender identity and assignment in DSD is provided as well as clinical recommendations for the management of individuals with DSD. CONCLUSIONS Given the complexity of this management, DSD individuals and their families need to be supported by a specialized multidisciplinary team, which has been universally recognized as the best practice for intersexual conditions. In case of juvenile GD in DSD, the prescription of gonadotropin-releasing hormone analogues, following the World Professional Association for Transgender Health and the Endocrine Society guidelines, should be considered. It should always be taken into account that every DSD person is unique and has to be treated with individualized care. In this perspective, international registries are crucial to improve the understanding of these challenging conditions and clinical practice, in providing a better prediction of gender identity.
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Affiliation(s)
- A D Fisher
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - J Ristori
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - E Fanni
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - G Castellini
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
- Psychiatric Unit, Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - G Forti
- Endocrine Unit, "Center for Research, Transfer and High Education on Chronic, Inflammatory, Degenerative and Neoplastic Disorders for the Development of Novel Therapies" (DENOThe), Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Careggi Hospital, Florence, Italy
| | - M Maggi
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
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20
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Boyle ME, Smith S, Liao LM. Adult Genital Surgery for Intersex: A Solution to What Problem? J Health Psychol 2016; 10:573-84. [PMID: 16014393 DOI: 10.1177/1359105305053431] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The desirability of routine genital surgery for infants with ambiguous genitalia is increasingly debated. But there is less discussion about intersex adults who choose genital surgery, despite evidence suggesting that the results are often unsatisfactory. This study reports on how six women with intersex conditions decided to have feminizing genital surgery and how they evaluated the outcomes. The initial analysis highlighted a chronological transition from surgery as nondilemmatic to surgery as a serious dilemma; a version of Foucauldian discourse analysis was then used to place the women’s experiences in a cultural context. The implications for psychological involvement in services for women with intersex conditions are discussed.
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Affiliation(s)
- Mary E Boyle
- Department of Psychology, University of East London, UK.
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21
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Hines M, Pasterski V, Spencer D, Neufeld S, Patalay P, Hindmarsh PC, Hughes IA, Acerini CL. Prenatal androgen exposure alters girls' responses to information indicating gender-appropriate behaviour. Philos Trans R Soc Lond B Biol Sci 2016; 371:20150125. [PMID: 26833843 DOI: 10.1098/rstb.2015.0125] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2015] [Indexed: 11/12/2022] Open
Abstract
Individual variability in human gender-related behaviour is influenced by many factors, including androgen exposure prenatally, as well as self-socialization and socialization by others postnatally. Many studies have looked at these types of influences in isolation, but little is known about how they work together. Here, we report that girls exposed to high concentrations of androgens prenatally, because they have the genetic condition congenital adrenal hyperplasia, show changes in processes related to self-socialization of gender-related behaviour. Specifically, they are less responsive than other girls to information that particular objects are for girls and they show reduced imitation of female models choosing particular objects. These findings suggest that prenatal androgen exposure may influence subsequent gender-related behaviours, including object (toy) choices, in part by changing processes involved in the self-socialization of gendered behaviour, rather than only by inducing permanent changes in the brain during early development. In addition, the findings suggest that some of the behavioural effects of prenatal androgen exposure might be subject to alteration by postnatal socialization processes. The findings also suggest a previously unknown influence of early androgen exposure on later processes involved in self-socialization of gender-related behaviour, and thus expand understanding of the developmental systems regulating human gender development.
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Affiliation(s)
- Melissa Hines
- Department of Psychology, University of Cambridge, Cambridge, UK
| | - Vickie Pasterski
- Department of Psychology, University of Cambridge, Cambridge, UK Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Debra Spencer
- Department of Psychology, University of Cambridge, Cambridge, UK
| | - Sharon Neufeld
- Department of Psychology, University of Cambridge, Cambridge, UK
| | | | | | - Ieuan A Hughes
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Carlo L Acerini
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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22
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Abstract
Congenital adrenal hyperplasia associated with deficiency of steroid 21-hydroxylase is the most common inborn error in adrenal function and the most common cause of adrenal insufficiency in the pediatric age group. As patients now survive into adulthood, adult health-care providers must also be familiar with this condition. Over the past several years, F1000 has published numerous commentaries updating research and practical guidelines for this condition. The purposes of this review are to summarize basic information defining congenital adrenal hyperplasia and to highlight current knowledge and controversies in management.
