Practice changes in childhood surgery for ambiguous genitalia?

Differences of sex development and surgical decisions: focus group interviews with health care professionals in Norway

Background

Differences of Sex Development (DSD) are congenital conditions where the chromosomal, gonadal and anatomical sex characteristics do not strictly belong to male or female categories, or that belong to both at the same time. Surgical interventions for individuals with DSD remain controversial, among affected individuals, caregivers, and health-care providers. A lack of evidence in support of, for deferring, or for avoiding surgery complicates the decision-making process. This study explores Norwegian health-care professionals' (HCPs) perspectives on decision-making in DSD-related surgeries and the dilemmas they are facing in this process.

Methods

Focus group interviews with 14 HCPs integrated into or collaborating with multidisciplinary DSD teams were analyzed using reflexive thematic analysis.

Results

Two overarching dilemmas shed light on the intricate considerations and challenges that HCPs encounter when guiding affected individuals and caregivers through surgical decision-making processes in the context of DSD. The first theme describes how shared decision-making was found to be influenced by fear of stigma and balancing the interplay between concepts of normality, personal experiences and external expectations when navigating the child's and caregivers' needs. The second theme illuminated dilemmas due to a lack of evidence-based practice. The core concepts within each theme were the dilemmas health-care professionals face during consultations with caregivers and affected individuals.

Conclusion

HCPs were aware of the controversies with DSD-related surgeries. However, they struggled to reconcile knowledge with parents' wishes for surgery and faced dilemmas making decisions in the best interests of the child. This study draws attention to the benefits of increased knowledge on the consequences of performing or withholding surgery as well as incorporating tools enabling shared decision-making between HCPs and affected individuals/caregivers.

Parental concerns about genital differences in children with congenital adrenal hyperplasia persist regardless of the selected intervention

BACKGROUND

Congenital Adrenal Hyperplasia (CAH) due to 21-hydroxylase deficiency (21HD) can affect the in utero development of the genital anatomy of people with the 46XX karyotype. Health professionals engage parents in decision-making regarding managing genitals with this difference, including genital surgery options and patient communication.

AIM

We sought to investigate parental communication with their daughters regarding clitoral size variation related to neonatal CAH.

METHODS

Semistructured in-person interviews of 24 parents of chromosomal XX children with clitoral size variation attributable to a neonatal CAH diagnosis comprised 3 management categories: (1) clitoral reduction surgery (RS) (7 parents, 9 children), (2) clitoral concealment surgery (CS) (8 parents, 8 children), and no surgery on or around the clitoris (NS) (9 parents, 7 children).

OUTCOMES

Four representative themes, Obvious Choice, Still Different, Parental Burden, and Ignorance Is Bliss, were common across all 3 treatment groups.

RESULTS

For most parents, none of the 3 options of genital appearance alteration via clitoral reduction, clitoral concealment surgery, or avoidance of clitoral surgery ameliorated concerns, with most parents expressing an aversion to educating their child on the topic of genital differences, past treatment, or future function.

CLINICAL IMPLICATIONS

Reliance on surgical treatment pathways to manage this psychosocial concern is ineffective in alleviating parental uncertainty without the application of psychosocial interventions.

STRENGTHS AND LIMITATIONS

This was a qualitative study but was limited to parents of children with a specific genital difference, without direct exploration of parental values regarding the clitoris or the application of adequate psychosocial care.

CONCLUSION

Healthcare services must have an impact on parental ability to engage in essential communication with their children in cases such as clitoral size variation related to neonatal CAH. Improved communication skills allow parents to engage in more genuine decision-making and adapt to enduring genital reality, including possible future sexual challenges for their adult child, without resorting to burdensome strategies focused on attempts to perpetuate a benevolent ignorance.

Long-term risks of childhood surgery

INTRODUCTION

Several patients, who underwent major reconstruction under the care of an experienced pediatric urologist are now, as adults, several years later, appearing with long term problems and complications. This consensus process was undertaken to give an overview of long term consequences (and their management) of urological childhood surgery.

MATERIAL AND METHODS

Several known urologists with experience in life-long follow up and revisional surgery of patients with congenital conditions were asked to review literature and comment based on their experience about several complications of childhood surgery.

