1
|
Pennesi CM, Berkeley J, Lossie AC, Quint EH, Zieman KD, Carroll S. International Experiences with Vaginal Lengthening Treatment Among Individuals with Müllerian Agenesis: A Mixed-Methods Study. J Pediatr Adolesc Gynecol 2023; 36:476-483. [PMID: 37182810 DOI: 10.1016/j.jpag.2023.05.004] [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: 11/16/2022] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 05/16/2023]
Abstract
STUDY OBJECTIVE To understand variations and experiences of vaginal lengthening internationally in individuals with congenital underdevelopment of the uterus, cervix, and upper vagina or Müllerian agenesis METHODS: In this study, we used a cross-sectional mixed-methods design incorporating quantitative and qualitative questionnaires. Adults with Müllerian agenesis completed questionnaires with quantitative and open-ended qualitative questions about their vaginal lengthening experiences. Data were analyzed using descriptive statistics and inductive thematic analysis. RESULTS Of 616 respondents meeting inclusion criteria (representing 40 countries), 46% (n = 284) reported no vaginal lengthening intervention. Vaginal lengthening was commonly reported by participants from North America and Europe (59%) and less commonly by participants from Africa, Asia, and South America (16%). Of those who had undergone vaginal lengthening, 72% reported dilator use, 34% coital dilation, and 39% surgery. Four major themes were identified in response to the open-ended vaginal lengthening experience question: (1) difficult physical symptoms, (2) practical and psychosocial challenges, (3) intimate relationships and sexual satisfaction, and (4) impact of experiences with healthcare providers. CONCLUSION This study highlights vaginal lengthening practices internationally and shared themes related to significant challenges and positive experiences. The findings show room for improvement in the counseling and care surrounding vaginal lengthening. Future research should investigate factors that influence decision-making about vaginal lengthening and work toward international consensus on best care practices in Müllerian agenesis.
Collapse
Affiliation(s)
- Christine M Pennesi
- University of Michigan, Department of Obstetrics and Gynecology, Ann Arbor, Michigan; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Jane Berkeley
- Beautiful You MRKH Foundation, Silver Spring, Maryland
| | - Amy C Lossie
- Beautiful You MRKH Foundation, Silver Spring, Maryland
| | - Elisabeth H Quint
- University of Michigan, Department of Obstetrics and Gynecology, Ann Arbor, Michigan
| | | | - Susan Carroll
- Psychology Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom of Great Britain and Northern Ireland, United Kingdom; King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom of Great Britain and Northern Ireland, United Kingdom
| |
Collapse
|
2
|
Xu ZY, Li LX, Wang XG, Wang MX, Cao GJ, Chen BL, Liu SJ. The long-term outcomes of vaginoplasty using acellular porcine small intestinal submucosa grafts in patients with Mayer-Rokitansky-Küster-Hauser syndrome: A case series. BJOG 2023; 130:645-652. [PMID: 36660801 DOI: 10.1111/1471-0528.17388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/11/2022] [Accepted: 11/28/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To investigate the long-term outcomes for Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) patients undergoing vaginoplasty using acellular porcine small intestinal submucosa grafts (SIS). DESIGN A case series. POPULATION Seventy-eight MRKH syndrome patients and a post-SIS patient who delivered a baby following the world's first robot-assisted uterus transplantation. METHODS Mayer-Rokitansky-Küster-Hauser syndrome patients were grouped based on the postoperative time and the diagnosis-surgery interval. Outcomes of sexual function and psychological status were assessed using the female sexual function index (FSFI), self-rating scale of body image (SSBI) and self-acceptance questionnaire (SAQ). Anatomical outcomes were measured by clinicians. MAIN OUTCOME MEASURES The primary outcome was restoration of sexual function, defined by an FSFI score in the 'good' range. Anatomical and psychological outcomes were also analysed. RESULTS Sexual function was restored in 42.3% (33/78) of patients and the total FSFI score was 23.44 ± 4.43. Three factors (body defect, recognition of physical appearance and willingness to change physical appearance scores) in the SSBI and two in the SAQ decreased as the postoperative time increased. Based on the interval between diagnosis and surgery, the total SSBI score was lower in the short-interval group than in the long-interval group (7.25 ± 5.55 versus 12.04 ± 10.21, p = 0.038). CONCLUSIONS Nearly half of MRKH patients in our study had good long-term sexual function after SIS vaginoplasty. Sexual function and psychological status improved as postoperative time increased. In addition, reducing the diagnosis to surgery interval was associated with improved psychological function.
Collapse
Affiliation(s)
- Zhi-Yang Xu
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ling-Xia Li
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xing-Guo Wang
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Meng-Xin Wang
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Gai-Jing Cao
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,Medical School of Yanan University, Yanan, China
| | - Bi-Liang Chen
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Shu-Juan Liu
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| |
Collapse
|
3
|
Stepanow C, Naderer A, Alexopoulos J, Walch K, Wenzl R, Leithner K. Sexual health and sexual well-being of women with Mayer-Rokitansky-Kuester-Hauser syndrome after vaginal reconstruction: a qualitative analysis. J Sex Med 2023; 20:57-64. [PMID: 36897238 DOI: 10.1093/jsxmed/qdac011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/29/2022] [Accepted: 10/23/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Contradictory findings on sexual health in women with Mayer-Rokitansky-Kuester-Hauser syndrome (MRKHS) after vaginal reconstruction point toward the need for more profound assessment of this subject, particularly as it is still unclear what constitutes sexual well-being, especially genital self-image or sexual self-esteem, in women with MRKHS and neovagina. AIM The aim of this qualitative study was to assess individual sexual health and sexual well-being in the context of MRKHS after vaginal reconstruction, with an emphasis on genital self-image, sexual self-esteem, sexual satisfaction, and coping with MRKHS. METHODS Qualitative semistructured interviews were conducted with women with MRKHS after vaginal reconstruction (n = 10) with the Wharton-Sheares-George surgical method and a matched control group without MRKHS (n = 20). Women were surveyed about their previous and current sexual activities, perception of and attitudes toward their genitals, disclosure to others, coping with the diagnosis, and perception of surgery. Data were analyzed through qualitative content analysis and compared with the control group. OUTCOMES The primary outcomes of the study were major categories, such as sexual satisfaction, sexual self-esteem, genital self-image, and dealing with MRKHS, as well as subcategories related to the content analysis. RESULTS Although half the women in the present study indicated that they were coping well with their condition and were satisfied with sexual intercourse, most felt insecure about their neovagina, were cognitively distracted during intercourse, and showed low levels of sexual self-esteem. CLINICAL IMPLICATIONS A better understanding of expectations and uncertainties regarding the neovagina might help professionals to support women with MRKHS after vaginal reconstruction to increase sexual well-being. STRENGTHS AND LIMITATIONS This is the first qualitative study focusing on individual aspects of sexual well-being, especially sexual self-esteem and genital self-image, in women with MRKHS and neovagina. The qualitative study indicates good interrater reliability and data saturation. The limitations of this study include the inherent lack of objectivity resulting from the method but also the fact that all the patients had a particular surgical technique, consequently resulting in limited generalizability of these findings. CONCLUSIONS Our data indicate that integrating the neovagina into the genital self-image is a prolonged process that is essential for sexual well-being and should thus be the focus of sexual counseling.
