1
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Lee PA, Mazur T, Houk CP. DSD/intersex: historical context and current perspectives. J Pediatr Endocrinol Metab 2023; 36:234-241. [PMID: 36630604 DOI: 10.1515/jpem-2022-0582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/18/2022] [Indexed: 01/13/2023]
Abstract
Intersex/Disorders/Differences of sex development conditions have been recognized for millennia. An organized approach was adopted in the 1960-70s using the philosophy that gender identity was fluid and malleable. Consequences of this approach were the lack of disclosure, stigmatization, and excessive surgery to "normalize" the genitalia. Often this led to quality of life issues for those patients. There have been many modifications in approach since then to avoid the problems noted. There is consensus on many of these changes (e.g. disclosure) but continued controversy on others (e.g. the benefits of early surgery). This review summarizes the historical context and the current areas of consensus and controversy.
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Affiliation(s)
- Peter A Lee
- Penn State College of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Tom Mazur
- Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, State University of New York, John R. Oistei Children's Hospital, Buffalo, NY, USA
| | - Christopher P Houk
- Medical College of Georgia, Augusta University Medical Center, Augusta, GA, USA
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2
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Mazzoli F, Cassioli E, Ristori J, Castellini G, Rossi E, Cocchetti C, Romani A, Angotti T, Giovanardi G, Mosconi M, Lingiardi V, Speranza AM, Ricca V, Vignozzi L, Maggi M, Fisher AD. Apparent autistic traits in transgender people: a prospective study of the impact of gender-affirming hormonal treatment. J Endocrinol Invest 2022; 45:2059-2068. [PMID: 35779204 PMCID: PMC9525411 DOI: 10.1007/s40618-022-01835-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/29/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE We evaluated differences in Autism Spectrum Quotient (AQ) scores between a sample of hormone-naïve transgender and cisgender people and the impact of gender-affirming hormonal treatment (GAHT) on AQ scores across time. Furthermore, we assessed alexithymia and social anxiety as possible mediators of changes in AQ scores. METHODS A cross-sectional comparison between cisgender and transgender people before GAHT and a prospective study on the effects of GAHT over time were performed. Transgender and cisgender people completed several psychometric tests. A total sample of 789 persons (n = 229 cismen; n = 172 ciswomen; n = 206 transmen; n = 182 transwomen) referring to the Florence and Rome Gender Clinics between 2018 and 2020 was enrolled. Of these, 62 participants referring to the Florence Gender Clinic were evaluated in a prospective study at baseline and 12 months after GAHT. RESULTS Groups showed significant differences in terms of autistic traits: ciswomen showed lower scores of AQ, while cismen reported higher scores of AQ than all other groups. Transgender individuals showed significant higher levels of Gender Dysphoria (GD), body uneasiness, alexithymia and social anxiety, compared to cisgender ones. No significant differences in general psychopathology were found between groups. Across time, transmen and transwomen showed a significant reduction in AQ scores. The decrease in alexithymia and social anxiety after GAHT did not predict the change in AQ scores. CONCLUSIONS The autistic traits in our sample may represent an epiphenomenon of GD rather than being part of an Autism Spectrum Disorder (ASD) condition, since they significantly decreased after 12 months of GAHT.
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Affiliation(s)
- F Mazzoli
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Careggi University Hospital, Florence University Hospital, Florence, Italy
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - E Cassioli
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - J Ristori
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Careggi University Hospital, Florence University Hospital, Florence, Italy
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - G Castellini
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - E Rossi
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - C Cocchetti
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Careggi University Hospital, Florence University Hospital, Florence, Italy
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - A Romani
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Careggi University Hospital, Florence University Hospital, Florence, Italy
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - T Angotti
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Careggi University Hospital, Florence University Hospital, Florence, Italy
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - G Giovanardi
- Department of Dynamic and Clinic Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - M Mosconi
- Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - V Lingiardi
- Department of Dynamic and Clinic Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - A M Speranza
- Department of Dynamic and Clinic Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - V Ricca
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - L Vignozzi
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Careggi University Hospital, Florence University Hospital, Florence, Italy
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - M Maggi
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - A D Fisher
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Careggi University Hospital, Florence University Hospital, Florence, Italy.
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy.
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3
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Goodman M, Yacoub R, Getahun D, McCracken CE, Vupputuri S, Lash TL, Roblin D, Contreras R, Cromwell L, Gardner MD, Hoffman T, Hu H, Im TM, Prakash Asrani R, Robinson B, Xie F, Nash R, Zhang Q, Bhai SA, Venkatakrishnan K, Stoller B, Liu Y, Gullickson C, Ahmed M, Rink D, Voss A, Jung HL, Kim J, Lee PA, Sandberg DE. Cohort profile: pathways to care among people with disorders of sex development (DSD). BMJ Open 2022; 12:e063409. [PMID: 36130763 PMCID: PMC9494584 DOI: 10.1136/bmjopen-2022-063409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The 'DSD Pathways' study was initiated to assess health status and patterns of care among people enrolled in large integrated healthcare systems and diagnosed with conditions comprising the broad category of disorders (differences) of sex development (DSD). The objectives of this communication are to describe methods of cohort ascertainment for two specific DSD conditions-classic congenital adrenal hyperplasia with 46,XX karyotype (46,XX CAH) and complete androgen insensitivity syndrome (CAIS). PARTICIPANTS Using electronic health records we developed an algorithm that combined diagnostic codes, clinical notes, laboratory data and pharmacy records to assign each cohort candidate a 'strength-of-evidence' score supporting the diagnosis of interest. A sample of cohort candidates underwent a review of the full medical record to determine the score cutoffs for final cohort validation. FINDINGS TO DATE Among 5404 classic 46,XX CAH cohort candidates the strength-of-evidence scores ranged between 0 and 10. Based on sample validation, the eligibility cut-off for full review was set at the strength-of-evidence score of ≥7 among children under the age of 8 years and ≥8 among older cohort candidates. The final validation of all cohort candidates who met the cut-off criteria identified 115 persons with classic 46,XX CAH. The strength-of-evidence scores among 648 CAIS cohort candidates ranged from 2 to 10. There were no confirmed CAIS cases among cohort candidates with scores <6. The in-depth medical record review for candidates with scores ≥6 identified 61 confirmed cases of CAIS. FUTURE PLANS As the first cohort of this type, the DSD Pathways study is well-positioned to fill existing knowledge gaps related to management and outcomes in this heterogeneous population. Analyses will examine diagnostic and referral patterns, adherence to care recommendations and physical and mental health morbidities examined through comparisons of DSD and reference populations and analyses of health status across DSD categories.
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Affiliation(s)
- Michael Goodman
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Rami Yacoub
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Darios Getahun
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, California, USA
| | - Courtney E McCracken
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Timothy L Lash
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
- Aarhus Universitet, Aarhus, Midtjylland, Denmark
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Richard Contreras
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lee Cromwell
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Melissa D Gardner
- Susan B Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Trenton Hoffman
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Haihong Hu
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Theresa M Im
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Brandi Robinson
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Fagen Xie
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rebecca Nash
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Qi Zhang
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Sadaf A Bhai
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Bethany Stoller
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Yijun Liu
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Maaz Ahmed
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - David Rink
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Ava Voss
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Hye-Lee Jung
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Jin Kim
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Peter A Lee
- Division of Endocrinology, Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - David E Sandberg
- Susan B Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Del Can Sánchez DJ, Dueñas Disotuar S, Piñar Gutiérrez A, Japón Rodríguez MÁ, Olea Comas I, Déniz García A, Soto Moreno A, Mangas Cruz MÁ. Gender Incongruity in a Person with 46,XY and Complete Androgen Insensitivity Syndrome Raised as a Female. ARCHIVES OF SEXUAL BEHAVIOR 2022; 51:2353-2357. [PMID: 34786658 DOI: 10.1007/s10508-021-02183-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 05/22/2021] [Accepted: 10/09/2021] [Indexed: 06/13/2023]
Abstract
We present the case of a patient with female sex assignment at birth whose parents consulted with a pediatrician when the child was 12 years old, indicating that despite female sex assignment, she felt that she (henceforth "he") had a male gender identity and was gynephilic. Medical examination revealed a 46XY karyotype, a primary amenorrhea and an appropriate testosterone increase after HCG stimulation test. The patient was diagnosed then with a 46,XY disorder of sex development with androgen insensitivity syndrome, but then he missed subsequent appointments. At the age of 24, he resumed medical follow-up to reaffirm his male gender identity through sex reassignment surgery. His physical examination showed a Tanner stage III-IV breast development, vulva, clitoris, normal-sized vagina, absence of uterus and ovaries on transvaginal ultrasound, bilateral cryptorchidism on abdominal-pelvic MRI and osteoporosis on bone densitometry. The results of the blood tests were LH 24.5 mIU/mL [normal range, 1.7-8.6 mIU/mL for men] and testosterone 8.8 nmol/L [8.7-33 nmol/L]; conversely, FSH, estradiol, progesterone, and prolactin levels were normal. The molecular genetic analysis revealed an androgen receptor gene mutation associated with complete androgen insensitivity syndrome. At present, the patient has undergone bilateral orchiectomy and has initiated treatment with topical testosterone and bisphosphonates. We have yet to evaluate the effects and decide the best therapy taking into account that he has a male gender identity but complete androgen insensitivity syndrome.
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Affiliation(s)
- Diego Jesús Del Can Sánchez
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain.
| | - Suset Dueñas Disotuar
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain
| | - Ana Piñar Gutiérrez
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain
| | | | - Isabel Olea Comas
- Department of Diagnostic Imaging of the University Hospital Virgen del Rocío, Seville, Spain
| | - Alejandro Déniz García
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain
| | - Alfonso Soto Moreno
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain
| | - Miguel Ángel Mangas Cruz
- Department of Endocrinology and Nutrition of the University Hospital Virgen del Rocío, Muro de los Navarros Street, Apt. 40, Door 12, 41013, Seville, Spain
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5
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Nordenström A, Ahmed SF, van den Akker E, Blair J, Bonomi M, Brachet C, Broersen LHA, Claahsen-van der Grinten HL, Dessens AB, Gawlik A, Gravholt CH, Juul A, Krausz C, Raivio T, Smyth A, Touraine P, Vitali D, Dekkers OM. Pubertal induction and transition to adult sex hormone replacement in patients with congenital pituitary or gonadal reproductive hormone deficiency: an Endo-ERN clinical practice guideline. Eur J Endocrinol 2022; 186:G9-G49. [PMID: 35353710 PMCID: PMC9066594 DOI: 10.1530/eje-22-0073] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
Abstract
An Endo-European Reference Network guideline initiative was launched including 16 clinicians experienced in endocrinology, pediatric and adult and 2 patient representatives. The guideline was endorsed by the European Society for Pediatric Endocrinology, the European Society for Endocrinology and the European Academy of Andrology. The aim was to create practice guidelines for clinical assessment and puberty induction in individuals with congenital pituitary or gonadal hormone deficiency. A systematic literature search was conducted, and the evidence was graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. If the evidence was insufficient or lacking, then the conclusions were based on expert opinion. The guideline includes recommendations for puberty induction with oestrogen or testosterone. Publications on the induction of puberty with follicle-stimulation hormone and human chorionic gonadotrophin in hypogonadotropic hypogonadism are reviewed. Specific issues in individuals with Klinefelter syndrome or androgen insensitivity syndrome are considered. The expert panel recommends that pubertal induction or sex hormone replacement to sustain puberty should be cared for by a multidisciplinary team. Children with a known condition should be followed from the age of 8 years for girls and 9 years for boys. Puberty induction should be individualised but considered at 11 years in girls and 12 years in boys. Psychological aspects of puberty and fertility issues are especially important to address in individuals with sex development disorders or congenital pituitary deficiencies. The transition of these young adults highlights the importance of a multidisciplinary approach, to discuss both medical issues and social and psychological issues that arise in the context of these chronic conditions.