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Affiliation(s)
- Phyllis W Speiser
- Department of Pediatrics, Cohen Children's Medical Center and Hofstra North Shore LIJ School of Medicine, New Hyde Park, NY 11040, USA
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23
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Pasterski V, Zucker KJ, Hindmarsh PC, Hughes IA, Acerini C, Spencer D, Neufeld S, Hines M. Increased Cross-Gender Identification Independent of Gender Role Behavior in Girls with Congenital Adrenal Hyperplasia: Results from a Standardized Assessment of 4- to 11-Year-Old Children. ARCHIVES OF SEXUAL BEHAVIOR 2015; 44:1363-75. [PMID: 25239661 DOI: 10.1007/s10508-014-0385-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 08/18/2014] [Accepted: 08/21/2014] [Indexed: 05/02/2023]
Abstract
While reports showing a link between prenatal androgen exposure and human gender role behavior are consistent and the effects are robust, associations to gender identity or cross-gender identification are less clear. The aim of the current study was to investigate potential cross-gender identification in girls exposed prenatally to high concentrations of androgens due to classical congenital adrenal hyperplasia (CAH). Assessment included two standardized measures and a short parent interview assessing frequency of behavioral features of cross-gender identification as conceptualized in Part A of the diagnostic criteria for gender identity disorder (GID) in the DSM-IV-TR. Next, because existing measures may have conflated gender role behavior with gender identity and because the distinction is potentially informative, we factor analyzed items from the measures which included both gender identity and gender role items to establish the independence of the two constructs. Participants were 43 girls and 38 boys with CAH and 41 unaffected female and 31 unaffected male relatives, aged 4- to 11-years. Girls with CAH had more cross-gender responses than female controls on all three measures of cross-gender identification as well as on a composite measure of gender identity independent of gender role behavior. Furthermore, parent report indicated that 5/39 (12.8 %) of the girls with CAH exhibited cross-gender behavior in all five behavioral domains which comprise the cross-gender identification component of GID compared to 0/105 (0.0 %) of the children in the other three groups combined. These data suggest that girls exposed to high concentrations of androgens prenatally are more likely to show cross-gender identification than girls without CAH or boys with and without CAH. Our findings suggest that prenatal androgen exposure could play a role in gender identity development in healthy children, and may be relevant to gender assignment in cases of prenatal hormone disruption, including, in particular, cases of severely virilized 46, XX CAH.
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Affiliation(s)
- Vickie Pasterski
- Department of Psychology, Free School Lane, University of Cambridge, Cambridge, CB2 3RQ, UK,
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24
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Hines M, Constantinescu M, Spencer D. Early androgen exposure and human gender development. Biol Sex Differ 2015; 6:3. [PMID: 25745554 PMCID: PMC4350266 DOI: 10.1186/s13293-015-0022-1] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 02/05/2015] [Indexed: 02/01/2023] Open
Abstract
During early development, testosterone plays an important role in sexual differentiation of the mammalian brain and has enduring influences on behavior. Testosterone exerts these influences at times when the testes are active, as evidenced by higher concentrations of testosterone in developing male than in developing female animals. This article critically reviews the available evidence regarding influences of testosterone on human gender-related development. In humans, testosterone is elevated in males from about weeks 8 to 24 of gestation and then again during early postnatal development. Individuals exposed to atypical concentrations of testosterone or other androgenic hormones prenatally, for example, because of genetic conditions or because their mothers were prescribed hormones during pregnancy, have been consistently found to show increased male-typical juvenile play behavior, alterations in sexual orientation and gender identity (the sense of self as male or female), and increased tendencies to engage in physically aggressive behavior. Studies of other behavioral outcomes following dramatic androgen abnormality prenatally are either too small in their numbers or too inconsistent in their results, to provide similarly conclusive evidence. Studies relating normal variability in testosterone prenatally to subsequent gender-related behavior have produced largely inconsistent results or have yet to be independently replicated. For studies of prenatal exposures in typically developing individuals, testosterone has been measured in single samples of maternal blood or amniotic fluid. These techniques may not be sufficiently powerful to consistently detect influences of testosterone on behavior, particularly in the relatively small samples that have generally been studied. The postnatal surge in testosterone in male infants, sometimes called mini-puberty, may provide a more accessible opportunity for measuring early androgen exposure during typical development. This approach has recently begun to be used, with some promising results relating testosterone during the first few months of postnatal life to later gender-typical play behavior. In replicating and extending these findings, it may be important to assess testosterone when it is maximal (months 1 to 2 postnatal) and to take advantage of the increased reliability afforded by repeated sampling.