Collapse
Affiliation(s)
- Clara Stepanow
- Department of Psychoanalysis and Psychotherapy, Medical University Vienna, Vienna A-1090, Austria
| | - Andrea Naderer
- Department of Psychoanalysis and Psychotherapy, Medical University Vienna, Vienna A-1090, Austria
| | - Johanna Alexopoulos
- Department of Psychoanalysis and Psychotherapy, Medical University Vienna, Vienna A-1090, Austria
| | - Katharina Walch
- Department of Obstetrics and Gynaecology, Medical University Vienna, Vienna A-1090, Austria
| | - Rene Wenzl
- Department of Obstetrics and Gynaecology, Medical University Vienna, Vienna A-1090, Austria
| | - Katharina Leithner
- Department of Psychoanalysis and Psychotherapy, Medical University Vienna, Vienna A-1090, Austria
| |
Collapse
|
4
|
Liu X, Ding J, Li Y, Hua K, Zhang X. Comparison of two different methods for cervicovaginal reconstruction: a long-term follow-up. Int Urogynecol J 2023; 34:247-254. [PMID: 36112181 DOI: 10.1007/s00192-022-05327-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/24/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION AND HYPOTHESIS As a consequence of the evolution of surgery in reconstructive techniques, cervicovaginal reconstruction has become an option for patients diagnosed with congenital cervical and vaginal atresia. This study was aimed at comparing long-term clinical and anatomical results in patients who had cervicovaginal reconstruction with either a small intestinal submucosa (SIS) graft or a split-thickness skin (STS) graft. METHODS This was a retrospective study of 34 patients who underwent cervicovaginal reconstruction using SIS or STS grafts between January 2012 and August 2017. The patients' postoperative resumption of menstruation, vaginal length, body image satisfaction, and sexual satisfaction were assessed. Quantitative and categorical variables were compared using Student's t test and Chi-squared test respectively. RESULTS The mean follow-up time was 81.29 ± 20.69 months. The SIS group had a shorter surgery time, an earlier return to work, and a higher cost (p < 0.05). All patients resumed menstruation, but 4 patients were diagnosed with cervical stricture. There was no significant difference in the length of the neovagina, and the satisfaction score of the sexual life of patients and their sexual partners was similar in both groups. Patients in the SIS group showed greater satisfaction with their bodies (p < 0.001). One patient in the SIS group got pregnant via assisted-reproduction techniques. CONCLUSIONS Cervicovaginal reconstruction using SIS or STS grafts is an effective treatment for patients diagnosed with congenital cervical and vaginal atresia. The method of SIS graft is simpler, with less surgical injury and greater body satisfaction, but it is more expensive.
Collapse
Affiliation(s)
- Xiaotong Liu
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China
| | - Jingxin Ding
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China
| | - Yuqi Li
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China
| | - Keqin Hua
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.
| | - Xuyin Zhang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.
| |
Collapse
|
5
|
Schäffeler N, Beckmann J, Schenk B, Schöller D, Wallwiener D, Enck P, Teufel M, Zipfel S, Rall K, Brucker S. [Burden of Affected Persons with MRKH Syndrome: Effect of an Intervention to Support Surgical Neovaginal Placement]. Psychother Psychosom Med Psychol 2022; 72:473-480. [PMID: 35504296 DOI: 10.1055/a-1778-5194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The diagnosis of Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS), a rare variant of female sexual development, is usually made during puberty. The uncertainty in self-image and the impos-sibility of becoming pregnant often lead to considerable stress. Although psychosomatic support is consistently recommended in the literature, there have been only a few studies on the psychological aspects of MRKHS. The aim of the present study is to investigate the quality of life or distress of women with MRKHS undergoing neovaginal surgery and, on the other hand, to evaluate effects of the intervention for support during treatment. Methods In an explorative quasi-experimental pre-post study at a national centre for neovaginal surgery, all patients were offered a psychosomatic intervention (intervention group IG, n=23) and their sexual function (FSFI), psychological distress (PHQ-D) and health-related quality of life (SF-12) were assessed before surgery (t0) and six months after (t1). These were compared with data from a sample collected before and after the intervention period (comparison group VG, n=30). Results While the physical quality of life (SF-12) of both groups was unremarkable at both time points, there was a significant impairment in the psychological quality of life. Both groups (IG, VG) improved from t0 to t1 in their sexual function (FSFI) and showed lower depression scores (PHQ-D). The specific intervention developed was well accepted by those affected and rated as helpful. However, this subjectively perceived effectiveness of the intervention was not reflected by improvement on the quality of life scale (SF-12) and depression scale (PHQ-D). Conclusion Those affected show a clear, clinically relevant distress (SF-12), but this is not reflected in the form of psychological comorbidity (PHQ-D). This apparent discrepancy points to psychologically stable women with acute distress due to the diagnosis of variant sex de-evolution. For them, a low-threshold support service with a supportive character seems to be necessary and helpful during the surgical treatment. The reconstructive therapy for the creation of a neovagina seems to have a positive influence on the psychological quality of life. The fact that pregnancy is still not possible due to the missing uterus could be a reason for not reaching the quality of life of the average population.
Collapse
Affiliation(s)
- Norbert Schäffeler
- Abteilung Psychosomatische Medizin und Psychotherapie, Medizinische Universitätsklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Julia Beckmann
- Abteilung Psychosomatische Medizin und Psychotherapie, Medizinische Universitätsklinik, Universitätsklinikum Tübingen, Tübingen, Germany.,Institut für transkulturelle Gesundheitsforschung, Duale Hochschule Baden-Württemberg - Villingen Schwenningen, Villingen-Schwenningen, Germany
| | - Bernadette Schenk
- Universitäts-Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Dorit Schöller
- Universitäts-Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | | | - Paul Enck
- Abteilung Psychosomatische Medizin und Psychotherapie, Medizinische Universitätsklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Martin Teufel
- Abteilung Psychosomatische Medizin und Psychotherapie, Medizinische Universitätsklinik, Universitätsklinikum Tübingen, Tübingen, Germany.,Klinik für Psychosomatische Medizin und Psychotherapie, LVR-Klinikum Essen, Essen, Germany
| | - Stephan Zipfel
- Abteilung Psychosomatische Medizin und Psychotherapie, Medizinische Universitätsklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Katharina Rall
- Universitäts-Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Sara Brucker
- Universitäts-Frauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
| |
Collapse
|
6
|
Beisert MJ, Chodecka AM, Walczyk-Matyja K, Szymańska-Pytlińska ME, Kędzia W, Kapczuk K. Psychological correlates of sexual self-esteem in young women with Mayer-Rokitansky-Küster-Hauser syndrome. CURRENT ISSUES IN PERSONALITY PSYCHOLOGY 2022; 10:333-342. [PMID: 38013735 PMCID: PMC10535637 DOI: 10.5114/cipp.2022.114044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/12/2021] [Accepted: 02/07/2022] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) is a difference (disorder) of sex development that results from Müllerian duct aplasia in 46,XX females. The diagnosis of MRKHS is usually established in late adolescence. The purpose of the study was to assess the impact of congenital absence of uterus and vagina (CAUV) on a patient's psychosexual functioning. PARTICIPANTS AND PROCEDURE Thirty-two women with MRKHS (mean age 22.9 years) and 32 matched healthy controls (mean age 24.75 years) completed three study questionnaires: the Sexual Self-Esteem Inventory for Women, the Rosenberg Self-Esteem Scale, and Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Statistical analysis was performed by IBM SPSS Statistics 22. RESULTS There was no difference in global self-esteem between the two study groups. MRKHS females had lower sexual self-esteem and experienced higher intensity of some psychological functioning characteristics (paranoia, psychasthenia, schizophrenia) than their peers. Correlations between sexual self-esteem and results on depression, psychopathic deviate, schizophrenia, social introversion and anxiety scales were observed in patients with MRKHS. Global self-esteem and schizophrenia results were significant predictors of sexual self-esteem in the clinical group. Higher global self-esteem and lower results in the schizophrenia scale were associated with higher sexual self-esteem in patients with MRKHS. CONCLUSIONS Psychological and medical counseling of women with MRKHS should address their impaired sexual self-esteem, especially sexual skills and experiences. While the number of diagnostic responses indicating the presence of specific symptoms in MRKHS females is statistically significantly different, the level of scores obtained does not exceed the threshold of clinical pathology.