RESULTS

Renal impairment, metabolic consequences, bladder stones, Vit B 12 deficiency and recurrent infections are often encountered. Also recurrent ureteric strictures and difficulties with catheterizable channel (both obstruction and incontinence) can be challenging to manage. Specific attention is needed regarding female sexuality and pregnancy. Both the development of malignancies in reconstructed bladders as secondary malignancies need to be taken into account during follow up.

CONCLUSION

Follow up of patients with rare congenital conditions is highly specialized and revisional surgery can be challenging. Therefore, follow up needs to be organized in specialized centers.

Challenges in Transition of Care for People with Variations in Sex Characteristics in the European Context

OBJECTIVE

People with variations in sex characteristics (VSCs) have been receiving inadequate care for many decades. The Chicago consensus statement in 2006 aimed to introduce improved comprehensive care, which would include the transition of care from pediatric to adult services organized by multidisciplinary teams. Yet, the evidence for transitional care is scarce. The aim of this paper is to outline the delivery of transition of care for adolescents and young adults with VSCs.

METHOD

Seven focus groups were conducted with health care professionals and peer support groups by care teams in Central, Northern, and Western Europe. The data from the focus groups were examined using reflexive thematic analysis.

RESULTS

Even though the transition of care has been implemented in the last two decades, it remains inadequate. There are differences among countries, as the quality of care depends on available resources and variations in sex characteristics. Moreover, there are significant hurdles to adequate transition of care, as there is lack of time and funding. The lack of adult care providers and psychosocial support often leaves young adults with VSCs to navigate the health care system alone.

CONCLUSION

The outcome of the study shows that the transition of care is organized through the department of pediatric endocrinology. The quality of care varies due to resources and variations in sex characteristics. A lack of adult specialists, and especially psychosocial support, represents the biggest obstacle for young adults and adults in navigating the health care system and for improvements in the provision of health care to adults. There is a risk of re-traumatization, as adolescents and young adults must often repeat their medical history and educate adult care providers who are insufficiently trained and knowledgeable.

Why do parents recommend clitoral surgery? Parental perception of the necessity, benefit, and cost of early childhood clitoral surgery for congenital adrenal hyperplasia (CAH)

Historically, medical management of Congenital Adrenal Hyperplasia (CAH) in girls typically involved feminising surgery, which meant reducing the size and/or visibility of the enlarged clitoris. This practice may have become less routine but remains a common response to genital differences associated with CAH. Parents typically give permission for the child to undergo surgery in early childhood and recommend other parents facing a similar situation do the same. The current report is based on a qualitative content analysis of interviews with sixteen parents whose daughters with CAH had undergone one of two forms of clitoral surgery. We observed that: (i) some parents were initially unconcerned about their child's genital presentation; (ii) in general, clitoral surgery was considered as a readily available and natural response to the child's bodily difference; (iii) the parents acknowledged that there would be some risk but anticipated various benefits; and (iv) there was an absence of ethical considerations when the parents evaluated the various effects of surgery afterwards. We conclude from our analysis that parents of girls with CAH may not receive psychologically and ethically informed counselling to encourage critical reflections prior to authorizing genital surgery.

Disorders or Differences of Sex Development? Views of Affected Individuals on DSD Terminology

Over a decade ago, the participants at the International Consensus Conference on Intersex proposed Disorders of Sex Development (DSD) as an umbrella term for "congenital conditions in which the development of chromosomal, gonadal, or anatomical sex is atypical". The Group recommended the terminology be sensitive to concerns of individuals having these conditions. Yet, controversy rages over the term DSD. This multicentre clinical evaluation study was initiated as part of the European research group dsd-LIFE to evaluate patient-reported outcome. In total, 1,040 individuals with conditions labeled as Disorders of Sex Development were recruited in Poland, Sweden, Germany, France, United Kingdom and the Netherlands. All participants were asked to rate the terms describing their conditions. Overall, a large majority of participants (69%) reported that the term Disorders of Sex Development applied to their condition or that they felt neutral about it. Most participants preferred terms that were specific to their somatic condition. Overall, our data do not support the view that, in general, the term Disorders of Sex Development is insensitive to concerns of affected persons and that it should therefore be abandoned. However, in the clinical encounter, we recommend that clinicians evaluate each patient's preferences.