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Affiliation(s)
- A Nordenström
- Pediatric Endocrinology, Department of Women’s and Children’s Health Karolinska Institutet, and Department of Pediatric Endocrinology and Inborn Errors of Metabolism, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Correspondence should be addressed to A Nordenström;
| | - S F Ahmed
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Royal Hospital for Children, Glasgow, UK
| | - E van den Akker
- Division of Pediatric Endocrinology and Obesity Center CGG, Department of Pediatrics, Erasmus MC Sophia Children’s Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J Blair
- Department of Endocrinology, Alder Hey Children’s Hospital, Liverpool, UK
| | - M Bonomi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - C Brachet
- Pediatric Endocrinology Unit, Hôpital Universitaire des Enfants HUDERF, Université Libre de Bruxelles, Bruxelles, Belgium
| | - L H A Broersen
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - H L Claahsen-van der Grinten
- Department of Pediatric Endocrinology, Amalia Childrens Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - A B Dessens
- Department of Child and Adolescent Psychiatry and Psychology, Sophia Children’s Hospital Erasmus Medical Center, Rotterdam, Netherlands
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University Ghent, Ghent, Belgium
| | - A Gawlik
- Department of Pediatrics and Pediatric Endocrinology, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - C H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - A Juul
- Department of Growth and Reproduction, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- International Research and Research Training Centre for Endocrine Disruption in Male Reproduction and Child Health (EDMaRC) and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - C Krausz
- Department of Biochemical, Experimental and Clinical Sciences ‘Mario Serio’, University of Florence, Florence, Italy
| | - T Raivio
- New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital, and Research Program Unit, Faculty of Medicine, Stem Cells and Metabolism Research Program, University of Helsinki, Helsinki, Finland
| | - A Smyth
- Turner Syndrome Support Society in the UK, ePAG ENDO-ERN, UK
| | - P Touraine
- Department of Endocrinology and Reproductive Medicine, Pitié Salpêtriere Hospital, Paris, France
- Sorbonne Université Médecine and Center for Endocrine Rare Disorders of Growth and Development and Center for Rare Gynecological Disorders, Paris, France
| | - D Vitali
- SOD ITALIA APS – Italian Patient Organization for Septo Optic Dysplasia and Other Neuroendocrine Disorders – ePAG ENDO-ERN, Rome, Italy
| | - O M Dekkers
- Department of Clinical Epidemiology, LUMC Leiden, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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6
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Sandberg DE, Gardner M. Differences/Disorders of Sex Development: Medical Conditions at the Intersection of Sex and Gender. Annu Rev Clin Psychol 2022; 18:201-231. [PMID: 35216524 PMCID: PMC10170864 DOI: 10.1146/annurev-clinpsy-081219-101412] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Defined as congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical, differences or disorders of sex development (DSDs) comprise many discrete diagnoses ranging from those associated with few phenotypic differences between affected and unaffected individuals to those where questions arise regarding gender of rearing, gonadal tumor risk, genital surgery, and fertility. Controversies exist in numerous areas including how DSDs are conceptualized, how to refer to the set of conditions and those affected by them, and aspects of clinical management that extend from social media to legislative bodies, courts of law, medicine, clinical practice, and scholarly research in psychology and sociology. In addition to these aspects, this review covers biological and social influences on psychosocial development and adjustment, the psychosocial and psychosexual adaptation of people born with DSDs, and roles for clinical psychologists in the clinical management of DSDs. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- David E Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA;
| | - Melissa Gardner
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA;
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7
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Listyasari NA, Juniarto AZ, Robevska G, Ayers KL, Sinclair AH, Faradz SMH. Analysis of the androgen receptor (AR) gene in a cohort of Indonesian undermasculinized 46, XY DSD patients. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2021. [DOI: 10.1186/s43042-021-00134-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Abstract
Background
Pathogenic variants in the androgen receptor (AR) gene located on chromosome Xq11-12, are known to cause varying degrees of undermasculinization in 46, XY individuals. The aim of this study was to investigate the frequency of pathogenic variants in the AR gene in a cohort of 46, XY undermasculinized individuals from Indonesia who were suspected of having androgen insensitivity syndrome (AIS). All patients with 46, XY DSD referred to our center between 1994 and 2019 were collected from our clinical database. All 46, XY DSD patients without a prior molecular diagnosis with an external masculinization score (EMS) ≤ 9 were included in this study. All exons and intron–exon boundaries of AR gene were analyzed using Sanger sequencing to identify pathogenic variants of the AR gene.
Results
A cohort of 75 undermasculinized patients were selected for the study. Direct Sanger sequencing of all eight exons of the AR gene led to a genetic diagnosis in 11 patients (14.67%). All of the variants identified (p.Arg841His; p.Ile604Asn; p.Val731Met; p.Pro672Ser; p.Gln739Arg; p.Ser302Glufs*3) have been previously reported in patients with AIS.
Conclusions
This is the first study in Indonesia that highlights the significance of molecular analysis in providing a definitive diagnosis of AIS for patients with 46, XY DSD undermasculinization. This is an uncommon finding in the Indonesian population presenting with 46, XY DSD undermasculinization. A genetic diagnosis allows optimal clinical management and genetic counseling for patients and their families. As 46, XY DSD can be caused by pathogenic variants in other genes involved in gonadal development and differentiation, further genetic analysis, such as whole exome sequencing, should be carried out on those patients that did not carry an AR variant.
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8
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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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Abstract
With the growing number of transgender and gender-nonbinary individuals who are becoming visible, it is clear that there is a need to develop a rigorous evidence base to inform care practice. Transgender health research is often limited to HIV/AIDS or mental health research and is typically subsumed in larger studies with general LGBTQ focus. Although the number of knowledgeable health care providers remains modest, the model for the medical approach to transgender health is shifting owing to growing social awareness and an appreciation of a biological component. Gender-affirming medicine facilitates aligning the body of the transgender person with the gender identity; typical treatment regimens include hormone therapy and/or surgical interventions. While broadly safe, hormone treatments require some monitoring for safety. Exogenous estrogens are associated with a dose-dependent increase in venous thromboembolic risk, and androgens stimulate erythropoiesis. The degree to which progressing gender-affirming hormone treatment changes cancer risk, cardiac heart disease risk, and/or bone health remains unknown. Guidelines referencing the potential exacerbation of cancer, heart disease, or other disease risk often rely on physiology models, because conclusive clinical data do not exist. Dedicated research infrastructure and funding are needed to address the knowledge gap in the field.
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10
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Babu R, Shah U. Gender identity disorder (GID) in adolescents and adults with differences of sex development (DSD): A systematic review and meta-analysis. J Pediatr Urol 2021; 17:39-47. [PMID: 33246831 DOI: 10.1016/j.jpurol.2020.11.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/24/2020] [Accepted: 11/08/2020] [Indexed: 12/19/2022]
Abstract
UNLABELLED Gender assignment in infants born with a difference in sexual development (DSD) remains one of the many difficult decisions faced by the multi-disciplinary treatment team as some of these children develop gender identity disorder (GID) when they become adults. In this systematic review and meta-analysis we have analyzed the prevalence of GID in adolescent and adults with DSD. The secondary outcome of this review is to help physicians in appropriate sex assignment of DSD children so that development of GID in later life can be reduced. METHODS Pubmed/Index medicus were searched for "intersex" [All fields] OR "disorders of sexual differentiation AND "gender identity disorder OR gender dysphoria" [MeSH] for articles published between 2005 and 2020. Typical diagnoses included were congenital adrenal hyperplasia (CAH); complete androgen insensitivity syndrome (CAIS); partial androgen insensitivity syndrome (PAIS); 5 alpha reductase deficiency (5ARD); 17-hydroxysteroid dehydrogenase deficiency (17HSD); mixed gonadal dysgenesis (MGD) and complete gonadal dysgenesis (CGD). GID or gender dysphoria (a strong feeling of dissatisfaction about oneself as male or female) prevalence in DSD patients older than 12 years of age was extracted. Within each condition, GID percentage was compared between female and male rearing. RESULTS The I2statistics for prevalence of GID in DSD showed high heterogeneity with I2 of 93% (95% C.I 90-95%) among the 20 articles included. The overall prevalence of GID among those with DSD was 15% (95% C.I 13-17%). CAH reared females had 4% GID while CAH reared males had significantly higher GID at 15% (p = 0.0056). All CAIS patients were raised as females and the prevalence of GID was 1.7%. GID prevalence was 12% in PAIS raised as females while 25% in those raised as males with no significant difference (p = 0.134). GID was significantly high in 5ARD (53%) and 17HSD (53%) reared as females with half of them virilizing at puberty forcing a gender change. Among sex chromosome DSD 22% of those reared as females had GID while none in those raised as male with no significant difference. CONCLUSIONS GID is low in women with CAH, CAIS and CGD favoring female sex of rearing in these conditions. GID is high in women with 5ARD/17HSD favoring male sex of rearing in these conditions. GID is variable in PAIS or MGD and no recommendations on sex of rearing could be made in these conditions. Each DSD patient is unique and they warrant multi-disciplinary care and long term psycho sexual support.
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Affiliation(s)
- Ramesh Babu
- Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education & Research, Chennai, 600116, India.
| | - Utsav Shah
- Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education & Research, Chennai, 600116, India
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11
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Veale J. The associations of genital-normalizing surgery and assigned gender in predicting gender outcomes: A pooled nested case study analysis of 282 adults with differences of sex development in 58 academic articles. UROLOGICAL SCIENCE 2021. [DOI: 10.4103/uros.uros_65_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Gürbüz F, Alkan M, Çelik G, Bişgin A, Çekin N, Ünal İ, Topaloğlu AK, Zorludemir Ü, Avcı A, Yüksel B. Gender Identity and Assignment Recommendations in Disorders of Sex Development Patients: 20 Years’ Experience and Challenges. J Clin Res Pediatr Endocrinol 2020; 12:347-357. [PMID: 32212580 PMCID: PMC7711639 DOI: 10.4274/jcrpe.galenos.2020.2020.0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Gender assignment in infants and children with disorders of sex development (DSD) is a stressful situation for both patient/families and medical professionals. METHODS The purpose of this study was to investigate the results of gender assignment recommendations in children with DSD in our clinic from 1999 through 2019. RESULTS The mean age of the 226 patients with DSD at the time of first admission were 3.05±4.70 years. 50.9% of patients were 46,XY DSD, 42.9% were 46,XX DSD and 6.2% were sex chromosome DSD. Congenital adrenal hyperplasia (majority of patients had 21-hydroxylase deficiency) was the most common etiological cause of 46,XX DSD. In 46,XX patients, 87 of 99 (89.7%) were recommended to be supported as a female, 6 as a male, and 4 were followed up. In 46,XY patients, 40 of 115 (34.8%) were recommended to be supported as a female, and 70 as male (60.9%), and 5 were followed up. In sex chromosome DSD patients, 3 of 14 were recommended to be supported as a female, 9 as a male. The greatest difficulty in making gender assignment recommendations were in the 46,XY DSD group. CONCLUSION In DSD gender assignment recommendations, the etiologic diagnosis, psychiatric gender orientation, expectation of the family, phallus length and Prader stage were effective in the gender assignment in DSD cases, especially the first two criteria. It is important to share these experiences among the medical professionals who are routinely charged with this difficult task in multidisciplinary councils.