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Affiliation(s)
- Melissa Hines
- Department of Psychology, University of Cambridge, Cambridge, UK
| | | | - Debra Spencer
- Department of Psychology, University of Cambridge, Cambridge, UK
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25
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Olvera-Hernández S, Fernández-Guasti A. Perinatal administration of aromatase inhibitors in rodents as animal models of human male homosexuality: similarities and differences. ADVANCES IN NEUROBIOLOGY 2015; 10:381-406. [PMID: 25287550 DOI: 10.1007/978-1-4939-1372-5_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In this chapter we briefly review the evidence supporting the existence of biological influences on sexual orientation. We focus on basic research studies that have affected the estrogen synthesis during the critical periods of brain sexual differentiation in male rat offspring with the use of aromatase inhibitors, such as 1,4,6-androstatriene-3,17 (ATD) and letrozole. The results after prenatal and/or postnatal treatment with ATD reveal that these animals, when adults, show female sexual responses, such as lordosis or proceptive behaviors, but retain their ability to display male sexual activity with a receptive female. Interestingly, the preference and sexual behavior of these rats vary depending upon the circadian rhythm.Recently, we have established that the treatment with low doses of letrozole during the second half of pregnancy produces male rat offspring, that when adults spend more time in the company of a sexually active male than with a receptive female in a preference test. In addition, they display female sexual behavior when forced to interact with a sexually experienced male and some typical male sexual behavior when faced with a sexually receptive female. Interestingly, these males displayed both sexual behavior patterns spontaneously, i.e., in absence of exogenous steroid hormone treatment. Most of these features correspond with those found in human male homosexuals; however, the "bisexual" behavior shown by the letrozole-treated rats may be related to a particular human population. All these data, taken together, permit to propose letrozole prenatal treatment as a suitable animal model to study human male homosexuality and reinforce the hypothesis that human sexual orientation is underlied by changes in the endocrine milieu during early development.
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Affiliation(s)
- Sandra Olvera-Hernández
- Department of Pharmacobiology, Center for Research and Advanced Studies (CINVESTAV), Calzada de los Tenorios 235 Colonia Granjas Coapa, 14330, México, D.F., Mexico,
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González R, Ludwikowski BM. Gender Dysphoria in 46,XX Persons with Adrenogenital Syndrome Raised as Females: An Addendum. Front Pediatr 2014; 2:140. [PMID: 25610825 PMCID: PMC4285136 DOI: 10.3389/fped.2014.00140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/14/2014] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ricardo González
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
| | - Barbara M Ludwikowski
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
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Zainuddin AA, Grover SR, Shamsuddin K, Mahdy ZA. Research on quality of life in female patients with congenital adrenal hyperplasia and issues in developing nations. J Pediatr Adolesc Gynecol 2013; 26:296-304. [PMID: 23507003 DOI: 10.1016/j.jpag.2012.08.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Revised: 07/30/2012] [Accepted: 08/07/2012] [Indexed: 11/16/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is the commonest cause of ambiguous genitalia for female newborns and is one of the conditions under the umbrella term of "Disorders of Sex Development" (DSD). Management of these patients require multidisciplinary collaboration and is challenging because there are many aspects of care, such as the most appropriate timing and extent of feminizing surgery required and attention to psychosexual, psychological, and reproductive issues, which still require attention and reconsideration, even in developed nations. In developing nations, however, additional challenges prevail: poverty, lack of education, lack of easily accessible and affordable medical care, traditional beliefs on intersex, religious, and cultural issues, as well as poor community support. There is a paucity of long-term outcome studies on DSD and CAH to inform on best management to achieve optimal outcome. In a survey conducted on 16 patients with CAH and their parents in a Malaysian tertiary center, 31.3% of patients stated poor knowledge of their condition, and 37.5% did not realize that their medications were required for life. This review on the research done on quality of life (QOL) of female patients with CAH aims: to discuss factors affecting QOL of female patients with CAH, especially in the developing population; to summarize the extant literature on the quality of life outcomes of female patients with CAH; and to offer recommendations to improve QOL outcomes in clinical practice and research.
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Affiliation(s)
- Ani Amelia Zainuddin
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
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Abstract
This article summarizes for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development (DSD) or with non-DSD transgenderism. Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Columbia University, 1051 Riverside Drive, Unit 15, New York, NY 10032, USA.