An experimental philosophical bioethical study of how human rights are applied to clitorectomy on infants identified as female and as intersex

Clitorectomies performed on the genitals of infants identified as female and as intersex have been described both as similar procedures and as different procedures. The former types of surgery have been recognised more consistently as human rights abuses than the latter in recent decades. We tested social psychological explanations of why human rights are differently recognised when infants are described as 'intersex' or 'female'; 122 laypeople in the UK read one of two near-identical descriptions of clitorectomies performed on intersex or female infants and reported their agreement with 22 items about the human rights of such infants. Clitorectomies were perceived as violating human rights more by women than by men, and more so when infants were described as female than intersex. Endorsement of human rights was better predicted by several psychological variables when infants were described as female than as intersex. Less politically conservative participants, as assessed by a Right-Wing Authoritarianism measure, and participants who trusted medical authority more recognised human rights violations of female infants more than intersex infants. Results are discussed with respect to human rights efforts to protect infants from medically non-necessary genital surgery on the basis of membership in identity categories or possession of sex characteristics.

'That decision really was mine…'. Insider perspectives on health care controversies about intersex/diverse sex development

After 20 years of debate on intersex care, there has been a slight movement away from the paradigm of 'optimal gender' including early genital modification to conform to predicted gender identity towards a paradigm of 'full consent' including the provision of full information about the risks, benefits and alternatives to interventions and the postponement of irreversible interventions on minors too young to give informed consent. However, controversy continues. Against this background, the aim of this study was to analyse core aspects of current debates in intersex care. Focus was placed on controversies about surgery on external genitalia; gonadectomies; the expressed wishes of patients under the age of consent; and how to deal with intersex within the family. Eight guideline-based interviews were conducted with two people with intersex/diverse sex development conditions who had been subjected to surgery, two parents of children with an intersex/dsd condition, two medical doctors, and two psychologists. Data were analysed thematically. Findings indicate that while 'full consent' influenced actions and debate, the persons involved held differing opinions about how this policy can or should be achieved. In addition, the data illustrated how concepts such as normalcy, identity and sexuality are relevant when dealing with intersex issues.

Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent

INTRODUCTION

Diverse sex development (dsd) is an umbrella term for different congenital conditions with incongruence of chromosomal, gonadal, and phenotypic sex characteristics. These are accompanied by various uncertainties concerning health-related, medical, psychosocial, and legal issues that raise controversial discussion.

AIM

The aim of this exploratory study was to investigate 3 questions: What are the most controversial and disputed issues in the context of intersex/dsd? Which issues are associated with the biggest knowledge gaps? Which issues involve the greatest difficulty or uncertainty in decision-making? A further aim was to investigate whether the group of persons concerned, the parents of intersex children, and the group of experts in the field had differing views regarding these questions.

METHODS

A self-developed questionnaire was distributed among persons concerned, parents of children with intersex/dsd, and experts in the field. It contained open and multiple-choice questions. The answers from 29 participants were entered into data analysis. A mixed-method approach was applied. Quantitative data were analysed descriptively. Qualitative data were analysed according to the principles of qualitative content analysis.

MAIN OUTCOME MEASURE

Participants answered questions on the most controversial and disputed issues, issues associated with the biggest knowledge gaps, and issues associated with the most difficulty or uncertainty in decision-making.

RESULTS

The findings indicate that controversial issues and uncertainties mainly revolve around surgical interventions but also around the question of how to adequately consider the consent of minors and how to deal with intersex in the family. Significant differences were found between persons concerned and parents vs academic experts in the field regarding the perceptions of procedure of diagnostic investigation and/or treatment in adulthood, on legal questions concerning marriage/registered civil partnerships, and on lack of psychosocial counseling close to place of residence.

CONCLUSION

The necessity of irreversible gonadal and genital surgery in early childhood is still a matter of strong controversy. To ensure the improvement in well-being of intersex persons, including a sexual health perspective, the positive acceptance of bodily variance is an important prerequisite. Psychosocial support regarding one-time decisions as well as ongoing and changing issues of everyday life appears to be an important means in reaching overall quality of life. Lampalzer U, Briken P, Schweizer K. Dealing With Uncertainty and Lack of Knowledge in Diverse Sex Development: Controversies on Early Surgery and Questions of Consent-A Pilot Study. Sex Med 2020;8:472-489.

The basics of transition in congenital lifelong urology

PURPOSE

Transition in urology is defined by the process that allows an adolescent or a young adult with a congenital or acquired urogenital anomaly to assume increasing responsibility for their own health care and to become the primary decision maker in their care.