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Affiliation(s)
- Fatih Gürbüz
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
| | - Murat Alkan
- Çukurova University Faculty of Medicine, Department of Pediatric Surgery, Adana, Turkey
| | - Gonca Çelik
- Çukurova University Faculty of Medicine, Department of Child Psychiatry, Adana, Turkey
| | - Atıl Bişgin
- Çukurova University Faculty of Medicine, Department of Medical Genetics, Adana, Turkey
| | - Necmi Çekin
- Çukurova University Faculty of Medicine, Department of Forensic Medicine, Adana, Turkey
| | - İlker Ünal
- Çukurova University Faculty of Medicine, Department of Biostatistics, Adana, Turkey
| | - Ali Kemal Topaloğlu
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
| | - Ünal Zorludemir
- Çukurova University Faculty of Medicine, Department of Pediatric Surgery, Adana, Turkey
| | - Ayşe Avcı
- Çukurova University Faculty of Medicine, Department of Child Psychiatry, Adana, Turkey
| | - Bilgin Yüksel
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey,* Address for Correspondence: Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey Phone: +90 532 516 91 31 E-mail:
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13
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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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14
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Palmer BF, Clegg DJ. A Universally Accepted Definition of Gender Will Positively Impact Societal Understanding, Acceptance, and Appropriateness of Health Care. Mayo Clin Proc 2020; 95:2235-2243. [PMID: 32448588 DOI: 10.1016/j.mayocp.2020.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/13/2020] [Accepted: 01/24/2020] [Indexed: 11/21/2022]
Abstract
When individuals do not conform to stereotypes associated with "male" or "female," they are often ridiculed, bullied, and rejected, which leads to depression, psychological problems, and even suicide. The number of individuals who identify themselves as transgender, gender queer, or who do not conform to societal norms with respect to gender appears to be increasing. Despite this apparent increase, clinicians and health care facilities are ill-prepared to meet the needs of these individuals in a professional and appropriate manner. Unfortunately, there is an inherit distrust of the medical community by individuals who do not conform to societal norms with respect to gender because of a perception that the medical community does not understand the unique challenges of these individuals. Therefore, reducing the social stigma associated with gender nonconforming individuals is one way to begin to break down barriers of distrust and enhance communication within and outside the medical community. In this review, we discuss the scant amount of scientific data on the biological origins of gender identity. We highlight the fact that the biological definition of gender remains elusive in part because molecular and biological techniques have not been available to accurately probe the development of gender identity. We therefore advocate for the importance of enhancing our knowledge of the origins of gender identity with advanced scientific tools. Enhancing scientific understanding of the biological origins of gender identity may reduce stigma and barriers to care.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Deborah J Clegg
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA.
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15
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Lee PA, Fuqua JS, Houk CP, Kogan BA, Mazur T, Caldamone A. Individualized care for patients with intersex (disorders/differences of sex development): part I. J Pediatr Urol 2020; 16:230-237. [PMID: 32249189 DOI: 10.1016/j.jpurol.2020.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 02/20/2020] [Indexed: 12/16/2022]
Abstract
The care of individuals with disorders/differences of sex development aims to enable affected individuals and their families to have the best quality of life, particularly those born with severe genital ambiguity. Two of the biggest concerns for parents and health professionals are: (1) making a gender assignment and (2) the decisions of whether or not surgery is indicated, and if so, when is best for the patient and parents. These decisions, which can be overwhelming to families, are almost always made in the face of uncertainties. Such decisions must involve the parents, include multidisciplinary contributions, have an underlying principle of full disclosure, and respect familial, philosophical, and cultural values. Assignment as male or female is made with the realization that gender identity cannot be predicted with certainty. Because of the variability among those with the same diagnosis and complexity of phenotype-genotype correlation, the use of algorithms is inappropriate. The goal of this article is to emphasize the need for individualized care to make the best possible decisions for each patient's unique situation.
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Affiliation(s)
- Peter A Lee
- Penn State College of Medicine, Hershey, PA 17033, USA.
| | - John S Fuqua
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | | | | | - Tom Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, John R. Oishei Children's Hospital, Buffalo, NY 14222, USA.
| | - Anthony Caldamone
- Hasbro Children's Hospital, Warren Alpert School of Medicine at Brown University, Providence, RI 02903, USA.
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16
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Sadr M, Khorashad BS, Talaei A, Fazeli N, Hönekopp J. 2D:4D Suggests a Role of Prenatal Testosterone in Gender Dysphoria. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:421-432. [PMID: 31975034 PMCID: PMC7031197 DOI: 10.1007/s10508-020-01630-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 06/10/2023]
Abstract
Gender dysphoria (GD) reflects distress caused by incongruence between one's experienced gender identity and one's natal (assigned) gender. Previous studies suggest that high levels of prenatal testosterone (T) in natal females and low levels in natal males might contribute to GD. Here, we investigated if the 2D:4D digit ratio, a biomarker of prenatal T effects, is related to GD. We first report results from a large Iranian sample, comparing 2D:4D in 104 transwomen and 89 transmen against controls of the same natal sex. We found significantly lower (less masculine) 2D:4D in transwomen compared to control men. We then conducted random-effects meta-analyses of relevant studies including our own (k = 6, N = 925 for transwomen and k = 6, N = 757 for transmen). In line with the hypothesized prenatal T effects, transwomen showed significantly feminized 2D:4D (d ≈ 0.24). Conversely, transmen showed masculinized 2D:4D (d ≈ - 0.28); however, large unaccounted heterogeneity across studies emerged, which makes this effect less meaningful. These findings support the idea that high levels of prenatal T in natal females and low levels in natal males play a part in the etiology of GD. As we discuss, this adds to the evidence demonstrating the convergent validity of 2D:4D as a marker of prenatal T effects.
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Affiliation(s)
- Mostafa Sadr
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Behzad S Khorashad
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Talaei
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nasrin Fazeli
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Johannes Hönekopp
- Department of Psychology, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK.
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17
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Clemens B, Derntl B, Smith E, Junger J, Neulen J, Mingoia G, Schneider F, Abel T, Bzdok D, Habel U. Predictive Pattern Classification Can Distinguish Gender Identity Subtypes from Behavior and Brain Imaging. Cereb Cortex 2020; 30:2755-2765. [PMID: 31999324 DOI: 10.1093/cercor/bhz272] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/02/2019] [Accepted: 09/12/2019] [Indexed: 11/13/2022] Open
Abstract
The exact neurobiological underpinnings of gender identity (i.e., the subjective perception of oneself belonging to a certain gender) still remain unknown. Combining both resting-state functional connectivity and behavioral data, we examined gender identity in cisgender and transgender persons using a data-driven machine learning strategy. Intrinsic functional connectivity and questionnaire data were obtained from cisgender (men/women) and transgender (trans men/trans women) individuals. Machine learning algorithms reliably detected gender identity with high prediction accuracy in each of the four groups based on connectivity signatures alone. The four normative gender groups were classified with accuracies ranging from 48% to 62% (exceeding chance level at 25%). These connectivity-based classification accuracies exceeded those obtained from a widely established behavioral instrument for gender identity. Using canonical correlation analyses, functional brain measurements and questionnaire data were then integrated to delineate nine canonical vectors (i.e., brain-gender axes), providing a multilevel window into the conventional sex dichotomy. Our dimensional gender perspective captures four distinguishable brain phenotypes for gender identity, advocating a biologically grounded reconceptualization of gender dimorphism. We hope to pave the way towards objective, data-driven diagnostic markers for gender identity and transgender, taking into account neurobiological and behavioral differences in an integrative modeling approach.
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Affiliation(s)
- Benjamin Clemens
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, 52074 Aachen, Germany.,Institute of Neuroscience and Medicine: JARA-Institute Brain Structure Function Relationship (INM 10), Wilhelm-Johnen-Straße 52425 Jülich, Germany
| | - Birgit Derntl
- Department of Psychiatry and Psychotherapy, University of Tübingen, 72076 Tübingen, Germany.,Werner Reichardt Center for Integrative Neuroscience (CIN), University of Tübingen, Otfried-Müller-Str. 25, 72076 Tübingen, Germany.,LEAD Research Network, Walter-Simon-Straße 12, 72072 Tübingen, Germany
| | - Elke Smith
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, 52074 Aachen, Germany.,Department of Psychology, Biological Psychology, University of Cologne, Bernhard-Feilchenfeld-Str. 11, 50969 Cologne, Germany
| | - Jessica Junger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, 52074 Aachen, Germany.,Institute of Neuroscience and Medicine: JARA-Institute Brain Structure Function Relationship (INM 10), Wilhelm-Johnen-Straße 52425 Jülich, Germany
| | - Josef Neulen
- Department of Gynecological Endocrinology and Reproductive Medicine, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Gianluca Mingoia
- Interdisciplinary Center for Clinical Research (IZKF), RWTH Aachen University, Faculty of Medicine, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Frank Schneider
- Institute of Neuroscience and Medicine: JARA-Institute Brain Structure Function Relationship (INM 10), Wilhelm-Johnen-Straße 52425 Jülich, Germany.,University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Ted Abel
- Department of Biology, University of Pennsylvania, 433 South University Avenue, Philadelphia, PA 19104, United States.,Department of Neuroscience & Pharmacology, Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, 51 Newton Road 5-660 Bowen Science Building, Iowa City, IA 52242, United States
| | - Danilo Bzdok
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, 52074 Aachen, Germany.,Institute of Neuroscience and Medicine: JARA-Institute Brain Structure Function Relationship (INM 10), Wilhelm-Johnen-Straße 52425 Jülich, Germany.,Parietal Team, INRIA/Neurospin Saclay, 1 rue Honoré d'Estienne d'Orves, Campus de l'École Polytechnique, 91120 Palaiseau, France.,Department of Biomedical Engineering, Faculty of Medicine, McGill University, 3775, rue University Montréal, QC H3A 2B4, Canada.,Montreal Institute for Learning Algorithms (MILA), 6666 St-Urbain, #200 Montreal, QC H2S 3H1, Canada
| | - Ute Habel
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, 52074 Aachen, Germany.,Institute of Neuroscience and Medicine: JARA-Institute Brain Structure Function Relationship (INM 10), Wilhelm-Johnen-Straße 52425 Jülich, Germany
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18
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Affiliation(s)
- Joshua D Safer
- From the Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York (J.D.S.); and the Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, and the Atlanta Veterans Affairs Medical Center - both in Atlanta (V.T.)
| | - Vin Tangpricha
- From the Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York (J.D.S.); and the Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, and the Atlanta Veterans Affairs Medical Center - both in Atlanta (V.T.)