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Sharma S, Gupta DK. Male genitoplasty for 46 XX congenital adrenal hyperplasia patients presenting late and reared as males. Indian J Endocrinol Metab 2012; 16:935-938. [PMID: 23226638 PMCID: PMC3510963 DOI: 10.4103/2230-8210.102994] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM To evaluate the clinical profile and management of 46 XX Congenital Adrenal Hyperplasia (CAH) patients presenting with severe virilization and assigned a male gender. MATERIALS AND METHODS Of 173 children diagnosed with CAH at the Pediatric Intersex Clinic since 1980, seven children with CAH presented late with severe virilization and were reared as males. All of them were assigned the male sex with removal of the female adnexa. Six were treated with male genitoplasty. Appropriate hormonal supplementation was offered after puberty. RESULTS The mean age at presentation was 14.2 years (7 - 21). Six patients had presented after puberty, only one at seven years of age. Staged male genitoplasty comprising of chordee correction, male urethroplasty, and bilateral testicular prosthesis was performed. The female adnexa (uterus, ovaries, most of the upper vagina, and the fallopian tubes) were removed. The mental makeup was masculine in six and bigender in one. Bilateral mastectomy was performed at puberty in all. Hormonal treatment comprised of glucocorticoids and testosterone. Six patients were comfortable with the outcome of the masculinizing genitoplasty. One had a short-sized phallus. One had repeated attacks of urinary tract infection arising from the retained lower vaginal pouch. Social adjustments were good in all, except in one who had a bigender mental makeup. CONCLUSION CAH patients with severe virilization presenting late and reared as males are extremely rare. However, the assigned gender can be retained adequately as males, meeting the socioeconomic compulsions of the society. The results are satisfactory following appropriate surgical procedures and hormonal supplementation.
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Affiliation(s)
- Shilpa Sharma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra K. Gupta
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
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Abstract
Disorders of sex development (DSDs) are estimated to be prevalent in 0.1-2% of the global population, although these figures are unlikely to adequately represent non-white patients as they are largely based on studies performed in Europe and the USA. Possible causes of DSDs include disruptions to gene expression and regulation-processes that are considered essential for the development of testes and ovaries in the embryo. Gender dysphoria generally affects between 8.5-20% of individuals with DSDs, depending on the type of DSD. Patients with simple virilizing congenital adrenal hyperplasia (CAH), as well as those with CAH and severe virilization, are less likely to have psychosexual disorders than patients with other types of DSD. Early surgery seems to be a safe option for most of these patients. Male sex assignment is an appropriate alternative in patients with Prader IV or V DSDs. Patients with 5α-reductase 2 (5α-RD2) and 17β-hydroxysteroid dehydrogenase 3 (17β-HSD3) deficiencies exhibit the highest rates of gender dysphoria (incidence of up to 63%). Disorders such as ovotesticular DSD and mixed gonadal dysgenesis are relatively rare and it can be difficult to conclusively evaluate patients with these conditions. For all DSDs, it is important that investigators and authors conform to the same nomenclature and definitions to ensure that data can be reliably analysed.
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Byne W, Bradley SJ, Coleman E, Eyler AE, Green R, Menvielle EJ, Meyer-Bahlburg HFL, Pleak RR, Tompkins DA. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. ARCHIVES OF SEXUAL BEHAVIOR 2012; 41:759-96. [PMID: 22736225 DOI: 10.1007/s10508-012-9975-x] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA's position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.
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Affiliation(s)
- William Byne
- Department of Psychiatry, JJ Peters VA Medical Center, Bronx, NY, USA.
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Jürgensen M, Kleinemeier E, Lux A, Steensma TD, Cohen-Kettenis PT, Hiort O, Thyen U, Köhler B. Psychosexual development in adolescents and adults with disorders of sex development--results from the German Clinical Evaluation Study. J Sex Med 2012; 10:2703-14. [PMID: 22548716 DOI: 10.1111/j.1743-6109.2012.02751.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Both biological and psychosocial factors influence psychosexual development. High levels of pre- and postnatal androgens lead to more male-typical behavior. So far, the influence of androgens on gender identity and sexual orientation is unclear. Disorders of sex development (DSDs) are heterogeneous genetic conditions with different levels of prenatal androgens resulting in variations of genital development. Through DSD, the role of the different factors, especially androgen exposure, on psychosexual development can be evaluated. AIM The purpose of the study was to assess psychosexual development in adolescents and adults with different forms of DSD. METHODS For the examination of psychosexual development of 66 adolescents and 110 adults with DSD, the authors used the Utrecht Gender Dysphoria Scale for adolescents, the Questionnaire of Gender Identity for adults, and a condition-specific DSD study questionnaire. Individuals were analyzed in four subgroups reflecting the karyotype, absence/presence of androgen effects, and gender of rearing. MAIN OUTCOME MEASURES Main outcome measures used were gender identity, friendships, love and sexual relationships, and sexual orientation in adolescents and adults with DSD. RESULTS Individuals with DSD did not show increased gender dysphoria. However, partnership and sexuality were identified to be difficult areas of life. Both adolescents and adults with DSD reported fewer experiences regarding love or sexual relationships compared with unaffected individuals. Especially men with DSD and undervirilization and women with DSD and androgen effects less often had a love relationship. Adult women with DSD and androgen effects more frequently engaged in love and sexual relationships with individuals of the same gender compared with women without DSD. CONCLUSION Individuals with DSD experience atypical hormonal influences (higher levels of androgens in girls/women and lower levels in androgens in boys/men); however, they did not show increased gender dysphoria in this study. However, partnership and sexual relationships are difficult areas of life for adolescents and adults with DSD. We recommend that individuals with DSD should get support from a multiprofessional team with competency in assessing and counseling issues regarding relationships and sexuality. Contact to other individuals with DSD can be helpful for nonprofessional support and exchange of experiences.