Collapse
Affiliation(s)
- Maria J. Beisert
- Faculty of Psychology and Cognitive Science, Adam Mickiewicz University, Poznan, Poland
| | | | - Katarzyna Walczyk-Matyja
- Division of Gynecology, Department of Perinatology and Gynecology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Witold Kędzia
- Division of Gynecology, Department of Perinatology and Gynecology, Poznan University of Medical Sciences, Poznan, Poland
| | - Karina Kapczuk
- Division of Gynecology, Department of Perinatology and Gynecology, Poznan University of Medical Sciences, Poznan, Poland
| |
Collapse
|
7
|
Long Term Findings Concerning the Mental and Physical Condition, Quality of Life and Sexuality after Laparoscopically Assisted Creation of a Neovagina (Modified Vecchietti Technique) in Young MRKHS (Mayer-Rokitansky-Küster-Hauser-Syndrome) Patients. J Clin Med 2021; 10:jcm10061269. [PMID: 33803863 PMCID: PMC8003280 DOI: 10.3390/jcm10061269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 11/17/2022] Open
Abstract
The Mayer-Rokitansky-Küster-Hauser-syndrome (MRKHS) is characterized by a congenital uterine and vaginal aplasia. A large body of literature reports that a diagnosis of MRKHS has a variety of psychological effects on patients and doubts about female identity. The aim of the underlying study was to detect the patient-reported physical and mental health and sexual function before and after laparoscopically assisted creation of a neovagina. 160 women with MRKHS who underwent this type of surgery between September 2009 and December 2015 were invited to complete the questionnaires. Packages consisting of six questionnaires were handed out before surgery, six and 12 months after surgery. Data from 82 patients could be included in the study. Patients had a mean age of 19.9 years at inclusion in the study. We detected an impairment of the health-related mental quality of life. There was no higher risk for psychological disorders. MRKHS patients show similar self-acceptance and normal body image compared to the general population. The sexual function is limited before surgery and normalizes after surgery. Useful factors for coping with the disease are an interdisciplinary approach in diagnostics and treatment, psychosocial adaptation as well as a supportive social environment.
Collapse
|
8
|
Carroll S, Laufer MR, Thomas-Kowal P, Lossie AC, Moss-Morris R. From Engulfment to Enrichment: Associations Between Illness Representations, Self-Concept, and Psychological Adjustment in Mayer-Rokitansky-Küster-Hauser Syndrome. J Pediatr Adolesc Gynecol 2020; 33:639-648. [PMID: 32688051 DOI: 10.1016/j.jpag.2020.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 05/07/2020] [Accepted: 07/09/2020] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) is a female reproductive disorder characterized by the absence or underdevelopment of the uterus, cervix and vagina. Limited research has examined factors related to psychological adjustment in MRKH. This study aimed to explore associations among illness representations, self-concept, psychological distress, and self-esteem in MRKH. DESIGN Cross-sectional. SETTING Participants were recruited globally online and from patient meetings. PARTICIPANTS A total of 263 patients with MRKH (age 16.1-74.4 years; mean = 31.7 years) completed questionnaires. INTERVENTION None. MAIN OUTCOME MEASURES Validated self-reported measures of psychological distress and self-esteem (outcomes) and illness representations, self-concept, social support-seeking, and positive affect (hypothesized correlates) were explored in correlation and hierarchical regression analyses, alongside demographic and clinical variables. RESULTS Younger age and shorter time since diagnosis was associated with higher distress and lower self-esteem. Patients with MRKH reported significantly higher distress and lower self-esteem than the general population. Higher distress and lower self-esteem were associated with higher reported engulfment (defining one's identity or feeling consumed by MRKH) and beliefs about the serious consequences of MRKH, and lower reported MRKH coherence, enrichment (positive changes to self-identity because of MRKH) and positive affect. CONCLUSIONS Findings suggest that the impact of MRKH on identity plays an important role in adjustment. High perceived coherence and maintenance of positive affect may play a protective role in psychological adjustment. A 12-month follow-up study is planned to examine associations among these variables longitudinally. Baseline data suggest that early availability of psychological support would be beneficial, and interventions focused on identity and psychoeducation about MRKH would be valuable.
Collapse
Affiliation(s)
- Susan Carroll
- Psychology Department, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK.
| | - Marc R Laufer
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA; Center for Young Women's Health and Division of Gynecology, Boston Children's Hospital, Boston, MA
| | - Phaedra Thomas-Kowal
- Center for Young Women's Health and Division of Gynecology, Boston Children's Hospital, Boston, MA
| | - Amy C Lossie
- Beautiful You MRKH Foundation, Silver Spring, MD; The Global MRKH Consortium, Silver Spring, MD
| | - Rona Moss-Morris
- Psychology Department, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| |
Collapse
|
9
|
Kirschen GW, Wood LF, Semenyuk N. A Practical Approach to Congenital Urogenital Anomalies in Female Pediatric Patients. Pediatr Ann 2020; 49:e188-e195. [PMID: 32275764 DOI: 10.3928/19382359-20200323-02] [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] [Indexed: 11/20/2022]
Abstract
Congenital anomalies of the female reproductive tract are relatively common and can be both confusing to understand as well as challenging to diagnose and manage in a busy pediatric clinical practice. Here, we lay out some of the most common genitourinary tract anomalies in female pediatric patients. We highlight the key embryologic development, present case examples, and discuss appropriate testing, treatment, and counseling for patients and their families regarding congenital disorders of the vulva, vagina, uterus, ovaries, and associated pathology. The goal of this review is to demystify these conditions and provide a practical guide for the general pediatrician who is often at the frontline making the initial diagnosis and caring for these patients. [Pediatr Ann. 2020;49(4):e188-e195.].
Collapse
|
10
|
Bohet M, Besson R, Jardri R, Manouvrier S, Catteau-Jonard S, Cartigny M, Aubry E, Leroy C, Frochisse C, Medjkane F. Mental health status of individuals with sexual development disorders: A review. J Pediatr Urol 2019; 15:356-366. [PMID: 31133504 DOI: 10.1016/j.jpurol.2019.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/09/2019] [Accepted: 04/10/2019] [Indexed: 11/16/2022]
Abstract
Healthcare recommendations for people with disorders of sexual development (DSDs) include mental health attention and active participation of psychiatrists and psychologists in dedicated multidisciplinary teams. Therefore, it seems crucial for them to improve knowledge about specific difficulties and needs of these patients. The aim of this article is to report in a synthesizing manner the recent works evaluating the mental health and psychological status of individuals with DSDs. After research conducted using PubMed and ScienceDirect, 18 studies were inventoried and qualitatively analyzed in response to three main questions: Do individuals with DSDs suffer more frequently and/or more severely from psychological conditions or mental disorders? From what kind of disorder do they suffer? and What are the determinant factors involved in their development? This work highlights an increased risk of affective disorders in individuals with DSDs, particularly anxiety and depressive disorders and interpersonal difficulties. Studies identified some potentially determining factors implicated in their development, among which are the etiology of DSDs, the life stage, the age at the time of diagnosis, and the lack of conformity of sexual phenotype with sex assignment. Taken together, the etiology of DSDs, the lack of conformity of sexual phenotype with sex assignment, and the feeling of being different from peers seem to be interesting factors to study in the future. Multicentric and longitudinal studies using standardized evaluation and control groups should be the most robust way to improve knowledge about these preoccupations.