METHODS

A review of the literature regarding transitional care for lifelong urologic congenital anomalies was performed with the aim of reporting expert opinion when data are non-existent. This review focuses on special considerations for adolescents and young adults with spina bifida, bladder exstrophy, anorectal malformations and differences of sexual development.

RESULTS

Urologic goals during the transition from childhood to adulthood continue to include attention to the preservation of renal function and optimization of lower urinary tract function. Additional concerns include care to decrease long-term surgical complications (especially after augmentation cystoplasty), to monitor for malignancy, to prepare for sex activity and fertility, and to help the adult patient in decision making. Transition aims to maximize quality of life and independence by ensuring uninterrupted appropriate care through a multidisciplinary approach which varies by geographical location and healthcare setting. Barriers include patient and family factors as well as provider and system related factors. A dedicated team is an important element of successful transition.

Sexual function and voiding status following one stage feminizing genitoplasty

BACKGROUND

The data on long-term outcome of feminizing genitoplasty (FG) with regard to the sexual function and voiding status is limited and nearly always retrospective, reviewing only small numbers of patients. Furthermore, most articles only looked at the success as an adequately open vagina with a feminized appearance. Success should include normal erotic sensation, lubrication, sexual satisfaction, orgasm, and intercourse without discomfort. These latter factors are just beginning to be studied OBJECTIVE: To investigate sexual function and voiding status in women who underwent vaginal reconstruction in childhood.

MATERIAL AND METHODS

We retrospectively reviewed medical files of patients who underwent FG at our center from 1988 to 2000. In addition, patients were asked to complete the following standardized questionnaires: Female Genital Self-Image Scale (FGSIS), dysfunctional voiding and incontinence symptoms score (DVISS), and Female Sexual Function Questionnaire (FSFI).

RESULTS

patients underwent one-stage FG; of those, 36 with median age of 21 years (range 18-30 years) who completed the puberty period were included into this study. Of the participants, 15 (41.6%) lived in a committed partnership, and 12 (80%) had sexual intercourse on a regular basis. Total FSFI was 22.2 + 3.1 (mean + SE). Domain scores were 3.9, 4.3, 4.5, 4.3, 4.9, and 4.7 for desire, arousal, lubrication, orgasm, satisfaction, and pain, respectively (Summary Figure). None of the patients reported on daytime incontinence or enuresis. Female genital self-image was found to be positive in all patients and related positively to women's sexual function.

DISCUSSION

The general rate of the sexual activity of our studied population was similar to that published in the literature 80% in our study vs 60-87% published in the literature. The overall FSFI was 22, showing some evidence of the female sexual dysfunction. However, only one patient regarding pain during vaginal penetration demonstrated mild dyspareunia. At the same time, we have not found any desire, arousal, lubrication, orgasm, satisfaction problems. Furthermore none of our patients complained on lower urinary tract symptoms during questioning, while three girls with congenital adrenal hyperplasia presented during follow-up with dribbling incontinence, which resolved with introitoplasty and creation of the wide vaginal opening.

CONCLUSIONS

Our data demonstrate that one -tage FG in childhood is a long-term effective surgical procedure that does not cause voiding dysfunction. If a secondary intervention is required prior to the sexual life, simple introitoplasty usually solves the problem. The FSFI score showed overall acceptable sexual function, whereas mild dyspareunia was a major complain.

Clitoral surgery on minors: an interview study with clinical experts of differences of sex development

OBJECTIVES

Clitoral surgery on minors diagnosed with differences of sex development is increasingly positioned as a violation of human rights. This qualitative study identified how health professionals (HPs) navigate the contentious issues as they offer care to affected families.

DESIGN

Qualitative analysis of audio-recorded semistructured interviews with HPs. All of the interviews were transcribed verbatim for theoretical thematic analysis.

SETTING

Twelve specialist multidisciplinary care centres for children, adolescents and adults diagnosed with a genetic condition associated with differences of sex development.

PARTICIPANTS

Thirty-two medical, surgical, psychological and nursing professionals and clinical scientists in 12 specialist centres in Britain and Sweden formed the interview sample.