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19
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Wisniewski AB, Batista RL, Costa EMF, Finlayson C, Sircili MHP, Dénes FT, Domenice S, Mendonca BB. Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life. Endocr Rev 2019; 40:1547-1572. [PMID: 31365064 DOI: 10.1210/er.2019-00049] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.
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Affiliation(s)
- Amy B Wisniewski
- Psychology Department, Oklahoma State University, Stillwater, Oklahoma
| | - Rafael L Batista
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Elaine M F Costa
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Courtney Finlayson
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maria Helena Palma Sircili
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Department of Surgery, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
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20
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Abstract
Transgender persons are a diverse group whose gender identity differs from their sex recorded at birth. Some choose to undergo medical treatment to align their physical appearance with their gender identity. Barriers to accessing appropriate and culturally competent care contribute to health disparities in transgender persons, such as increased rates of certain types of cancer, substance abuse, mental health conditions, infections, and chronic diseases. Thus, it is important that clinicians understand the specific medical issues that are relevant to this population.
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Affiliation(s)
- Joshua D Safer
- Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York (J.D.S.)
| | - Vin Tangpricha
- Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, Georgia (V.T.)
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21
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Luoto S, Krams I, Rantala MJ. A Life History Approach to the Female Sexual Orientation Spectrum: Evolution, Development, Causal Mechanisms, and Health. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:1273-1308. [PMID: 30229521 DOI: 10.1007/s10508-018-1261-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 05/29/2018] [Accepted: 06/14/2018] [Indexed: 05/12/2023]
Abstract
Women's capacity for sexual fluidity is at least as interesting a phenomenon from the point of view of evolutionary biology and behavioral endocrinology as exclusively homosexual orientation. Evolutionary hypotheses for female nonheterosexuality have failed to fully account for the existence of these different categories of nonheterosexual women, while also overlooking broader data on the causal mechanisms, physiology, ontogeny, and phylogeny of female nonheterosexuality. We review the evolutionary-developmental origins of various phenotypes in the female sexual orientation spectrum using the synergistic approach of Tinbergen's four questions. We also present femme-specific and butch-specific hypotheses at proximate and ultimate levels of analysis. This review article indicates that various nonheterosexual female phenotypes emerge from and contribute to hormonally mediated fast life history strategies. Life history theory provides a biobehavioral explanatory framework for nonheterosexual women's masculinized body morphology, psychological dispositions, and their elevated likelihood of experiencing violence, substance use, obesity, teenage pregnancy, and lower general health. This pattern of life outcomes can create a feedback loop of environmental unpredictability and harshness which destabilizes intrauterine hormonal conditions in mothers, leading to a greater likelihood of fast life history strategies, global health problems, and nonheterosexual preferences in female offspring. We further explore the potential of female nonheterosexuality to function as an alloparental buffer that enables masculinizing alleles to execute their characteristic fast life history strategies as they appear in the female and the male phenotype. Synthesizing life history theory with the female sexual orientation spectrum enriches existing scientific knowledge on the evolutionary-developmental mechanisms of human sex differences.
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Affiliation(s)
- Severi Luoto
- English, Drama and Writing Studies, University of Auckland, Arts 1, Building 206, Room 616, 14A Symonds St., Auckland, 1010, New Zealand.
- School of Psychology, University of Auckland, Auckland, New Zealand.
| | - Indrikis Krams
- Department of Zoology and Animal Ecology, University of Latvia, Riga, Latvia
- Institute of Ecology and Earth Sciences, University of Tartu, Tartu, Estonia
| | - Markus J Rantala
- Department of Biology & Turku Brain and Mind Center, University of Turku, Turku, Finland
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22
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CHEN G, WANG X, TANG D. [Progress on evaluation, diagnosis and management of disorders of sex development]. Zhejiang Da Xue Xue Bao Yi Xue Ban 2019; 48:358-366. [PMID: 31901037 PMCID: PMC8800683 DOI: 10.3785/j.issn.1008-9292.2019.08.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/30/2019] [Indexed: 06/10/2023]
Abstract
Disorders of sex development (DSD) refer to a group of diseases characterized by abnormal congenital development of chromosomes, gonad or genitals with different pathophysiological changes and clinical manifestations. DSD is more common in neonates and adolescents, and neonates often show genital abnormalities while adolescents show abnormal sexual development during puberty. It is the international consensus that the scope of DSD should include basic clinical evaluation (internal and external genitalia and endocrine hormones), diagnostic confirmation (chromosome, genetic diagnosis), psychological assessment for children and family, treatment (sex assignment, hormone replacement and surgical intervention), potential fertility protection and long-term follow-up, which require the expertise of pediatric endocrinology, pediatric urology, clinical psychology, genetic disciplines, medical images and other related disciplines; that is, individualized management of children with DSD requires an experienced multidisciplinary team (MDT). This article reviews the recent progress on the evaluation, diagnosis and management of disorders of sex development.
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Affiliation(s)
| | | | - Daxing TANG
- 唐达星(1961—), 男, 博士, 硕士生导师, 主任医师, 主要从事小儿泌尿外科学研究; E-mail:
;
https://orcid.org/0000-0003-2103-4931
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23
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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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Deeb A, Khamis M, Sayed SA, Magdy Omar O, Odeh R, Ladjouze A, Ameri EA. Sex assignment practice in disorders of sexual differentiation: survey results from paediatric endocrinologists in the Arab region. J Pediatr Endocrinol Metab 2019; 32:75-82. [PMID: 30864373 DOI: 10.1515/jpem-2018-0323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 11/16/2018] [Indexed: 11/15/2022]
Abstract
Background Sex assignment is a major issue in disorders of sexual differentiation (DSD). Not all conditions of DSD have clear recommendations on assignment and timing of surgery. Reports about sex assignment practice and the influence of culture and religion in the Arab region are scarce. Methods A survey questionnaire was distributed to participants in a paediatric endocrinology conference. Four DSD cases were presented. Participants were asked to fill in their answers on sex assignment choice, reasons for the particular assignment, strength of own recommendation and timing of surgery based on their practice. The cases presented were severely virilised XX congenital adrenal hyperplasia (CAH), complete androgen insensitivity syndrome (CAIS), severely undervirilised 5α reductase deficiency (5α RD) and XX ovotesticular case. Results Eighty-five endocrinologists participated in the study. Eighty (97.5%) chose a female sex to assign for the XX CAH. For the CAIS, 64 (78%) chose a female sex. Seventy-one (86.5%) voted for a male sex for the XY case of 5α RD. Forty-seven (57%) and 35 (43%) chose a female and a male sex for the ovotesticular case, respectively. The majority indicated that their advice for sex assignment is based on strong recommendations for the CAH, CAIS and 5α RD patients but they were open to the parents' cultural and religious beliefs in their decision of the assignment for the ovotesticular case. Conclusions Practice in the Arab region appears to be in line with the international guidelines in the majority of DSD sex assignment and timing of surgery issues. However, culture and religious beliefs influence the practice in certain circumstances.
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Affiliation(s)
- Asma Deeb
- Paediatric Endocrinology Department, Mafraq Hospital, Abu Dhabi, UAE
| | - Maryam Khamis
- Paediatric Endocrinology Department, Mafraq Hospital, Abu Dhabi, UAE
| | - Shayma Al Sayed
- Paediatric Endocrinology and Diabetology Department, Alexandria University, Alexandria, Egypt
| | - Omneya Magdy Omar
- Pediatric Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Rasha Odeh
- Department of Paediatrics, School of Medicine, University of Jordan, Amman, Jordan
| | - Asmahane Ladjouze
- Paediatric Department, Bab el Oued Teaching Hospital, Algiers, Algeria
| | - Elham Al Ameri
- Pediatric Endocrinology Department, Al Qassimi Hospital, Sharjah, UAE
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Turban JL, Ehrensaft D. Research Review: Gender identity in youth: treatment paradigms and controversies. J Child Psychol Psychiatry 2018; 59:1228-1243. [PMID: 29071722 DOI: 10.1111/jcpp.12833] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pediatric gender identity has gained increased attention over the past several years in the popular media, political arena, and medical literature. This article reviews terminology in this evolving field, traditional models of gender identity development and their limitations, epidemiology and natural history of cross-gender identification among children and adolescents, co-occurring conditions and behaviors, research into the biological and psychosocial determinants of cross-gender identification, and research into the options regarding and benefits of clinical approaches to gender incongruent youth. METHODS Based on a critical review of the extant literature, both theoretical and empirical, that addresses the issue of pediatric gender identity, the authors synthesized what is presently known and what is in need of further research in order to elucidate the developmental trajectory and clinical needs of gender diverse youth. RESULTS The field of pediatric gender identity has evolved substantially over the past several years. New research suggests that cross-gender identification is prevalent (approximately 1% of youth). These youth suffer disproportionately high rates of anxiety, depression, and suicidality. Although research into the etiology of cross-gender identification is limited, emerging data have shown that affirmative treatment protocols may improve the high rates of mental health difficulties seen among these patients. CONCLUSIONS The field of pediatric gender identity has evolved dramatically. Emerging data suggest that these patients' high rates of anxiety, depression, and suicidality appear to be improved with affirmative protocols, although future longitudinal data are needed.
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Affiliation(s)
- Jack L Turban
- Division of Child & Adolescent Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Diane Ehrensaft
- Child and Adolescent Gender Center, University of California San Francisco, San Francisco, CA, USA
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Strandqvist A, Herlitz A, Nordenskjöld A, Örtqvist L, Frisén L, Hirschberg AL, Nordenström A. Cognitive abilities in women with complete androgen insensitivity syndrome and women with gonadal dysgenesis. Psychoneuroendocrinology 2018; 98:233-241. [PMID: 29884451 DOI: 10.1016/j.psyneuen.2018.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 04/27/2018] [Accepted: 05/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many questions regarding the mechanisms behind sex differences in cognitive abilities are still unanswered. On a group level, men typically outperform women on certain spatial tasks, whereas women perform better on certain tests of memory and verbal ability. The prevailing theories concerning the biological predispositions for these and other differences in behaviour and brain function focus on early and prolonged exposure to sex hormones. There is, however, evidence of direct effects of sex chromosomes on sex-typical behaviour in other species. OBJECTIVES To study the influence of sex hormones and sex chromosomes on cognition in women with Complete androgen insensitivity (CAIS) and Gonadal dysgenesis (GD). METHODS Eighteen women with CAIS, 6 women with 46,XYGD, and 7 women with 46,XXGD were compared with age-matched male and female controls on tests of spatial and verbal abilities, memory functions, and emotion recognition. RESULTS Women with CAIS, XYGD, and XXGD performed similar to female controls on cognitive tasks. However, on a test of emotion recognition, women with XXGD outperformed the other groups, whereas women with CAIS and XYGD performed similar to male controls. CONCLUSION Our results support theories of androgen effects on cognitive abilities and suggest that factors related to sex chromosomes may influence emotion recognition. Implications of an atypical sex hormone situation and sex chromosome variation are discussed.
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Affiliation(s)
- Anna Strandqvist
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
| | - Agneta Herlitz
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden; Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
| | - Lisa Örtqvist
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
| | - Louise Frisén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Child and Adolescent Psychiatry Research Center, Stockholm, Sweden.
| | - Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden.