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Affiliation(s)
- Martina Jürgensen
- Institute for Social Medicine, University Lübeck, Germany Department for Paediatric and Adolescent Medicine, University Lübeck, Germany Institute for Biometry and Medical Informatics, University Otto-von-Guericke, Magdeburg, Germany Gender Clinic, VU University Medical Centre, Amsterdam, The Netherlands Department of Paediatric Endocrinology, University Children's Hospital, Charité, Humboldt University, Berlin
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Abstract
An incongruence between one's physiological sex and the gender identity that is one's basic sense of self as a man or a woman is known as gender identity disorder. In general, the conditions of physiological men having female gender identity and physiological women having male gender identity are called male-to-female and female-to-male gender identity disorder, respectively. Although the precise pathogenesis of gender identity disorder remains unclear, the prevalence of gender identity disorder is quite high, with the rates calculated for male-to-female to be 1:25,000 and female-to-male to be 1:12,000 in Hokkaido, Japan. The diagnosis and treatment of gender identity disorder in Japan are based on the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder, 4th edition. Although gender identity disorder was previously thought to be a psychiatric condition, it is extremely difficult to assign gender identity to physiological sex by psychiatric and psychological treatments. To adapt the figure of the body to the native gender identity, physical treatments such as administration of cross-sex steroids and sex reassignment surgery are considered. However, there are very few institutions that routinely carry out sex reassignment surgery in Japan, even though it is mandatory for changing sex on the census register at the present time. Sex reassignment surgery for male-to-female and female-to-male patients includes orchiectomy, penectomy, clitoroplasty, vaginoplasty and vulvoplasty, and hysterectomy, ovariectomy, metoidioplasty and phalloplasty, respectively. To provide accurate information about physical treatment for patients with gender identity disorder, even urologists who are not actively involved in the diagnosis and treatment of gender identity disorder should understand the fundamental aspects and contemporary problems of gender identity disorder.
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Affiliation(s)
- Naoya Masumori
- GID Clinic, Sapporo Medical University Hospital, and Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan.
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Reiner WG, Reiner DT. Thoughts on the nature of identity: how disorders of sex development inform clinical research about gender identity disorders. JOURNAL OF HOMOSEXUALITY 2012; 59:434-449. [PMID: 22455329 DOI: 10.1080/00918369.2012.653312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Disorders of sex development (DSD), like gender dysphoria, are conditions with major effects on child sexuality and identity, as well as sexual orientation. Each may in some cases lead to change of gender from that assigned neonatally. These similarities-and the conditions' differences-provide a context for reviewing the articles in this issue about clinical approaches to children with gender dysphoria, in relation to assessment, intervention, and ethics.
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Affiliation(s)
- William G Reiner
- Department of Urology, Pediatric Urology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104, USA.
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Jordan-Young RM. Hormones, context, and "brain gender": a review of evidence from congenital adrenal hyperplasia. Soc Sci Med 2011; 74:1738-44. [PMID: 21962724 DOI: 10.1016/j.socscimed.2011.08.026] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 07/19/2011] [Accepted: 08/23/2011] [Indexed: 11/16/2022]
Abstract
Brain organization theory suggests that steroid hormones during fetal development permanently organize the brain for gender, including patterns of sexuality, cognition, temperament, and interests that differ by sex. This widely-accepted theory has important implications for health, ranging from medical management of infants with intersex conditions to suggested etiologies for sex differences in autism, depression, and other mental health problems. Studies of genetic females with congenital adrenal hyperplasia (CAH), in which high prenatal androgens have been linked to both atypical genitals and "masculine" patterns of gender and sexuality, are particularly important. Based on a comprehensive review of research on CAH, this article demonstrates that such studies have neglected four broad categories of variables that plausibly affect psychosexual development: (1) physiological effects of CAH, including complex disruption of steroid hormones from early development onwards; (2) intensive medical intervention and surveillance, which many women with CAH describe as traumatic; (3) direct effects of genital morphology on sexuality (versus indirect effects that "masculine" genitals may have on gender socialization); and (4) expectations of masculinization that likely affect both the development and evaluation of gender and sexuality in CAH. Complex and iterative interactions among postnatal biological variables, medical interventions, and social context provide a more plausible explanation for atypicalities in psychology and behavior that have been reported for genetic females with CAH than the conventional explanation that early androgens have "masculinized" their brains.