Collapse
Affiliation(s)
- M Bohet
- CHU Lille, Centre de Référence du développement génital DEV GEN, Service de psychiatrie de l'enfant et de l'adolescent, Hôpital Fontan, F-59000 Lille, France.
| | - R Besson
- CHU Lille, Centre de Référence du développement génital DEV GEN, Service de chirurgie pédiatrique, Hôpital Jeanne de Flandres, F-59000 Lille, France
| | - R Jardri
- CHU Lille, Service de psychiatrie de l'enfant et de l'adolescent, Hôpital Fontan, F-59000 Lille, France; Univ Lille, CNRS UMR-9193 (SCA-Lab) & CHU Lille, Hôpital Fontan (CURE), F-59000 Lille, France
| | - S Manouvrier
- CHU Lille, Centre de Référence du développement génital DEV GEN, Service de génétique clinique, Hôpital Jeanne de Flandres, F-59000 Lille, France
| | - S Catteau-Jonard
- CHU Lille, Centre de Référence du développement génital DEV GEN, Service de gynécologie médicale, Hôpital Jeanne de Flandres F-59000 Lille, France
| | - M Cartigny
- CHU Lille, Centre de Référence du développement génital DEV GEN, Service d'endocrinopédiatrie, Hôpital Jeanne de Flandres F-59000 Lille, France
| | - E Aubry
- CHU Lille, Centre de Référence du développement génital DEV GEN, Service de chirurgie pédiatrique, Hôpital Jeanne de Flandres, F-59000 Lille, France
| | - C Leroy
- CHU Lille, Centre de Référence du développement génital DEV GEN, Service d'andrologie, Hôpital Albert Calmette F-59000 Lille, France
| | - C Frochisse
- CHU Lille, Centre de Référence du développement génital DEV GEN Service de psychiatrie de l'enfant et de l'adolescent, Hôpital Fontan, F-59000 Lille, France
| | - F Medjkane
- CHU Lille, Centre de Référence du développement génital DEV GEN Service de psychiatrie de l'enfant et de l'adolescent, Hôpital Fontan, F-59000 Lille, France
| |
Collapse
|
11
|
Fliegner M, Richter-Appelt H, Krupp K, Brucker SY, Rall K, Brunner F. Living with permanent infertility: A German study on attitudes toward motherhood in individuals with Complete Androgen Insensitivity Syndrome (CAIS) and Mayer-Rokitansky-Küster-Hauser Syndrome (MRKHS). Health Care Women Int 2018; 39:1295-1315. [PMID: 30362901 DOI: 10.1080/07399332.2018.1490739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In this study the authors examined the issue of permanent infertility in two diagnoses of the diverse sex developments (DSD) spectrum: Complete Androgen Insensitivity Syndrome (CAIS) and Mayer-Rokitansky-KÏster-Hauser Syndrome (MRKHS). The participants with CAIS (n = 12) was older, showed a lower wish for a child and was less distressed about their infertility compared to participants with MRKHS (n = 49). Our data indicated an "indifferent" attitude toward motherhood in CAIS and an "ambivalent" attitude in MRKHS. Depression was frequent in both. Infertility is a source of distress. However, the two groups seem to cope in different ways. Comprehensive medical information and psychological support should be provided.
Collapse
Affiliation(s)
| | - Hertha Richter-Appelt
- a University Medical Center Hamburg-Eppendorf, Institute for Sex Research and Forensic Psychiatry , Hamburg , Germany
| | - Kerstin Krupp
- a University Medical Center Hamburg-Eppendorf, Institute for Sex Research and Forensic Psychiatry , Hamburg , Germany
| | - Sara Y Brucker
- b Tübingen University Hospital, Center for Women's Health , Tübingen , Germany
| | - Katharina Rall
- b Tübingen University Hospital, Center for Women's Health , Tübingen , Germany
| | - Franziska Brunner
- a University Medical Center Hamburg-Eppendorf, Institute for Sex Research and Forensic Psychiatry , Hamburg , Germany
| |
Collapse
|
12
|
Wagner A, Brucker SY, Ueding E, Gröber-Grätz D, Simoes E, Rall K, Kronenthaler A, Schäffeler N, Rieger MA. Treatment management during the adolescent transition period of girls and young women with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS): a systematic literature review. Orphanet J Rare Dis 2016; 11:152. [PMID: 27852280 PMCID: PMC5112722 DOI: 10.1186/s13023-016-0536-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 11/09/2016] [Indexed: 12/26/2022] Open
Abstract
Introduction In health services research, there is a special emphasis on the transition from adolescence into adulthood. During this transition period, adolescents change from pediatric to adult medical care. This process must be carefully structured, particularly when special medical care is required. Challenges and difficulties become apparent particularly in the case of rare diseases. This is increasingly so when the rare disease affects the adolescence-specific development of patients, such as Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS), also known as Müllerian agenesis. Methods A systematic literature review identified the care requirements of girls and young women with MRKHS, as well as studies of medical care during the adolescent transition period for various other diseases. This investigation was carried out in the years 2012 and 2013, and was updated in 2014/2015. In addition, the reference lists of the identified studies were reviewed. Results Nine publications on MRKHS and ten publications on the transition from adolescence to adulthood were included. Medical care requirements and measures were identified for the following areas: diagnosis during adolescence and organization of medical care, reactions to the diagnosis, functional infertility, psychological stress and threat to self-image, contact with others, and dealing with MRKHS coping strategies. Discussion There is still a great demand for research in the area of care during the transition period from adolescence into adulthood, particularly for rare diseases. The recommendations for treating MRKHS patients derived from the literature should be implemented and evaluated with regard to their effectiveness.
Collapse
Affiliation(s)
- Anke Wagner
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital Tuebingen, Wilhelmstraße 27, 72074, Tübingen, Germany.
| | - Sara Yvonne Brucker
- Centre of Women's Health, University Hospital Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Esther Ueding
- Women's Health Research Institute, Calwerstraße 7, 72076, Tübingen, Germany
| | - Dagmar Gröber-Grätz
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital Tuebingen, Wilhelmstraße 27, 72074, Tübingen, Germany
| | - Elisabeth Simoes
- Centre of Women's Health, University Hospital Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Katharina Rall
- Centre of Women's Health, University Hospital Tübingen, Calwerstraße 7, 72076, Tübingen, Germany
| | - Andrea Kronenthaler
- Institute of General Practice, University of Tübingen, Österbergstraße 9, 72074, Tübingen, Germany
| | - Norbert Schäffeler
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Germany, Osianderstraße 5, 72076, Tübingen, Germany
| | - Monika A Rieger
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital Tuebingen, Wilhelmstraße 27, 72074, Tübingen, Germany
| |
Collapse
|
13
|
Leithner K, Naderer A, Hartung D, Abrahamowicz C, Alexopoulos J, Walch K, Wenzl R, Hilger E. Sexual and Psychosocial Functioning in Women with MRKHS after Neovaginoplasty According to Wharton-Sheares-George: A Case Control Study. PLoS One 2015; 10:e0124604. [PMID: 25901735 PMCID: PMC4406725 DOI: 10.1371/journal.pone.0124604] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 03/04/2015] [Indexed: 11/18/2022] Open
Abstract
Background Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) has a major impact on a woman’s psychological and sexual well-being. In most of the studies that addressed treatment techniques, postoperative sexual function was reported to be satisfactory; however, comparatively few studies have additionally provided an accurate analysis of psychosocial functions in MRKHS patients following different kinds of neovaginal treatment. This study is to evaluate sexual and psychosocial functioning after creation of a neovagina according to Wharton-Sheares-George in women with MRKHS. Methods We performed a case-control-study using multiple measures to assess sexual and psychosocial functioning. Ten MRKHS patients and 20 controls of a University hospital and tertiary center for pediatric and adolescent gynecology were assessed. The follow-up assessment comprised 6 standardized questionnaires (Female Sexuality Function Index, FSFI; Patient Health Questionnaire, PHQ; Brief Symptom Inventory, BSI; World Health Organization Quality of Life Assessment, WHOQoL-BREF; Parental Bonding Instrument, PBI; and a German questionnaire on body image). The main outcome measures were sexual function, psychological status, quality of life, body image, and parental bonding styles. Findings Sexual function, psychological status (including depressive and somatic symptoms), quality of life, and own-body experience were at least as good in operated MRKHS patients as in controls. In some measures (FSFI, PHQ-15, psychological domain of the WHOQoL-BREF, and BSI Positive Symptom Total), patients scored significantly better than controls. The results of the PBI indicated a close and sustainable mother-daughter-relationship in MRKHS patients. Conclusions We found no evidence for an impairment of sexual or psychosocial functioning in patients after neovaginoplasty according to Wharton-Sheares-George. MRKHS may not necessarily compromise sexual and psychological well-being, provided that the syndrome is properly managed by a multidisciplinary team of health professionals.