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
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27
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Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, De Cuypere G, Feldman J, Fraser L, Green J, Knudson G, Meyer WJ, Monstrey S, Adler RK, Brown GR, Devor AH, Ehrbar R, Ettner R, Eyler E, Garofalo R, Karasic DH, Lev AI, Mayer G, Meyer-Bahlburg H, Hall BP, Pfäfflin F, Rachlin K, Robinson B, Schechter LS, Tangpricha V, van Trotsenburg M, Vitale A, Winter S, Whittle S, Wylie KR, Zucker K. Normas de Atención para la salud de personas trans y con variabilidad de género. INT J TRANSGENDERISM 2018. [DOI: 10.1080/15532739.2018.1503902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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28
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Al-Juraibah FN, Lucas-Herald AK, Alimussina M, Ahmed SF. The evaluation and management of the boy with DSD. Best Pract Res Clin Endocrinol Metab 2018; 32:445-453. [PMID: 30086868 DOI: 10.1016/j.beem.2018.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Atypical genitalia in a boy may have a very wide and diverse aetiology and a definitive diagnosis is often challenging to reach. Detailed clinical evaluation integrated with extensive biochemical and genetic studies play an important role in this process. Such care should be undertaken in highly specialized centres that can also provide access to a multidisciplinary team for optimal long-term care.
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Affiliation(s)
- F N Al-Juraibah
- Developmental Endocrinology Research Group, University of Glasgow, UK; Department of Paediatrics, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - A K Lucas-Herald
- Developmental Endocrinology Research Group, University of Glasgow, UK
| | - M Alimussina
- Developmental Endocrinology Research Group, University of Glasgow, UK
| | - S F Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, UK.
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29
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M Selveindran N, Syed Zakaria SZ, Jalaludin MY, Rasat R. Quality of Life in Children with Disorders of Sex Development. Horm Res Paediatr 2018; 88:324-330. [PMID: 28965114 DOI: 10.1159/000478780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 05/10/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Disorders of sex development (DSD) are a heterogeneous group of rare conditions. Evidence-based treatment is challenged by a lack of clinical longitudinal outcome studies. We sought to investigate the quality of life of children with DSD other than congenital adrenal hyperplasia. METHODS The participants (aged 6-18 years) were 23 patients raised as males and 7 patients raised as females. Control data were obtained from representatives of the patients' siblings matched for age and gender. The Pediatric Quality of Life InventoryTM Version 4.0 (PedsQL) Generic Core Scales were used as the study tool. RESULTS In comparison with the reference data, the patient group had significantly lower overall PedsQL (p < 0.01) and school functioning (p < 0.01) scores. Also, the total PedsQL score was significantly lower in patients with DSD who were of female social sex as compared to the controls who were females. Family income, surgical procedures, degree of virilization, and mode of puberty did not influence the PedsQL scores. CONCLUSION This study revealed a poorer quality of life for patients with DSD as compared to the age-matched control group. This highlights the need for a skilled multidisciplinary team to manage this group of patients.
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Affiliation(s)
| | | | | | - Rahmah Rasat
- Department of Paediatrics, University Kebangsaan Malaya Medical Centre, Kuala Lumpur, Malaysia
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Lee PA, Mazur T, Houk CP, Blizzard RM. Growth Hormone Deficiency Causing Micropenis: Lessons Learned From a Well-Adjusted Adult. Pediatrics 2018; 142:peds.2017-4168. [PMID: 29959177 DOI: 10.1542/peds.2017-4168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2018] [Indexed: 11/24/2022] Open
Abstract
This report of a 46,XY patient born with a micropenis consistent with etiology from isolated congenital growth hormone deficiency is used to (1) raise the question regarding what degree testicular testosterone exposure to the central nervous system during fetal life and early infancy has on the development of male gender identity, regardless of gender of rearing; (2) suggest the obligatory nature of timely full disclosure of medical history; (3) emphasize that virtually all 46,XY infants with functional testes and a micropenis should be initially boys except some with partial androgen insensitivity syndrome; and (4) highlight the sustaining value of a positive long-term relationship with a trusted physician (R.M.B.). When this infant presented, it was commonly considered inappropriate to gender assign an infant male whose penis was so small that an adult size was expected to be inadequate, even if the karyotype was 46,XY, and testes were functional. Concomitantly, female gender assignment was considered the appropriate decision, believing that parental rearing in the assigned gender was considered the major factor determining established adult gender identity. Full disclosure of medical information was considered inappropriate. Progress in appreciating the complexities of gender identity development, which is not yet completely understood, and sexuality, coping ability, and outcome data has resulted in a change of practice in initial gender assignment. A 46,XY individual with functional testes and verified androgen responsiveness should be assigned and reared as male, regardless of penis size. Without androgen responsiveness, the multiple factors must be carefully considered and disclosed.
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Affiliation(s)
- Peter A Lee
- Department of Pediatrics, College of Medicine, Penn State University, Hershey, Pennsylvania;
| | - Tom Mazur
- Center for Psychosexual Health, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo and John R. Oishei Children's Hospital, Buffalo, New York
| | - Christopher P Houk
- Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, Georgia; and
| | - Robert M Blizzard
- Department of Pediatrics, College of Medicine, University of Virginia, Charlottesville, Virginia
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31
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Kreukels BPC, Köhler B, Nordenström A, Roehle R, Thyen U, Bouvattier C, de Vries ALC, Cohen-Kettenis PT. Gender Dysphoria and Gender Change in Disorders of Sex Development/Intersex Conditions: Results From the dsd-LIFE Study. J Sex Med 2018; 15:777-785. [PMID: 29606626 DOI: 10.1016/j.jsxm.2018.02.021] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 02/22/2018] [Accepted: 02/26/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Information on the psychosexual outcome of individuals with disorders of sex development (DSDs) and intersex conditions is of great importance for sex assignment at birth of newborns with DSD. AIM To assess gender change and gender dysphoria in a large sample of individuals with different DSDs. METHODS A cross-sectional study was conducted in 14 European centers with 1,040 participants (717 female-identifying and 311 male-identifying persons and 12 persons identifying with another gender) with different forms of DSD. The cohort (mean age = 32.36 years, SD = 13.57) was divided into 6 major subgroups: women with 45,X DSD and variants (Turner syndrome; n = 325), men with 47,XXY DSD and variants (Klinefelter syndrome; n = 219), women with XY DSD without androgen effects (n = 107) and with androgen effects (n = 63), men with XY DSD (n = 87), and women with 46,XX congenital adrenal hyperplasia (n = 221). Data on psychosexual outcome were gathered by medical interviews and questionnaires. OUTCOMES Gender change and gender dysphoria. RESULTS Although gender changes were reported by 5% of participants, only in 1% (3% if those with Klinefelter and Turner syndromes-conditions in which gender issues are not prominent-are excluded) did the gender change take place after puberty and was likely initiated by the patient. 39 participants (4%) reported gender variance: between male and female, a gender other than male or female, or gender queer, alternating gender roles, or a gender expression that differed from the reported gender. This group had lower self-esteem and more anxiety and depression than the other participants. CLINICAL IMPLICATIONS Clinicians should be aware of and sensitive to the possibility that their patients with DSD not only might have transgender feelings and a desire to change gender, but also identify as different from male or female. The complexity of their feelings might require counseling for some patients. STRENGTHS AND LIMITATIONS The study is unique in the large number of participants from many different clinics, with sizable numbers in most subgroups, and in the large number of aspects that were measured. However, the very broadness of the study made it impossible to focus in detail on gender issues. Also, there is a need for instruments specifically measuring gender dysphoria in individuals with DSD that take non-binary genders into account. CONCLUSION To make appropriate gender care possible for people with DSD, the gender-normative and gender-variant development of children with DSD should be studied in longitudinal studies. Kreukels BPC, Köhler B, Nordenström A, et al. Gender Dysphoria and Gender Change in Disorders of Sex Development/Intersex Conditions: Results From the dsd-LIFE Study. J Sex Med 2018;15:777-785.
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Affiliation(s)
- Baudewijntje P C Kreukels
- Department of Medical Psychology and Medical Social Work, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
| | - Birgit Köhler
- Klinik für Pädiatrie m.S. Pädiatrische Endokrinologie CVK, Charité Universitätsmedizin, Berlin, Germany
| | - Anna Nordenström
- Division of Pediatric Endocrinology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Robert Roehle
- Koordinierungszentrum Klinische Studien (KKS), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ute Thyen
- Klinik für Kinder- und Jugendmedizin Universität zu Lübeck, Lübeck, Germany
| | - Claire Bouvattier
- Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Paris Sud University, Paris, France
| | - Annelou L C de Vries
- Department of Child Psychiatry, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology and Medical Social Work, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
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Tejwani R, Jiang R, Wolf S, Adkins DW, Young BJ, Alkazemi M, Wiener JS, Pomann GM, Purves JT, Routh JC. Contemporary Demographic, Treatment, and Geographic Distribution Patterns for Disorders of Sex Development. Clin Pediatr (Phila) 2018; 57:311-318. [PMID: 28758411 PMCID: PMC5891214 DOI: 10.1177/0009922817722013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aimed to describe the demographic characteristics, hospital utilizations, patterns of inpatient surgical management, and the overall state/regional variation in surgery rate among patients with disorders of sex development (DSD). We analyzed the Nationwide Inpatient Sample from 2001 to 2012 for patients younger than 21 years. DSD-related diagnoses and procedures were identified via International Classification of Diseases, Ninth Revision (ICD-9) codes. We identified a total of 43,968 DSD-related admissions. Of these, 73.4% of the admissions were designated as female and 642 (1.9%) were inpatient surgical admissions. Among neonates, less than 1% underwent any type of genital surgery. Nonsurgical admissions were associated with longer length of stay and higher cost. There was no significant regional variation in the rate of DSD surgeries, but we observed higher concentrations of DSD surgeries in states associated with tertiary referral centers.
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33
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Huang KH, Chen KT, Tai YS, Chiang IN, Chang HC. Gonadectomy in patients with disorder of sexual development. UROLOGICAL SCIENCE 2018. [DOI: 10.4103/uros.uros_35_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
The newborn infant with atypical genitalia presents a challenging clinical scenario and requires expert input. There have been appreciable advances in our knowledge of the underlying causes that may lead to a mere difference or a more serious disorder of sex development (DSD), the natural history of conditions, as well as the short and long-term complications of these conditions themselves, together with the clinical interventions that are associated with these conditions. With this information, the DSD expert can be more confident when discussing options with the parents of the newborn infant. By working within a multidisciplinary team, the expert should be able to support the family whilst individualising the management plan so that it is also cognizant of the shifts in societal attitudes and expectations around concepts of diversity and openness. It is, therefore, likely that the practice of assigning sex, especially in those cases where sex assignment is unclear on expert assessment, will continue to show temporal, social and geographical variations. It is imperative that clinical data for rare conditions such as these are collected in a standardized format and shared through a common registry so that any evidence that is used for future shifts in practice has a stronger foundation than that which is currently available.
