Fertility Discussions: Perspectives of Adolescents and Young Adults With Differences of Sex Development

Family functioning in adolescents and young adults with differences of sex development

OBJECTIVE

Family functioning influences various psychosocial outcomes for individuals with pediatric chronic health conditions (e.g., Leeman, J., Crandell, J. L., Lee, A., Bai, J., Sandelowski, M., & Knafl, K. (2016). Family Functioning and the Well-Being of Children With Chronic Conditions: a Meta-Analysis. Research in Nursing & Health, 39, 229-243), but this has not been examined among families of youth with differences of sex development (DSD). The objective of this study was to examine (a) differences in family functioning based on DSD-related and demographic characteristics, (b) the associations between family functioning and psychosocial outcomes, and (c) the moderating effects of current age.

METHODS

Participants were 57 adolescents and 40 young adults (AYA) ages 12-25 years (M  = 16.97) with DSD resulting in atypical genital appearance and/or discordance between phenotypic and chromosomal sex who participated in a cross-sectional study examining psychosocial outcomes. Participants completed the Family Environment Scale, the McMaster Family Assessment Device, the Perceived Acceptance Scale, and outcome measures including the Youth Self-Report/Adult Self-Report and the Connor-Davidson Resilience Scale. Analyses included t-tests and linear regressions with moderation effects.

RESULTS

AYA reported better family functioning if they were diagnosed at a younger age, learned about their diagnosis at a younger age, had 46, XY karyotype, and identified as male. General family functioning, family conflict, and family acceptance had the strongest associations with psychosocial outcomes. Greater family acceptance was associated with fewer total problems, and this association was stronger for adolescents (ps < .05).

CONCLUSIONS

AYA with certain DSD-related characteristics may demonstrate more adaptive family functioning. Family functioning is strongly associated with psychosocial outcomes for AYA with DSD. Results highlight the importance of developing family-focused interventions to promote psychosocial functioning in AYA with DSD.

Defining Success in the Delivery of Fertility-Related Care for Patients with Differences of Sex Development

INTRODUCTION

Individuals with differences of sex development (DSD) experience complex, often competing, medical and psychosocial challenges surrounding fertility. The study aimed to characterize how "success" in fertility-related care is conceptualized and attained among individuals with a DSD, their parents or caregivers, healthcare providers, and other stakeholders.

METHODS

As part of a larger study, DSD stakeholders (n = 110) participated in semi-structured interviews covering the clinical care of patients with DSD. Primary questions included "What is a successful outcome in DSD care?" and "How do you achieve it?" with fertility as either a spontaneous or suggested topic of discussion. Transcripts were analyzed utilizing a phenomenological approach. This analysis focuses on the extracted themes related to fertility.

RESULTS

Fertility was discussed by 19/24 individuals with DSD, 12/19 parents or caregivers, 35/37 healthcare providers, and 19/30 other stakeholders. Components of successful fertility-related care included (1) specific discussions surrounding the relationship between DSD and fertility potential, options for fertility preservation, and options for non-biologic parenthood; (2) early and repeated introduction of these topics; and (3) consideration of age, developmental maturity, and cultural context on decisions around fertility. Challenges included the lack of fertility outcome data in this population and the irreversibility of gonadectomy. Trade-offs identified included anatomic typicality versus function, fertility preservation versus cancer risk reduction, and balancing the different priorities of stakeholders.

DISCUSSION/CONCLUSIONS

A wide range of DSD stakeholders highlighted the importance of addressing fertility concerns in achieving favorable outcomes for individuals with DSD. These stakeholder perspectives should inform fertility-related education, shared decision-making processes, and clinical care.

Understanding sexual health concerns among adolescents and young adults with differences of sex development: a qualitative study

PURPOSE

Differences of sex development (DSD) are congenital conditions that involve variations in individuals' sex chromosomes, genes, external and/or internal genitalia, hormones, and/or secondary sex characteristics. This study sought to elucidate the experiences of adolescents and young adults living with DSD by focusing on their experiences of intimacy and sexual health.

METHODS

An interpretative phenomenological research design was adopted. Semi-structured qualitative interviews were conducted with 11 Norwegian adolescents and young adults aged 16-26 years who had five different DSD conditions. The interview findings were analysed by means of a reflexive thematic analysis.

RESULTS

The participants reported feeling different, both in terms of how their body functioned and how their body looked. Lack of knowledge increased this feeling of differentness. Moreover, lack of everyday language with which to talk about intimacy and sexual concerns resulted in the participants feeling stigma. Anticipating stigmatization and lacking everyday language complicated the participants' communication regarding their DSD and sexual health.

CONCLUSIONS

The sexual experiences of adolescents and young adults with DSD are diverse. Fear of stigmatization and lack of everyday language complicate communication with healthcare professionals and others. Understanding their unique needs is crucial to helping individuals achieve good sexual health.

Surgical experiences in adolescents and young adults with differences of sex development: A qualitative examination

BACKGROUND

Surgical intervention in youth with differences of sex development (DSD) is a controversial topic. Historically, evidence suggests that genital surgery in DSD is associated with mixed patient satisfaction. However, less is known about surgical outcomes under therapeutic advancements in the past several decades.

OBJECTIVE

The purpose of the current study is to provide an updated and empirical qualitative examination of the surgical experiences and responses to care of adolescents and young adults (AYA) with DSD in order to fill this gap in the literature and inform patient care.

METHODS

Qualitative interviews were conducted with 37 AYA (ages 12-26) with DSD. Interviews were transcribed, coded, and analyzed thematically.

RESULTS

Three major themes were identified: 1) knowledge related to surgery; 2) surgical and medical experience; and 3) psychosocial factors related to surgery. Results demonstrated that most AYA were not involved in the decision to pursue surgery and were observed to have varying levels of knowledge regarding their surgeries. Most participants in the current study had received a DSD-related surgery and the majority described having positive surgical experiences and few regrets. Nonetheless, AYA described both medical and psychosocial challenges related to their surgeries and recoveries and offered feedback on ways to improve the surgical process.

DISCUSSION

The current study provides a qualitative examination of the surgical experiences of 37 AYA with DSD. Findings highlight the importance of regular and ongoing communication with providers to improve knowledge related to surgery during the decision-making process as well as after surgical intervention. Results underscore the benefits of multidisciplinary teams and the value of patient handouts and decision aids in assisting AYA in the decision to pursue surgical intervention. Other specific recommendations for providers include increased patient privacy during genital exams, greater emphasis on psychoeducation and pain management strategies, and the use of behavioral health services to assist with challenges and social support.

CONCLUSIONS

The decision to pursue surgical intervention in youth with DSD remains a complex and controversial issue, and more information regarding patients' perspectives on surgery is needed. The current study provides novel insights into patient experiences of surgical intervention and highlights the need for psychosocial support throughout the shared decision-making process.