RESULTS

All interviewees were aware of the controversial nature of clitoral surgery and perceived themselves and their teams as non-interventionist compared with other teams. Data analyses highlighted four strategies that the interviewees used to navigate their complex tasks: (1) engaging with new thinking, (2) holding on to historical assumptions, (3) reducing the burden of dilemmas and (4) being flexible. In response to recent reports and debates that challenge clitoral surgery on minors, HPs had revised some of their opinions. However, they struggled to reconcile their new knowledge with the incumbent norms in favour of intervention as they counsel care users with variable reactions and expectations. The flexible approach taken may reflect compromise, but the interviewees were often trapped by the contradictory values and assumptions.

CONCLUSIONS

If the pathology-based vocabularies and narratives about genital diversity could be modified, and normative assumptions are questioned more often, clinicians may be more adept at integrating their new knowledge into a more coherent model of care to address the psychosocial concerns that genital surgery purports to overcome.

Management of disorders of sex development - With a focus on development of the child and adolescent through the pubertal years

Disorders of sex development, congenital conditions in which chromosomal, gonadal or anatomic sex is atypical at birth, require urgent assessment by a multidisciplinary team, to define whether there is a life threatening disorder of congenital adrenal hyperplasia or a healthy child with a complex condition. Uncertainty, stigma and taboo complicate counselling which must be knowledgeable, comprehensive and sensitive to different circumstances, religions and cultures. This articles will discuss clinical and genetic diagnosis, decisions regarding sex of rearing, ethical dilemmas, medical management of the infant and of the child or adolescent presenting for the first time with a DSD. Surgical options, timing and management are outlined.

Intersex or Diverse Sex Development: Critical Review of Psychosocial Health Care Research and Indications for Practice

Intersex or diverse sex development (dsd) can be conceptualized as an aspect of bodily diversity that has particular psychosocial implications. This is a review of psychosocial health care literature, published from 2007 to 2017, focusing on the well-being of people with a diagnosis relating to sex development. The analysis I offer here takes a critical psychological approach, questioning norms and taken-for-granted assumptions. This approach works from the understanding that how we know and how we talk about a phenomenon affects people in material and life-changing ways. This article offers recommendations concerning health care communication, the importance of taking time for emotion, and the process of building supportive relationships. The research reviewed provides clear evidence of psychosocial harm that is done through genital intervention and evidence that parents do not routinely give fully informed consent before their children undergo treatment. Finally, I highlight key points and recommendations for health professionals, indicating how psychosocial professionals can contribute to health care and well-being in the context of dsd when appropriately resourced and trained.

Meeting the challenges of reconstructive urology - Where are we now?

This is based on the 2018 Storz Urology Lecture at the BAPS Conference and is a personal review of three reconstructive paediatric urological conditions: hypospadias, congenital adrenal hyperplasia, and bladder exstrophy from the perspective of changing expectations and outcomes. LEVEL OF EVIDENCE: V (Expert Opinion).

Controversies on Timing of Sex Assignment and Surgery in Individuals With Disorders of Sex Development: A Perspective

Appropriate management of disorders of sex development (DSD) has been a matter of discussion since the first guidelines were published in the 1950s. In the last decade, with the advent of the 2006 consensus, the classical methods, especially regarding timing of surgery and sex of rearing, are being questioned. In our culture, parents of DSD newborns usually want their children to undergo genital surgery as soon as possible after sexual assignment, as surgery helps them to confirm the assigned sex. Developmental psychology theories back this hypothesis. They state that anatomic differences between sexes initiate the very important process of identification with the parent of the same sex. Sex-related endocrinological issues also demand early care. For example, using dihydrotestosterone cream to increase penile length or growth hormone treatment to improve final height require intervention at young ages to obtain better results. Although the timing of surgery remains controversial, recent evidence suggests that male reconstruction should be performed between 6 and 18 months of age. Feminizing surgery is still somewhat controversial. Most guidelines agree that severe virilization requires surgical intervention, while no consensus exists regarding mild cases. Our perspective is that precocious binary sex assignment and early surgery is a better management method. There is no strong evidence for delays and the consequences can be catastrophic in adulthood.