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Affiliation(s)
- Renata Markosyan
- Yerevan State Medical University, Muratsan University Hospital, Clinic of Endocrinology, Yerevan, Armenia
,
University of Glasgow School of Medicine, Developmental Endocrinology Research Group, Glasgow, United Kingdom
| | - S. Faisal Ahmed
- University of Glasgow School of Medicine, Developmental Endocrinology Research Group, Glasgow, United Kingdom
,* Address for Correspondence: University of Glasgow School of Medicine, Royal Hospital for Children, Developmental Endocrinology Research Group, Glasgow, United Kingdom Phone: +44 141 451 5841 E-mail:
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35
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Bramble MS, Lipson A, Vashist N, Vilain E. Effects of chromosomal sex and hormonal influences on shaping sex differences in brain and behavior: Lessons from cases of disorders of sex development. J Neurosci Res 2017; 95:65-74. [PMID: 27841933 DOI: 10.1002/jnr.23832] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/30/2016] [Accepted: 06/20/2016] [Indexed: 01/15/2023]
Abstract
Sex differences in brain development and postnatal behavior are determined largely by genetic sex and in utero gonadal hormone secretions. In humans however, determining the weight that each of these factors contributes remains a challenge because social influences should also be considered. Cases of disorders of sex development (DSD) provide unique insight into how mutations in genes responsible for gonadal formation can perturb the subsequent developmental hormonal milieu and elicit changes in normal human brain maturation. Specific forms of DSDs such as complete androgen insensitivity syndrome (CAIS), congenital adrenal hyperplasia (CAH), and 5α-reductase deficiency syndrome have variable effects between males and females, and the developmental outcomes of such conditions are largely dependent on sex chromosome composition. Medical and psychological works focused on CAH, CAIS, and 5α-reductase deficiency have helped form the foundation for understanding the roles of genetic and hormonal factors necessary for guiding human brain development. Here we highlight how the three aforementioned DSDs contribute to brain and behavioral phenotypes that can uniquely affect 46,XY and 46,XX individuals in dramatically different fashions. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Matthew S Bramble
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Allen Lipson
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Neerja Vashist
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Eric Vilain
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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Controversies of Sex Re-assignment in Genetic Males with Congenital Inadequacy of the Penis. Indian J Pediatr 2017; 84:700-708. [PMID: 28687949 DOI: 10.1007/s12098-017-2412-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/08/2017] [Indexed: 10/19/2022]
Abstract
Sex assignment in 46XY genetic male children with congenital inadequacy of the penis (CIP) is controversial. Traditionally, children with penile length less than 2 cm at birth are considered unsuitable to be raised as males. They are typically re-assigned to female-sex and feminizing genitoplasty is usually done in infancy. However, the concept of cerebral androgen imprinting has caused paradigm shift in the philosophy of sex re-assignment. Masculinization of the brain, rather than length of the penis, is the modern criterion of sex re-assignment in CIP. This review summarizes the current understanding of the complex issue. In 46XY children with CIP, male-sex assignment appears appropriate in non-hormonal conditions such as idiopathic micropenis, aphallia and exstrophy. Female-sex re-assignment appears acceptable in complete androgen insensitivity (CAIS), while partial androgen insensitivity syndrome (PAIS) patients are highly dissatisfied with the assignment of either sex. Children with 5-alpha reductase deficiency are likely to have spontaneous penile lengthening at puberty. Hence, they are better raised as males. Although female assignment is common in pure gonadal dysgenesis, long-term results are not known to justify the decision.
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Chen MJ, McCann-Crosby B, Gunn S, Georgiadis P, Placencia F, Mann D, Axelrad M, Karaviti L, McCullough LB. Fluidity models in ancient Greece and current practices of sex assignment. Semin Perinatol 2017; 41:206-213. [PMID: 28478088 PMCID: PMC5950726 DOI: 10.1053/j.semperi.2017.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Disorders of sexual differentiation such as androgen insensitivity and gonadal dysgenesis can involve an intrinsic fluidity at different levels, from the anatomical and biological to the social (gender) that must be considered in the context of social constraints. Sex assignment models based on George Engel's biopsychosocial aspects model of biology accept fluidity of gender as a central concept and therefore help establish expectations within the uncertainty of sex assignment and anticipate potential changes. The biology underlying the fluidity inherent to these disorders should be presented to parents at diagnosis, an approach that the gender medicine field should embrace as good practice. Greek mythology provides many accepted archetypes of change, and the ancient Greek appreciation of metamorphosis can be used as context with these patients. Our goal is to inform expertise and optimal approaches, knowing that this fluidity may eventually necessitate sex reassignment. Physicians should provide sex assignment education based on different components of sexual differentiation, prepare parents for future hormone-triggered changes in their children, and establish a sex-assignment algorithm.
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Affiliation(s)
- Min-Jye Chen
- Divison of Pediatric Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Street, Suite 1020, Houston, TX 77030
| | - Bonnie McCann-Crosby
- Divison of Pediatric Endocrinology, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1020, Houston, TX 77030.
| | - Sheila Gunn
- Divison of Pediatric Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Street, Suite 1020, Houston, TX 77030
| | - Paraskevi Georgiadis
- Section of Neonatology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Frank Placencia
- Section of Neonatology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - David Mann
- Department of Anesthesiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Marni Axelrad
- Section of Psychology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - L.P Karaviti
- Divison of Pediatric Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Street, Suite 1020, Houston, TX 77030
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Motta-Mena NV, Puts DA. Endocrinology of human female sexuality, mating, and reproductive behavior. Horm Behav 2017; 91:19-35. [PMID: 27866819 DOI: 10.1016/j.yhbeh.2016.11.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 11/02/2016] [Accepted: 11/12/2016] [Indexed: 10/20/2022]
Abstract
Hormones orchestrate and coordinate human female sexual development, sexuality, and reproduction in relation to three types of phenotypic changes: life history transitions such as puberty and childbirth, responses to contextual factors such as caloric intake and stress, and cyclical patterns such as the ovulatory cycle. Here, we review the endocrinology underlying women's reproductive phenotypes, including sexual orientation and gender identity, mate preferences, competition for mates, sex drive, and maternal behavior. We highlight distinctive aspects of women's sexuality such as the possession of sexual ornaments, relatively cryptic fertile windows, extended sexual behavior across the ovulatory cycle, and a period of midlife reproductive senescence-and we focus on how hormonal mechanisms were shaped by selection to produce adaptive outcomes. We conclude with suggestions for future research to elucidate how hormonal mechanisms subserve women's reproductive phenotypes.
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Affiliation(s)
- Natalie V Motta-Mena
- Department of Psychology, Pennsylvania State University, University Park, PA 16802, United States
| | - David A Puts
- Department of Anthropology, Center for Brain, Behavior, and Cognition, Center for Human Evolution and Diversity, Pennsylvania State University, University Park, PA 16802¸ United States.
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Bennecke E, Thyen U, Grüters A, Lux A, Köhler B. Health-related quality of life and psychological well-being in adults with differences/disorders of sex development. Clin Endocrinol (Oxf) 2017; 86:634-643. [PMID: 28005277 DOI: 10.1111/cen.13296] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 11/17/2016] [Accepted: 12/14/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Rare congenital conditions with incongruence of chromosomal, gonadal and phenotypic sex have been classified as differences/disorders of sex development (DSD). Included in DSD are conditions with diverse genetic aetiology, varying levels of prenatal androgen effects, phenotypes and, subsequently, different medical treatments. Quality of life (QoL) and psychological well-being are indicators of successful psychosocial adaptation to the conditions. We sought to investigate the HRQoL and psychological well-being in this population. DESIGN This multicentre clinical evaluation study was part of a German network related to DSD funded by the German Ministry of Science and Education (BMBF 2003 to 2007). METHODS To assess health-related quality of life (HRQoL), we used the Short Form Health Survey (SF-36), and for psychological well-being, the Brief Symptom Inventory (BSI). Participants were classified into five groups: females with CAH, females with XY DSD conditions where there is a partial androgen effect (partial androgen insensitivity, mixed/partial gonadal dysgenesis, disorders of androgen biosynthesis), females with XY DSD without androgen effect (complete androgen insensitivity, complete gonadal dysgenesis), males with XY DSD, and individuals with DSD conditions and other gender. RESULTS Participants included 110 adults with DSD (age range 17-62). We found a trend of lowered mental HRQoL and significant higher physical HRQoL for participants as compared to the norm. The high physical HRQoL especially applied to females with androgen effect and XY karyotype. Participants reported significant higher psychological distress compared to the norm. Forty-seven participants (42·7%) reported distress in a clinically relevant range on the BSI. CONCLUSIONS Although we did not find significant impairments in overall HRQoL, participants reported significant impaired psychological well-being. Specialized interdisciplinary care should focus in particular on psychological issues to ensure good overall health and well-being.
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Affiliation(s)
- Elena Bennecke
- Division of Endocrinology and Diabetology, Department of Paediatrics, Charité, University Medicine, Berlin, Germany
| | - Ute Thyen
- Hospital for Children and Adolescents, University of Lübeck, Lübeck, Germany
| | - Annette Grüters
- Division of Endocrinology and Diabetology, Department of Paediatrics, Charité, University Medicine, Berlin, Germany
| | - Anke Lux
- Institute for Biometrics and Medical Informatics, Otto-von-Guericke University, Magdeburg, Germany
| | - Birgit Köhler
- Division of Endocrinology and Diabetology, Department of Paediatrics, Charité, University Medicine, Berlin, Germany
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Swift-Gallant A, Coome LA, Monks DA, VanderLaan DP. Handedness is a biomarker of variation in anal sex role behavior and Recalled Childhood Gender Nonconformity among gay men. PLoS One 2017; 12:e0170241. [PMID: 28234947 PMCID: PMC5325203 DOI: 10.1371/journal.pone.0170241] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 12/30/2016] [Indexed: 11/24/2022] Open
Abstract
Developmental theories of the biological basis of sexual orientation suggest that sexually differentiated psychological and behavioural traits should be linked with sexual orientation. Subgroups of gay men delineated by anal sex roles differ according to at least one such trait: gender expression. The present study assessed the hypothesis that handedness, a biologically determined sexually differentiated trait, corresponds to differences in subgroups of gay men based on anal sex role. Furthermore, it assessed whether handedness mediates the association between gender nonconformity and male sexual orientation. Straight and gay men (N = 333) completed the Edinburgh Inventory of Handedness and the Recalled Childhood Gender Nonconformity Scale. Gay men also completed measures of anal sex role preference. As in previous studies, gay men showed greater non-right-handedness and gender nonconformity than straight men. Also, among gay men, bottoms/versatiles (i.e., gay men who take a receptive anal sex role, or who take on both a receptive and insertive anal sex role) were more gender-nonconforming than tops (i.e., gay men who take an insertive anal sex role). In support of the hypothesis, bottoms/versatiles were more non-right-handed than tops and handedness mediated the male sexual orientation and anal sex role differences in Recalled Childhood Gender Nonconformity. Together, these findings suggest that developmental processes linked to handedness underpin variation among men in sexual orientation and gender nonconformity as well as variation among subgroups of gay men that are delineated by anal sex roles.