Collapse
Affiliation(s)
- Katharina Leithner
- Department of Psychoanalysis and Psychotherapy, Medical University Vienna, Vienna, Austria
- * E-mail:
| | - Andrea Naderer
- Department of Psychoanalysis and Psychotherapy, Medical University Vienna, Vienna, Austria
| | - Dorothee Hartung
- Department of Psychoanalysis and Psychotherapy, Medical University Vienna, Vienna, Austria
| | - Clara Abrahamowicz
- Department of Psychoanalysis and Psychotherapy, Medical University Vienna, Vienna, Austria
| | - Johanna Alexopoulos
- Department of Psychoanalysis and Psychotherapy, Medical University Vienna, Vienna, Austria
| | - Katharina Walch
- Department of Obstetrics and Gynaecology, Divison of Gynaecology and Gynaecological Oncology, Medical University Vienna, Vienna, Austria
| | - René Wenzl
- Department of Obstetrics and Gynaecology, Divison of Gynaecology and Gynaecological Oncology, Medical University Vienna, Vienna, Austria
| | - Eva Hilger
- Department of Neurology, Medical University Vienna, Vienna, Austria
| |
Collapse
|
14
|
Simoes E, Kronenthaler A, Emrich C, Rieger MA, Rall KK, Schäffeler N, Hiltner H, Ueding E, Brucker SY. Development of a provisional model to improve transitional care for female adolescents with a rare genital malformation as an example for orphan diseases. BIOMED RESEARCH INTERNATIONAL 2014; 2014:913842. [PMID: 25544945 PMCID: PMC4269155 DOI: 10.1155/2014/913842] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 11/23/2014] [Accepted: 11/23/2014] [Indexed: 11/18/2022]
Abstract
Deficits of care exist during the transitional period, when young people with ongoing needs of support to achieve their physical, social, and psychological potential are entering adulthood. This study aims to develop a patient oriented, structured provisional model to improve transitional care for adolescents with Mayer-Rokitansky-Kuester-Hauser-Syndrome as an example for orphan diseases, where problems of access and continuity are even more complex. The study is funded by the German Federal Ministry of Education and Research (BMBF-Funding Code 01GY1125). The target patient group are young females with this disorder, treated at the Centre for Rare Genital Malformations in Women (ZSGF), University Hospital of Tuebingen. The study comprises five phases: an appraisal of literature, assessment of patients (n = 25), parents', partners', and health and social care providers' (n = 24) needs and experienced deficits in care and support in a qualitative approach, construction of a provisional model via scenario technique, followed by communicative validation (including interested public, n = 100), preference finding, and identification of patient-oriented quality aims for follow-up. Quantitative data from questionnaires and chart review (as sociodemographic data, nonresponder analysis, and preference rating) are worked up for descriptive statistics. The results provide a platform for the development of future multidisciplinary transitional intervention programs in orphan diseases.
Collapse
Affiliation(s)
- Elisabeth Simoes
- Centre of Women's Health, University Hospital Tuebingen, 72076 Tuebingen, Germany
- Women's Health Research Institute, 72076 Tuebingen, Germany
- Social Medicine Staff Unit, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Andrea Kronenthaler
- Institute of General Practice, University of Tuebingen, 72074 Tuebingen, Germany
| | - Christine Emrich
- Institute of Occupational and Social Medicine and Health Services Research, 72074 Tuebingen, Germany
| | - Monika A. Rieger
- Institute of Occupational and Social Medicine and Health Services Research, 72074 Tuebingen, Germany
| | | | - Norbert Schäffeler
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Hanna Hiltner
- Institute of General Practice, University of Tuebingen, 72074 Tuebingen, Germany
| | - Esther Ueding
- Women's Health Research Institute, 72076 Tuebingen, Germany
| | - Sara Y. Brucker
- Centre of Women's Health, University Hospital Tuebingen, 72076 Tuebingen, Germany
- Women's Health Research Institute, 72076 Tuebingen, Germany
| |
Collapse
|
15
|
Delaine M, Ohl J. [Sexual activity and quality of life in patients with Mayer-Rokitansky-Kuster-Hauser syndrome]. ACTA ACUST UNITED AC 2014; 42:865-71. [PMID: 25456491 DOI: 10.1016/j.gyobfe.2014.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 10/14/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study evaluated the sexual activity and the quality of life in patients with a Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. PATIENTS AND METHODS The study is based on a series of patients hospitalized for the treatment of MRKH syndrome in CMCO between 1997 and 2010. Through the medical reports, we recovered information about the pathology, the treatment given and the psychological support proposed to or wished by the patients. The patients also had to answer a questionnary concerning the quality of the informations they received about the treatment, the different types of supports proposed and wanted, their life as a couple and how they communicated about their disease. RESULTS Eleven medical reports have been reviewed. The patients were aged 21 in average at the moment of the treatment. Three patients had some associated malformations. Different methods of treatment were represented (Frank's method, Vecchietti's technique, sigmoid vaginoplasty, McIndoe's technique). Sexual intercourse was assessed as satisfactory by 4 patients. In 8 cases, the partner accepted well the pathology. Only 4 out of the eleven medical reports mentioned a psychological support. Nine out of the eleven patients accepted to answer the questionnary. DISCUSSION AND CONCLUSION The review of the literature and our own results show that the patients with MRKH syndrome have a real need for psychological support. They are able to have sexual intercourse that is satisfactory in the domains of excitation, lubrification and desire, especially after treatment. The main problem is the inability to bear children, a problem which might by solved by the future researches about uterus graft and the evolution of the laws concerning gestational surrogacy.
