Clinical Management of Gender in Egypt: Intersexuality and Transsexualism

Access Denied: A qualitative Study on transgender health policy in Egypt

For this paper, I conducted an interdisciplinary qualitative study to investigate transgender experiences accessing gender-affirming healthcare (GAH) in Egypt. I outline how the current health policy on GAH was developed and its negative impact, celebrating the resilience of transgender people in navigating the hostile anti-transgender environment, and conclude by offering some health policy recommendations to improve the GAH situation. Since 2003, Egypt has introduced an Islamic Sharia-influenced policy that banned accessing GAH for transgender people, placing professional and legal liability on healthcare providers. The policy created an anti-transgender medical environment, forcing transgender people to rely on Do-It-Yourself GAH or underground, risky, ill-equipped, and overpriced medical facilities. Other non-medical factors also impacted transgender people's ability to access GAH: social stigma, family rejection, state persecution, and economic insecurity. Despite this multilayered anti-transgender environment, transgender people proved to be innovative and resilient, creating ways to overcome these challenges and continue to exist. Transgender people created communal spaces online to guide each other in navigating the challenges of accessing GAH and used various means to challenge bans on GAH. Egypt, Gender-Affirming Health Care, Islam, Policy, DIY, Transgender, Law.

A literature analysis of scientific research on gender incongruence in Muslim nations

This study aims to chart and review the unexplored transgender research portfolio of Muslim countries using bibliometric method. Data retrieved from the Scopus database were analyzed using CiteSpace, VOSviewer, Biblioshiny, and ScientoPy software. It was found that barring Turkey and Iran, transgender research has been minimal in most Muslim countries. The collective productivity is gradually but surely rising. Around 84% of the publications have been collaborative efforts. The keyword analysis revealed that gender dysphoria, human immunodeficiency virus, LGBT, and vaginoplasty were the most frequently used keywords. The socio-economic circumstances of the transgender community are generally deplorable in most Muslim nations. Overall, there is a dire need for high-quality multifaceted transgender research in the Muslim world to raise general awareness. Resolving disputes on gender dysphoria or sex reassignment surgeries and reinstating the social rights of the transgender community should be the utmost priority of future research in Muslim countries.

"Waking up" the sleeping metaphor of normality in connection to intersex or DSD: a scoping review of medical literature

The aim of the study is to encourage a critical debate on the use of normality in the medical literature on DSD or intersex. For this purpose, a scoping review was conducted to identify and map the various ways in which "normal" is used in the medical literature on DSD between 2016 and 2020. We identified 75 studies, many of which were case studies highlighting rare cases of DSD, others, mainly retrospective observational studies, focused on improving diagnosis or treatment. The most common use of the adjective normal was in association with phenotypic sex. Overall, appearance was the most commonly cited criteria to evaluate the normality of sex organs. More than 1/3 of the studies included also medical photographs of sex organs. This persistent use of normality in reference to phenotypic sex is worrisome given the long-term medicalization of intersex bodies in the name of a "normal" appearance or leading a "normal" life. Healthcare professionals should be more careful about the ethical implications of using photographs in publications given that many intersex persons describe their experience with medical photography as dehumanizing.

Clinical profile and management challenges of disorders of sex development in Africa: a systematic review

OBJECTIVES

To review the published literature regarding disorders of sex development (DSD) in Africa which will highlight clinical characteristics, and challenges of evaluation and treatment of DSD.

CONTENT

We performed systematic review of articles published on DSD in Africa between January 2001 and December 2020.

SUMMARY

Eighteen studies involving 1980 patients from nine countries were analyzed. Overall mean age at presentation was 9.3 years (range 1 day-33 years) with 52.5 and 45.1% reared as females and males, respectively, prior to presentation. Following evaluation however, 64% were assigned female sex, 32.1% were assigned male sex, and 21.8% of the cases required sex reassignment. Only 7 (38.9%) of the publications reported medical treatment of DSD, 4 (22.2%) reported on psychosocial management and 5 (27.8%) documented multidisciplinary team management. Barring regional variations, the documented challenges of management include delayed presentation, loss to follow up, financial challenges, and lack of facilities for care of DSD. Comparison of the cases managed in the last decade (2011-2020) with those managed in the earlier decade (2001-2010) showed a trend towards earlier presentation and reduced rate of sex reassignment in the last decade. However, the challenges persisted.

OUTLOOK

Barring regional differences, a high proportion of DSD in Africa may have delayed presentation with inappropriate sex of rearing, inadequate evaluation and need for sex reassignment. Specific efforts to improve time to diagnosis, patient evaluation, improvement of healthcare funding, and collaboration with more developed countries may improve the care of patients with DSD in Africa.

Genetic profiling of CAH Egyptian children: rapid guide to clinical interpretation of common mutations

OBJECTIVES

The prevalence of CAH in Egypt is reported to be ten times more than that of the worldwide prevalence. The study aimed at genetic screening of children diagnosed with 21-alpha hydroxylase deficiency congenital adrenal hyperplasia (21OHD-CAH). In addition, the study offers a rapid and easy guide for clinical reporting of common mutations for endocrinologists.

METHODS

A cohort of 174 unrelated Egyptian children with 21OHD-CAH were screened for 11 common CYP21A2 gene mutations using a strip hybridization assay, and then, bioinformatics analysis was done to report the pathogenicity of the common mutations for clinical classification.

RESULTS

The most common mutations were I2 splice and p.Q318X. Deletions/conversions comprised 45.9% of the cohort, whereas 7.4% of the cases were negative for all mutations. The least positively detected point mutations were p.P453S, cluster E6, p.R483P, and p.L307FS, which were detected in fewer than 5% of cases.

CONCLUSION

Strip hybridization assay is a rapid screening tool for the diagnosis of CAH. The authors hypothesized an easy and rapid scheme for clinical interpretation of the strip results to gain the highest value of the strip in diagnosis.

Sex assignment practice in disorders of sexual differentiation: survey results from paediatric endocrinologists in the Arab region

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.

Genetics and Genomic Medicine in Egypt: steady pace

Genetics and Genomic Medicine in Egypt: steady pace.

Social stigmatisation in late identified patients with disorders of sex development in Indonesia

OBJECTIVES

To assess social stigmatisation related to atypical appearance of the body, including, but not limited to the external genitalia, among Indonesian patients with a disorder of sex development (DSD). Until recently, diagnostic evaluation, information about the underlying causes of DSD and treatment options were sparsely available for these patients.

METHODS

Eighty-one parents of children and adolescents with DSD (aged 6-17 years) and 34 adult patients with DSD (aged 18-41 years) completed the Social Stigmatisation Scale towards DSD, an instrument developed to assesses the frequency of stigmatisation and the level of stress associated with these experiences. Open-ended questions investigated detailed information on stigmatisation as well as parents' and patients' emotional and behavioural reactions to these experiences. Differences in stigmatisation were explored across sex of rearing, gender change history, treatment status and DSD characteristics that could be easily identified by others (e.g., masculinisation of the body in women).

RESULTS

Social stigmatisation was reported by patients with atypical appearance of their genitalia, atypical appearance of their body aside from their genitals, among those who displayed cross-gender behaviour and those who changed gender. Among participants reared as women and among children and adolescents who changed gender, social stigmatisation was associated with ostracism, depressive symptoms and social isolation.

CONCLUSIONS

Patients unable to conceal their condition (those with visible physical atypicality and those who changed gender) experienced social stigmatisation. Stigmatisation was stressful and related to isolation and withdrawal from social interaction. Education about DSD, self-empowerment and medical interventions to prevent atypical physical development may remove barriers to acceptance by others for affected individuals.