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Affiliation(s)
- Ashlyn Swift-Gallant
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
- Department of Psychology, University of Toronto at Mississauga, Mississauga, Ontario, Canada
| | - Lindsay A. Coome
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
- Department of Psychology, University of Toronto at Mississauga, Mississauga, Ontario, Canada
| | - D. Ashley Monks
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
- Department of Psychology, University of Toronto at Mississauga, Mississauga, Ontario, Canada
| | - Doug P. VanderLaan
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
- Department of Psychology, University of Toronto at Mississauga, Mississauga, Ontario, Canada
- Child, Youth and Family Division, Underserved Populations Research Program, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
- * E-mail:
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41
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Liu H, Tong XM. [Clinical evaluation and management of neonates with disorder of sexual development]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:1313-1318. [PMID: 27974129 PMCID: PMC7403084 DOI: 10.7499/j.issn.1008-8830.2016.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/02/2016] [Indexed: 06/06/2023]
Abstract
Disorder of sexual development or disorder of sex differentiation (DSD) refers to the inconsistency between karyotype and gonad phenotype and/or gonad anatomy in neonates and is manifested as the difficulty in identifying neonates' sex. According to the karyotype, DSD is classified as 46,XY DSD, 46,XX DSD, and sex chromosome DSD. A combination of detailed medical history, physical examination, and laboratory and imaging examinations is required for the diagnosis and comprehensive assessment of neonatal DSD and the determination of potential causes in clinical practice. Sex identification can only be made after all diagnostic evaluations have been completed. Sex identification of DSD neonates is influenced by various medical and social factors, including genotype (karyotype), sex hormones (levels of testosterone, dihydrotestosterone, and adrenal steroids), sex phenotype (appearance of internal and external genitals), reproduction (fertility potential), feelings of their parents, and even social acceptance and religious customs. A team with multidisciplinary cooperation is required, and patients must be involved in the whole process of sex identification. The major task of neonatal physicians for DSD is to assess the condition of neonates and provide management.
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Affiliation(s)
- Hui Liu
- Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China.
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42
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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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Callens N, Van Kuyk M, van Kuppenveld JH, Drop SLS, Cohen-Kettenis PT, Dessens AB. Recalled and current gender role behavior, gender identity and sexual orientation in adults with Disorders/Differences of Sex Development. Horm Behav 2016; 86:8-20. [PMID: 27576114 DOI: 10.1016/j.yhbeh.2016.08.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 08/24/2016] [Accepted: 08/25/2016] [Indexed: 01/08/2023]
Abstract
The magnitude of sex differences in human brain and behavior and the respective contributions of biology versus socialization remain a topic of ongoing study in science. The preponderance of evidence attests to the notion that sexual differentiation processes are at least partially hormonally mediated, with high levels of prenatal androgens facilitating male-typed and inhibiting female-typed behaviors. In individuals with Disorders/Differences of Sex Development (DSD), hormonal profiles or sensitivities have been altered due to genetic influences, presumably affecting gender(ed) activity interests as well as gender identity development in a minority of the affected population. While continued postnatal androgen exposure in a number of DSD syndromes has been associated with higher rates of gender dysphoria and gender change, the role of a number of mediating and moderating factors, such as initial gender assignment, syndrome severity and clinical management remains largely unclear. Limited investigations of the associations between these identified influences and gendered development outcomes impede optimization of clinical care. Participants with DSD (n=123), recruited in the context of a Dutch multi-center follow-up audit, were divided in subgroups reflecting prenatal androgen exposure, genital appearance at birth and gender of rearing. Recalled childhood play and playmate preferences, gender identity and sexual orientation were measured with questionnaires and semi-structured interviews. Data were compared to those of control male (n=46) and female participants (n=79). The findings support that (a) prenatal androgen exposure has large effects on (gendered) activity interests, but to a much lesser extent on sexual orientation and that (b) initial gender of rearing remains a better predictor of gender identity contentedness than prenatal androgen exposure, beyond syndrome severity and medical treatment influences. Nonetheless, 3.3% of individuals with DSD in our sample self-reported gender dysphoria from an early age and changed gender, which further underlines the need for thorough long- term follow-up and specific clinical support.
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Affiliation(s)
- Nina Callens
- Department of Pediatrics, Division of Pediatric Endocrinology, University Hospital Ghent and Ghent University, Ghent, Belgium; Department of Pediatrics, Division of Pediatric Endocrinology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maaike Van Kuyk
- Department of Medical Psychology, Radboud University Medical Center - Amalia Children's Hospital Nijmegen, The Netherlands
| | - Jet H van Kuppenveld
- Department of Medical Psychology, Radboud University Medical Center - Amalia Children's Hospital Nijmegen, The Netherlands
| | - Stenvert L S Drop
- Department of Pediatrics, Division of Pediatric Endocrinology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology and Medical Social Work, Vrije Universiteit Medical Center, Amsterdam, The Netherlands; Center of Expertise on Gender Dysphoria, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Arianne B Dessens
- Department of Pediatrics, Division of Pediatric Endocrinology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands.
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Lucas-Herald A, Bertelloni S, Juul A, Bryce J, Jiang J, Rodie M, Sinnott R, Boroujerdi M, Lindhardt Johansen M, Hiort O, Holterhus PM, Cools M, Guaragna-Filho G, Guerra-Junior G, Weintrob N, Hannema S, Drop S, Guran T, Darendeliler F, Nordenstrom A, Hughes IA, Acerini C, Tadokoro-Cuccaro R, Ahmed SF. The Long-Term Outcome of Boys With Partial Androgen Insensitivity Syndrome and a Mutation in the Androgen Receptor Gene. J Clin Endocrinol Metab 2016; 101:3959-3967. [PMID: 27403927 PMCID: PMC5095251 DOI: 10.1210/jc.2016-1372] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND In boys with suspected partial androgen insensitivity syndrome (PAIS), systematic evidence that supports the long-term prognostic value of identifying a mutation in the androgen receptor gene (AR) is lacking. OBJECTIVE To assess the clinical characteristics and long-term outcomes in young men with suspected PAIS in relation to the results of AR analysis. METHODS Through the International Disorders of Sex Development Registry, clinical information was gathered on young men suspected of having PAIS (n = 52) who presented before the age of 16 years and had genetic analysis of AR. RESULTS The median ages at presentation and at the time of the study were 1 month (range, 1 day to 16 years) and 22 years (range, 16 to 52 years), respectively. Of the cohort, 29 men (56%) had 20 different AR mutations reported. At diagnosis, the median external masculinization scores were 7 and 6 in cases with and without AR mutation, respectively (P = .9), and median current external masculinization scores were 9 and 10, respectively (P = .28). Thirty-five men (67%) required at least one surgical procedure, and those with a mutation were more likely to require multiple surgeries for hypospadias (P = .004). All cases with an AR mutation had gynecomastia, compared to 9% of those without an AR mutation. Of the six men who had a mastectomy, five (83%) had an AR mutation. CONCLUSIONS Boys with genetically confirmed PAIS are likely to have a poorer clinical outcome than those with XY DSD, with normal T synthesis, and without an identifiable AR mutation. Routine genetic analysis of AR to confirm PAIS informs long-term prognosis and management.
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MESH Headings
- Adolescent
- Adult
- Aging
- Androgen-Insensitivity Syndrome/diagnosis
- Androgen-Insensitivity Syndrome/genetics
- Androgen-Insensitivity Syndrome/physiopathology
- Child
- Child, Preschool
- Cohort Studies
- Disease Progression
- Disorder of Sex Development, 46,XY/diagnosis
- Disorder of Sex Development, 46,XY/genetics
- Disorder of Sex Development, 46,XY/physiopathology
- Gynecomastia/etiology
- Gynecomastia/surgery
- Humans
- Hypospadias/etiology
- Hypospadias/surgery
- Infant
- Infant, Newborn
- International Agencies
- Male
- Mastectomy
- Middle Aged
- Mutation
- Prognosis
- Puberty, Delayed
- Receptors, Androgen/genetics
- Receptors, Androgen/metabolism
- Registries
- Retrospective Studies
- Severity of Illness Index
- Young Adult
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Affiliation(s)
- A Lucas-Herald
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - S Bertelloni
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - A Juul
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - J Bryce
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - J Jiang
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - M Rodie
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - R Sinnott
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - M Boroujerdi
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - M Lindhardt Johansen
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - O Hiort
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - P M Holterhus
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - M Cools
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - G Guaragna-Filho
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - G Guerra-Junior
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - N Weintrob
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - S Hannema
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - S Drop
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - T Guran
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - F Darendeliler
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - A Nordenstrom
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - I A Hughes
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - C Acerini
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - R Tadokoro-Cuccaro
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
| | - S F Ahmed
- University of Glasgow (A.L.-H., J.B., J.J., M.R., R.S., M.B., S.F.A.), Glasgow G51 4TF, United Kingdom; University Hospital Pisa (S.B.), 56125 Pisa, Italy; Copenhagen University Hospital (A.J., M.L.J.), 2100 Copenhagen, Denmark; University of Luebeck (O.H.), 23562 Luebeck, Germany; Christian-Albrechts-University of Kiel and University Hospital of Schleswig-Holstein (P.M.H.), 24105 Kiel, Germany; University Hospital Ghent and Ghent University (M.C.), B-9000 Ghent, Belgium; State University of Campinas (UNICAMP) (G.G.-F., G.G.-J.), Campinas 13083-970, Brazil; Dana Dwek Children's Hospital (N.W.), Tel Aviv University, Tel Aviv 64239, Israel; Leids Universitair Medisch Centrum (S.H.), 2333 ZA Leiden, The Netherlands; Sophia Children's Hospital (S.H.), Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands; Marmara University (T.G.), 34722 Istanbul, Turkey; Istanbul University (F.D.), 34452 Istanbul, Turkey; Karolinska Institutet (A.N.), SE-171 77 Stockholm, Sweden; and University of Cambridge (I.A.H., C.A., R.T.-C.), Cambridge CB2 1TN, United Kingdom
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Gangaher A, Chauhan V, Jyotsna VP, Mehta M. Gender identity and gender of rearing in 46 XY disorders of sexual development. Indian J Endocrinol Metab 2016; 20:536-41. [PMID: 27366722 PMCID: PMC4911845 DOI: 10.4103/2230-8210.183471] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Disorders of sexual development (DSD) may pose a challenge to live as a fully-functioning male or female. In this study, we prospectively assessed eleven 46 XY DSD patients who were being treated at our center over the last 8 months for gender dysphoria. MATERIALS AND METHODS To determine gender dysphoria, age-appropriate gender identity (GI) questionnaires were used. For patients, 12 years and below, parent report GI questionnaire for children was used and for those above 12 years of age, GI/gender dysphoria questionnaire for adolescents and adults was administered. RESULTS Of 11 patients with 46 XY DSD, three were diagnosed with 5 alpha reductase deficiency (5aRD), two with partial gonadal dysgenesis, three with partial androgen insensitivity syndrome, one each with ovotesticular, complete gonadal dysgenesis, and complete androgen insensitivity. Gender assigned at birth was female in eight and male in three patients. Among the eight reared as female, gender had been reassigned as male in three patients well before the present study was conducted. None of the eleven patients had gender dysphoria at the time of this study. CONCLUSION Early gender of rearing was seen to be a critical indicator of present GI in our patients except in cases of 5aRD.