Collapse
Affiliation(s)
- M Delaine
- Service de gynécologie-obstétrique, hôpital de Hautepierre, 1, avenue Molière, 67100 Strasbourg, France.
| | - J Ohl
- Service de gynécologie-obstétrique, CMCO, 19, rue Louis-Pasteur, 67300 Schiltigheim, France
| |
Collapse
|
16
|
Callens N, Weyers S, Monstrey S, Stockman S, van Hoorde B, van Hoecke E, De Cuypere G, Hoebeke P, Cools M. Vaginal dilation treatment in women with vaginal hypoplasia: a prospective one-year follow-up study. Am J Obstet Gynecol 2014; 211:228.e1-228.e12. [PMID: 24681288 DOI: 10.1016/j.ajog.2014.03.051] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/19/2014] [Accepted: 03/21/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Vaginal dilation treatment has been shown to be a (cost) effective first-line alternative to surgery in normalizing vaginal length and improving sexual function in women with vaginal hypoplasia. There remains, however, a need for prospective studies, with long-term assessment of multiple outcomes. STUDY DESIGN This was a prospective, single-centre observational study of 16 women with Mayer-Rokitansky-Küster-Hauser syndrome (n = 12) or 46,XY disorders of sex development (n = 4). All women underwent an outpatient vaginal dilation program supervised by a psychologist and physiotherapist. At baseline (T0), stop of treatment (T1) and 1 year follow-up (T2), semistructured interviews, and validated questionnaires assessed sexual function and distress, self-esteem, vaginal perceptions, and health-related quality of life. Gynecological examinations evaluated vaginal dimensions. RESULTS Ten women completed the program, 3 are still in the program, and dilation failed in 3 and chose vaginoplasty. Sixty-nine percent reached a normal vaginal length (≥6.5 cm) in 5.8 ± 3.3 months. Seventy percent were sexually active with pleasurable experiences at T1, 57% at T2. The significant decrease in sexual distress at T1 (P < .05) was followed by a nonsignificant increase at T2. Depressive mood symptomatology remained high at T1 and T2, related to loss of bodily integrity and fertility. The majority refused further psychological counseling. CONCLUSION Vaginal dilation treatment should remain the cornerstone of treatment in women with vaginal hypoplasia. However, the diagnosis remains to have a negative impact on emotional well-being in the long term. The role of psychological intervention as both a primary and adjuvant treatment needs clear evaluation.
Collapse
Affiliation(s)
- Nina Callens
- Department of Pediatric Endocrinology, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Steven Weyers
- Department of Obstetrics and Gynecology, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Stan Monstrey
- Department of Plastic Surgery, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Sabine Stockman
- Department of Urology, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Birgit van Hoorde
- Department of Sexology and Gender Problems, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Eline van Hoecke
- Department of Pediatric Psychology, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Griet De Cuypere
- Department of Sexology and Gender Problems, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Piet Hoebeke
- Department of Urology, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Martine Cools
- Department of Pediatric Endocrinology, Ghent University and University Hospital Ghent, Ghent, Belgium.
| |
Collapse
|
17
|
Yaman Ş, Ayaz S. Hymen Tearing in the Treatment of Vaginal Agenesis: Implications on Women in Turkey. J Transcult Nurs 2014; 25:303-6. [PMID: 24518059 DOI: 10.1177/1043659614522649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Rupture of the hymen before marriage is a significant problem for a woman and her family. The purpose of this article is to present a case report where hymen membrane perforation was required for vaginal agenesis in a 13-year-old adolescent, identify psychosocial issues related to the torn hymen in the Turkish culture, discuss gender inequality affecting health care of women with a torn hymen, identify the impact of a torn hymen on a Turkish woman's social status, and discuss health care implications for the woman and her family. The girl could not understand the situation and experienced feelings of guilt. The parents displayed an intense reaction of shock and denial after being informed about the disorder and treatment process and felt a sense of hopelessness about the future of their daughter. Nurses are expected to fulfill their training, counseling, and advocacy roles about this issue.
Collapse
Affiliation(s)
- Şengül Yaman
- Gazi University Faculty of Health Sciences, Ankara, Turkey
| | - Sultan Ayaz
- Gazi University Faculty of Health Sciences, Ankara, Turkey
| |
Collapse
|
18
|
Krupp K, Fliegner M, Brunner F, Brucker S, Rall K, Richter-Appelt H. Quality of Life and Psychological Distress in Women with Mayer-Rokitansky-Küster-Hauser Syndrome and Individuals with Complete Androgen Insensitivity Syndrome. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojmp.2014.33023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
19
|
“Differently normal” and “normally different”: Negotiations of female embodiment in women's accounts of ‘atypical’ sex development. Soc Sci Med 2013; 98:232-8. [DOI: 10.1016/j.socscimed.2013.09.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 09/20/2013] [Accepted: 09/23/2013] [Indexed: 11/19/2022]
|
20
|
Fliegner M, Krupp K, Brunner F, Rall K, Brucker SY, Briken P, Richter-Appelt H. Sexual life and sexual wellness in individuals with complete androgen insensitivity syndrome (CAIS) and Mayer-Rokitansky-Küster-Hauser Syndrome (MRKHS). J Sex Med 2013; 11:729-42. [PMID: 24165016 DOI: 10.1111/jsm.12321] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Sexual wellness depends on a person's physical and psychological constitution. Complete Androgen Insensitivity Syndrome (CAIS) and Mayer-Rokitansky-Küster-Hauser Syndrome (MRKHS) can compromise sexual well-being. AIMS To compare sexual well-being in CAIS and MRKHS using multiple measures: To assess sexual problems and perceived distress. To gain insight into participants' feelings of inadequacy in social and sexual situations, level of self-esteem and depression. To determine how these psychological factors relate to sexual (dys)function. To uncover what participants see as the source of their sexual problems. METHODS Data were collected using a paper-and-pencil questionnaire. Eleven individuals with CAIS and 49 with MRKHS with/without neovagina treatment were included. Rates of sexual dysfunctions, overall sexual function, feelings of inadequacy in social and sexual situations, self-esteem and depression scores were calculated. Categorizations were used to identify critical cases. Correlations between psychological variables and sexual function were computed. Sexually active subjects were compared with sexually not active participants. A qualitative content analysis was carried out to explore causes of sexual problems. MAIN OUTCOME MEASURES An extended list of sexual problems based on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision, by the American Psychiatric Association and related distress. Female Sexual Function Index (FSFI), German Questionnaire on Feelings of Inadequacy in Social and Sexual Situations (FUSS social scale, FUSS sexual scale), Rosenberg Self-Esteem Scale (RSE), Brief Symptom Inventory (BSI) subscale depression. Open question on alleged causes of sexual problems. RESULTS The results point to a far-reaching lack of sexual confidence and sexual satisfaction in CAIS. In MRKHS apprehension in sexual situations is a source of distress, but sexual problems seem to be more focused on issues of vaginal functioning. MRKHS women report being satisfied with their sex life. CONCLUSION Different conditions can affect individuals in diagnosis-specific ways despite some shared clinical features. Professionals should adopt an interdisciplinary approach and provide custom-made care in order to promote sexual well-being in patients.
Collapse
Affiliation(s)
- Maike Fliegner
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | | | | | | |
Collapse
|
21
|
Guntram L. Creating, maintaining and questioning (hetero)relational normality in narratives about vaginal reconstruction. FEMINIST THEORY 2013. [DOI: 10.1177/1464700112468573] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Analysing ten interviews with women diagnosed with and treated for congenital absence of the vagina, this article theorises the notion of ideal (hetero)relational normality. It explores how women in my case study negotiate, relate to and challenge this notion and examines the normative and bodily work for which it calls. The article specifically underscores the corporeal dimension of (hetero)relational normality. I argue that this notion of normality shapes the bodies of the women through medical interventions, while concurrently being reinforced through the corporeal shapings that the women undergo. These corporeal shapings consolidate enacted norms concerning heterosexuality and form understandings of female and male bodies. The analysis also reveals how these women nevertheless find ways to re-negotiate and question the notion of ideal (hetero)relational normality and its intertwinement with medical practice. The article contributes both to the critical examination of genital surgery and to feminist discussions of how to critically examine heterosexuality without rejecting it. Furthermore, it provides a deeper understanding of how medical interventions designed to create a vagina, or dilate a vagina considered ‘too small’, are made meaningful by the women affected.