Does Patient-centered Care Change Genital Surgery Decisions? The Strategic Use of Clinical Uncertainty in Disorders of Sex Development Clinics

Genital surgery in children with ambiguous or atypical genitalia has been marred by controversies about the appropriateness and timing of surgery, generating clinical uncertainty about decision making. Since 2006, medical experts and patient advocates have argued for putting the child's needs central as patient-centered care. Based on audio recordings of 31 parent-clinician interactions in three clinics of disorders of sex development, we analyze how parents and clinicians decide on genital surgery. We find that clinicians and parents aim for parent-centered rather than infant-centered care. Parents receive ambivalent messages about surgery: while clinicians express caution, they also present the surgery as beneficial. We examine how parents and clinicians reach agreement about surgery-differentiating parents who push strongly for surgery from parents who do not express any preconceived preferences about surgery and parents who resist surgery. We conclude that clinicians use clinical uncertainty about surgery strategically to direct parents toward perceived clinically appropriate decisions.

Navigating Surgical Decision Making in Disorders of Sex Development (DSD)

Surgical management of disorders of sex development (DSD) is associated with contentious debate between and within stakeholder communities. While the intent of surgical management of the genitals and gonads is to benefit the patient physically and psychosocially, these goals have not always been achieved; reports of harm have surfaced. Harm experienced by some patients has resulted in the emergence of an activist platform calling for a moratorium on all surgical procedures during childhood-excepting those forestalling threats to life within the childhood years. This ban is not universally endorsed by patient advocacy groups. Parents, meanwhile, continue to need to make decisions regarding surgical options for their young children. Constructive paths forward include implementation of Consensus Statement recommendations that call for comprehensive and integrated team care, incorporating mental health services, and adopting shared decision making.

[Differences of Sex Development (DSD): Controversies and Challenges]

DSD for "Differences of Sex Development" or "Sexual Differences Development" refers to situations where chromosomal, gonadal or anatomical sex is atypical. DSD 46,XX are mainly represented by congenital adrenal hyperplasia (HCS) and are not a diagnostic issue. DSD 46,XY involve genes for the determination and differenciation of the bipotential gonad, making sometimes difficult the choice of sex at birth. They remain without diagnosis in about half of the cases, despite the new genetic techniques (exome, NGS). The management of DSD is complex as well as are the long-term consequences, particularly in terms of options for medical or surgical treatments, fertility and quality of life of patients that should be discussed. This review describes the main causes of DSD and the recent issues of their clinical management. It addresses the difficult question of identity of these patients, in a society that leaves no place for difference.

Violence motivated by perception of sexual orientation and gender identity: a systematic review

OBJECTIVE

To assess the prevalence of physical and sexual violence motivated by perception of sexual orientation and gender identity in sexual and gender minorities.

METHODS

We searched nine databases without language restrictions for peer-reviewed and grey literature published from 2000 to April 2016. We included studies with more than 50 participants that measured the prevalence of physical and sexual violence perceived as being motivated by sexual orientation and gender identity or gender expression. We excluded intimate partner violence and self-harm. Due to heterogeneity and the absence of confidence intervals in most studies, we made no meta-analysis.

FINDINGS

We included 76 articles from 50 countries. These covered 74 studies conducted between 1995 and 2014, including a total of 202 607 sexual and gender minority participants. The quality of data was relatively poor due to a lack of standardized measures and sometimes small and non-randomized samples. In studies where all sexual and gender minorities were analysed as one population, the prevalence of physical and sexual violence ranged from 6% (in a study including 240 people) to 25% (49/196 people) and 5.6% (28/504) to 11.4% (55/484), respectively. For transgender people the prevalence ranged from 11.8% (of a subsample of 34 people) to 68.2% (75/110) and 7.0% (in a study including 255 people) to 49.1% (54/110).

CONCLUSION

More data are needed on the prevalence, risk factors and consequences of physical and sexual violence motivated by sexual orientation and gender identity in different geographical and cultural settings. National violence prevention policies and interventions should include sexual and gender minorities.

Coping With Diverse Sex Development: Treatment Experiences and Psychosocial Support During Childhood and Adolescence and Adult Well-Being

Objectives

The purpose of this exploratory, retrospective, and correlational study was to examine the relationships between childhood treatment experiences, parental care, and social support, and outcome in adults with different diverse sex development (DSD).

Methods

The data of 69 participants from an exploratory questionnaire were collected in a retrospective German study.

Results

The majority received medical treatment in relation to their DSD during childhood and adolescence. Seventy percent reported having had a best friend and 29% a confidant during childhood. Sixty-one percent showed clinically relevant psychological distress, and 45% reported suicidal thoughts at least at one point in their lives. Quality of parental care and having had a best friend correlated positively with adult outcome, whereas treatment experiences correlated with aspects of impaired adjustment.