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Affiliation(s)
- Rebecca M Jordan-Young
- Department of Women's, Gender, and Sexuality Studies, Barnard College, Columbia University, 3009 Broadway, New York, NY 10027, USA.
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Sexual differentiation of human behavior: effects of prenatal and pubertal organizational hormones. Front Neuroendocrinol 2011; 32:183-200. [PMID: 21397624 DOI: 10.1016/j.yfrne.2011.03.001] [Citation(s) in RCA: 189] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 02/26/2011] [Accepted: 03/04/2011] [Indexed: 01/10/2023]
Abstract
A key question concerns the extent to which sexual differentiation of human behavior is influenced by sex hormones present during sensitive periods of development (organizational effects), as occurs in other mammalian species. The most important sensitive period has been considered to be prenatal, but there is increasing attention to puberty as another organizational period, with the possibility of decreasing sensitivity to sex hormones across the pubertal transition. In this paper, we review evidence that sex hormones present during the prenatal and pubertal periods produce permanent changes to behavior. There is good evidence that exposure to high levels of androgens during prenatal development results in masculinization of activity and occupational interests, sexual orientation, and some spatial abilities; prenatal androgens have a smaller effect on gender identity, and there is insufficient information about androgen effects on sex-linked behavior problems. There is little good evidence regarding long-lasting behavioral effects of pubertal hormones, but there is some suggestion that they influence gender identity and perhaps some sex-linked forms of psychopathology, and there are many opportunities to study this issue.
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Bao AM, Swaab DF. Sexual differentiation of the human brain: relation to gender identity, sexual orientation and neuropsychiatric disorders. Front Neuroendocrinol 2011; 32:214-26. [PMID: 21334362 DOI: 10.1016/j.yfrne.2011.02.007] [Citation(s) in RCA: 204] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Revised: 02/04/2011] [Accepted: 02/14/2011] [Indexed: 11/28/2022]
Abstract
During the intrauterine period a testosterone surge masculinizes the fetal brain, whereas the absence of such a surge results in a feminine brain. As sexual differentiation of the brain takes place at a much later stage in development than sexual differentiation of the genitals, these two processes can be influenced independently of each other. Sex differences in cognition, gender identity (an individual's perception of their own sexual identity), sexual orientation (heterosexuality, homosexuality or bisexuality), and the risks of developing neuropsychiatric disorders are programmed into our brain during early development. There is no evidence that one's postnatal social environment plays a crucial role in gender identity or sexual orientation. We discuss the relationships between structural and functional sex differences of various brain areas and the way they change along with any changes in the supply of sex hormones on the one hand and sex differences in behavior in health and disease on the other.
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Affiliation(s)
- Ai-Min Bao
- Department of Neurobiology, Key Laboratory of Medical Neurobiology of Ministry of Health of China, Zhejiang Province Key Laboratory of Neurobiology, Zhejiang University School of Medicine, Hangzhou, China.
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Review of Outcome Information in 46,XX Patients with Congenital Adrenal Hyperplasia Assigned/Reared Male: What Does It Say about Gender Assignment? INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:982025. [PMID: 21197442 PMCID: PMC3010645 DOI: 10.1155/2010/982025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 10/14/2010] [Accepted: 11/26/2010] [Indexed: 01/06/2023]
Abstract
There is ample historical verification of 46,XX congenital adrenal hyperplasia (CAH) patients being born with essentially male genitaliawhile outcome information is scant. Prior to glucocorticoid therapy, most patients died very young from adrenal insufficiency. Most available reports from laterchildhood, contain little information concerning sexual identity. Reports on older individuals lack adequate information about sexual identity and quality of life. The difficulty in assessing the relative impact of multiple dynamic environmental factors on the development of sexual identity, self- and body esteem and overall adjustment to life is clear. Nevertheless, it remains unclear whether those infants whose masculine genitalia at birth resulted in an initial male assignment would have enjoyed a better adult outcome had they been allowed to remain male rather than the female reassignment that most received. Further, one could ask whether a male sex of rearing should be considered in 46,XX CAH infants with male external genitalia. After reviewing available literature, we conclude that because those extremely virlized 46,XX CAH patients who were reared male with healthy social support demonstrated satisfactory levels of social and sexual function as adults a male sex assignment should be considered in these types of infants when social and cultural environment are supportive.