Collapse
|
22
|
Krupp K, Fliegner M, Brunner F, Brucker S, Rall K, Richter-Appelt H. How do Individuals with Complete Androgen Insensitivity Syndrome, Mayer-Rokitansky-Küster-Hauser Syndrome or Polycystic Ovary Syndrome Experience Contact to Other Affected Persons? Geburtshilfe Frauenheilkd 2012; 72:1009-1017. [PMID: 25258457 DOI: 10.1055/s-0032-1327979] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/18/2012] [Accepted: 10/17/2012] [Indexed: 10/27/2022] Open
Abstract
Persons with different sex characteristics may suffer from a feeling of being "different" or "not normal". In this study, persons with one of 3 diagnoses (complete androgen insensitivity syndrome [CAIS]; Mayer-Rokitansky-Küster-Hauser syndrome [MRKHS], polycystic ovary syndrome [PCOS]) were asked whether they had contact to other affected persons and how they assessed this contact. The correlation between contact and psychological distress was evaluated. Material and Methods: Information on contacts to other affected individuals was obtained using a written questionnaire. Psychological distress was measured using the German version of the BSI (Brief Symptom Inventory). Results: Data from 11 individuals with CAIS, 49 women with MRKHS and 55 women with PCOS was analysed. The frequency of contacts to other affected individuals differed between the different diagnostic groups (with the highest frequency reported for the group with CAIS, and the lowest for the group with PCOS). Overall, the majority of individuals considered such contacts beneficial (CAIS 81.8 %; MRKHS 90 %; PCOS 83.3 %). The frequency of contacts and their assessment were not found to be correlated with psychological distress. The three diagnostic groups differed in the proportion of people who indicated a wish for contact with other affected persons. The desire to have contact with other affected persons was most commonly expressed by women with PCOS and high levels of psychological distress (60.9 %). Conclusion: Persons with different sex characteristics can benefit from contact to other affected individuals. Particularly women with PCOS and increased levels of psychological distress may benefit if the issue of support groups is addressed during treatment.
Collapse
Affiliation(s)
- K Krupp
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg
| | - M Fliegner
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg
| | - F Brunner
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg
| | - S Brucker
- Department of Obstetrics and Gynaecology, Tübingen University Hospital, Tübingen
| | - K Rall
- Department of Obstetrics and Gynaecology, Tübingen University Hospital, Tübingen
| | - H Richter-Appelt
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg
| |
Collapse
|
23
|
Callens N, De Cuypere G, Wolffenbuttel KP, Beerendonk CC, van der Zwan YG, van den Berg M, Monstrey S, Van Kuyk ME, De Sutter P, Dessens AB, Cools M. Long‐Term Psychosexual and Anatomical Outcome after Vaginal Dilation or Vaginoplasty: A Comparative Study. J Sex Med 2012; 9:1842-51. [DOI: 10.1111/j.1743-6109.2012.02747.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
24
|
Clinical approach for the classification of congenital uterine malformations. ACTA ACUST UNITED AC 2012; 9:119-129. [PMID: 22611348 PMCID: PMC3338910 DOI: 10.1007/s10397-011-0724-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Accepted: 12/28/2011] [Indexed: 11/05/2022]
Abstract
A more objective, accurate and non-invasive estimation of uterine morphology is nowadays feasible based on the use of modern imaging techniques. The validity of the current classification systems in effective categorization of the female genital malformations has been already challenged. A new clinical approach for the classification of uterine anomalies is proposed. Deviation from normal uterine anatomy is the basic characteristic used in analogy to the American Fertility Society classification. The embryological origin of the anomalies is used as a secondary parameter. Uterine anomalies are classified into the following classes: 0, normal uterus; I, dysmorphic uterus; II, septate uterus (absorption defect); III, dysfused uterus (fusion defect); IV, unilateral formed uterus (formation defect); V, aplastic or dysplastic uterus (formation defect); VI, for still unclassified cases. A subdivision of these main classes to further anatomical varieties with clinical significance is also presented. The new proposal has been designed taking into account the experience gained from the use of the currently available classification systems and intending to be as simple as possible, clear enough and accurate as well as open for further development. This proposal could be used as a starting point for a working group of experts in the field.
Collapse
|
25
|
Callens N, van der Zwan YG, Drop SLS, Cools M, Beerendonk CM, Wolffenbuttel KP, Dessens AB. Do surgical interventions influence psychosexual and cosmetic outcomes in women with disorders of sex development? ISRN ENDOCRINOLOGY 2012; 2012:276742. [PMID: 22462013 PMCID: PMC3313564 DOI: 10.5402/2012/276742] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 12/25/2011] [Indexed: 11/28/2022]
Abstract
Clinical practice developed to promote psychosexual well-being in DSD is under scrutiny. Although techniques for genital surgery have much improved lately, long-term studies on psychosexual functioning and cosmetic outcome on which to base treatment and counseling are scarce. We studied 91 women with a DSD. Feminizing surgery was performed in 64% of the women; in 60% of them, resurgery in puberty was needed after a single-stage procedure. Both patients and gynecologists were satisfied with the cosmetic appearance of the genitalia. However, forty percent of these females experienced sexuality-related distress and 66% was at risk for developing a sexual dysfunction, whether they had surgery or not. Recognizing the difficulty of accurate assessment, our data indicate that feminizing surgery does not seem to improve nor hamper psychosexual outcome, especially in patients with severe virilization.
Collapse
Affiliation(s)
- Nina Callens
- Division of Pediatric Endocrinology, Department of Pediatrics, Erasmus MC-Sophia, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University and University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium
| | - Yvonne G. van der Zwan
- Division of Pediatric Endocrinology, Department of Pediatrics, Erasmus MC-Sophia, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Stenvert L. S. Drop
- Division of Pediatric Endocrinology, Department of Pediatrics, Erasmus MC-Sophia, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Martine Cools
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University and University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium
| | - Catharina M. Beerendonk
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Katja P. Wolffenbuttel
- Department of Urology, Erasmus MC-Sophia, P.O. Box 1738, 3000 CB Rotterdam, The Netherlands
| | - Arianne B. Dessens
- Division of Pediatric Endocrinology, Department of Pediatrics, Erasmus MC-Sophia, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| |
Collapse
|
26
|
Liao LM, Conway GS, Ismail-Pratt I, Bikoo M, Creighton SM. Emotional and sexual wellness and quality of life in women with Rokitansky syndrome. Am J Obstet Gynecol 2011; 205:117.e1-6. [PMID: 21571248 DOI: 10.1016/j.ajog.2011.03.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 02/14/2011] [Accepted: 02/28/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of the study was to investigate health, well-being, and sexual function in women with Rokitansky syndrome. STUDY DESIGN Fifty-eight women with Rokitansky syndrome completed 4 questionnaires assessing health-related quality of life, emotional distress, and sexual function and attended for a vaginal examination. RESULTS Participants reported better overall physical health and poorer overall mental health compared with normative data. Anxiety levels were higher, especially for women who had undergone vaginal treatment. Sexual wellness and function scores were poor. Mean vaginal length was 5.4 cm and was greater in women currently sexually active. Vaginal length had a positive correlation with overall sexual satisfaction but was not related to overall quality of life. CONCLUSION Rokitansky syndrome has a negative impact on emotional and sexual wellness. Relationships between physical and psychological parameters are complex and require further exploration. There is a need for better treatment studies using prospective methodology to assess the effects of surgical and nonsurgical treatments.