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Affiliation(s)
- Arushi Gangaher
- 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
| | - Viveka P. Jyotsna
- 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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Mouriquand PDE, Gorduza DB, Gay CL, Meyer-Bahlburg HFL, Baker L, Baskin LS, Bouvattier C, Braga LH, Caldamone AC, Duranteau L, El Ghoneimi A, Hensle TW, Hoebeke P, Kaefer M, Kalfa N, Kolon TF, Manzoni G, Mure PY, Nordenskjöld A, Pippi Salle JL, Poppas DP, Ransley PG, Rink RC, Rodrigo R, Sann L, Schober J, Sibai H, Wisniewski A, Wolffenbuttel KP, Lee P. Surgery in disorders of sex development (DSD) with a gender issue: If (why), when, and how? J Pediatr Urol 2016; 12:139-49. [PMID: 27132944 DOI: 10.1016/j.jpurol.2016.04.001] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/25/2016] [Accepted: 04/04/2016] [Indexed: 01/25/2023]
Abstract
Ten years after the consensus meeting on disorders of sex development (DSD), genital surgery continues to raise questions and criticisms concerning its indications, its technical aspects, timing and evaluation. This standpoint details each distinct situation and its possible management in 5 main groups of DSD patients with atypical genitalia: the 46,XX DSD group (congenital adrenal hyperplasia); the heterogeneous 46,XY DSD group (gonadal dysgenesis, disorders of steroidogenesis, target tissues impairments …); gonosomic mosaicisms (45,X/46,XY patients); ovo-testicular DSD; and "non-hormonal/non chromosomal" DSD. Questions are summarized for each DSD group with the support of literature and the feed-back of several world experts. Given the complexity and heterogeneity of presentation there is no consensus regarding the indications, the timing, the procedure nor the evaluation of outcome of DSD surgery. There are, however, some issues on which most experts would agree: 1) The need for identifying centres of expertise with a multidisciplinary approach; 2) A conservative management of the gonads in complete androgen insensitivity syndrome at least until puberty although some studies expressed concerns about the heightened tumour risk in this group; 3) To avoid vaginal dilatation in children after surgical reconstruction; 4) To keep asymptomatic mullerian remnants during childhood; 5) To remove confirmed streak gonads when Y material is present; 6) It is likely that 46,XY cloacal exstrophy, aphallia and severe micropenis would do best raised as male although this is based on limited outcome data. There is general acknowledgement among experts that timing, the choice of the individual and irreversibility of surgical procedures are sources of concerns. There is, however, little evidence provided regarding the impact of non-treated DSD during childhood for the individual development, the parents, society and the risk of stigmatization. The low level of evidence should lead to design collaborative prospective studies involving all parties and using consensual protocols of evaluation.
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Affiliation(s)
- Pierre D E Mouriquand
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France.
| | - Daniela Brindusa Gorduza
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France
| | - Claire-Lise Gay
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France
| | - Heino F L Meyer-Bahlburg
- NYS Psychiatric Institute, New York, NY, USA; College of Physicians & Surgeons of Columbia University, New York City, NY, USA
| | - Linda Baker
- Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Laurence S Baskin
- Pediatric Urology, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Claire Bouvattier
- Service d'Endocrinologie de l'enfant, GHU Paris-Sud, Hôpital de Bicêtre, Paris, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Paris, France
| | - Luis H Braga
- Division of Urology, Department of Surgery, McMaster University, Toronto, Canada
| | - Anthony C Caldamone
- Pediatric Urology, Hasbro Children's Hospital, Providence, RI, USA; Surgery (Urology) and Pediatrics, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Lise Duranteau
- Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Paris, France; Adolescent Gynaecology, Hôpitaux Universitaires Paris Sud (Bicêtre), Paris, France
| | - Alaa El Ghoneimi
- Pediatric Surgery and Urology, University Hospital Robert Debré, APHP, University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Terry W Hensle
- College of Physicians & Surgeons of Columbia University, New York City, NY, USA
| | - Piet Hoebeke
- Urology, Ghent University Hospital, Gent, Belgium
| | - Martin Kaefer
- Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicolas Kalfa
- Service de Chirurgie Viscérale et Urologique Pédiatrique, Hôpital Lapeyronie, CHU de Montpellier, Université de Montpellier, France
| | - Thomas F Kolon
- Pediatric Urology, Children's Hospital of Philadelphia, PA, USA; Perelman School of Medicine at University of Pennsylvania, PA, USA
| | - Gianantonio Manzoni
- Pediatric Urology, Fondazione IRCCS CaGranda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pierre-Yves Mure
- Department of Paediatric Urology/Paediatric Surgery, Université Claude-Bernard, Hospices Civils de Lyon, Lyon, France; Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement Génito-Sexuel, Lyon, France
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - J L Pippi Salle
- Department of Surgery, Sidra Medical and Research Center, Doha, Qatar
| | - Dix Phillip Poppas
- Komansky Center for Children's Health, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Philip G Ransley
- Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - Richard C Rink
- Service de Chirurgie Viscérale et Urologique Pédiatrique, Hôpital Lapeyronie, CHU de Montpellier, Université de Montpellier, France
| | - Romao Rodrigo
- Department of Surgery, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada; Department of Urology, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Léon Sann
- Conseil d'éthique pédiatrique, Centre Hospitalo-Universitaire de Lyon, France
| | | | - Hisham Sibai
- Paediatric Surgery, University of Casablanca, Morocco
| | | | - Katja P Wolffenbuttel
- Department of Urology and Pediatric Urology, Erasmus MC Sophia Children's Hospital, Rotterdam
| | - Peter Lee
- Penn State Hershey Pediatric Endocrinology, PA, USA
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Psychosocial well-being in Dutch adults with disorders of sex development. J Psychosom Res 2016; 83:57-64. [PMID: 27020078 DOI: 10.1016/j.jpsychores.2016.03.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 03/04/2016] [Accepted: 03/10/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Atypical sex development is associated with psychosocial vulnerability. We investigated psychosocial well-being in individuals with disorders of sex development (DSD) and hypothesized that psychosocial well-being was related to degree of genital atypicality at birth. METHODS 120 male (n=16) and female (n=104) persons with DSD, aged 14-60 years, participated in a follow-up audit on psychosocial well-being. They were stratified in: women with 1) 46,XY and female genitalia, 2) 46,XY or 46,XX and atypical genitalia, and 3) men with 46,XY and atypical genitalia. We used the Illness Cognition Questionnaire (ICQ), Checklist Individual Strength (CIS8R), TNO-AZL Quality of Life questionnaire (TAAQOL), Adult Self-Report (ASR), and the Rosenberg Self-Esteem Scale (RSES). RESULTS Data were compared to reference groups. Participants generally were coping well with DSD (ICQ). Women with DSD reported elevated levels of fatigue (CIS8R) and slightly more attention and memory problems (TAAQOL, ASR). Women with atypical genitalia reported more emotional and behavioral problems. On the ASR Rule-breaking Behavior and Antisocial Personality scales, these women had similar scores as reference men. Women with DSD reported a higher self-esteem (RSES). No differences in psychosocial well-being were found between men with DSD and reference men. CONCLUSION Individuals with DSD across all diagnostic groups generally reported a good psychosocial well-being. The results further suggest involvement of prenatal androgens in the development of personality traits related to assertiveness and egocentricity. We recommend that individuals with a DSD and their families are involved in decision-making processes and have access to multidisciplinary care.
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Glidden D, Bouman WP, Jones BA, Arcelus J. Gender Dysphoria and Autism Spectrum Disorder: A Systematic Review of the Literature. Sex Med Rev 2016; 4:3-14. [DOI: 10.1016/j.sxmr.2015.10.003] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/01/2015] [Indexed: 11/25/2022]
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Brunner F, Fliegner M, Krupp K, Rall K, Brucker S, Richter-Appelt H. Gender Role, Gender Identity and Sexual Orientation in CAIS ("XY-Women") Compared With Subfertile and Infertile 46,XX Women. JOURNAL OF SEX RESEARCH 2015; 53:109-124. [PMID: 26133743 DOI: 10.1080/00224499.2014.1002124] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The perception of gender development of individuals with complete androgen insensitivity syndrome (CAIS) as unambiguously female has recently been challenged in both qualitative data and case reports of male gender identity. The aim of the mixed-method study presented was to examine the self-perception of CAIS individuals regarding different aspects of gender and to identify commonalities and differences in comparison with subfertile and infertile XX-chromosomal women with diagnoses of Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) and polycystic ovary syndrome (PCOS). The study sample comprised 11 participants with CAIS, 49 with MRKHS, and 55 with PCOS. Gender identity was assessed by means of a multidimensional instrument, which showed significant differences between the CAIS group and the XX-chromosomal women. Other-than-female gender roles and neither-female-nor-male sexes/genders were reported only by individuals with CAIS. The percentage with a not exclusively androphile sexual orientation was unexceptionally high in the CAIS group compared to the prevalence in "normative" women and the clinical groups. The findings support the assumption made by Meyer-Bahlburg ( 2010 ) that gender outcome in people with CAIS is more variable than generally stated. Parents and professionals should thus be open to courses of gender development other than typically female in individuals with CAIS.
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Affiliation(s)
- Franziska Brunner
- a Institute for Sex Research and Forensic Psychiatry , University Medical Center Hamburg-Eppendorf
| | - Maike Fliegner
- a Institute for Sex Research and Forensic Psychiatry , University Medical Center Hamburg-Eppendorf
| | - Kerstin Krupp
- a Institute for Sex Research and Forensic Psychiatry , University Medical Center Hamburg-Eppendorf
| | - Katharina Rall
- b Department of Obstetrics and Gynaecology , Tübingen University Hospital
| | - Sara Brucker
- b Department of Obstetrics and Gynaecology , Tübingen University Hospital
| | - Hertha Richter-Appelt
- a Institute for Sex Research and Forensic Psychiatry , University Medical Center Hamburg-Eppendorf
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Ediati A, Juniarto AZ, Birnie E, Drop SLS, Faradz SMH, Dessens AB. Gender Development in Indonesian Children, Adolescents, and Adults with Disorders of Sex Development. ARCHIVES OF SEXUAL BEHAVIOR 2015; 44:1339-1361. [PMID: 25813609 DOI: 10.1007/s10508-015-0493-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 04/08/2014] [Accepted: 10/04/2014] [Indexed: 06/04/2023]
Abstract
In most Western countries, clinical management of disorders of sex development (DSD), including ambiguous genitalia, begins at diagnosis soon after birth. For many Indonesian patients born with ambiguous genitalia, limited medical treatment is available. Consequently, affected individuals are raised with ambiguous genitalia and atypical secondary sex characteristics. We investigated gender identity and gender role behavior in 118 Indonesian subjects (77 males, 41 females) with different types of DSD in comparison with 118 healthy controls matched for gender, age, and residential setting (rural, suburban, or urban). In Study 1, we report on methodological aspects of the investigation, including scale adaptation, pilot testing, and determining reliability and validity of measures. In Study 2, we report on gender development in 60 children (42 boys, 18 girls), 24 adolescents (15 boys, 9 girls), and 34 adults (19 men, 15 women) with DSD. The majority of participants with DSD never received any medical or surgical treatment prior to this study. We observed a gender change in all age groups, with the greatest incidence in adults. Among patients who changed, most changed from female to male, possessed a 46,XY karyotype, and had experienced significant masculinization during life. Gender identity confusion and cross-gender behavior was more frequently observed in children with DSD raised as girls compared to boys. Puberty and associated masculinization were related to gender problems in individuals with 46,XY DSD raised female. An integrated clinical and psychological follow-up on gender outcome is necessary prior to puberty and adulthood.
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Affiliation(s)
- Annastasia Ediati
- Department of Clinical Psychology, Faculty of Psychology, Diponegoro University, Tembalang, Semarang, 50275, Indonesia,
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