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Abstract
By its title, Sex and Gender announced a conceptual breakthrough in distinguishing basic elements of human experience. In Robert Stoller's first book, patients illustrating this divergence were lucidly presented. Transvestites and the newly publicized transsexuals were two examples. Clinical and dynamic distinctions between the two formed a basis for Stoller's criteria for patient selection for "sex change." They remain current. The complex identity of the intersexed was described with sensitivity and insight. It, too, remains timely. An innovative description of the genesis of boyhood transsexualism was presented in considerable detail. This finding is less commonly reported today but is also not looked for. Stoller was sympathetic to the request for sex change. He credited a biological contribution to the development of masculinity and femininity. Both stances were remarkable for a psychoanalyst. Robert Stoller introduced the term "gender identity." It is now our vocabulary when we articulate this bedrock of personhood.
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Affiliation(s)
- Richard Green
- Psychological Medicine, Imperial College, St. Dunstan's Road, London, W6 8RP, UK.
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Congenital adrenal hyperplasia: classification of studies employing psychological endpoints. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:191520. [PMID: 20976294 PMCID: PMC2952788 DOI: 10.1155/2010/191520] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 07/07/2010] [Accepted: 07/30/2010] [Indexed: 11/25/2022]
Abstract
Psychological outcomes in persons with congenital adrenal hyperplasia (CAH) have received substantial attention. The objectives of this paper were to (1) catalog psychological endpoints assessed in CAH outcome studies and (2) classify the conceptual/theoretical model shaping the research design and interpretation of CAH-related psychological effects. A total of 98 original research studies, published between 1955 and 2009, were categorized based on psychological endpoints examined as well as the research design and conceptual model guiding analysis and interpretation of data. The majority of studies (68%) investigated endpoints related to psychosexual differentiation. The preponderance of studies (76%) examined a direct relationship (i.e., inferring causality) between prenatal androgen exposure and psychological outcomes. Findings are discussed in relation to the observed imbalance between theoretical interest in the role of prenatal androgens in shaping psychosexual differentiation and a broader conceptual model that examines the role of other potential factors in mediating or moderating the influence of CAH pathophysiology on psychological outcomes in both affected females and males. The latter approach offers to identify factors amenable to clinical intervention that enhance both health and quality of life outcomes in CAH as well as other disorders of sex development.
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Nimkarn S, New MI. Congenital adrenal hyperplasia due to 21-hydroxylase deficiency: A paradigm for prenatal diagnosis and treatment. Ann N Y Acad Sci 2010; 1192:5-11. [PMID: 20392211 DOI: 10.1111/j.1749-6632.2009.05225.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
21-Hydroxylase deficiency is the most common cause of congenital adrenal hyperplasia (CAH), an inherited disorder of steroidogenesis. In its severe form, CAH causes genital ambiguity in females. Molecular genetic analysis of fetal DNA obtained by amniocentesis or chorionic villus sampling is used to diagnose steroid 21-OHD deficiency in utero. Large ongoing studies show that appropriate prenatal treatment of pregnant mothers with dexamethasone is effective and safe for both the fetus and the mother. It reduces ambiguous genitalia in the female affected fetus and thus avoids unnecessary genitoplasty in the newborn female.
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Affiliation(s)
- Saroj Nimkarn
- Department of Pediatrics, Mount Sinai School of Medicine, New York, NY, USA
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Meyer-Bahlburg HFL. From mental disorder to iatrogenic hypogonadism: dilemmas in conceptualizing gender identity variants as psychiatric conditions. ARCHIVES OF SEXUAL BEHAVIOR 2010; 39:461-76. [PMID: 19851856 PMCID: PMC2844928 DOI: 10.1007/s10508-009-9532-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
The categorization of gender identity variants (GIVs) as "mental disorders" in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association is highly controversial among professionals as well as among persons with GIV. After providing a brief history of GIV categorizations in the DSM, this paper presents some of the major issues of the ongoing debate: GIV as psychopathology versus natural variation; definition of "impairment" and "distress" for GID; associated psychopathology and its relation to stigma; the stigma impact of the mental-disorder label itself; the unusual character of "sex reassignment surgery" as a psychiatric treatment; and the consequences for health and mental-health services if the disorder label is removed. Finally, several categorization options are examined: Retaining the GID category, but possibly modifying its grouping with other syndromes; narrowing the definition to dysphoria and taking "disorder" out of the label; categorizing GID as a neurological or medical rather than a psychiatric disorder; removing GID from both the DSM and the International Classification of Diseases (ICD); and creating a special category for GIV in the DSM. I conclude that-as also evident in other DSM categories-the decision on the categorization of GIVs cannot be achieved on a purely scientific basis, and that a consensus for a pragmatic compromise needs to be arrived at that accommodates both scientific considerations and the service needs of persons with GIVs.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute and Department of Psychiatry, Columbia University, 1051 Riverside Drive, Unit 15, New York, NY 10032, USA.