Collapse
Affiliation(s)
- Lih-Mei Liao
- Elizabeth Garrett Anderson UCL Institute of Women's Health, University College London, London, United Kingdom
| | | | | | | | | |
Collapse
|
27
|
Mayer-Rokitansky-Küster-Hauser syndrome: fertility counseling and treatment. Fertil Steril 2010; 94:1941-3. [DOI: 10.1016/j.fertnstert.2010.01.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 01/11/2010] [Accepted: 01/14/2010] [Indexed: 11/18/2022]
|
28
|
Routh JC, Laufer MR, Cannon GM, Diamond DA, Gargollo PC. Management strategies for Mayer-Rokitansky-Kuster-Hauser related vaginal agenesis: a cost-effectiveness analysis. J Urol 2010; 184:2116-21. [PMID: 20850825 DOI: 10.1016/j.juro.2010.06.133] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Indexed: 12/20/2022]
Abstract
PURPOSE The optimal method for neovagina creation in patients with vaginal agenesis is controversial. Progressive perineal dilation is a minimally invasive method with high success rates. However, the economic merits of progressive perineal dilation compared to surgical vaginoplasty are unknown. MATERIALS AND METHODS We performed a Markov based cost-effectiveness analysis of 3 management strategies for vaginal agenesis-progressive perineal dilation with and without subsequent vaginoplasty, and up-front vaginoplasty. Cost data were drawn from the Pediatric Health Information System database (2004 to 2009) for inpatient procedures and from governmental cost data (2009) for outpatient procedures and clinical followup. Other model parameters were derived from a systematic literature review and comparison with other congenital and acquired pediatric and/or adolescent gynecologic conditions. Bounded and probabilistic sensitivity analyses were used to assess model stability. RESULTS Including all procedures, equipment and physician visits, progressive perineal dilation had a mean cost of $796, while vaginoplasty cost $18,520. Up-front vaginoplasty was strongly dominated at any age, ie was more expensive but no more effective than other options. In cases of progressive perineal dilation failure the incremental cost-effectiveness ratio of progressive perineal dilation with subsequent vaginoplasty was $1,564 per quality adjusted life-year. Only the utility weights of life after treatment impacted model outcomes, while frequency of followup and probability of treatment success did not. CONCLUSIONS Initial progressive perineal dilation followed by vaginoplasty in cases of dilation failure is the most cost-effective management strategy for vaginal agenesis. Initial vaginoplasty was less cost-effective than initial progressive perineal dilation in 99.99% of simulations.
Collapse
Affiliation(s)
- Jonathan C Routh
- Department of Urology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA.
| | | | | | | | | |
Collapse
|
29
|
Fine needle vaginoplasty: a simplified novel approach for correction of vaginal aplasia. Fertil Steril 2010; 94:309-12. [DOI: 10.1016/j.fertnstert.2009.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 02/04/2009] [Accepted: 02/04/2009] [Indexed: 11/19/2022]
|
30
|
Grimbizis GF, Campo R. Congenital malformations of the female genital tract: the need for a new classification system. Fertil Steril 2010; 94:401-7. [PMID: 20356581 DOI: 10.1016/j.fertnstert.2010.02.030] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2009] [Revised: 02/04/2010] [Accepted: 02/15/2010] [Indexed: 11/25/2022]
Abstract
Current proposals for classifying female genital anomalies seem to be associated with limitations in effective categorization, creating the need for a new classification system that is as simple as possible, clear and accurate in its definitions, comprehensive, and correlated with patients' clinical presentation, prognosis, and treatment on an evidence-based foundation. Although creating a new classification system is not an easy task, it is feasible when taking into account the experience gained from applying the existing classification systems, mainly that of the American Fertility Society.
Collapse
|
31
|
Bean EJ, Mazur T, Robinson AD. Mayer-Rokitansky-Küster-Hauser syndrome: sexuality, psychological effects, and quality of life. J Pediatr Adolesc Gynecol 2009; 22:339-46. [PMID: 19589707 DOI: 10.1016/j.jpag.2008.11.006] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Revised: 11/18/2008] [Accepted: 11/18/2008] [Indexed: 12/31/2022]
Abstract
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital condition in which a genetic female is born with vaginal agenesis and a rudimentary to absent uterus. This condition affects a woman's ability to menstruate, to engage in penile-vaginal intercourse, and to bear children. Much has been published about how best to create a neovagina in women with MRKH, but little has been written about the psychological impact of MRKH and quality of life outcomes for women with the condition. A review of the extant literature published from 1955 to 2007 supports that (1) surgical or non-surgical creation of a neovagina alone does not ensure a successful psychological outcome, (2) psychological support at critical times can be helpful, and (3) how professionals use language to discuss the condition may positively or negatively influence a female's experience of MRKH. This article discusses the implications that existing knowledge has on future research and on clinical practice. Understanding how women with MRKH cope with and adjust to the condition will help healthcare professionals provide optimal care.
Collapse
Affiliation(s)
- E J Bean
- The MAGIC Foundation, Chicago, Illinois, USA
| | | | | |
Collapse
|
32
|
Darwish AM. Transretropubic traction vaginoplasty for correction of vaginal aplasia. Int J Gynaecol Obstet 2009; 107:262-5. [PMID: 19716132 DOI: 10.1016/j.ijgo.2009.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Revised: 06/18/2009] [Accepted: 07/20/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To introduce an alternative approach to vaginoplasty using transretropubic traction (TRT). METHODS In this case series with 4 patients with complete vaginal aplasia, a plastic "olive" placed on the vaginal dimple was lifted by a mesh tape inserted through the space of Retzius and anchored to the anterior abdominal wall. RESULTS On day 8 postoperatively all patients had a reasonable vaginal size, 2.5 to 3 cm in width and 6 to 7.5 cm in length. The mean satisfaction scores were 86 points for the patients and 89 points for their husbands, who also reported a mean penetration score of 90 points. CONCLUSION As a minimal-access and relatively simple operation, TRT vaginoplasty could be performed by trained gynecologists. Studies with larger populations are required to support this preliminary report.
Collapse
|
33
|
Laggari V, Diareme S, Christogiorgos S, Deligeoroglou E, Christopoulos P, Tsiantis J, Creatsas G. Anxiety and depression in adolescents with polycystic ovary syndrome and Mayer-Rokitansky-Küster-Hauser syndrome. J Psychosom Obstet Gynaecol 2009; 30:83-8. [PMID: 19533486 DOI: 10.1080/01674820802546204] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The purpose of this study was to assess self-reported depressive and anxiety symptoms in adolescents with polycystic ovary syndrome (PCOS) and those with the rare Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS), compared with healthy adolescents. MATERIAL AND METHODS The participants were 49 adolescent girls, of whom 27 were patients with confirmed menstrual disorder, 22 with PCOS and 5 with MRKHS; and 22 were healthy eumenorrheic adolescents (control group) matched by age and school grade. The Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI-Gr) were used to measure depression and anxiety, respectively. RESULTS The results showed that it was 1.08 times more likely for the PCOS group (p = 0.043) and 1.12 times more likely for the MRKHS group (p = 0.039) to have higher scores than healthy adolescents on the anxiety scale. The MRKHS group was 1.40 times more likely to have a higher number of depressive symptoms (p = 0.040) than the control group. CONCLUSIONS These findings, although based on a small sample, suggest a relationship between PCOS and MRKHS and the presence of psychological problems, such as anxiety and depressive symptoms in adolescents. This study is among the first to examine psychological difficulties in adolescents with such a rare menstrual syndrome as MRKHS.
Collapse
Affiliation(s)
- Varvara Laggari
- Department of Child Psychiatry, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece
| | | | | | | | | | | | | |
Collapse
|