Conclusions

Social support and DSD-related treatment experiences appear to have an impact on adult well-being. Appropriate psychosocial care including peer-to-peer support should be made available to children with DSD and their families.

Public challenge and endorsement of sex category ambiguity in online debate: 'The sooner people stop thinking that gender is a matter of choice the better'

Despite academic feminist debate over several decades, the binary nature of sex as a (perhaps the) primary social classification is often taken for granted, as is the assumption that individuals can be unproblematically assigned a biological sex at birth. This article presents analysis of online debate on the BBC news website in November 2013, comprising 864 readers' responses to an article entitled 'Germany allows 'indeterminate' gender at birth'. It explores how discourse reflecting Western essentialist beliefs about people having one sex or 'the other' is maintained in debates conducted in this online public space. Comments were coded thematically and are presented under five sub-headings: overall evaluation of the German law; discussing and disputing statistics and 'facts'; binary categorisations; religion and politics; and 'conversations' and threads. Although for many the mapping of binary sex onto gender was unquestionable, this view was strongly disputed by commentators who questioned the meanings of 'natural' and 'normal', raised the possibility of removing societal binary male-female distinctions or saw maleness-femaleness as a continuum. While recognising that online commentators are anonymous and can control their self-presentation, this animated discussion suggests that social classifications as male or female, even if questioned, remain fundamental in public debate in the early 21^st century.

Clitoral hoodplasty in females with disorders of sex development

INTRODUCTION

The surgical management of girls with masculinized genitalia is gradually changing towards a more conservative approach. Reports on loss of clitoral sensitivity and related impairment of sexual function in women after feminizing genital surgery in childhood have been pivotal in this evolution. An exposed clitoral glans is occasionally seen at follow-up, and while patients may complain of aesthetics, no clitoral discomfort secondary to glans exposure has been reported. A technique has been developed to reconstruct the clitoral hood and the present study reports the preliminary results.

OBJECTIVES

To report the novel technique and preliminary results of clitoral hood reconstruction to cover an exposed glans after previous clitoroplasty in patients with congenital adrenal hyperplasia (CAH).

PATIENTS AND METHODS

Six female patients (mean age 13, range 4-21 years) with CAH sought medical help for clitoral concerns after previous reduction clitoroplasty. In two of the six patients, the main complaint was clitoral hypersensitivity or even pain. The clitoral glans was completely exposed in all patients, who were subsequently treated with a bi-laminar V-Y clitoral hoodplasty to create a mobile and natural-looking clitoral hood composed of an inner and outer preputial skin layer.

RESULTS

Postoperative covering of the glans was complete in five patients, and partial in one. The two patients with pre-operative pain became asymptomatic; all six patients were pleased with the cosmetic postoperative results.

CONCLUSION

Clitoral hoodplasty provides simple, yet effective, relief for women with cosmetic concerns or clitoral discomfort after previous feminizing surgery.

Deferring surgical treatment of ambiguous genitalia into adolescence in girls with 21-hydroxylase deficiency: a feasibility study

Background

Genital surgery in Disorders of Sex Development (DSD) has been an area of debate over the past 20 years. Emerging scientific evidence in the late 1990s defied the then routine practice to surgically align genitalia to the sex of rearing, as early as possible. However, despite multitude of data showing detrimental effects to genital sensation and sexuality, few patients born with ambiguous genitalia have remained unoperated into adolescence.

Methods

We followed up girls with 21 hydroxylase deficiency (21- OHD) in genital morphology during childhood and acceptability among patients and parents of such an approach.

Results

Preliminary results from 7 children, aged 1–8 years (median 4.5 years), suggest that it is acceptable among patients and families to defer genital operation in 21-OHD. All patients had a Prader stage III and above. Median clitoral length at birth was 24 mm (20-28 mm) and had diminished to a median of 9 mm (5-15 mm) at their last visit. Height and weight have remained strictly normal in all patients. So far girls and their parents have not expressed significant concerns regarding genital ambiguity.

Conclusions

With this encouraging data at hand, we propose to formally address levels of anxiety, adaptation and quality of life during childhood, with an ultimate goal to assess long term satisfaction and effects on sexuality through deferring genital surgery for adolescence.