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43
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Biological and psychosocial correlates of adult gender-variant identities: A review. PERSONALITY AND INDIVIDUAL DIFFERENCES 2010. [DOI: 10.1016/j.paid.2009.09.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Lee P, Houk C. Review of Outcome Information in 46,XX Patients with Congenital Adrenal Hyperplasia Assigned/Reared Male: What Does It Say about Gender Assignment? INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-982025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Savic I, Garcia-Falgueras A, Swaab DF. Sexual differentiation of the human brain in relation to gender identity and sexual orientation. PROGRESS IN BRAIN RESEARCH 2010; 186:41-62. [DOI: 10.1016/b978-0-444-53630-3.00004-x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Nimkarn S, New MI. Prenatal diagnosis and treatment of congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Mol Cell Endocrinol 2009; 300:192-6. [PMID: 19101608 DOI: 10.1016/j.mce.2008.11.027] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 11/26/2008] [Accepted: 11/26/2008] [Indexed: 11/16/2022]
Abstract
Congenital adrenal hyperplasia (CAH) applies to a group of inherited disorders caused by an enzyme deficiency in steroid biosynthesis. The most common form of CAH is 21-hydroxylase deficiency (21-OHD), which in its severe form can cause genital ambiguity in females. Affected females experience virilization both physically and psychologically. Steroid 21-OHD can be diagnosed in utero through molecular genetic analysis of fetal DNA. Appropriate prenatal treatment by dexamethasone administration to the at-risk pregnant mother is effective in reducing genital virilization in the fetus, thus avoiding unnecessary genitoplasty in affected females. Current data from large human studies show that prenatal diagnosis and treatment are safe in the short term for both the fetus and the mother. Preliminary data from long-term studies support these results.
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Affiliation(s)
- Saroj Nimkarn
- Department of Pediatrics, Mount Sinai School of Medicine, USA
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Abstract
Disorders of sex development comprise a group of diagnoses that represent significant and controversial management difficulties, such as those relating to gender assignment, genital surgery and risk of gonadal malignancy or future gender dysphoria. These issues arise on the background of a diagnosis that is often fraught with psychological trauma for patients and their families. There have been many changes in the medical approach to management in recent years; however, more research is required. This should focus on achieving accurate diagnosis in the first case, and on following outcomes to advise best practice. Finally, rational dialogue between multidisciplinary care providers, ethicists and patients and their families will only lead to improved care for these children.
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Affiliation(s)
- Jacqueline K Hewitt
- Doctoral student, Molecular Development Unit, Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, Parkville, Victoria 3052, Australia
| | - Garry L Warne
- Professor and Senior Endocrinologist, Department of Endocrinology & Diabetes, Royal Children’s Hospital, Parkville, Victoria 3052, Australia
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Hare L, Bernard P, Sánchez FJ, Baird PN, Vilain E, Kennedy T, Harley VR. Androgen receptor repeat length polymorphism associated with male-to-female transsexualism. Biol Psychiatry 2009; 65:93-6. [PMID: 18962445 PMCID: PMC3402034 DOI: 10.1016/j.biopsych.2008.08.033] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Revised: 08/13/2008] [Accepted: 08/25/2008] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a likely genetic component to transsexualism, and genes involved in sex steroidogenesis are good candidates. We explored the specific hypothesis that male-to-female transsexualism is associated with gene variants responsible for undermasculinization and/or feminization. Specifically, we assessed the role of disease-associated repeat length polymorphisms in the androgen receptor (AR), estrogen receptor beta (ERbeta), and aromatase (CYP19) genes. METHODS Subject-control analysis included 112 male-to-female transsexuals and 258 non-transsexual males. Associations and interactions were investigated between CAG repeat length in the AR gene, CA repeat length in the ERbeta gene, and TTTA repeat length in the CYP19 gene and male-to-female transsexualism. RESULTS A significant association was identified between transsexualism and the AR allele, with transsexuals having longer AR repeat lengths than non-transsexual male control subjects (p=.04). No associations for transsexualism were evident in repeat lengths for CYP19 or ERbeta genes. Individuals were then classified as short or long for each gene polymorphism on the basis of control median polymorphism lengths in order to further elucidate possible combined effects. No interaction associations between the three genes and transsexualism were identified. CONCLUSIONS This study provides evidence that male gender identity might be partly mediated through the androgen receptor.
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Affiliation(s)
- Lauren Hare
- Human Molecular Genetics Laboratory, Prince Henry's Institute of Medical Research, Melbourne, Australia
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Meyer-Bahlburg HF. Male Gender Identity in an XX Individual with Congenital Adrenal Hyperplasia. J Sex Med 2009; 6:297-8; author reply 298-9. [DOI: 10.1111/j.1743-6109.2008.00986_1.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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