[Clinical evaluation and management of neonates with disorder of sexual development]

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.

Surgery in disorders of sex development (DSD) with a gender issue: If (why), when, and how?

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.

Transition to Adult Care in Persons With Disorders of Sexual Development: The Role of the Gynecologist

Disorders of sexual development (DSD) are a spectrum of conditions diagnosed in infancy resulting from atypical development of the external genitalia, in adolescence resulting from atypical pubertal development, or in adulthood as a result of infertility. Obstetricians may be the first health care providers to identify a disorder of sexual development in the fetus or newborn and should be part of the interdisciplinary team assembled to best care for these patients. Gynecologists must be familiar with the diagnosis and management of these conditions in late adolescence and adulthood. The creation of DSD "centers of excellence" may provide optimal care for individuals with these conditions but many will live too far from such centers and need to be followed by local gynecologists. The purpose of this commentary is to emphasize important medical and psychological issues so gynecologists can provide optimal care for their patients with DSD conditions.

Vaginal Rejuvenation with Gore-Mycromesh

Recently, we introduced functional vaginal rejuvenation with elastic silicone threads. However, some patients with specific indications need other biocompatible materials for rejuvenation of the vagina. Gore-Mycromesh is one of the most commonly used materials in plastic and reconstructive surgical fields and it is composed of expanded poly-tetrafluroethylene. In this study, we introduced our clinical experience with static vaginal rejuvenation using Gore-Mycromesh to specifically assess the overall patient satisfaction (Female Sexual Function Index, FSFI). This study included 50 patients who underwent vaginal rejuvenation with a Gore-Mycromesh between 2010 and 2012. After marking two incisions at the inner side of the vaginal inlet and posterior wall, respectively, we performed submucosal dissection at the posterior vaginal wall and then grafted and secured a Gore-Mycromesh to the dissected area (muscle/fascia). Overall the FSFI improved as time progressed up to a year postoperatively. This is especially prominent in the FSFI satisfaction subscore. All but eight patients (42/50, 84 %) were "very satisfied (5)" or "satisfied (4)" with the outcomes after the vaginal rejuvenation. The overall complication rate was 8 %. Based on our clinical experience with the 50 cases, we think that vaginal rejuvenation with Gore-Mycromesh significantly improved postoperative outcomes, resulting in improved sexual function with a focus on improving the FSFI satisfaction subscore in mid-term follow-up. Elderly patients experience better outcomes using gore mycromesh rather than silicone thread because we can plicate the vaginal posterior wall with senile changes simultaneously using an open technique. However, further studies would be warranted for better positioning and adherence of grafted implants to surrounding tissue and for increasing the tightening effect of the implant and its sufficient longevity.

Congenital adrenal hyperplasia: current surgical management at academic medical centers in the United States

PURPOSE

Controversy exists on the necessity for and timing of genitoplasty in girls with congenital adrenal hyperplasia. Our knowledge of surgical preferences is limited to retrospective series from single institutions and physician surveys, which suggest a high rate of early reconstruction. We evaluated current surgical treatment for congenital adrenal hyperplasia at academic centers.

MATERIALS AND METHODS

We queried the Faculty Practice Solutions Center database to identify all female patients younger than 18 years with a diagnosis of congenital adrenal hyperplasia between 2009 and 2012. Procedures were identified by CPT codes for vaginoplasty, clitoroplasty and other genital procedures. Reconstruction type, age at surgery and surgeon volume were analyzed.

RESULTS

We identified 2,614 females in the database with a diagnosis of congenital adrenal hyperplasia who were seen at a total of 60 institutions. Of infants younger than 12 months between 2009 and 2011 as few as 18% proceeded to surgery within a 1 to 4-year followup. Of those referred to a pediatric urologist 46% proceeded to surgery. Of patients who underwent surgery before age 2 years clitoroplasty and vaginoplasty were performed in 73% and 89%, respectively, while 68% were treated with a combined procedure. A medium or high volume surgeon was involved in 63% of cases.

CONCLUSIONS

Many patients with congenital adrenal hyperplasia in the database did not proceed to early reconstructive surgery. Of those referred to surgeons, who were possibly the most virilized patients, about half proceeded to early surgery and almost all underwent vaginoplasty as a component of surgery. About two-thirds of the procedures were performed by medium or high volume surgeons, indicative of the surgical centralization of disorders of sexual development.